Psychopathology - The Cognitive Approach to Depression

Question 1

What are the behavioural factors of depression?

Answer 1

• Activity levels: Sufferers of depression have reduced levels of energy making them lethargic. In extreme cases, this can be so severe that the sufferer cannot get out of bed.
• Disruption to sleep and eating behaviour: Sufferers may experience reduced sleep (insomnia) or an increased need for sleep (hypersomnia). Appetite may increase or decrease, leading to weight gain or loss.

Question 2

What are the emotional factors of depression?

Answer 2

• Lowered mood: More pronounced than the daily experience of feeling lethargic or sad. Sufferers often describe themselves as ‘worthless’ or ‘empty’.
• Anger: On occasion, such emotions lead to aggression or self-harming behaviour.

Question 3

What are the cognitive factors of depression?

Answer 3

• Poor concentration: Sufferers may find themselves unable to stick with a task as they usually would, or they might find simple decision making difficult.
• Absolutist thinking: ‘Black and white thinking’, when a situation is unfortunate it is seen as an absolute disaster.

Question 4

What is faulty information processing?

Answer 4

Aaron Beck (1967) suggested that some people are more prone to depression because of faulty information processing, i.e. thinking in a flawed way. They make fundamental errors in logic.

When depressed people attend to the negative aspects of a situation and ignore positives, they also tend to blow small problems out of proportion (magnification) and think in ‘black and white’ terms.

Question 5

What are negative self-schemas?

Answer 5

A schema is a ‘package’ of ideas and information developed through experience. We use schemas to interpret the world, so if a person has a negative self-schema they interpret all information about themselves in a negative way.

Question 6

What is the negative triad?

Answer 6

Beck built on the idea of maladaptive responses, and suggested that people with depression become trapped in a cycle of negative thoughts. There are three elements to the negative triad:

• negative views of the world
• negative view of the future
• negative view of the self

Question 7

What is Ellis’s ABC model?

Answer 7

• Activating event
• Beliefs
• Consequences

Question 8

What is the activating event?

Answer 8

Albert Ellis suggested that depression arises from irrational thoughts. According to Ellis, depression occurs when we experience negative events, e.g. failing an important test or ending a relationship.

Question 9

What are the beliefs?

Answer 9

Negative events trigger irrational beliefs, for example:

• Ellis called the belief that we must always succeed ‘musterbation’.
• ‘I-can’t-stand-it-itis’ is the belief that it is a disaster when things do not go smoothly.
• ‘Utopianism’ is the belief that the world must always be fair and just.

Question 10

What are the consequences?

Answer 10

When an activating event triggers irrational beliefs, there are emotional and behavioural consequences. For example, if you believe you must always succeed and then you fail at something, the consequence is depression.

Question 11

What are the strengths of the cognitive approach to explaining depression?

Answer 11

• Beck’s theory has good supporting evidence

- Beck’s theory has practical application as a therapy

Question 12

What are the weaknesses of the cognitive approach to explaining depression?

Answer 12

• Beck’s theory does not explain all aspects of depression
• Ellis’s model is a partial explanation of depression
• cognitions may not cause all aspects of depression
• reductionist because it doesn’t take into consideration other factors

Question 13

What supporting evidence is there of Beck’s theory?

Answer 13

Grazioli and Terry (2000) assessed 65 pregnant women for cognitive vulnerability and depression before and after birth.

They found that those women judged to have been high in cognitive vulnerability were more likely to suffer post-natal depression.

These cognitions can be seen before depression develops, suggesting that Beck may be right about cognition causing depression, at least in some cases.

Question 14

What practical application does Beck’s theory have?

Answer 14

Beck’s cognitive explanation forms the basis of cognitive behaviour therapy (CBT).

The components of the negative triad can be easily identified and challenged in CBT. This means a patient can test whether the elements of the negative triad are true.

This is a strength of the explanation because it translates well into a successful therapy.

Question 15

How does Beck’s theory not explain all aspects of depression?

Answer 15

Depression is a complex disorder. Some depressed patients are deeply angry and Beck cannot easily explain this extreme emotion.

Some depressed patients suffer hallucinations and bizarre beliefs, or suffer Cotard syndrome, the delusion that they are zombies (Jarrett 2013).

Beck’s theory cannot always explain all cases of depression, and just focuses on one aspect of the disorder.

Question 16

How is Ellis’s model a partial explanation of depression?

Answer 16

There is no doubt that some cases of depression follow activating events.

Psychologists call this reactive depression and see it as different from the kind of depression that arises without an obvious cause.

This means that Ellis’ explanation only applies to some kinds of depression.

Question 17

How may cognitions not cause all aspects of depression?

Answer 17

Cognitive explanations are closely tied up with the concept of cognitive primacy, the idea that emotions are influenced by cognition (your thoughts).

This is sometimes the case, but not necessarily always. Other theories of depression see emotions, such as anxiety and distress, as stored like physical energy, to emerge sometime after their causal event.

This casts doubt on the idea that cognitions are always the root cause of depression and suggests that cognitive theories may not explain all aspects of the disorder.

Also, depressed patients undoubtedly have negative thought. But do the negative thoughts cause depression, or do they merely occur as a result of being depressed?

Question 18

What are affective disorders?

Answer 18

• affective disorders are characteristics of mood and are disabling
• common diagnoses are depression or bipolar disorder
• most affective disorders exist along a continuum
• with affective disorders, the fundamental mood is changed moving along a continuum between depression and elation (mania); hence mood disorders
• bipolar disorders are where moods fluctuate between manic and depressive episodes; there are periods of normality in between
• depression exists along a continuum, and irritability and anger is a common symptom in children as opposed to sadness

Question 19

What does the DSM-5 recognise?

Answer 19

• major depressive disorder: severe but often short-term depression
• persistent depressive disorder: long-term or recurring depression
• disruptive mood dysregulation disorder: childhood temper tantrums
• premenstrual dysphoric disorder: disruption of mood prior to/during menstruation

Question 20

What is depression?

Answer 20

DSM:

• insomnia most nights
• fidgeting or lethargy
• tiredness
• worthlessness or guilt
• less ability to concentrate
• recurrent thoughts of death

Question 21

What is the biological basis of depression?

Answer 21

• low levels of serotonin

- does depression reduce serotonin output or does low serotonin output lead to depression?

Question 22

What did Oruc et al. (1998) find?

Answer 22

• Depression often runs across generations in families.
• The closer the genetic relationship, the more likely people are to share a diagnosis of depression.
• First degree relatives - brothers, sisters, sons, daughters, fathers and mothers - share 50% of their genes.
• First degree relatives of people diagnosed with depression are two or three times more likely to receive a similar
  diagnosis than first degree relatives of those who have not received a diagnosis of depression.

Question 23

What are twin studies?

Answer 23

• Monozygotic (MZ) twins share 100% of their genes.
• Dizygotic (DZ) twins share around 50% of their genes.
• Studies support the idea that a higher proportion of identical twins share the disorder.

Question 24

What did McGuffin et al. (1996) find?

Answer 24

McGuffin et al, 1996: 200 pairs of twins it was found that when an MZ twin was diagnosed with depression, there was a 46% chance that the other twin would receive a similar diagnosis, whereas the figure for DZ twins is 20%.

Question 25

What are adoption studies?

Answer 25

• Research from families and twins is limited: they usually share the same environment.
• Partly overcome by adoption studies.
• These studies compare people who have been adopted at an early age with their biological and adoptive relatives. Since they were raised apart from their biological relatives, similarities with those relatives would indicate genetic influences.

Question 26

What did Wender et al. (1986) find?

Answer 26

Adopted children who later develop a mood disorder appear to be much more likely to have a biological parent who has/had a mood disorder, been an alcoholic or committed suicide, even though the adopted children are raised in very different environments (Wender et al, 1986).

Question 27

What are the key assumptions of the cognitive approach?

Answer 27

• Regards internal mental processes as important in determining behaviour.
• What is studied are the processes that come between an external stimulus and the behavioural response.
• It is assumed that the brain is like a computer.

Question 28

What is the cognitive approach to depression?

Answer 28

• There are a number of cognitive explanations of depression which believe that the disorder is the result of disturbance in ‘thinking’.
• They focus on an individual’s negative thoughts, irrational beliefs and misinterpretation of events as being the cause of depression.

Question 29

What is Beck’s cognitive approach to depression?

Answer 29

• Beck suggested that there is a cognitive explanation as to why some people are more vulnerable to depression than others.
• He suggested three parts to this cognitive vulnerability.

1. faulty information processing
2. negative self-schemas
3. the negative triad

Question 30

Aim

Weissman and Beck (1978) Negative Schemas

Answer 30

To investigate the thought processes of depressed people to establish if they make use of negative schemas.

Question 31

Procedure

Weissman and Beck (1978) Negative Schemas

Answer 31

Thought processes were measuring using a ‘dysfunctional attitude scale’. Participants were asked to fill in a questionnaire by ticking whether they agreed or disagreed with a set of statements. For example, ‘people will probably think less of me if I make a mistake’.

Question 32

Results

Weissman and Beck (1978) Negative Schemas

Answer 32

They found that depressed participants made more negative assessments than non-depressed people. When given some therapy to challenge and change their negative schemas, there was an improvement in their self-ratings.

Question 33

Conclusion

Weissman and Beck (1978) Negative Schemas

Answer 33

Depression involves the use of negative schemas.

Question 34

What are the features of cognitive behaviour therapy?

Answer 34

• Beck: Patient and therapist work together.
• Challenging negative thoughts relating to negative triad.
• The ‘patient as scientist’.
• Ellis’s rational emotive behaviour therapy (REBT).
• Challenging irrational beliefs.
• Behavioural activation.

Question 35

How do patients and therapists work together in Beck’s treatment?

Answer 35

• work together to clarify the patient’s problems

- identify where there might be negative or irrational thoughts that will benefit from challenge

Question 36

What is the aim of Beck’s cognitive behavioural therapy?

Answer 36

• the aim is to identify negative thoughts about the self, the world and the future - the negative triad
• these thoughts must be challenged by the patient taking an active role in their treatment

Question 37

What is the patient expected to do in Beck’s treatment?

Answer 37

Patients are encouraged to test the reality of their irrational beliefs.

They might be set homework, e.g. to record when they enjoyed an event or when people were nice to them This is referred to as the ‘patient as scientist’.

In future sessions, if patients say that no-one is nice to them or there is no point going on, the therapist can produce this evidence to prove the patient’s beliefs incorrect.

Question 38

What is Ellis’s rational emotive behaviour therapy?

Answer 38

REBT extends the ABC model to an ABCDE model:

• D for dispute (challenge) irrational beliefs
• E for effect (see a more beneficial effect on thought and behaviour)

Question 39

How would a therapist challenge an irrational belief in Ellis’s treatment?

Answer 39

A patient might talk about how unlucky they have been or how unfair life is. An REBT therapist would identify this as utopianism and challenge it as an irrational belief.

• Empirical argument: disputing whether there is evidence to support the irrational belief.
• Logical argument: disputing whether the negative thought actually follows from the facts.

Question 40

What is behavioural activation?

Answer 40

As individuals become depressed, they tend to increasingly avoid difficult situations and become isolated, which maintains or worsens symptoms.

The goal of treatment, therefore, is to work with depressed individuals to gradually decrease their avoidance and isolation, and increase their engagement in activities that have been shown to improve mood, e.g. exercising, going out to dinner, etc.

Question 41

What are the strengths of the cognitive approach to treating depression?

Answer 41

• CBT is effective, particularly when combines with drug treatment
• client is actively involved in their recovery
• CBT is not physically invasive
• clients learn to help themselves, and can use the skills in new situations

Question 42

What are the weaknesses of the cognitive approach to treating depression?

Answer 42

• it may not work for the most severe cases of depression, people must want to change
• success may be due to the therapist-patient relationship
• clients can become dependent on their therapist, or non-cooperative
• some patients really want to explore their past
• there may be an overemphasis on cognition
• CBT is not a quick fix

Question 43

How is CBT effective?

Answer 43

There is a large body of evidence to support the effectiveness of CBT for depression, e.g. March et al. (2007) compared the effects of CBT with antidepressant drugs and a combination of the two in 327 depressed adolescents.

After 36 weeks, 81% of the CBT group, 81% of the antidepressant group and 86% of the CBT + antidepressants group were significantly improved. CBT emerged as just as effective as medication and helpful alongside medication.

According to Fava et al. (1994), it is as effective as antidepressants for many types of depression.

This suggests there is a good case for making CBT the first choice of treatment in public health care systems like the NHS.

Question 44

Why might CBT not work for the most severe cases of depression?

Answer 44

In some cases, depression can be so severe that patients cannot motivate themselves to take on the hard cognitive work required for CBT.

Where this is the case, it is possible to treat patients with antidepressant medication and commence CBT when they are more alert and motivated.

This is a limitation of CBT because it means CBT cannot be used as the sole treatment for all cases of depression.

Question 45

How might success be due to the therapist-patient relationship?

Answer 45

Rosenzwieg (1936) suggested that the differences between various methods of psychotherapy might actually be quite small.

All psychotherapies have one essential ingredient - the relationship between therapist and patient. It may be the quality of this relationship that determines success rather than any particular technique.

Many comparative reviews (e.e. Luborsky et al. 2002) find very small differences between therapies, suggesting they share a common basis.

Question 46

Why is some patients wanting to explore their past a weakness?

Answer 46

One of the basic principles of CBT is that the focus of the therapy is on the patient’s present and future, rather than their past.

In some other forms of psychotherapy, patients make links between childhood experiences and current depression.

The ‘present-focus’ of CBT may ignore an important aspect of the depressed patient’s experience.

Question 47

How is there an overemphasis on cognition?

Answer 47

CBT may end up minimising the importance of the circumstances in which the patient is living (McCusker 2014).

A patient living in poverty or suffering abuse needs to change their circumstances, and any approach that emphasises what is in the patient’s mind rather than their environment can prevent this.

CBT techniques used inappropriately can demotivate people to change their situation.

Question 48

What is CBT?

Answer 48

• CBT: most commonly used psychological treatment for depression, (also anxiety, panic, phobias, stress, bulimia, OCD, Post-Traumatic Stress Disorder, bipolar disorder.
• Uses both behavioural and cognitive techniques.
• The therapist aims to make the client aware of the relationship between thought, emotion and actions.
• CBT can help people to change how they think (‘cognitive’) and what they do (‘behaviour’). These changes can help them to feel better.

Question 49

What does CBT involve?

Answer 49

1. assessment
2. formulation and goals
3. treatment
4. homework and monitoring
   (repeat of step 3 and 4)
5. treatment

Question 50

What is REBT?

Answer 50

• Ellis (1962) irrational thoughts are the main cause of all types of emotional distress and behaviour disorders.
• REBT is based on the premise that whenever we become upset, it is not the events taking place in our lives that upset us; it is the beliefs that we hold that cause us to become depressed, anxious, enraged, etc.
• Ellis believed that irrational beliefs make impossible demands on the individual, leading to anxiety, failure and psychological difficulty.
• REBT challenges the client to prove these statements, and then replace them with more reasonable realistic statements (empirical disputing/logical disputing).

Question 51

What alternative explanations are there for depression?

Answer 51

The biological approach to understanding mental disorders suggests that genes and neurotransmitters may cause depression.

The success of drug therapies for treating depression suggest that neurotransmitters do play an important role. The medication alters the levels of specific neurotransmitters and reduces the symptoms. But does depression lead to different levels of neurotransmitters, or does different levels of neurotransmitters lead to depression?

A diathesis-stress approach might be advisable, suggesting that individuals with a genetic vulnerability for depression are more prone to the effects of living in a negative environment, which then leads to negative irrational thinking.

Question 52

What does ABCDE stand for?

Answer 52

A - Activating event or adversity
B - Beliefs about the event or adversity
C - the emotional Consequences
D - Disputations to challenge irrational beliefs
E - Effective new beliefs replace the irrational ones

Question 53

Aim

Newark et al. (1973) Irrational Attitudes

Answer 53

They wanted to know if people with psychological problems had irrational attitudes.

Question 54

Procedure

Newark et al. (1973) Irrational Attitudes

Answer 54

Two groups of participants were asked if they agreed with the following statements identified by Ellis as irrational:

• it is essential that one be loved or approved of by virtually everyone in the community
• one must be perfectly competent, adequate and achieving in order to consider oneself worthwhile

One group consisted of people who had been diagnosed with anxiety. The other group had no psychological problems. They were defined as ‘normal’.

Question 55

Results

Newark et al. (1973) Irrational Attitudes

Answer 55

A total of 65% of the anxious participants agreed with statement A compared to 2% of non-anxious participants.

For statement B, 80% of anxious participants agreed, compared to 25% of non-anxious participants.

Question 56

Conclusion

Newark et al. (1973) Irrational Attitudes

Answer 56

People with emotional problems think in irrational ways.

Question 57

What are the implications of psychological research on the economy?

Answer 57

• treating mental health disorders increases people’s ability to work
• allows them to contribute as affective members of society
• benefits employers because less days are taken off
• improves productivity

Question 58

What had the WHO predicted about the implications of depression on the economy?

Answer 58

The World Health Organisation have predicted that by 2020, depression will be the biggest single disease burden, costly to individuals, families, communities and the economy as a whole through lowered productivity, absenteeism and unemployment.

Therefore, if psychological research shows that people with a disorder such as depression are less likely to suffer a relapse after having cognitive therapy then, even though cognitive therapy might initially be more expensive than drug therapy, in the long-term it might be more economically sound to offer cognitive therapy as people would have less time off work.