Causality in mental distress

Question 1

what is causality?

Answer 1

• Aetiology or causality is the study of factors, mechanisms, and relationships between factors and mechanisms that cause mental distress
  ○ Factors that cause mental distress specifically
  
  • Often we immediately think about causes e.g. problems at uni, relationships- these are causal attributions
  • Causal attributions are every day, common sense explanations of behaviour and its consequences
  • Causality is not a straightforward concept because we cannot see it- we do not see causality happening in the real world
  • Clinical psychology is predicated on notions of causality
    ○ E.g. most clinical interventions assume that changes in one variable (for example dysfunctional thoughts) will lead to changes in mental distress (for example, reduced anxiety)
  • Clinical psychologists will therefore develop causal models that are trying to explain relationships between variables that could cause mental distress
  • Causal models are then used to inform psychological assessment and clinical interventions
    Clinical psychology does not doubt causality- interventions change causal factors to reduce mental distress e.g. reducing anger problems to eliminate violent behaviour (assuming a causal relationship)

Question 2

thought experiment

Answer 2

• Used to show how we can only infer causality because of observed relationships that we can see- wet grass outside so we assume it has rained
  
  • Correlating rain with wet grass so we can understand how the physical world works
    Large debate about whether looking at causal relationships reflects what exists or whether we assume it to make sense of what is happening around us

Question 3

how do we establish causality?

Answer 3

1. Covariation: If X is a cause of Y, then X should occur more often than not when Y is present
   
   • If we think that someone engages in binge drinking as a result of negative emotions, this means that more often than not they drink when they feel low. Many people do it in certain contexts e.g. only when in a social setting not alone- hard to establish covariation in research
   • Problems with covariation- hard to establish a causal relationship because there could be a third variable that causes both variables e.g. broken relationship causes negative emotions and binge drinking
   • We need to know that the cause proceeds the mental distress in time to establish a causal relationship
     2. Temporal precedence: the cause must precede mental distress in time
     3. Alternative explanations: must be able to exclude any alternative explanations for the causal relationships
     4. Logical connections: must be able to explain how X causes Y
   • Where psychological theory comes in
     Important for causal models to explain how they lead to mental distress

Question 4

causality in mental distress

Answer 4

• Causality in mental distress is probabilistic, which means that causal influences change the likelihood of mental distress occurring
  
  • There are many possible causes of mental distress and often there is more than one causal influence
    ○ Any type of model has to be able to account for different causes not just one factor- cannot be reductionist
  • Causality in mental distress is ‘over determined’ which means that mental distress can often be explained in more than one way
    ○ Often mental distress can be explained by multiple valid explanations which can account for why mental distress developed but some exclude each other e.g. biomedical model vs social model- both are often not true at the same time (over determined)
  • Causal influences on metal distress operate contingently, meaning they interact with each other in way that are difficult to predict and to identify
    ○ Operate contingently- interact and depend on each other
    Difficult to predict how and when they will interact with each other e.g. stress and trauma interact with neurological processes but difficult to predict which trauma/which processes

Question 5

sufficient causes

Answer 5

• Y always occurs after X
  ○ For example, the consumption of carbohydrates and glucose rich foods (X) can lead to raised blood glucose levels (Y) in people who have diabetes
  
  • But Y can also occur in the absence of X
    ○ There are no identified sufficient causes for mental distress
    For example, depression does not always occur after abuse, low serotonin, poverty, inequality, bullying etc

Question 6

necessary causes

Answer 6

• Y never occurs without the prior occurrence of X
  ○ For example, an STI (Y) never occurs without the prior occurrence of sexual contact (X)
  
  • But X can also occur without leading to Y
    For example, not everybody who is depressed has low serotonin, or experienced bullying, abuse, poverty etc

Question 7

insufficient causes

Answer 7

• Y only occurs after X occurs with another variable (Z). Y does not occur when X occurs alone
  ○ For example, a person might develop a particular condition such as schizophrenia (Y) only when they carry a genetic susceptibility (Z) and are exposed to a life stressor (X)
  For mental distress, there are only sufficient causes- and there are many insufficient causes that interact with each other

Question 8

difficulties

Answer 8

• Many studies (and clinical assessments) are cross sectional rather than longitudinal
  ○ The evidence measures mental distress and causal factors at the same time- there are ways in which we can measure experiences before mental distress e.g. attachment and personality so we can guess a causal relationship but nothing is longitudinal (follow people over time and measure causal factors and mental distress)
  
  • Difficult to prospectively study important influences. For example, the impact of parenting practices only becomes apparent many years later
  • Many influences occur over different time periods, happen in different places and interact with other variables
  • It is impossible for studies to include all important influences
    ○ Researchers have to choose what to measure- selection bias
  • Practical and ethical limitations in manipulating causal influences on mental distress to establish cause and effect e.g. ethnicity
    ○ Best test of causality is if we manipulate a causal factor and see if it induces mental distress but it is hard to manipulate factors such as trauma and socioeconomic status in a lab
  • Many important influences are sensitive- sampling bias
    ○ Sensitive for participants to talk about trauma- end up with a sampling bias in studies where participants who are more comfortable in engaging with the topic participate
    ○ Might not capture results for people who find this matter very triggering
  • We are often not aware of all factors that lead to feeling distressed. It is difficult, not impossible to articulate all causal influences on ones distress
    ○ Hard to identify what it is that makes you have a low mood- often takes years of analysis to discover the cause of mental distress
  • Researchers and clinicians may have (unconscious) biases that influence measurement and models
  • Causal attributions are always influenced by social and cultural norms and values
  • How we measure mental distress can limit the conclusions we draw e.g. the lack of validity of the diagnostic categories used in research
    ○ When people are diagnosed with different forms of mental distress they have to have 5/9 symptoms present (from DSM)- if you create a depressed and non depressed group they won’t be that different (median split)- this makes it hard to detect causality
    Also different combinations of symptoms and experiences- people in each group are not similar to each other so it is hard to find a common causal factor

Question 9

‘schizophrenia does not exist’

Answer 9

• These authors argue that what we call schizophrenia refers t a spectrum, where people are more vulnerable to hallucinations
  Criticism about mental distress- people often get categorised but it does not refer to real forms of mental distress in the real world

Question 10

methods to study causality

Answer 10

• Deductive approach- tests a theory of causality using predetermined variables e.g. surveys, experiments etc
  ○ Preconceived theories about factors that cause mental distress then set up an experiment
  
  • Inductive approach- explores experiences, and links them to causal theories or devise new causal theories (case studies, interviews, focus groups etc)
    ○ Researchers have no preconceived ideas- instead capture the experiences of those with mental distress and work backwards
  • Epidemiological approach- studies determinants and distribution of health related topics
    Looks at prevalence in different groups and link to different factors

Question 11

survey method- deductive

Answer 11

• Ask participants directly about the occurrences of variables associated with distress
  
  • Clinical interviews, self report questionnaires
  • Participants can be sampled via quasi-random sampling e.g. the electoral register
  • Uses a predefined range of variables at interest
    ○ Start with a theory then measure this
  • Advantages
    ○ Useful if large random samples are used together with valid and reliable clinical instruments
    ○ Explores real variation in influences and mental distress
    ○ Can be used longitudinally- easier to implement this over time
  • Disadvantages
    ○ Data depends on the questions being asked and the preconceptions of the researcher- researcher makes a decision which inevitably means other things are not being mentioned
    ○ Depends on what participants are able and willing to tell the researchers
    Some people with relevant mental health experiences might be excluded if quasi-random sampling is used

Question 12

experiments- deductive

Answer 12

• Manipulate a variable (X) to explore its effect on another variable (Y)
  
  • Participants are sampled in a random way
  • The sample is then divided into an experimental group and control group
    ○ Differences in two groups due to the manipulation of a causal factor
  • Differences are compared between the groups in a set of relevant measures e.g. RCTs
    ○ Randomised control trials- follow this experimental design but double blinded (participants and researchers do not know who is in what group and which group is which)
  • Advantages
    ○ Can provide the strongest inference of causality
    ○ High internal validity since they provide a controlled environment
  • Disadvantages
    ○ Low external validity- difficult to generalise a controlled environment to the ‘real world’
    ○ We can’t control many other confounding variables
    ○ Convenience sample (e.g. student samples) means important causal influences in other groups might be missed
    Ethical and practical constraints

Question 13

qualitative studies- inductive

Answer 13

• deals with language, images and non numerical data rather than measures, scales or questionnaires
  
  • Does not test preconceived hypotheses
  • Many approaches and methods e.g., interviews, focus groups, observation, ethnography
  • Advantages
    ○ Explores how the meaning of causal influences impacts peoples experiences
    ○ Can help identify the causal order or temporal precedence
    § More in depth and can help identify which causal factor comes first and the interactions between influences interact in mental distress
    ○ Can tell us something about how different influences interact in mental distress
    ○ Good for generating new hypotheses for quantitative studies
    ○ Good for studying complex cases
  • Disadvantages
    ○ Cannot be generalised to the entire population
    § Sample sizes are small because analysis is in depth- not about generalisation it is about finding things to test further
    ○ Does not test hypotheses
    § Based on qual findings you can create quant studies
    ○ Can be difficult to relate back to quantitative findings

Question 14

case studies- inductive

Answer 14

• in-depth analysis of a real life case
  
  • Advantages
    ○ Useful to generate new hypotheses
    ○ Helpful to explore complex phenomena
    ○ Can help to identify rare occurrences
    ○ Can help identify some the meanings associated with quantitative findings
  • Disadvantages
    Cannot be generalised to the entire population

Question 15

epidemiological studies

Answer 15

• Study the determinants and distribution of health related topics
  
  • Frequently uses clinical information gathered by doctors and other professionals
    ○ Based on medical framework and research- tries to then link the number of diagnoses of mental distress to all of these lifestyle factors they are also measuring
  • Studies how frequently diseases occur in different populations
  • Link variations in the prevalence of diseases to other variables such as SES, lifetsyle choices, employment history
  • Advantages
    ○ Often provides the most comprehensive picture of associations between demographic characteristics, lifetsyle variables and distress
    ○ Can access in patient, clinic and hospital populations (and community samples)
    ○ Can be more effective than survey methods due to its access to clinical information
  • Disadvantages
    ○ Data is based on diagnostic categories which are argued to lack validity
    Prone to pre-existing biases that are difficult to measure

Question 16

causal factors in mental distress

Answer 16

· Impossible to summarise all the factors so we categorise them into different groups
· Cromby- divided into relational biological and social
· Relational- anything that happens between people e.g. bullying, neglect- pretty good evidence that they occur before mental distress and covary with this
· Biological- anything in the body
· Social- inequalities within the society e.g. poverty, resources
· All of these have statistically been linked but not a necessary or sufficient cause- in terms of causal models they can focus on one of these factors e.g. neurodevelopmental model focus on genes, BMM on biological factors, trauma models focussing on relational factors or societal factors
· Some look at interactions between specific factors e.g. traumagenic neurodevelopmental model- interaction between stress and brain development can lead to psychosis (early trauma effects how the brain develops and because of differential activity that leads to mental distress
Biopsychosocial model- all of these factors interact with each other e.g. our genes influence our relational factors that lead to mental distress or trauma can change gene expression (too broad to put into practice- no one is specialised in all of these factors)

Question 17

biomedical model

Answer 17

• Assumes that individual differences in biological processes (e.g. neurotransmitters, genes, brain structure and functioning) cause mental distress
  ○ Neurotransmitters0 responsible for transmitting signals in the brain rwlating to psychological functions e.g. inhibiting negative stimuli and directing attention towards positive stimuli
  ○ Evidence to suggest that different forms of mental distress are aossicated with too much or little neurotransmitters e.g. depression and low levels of serotonin
  ○ Interaction of genes
  ○ Brain structure is different in those with mental distress e.g. activity in temporal lobe is different in schizophrenia so people hallucinate
  
  • There is no meaningful distinction between mental and physical diseases, and mental disyress can be treated with biological treatment
    BMM draws on all of this to help explain symptoms of distress

Question 18

Erritzoe et al (2023): Brain imaging comparing 17 ppts with depression to 20 healthy controls

Answer 18

• All ppts were given amphetamine to stimulate serotonin release in the brain
  
  • Measured how much serotonin was binding to receptors in the brain using radioactive tracing
    ○ Study is movel- first time they can measure serotonin binding to receptors
  • Participants diagnosed with depression had lower levels of serotonmin compared to controls
  • Suggests reduced neurotransmission of serotonin in people with depression
  • Biomedical thinking is something that is very present in the public- studies that ask people about causal beliefs people often mention chemical imbalances
  • Also present in the public discourse- newspaper articles about depression often around metabolism, brain structure, gut microbes
    Prominent idea that mental distress is caused by biology

Question 19

Deacon et al., biomedical model

Answer 19

• Useful to understand the history of the BMM- read this for the position paper
  
  • Long history of biomedical approaches to mental distress
    ○ Penicillin as a cure for general paresis- general paresis symptoms are anti-social behaviour, chronic fatigue which is caused by untreated syphilis, found you could treat with penicillin
    ○ Electro-convulsive therapy to stimulate activity in regions of the brain
    Lobotomies (surgical procedure separating the frontal lobe to reduce symptoms of mental distress)as a treatment approach e.g. for depression and schizophrenia

Question 20

BMM

Answer 20

• Psychopharmacological ‘revolution’ in the 1950s-1960s: medication to reduce mental illness
  ○ Lots of medication was developed at the the same time the biological mechanisms of mental distress were being formed e.g. SSRIs- if they work then low serotonin is a cause of depression
  
  • Introduction of the chemical imbalance theory of depression
  • Publication of DSM-III in 1980 introducing diagnostic criteria for mental distress
  • Marketing of biomedical advances and growing collaborations with the pharmacological industry
  • Growing ties between patient advocacy groups, APA and National Institutes
    Patient advocacy groups promoted a biological approach to reduce stigma- people are not to blame for their distress

Question 21

criticisms of BMM

Answer 21

• No clear evidence for the chemical imbalance theory when pooling results together (Moncrieff et al., 2022)
  ○ After years of research when we look at the studies together- do not see any differences between people with or without a diagnosis in terms of biological differences. This is used to argue that the. Biological approach is developed because of false positives (small sample sizes)
  
  • SSRI efficacy does not prove that depression is caused by reduced levels of serotonin (Lacasse & Leo, 2005)
    ○ Plenty of interventions improve mental health without tackling the root cause
  • Biological differences might result from medication or mental distress (e.g. Moncrieff et al., 2022), which is often not controlled for in research
    Some of these biological differences may result from different factors e.g. mediciation- mental distress itself can impact biological processes. Differences then not because of biological factors but instead the mental distress causes them

Question 22

Schmaal et al 2015

Answer 22

• MRI data from a large sample (N>8000; Europe, USA, Australia)
  
  • Hippocampal volume reduced in participants with depression
    ○ They found there was a significant relationship with the size of the hippocampus and the number of depressive episodes
    ○ So actually depression damages the hippocampus not the other way round
  • Implicated in memory and emotion processing
  • Volume reduction correlated with number of depressive episodes
    Recently replicated by Videbech & Ravnkilde (2024)

Question 23

criticisms of schmaal

Answer 23

• Promotion, research funding and selective reporting (Deacon, 2013; Ionnidis, 2008)
  ○ Because a lot of research is funded by pharmacologocal companies there is an interest in publishing positive findings
  
  • Biomedical beliefs might increase stigma (Clement et al., 2010; Schomerus et al., 2012)
    ○ Originally advocated to reduce stigma but recent evidence suggests it may increase it (biological symptoms are deterministic)
  • Validity of diagnostic categories e.g. DSM- can we even identify biomarkers for such heterogenous experiences?
    ○ E.g. depression can be diagnosed with 227 different symptom combinations
    ○ Diagnoses are not really valid and it does not make sense to find biological markers for heterogenous symptoms
  • Reductionist- is it realistic to ignore non biological factors that might cause distress? Does it map onto the causal beliefs that people have about their own experiences of mental distress?
    Not realistic to ignore other factors- can it accurately describe what is happening?

Question 24

causal beliefs and stigma

Answer 24

• Complex relationship between biomedical vs psychosocial beliefs and stigma
  
  • Lebowitz & Appelbaum (2019) Review:
    ○ BM reduces blame from others and potentially self blame
    ○ But at the expense of perceptions of dangerousness and immutability
    ○ ‘mixed blessings model’- some of it does reduce stigma but it comes at the extent of forming other stigmas around help seeking
  • Was expected to reduce stigma however ideas around persistence of symptoms has increased stigma

Question 25

causal beliefs and treatment preferences

Answer 25

• Causal beliefs liekly influence treatment preferences (medication, psychotherapy, type of psychotherapy; Tompkins et al., 2017)
  
  • Read et al (2015): Large sample of >1800 participants in New Zealand who were prescribed anti-depressants
    ○ Diverse range of causal beliefs e.g. chemical imbalance, stress, relationship problems, childhood trauma
    ○ Those with biomedical causal beliefs thought of anti-depressants as more effective
    But- sampling bias: most participants had biomedical beliefs and if they are an effective biological treatment you may adopt biomedical causal beliefs

Question 26

causal beliefs about prognosis/recovery

Answer 26

• Biomedical beliefs tend to be associated with more pessimistic views about recovery
  
  • Kemp et al (2014)- experiment in participants with recurrent depression:
    ○ Participants were either told that they had low (condition 1) or normal (condition 2) serotonin levels
    ○ Measured expectations about prognosis/recovery
    ○ Participants in the low serotonin condition were more pessimistic about their recovery
    ○ Similar findings for other forms of mental distress (Lebowitz et al., 2013)

Question 27

a psychological model of mental distress

Answer 27

• Kinderman, P. (2005) A psychological model of mental disorder. Harvard Review of Psychiatry, 13: 206–217.
  
  • Biopsychosocial model proposes that mental distress results from biological and psychosocial (relationships, family, wider society) factors
  • Important to distinguish between circumstantial and social factors, and psychological processes
    Psychological processes refer to ‘the process by which personal meaning is ascribed by events’ (p. 208)

Question 28

Kinderman et al., 2013

Answer 28

Measures- causal factors
- Familial mental health problems: whether a practitioner has previously made mental health diagnoses (yes/no)
- Two cognitive tests from the Cambridge Neuropsychological Test Automated Battery (CANTAB)
○ Delyaed matching to sample test and affective go/no go tast
○ Not included in the analysis due to missing data
- Social inclusion- social relationships with friends and family and participation in social activities
- Demographic indicators- relationship status, income, education level
- List of Threatening Experiences Questionnaire (LTE-Q; Brugha & Cragg, 1990): stressful life events in adulthood
- Historical life events (Bernstein & Fink, 1994): participants indicated if they believed they had been physically, sexually or emotionally abused, or bullied at school

Measures- psychological processes
- Response Style Questionnaire (adapted; Nolen-Hoeksma et al., 2008): measures the coping styles that persons use to low mood
- 3 response styles
○ Rumination: e.g. think of shortcomings, failings; how passive and unmotivated you feel; isolate yourself and think of the reasons you feel sad
○ Adaptive/problem solving: e.g. do something that has made you feel better in the past, make a plan to overcome a problem
○ Dangerous activities: drink alcohol excessively, take recreational drugs, do something reckless
- Internal Personal, Situational and Attributions Questionnaire (IPSAQ; Kinderman & Bentall, 1996): measures the degree to which persons generate internal, personal or circumstantial causes for events
○

Mental health and wellbeing
- Mental health typically focuses on negative emotions and dysfunction
- Wellbeing is a ‘state in which the individual is able to develop their potential, work productively and creatively, build strong and positive relationships with others, and contribute to their community’ (Schwannauer rt al, 2010, p.1)
- Both terms are related but distinct (‘two continua’ model; Westerhof & Keyes, 2010)

Measures- mental health and wellbeing
- Goldberg Anxiety and Depression Scales (GAD; Goldberg et al., 1998)- 18 item dimensional measure of anxiety and depression
- BBC Subjective Wellbeing Scale (Kinderman et al., 2011)- psychological well being, physical health and satisfaction with relationships
○ Do you feel satisfied with yourself as a person?
○ Are you satisfied with your opportunity for exercise?
○ Are you satisfied with your friendships and personal relationships?

Key findings
- Model with psychological processes as mediators significantly improved the extent to which the model could explain the data ~ excellent fit
- Circumstantial factor was the strongest predictor of mental health problems and wellbeing
- Followed by family history of mental health problems and social status (mental health) and social inclusion (wellbeing)
- Response style and attribution style significantly mediated these relationships
- The way we process information and perceive the world determines the impact of biological, social and circumstantial factors on mental health and wellbeing

Question 29

Kinderman at al., 2015

Answer 29

• Overall, the relationship between life events and mental health problems is relatively weak
  
  • But, mediating effects of rumination:
    ○ Low rumination x many life events ~ low mental health problems
    High rumination x many life events ~ high levels of mental health problems
  • Overall, clear relationship between wellbeing and social activities
  • Mediating effects of coping:
    ○ Low social activity x high adaptive coping ~ less likely to report low levels of wellbeing

Wellbeing and psychological processes
- Positive psychology focuses on strengths and capabilities rather than dysfunction or illnesses
- Positive Psychology Interventions (PPI)- aim to induce positive feelings, cognitions and behaviours (Dennis & Ogden, 2022)
○ E.g. interventions promote optimism, gratitude, social connectedness etc
○ Helps people cope with negative emotions and difficult situations
○ Simple interventions, low cost –> easy to implement in daily life and in treatment
- Best Possible Future Self (King, 2001): exercise that asks participants to focus on the best possible version pf their future self after everything has gone as well as it possibly could
○ Uses life domains related to wellbeing e.g. romantic life, education, career, physical health, social life
- Expressing gratitude (Emmons & McCullough, 2003)- exercise that asks participants to reflect on feelings of gratitude
E.g. write (but not send) a letter to another person about times they were grateful that the other person had done for them