psychopathology Flashcards
statistical infrequency AO1
when an individual has a less common characteristic than most of the population, behaviour is less frequent in society.
deviation from social norm AO1
any behaviour which differs from that which society expects as abnormal.
failure to function adequately AO1
abnormality judged as inability to deal with the demands of everyday living failure to maintain basic nutrition, hygiene, relationships, employment.
deviation from ideal mental health AO1
defines abnormality as the absence of signs of good mental health.
definitions of abnormality AO1
statistical infrequency
deviation from social norms
failure to function adequately
deviation from ideal mental health.
what were Rosenhan & Seligman (1989) proposed signs for failure to function adequately AO1
not conforming to interpersonal rules (eye contact, personal space)
experience of severe personal distress
behaviour is irrational or dangerous to themselves/others.
Jahoda (1958) criteria for the ideal mental health AO1
- accurate perception of reality
- positive attitude to him/herself (good self esteem and of lack guilt)
- self actualisation - reach potential
- resistance to stress
- environmental mastery
- be independent of other people (autonomy)
statistical infrequency AO3 limitation
many abnormal behaviours are desirable
very few people have an IQ over 150 yet having such an IQ is not desirable, there are some common behaviours that are seen to be undesirable.
experiencing depression is relatively common but the disorder is considered abnormal and undesirable.
we are unable to distinguish between desirable and undesirable behaviours.
statistical infrequency AO3 strength
it is an appropriate measure in certain circumstances.
IQ is measured in terms of normal distribution for those who are two or more standard deviation below the mean.
this means this definition has real life applications as it is used as a real measure for certain behaviours.
this increases the validity of the definition in using it as a measure to define abnormality.
deviation from social norms AO3 limitation
social norms chance across time periods and therefore it is not consistent across time.
homosexuality is today socially acceptable in most western cultures but in the past, it was a classification in the DSM and even illegal.
whether somebody is defined as abnormal is then dependent upon the prevailing social morals and attitudes.
this can then produce inconsistent results across history meaning the measure lacks temporal validity.
deviation from social norms AO3 strength
can be useful for clinical practice
key defining characteristic of antisocial personality disorder is the failure to conform to culturally acceptable ethical standards.
deviation from social norms is also helpful in diagnosing schizotypal personality disorder involving strange beliefs and behaviours.
this means that deviation from social norms is useful in psychiatric diagnosis.
failure to function adequately AO3 limitation
requires an objective judgement of a way of life
some may not be having a job as a failure to function adequately but others of an alternative lifestyle may disagree. those who enjoy extreme sports may also be seen to be behaving in a maladaptive way.
if we treat these as failures of adequate functioning, we may be limiting personal freedom and discriminating minority groups.
this poses a challenge for this definition of abnormality because it may depend on who is making the judgement rather than the behaviour itself.
failure to function adequately AO3 strength
it does take into account the patients subjective perspective
it allows us to view the mental disorder from the point of view of the person experiencing it.
it is also relatively easy to judge objectively because we can list behaviours (eg. can dress self, prepare meals etc.) and check whether a person is functioning.
therefore if treatment and support is required it can be specific to the patients individual needs.
deviation from ideal mental health AO3 limitation
it sets high standards for mental health which may be unacheivable for most people
few people achieve full ‘self actualisation’. it is hard to even be sure what this is for each person. therefore this definition says a large number of people have aspects of abnormality.
furthermore the criteria are quite difficult to measure for example how east is it to assess whether someone has the capacity for personal growth.
therefore it could be argued that this definition is not usable when it comes to defining abnormality but may be better within the field of positive psychology at criteria to strive for.
deviation from ideal mental health AO3 strength
it is highly comprehensive
jahodas concept included a wide range of criteria and covers most of the reasons people seek mental health
this allows mental health to be discussed meaningfully with a range of professional with different theoretical views. eg. psychiatrist or CBT therapist
this means that ideal mental health provides a checklist against which we can assess and discuss psychological issues.
cultural relativism, AO1
the idea that one can judge behaviour properly unless it is viewed in the cultural context from which it originated.
what can a lack of cultural relativism result in
the norms of the home culture being used to assess the behaviour of individuals from another culture - this is an example of ethnocentrism.
3 examples of cultural relativism
- in the 1930s single mothers could be committed to psychiatric units
- in australia in the early 1970s homosexuals were given electric shocks to cure them of their illness
- in chins people fear the wind as it is beloved by some to carry negative energy (yin)
limitation of the 4 definitions of abnormailty
it does not consider cultural relativism.
what are the 2 diagnostic manuals most commonly used in psychiatry
DSM and ICD
diagnostic statistical manual
international statistical classification of diseases.
what are the 3 categories of symptoms that you need to be aware of
emotional - feelings
behavioural - actions
cognitive - thoughts
definition of a phobia
persistent irrational fear that is disruptive to everyday life which is consistently either strenuously avoided or endured with marked distress
eg. arachnophobia
what are the 3 categories of phobias recognised by DSM - 5
Specific phobia - phobia of an object such as an animal or body part or a situation such as flying or having an injection
Social phobia – phobia of a social situation, such as public speaking or using a public toilet
agoraphobia – phobia of being outside or in a public place
what are the diagnostic criteria for phobias for DSM - 5
more than 6 months; intensity, distress
presence of the emotional, behavioural, and cognitive responses is almost always triggered in response to the phobic stimulus for a period of 6 months or more.
the emotional symptoms associated with phobias
anxiety – by definition phobias involve the emotional response of anxiety: high arousal
fear – immediate and unpleasant response when we encounter or think about a phobic stimulus
unreasonable – disproportionate to any threat posed
the behavioural symptoms associated with phobias
panic – phobic people experience panic which can cause shortness of breath, shaking, and high heart rates.
avoidance – they show effort to avoid the phobic stimulus (which can affect their daily life, eg. Reducing amount of sleep)
.
endurance – occurs when the person chooses to remain in the presence of the phobic stimulus eg. A person with arachnophobia remaining in a room with a spider I keep an eye on it, rather than leaving.
cognitive symptoms associated with phobias
selective attention – person finds it hard to look away from the phobic stimulus
irrational beliefs – the phobic person does not respond to evidence eg. Finding out that flying is less dangerous than driving does not reduce the phobia.
cognitive distortions – thoughts about the phobic stimulus are distorted eg. Someone with arachnophobia sees them as bigger than they really are.
definition of depression
persistent sadness and lack of interest in pleasure
can disturb sleep and appetite tiredness and poor concentration are common
4 categories of depression recognised by DSM - 5
major depressive – severe, but often short-term depression.
persistent depressive – long term or recurring depression, including sustained major depression
disruptive mood dysregulation – childhood temper tantrums.
premenstrual dysphoric – disruption to mood prior to and/or during menstruation
specific phobia
phobia of an object such as an animal or body part or a situation such as flying or having an injection
social phobia
phobia of a social situation such as public speaking or using a public toilet
agoraphobia
phobia of being outside or in a public place
anxiety
by definition phobias involve the emotional response of anxiety : high arousal
fear
immediate and unpleasant response when we encounter or think about a phobic stimulus
unreasonable (phobias)
disproportionate to any threat posed
panic (phobias)
phobic people experience panic which can cause shortness of breath shaking and high heart rates.
avoidance of phobias
they show effort to avoid the phobic stimulus which can affect their every day life
endurance in phobias
occurs when the person chooses to remain in the presence of the phobic stimulus
selective attention (phobias)
person finds it hard to look away from the phobic stimulus
irrational beliefs in phobiasn
the phobic person does not respond to evidence
eg finding out that flying is less dangerous than driving doesn’t reduce the phobia
cognitive distortions (phobias)
thoughts about the phobic stimulus are distorted
eg someone sees them as bigger than what they are (arachnophobia)
major depressive
sever but often short term depression
persistent depressive
long term or recurring depression including sustained major depression
disruptive mood regulation (depression)
childhood temper tantrums
premenstrual dysphoric (depression)
disruption to mood prior to and/or during menstruation
what are the diagnostic criteria for depression for DSM - 5
5 symptoms every day, 2 weeks.
Depressed mood most of the day, nearly every day, anhedonia, and at least 5 of the listed symptoms persisting for at least 2 weeks.
emotional symptoms associated with depression
Low mood - this can include feeling ‘empty’ and ‘worthless’ or ‘hopeless’
Anhedonia – loss of interest or pleasure in hobbies and activities that were once enjoyed; may be accompanied by abolition (loss of motivation to perform goal-directed activities)
Anger – directed towards others or self – this comes from the general feeling of being emotionally hurt.
Low self esteem – low perception of self; can lead to self-loathing.
low mood (depression)
this can include feeling empty and worthless or hopeless
anhedonia (depression)
loss of interest or pleasure in hobbies and activities that were once enjoyed , may be accompanied by abolition (loss of motivation to perform goal directed activities)
anger (depression)
directed towards others or self this comes from the general feeling of being emotionally hurt
low self esteem (depression)
low perception of self can lead to self loathing
behavioural symptoms associated with depression
Low activity level – therefore sufferers show a sense of tiredness, desire to sleep and lower activity can be opposite psychomotor agitation.
disrupted sleep
disrupted eating – eat more or less
aggression/self harm – increased irritability; can become verbally or physically aggressive; can lead to ending a job or relationship; self harm can result in cutting or suicide attempts.
cognitive symptoms associated with depression
poor concentration – suffered cannot focus on a test as much as normal and find it difficult to make decisions
attention to the negative – these include negative self-beliefs such as guilt and a sense of worthlessness
abolutist thinking – see things as ‘black and white – can catastrophise situations, seeing something unfortunate as an absolute disaster.
memory bias – sufferers show cognitive bias of remembering unhappy events more easily.
definition of OCD
obsessive thought and compulsive behaviours
4 categories of OCD recognised by DSM - 5
OCD – obsessive, recurring thoughts, images, and or compulsions (repetitive behaviours, such as hand washing; most patients with OCD have both symptoms
Trichotillomania – compulsive hair-pulling
Hoarding – compulsive gathering of possessions and the inability to part with anything, regardless of value.
Excoriation – compulsive skin picking
diagnostic criteria for OCD afro DSM - 5
more than an hour a day ;distress
emotional symptoms associated with OCD
Anxiety and distress – obsessive thoughts are intrusive and frightening. The urge to compulsively repeat behaviour also produces anxiety.
Depression- OCD is often accompanied by depression; compulsive behaviour can bring relief, but is short term only
Guilt/disgust – OCD sufferers are often aware that their obsessive thoughts are irrstional and that their compulsive behaviours are abnormal. Alternatively, they can suffer guilt over minor moral issues. Disgust may be direct towards the self, or externally, like dirt.
behavioural symptoms associated with OCD
Repetitive Compulsive behaviours: Sufferers feel compelled to act on their obsessive thoughts with repetitive behaviours acts, called compulsions, such as handwashing. Other examples: praying, counting, tidying, ordering groups of objects. These behavoiurs are repetitive, unpleasant, and interfere with daily life.
- Compulsions reduce anxiety: compulsive behaviours often performed to reduce anxiety caused by obsessions, eg compulsive handwashing in response to obsessive fear of germs; compulsive checking (eg that a door is locked, or appliance switched off), in response to the obsessive thought that it might have been left unsecured
- Avoidance: Sufferers may attempt to avoid situations which trigger obsessions and compulsions, e.g. avoiding obsessive thoughts about germs by not emptying their bin
cognitive symptoms associated with OCD
Obsessive thoughts: obsessions are intrusive/recurring/unwanted thoughts. 90% of OCD sufferers experience obsessive thoughts. Examples: Thoughts about dirt in the environment leading to being contaminated. Worrying that the front door isn’t locked even though it’s been checked. These thoughts are repetitive, unpleasant, and interfere with daily life. Theyare present on most
days, for a period of 2 weeks or more
- Hypervigilance: selective attending and increased awareness of source of obsession in new situations
- Sufferer is aware these obsessive thoughts are irrational: OCD sufferers are aware that their cognitions are irrational. Despite this they maintain constant alertness and focus on potential hazards.
- Cognitive coping strategies: eg a religious person tormented by guilt may respond by praying or meditating, which helps manage anxiety, but can become a distraction
what is the behavioural approach
Behaviourism is a theory of learning which states all behaviours are learned through interaction with the environment through a process called conditioning.
Behaviour is simply a response to environmental stimuli.
what is classical conditioning
learning through association
who researched classical conditioning
Pavlovs dogs
Watsons little albert
how did Pavlov research CC
UCS (food)
UCR (salivation)
NS (bell)
CS (bell after conditioning)
CR (salivation after conditioning from the bell)
operant conditioning
learning through consequences
research associated with operant conditioning
Skinners
skinners box
positive reinforcement -behaviour that is rewarded is repeated
negative reinforcement - behaviour that avoids an unpleasant stimulus is repeated
punishment - a behaviour that results in an unpleasant outcome will not be repeated.
what is Mowrers 2 process model
1960
- Phobias are acquired or initiated through classical conditioning
- Phobias are maintained or continued through operant conditioning.
Explains avoidance behaviour but not phobic cognitions.
how are phobias initiated
According to the behavioural approach a phobia is acquired through learning an association.
how are phobias maintained
operant conditioning which takes place when behaviour is reinforced.
little albert study
- Little Albert – Watson and Rayner (1920). The most famous case of conditioning a phobic response.
- He was conditioned to associate a white rat with a feared response.
- This phobia was then generalized to other furry white objects. Little Albert showed anxiety when exposed to a fur coat, cotton wool and Watson wearing a Santa clause beard.
strength of the behavioural approach as an explanation of phobias
there is supportive empirical case study evidence.
watson and rayner - little albert
supports CC as little albert has no phobias before the experiment
increases the validity of the theory that phobias are learnt and not innate.
strength of the two process model (De Jongh)
is evidence for a link between bad experiences and phobias
De Jongh (2006) found that 73 % of dental phobias had experienced a trauma
control group with low dental anxiety - 21% had experienced a traumatic event
supports the proposal that the association between stimulus and response can lead to a phobia
strength that of the two process model
real world applications in exposure therapies (such as systematic desensitisation)
once avoidance behaviour is prevented it ceases to be reinforced by the reduction of anxiety
avoidance therefore declines - avoidance prevented phobia cured
shows value of 2 process model - identifies a means of treating phobias
limitation of the behavioural approach to explaining phobias (bounton & seligman)
it does not offer a complete explanation of phobias.
Bounton (2007) highlights that evolutionary factors could play a role in phobias - especially i’d the stimulus could have caused pain or death to our ancestors. suggests that phobias are not learnt and are innate as phobias acted as survival mechanism for ancestors.
biological preparedness (seligman 1971) casts doubt on the 2 process model
limitation of the behavioural explanation for development of phobias
it ignores the role of cognition (thinking)
cognitivists argue that phobias develop as a result of irrational thinking not just learning.
CBT is suggested to be a more successful treatment than the behavioursit treatments
challenged the validity of the behavioural explanation and suggest that the cognitive explanation of phobias may be a more appropriate one.
both behavioural treatments are based on which principle
counter conditioning - a new response to the phobia stimulus is learned by pairing with relaxation instead of anxiety
systematic desensitisation basis
classical conditioning
reciprocal inhibition
fear and relaxation cannot coexist
3 steps of systematic desensitisation
anxiety hierarchy
relaxation
gradual exposure
anxiety hierarchy in systematic desensitisation
SD involves the client and the therapist designing a list of hierarchy of frightening/stressful events or objects. It is important to give examples in exam questions (and relate to scenario of present)
relaxation in SD
the client is then taught deep muscle relaxation.
- it is impossible to experience fear me be relaxed at the same time (reciprocal inhibition)
- involves breathing exercises, meditation or mental imagery.
- can also involve drugs, such as valium, or hypnosis.
gradual exposure is SD
the therapist helps the client to work their way up the hierarchy while maintaining this deep relaxation
stages of SD
Stage 1 – SD based on CC procedure. Fear is replaced with relaxation
Stage 2 – SD gradually increases exposure to feared stimulus so it becomes more familiar
Stage 3 – exposure is through an anxiety hierarchy – least to most fearful – give examples
Stage 4- the client learns relaxation techniques to practice at each stage of hierarchy. This must be achieved before they move onto the next stage.
Stage 5 – fear and relaxation cannot coexist – reciprocal inhibition. Client achieves relaxation at last stage of the hierarchy then phobia is extinguished.
at each stage if the client becomes upset they can return to an earlier stage and regain their relaxed state.
how is flooding different from SD in terms of exposure
It also involves exposing phobia patients to their fear but without gradual build up in an anxiety hierarchy. Instead flooding involves immediate exposure to a very frightening situation to prevent avoidance.
what does flooding stop patients from doing
prevents avoidance behaviour, so the patient quickly. Learns that the phobic stimulus is harmless. In classical conditioning terms this process is called extinction.
how many sessions are needed for flooding phobias
Flooding sessions are typically longer than SD, with one session usually lasting two to three hours. Sometimes only one long session is needed to cure a phobia.
how does flooding work for treating phobias
A learned response is extinguished when the CS (eg. Dog) is encountered without the learnt response of fear (CR) as the association with the UCS has been broken.
The result is that the CS no longer produces the CR (fear)
In some cases the patient may achieve relaxation simply because they become exhausted by their fear response due to the immediate exposure.
a strength of SD as a treatment for phobias
(McGrath et al. & Gilroy et al. )
is that it has supportive evidence to demonstrate its effectiveness.
McGrath et al. (1990) reported that 75% of patients with phobias responded to the SD.
Gilroy et al. (1990) examines 42 patients with arachnophobia using 3x45 min sessions and found reduced fear 33months layer compared to a control group of relaxation techniques only.
increases the validity of the treatment as a way to overcome phobias.
strength of SD compared to flooding is
that it is often preferred as treatment for phobias by patients
because it does not cause the same levels of distress that can occur when presented with the fear
considered a more appropriate treatment for individuals who may suffer from severe anxiety disorders
SD may be seen as more ethical
a strength of SD is that
(learning disabilities)
it can be used to help people who may not be able to access other treatments such as patients with learning difficulties.
people with learning disabilities often struggle with cognitive therapies that require complex rational thoughts.
they may also feel confused and distressed by the traumatic experience of flooding
SD is often most appropriate treatment for those with learning disabilities.
a strength of SD is that
(VR)
it can be used in conjunction with VR rather than in person in a real world setting
however there is some evidence to suggest that VR exposure may be less effective than real exposure for social phobias because it lacks realism (Wescler et al 2019)
VR may be suitable for some but not all phobias
a limitation is that SD is not effective in treating all phobias
patients with phobias which have not been developed through CC are not effectively treated using SD so phobia has not been learnt and therefore can’t be unlearnt.
certain phobias have an evolutionary survival benefit -not result of learning
a strength of flooding as a treatment of phobias is that
(ougrin)
it is at least as effective as other treatments for specific phobias but more cost effective.
Ougrin (2011) compared flooding to cognitive therapies and found that flooding is highly effective and quicker than alternative.
implication for the economy as it could reduce the financial burden in the NHS by offering a quicker cheaper treatment
limitation of flooding
(schumacher 2015)
it is not appropriate for all patients due to how traumatic it can be.
Schumacher 2015 found that patients and therapists rated flooding as significantly more stressful than SD. patients often unwilling to see it through to the end as it can be extremely distressing.
intensity of the experience can lead to high attrition rates (people that drop out) and can make phobias worse if not completed.
individual difference can be a limitation of how effective flooding can be.
how does the behavioural approach to treatment of phobias link to reductionism
- The behavioral explanation may be overly simplistic in reducing complex behaviour down to a simple S-R association.
- Ignores the role of cognition: phobias may be due to irrational thinking.
Positive thing – want the simplest explanation that explains the most information
But can lose information as information is cut down
Ignores the role of cognition so the conditioning could be insignificant as it wasn’t a conditioned response in the first place.
how does the behavioural approach to treatment of phobias link to determinism
- The behavioural explanation ignores the role of free will in the formation of phobias, implying environmental determinism.
- Not every person bitten by a dog develops a phobia of dogs, so other processes must be at play.
Not everyone develops phobias the same way so it is more deterministic as it’s not all down to free will
how does the behavioursit approach to treatment of phobias link to nomothetic vs idiopathic
- The behavioural approach suggests a nomothetic approach, implying universal laws.
- But if individual cognition plays a part, a more idiographic approach may be preferred.
cognitive theories of depression state what is the cause of depression
The cognitive approach links psychological disorders such as depression to cognitive distortions. This is dysfunctional or irrational thinking.
Beck (1967) negative triad
Automatic faulty information processing -> cognitive biases
* Overgeneralisation
* Absolutist thinking
* Catastrophizing
Negative schemas
Cognitive triad
* One self
* The future
* the world
what 3 biases does faulty information processing lead to
overgeneralisation
absolutist thinking
catastrophising
what can produce cognitive biases
People with depression attend to the negative aspects of a situation and ignore positives, and tend towards ‘black and white’ thinking.
This is automatic and can produce cognitive biases.
overgeneralisation
holding extreme beliefs on the basis of a single incident and plying it to a different and inappropriate situation. Eg. A depressed woman has relationship problems with her boss so may believe she is a failure in all other types of relationships.
absolutist thinking
an ‘all-or-nothing’ ‘good or bad’ and ‘either-or’ approach to viewing the world. Eg. At one extreme, a woman who perceives herself as perfect and immune from making mistakes, at at the other extreme a woman who believes she is totally incompetent.
catastrophising
where a minor setback becomes exaggerated and viewed as disastrous. Eg. i’ve failed one end of unit tests and therefore I am never going to study at university or get a job.
what is a schema
a shortcut
A cognitive framework or mental representations of knowledge which helps us interpret the world.
They can be used to navigate a complex world.
Often leads to oversimplification which causes errors.
Develop during childhood.
3 examples of negative schema
- An ineptness schema, which makes sufferers expect to fail.
- A self blame schema that makes them feel responsible for any misfortunes.
- A negative self evaluation schema that constantly reminds them of their worthlessness
what is the cognitive triad
negative views about the world about oneself and the world
For sufferers of depression these thoughts occur automatically and are symptomatic of depressed people.
Ellis (1962) ABC model states that depression is caused bŷ
Ellis developed his model to explain response to negative events – how people react differently to stress and adversity. Ellis suggested that it is through irrational thinking.
Ellis ABC model
Activating events
Beliefs
Consequences
what are activating events (ellis)
An adversity or event to which there is a reaction.
Eg. You pass a friend in the corridor at school and he/she ignores you, despite the fact you said hello.
what is the role of beliefs
The belief or explanation about why the situation occurred, which could either be rational or irrational
- A rational interpretation of the event might be that your friend is very busy and possibly stressed and he/she simply didn’t see or hear you.
- An irrational interpretation of the event might be that your friend dislikes you and never wants to talk to you again.
what is mustabatory thinking
thinking that certain ideas or assumptions must be true in order for an individual to be happy.
Ellis identified the three most important irrational beliefs
- I must be approved of or 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.
An individual who holds such high expectation is bound to be disappointed and is at risk of becoming depressed. In order to treat depression which arises out of negative thinking, such irrational thoughts need to be challenged and turned into more positive beliefs.
what are comsequences in Ellis’model
The feelings and behaviour the belief now causes. in essence the external event is blamed for the unhappiness being experienced.
Eg. ‘I will talk to my friend later and see if he/she is okay’ – rational beliefs
‘I will ignore my friend and delete their mobile number, as they clearly don’t want to talk to me’ – irrational beliefs.
a strength of becks explanation that faulty information processing is linked to depression is that
(Clark and Beck)
there is supportive evidence that this predisposed people to become depressed.
Clark and Beck (1999)’s literature review concluded that these were it only more common in depressed people but preceded symptoms.
supported in a study by Cohen et al. (2019) which tracked 473 adolescents and confirmed that cognitive vulnerability predicted later depression
a strength of becks cognitive model of depression is its application in screening and treatment for depression
(cohen et al. and Gautum)
cohen et al (2019) found that the ability to identify cognitive vulnerability in high risk individuals prior to onset of depressive symptoms, enabled them to be monitored, and offered treatment in the acutely phase of the expression of symptoms
supports the application of CBT which gautum (2020) states that research has consistently found CBT to be one of the most effective treatments by challenging irrational beliefs.
a limitation of the cognitive explanation of depression can be criticised for being reductionist, as it only considers the role of thinking as the cause of depression
argues that depression is caused by thinking in a negative or irrational way eg. mustabatory thinking but doesn’t account for other symptoms as well.
this ignores that biological research has indicated that depression can be as a result of low levels of neurotransmitter serotonin.
can be seen as too simplistic
what is the most commonly used treatment for depression by the NHS
cognitive behavioural therapy (CBT)
what is the cognitive element of CBT
The cognitive element aims to identify irrational and negative thoughts and replace these negative thoughts with more positive ones.
what is the behavioural element of CBt
The behavioural element of CHT encourages patients to test their beliefs through behavioural experiments and homework.
what is the central premise of CBT
Thoughts, feelings and behaviour impact each other, so if an irrational thoughts can be identified it can also change peoples emotions and behaviour.
how is CBT administered
Initial assessment: CBT therapist works with the patient to identify the patients problems.
Goal setting: patient and therapist agree on a set of goals and a plan of action to achieve them.
Identify automatic negative and irrational thoughts in relation to themselves, thei world and their future (becks negative triad) or activating events and beliefs (ellis’ ABC model)
what is patient as scientist
Generating and testing hypotheses about the validity of their irrational thoughts; when they realise their thoughts don’t match reality, this will change their schemas and the irrational thoughts can be discarded, leading to cognitive restructuring.
what is cognitive restructuring
In which perspectives are reframed, leading to a change I feelings and behaviours.
what is thought catching
Patients engage in thought catching:identifying irrational thoughts coming from the negative triad of schemas.
what is behavioural activation
CBT homework may also include behavioural activation – engaging in more active and enjoyable activities (eg sports, socialising, travelling). This is especially important to combat depressive symptoms of isolation and loss of interest.
what is ellis’ ABCDE model
rational emotive behavioural therapy (REBT)
Ellis extended his ABC model of explanation and added 2 stages (ABCDE) of treatment:
Dispute – the therapist asks the client to situate or challenge their irrational thoughts and beliefs as utopianism; often involves a vigorous argument (hallmark of REBT)
Effective new response – at this stage the therapist asks the client to think of more rational thoughts.
what are the types of disputing
Empirical disputing – assessing whether there is evidence for the thought
Logical disputing – assessing whether the thoughts follow from the facts
Pragmatic disputing – assessing if the thought is helpful
what is empirical disputing
assessing whether there is evidence for the thought
what is logical disputing
assessing whether the thoughts follow from the facts
what is pragmatic disputing
assessing if the thought is helpful
a strength of CBT as a treatment for depression is
march et al.
that there is a large body of evidence to support its effectiveness especially in combination with antidepressant treatment
March et al. (2007) examined 327 adolescents with a diagnosis of depression and looked at the effectiveness of CBT, antidepressants and a combination of the both. after 36 weeks 81% of the antidepressant group and 81% of the CHT group had improved, 86% when both were used.
CBt is effective but best together.
limitation of CBT is that it may not be suitable for all patients such as those with learning difficulties.
Sturney
Counterpoint Lewis and Lewis
Sturney 2005 proposed that patients with learning disabilities may not be able to access the complex rational thinking of any form of talking therapy. or patients whose depression is so severe may not be able to motivate themselves to engage with the cognitive work of CBT.
not suitable for everyone.
Lewis and Lewis (2016) contradict this as they found that efficiency of CBT a with appropriate adjustments could be used for patients with learning difficulties.
a limitation of CBT for the treatment of depression is it’s high relapse rates
Ali et al
Ali et al (2017) assessed depression in 439 clients every month for 123 months following a course of CBT. 42% of patients relapse within 6 months and 53% within a year.
no one looked at long term.
could be difficult to maintain as motivation is lost.
lacks prolonged efficiency.
what is a gene
a segment of DNA.
a specific sequence of necleotides and acts as a blueprint for making proteins that influence characteristics, such as eye colour.
what is an allele
sometimes there are variations in the sequence of nucleotides within a gene.
contributes to the variation among humans affecting how genes function.
how do alleles relate to disease vulnerability
depending on the role of the gene these effects can have no effect, be beneficial or can cause harmful biological changes which can lead to various diseases.
what are the two types of twins
fraternal (dizygotic,DZ)
identical (monozygotic, MZ)
how are DZ twins made
2 eggs are released during menstruation
both eggs are fertilised
there are therefore 2 zygotes (fertilised eggs)
they share 50% of their DNA.
how are MZ twins made
1 egg is released during menstruation
the egg is fertilised but shortly afterwards it splits into 2
there are 2 zygotes but they came from 1 zygote
they share 100% of DNA.
what is a neurotransmitter
Brain cells are called neurons (and is influenced by genes)
They communicate in 2 ways:
- Electrical – an electrical signal (the nerve impulse) passes down the body of the neutron to reach an axon terminal, where there is a gap (synapse)
- Chemical- as the electrical signal arrives at the end of the axon terminal of the pre-synaptic neuron, it causes a chemical (a neurotransmitter) to be released across the synapse
- on the other side of the synapse, there are receptors located on the receiving neuron (the post-synaptic neuron)
- the neurotransmitter (eg. Dopamine) binds to post synaptic receptors whose shape fits this neurotransmitter
- this activation of the receptors determines whether the post-synaptic neuron will generate an electrical signal.
GENETIC EXPLANATION
what evidence is there from family studies that OCD has a genetic component?
Nestadt et al. (2000) found that first degree relatives (parents, siblings and children) of OCD sufferers had a higher chance of developing the disorder
- 12% chance for those with first degree relatives diagnosed with OCD
- 3% risk for control groups.
Marini and Stebnick (2012) found that a person with a family member with OCD is around 4 times as likely to develop it as someone without.
Since family members are more closely genetically related, this supports a role for a genetic vulnerability.
GENETIC EXPLANATIONS
which 2 candidate genes have been associated with OCD
COMT gene
SERT gene
these genes produce changes in neurotransmitters in the brain.
how would each candidate gene cause changes relevant to OCD
(COMT)
- there is a mutation of this gene which causes low levels of the enzyme catchecolo-methyltransferase (COMT)
- enzymes break down (metabolise) other molecules, such as neurotransmitters (anything ending in the suffix ‘-ase’ is an enzyme).
- This enzyme therefore regulates the amount of the neurotransmitter dopamine in the brain
- Low levels of the COMT enzyme means less dopamine is broken down, so high levels of dopamine. (higher levels of dopamine are linked to OCD)
Turkel et al. (2013) found that the low activity version of the COMT gene was more common in patients with OCD compared to controls.
how would SERT cause changes relevant to OCD
- The SERT gene creates a protein, called a SERotonin Transporter, which removes serotonin. Transporters detect the amount of neurotransmitter in the synapse, and remove from the synapses after it is released.
- When a mutation of this gene creates too much of the serotonin transporter, serotonin levels go down (because the transporter is removing serotonin from the synapse)
- Ozaki et al. (2003) found two families with the high activity version of the gene (which made too much of the protein) : 6/7 people in these families had OCD. (low serotonin levels are linked to OCD)
what evidence is there that OCD may be polygenic and what does it mean to say that OCD is aetiologically heterogenous.
Polygenic/ Aetiological heterogenous
- OCD is likely to be polygenic (caused by more than one gene) inc. SERT and COMT
- Taylor (2013) found evidence of up to 230 candidate genes – OCD is likely to be polygenic.
- OCD is also aetiologically heterogenous (many causes), meaning different combinations of genes cause different types of OCD aim different people.
- Different combinations can cause OCD eg. One ppt has gene 1,2,3 and another has genes 4,5,6 but both have OCD.
what is the diathesis stress model in relation to OCD
According to the diathesis stress model certain genes leave some people more likely to suffer a mental disorder but it is not certain as some environmental stress is necessary to trigger the condition
Diathesis = genetic vulnerability
Stress = environment
strength of the genetic explanation of OCD is the increased concordance between monozygotic compared to dizygotic twins.
netstadt
E – Netstadt (2010) shows that there is a higher concordance rate (how much the twins have in common with each twin) for OCD in MZ twins (68%) compared to DZ twins (31%)
E – this supports the role of genetics in OCD, since MZ and DZ twins grow up sharing similar environments like food, upbringing and education, and life events like bereavement or parental divorce, so non-genetic factors can be controlled for when comparing MZ and DZ twins.
C – however, increased concordance rates does not necessarily indicate a role of genetics: monozygotic twins may be treated more similarly because they look alike, compared to dizygotic,non-identical twins. Also since the concordance rate was 68% and not 100%, there must be an environmental component to OCD.
L – this suggests that the additional shared FNA in MZ twins may be responsible for the increased concordance rate, but that this evidence should be treated cautiously, and may be best understood as a diathesis stress model, whereby a genetic vulnerability is inherited and triggered by an environmental stressor.
a limitation of the genetic model is that there are also environmental factors.
cromer
E – Cromer et al. (2007) found that over half of the OCD patients in their sample had experienced a traumatic life event, and that OCD was more severe in those, suggesting a diathesis stress model, suggesting a diathesis stress model one or more traumas.
E – this supports the idea that OCD is not entirely genetic in origin, and that environmental factors can also trigger, or increase the risk, of developing OCD.
L – this means that genetic vulnerability only provides a partial explanation for OCD, and may therefore be too reductionist, which limits the validity of this explanation.
a limitation of the genetic model is that there are creditable alternative explanations for the development of OCD, such as the two process model proposed by behavioursits, such that suggests that learning plays a crucial role.
albucher
E – support for this alternative explanation is found in the success of behavioural treatments for OCD where symptoms of patients are improved for 60-90% of adults (Albucher et al. 1998)
E – initial learning of the feared stimulus could occur through classical conditionings associative process where p, for example, dirt is paired with anxiety. This behaviour pattern would be maintained through operant conditioning and negative reinforcement whereby the stimulus is avoided so the anxiety is removed. This could result in an obsession forming which is linked to the development of compulsion eg. Washing of hands, which serves to reduce the anxiety felt.
L - this suggests that the genetic model may only provide a partial explanation for OCD.
NEURAL EXPLANATIONS
how is serotonin involved in OCD.
Serotonin is important for the regulation of mood. It has an overall calming effect in the brain.
Low levels of serotonin means that the brain does not communicate information about mood effectively.
This reduction in functioning seems to be linked to OCD.
Low levels of serotonin have been associated with the symptoms of OCD eg. Anxiety.
Piggot et al. (1990) reported that SSRIs which reduce the uptake of serotonin, and so prolong its action at the synapse, are effective in treating OCD.
NEURAL EXPLANATIONS
how is dopamine involved in OCD.
Dopamine is a neurotransmitter which is important for maintaining interest and motivation.
High levels of dopamine could therefore help to maintain a compulsive environment thought or behaviour, therefore leading to some of the symptom of OCD, in particular, compulsive behaviours.
explain the neural pathway thought to be associated with OCD
- The orbitofrontal cortex is a region which converts sensory information into thoughts and actions.
- PET scans have found higher activity in the orbitofrontal cortex in patients with OCD when, for example, a patient is asked to hold a dirty item with a potential hazard.
- Heightened activity in the orbitofrontal cortex2 may increase the the conversion of sensory information to actions (behaviours) which results in compulsions.
what other brain region has been implicated in OCD and how is it related.
- The basal ganglia is a cluster of neutrons, including the caudate nucleus, at the base of the forebrain, which is involved in multiple processes, including the coordination of movement.
- Patients who suffer head injuries in this region often develop OCD – likel symptoms.
the worry curcuit
- OFC senses ‘worry’ signal to thalamus to report on things which should cause worry eg. A potential germ hazard or a door which might not be locked.
- In normal functioning, the basal ganglia filter out minor worries coming from the OFC, but if this areas is hyperactive, even small worries get to the thalamus, which is then passed back to OFC, forming a loop (recurring obsessive thoughts)
- Repetitive motor functions (compulsions) are an attempt to break this loop. While carrying out the compulsion may give temporary relief, the hyperactive basal ganglia will soon resume the worry curcuit.
what is the parahippocampal gyrus in association with OCD
The Parahippocampal gyrus, an area of cortex close to the hippocampus on the brains underside, is also linked to OCD. It is responsible for regulating and processing unpleasant emotions and has been seen to function abnormally in cases of OCD.
A strength of the neural explanation of the orbito-frontal cortex (OFC) having a role in OCD is that there is supporting empirical evidence from both structural and functional imaging studies.
menzies et al.
E – Menzies et al. (2007) found that OCD sufferers and their family members had reduced grey matter in the key regions of the brain including the oFC. In addition, several neurotic aging studies using PET scanners have shown hyperactivity in the OFC and the caudate nucleus in people with OCD both while scanning the brain at rest and when symptoms ared stimulated.
E – this supports the involvement of the ventral motivation cortico-striata-thalamic curcuit in OCD, also known as the ‘worry curcuit’.
C – however, one problem with this evidence is that it is correlational : researchers cannot be sure if the hyperactivity in these areas is the cause of OCD or a consequence of having OCD. Maia et al. (2008) reviewed evidence from other lines which permitted stronger causal inferences, including the development of OCD following brain injury, paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection, and neurosurgical lesions that attenuate OCD.
L - these findings therefore suggest that there are multiple lines of evidence which support the involvement of the OFC and caudate in OCD, which strengthen the validity of the biological explanation.
A strength of of the neural explanation of OCD is that there is some empirical evidence from the effects of SSRIs that neurotransmitters do play a role.
soomro et al.
E – a meta-analysis by Soomro et al. (2008) demonstrated SSRIs are more effective than placebos, suggesting theirs is serotonergic involvement in OCD
E – these drives are effective at reducing OCD symptoms, and SSRIs work by increasing the levels of this neurotransmitter by blocking the serotonin reuptsje process, the data therefore suggests that serotonin does play a role in OCD.
C – however despite altering levels of serotonin in the synapse within hours, these drugs take weeks to reduce symptoms, and 40% to 60% of patients show no or just partial symptom improvement
L – these findings suggest low levels of serotonin have role to play in OCD but are not the sole cause of OCD
what does SSRI stand for and an example
selective serotonin reuptake inhibitors
common brand names are Prozac (20mg daily dose) and Sertraline.
1st line treatment for OCD.
what levels of serotonin are associated with OCD
Low levels are associated with OCD as well as depression
SSRi increase levels of serotonin in the brain, which regulates mood and anxiety
how do SSRIs work
Serotonin Specific Reuptake Inhibitors (SSRIs) block the reuptake of serotonin so increase its presence in the synapse. (this is thought to reduce symptoms of OCD. )
When serotonin is released into the synapse it will either bind to the receptor or it willl be removed from the synapse by reuptake mechanisms. SSRIs block this reuptake so more serotonin is present in the synapse and can therefore bind with the post synaptic receptors.
what are the 3 alternatives to SSRIs
Tricyclic antidepressants
SNRIs (serotonin and noradrenaline reuptake inhibitors)
Benzodiazepines
what does SNRI stand for and an example
serotonin and noradrenaline reuptake inhibitors.
venlaxafine
Duloxetine
how do SNRIs work
SNRIs (more selectively than tricyclics) block the transporter mechanism that re-absorbs both serotonin and noradrenaline.
There is a lot of evidence that noradrenaline is involved in OCD. When levels are low, a person is unable to focus their attention which may result in anxiety and compulsions.
Although low noradrenaline may not necessarily cause OCD, preventing reuptake of this neurotransmitter has been associated with relief of symptoms and anxiety.
2nd line treatment for those non-responsive to SSRIs.
give an example of a tricyclic antidepressant
Clomipramime -older type of antidepressant, the first medication approved for OCD.
how do tricyclic antidepressants work
Increase serotonin and noradrenaline by blocking their reuptake, causing an increase in the levels of these neurotransmitters at the synapse.
They also act at various other receptors (less selective) which may contribute to both the clinical efficacy and side effect.
Has more severe side effects than SSRIs, so used only for those who don’t respond to SSRIs or SNRIs.
an example of benzodiazepines and how they work
Valium and Diazepam
BZs work by increasing the activity of the neurotransmitter GABA (gamma-aminonutryic acid), which is an inhibitory neurotransmitter which claims and reduces the activity of neutrons.
When GABA docks at the receptor site of a neutron, it makes it less linkely to fire an electrical signal (action potential)
Commonly used to reduce anxiety
A strength of drug therapy is that it is more cost effective and less disruptive on patients lives compared to talking therapies.
E - As SSRIs are cheaper than talking therapies it has economic implications for the UK. It is better for the NHS as it could reduce the financial pressure on an already struggling public service.
E - Drug therapies are also less disruptive on a patients life. The patient just needs to take one tablet a day compared to attending weekly sessions and completing homework for CBT.
C - However, a systematic review by Skapinakis et al. (2016) found that cognitive and behavioural (exposure) therapies were more effective than SSRIs for OCD
L - For these reasons drug therapies can be the preferred treatment for many patients, however, increased efficacy of SSRIs may be a better long term solution.
A strength of drug treatment in treating OCD is there is considerable supporting evidence.
E - Soomro et al (2009) reviewed studies comparing SSRIs to placebos in the treatment of OCD and concluded that all 17 studies (meta-analysis) showed significantly better results for the SSRI groups in the short term.
E - This supports the argument that biological treatments are effective as on average 70% of OCD patients had improved symptoms with drug therapy, also suggesting serotonin has a role in the development of the disorder.
C - However, a limitation of the studies is that they were typically 3-4 months long and therefore there is little data on the long-term effects of drug therapy.
L - This suggests that randomized, double-blind clinical trials of SSRIs of 12 months or longer to establish whether efficacy observed in shorter trials is maintained, and whether additional side effects emerge
A limitation of drug therapy is that they often have unpleasant side effects.
E - Even first line treatments such as SSRIs can cause indigestion, blurred vision and a loss of sex drive. Clomipramine can also cause more serious problems: more than 1 in 10 experience erectile dysfunction and weight gain; 1 in 100 become aggressive and experience heart-related problems.
E - Ashton (1997) recommends that drugs for OCD are used for no longer than 4 weeks due to the side effects.
L - It could therefore be argued that drug therapies are therefore not an effective long-term treatment for OCD.
A limitation of the biological approach to OCD is that drug treatments are criticized for treating the symptoms of the disorder and not the cause.
E - Koran et al. (2007) suggest that psychological treatments such as CBT may be a more effective long‐term solution to provide a lasting treatment and a potential cure.
E - This is because although SSRIs work by increasing the levels of serotonin in the brain, which reduces anxiety and alleviates the symptoms of OCD, but it does not treat the underlying cause of OCD. Furthermore, once a patient stops taking the drug, they are prone to relapse.
L - This suggests that the biological issues that drug treatments are intended to target may not be fundamental to the disease, so only have symptomatic effects. This means that the use of drug therapy is only a temporary treatment for OCD, and that the biological causes of the disease may be unknown.
A limitation of the evidence for the effectiveness of drug treatment for OCD is the concern of publication bias.
E - Turner (2008) claims there is evidence to show a ‘favourable outcome’ publication bias in that more studies are published in peer reviewed journal that show the treatment to be effective.
E - This could be critically explained by the fact that drug companies often sponsor the research into the effectiveness of drug treatment and therefore have a strong interest in the continuing success of drug treatment. Currently many drug companies do not publish all of their results and may indeed be supressing evidence.
L - This suggests that maybe not all of the outcomes are published, so the evidence may be very biased towards positive outcomes
vesicle
where the neurotransmitters are stored, release the neurotransmitters across the synapse after binding to the pre-synaptic neuron membrane.
