Clinical Psychology & Mental Health - AO1

What are the four definitions in the field of mental health?

1. Deviation from ideal mental health

2. Deviation from social/cultural norms

3. Failure to function adequately

4. Statistical infrequency

What is deviation form ideal mental health?

Deviation from ideal mental health is failing to have any one of Jahoda’s criteria for good mental health.

What is Jahoda’s criteria for good mental health?

Jahoda identifies 6 categories that an individual should display if they have ideal mental health. These categories are:

Criteria	Description
Resisting stress	Having effective coping strategies and being able to cope with everyday anxiety-provoking situations.
Accurate perception of reality	Perceiving the world in a non-distorted fashion. Having an objective and realistic view of the world.
Self-actualisation	Experiencing personal growth and development. ‘Becoming everything one is capable of becoming’.
Environmental mastery	Being competent in all aspects of life and able to meet the demands of any situation. Having the flexibility to adapt to changing life circumstances.
Autonomy	Being independent, self-reliant and able to make personal decisions.
Positive attitude towards oneself	Having self-respect, a positive self-concept and a strong sense of identity

What is deviation from social/cultural norms?

If a behaviour goes against social norms it may be labelled as atypical.

• Behaviour that goes against the unwritten rules of society.

• Behaviour that is different from how society expects people to behave. 

• Anti-social or undesirable behaviour that goes against social norms.

• Varies depending on cultural and historical context

What are social/cultural norms?

Social/cultural norms are a set of written and unwritten rules and shared beliefs that guide how individuals are expected to behave, think, and act in a particular context, e.g.:

• Queuing for a bus rather than pushing to the front

• Speaking at a volume deemed acceptable for the environment, i.e., shouting is acceptable at a football match but not in a café

What is failure to function adequately?

Being unable to cope with the demands of everyday life. For example, not contributing to society by being unemployed or being unable to to keep up with personal hygiene. This can cause distress to the individual and others.

What did Rosenhan & Seligman identify?

Rosenhan & Seligman (1989) identified some distinct signs that indicate failure to function adequately including:

• severe personal distress

• behaviour which 'stands out' or seems to go against social/cultural norms

• behaving irrationally

• harm that is self-inflicted or directed at others

• Observer discomfort

• Unpredictability

• Dysfunctional behaviour

• Maladaptive behaviours

What is statistical infrequency?

Behaviour or characteristic that is rare/uncommon and doesn’t fit within the ‘normal distribution’. This defines behaviour according to how often it is observed.

What are behavioural characteristics of a mental disorder?

Ways that people act with the mental disorder

What are emotional characteristics of a mental disorder?

A persons feelings or mood with the mental disorder

What are cognitive characteristics of a mental disorder?

The thoughts and mental process someone has with the mental disorder

What is a phobia?

A phobia is an example of an anxiety disorder — it's an extreme, irrational fear of a particular object or situation.

The DSM classifies several types of phobia:

• Specific phobia: fear of an object or situation.

• Social anxiety (social phobia): fear of social situations.

• Agoraphobia: fear of public places (being trapped).

What are the behavioural characteristics of phobias?

• Crying

• Screaming 

• Running away

• Avoidance

• Endurance

• Freezing 

• Fainting 

What are the emotional characteristics of phobias?

• Fear (Irrational, unreasonable and persistent.)

• Anxiety 

• Panic 

What are the cognitive characteristics of phobias?

• Selective attention

• Irrational beliefs

• Awareness of unreasonable behaviour

• Cognitive distortions

What is depression?

Depression is a mood disorder (also known as an affective disorder) characterised by low mood, lack of energy and motivation and loss of interest in activities that were once pleasurable. Symptoms of depression must have been present for no less than two weeks for a diagnosis to be determined

The DSM-5 includes the following categories of depressive disorders:

• Major depressive disorder: severe but often short-term depression 

• Disruptive mood dysregulation disorder: ongoing irritability, anger, and frequent, intense temper outbursts usually in children and adolescents

• Persistent depressive disorder: long-term, recurring depression, including sustained major depression 

• Premenstrual dysphoric disorder: disruption of mood before and/or during menstruation 

What are the behavioural characteristics of depression?

• Changes to usual activity levels

• Changes to sleep and eating patterns

• possibly aggression or self-harm.

What are the emotional characteristics of depression?

• Lowered mood

• anger

• decline in self-esteem.

What are the cognitive characteristics of depression?

• Poor concentration

• bias towards seeing the negative

• ‘black and white thinking’.

What is OCD?

Obsessive-Compulsive Disorder (OCD) is an anxiety disorder which is characterised by persistent, intrusive thoughts and repetitive behaviours

• Obsessions take the form of intrusive, persistent thoughts, e.g.,

  • 'Germs are everywhere; they could harm me and my family'

  • 'The outside world is a terrifying and dangerous place so I must do what I can to protect myself and my family'

• Compulsions take the form of repetitive behaviours, e.g.,

  • 'I must wash my hands thoroughly every time I touch any sort of surface'

  • 'I must check that I've locked the door at least seven times before I go to bed'

What are the behavioural characteristics of OCD?

• Compulsive behaviour

  • to reduce anxiety

  • are repetitive

• Avoidance

What are the emotional characteristics of OCD?

• anxiety

• depression

• guilt

What are the cognitive characteristics of OCD?

• obsessive thoughts

  • coping mechanisms to deal with the thoughts (rituals)

• Insight into excessive anxiety (know its not rational)

How does behaviourism explain phobias?

The two process model (by Hobart Mowrer)

What is the two process model?

The theory that phobias are acquired and maintained by classical and operant conditioning

According to behaviourism, how are phobias acquired?

Through classical conditioning (learning by association) :

Neutral stimuli (e.g. snake) --> no response

Unconditioned stimulus (e.g. snake bite) --> unconditioned response (FEAR!!)

Neutral stimuli (snake) + unconditioned stimuli (bite) --> unconditioned response (fear)

Conditioned stimuli (snake) --> conditioned response (FEAR)

According to behaviourism, how are phobias maintained?

Through operant conditioning (learning through consequences). Specifically through negative conditioning. When someone avoids the phobic stimulus, they are removing an unpleasant consequence (fear) so the beahviour is repeated and the stimulus is constantly avoided.

What is an alternative behaviourist (kind of) explanation?

Social learning theory. The phobia is learned from imitating role models (e.g. if parent has a fear of spiders the child will see and imitate this)

What is the behaviourist approach to treating phobias?

Systematic desensitisation and flooding.

What is systematic desensitisation?

• The most commonly used behavioural therapy to treat phobias

• SD takes place over weeks or even months as it a gradual, stage-based process, putting the patient in charge of their own progress

• SD works along the principles of classical conditioning as follows:

  • The phobic stimulus was originally a neutral stimulus, i.e., before it became the conditioned stimulus, triggering the conditioned fear response

  • By reversing the mechanisms of classical conditioning, it is possible for the conditioned phobic stimulus to revert to being the neutral stimulus again, i.e., it produces no fear response in the person

  • By gradually exposing the phobic person to the phobic stimulus, a process of 'unlearning' happens - they are conditioned to view the stimulus without fear (this is counter conditioning)

• The three stages of systematic desensitisation are: 

  • Anxiety Hierarchy

    • The patient and therapist work together to construct an anxiety hierarchy, which is a list of situations that involve the phobic stimulus from least to most frightening, e.g. for a phobia of spiders:

  • Relaxation

    • Breathing exercises help to calm the patient physiologically by slowing down and controlling the breath

    • Visualisation involves the patient placing themselves, mentally, in a relaxing, calming environment, e.g., a beach or a meadow

  • Exposure

    • Whilst in a relaxed state the patient is exposed to the phobic stimulus starting at stage 1 of the anxiety hierarchy

    • The patient moves up the hierarchy stage by stage, continually checking for signs of panic and slowing down if necessary

    • The aim of exposure is for the patient to move to the top of the hierarchy, whilst remaining relaxed and in control

What is flooding?

• A less widely-used and more controversial behavioural treatment for phobias

• Flooding involves a sudden, extreme exposure to the phobic stimulus without any prior build-up or gradual, stage-by-stage approach

• Unlike SD, flooding does not rely on relaxation training or a fear hierarchy — it is an 'all or nothing' approach:

  • The individual is exposed directly to their most feared stimulus, either in real life (in vivo) or through imagination (imaginal exposure)

  • The patient must remain in sustained contact with the fear trigger without engaging in any avoidant or safety behaviours

  • It may take place in one session lasting a few hours

  • The sudden exposure to the phobic conditioned stimulus is designed to extinguish the fear

• Anxiety initially peaks but, because no actual danger occurs, the fear response cannot be maintained indefinitely and eventually subsides

• This process is known as extinction — it occurs because the patient cannot avoid or escape the phobic stimulus

• Works because the body cannot remain in a state of fear for a prolonged period of tiem as adrenaline levels naturally decrease and this state takes up lots of energy. Therefore the patient will eventually become more relaxed

How does the cognitive approach explain depression?

Depression is due to irrational thinking as a result of maladaptive internal mental processes. The two key psychologists here are Beck and Ellis.

How does Beck explain depression?

Through the negative triad, negative self schemas and cognitive bias.

What is the negative triad?

The negative triad is divided into the following: 

• Negative view of the self: I am worthless/unimportant/useless/a waste of time 

• Negative view of the world: Everyone is against me 

• Negative view of the future: I am never going to amount to anything  

What is a negative self schema?

• Depressed people possess negative self-schemas, which may come from negative experiences, for example criticism, from parents, peers or even teachers

• A person with a negative self-schema is likely to interpret information about themselves in a negative way, which could lead to cognitive biases.

What is a cognitive bias?

• Depressed people are more likely to focus on the negative aspects of a situation, while ignoring the positives. 

• They are prone to distorting and misinterpreting information, a process known as cognitive bias.

• Two main types of cognitive bias include: 

  • Over-generalisations: A depressed person may make over-generalisations, where they make a sweeping conclusion based on a single incident 

  • E.g. ‘I’ve failed one end of unit test and therefore I’m going to fail ALL of my AS exams!’ 

  • Catastrophising: Exaggerating a minor setback and believing it’s a complete disaster

  • E.g. ‘I’ve failed one end of unit test and therefore I am never going to study at University or get a good job!’

How did Ellis explain depression?

Using the ABC model.

Irrational beliefs make us over-react to events and get depressed. 

A = activating event (A negative life event)

B = beliefs (Your belief is your interpretation of the event, which can either be rational or irrational.)

C = consequences (Rational beliefs lead to healthy emotional outcomes, whereas irrational beliefs lead to unhealthy emotional outcomes, including depression.)

What (according to Ellis) is the source of irrational thinking?

Musturbatory thinking - source of irrational beliefs. Thinking that certain beliefs or assumptions must be true in order for an individual to be happy. Irrational belief of always needing to succeed or be perfect. Ellis identified 3 important irrational beliefs:

• I must be approved of accepted by people I find important

• I must do well or very well, or I am worthless

• The world must give me happiness, or I will die.

Utopianism - type of musturbatory belief that life should always be fair.

What is the cognitive approach to treating depression?

Cognitive behavioural therapy (CBT)

( need to also know the specific type called rational emotive behavioural therapy (REBT - from Ellis))

What is CBT?

• Most commonly used treatment for depression.

• Combines cognitive and behavioural techniques.

• Cognitive element:

  • Assessment - client and therapist identify problems and set goals

  • Plan is put in place

  • Identifies and challenges negative/irrational thoughts (negative triad)

• Behavioural element:

  • Work to change unhelpful thought patterns and put more effective behaviours in place.

  • Homework set to record positive experiences to use in therapy to demonstrate reality (reality testing).

  • Behavioural activation: Encourage patient to be more active and engage in enjoyable activities.

• Key techniques:

  • Patient as scientist - patient identifies issues and tries to notice the thinking

  • Thought catching - Trying to identify the irrational thinking

  • Homework tasks - clients are asked to complete assignments between therapy sessions often to identlfy things that can be used to combat negative thinking

  • Behavioural activation- Encourage patient to be more active and engage in enjoyable activities.

  • Unconditional positive regard (often in REBT) - non-judgemental relationship between client and therapist. Therapist provides respect and appreciation regardless of what the client says and does.

What is Ellis’s CBT?

Ellis’s rational emotive behaviour therapy (REBT)

• Talking therapy that extends the ABC model.

• Identifies and Disputes irrational thoughts. 

• Replaces them with more Effective ones.

• Results in new Feelings being produced.

Types of disputing:

• Logical - ‘Does thinking this way make sense?’

• Empirical - ‘Is there proof to support this belief?’

• Pragmatic - ‘How useful/practical is this belief?’

What is the biological approach to explaining OCD?

Genetics ans neural explainations

How do genetics cause OCD

• A genetic explanation of OCD assumes that mental illnesses are heritable (i.e., they are generationally transmitted)

• The risk of developing OCD is higher for first-degree relatives (siblings or children), and the risk of inheriting OCD is higher in some families than in others (though research so far cannot explain why this is so)

• Researchers have identified candidate genes as genes that code for vulnerability to OCD 

  • OCD is polygenic; it is not caused by one single gene but by a combination of genetic variations that together cause significantly increased vulnerability

• A specific gene variation or group of genes may result in OCD in one person, but not for everyone with that genetic profile

• OCD-relevant genes include those involved in serotonergic and dopaminergic pathways

  • Both dopamine and serotonin are neurotransmitters linked to mood, emotion and motivation

• Research suggests a variation of the COMT gene is linked to OCD

  • COMT plays an important role in de-activating dopamine

    • Irregular dopamine levels are implicated in OCD

    • COMT gene helps to balance dopamine levels

    • Hence, COMT gene variation may contribute to OCD as it may help to control compulsive behaviours

• The SERT gene has also been linked with OCD, affecting the transport of serotonin

  • Lower levels of serotonin activity are implicated in OCD

  • Serotonin plays a role in balancing mood, which in turn may help to regulate obsessive thoughts

• The COMT gene produces an enzyme, which regulates the neurotransmitter dopamine. This results in higher levels of dopamine which is more common in patients with OCD, compared to those without OCD.

• The SERT gene (5-HTT gene) is linked to the neurotransmitter serotonin and affects the transport of serotonin, causing lower levels of serotonin which is also associated with OCD (and depression).

What are neural explanations of OCD?

• Neural explanations for OCD focus on neurotransmitters AND brain structures.

• Abnormal levels of neurotransmitters, in particular serotonin and dopamine, are implicated in OCD.

• Dopamine: Abnormal transmission of movement related information

  • High dopamine = OCD compulsions

  Serotonin: Abnormal transmission of mood relevant information. 

  • Low serotonin = OCD symptoms (serotonin may be removed too quickly from the synapse before impulses have been passed on)

• ‘Worry circuit’ of the brain - a set of structures that appear to be overactive in those with OCD.

  • Orbitofrontal cortex (OFC)

  • Basal ganglia system (especially the caudate nucleus)

  • Thalamus 

  The parahippocampal gyrus (processing of unpleasant emotions) has also been found to function abnormally in cases of OCD.

How does the biological approach treat OCD?

Drug therapy

What do SSRIs do?

• Antidepressants target neurotransmitter levels in the brain.

SSRIs (selective serotonin reuptake inhibitors) are a type of antidepressant

• E.g. Prozac

• Increase serotonin in the synapse by preventing reuptake in the presynaptic neuron.

• This results in more serotonin being received by the postsynaptic neuron and reduces OCD symptoms.

Combination treatment

• SSRIs combined with psychological therapies like CBT and with other drugs.

Alternatives to SSRIs

• Tricyclics – Clomipramine

• SNRIs – Serotonin-noradrenaline reuptake inhibitors

What do anti anxiety drugs do in relation to OCD?

Anti-anxiety drugs

• Anti-anxiety medication can also be used to treat OCD.

Benzodiazepines (BZs)

• e.g. Valium, Diazepam.

• Work to enhance the effect of the GABA neurotransmitter.

• BZs reduce activity of neurotransmitters in the brain, which reduces anxiety from obsessive thoughts.