Mental Health and Distress Flashcards
How does WHO define mental health?
A state of welling being where an individual can realise their potential, cope with the normal stresses on life, be productive and contribute to the community
What is distress?
A generic term describing a range of experiences in a person’s life that are troubling and confusing
These experiences may lead someone to seek support
Has a wider scope that “mental illness” - may have symptoms of mental illness without being “ill”
What is psychiatry?
A medical speciality
Focus on study, diagnosis, treatment and prevention of mental disorders including affective, behavioural, cognitive and perceptual abnormalities
What does psychiatry use to give a diagnosis?
DSM-5
What does the DSM-5 define a mental disorder as?
A syndrome characterised by dysfunction in the processes of underlying mental functioning (psychological, biological and developmental)
usually associated with significant distress/disability
What is clinical psychology?
The use of psychological theory, methods and clinical knowledge to understand, reduce and prevent distress and promote psychological well-being
Define psychological distress (clinical psych)
State of emotional suffering associated with stressors and demands that are difficult to cope with in daily life
What are the 5 defining characteristics of psychological distress (clinical psych)
- perceived inability to cope
- changes in emotional status
- discomfort
- communication of discomfort
- harm
What are categorical classifications associated with?
Psychiatry
How does the DSM-5 categorise a mental disorder?
- significant behaviours associated with distress/disability
- unexpected response to common stressors/losses
- manifestation of behavioural, psychological or biological dysfunction
- the deviance/conflict has to be a symptom of dysfunction in the individual
Did homosexuality use to be included in the DSM-5? Is it still included? What does this suggest?
Yes
Now changed to distress by homosexuality
Shows DSM can pick and choose what is considered a disorder
What are dimensional approaches associated with?
Clinical psych
What are the characteristics of the dimensional approach?
- no sharp defining line between normal and abnormal
- describe distressing experiences on a continuum with normal functioning
- inter-related
- Mental health = dynamic, fluctuates and responds to what is happening to us
Give examples of which mental health disorders the dimensional approach is better used for
- anxiety
- depression
- psychosis
- mania/grandeur
What word is often used instead of “patient”
Service users
Client
People with lived experience
Why is the term “patient” not used?
- often not useful
- may not have illness
- may not be accessing treatment
- may not be “help-seeking”
When does an issue with mental health become a problem?
When it is:
- prolonged
- uncontrollable - can’t cope
- causes disruption
What are the 3 approaches to distinguishing between normality and abnormality? (Psychiatry)
Social approach - approved vs. disapproved behaviours in culture
Medical approach - well being vs. endangering behaviours
Statistical approach - statistically usual vs. unusual behaviours
What is the categorical model? (psychiatry)
- assume sharp distinction between normal and abnormal
- rigid way of separating people
- yes/no approach into what is considered abnormal
What are 2 limitations of the categorical model?
- doesn’t work/apply to everyone
- leads to contradictions and arbitrary exceptions
How common are “common” mental health difficulties e.g., low mood and anxiety?
- 20% experienced in last year
- 30% experienced in lifetime
What is the medical (biomedical) model? (Laing)
- set of procedures in which all doctors are trained
- assume mental health difficulties are a result of physical problems and should be treated medically
- biological emphasis with medical treatments e.g., medications, electroconvulsive therapy
Name an alternative to the biomedical model
the bio-psycho-social model (Engel)
What are the 3 components of the bio-psycho-social model? Give examples
Biological - genetic vulnerabilities, physical health, disability, effect of medication
Psychological - cognitive style, personality, attachment style, emotion regulation
Social - social support, family env., culture, life events/trauma
Explain the bio-psycho-social model
Components are entwined and have complex interactions
Interventions should address all components
What is a critique of the bio-psycho-social model?
Possibly better as an approach rather than a model as mapping of this interaction is rarely specified
What are the 2 types of recovery?
Clinical recovery
Personal recovery
What is clinical recovery?
Symptoms disappear
This sometimes happens without treatment
What is personal recovery?
Building resilience, having control over problems, leading a meaningful life
“post-traumatic growth” - enriched experience
recovery-orientated approached used by many services - argues against treating symptoms but rather focusing on building resilience and supporting emotional distress
Was there recent concern at the over-medicalisation of mental disorder? What was this called?
yes
the bio-bio-bio model
Why is it important to consider the validity of different models of mental health and distress?
- scientific duty
- the approach we use to conceptualise mental health and distress influences how we relate/interact with people in distress in:
- clinical practice
- society as a whole (e.g., stigma)
What is a psychiatric diagnosis?
- the act of classifying a disorder
- each disorder category is divided into types and subtypes that are distinct
- a set of criteria which define each diagnosis
- a minimum threshold must be met for someone to fit criteria for diagnosis
e. g., minimum number of symptoms, time frame, change in daily functioning
What are the 2 most common classification system in psychiatry?
ICD - 11
DSM - 5
What is the ICD - 11?
published by WHO, used by NHS
can be accessed online and is free to use
contains codes for all physical diseases, illnesses, MH problems but is also descriptive e.g., bitten by crocodile
What is the DSM - 5?
published by APA, can purchase online
lists all currently recognised mental disorders (157) and their characteristic symptoms needed for a diagnosis
mainly used in US
first published in 1952
What are the uses of a psychiatric diagnosis for health services and clinicians?
facilitating clinical assessment (mainly psychiatrists) communication shorthand guiding treatment decisions organising mental health services research
What are the uses of psychiatric diagnosis for individuals?
gives name to difficulties
allows individuals to look it up online
offers meaning, understanding, relief and explanation
facilitates communication with and understanding from others
provides access to care and support e.g., benefits
facilitates process of finding and forming support groups (peer/carer)
What was the Rosenhan experiment?
8 pseudo-patients gained access to 12 psychiatric hospitals by faking the same single symptoms of hearing a voice saying “dull, empty, thud”
were admitted with Sz and then acted normal but weren’t allowed to leave for between 8-52 days
Discharged with “remitted paranoid Sz” - diagnostic labels stick
Patients in hospital weren’t treated - staff more like babysitters
follow up study - hospitals asked Rosenhan to send more pseudo patients, identified 41/193 as pseudo-patients but no one was ever sent
Is the DSM reliable? (inter-rater reliability)
no
field tests for DSM-5 diagnoses were conducted using professionals with reliability being determined using a kappa statistic (measure of agreement from -1 to 1)
originally found many diagnoses present unreliable kappa values so changed to boundaries to make them reliable to the extent were it barely exceed the level of agreement you might get by pure chance (0)
Are diagnostic categories valid? (measuring what they mean to)
Research suggests that specific diagnoses aren’t the best predictor of outcomes under circumstances
presence and severity of symptoms are more important
Do diagnostic categories have construct validity? (do symptoms of specific psych diagnoses correlate with each other?)
no
e.g., there are at least 3 clusters of Sz symptoms but people have these in different severities or may not have all 3
implications - people receiving some diagnosis have different problems and need different treatments
What is the issue of comorbidity with diagnostic categories?
Comorbidity is the norm
suggests that diagnoses aren’t distinct and separate
raises significant questions about underlying structure and assumptions of classification
Does diagnosis predict treatment response?
different illnesses should respond to different treatments but this is not the case
e.g., Johnstone found that drug response is symptom-specific rather than diagnosis-specific
delusions + hallucinations - neuroleptics
mood difficulties = lithium carbonate
Does the NHS use diagnosis as inclusions criteria?
Mostly no
- services using diagnosis = ED, learning difficulties
- services responding to specific needs/severity (largest) = IAPT services, secure services, crisis team
- services working with specific problems but non-diagnostic = traumatic stress, alcohol + drug misuse, early intervention in psychosis
- services supporting specific life circumstances = military vets, homeless + traveller team, perinatal MH
How is the language used a critique of diagnosis categories?
- language from biomedical model means difficulties are seen as problems belonging within the individual
How is the labelling used a critique of diagnosis categories?
Pathologies normal responses to adverse events e.g., trauma, grief
How is the stigma used a critique of diagnosis categories?
associated with perceptions of dangerousness and unpredictability
fear and desire for social distance
True or false?
psychiatric diagnoses contribute to power imbalances between clients and clinicians
true
as it is the clinicians giving the diagnosis
Do psychiatric diagnosis have an embedded bias for race and culture?
yes - psychiatry = ethnocentric and western
leads to overdiagnosis and greater detention of minority groups compared to white people
Do psychiatric diagnosis have an embedded bias for gender?
yes
women more likely to be diagnosed with BDP - disorder which has been linked to sexual trauma
should see women’s distress as a response to social violence and oppression instead
Do psychiatric diagnoses take context into account? Is this right?
no
but should as context is key
Are adverse life experiences only lead PTSD? Is this recognised in psychiatric categories? What are the implications of this?
no can also lead to anxiety and depression
Trauma is only recognised as a symptom of PTSD
implications - people don’t always receive support and treatment that addresses underlying issues
What are the 2 ways that trauma can be defined?
a distressing reaction - resulting from adverse life experiences that exceeds a person’s ability to cope short and long term
exposure to events and circumstances - experienced as harmful/life threatening - lasting impacts on mental, physical, emotional and/or social well-being
Is trauma due to single or multiple events that occur over time?
both
What are the 6 types of trauma?
Big T - major distressing life event (rape, domestic violence)
Small T - more common events that have potential to negatively affect MH
Childhood trauma type 1 - single events e.g., rape, serious accident
Childhood trauma type 2 - repeated exposure to external events e.g., ongoing sexual abuse
Complex childhood and developmental traumas - e.g., bullying, SA, war, abandonment etc.
Social trauma - e.g., inequality, racism and poverty, historical trauma, legacy trauma e.g., Holocaust, slavery
When are trauma responses more likely to develop?
When they are: repeated/prolonged escape is difficult/ impossible interpersonal multiple or occurring at critical stage of development e.g. during life transitions
What is the neurodevelopmental impact of neglect in childhood?
abnormal brain development following sensory neglect in early childhood
led to smaller than average brain, enlarged ventricles and cortical atrophy
Can children benefit from early removal from sensory neglect?
Yes but the later the removal is left the less beneficial it becomes
by 4 years there is no significant benefit to be found
What are adverse childhood experiences (ACE)
a set of 10 traumatic events occurring before age 18
they increase the risk of adult MH problems and serious disease
5 related to forms of childhood abuse and neglect
5 relate to forms of family dysfunction that increase a child’s exposure to trauma
What are the 10 ACEs?
physical, sexual and psychological abuse
physical and psychological neglect
witnessing domestic abuse
having close family misusing drugs/ alcohol
having close family with MH problems
having close family spend time in prison
parental separation/ divorce on account of relationship breakdown
What did a study find about ACEs and the relationship to serious disease?
experiencing 4 or more ACEs before 18 predicted onset of life threatening diseases e.g., heart failure, diabetes, cancer
strong + cumulative impact
What does the dose-response relationship suggest?
suggests for each increase in the dose of a risk factor, there is a corresponding increase in the probability of developing a certain problem
What is the dose-response relationship important for?
important when trying to establish causal relationships
How does the dose-response relationship link to ACEs?
many studies have shown that greater doses of ACE (>4) lead to a heighted risk of a range of health outcomes
What is the link between ACEs and the likelihood of engaging in health harming behaviours?
if >= 4: 2.5x more likely to engage in sexual risk behaviour and have STIs 5x more likely to use drugs 7x more likely to be addicted to alcohol 12x more likely to attempt suicide
What is the link between ACEs and the likelihood of engaging in health harming behaviours? - UK specific
2x more likely to binge drink and have poor diet
3x more likely to smoke
5x more likely to have sex before 16
6x more likely o have had/ caused unplanned teenage pregnancy
7x more likely to have been involved in violence in past year
11x more likely to have used heroin or been incarcerated
How common are adverse, potentially traumatic life experiences in the UK?
47% reported at least 1 adverse childhood life experience
9% reported four or more adverse childhood life experience
How common are adverse, potentially traumatic life experiences in the Wales?
47% reported at least 1 adverse childhood life experience
13% reported four or more adverse childhood life experiences
ACEs lead to an increased risk of which physical health conditions? (name 5)
physical inactivity and severe obesity ischemic heart disease cancer chronic lung disease skeletal fractures
ACEs and a typical life course?
Uninterrupted, exposure to toxic stress childhood has a cumulative impact = excessive load on the immune + hormonal systems.
Brain adapts to the threat + fear in the environment
Learning at school = impossible due to heightened physiological arousal + hypervigilance to threat.
Coping strategies developed - relieve distress temporarily (eg, smoking, drugs, alcohol) but repeated use = health harming and disease burden increases.
Social problems go hand in hand and with 6 ACEs premature morbidity of 20 years is likely.
What did a meta-analysis find between ACEs and common MH difficulties?
Found strong associations between ACEs and the risk of developing common MH difficulties
Is there a link between ACEs and psychosis?
Yes - increased risk o developing psychosis (3x more likely)
up to 1/3 of cases of psychosis could be attributed to impact of childhood adversities
What evidence is there for a dose-response relationship between childhood trauma and psychosis
People exposed to 1 type of childhood trauma (e.g. sexual abuse) were 2.5 times more likely to have experienced psychosis
People exposed to 5 types of childhood trauma (e.g. sexual abuse, physical abuse, neglect) were 53 times more likely to have experienced psychosis
Is there a link between ACEs and bipolar disorder?
PEOPLE WITH BIPOLAR DISORDER ARE 2.5 TIMES MORE LIKELY THAN ‘CONTROLS’ TO REPORT CHILDOOD ADVERSITIES IN GENERAL
4 TIMES MORE LIKELY TO REPORT CHILDHOOD EMOTIONAL ABUSE
Is there a link between ACEs and BPD?
PEOPLE WITH BORDERLINE PERSONALITY DISORDER ARE 13 TIMES MORE LIKELY THAN ‘CONTROLS’ TO REPORT CHILDOOD ADVERSITIES IN GENERAL
38 TIMES MORE LIKELY TO REPORT CHILDHOOD EMOTIONAL ABUSE
Are individuals belonging to minorities at higher risk of MH difficulties? Give and example and a potential explanation
Yes
Meta-analyses have linked exposure to discrimination to many physical and mental health conditions in these groups
Higher rates of psychosis have been found, likely explained by greater levels of life adversities that members of these groups face in their daily lives
Greater exposure to discrimination may be associated to greater risk for psychosis in a dose-response fashion.
Is social inequality a robust predictor of health and well-being?
Yes
The extent to which wealth and social resources are unequally distributed in given population (e.g. those with a lower social status have less access to them) is correlated with the incidence of many mental health issues
What are the biological impacts of adverse experiences?
Sensitivity to stress
Impact on key brain areas involved in emotion and stress regulation (frontal cortex, amygdala) and memory (hippocampus) etc.
What are the psychological impacts of adverse experiences?
- Negative beliefs about self, others and the world
- Sense of threat
- ‘Maladaptive’ thinking styles (rumination and worry) etc.
What are the social impacts of adverse experiences?
- Difficulties in relationships
- Lack of social support
- Reduced access to opportunities (education, work etc.) etc.
Is trauma a fact of life?
No
Many people exposed to adversities show resilience
Positive life experiences + relationships across the lifespan can buffer the impact of life adversities (i.e., protective factors)
Access to ‘corrective experiences’ can help survivors even after they have developed MH problems as a result to life experiences and circumstances
What is behaviour genetics?
Studies variation among individuals on traits to distinguish a genetic component
Study design involves a measure of heritability
What is heritability?
Proportion of variation between individuals in a population on a given characteristic that is attributed to genetic factors
What are family studies?
Assess the first-degree relatives of an affected individuals for a particular disorder
Compare with prevalence in a control group
What are twin studies?
Look at concordance rates of a MD between Mz and Dz twins
Mz twins share 100% of genes
Dz twins share 50% of genes
What is a concordance rate?
% of cases in which both members of a pair have a particular attribute
What is a heritability estimate?
Derived from comparing Mz and Dz twins’ likelihood of being affected by the same disorder when one twin is affected
What are adoption studies?
A child is either born to a parent with or without a MD and then adopted at/near birth to an unaffected parent
Compare prevalence of disorder in adulthood
Enables disentangling of environment from genetic influence
What was Heston’s adoption study?
Adoptees born to Sz mothers
10.6% of index group compared to 0 of match CG were diagnosed with Sz in later life
What are the 4 limitations of behaviour genetic studies?
- family and twin studies likely to overestimate genetic contributions (non-genetic psychological factors that affect Mz more than Dz twins include being treated more similarly and having similar rates of negative life events)
- unable to consider shared environmental factors
- twin studies involve mostly “Euro-Austro-American” samples
- adoption study designs are methodologically superior but are relatively rare and adoptees are often placed in families resembling the biological family
What are polymorphic genes?
Have different variants that commonly occur in population
More than 1 allele occupies that gene’s position in the chromosome as opposed to just 1 allele
What are molecular genetic association studies?
focus on identified genetic polymorphisms that:
- naturally vary in population - no direct adverse effect on individual
- code for a protein that could be linked to MD
What is a case control design?
Index individual with a specific MD vs. induvial without the specific MD
What is a family based design?
Index individual with specific MD vs. An unaffected sibling
How many genes have been associated with Sz?
128
What did Lee find about gene clusters and MDs?
Common clusters of common gene variants across 8 disorders
Multiple genes of small effects interact together = polygenic
Consistent with the different ways in which a MD can manifest
What are the limitations of Genetic association studies?
- effects are often very small
- many failed replications (false +ves likely due to very large samples, most studies dont consider environmental stress)
- Most DNA data comes from European ancestries
What are brain imaging studies?
suggest differences in structure/function of brain areas between ppts with MD compared to without MD
comparatively heightened/reduced activation in specific brain areas (often when completing a specific task) implicates brain dysfunction
How is the hypothalamus involved in depression?
hypothalamus = small structure at base of brain
regulates hormones and head of hypothalamus-pituitary-adrenal system
Dysregulation/ hyperactivity of HPA axis is well characterised in depression and stress
Involved in many sins of depression e.g., disordered day-night rhythm, lack of reward feelings, disturbed eating, sex and cognition
What is the hypothalamic-pituitary-adrenal system?
Responds to stressors, leading to release of stress hormones e.g., cortisol
How are the frontal lobes involved in depression?
Lower activation and smaller volume associated with major depression (linked with rigid thinking, impulsivity etc.)
How is the hippocampus involved in depression? What did McQueen find?
Links perceptual systems with memory (especially LTM)
Encodes emotional context of events of amygdala
Reduced hippocampal volume, especially if recurrent/ early onset, linked with depression
McQueen - lower hippocampal volume only in multiple episodes (not first time) compared with controls - both depressed groups had poorer recollection memory
How is the Thalamus involved in psychosis?
Critical hub for relaying incoming sensory information for cognition and emotion processing (info stored –> integrated –> edited –> routed)
reduced volume in Sz may explain changes in sensory experience and attribution
young people with psychosis spectrum symptoms also show smaller volume in a specific area of the thalamus
How is the hippocampus involved in psychosis?
Role in memory’s linked with perceptual and context information
Reduced volume in psychosis
Reduced activity linked with visual hallucinations
How is the amygdala involved in psychosis?
Generates emotional responses for senses, especially fear/ anger
Increased hippocampus - amygdala connectivity found in paranoid Sz
Smaller volume linked with psychosis
How are the temporal lobes involved in psychosis?
Processing speech/ sounds, emotions, visual memories
Grey matter density + activation affected in individuals with auditory hallucinations
What are the 2 limitations of brain and biological mechanism underlying MD?
- brain studies do not consider role of environmental factors (possible mediators)
- Group brain differences are relative (dysfunction, abnormalities and anomalies commonly reported in brain imaging studies imply a known absolute threshold)
What are gene by environment (GxE) studies?
- do environmental factors modify the effects of gene polymorphisms that might then be associated with mental disorders? e.g., stress, childhood maltreatment etc.
- tests a stress-diathesis model - MH difficulties are a result of interactions between genetic predisposition vulnerability and stressful events
What did a study find about serotonin and stressful events?
Serotonin transporter gene linked to low mood only when combined with more stressful life events
What are behavioural epigenetic studies?
modification in gene expression (phenotype) rather than the genetic code itself (genotype) as a result of environmental influence
genes are expressed or silenced as a result affecting how the cells read the genes
epigenetic changes in particular biological systems may lead to increased susceptibility to MH difficulties
studies use molecular biological techniques
Who were hippocampal epigenetic “alterations” found among?
maltreated children who were separated from parents
adults who reported childhood traumatic life events
What is a strength of GxE studies?
May fill the gap between high heritability suggested in behaviour genetics studies and the few genetic variants strongly associated with MD
What are 2 limitations of GxE studies?
Research mainly based on mouse studies
a lack of replication and longitudinal findings
What are the 3 types of behaviour genetics studies?
family studies
twin studies
adoption studies
What are the 2 types of genetic association studies?
case control design
family based design
What are the 2 types of brain studies?
functional and structural brain imaging studies
lesion studies
What are the 2 types of Environment shapes brain-biology studies?
Gene-environment interaction studies
Epigenetics
What does a transdiagnostic approach mean?
Across diagnosis
What are 3 issues of the classification system that suggests a transdiagnostic approach instead?
Elevated rates on symptoms not related to a person’s diagnosis
High levels of co-morbidity
Instability of Diagnosis
Where have elevated rates of depression and anxiety been found?
Psychiatric disorders
EDs
Substance abuse disorders
What does elevated rates of symptoms not related to their diagnosis mean?
person is diagnosed with one category but score highly on symptom clusters related to other categories in the classification system
What do studies show about frequency of co-morbidity?
Kessler - 50% of people diagnosed in a given year meet the criteria for multiple disorders
This number varies between 32 - 80% depending on the study
What research is there suggests that diagnoses are unstable?
Only 29% of specific personality disorders are stable over time
30% of Sz diagnoses are unstable
What does instability for diagnosis mean?
Some people recover from diagnosis
Some people shift in their diagnosis over time
A significant proportion of diagnoses that shift/ change over time come from childhood diagnoses –> hard to pin down one specific category
What study found an underlying dimension for psychopathology?
birth cohort study that examined structure of psychopathology taking into account a range of factors
assessed diagnostic symptoms for a range of disorders
Found evidence for one general underlying dimension for developing any and all forms of common psychopathologies –> p factor
p - factor = great life impairment/ childhood maltreatment etc.
explains why it is challenging to find causes, consequences, biomarkers and treatments with specificity to an individual MD
Suggests a transdiagnostic approach
What 3 factors might be transdiagnostic?
Biological - genetic factors e.g., many MD share genetic factor i.e., Sz, BD, ADHD, MD
Social - shared interpersonal factors (e.g., hostility and over criticism from family members) - predicts relapse in BD, Sz, anxiety, depression etc.
Brain Circuity - structurally = grey matter loss converged across diagnosis in 3 regions
- functional patterns = assessing areas of the brain –> active + differentiate people with MD - found overlapping areas across disorders
What 4 brain circuits with different functions were found to be involved in psychopathology? What does this suggest?
frontal-parietal = working memory and performance monitoring
default mode network = ToM and perspective taking
corticolimbic amygdala = threat detection
frontal-striatal = reward, decision making and motivation
Don’t map onto specific disorders - each network is involved in a transdiagnostic model
What are cognitive and behavioural processes? Give 3 examples. How are they found in psychological disorders and what does this suggest?
- patterns of thinking and behaviour that maintain distress e.g., worry, avoidance and selectively attending to a threat in the environment
- these are all elevated across psychological disorders suggesting transdiagnostic factors
What did a literature review of the transdiagnostic model find?
Found 12 different processes that were definitely transdiagnostic
At least 4 disorders showed these processes to be elevated compared to non clinical controls in well designed studies
How can a classification be useful and compared to Darwin’s theory of natural selection?
- people’s diagnoses change over time
- there’s huge individuals differences between people with the same diagnosis
- there’s continuity
- some of these symptoms are actually functional e.g., worry leading to motivation
What symptom is a characteristic of a variety of disorders?
Loss of control and regaining control during recovery
Loss of control = distressing
What are 2 theories considering the role of control?
Cognitive –> focus on individuals’ thinking
Behavioural –> focus on individuals behaviour
Is control essential for sustaining life?
Yes
Does control happen automatically? Give an example
Yes
e.g., regulation of body temperature
What is perceptual control theory?
Explains how control works
Proposes that psychological distress is the loss of control due to unresolved goal conflict –> various reasons for loss of control e.g., injury, war etc.
We have internal standards and we act on our environment to make our experiences reflect these standards
Conflict arises when we are unable to control important areas of our lives (can be intra/inter personal)
This conflict is resolved through shifting and sustaining attention to the source of conflict - requires flexible use of multiple brain networks
What is a clinical application of perceptual control theory?
Method of levels therapy
What is method of levels therapy?
Talking based therapy based on PCT
Directs an individual’s attention towards identifying important goals
Helps individuals identify conflicting goals
Supports individuals in finding solutions to their own problems
What are the 2 main goals of method of levels therapy?
Keep the person talking about the problem
Notice disruptions
What are some distinctive features of method of levels therpay?
Client books appointments and talks about a problem of their choice
therapist = curious, keeps out of the way, has goals but no specific techniques
assumes change happens spontaneously within client
assumes the client knows when they no longer need MoL therpay
What is phenomenology?
the study of lived experience
Why study phenomenology?
informs the content of symptoms of psychiatric disorders
groundwork for building theory
may reveal/ inform how psychological and health interventions work
ensure we are asking the right questions in research
helps to develop and refine questionnaires and other assessment tools
promotes understanding and empathy
places the individual’s experiences at the centre of any intervention
What are the methods to studying phenomenology?
qualitative methods:
- interviews, focus groups etc.
- collect rich and detailed data
- tends to be inductive
What are experts by experience?
people with lived experience of MHD
What basic emotion is low mood linked to?
sadness –> emotional response characterised by feelings of loss, disappointment, disadvantage, grief etc.
What is the adaptive value of low mood?
negative affect signals the presence of unmet important goals, values and needs
motivate the avoidance of actions that might lead to future loss
elicit empathy and comforting behaviour in others, strengthen social bonds
When does low mood become a problem?
when present for a prolonged period of time
when perceived as distressing and uncontrollable
when it causes disruption to social and occupational functioning –> interferes with a person’s goals/values
What affect/ emotional changes occur when depressed?
sadness, guilt, hopelessness
irritability, anger (especially in men)
reduced hedonic capacity –> capacity to feel pleasure
What bodily/ physiological changes occur when depressed?
alteration in sleep, eating, interest in sex etc.
loss of energy
physical complaints e.g., aches and pains
What behavioural changes occur when depressed?
often there are more overt behaviours typically associated with intense sadness e.g., crying
often reduced activity but also restlessness and agitation
What cognitive changes occur when depressed?
negative thought/ beliefs about self, world and future
rumination
memory and concentration difficulties
What psychological theories explain low mood/ depression?
- ) negative triad - a set of negative views about self, world and future that promote and maintain low mood
- ) attributions - internal, stable and global attributional style to make sense of negative life experiences
- ) rumination - compulsively focused attention on the symptoms of one’s distress and possible causes and consequences, as opposed to its solutions
What basic emotion is linked to anxiety?
fear –> emotional response to perceived threat
What is the adaptive value of fear?
worry promotes threat monitoring
essential to survival e.g., fight/flight
When does fear become a problem?
when present for a long period
when it is distressing and uncontrollable
when it disrupts functioning
What affect/ emotional changes occur when anxious?
fear and associated emotions e.g., feeling tense
What bodily/ physiological changes occur when anxious?
sweating, increased HR/ palpitations, increased rate of breathing/ struggling to breathe
dizziness, nausea, trembling, muscular tension, agitation, sleep difficulties
What behavioural changes occur when anxious?
fight/flight, freezing, escape/avoidance, being hypervigilant
What cognitive changes occur when anxious?
fearful/threatening mental images/memories
overestimation of threat and its consequences
underestimation of ability to cope
excessive and uncontrollable “what if” thoughts
What psychological theories explain anxiety?
- ) catastrophic appraisals –> overestimating threat and its consequences
- ) excessive wary and other anticipatory processes
- ) attentional processes –> in particular, selective attention towards threat related information
- ) safety-seeking behaviour and avoidance
When does trauma occur?
After experiencing a negative life event that exceeds a person’s ability to cope
What affect/ emotional changes occur due to trauma?
intense emotions e.g., fear, shame, guilt, disgust
feeling emotionally numb/ detached
What bodily/ physiological changes occur due to trauma?
hyper-arousal, feeling on edge/alert
pain, sweating, nausea, trembling etc.
What behavioural changes occur due to trauma?
avoidance of external reminders e.g., people, places, conversations, activities
difficulty sleeping
irritability and anger
What cognitive changes occur due to trauma?
re-experiencing –> flashbacks, nightmares, negative thoughts about others/ self/ world
concentration difficulties
avoidance
dissociation (detachment)
What psychological theory could explain trauma?
memory accounts –> proposed to explain “re-experiencing” features of trauma related difficulties:
- ) intense emotional distress and other cognitive reactions during traumatic event disrupt normal encoding memory processes
- ) trauma memories = stored in fragmented, de-contextualised way
- ) experience chaotic intrusive memories = vivid and easily triggered by contextual ones that are only loosely associated with the trauma
What are the affect/ emotional changes of mania?
intense elated mood
irritable and agitated mood
What are the bodily/ physiological changes of mania?
decreased need for sleep, increased sense of energy, psychomotor agitation
What are the behavioural changes of mania?
excessive involvement in pleasurable risk-taking activities
pressure of speech
increased goal-directed activity
What are the cognitive changes of mania?
inflated self-esteem/grandiosity
flight of ideas/ racing thoughts
distractibility
How common is hypomania?
35.1% of 148 ppts in a uni sample
How common is mania?
4 - 9% prevalence in general population
0.5 - 1.5% severe enough for a bipolar disorder diagnosis (chronic and high mortality)
How can mania and depression occur?
often co-occur with depression
can be distinct or concurrent episodes
What are 4 ways that depression and bipolar can occur?
unipolar depression
Bipolar I
Bipolar II
Bipolar I - unipolar mania
What are the psychological factors of mania?
- highly unstable and fluctuating self esteem
- conflictual appraisals about mood and internal states –> people with extreme mood swings hold conflictual beliefs about their mood states therefore fuelling swings in mood
What is psychosis?
loss of contact with reality significant changes in: - person's ability to think clearly - telling the difference between reality and inner experiences - changes in the way people behave
What are the 2 types of symptoms of psychosis?
positive and negative symptoms
What are positive symptoms of psychosis? Give some examples
The presence of states and experiences not normally experienced
e.g., hallucinations - sensory perceptions unrelated to outside events –> often auditory
delusions - false belief –> often held with great conviction such as grandiose or paranoid beliefs
- thought disorder - incomprehensive thought patterns evidence by disorganised speech –> e.g., flight of ideas
What are negative symptoms of psychosis? Give some examples
The absence of emotional responses, thought processes and behaviours that are normally present (deficits)
e. g., alogia - poverty of speech
- avolition - lack of motivation
- blunted, flat or reduced affect - inability to express appropriate emotions
- anhedonia - inability to experience pleasure
- asociality - social withdrawal, lack of desire to engage in social interactions/ form relationships
Does psychosis exist on a continuum? Give some examples
yes, on a continuum with normal functioning
e. g., paranoia builds on common worries
- hearing voices –> most people have some level of predisposition
Are auditory hallucinations always negative?
no they can be positive and not inherently distressing
How can psychosis be distressing?
can cause sever distress, disability and mortality
symptoms can interfere with a person’s functioning, life goals etc.
What are the psychological theories of psychosis?
- associated with the emergence of psychotic experiences
e.g., hallucinations = source of monitoring bias
delusions/ paranoia = ToM difficulties, jumping to conclusions biases, attributional style
psychosocial factors = stressful life, trauma, inequality etc. - associated with distress
e.g., negative beliefs about self and world often from powerlessness and victimisation
negative, threatening appraisal of psychotic experiences
What are the psychological theories of psychosis?
- associated with the emergence of psychotic experiences
e.g., hallucinations = source of monitoring bias
delusions/ paranoia = ToM difficulties, jumping to conclusions biases, attributional style
What is personality?
collection of enduring behavioural and psychological traits that distinguish us as humans
What are personality difficulties?
maladaptive and enduring patterns of behaviour, thought, inner experience etc. exhibited across many contexts –> differ from those socially accepted
What 2 areas are personality disorders most evident?
- expression and self-regulation of distressing emotions
- interpersonal relationships
What are some common experiences of personality disorders?
intense and overwhelming negative feelings
difficulties in managing overwhelming feelings –> may SH or abuse substances to cope
difficulties in maintaining stable and close relationships
What is the prevalence of personality disorders in the UK population?
4 - 5 %
What are some stigmas associated with personality disorders?
negative reaction from MH professionals who except to have negative reactions
seen as untreatable, manipulative and attention seeking
What are the psychological theories of personality disorders?
- attachment –> attachment styles determine effective emotional self-regulation with insecure attachment styles being linked
- emotional neglect, dismissing family environment, adverse early life experiences
What are the 2 types of models for how psychiatric drugs work?
Disease-centred model
Drug-centred model
What is the disease centred model?
drugs are correcting a defective brain or chemical imbalance
drugs make brain more “normal”:
- reverses underlying imbalance/ abnormality
- names of psychiatric drugs reinforce this
What is the drug centred model?
all psychoactive drugs alter functioning of NS
create abnormal brain state –> superimposes onto manifestations of distress
drugs don’t specifically and uniquely target psychiatric symptoms
What are the 2 types of drug therapies?
- ) Agnostic drugs
2. ) Antagonists drugs
What are agnostic drugs?
increase the action of the neurotransmitter by increasing its availability by:
- preventing reuptake at synapses
- preventing degradation within synaptic cleft
- replacing low levels of neurotransmitter with pharmacological equivalent
What are antagonists drugs?
inhibit action of neurotransmitter by decreasing its availability or replacing the active transmitter with an inert chemical
What is the goal or drug therapies?
Modify levels of neurotransmitters believed to be involved in symptoms
What are the 6 main groups of psychiatric medications?
depressants –> reduce arousal and stimulation
stimulants –> induce temporary improvements in mental and physical functions
antidepressants
antipsychotics
mood stabilisers
anxiolytics
How do antidepressants work?
Work by correcting deficiency of neurotransmitters thought to underlie depressive symptoms (e.g., noradrenaline, serotonin)
What are antidepressants recommended for?
Moderate to sevre depression
What is a type of antidepressant and how do they work? Give some examples
SSRIs e.g., fluoxetine, citalopram
block the reuptake of serotonin by limiting re-absorption in the pre-synaptic cell, therefore increasing levels of neurotransmitters in the synaptic cleft
What are some effects of SSRIs?
adverse side effects e.g., increased suicidality in under 25s
withdrawal effects e.g., anxiety, irritability, flu-like symptoms, insomnia, nausea etc.
56% report withdrawal effects
46% describe the withdrawal effects as severe
What is the dopamine hypothesis of Sz?
abnormal dopamine functioning
increased dopamine receptor sites (D2 receptors) on post-synaptic terminal lead to patients being supersensitive to normal levels of dopamine
What do antipsychotics do?
can reduce impact of psychotic symptoms but people continue to experience distressing symptoms despite medication
What are some side effects of antipsychotics?
- Block D2 receptors reducing dopamine signalling –> reduce activity in basal ganglia (controls movement and influences thought, emotion and motivation)
- Parkinsonian symptoms –> stiffness in arms and legs, flat facial expressions
- Tardive dyskinesia –> repetitive, involuntary, purposeless movements
What are some side effects of atypical antipsychotics? Give some examples of atypical antipsychotics
e.g., clozapine, olanzapine, quetiapine
increase appetite/ weight gain
What are some criticisms of drug therapies?
- ) distressing side effects and decreased life expectancy
- ) many patients are over medicated
- ) withdrawal symptoms and relapse following drug discontinuation
- ) patients are offered no alternatives other than taking drugs (Sz especially)
- ) little evidence for disease-centred model –> no evidence for specific abnormalities or that specific drugs work better for specific disorders
- ) temporary fix, not a cure –> may act as a barrier to addressing other factors involved in maintenance of MHD (e.g., interpersonal difficulties, trauma)
What does electroconvulsive therapy (ECT) involve?
involves brief discharge of electric current through brain
aim of inducing controlled epileptic convulsion
ppt used to be fully conscious but is now done using general anaesthetic and muscle relaxants
done over a course (usually between 6 -12 sessions)
What is the use of electroconvulsive therapy (ECT)?
not widely used –> mostly used on women and over 60s
treatment for resistant depression, mania, catatonia with strong likelihood of suicide
What is the evidence for electroconvulsive therapy (ECT)?
- anecdotal evidence
- NICE –> concludes that it is effective in certain groups however there is still a number of uncertainties e.g., long term outcomes
- review of 5 meta-analysis on ECT found they were all based on 11 poor quality studies all conducted pre 1986
- no evidence ECT prevents suicide
why is electroconvulsive therapy (ECT) controversial?
- 1/3 of ppts are given ECT without consent
- adverse effects e.g., permanent memory loss, major cardiac events
- mechanism involved is still unknown –> assumed to be serotonin sensitivity in post-synaptic neurons)
What are psychological interventions?
- non-pharmacological interventions focused on psychological/ social factors
- improves symptoms, functioning, quality of life and social inclusion
- used to help with MHD
What does psychotherapy translate to?
heal soul
What is the modern use of psychotherapies?
talking therapies aiming to relieve distress
What does psychotherapy involve?
verbal communication between therapist and client
can also include drama, music, art
How many different treatment models and techniques are there for MH?
between 250 - 1000
What are the main psychological therpaies?
behavioural cognitive psychodynamic humanistic systematic motivational social and environmental
What is the do no harm rule?
1st rule of therapy as 10% of clients come out of therapy feeling worse than when they entered
psychologists follow ethical principles and code of conduct
Psychology is regulated by the Health and Care Professionals Council (HCPC)
Who is a key figure in psychoanalysis?
Freud
What is the principles of psychoanalysis?
- conscious thoughts, feelings and beliefs are determined by unconscious mental dynamics
- psychological distress occurs when unconscious thoughts etc. are blocked from consciousness
- symptoms are manifestations of unconscious processes
- distress is resolved by bringing unconscious conflicts into awareness
What does psychoanalysis aim to do?
bring unconscious material into the conscious mind
Is psychoanalysis time limited?
no it is opened ended so there is no time limit to the number of sessions
How does change take place in psychoanalysis?
change is facilitated through access to and interpretation of unconscious material
What techniques does psychoanalysis used?
- ) free association –> say what comes to mind
- ) interpretation of dreams –> provides access to unconscious material for interpretation
- ) transference –> the “echo” of past relationships in current relationships
What theory is psychoanalysis grounded in?
Freud’s psychodynamic theory
Is psychodynamic therapy available on the NHS?
a short term therapy is available that has 16 sessions
used for depression (with a long term condition) but i not widely available
What are humanistic and existential therapies?
- more holistic
- less focus on pathology, past experiences and environmental influences
- more focus on the positive side of human nature
Who are key figures in humanism and what was their contributions?
Maslow’s hierarchy of needs and motivations
Rogers’ person-centred approach
What theory is person-centred therapy grounded in?
grounded in humanistic and existential theory –> quest for meaning is central to our lives
When does distress occur according to person-centred therapy?
psychological distress occurs when our tendencies towards individuality are stopped by conventions of society/ conduct of others
What is the person-centred approach to therapy?
- non-directive therapy
- aim to provide safe and accepting env. so client can voice suppressed feelings
- aim to rekindle in-built self-confidence
- Rogers asks what conditions a therapist needs to offer to foster the client’s capacity to grow
- being not doing
What conditions enable growth in person-centred therapy?
- empathy
- congruence –> therapist being genuine
- unconditional positive regard –> accepting and non-judgemental
What theory is behaviour therapy grounded in?
behaviourism
Who are key figures in behaviour therapy?
Wolpe and Eysenck
What does behaviour therapy place focus on
Give an example of a type of therapy
- emphasis on measurements and treatment of observable behaviours e.g., irrational phobias
- no emphasis on thoughts/ feelings
- systematic desensitisation
What is cognitive therapy?
- emphasised that the way people make sense and interpret events is important
What does cognitive therapy believe distress is caused by?
distress occurs as a result of how we interpret/ make sense of what happens to us
Who are key figures in cognitive therapy? What did they believe?
Ellis and Beck
- assumed cognitive responses to events determine mood (ABC model)
- MHD are a consequence of irrational thinking etc.
What is the aim of cognitive therapy?
aims to change the way people think
What is the ethos of cognitive therapy?
- focus on conscious mental processes
- client becomes aware of conscious experiences and often change the way they interpret them
- encourages conscious awareness through close questioning, listening and developing shared understanding
Where did CBT come from?
came from a fusion as cognitive and behaviour therapists recognised the limitations of a single approach
How is CBT normally offered?
as 12 sessions (or 6 -8)
sessions cover several stages
What does CBT involve?
- ) collaborative work between client and therapist (equal power)
- ) problem focussed –> client talks about current problems and sets their own goals for therapy
- ) cognitive-behavioural assessment –> therapist questions client about problems (thoughts, feelings, memories, triggers etc.)
- ) both work out a map for how these factors could combine positively or negatively
- ) client encourage to test out new ways of thinking and behaving to see is they are helpful
- ) once difficulties improve, client is encouraged to manage more independently
What evidence is there for psychological interventions?
- ) CBT most research and is recommended for most MHD
- ) studies have shown better resistance to relapse compared to medication
- ) superior to non-psychological interventions
- ) some evidence that CBT is superior to other psychological treatments
- ) meta-analysis suggests CBT is superior to psychodynamic therapies but not others (this is contradicted)
- ) all psychotherapies appear to be equally effective
Why might all psychotherapies appear to be equally effective?
- all approaches aim to change factors that cause distress but these factors vary across the different approaches
- similar in purpose but different in technique
- common factor –> collaborative relationship between client and therapist (varies in importance) - this is an important ingredient but not the only one
