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Psycopathology Flashcards

1
Q

What are the evaluation points for the biological approach to treating OCD?

A

+) effectiveness of drug therapy
C.P -> 30% patients do not repsond to SSRI’s
-) cost-effectiveness
C.P-> ST solution, CBT could be LT solution
-) reductionist perspective
C.P-> validity

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2
Q

How is effectiveness of drug therapy a strength of the biological approach to treating OCD?

A

Point: Drug therapies, like SSRIs, are effective in reducing OCD symptoms.
Evidence: Soomro et al. (2009) found SSRIs helped reduce symptoms in 70% of patients.
Explanation: This supports the biological approach, suggesting SSRIs balance serotonin levels, alleviating OCD symptoms. They are often prescribed as a first-line treatment.
Link: Therefore, SSRIs offer a practical, effective biological treatment for OCD, helping many patients manage their symptoms.
Counterpoint: However, about 30% of patients do not respond to SSRIs, indicating that drug therapy isn’t universally effective, and other treatments may be needed.

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3
Q

How is cost-effectiveness a strength of the Biological approach to treating OCD?

A

Point: Drug therapies are more cost-effective than psychological therapies like CBT.
Evidence: Medication is cheaper and quicker to administer, requiring fewer healthcare resources.
Explanation: This makes drug therapy an accessible option, especially for those with severe symptoms who may struggle with therapy.
Link: Thus, drugs can be a practical first-line intervention for OCD.
Counterpoint: However, drug therapies don’t address the root causes of OCD. While cost-effective, they lack long-term helpfulness, as symptoms may return once treatment ends, unlike therapies targeting underlying issues.

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4
Q

How is a reductionist perspective a limitation of the biological approach to treating OCD?

A

Point: The biological approach is reductionist, focusing only on brain chemistry and ignoring other factors.
Evidence: CBT is more effective for some, addressing cognitive distortions and environmental triggers.
Explanation: This suggests the biological approach oversimplifies OCD, which may limit its effectiveness for some individuals.
Link: Therefore, a combination of biological and psychological treatments may provide a more comprehensive solution.
Counterpoint: However, despite being reductionist, the biological approach has validity. Research shows neurotransmitter imbalances, like low serotonin levels, are linked to OCD, making the biological model a credible and evidence-based treatment.

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5
Q

What are the causes of OCD according to the biological approach ?

A

genetic factors
neutransmitter imbalances
brain structure abnormalities, caudate nucleus
low seretonin

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6
Q

How does seretonin play a role in OCD?

A

Low levels of sereton linked to OCD
seretonin helps regulate mood and anxiety
defieicency may contribute to intrusive thoughts and compulsive behaviours

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7
Q

What are SSRI’s and how do they work in treating OCD?

A

SSRI’s increase seretonin levels in the brain by blocking reuptake
allevites OCD symptoms by improving seretonin function

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8
Q

What is an SSRI example?

A

sertraline

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9
Q

What is an evidence for SSRI’s?

A

Soomro et al (2009) meta-analysis showed SSRI’s more effective than placebo.
60-70% of patients showed sig improvement

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10
Q

What are tricyclics and how do they work in treatment for OCD?

A

older class of anti-depressants that increase seretonin levels in brain
used when SSRI’s are ineffective but have more side-effect

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11
Q

What are the evaluation points for evaluating genetic explanations?

A

+) research support for genetic explanations
C.P-> concordance not 100
-)

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12
Q

How is research support for genetic explanations a strength of the biological approach to treating depression?

A

Point: Genetic explanations for OCD are supported by research evidence.
Evidence: Bolton found a concordance rate of 57% in MZ twins and 22% in DZ twins.
Explanation: MZ twins share 100% of their DNA, while DZ twins share only 50%. The higher concordance in MZ twins suggests a genetic component to OCD.
Link: This indicates a probable genetic basis for OCD.
Counterpoint: However, if OCD were purely genetic, concordance in MZ twins would be 100%, so genetics are not the sole explanation.

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13
Q

How are family studies a strength of genetic explanations of the biological approach to treating OCD?

A

Point: Family studies provide evidence for a genetic element in OCD.
Evidence: Lewis (1936) found that 37% of OCD patients had parents with OCD, and 21% had siblings with the disorder.
Explanation: This suggests that genetics may play a role in the development of OCD, as it appears to run in families.
Link: Therefore, genetic explanations may account for OCD in some individuals.
Counterpoint: However, the percentages are relatively low, indicating that genetics alone cannot explain OCD, and other factors must contribute.

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14
Q

How is a lack of sucsess in drug therapy a limitation of neural explanations?

A

Point: The lack of success in drug therapy highlights limitations in the biological approach to explaining OCD.
Evidence: SSRIs, which target serotonin levels, are ineffective for about 40% of OCD patients.
Explanation: This suggests that while serotonin imbalances may contribute to OCD in some individuals, they do not account for all cases. The 40% who do not respond may have alternative causes, such as environmental or cognitive factors.
Link: This limitation shows that the biological approach cannot fully explain OCD in all individuals.

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15
Q

How is research support for dopamine’s role a strength of the neural explanations for OCD?

A

Point: Research supports the role of dopamine in OCD.
Evidence: Szechtmann found that animals exhibited stereotypical movements and behaviors when dopamine levels were artificially increased in a controlled lab setting.
Explanation: This suggests dopamine is linked to OCD, as the controlled conditions make the findings valid and reliable.
Counterpoint: However, animal studies are difficult to generalize to humans due to differences in brain complexity, as human brains are far more intricate than animal brains.
Link: While dopamine may play a role in OCD, it cannot fully explain the disorder in all individuals.

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16
Q

What are the evaluiation points for the biological approach to explaining OCD?

A

Genetic
+) family studies c.p-> low %
+) research ev C.P -> concordance is not 100
Neural
-) lack of sucsess in drug therapy
+) research support

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17
Q

What is the role of genetics in the biological explanation of OCD?

A

Genetics suggest that OCD is inherited. It is believed to be polygenic, meaning multiple genes contribute to its development.

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18
Q

How do twin studies support the genetic explanation of OCD?

A

Twin studies show higher concordance rates for OCD in monozygotic (MZ) twins, who share 100% of their DNA, compared to dizygotic (DZ) twins, who share 50%.

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19
Q

How is serotonin involved in the neural explanation of OCD?

A

OCD is linked to low levels of serotonin, which impairs communication between neurons, affecting mood and repetitive behaviors.

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20
Q

What is the COMT gene, and how is it linked to OCD?

A

The COMT gene regulates dopamine levels. A variation of this gene leads to higher dopamine levels, which are linked to compulsive behaviors seen in OCD.

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21
Q

What is the SERT gene, and how is it linked to OCD?

A

The SERT gene is involved in the transport of serotonin. A variation of this gene causes lower serotonin levels, which are associated with symptoms of OCD.

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22
Q

What role does dopamine play in OCD?

A

High levels of dopamine are associated with compulsive behaviors, as they can enhance repetitive actions.

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23
Q

What are the evaluation points for the cognitive treatments of depression?

A

+) research support
-) too much effort
+) meta-analysis

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24
Q

How is research support a strength of the coginitive treatments of depression?

A

Point: Research supports the effectiveness of CBT in treating depression.
Evidence: A 36-week study found that 81% of the antidepressant group and 81% of the CBT group showed significant improvement. The combination group (CBT + antidepressants) had an even higher improvement rate at 86%.
Explanation: This highlights that CBT is effective, supporting the usefulness of the cognitive approach in treatment.
Link: However, as the combination of CBT and antidepressants is most effective, this suggests that biological elements should also be considered alongside CBT.

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25
Q

What are 2 explanations of the cognitive approach to treating depression?

A

Becks negative triad
Ellis’s ABC model

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26
Q

How is requireing tooo much effor a limitation of the congitice approachj to treating depression?

A

Point: CBT requires significant effort from the patient, leading to mixed success rates.
Evidence: Severely depressed individuals may struggle to engage with CBT or even attend sessions, making it less effective for them. Antidepressants may be more suitable in such cases.
Explanation: This suggests that CBT is ineffective for severely depressed patients, where the biological approach may offer better outcomes.
Link: Therefore, the cognitive approach is not successful for everyone and may need to be combined with biological treatments for greater effectiveness.

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27
Q

What is added to the ABC model to make REBT?

A

dispute and effect

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28
Q

What is disputing irrational thoughts in the congitive approach to treating depression?

A

dispute whether thoughts are empirical, logical or pragmatic

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29
Q

What is the effect in the ABCDE REBT model?

A

client goes from catatstrophising to making rational interpretations when facing eith the activating event

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30
Q

What are parts of the Beck’s CBT?

A

Goal-setting
Homework
Identifying irrational thoughts

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31
Q

What is goal setting?

A

therapist and patient jointly identify goals for therapy and put together a plan to achieve them

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32
Q

What is homework?

A

CBT involves working to change negative and irrational thoughts and replace hem with more effective behaviours

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33
Q

What is identifying irrational thoughts?

A

identify where there may be negative or irrational thoughts that would benifit being challenged

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34
Q

What is a commmon feature of the congitive approach to ttreating depresion in the therapies?

A

unconditional positive regard where therpaist values client and makes them feel worthwhile. makes client more invested in treatment

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35
Q

How is meta-analysis support a strength of the congitive treatment fr derpression?

A

Point: Meta-analyses provide strong evidence for the effectiveness of cognitive therapies like REBT and CBT.
Evidence: Ellis reported a 90% success rate for REBT, and Cuijpers’ meta-analysis of 75 studies found CBT significantly more effective than no treatment. Success rates were measured using standardized, ethically validated questionnaires.
Explanation: The use of large-scale, rigorously conducted meta-analyses ensures that the findings are valid and reliable.
Link: This highlights the usefulness and success of cognitive therapies in treating depression, supported by robust research evidence.

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36
Q

How is research support a strength of the congitive explanations of depression?

A

Point: Research supports the role of cognitive vulnerability in depression.
Evidence: In a study of 65 pregnant women assessed for cognitive vulnerability and depression, those with high cognitive vulnerability were more likely to develop postnatal depression. Cognitive distortions were observed before the depression developed.
Explanation: This suggests that cognitive distortions could contribute to the onset of depression, rather than just being a characteristic of it.
Counterpoint: However, the study shows a correlation, not causation, meaning other factors, such as hormonal changes, could be influencing both cognitive vulnerability and depression.
Link: Despite this, the findings support the cognitive approach as a valuable explanation for depression.

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37
Q

How is not all depression being caused by an activating event a limitation?

A

Point: Ellis’s ABC model suggests that activating events trigger irrational thoughts, leading to depression.
Evidence: Some depression follows specific activating events, referred to as reactive depression, which is different from depression that arises without any clear cause.
Explanation: This means Ellis’s ABC model could accurately explain the cause of reactive depression.
Counterpoint: However, in cases of clinical depression where there is no identifiable activating event, the ABC model fails to explain how depression develops.
Link: Therefore, while the model can explain some types of depression, it cannot account for all cases, limiting its overall applicability.

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38
Q

How is alternative explanations a limitations of the cognitive explanations of depression?

A

Point: The biological approach offers an alternative explanation for depression, suggesting low levels of serotonin contribute to the condition.
Evidence: Drug therapies that increase serotonin levels have shown success in treating depression, supporting this biological explanation.
Explanation: The success of these treatments strengthens the argument that there is a biological component to depression.
Counterpoint: However, this explanation cannot account for all cases of depression, as it fails to consider the role of cognitive factors and ignores the complexity of depression’s causes.
Link: Therefore, while the biological approach provides valuable insight, it does not offer a complete explanation of depression.

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39
Q

What are the evaluartion points for the congitive approach explaining depression?

A

+) research support
-) alternative explanation
-) not all depression has an activating event

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40
Q

What are the 3 componennts of Beck’s negative triad?q

A

Cognitive bias
Negative self-schemas
the negative triad

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41
Q

What are the irrational thoughts in congitive bias?

A

Arbitrary inference
Overgeneralisation
catastrophising

42
Q

What are negative self-schemeas?

A

SCHEMAS DEVELOPED DURING CHILDHOOD
depressed epople possess negative self-schemas, come from negative experiences

43
Q

How does faulty information processing in negative self-schemas happen?

A

congitive distortions
coongitive deficiencies

44
Q

What is the A in the ABC model?

A

Activating agent - external events trigger depressive thoughts

45
Q

What is the B in the ABC model>

A

Belief - rational or irrational

46
Q

What is the C in the ABC model>

A

Consequence - healthy emotiuons or irratiopnal beliefs

47
Q

What are the evaluation points for systematic desensitisation as an element of the behaviourial approach to treating phobias?

A

+) research support
C.P-> not 100%
+) self-administered
C.P -> avoidance behaviours

48
Q

How is research support a strength of systematic desensitisation as an element of the behaviourial approach to treating phobias?

A

P - A strength of systematic desensitisation (SD) is its research support for success.
E - McGrath found 75% of patients were successfully treated for their phobia using SD.
E - This shows SD is largely effective in treating phobias.
L - It can treat phobias for most people to a significant extent.
C.P - However, SD is not 100% effective, meaning not everyone can be treated successfully. Therefore, SD cannot address phobias in all individuals.

49
Q

How is being self-administered a strength of SD?

A

P - SD can be self-administered, increasing accessibility.
E - Self-administered SD is as effective as therapist-led SD.
E - This allows more people to access treatment, avoiding waiting lists or high costs.
L - SD can successfully treat more individuals.
C.P - However, it requires self-discipline and motivation, which may be challenging for those with avoidance behaviors, reducing its effectiveness.

50
Q

What are the evaluations for flooding?

A

+) effective and timely nature
C.P-> less traumatic to go for SD
-) not effective for all people
C.P-> LT benefits

51
Q

How is flooding not being effective for all people a limitation?

A

P - A limitation of flooding is that it is not effective for everyone.
E - Some individuals may respond poorly, especially if they have traumatic experiences, leading them to quit.
E - This means phobias are not successfully treated for all individuals in all contexts.
L - Flooding cannot universally treat phobias across all people and situations.
C.P - Despite this, flooding is highly effective for many, with quick results and long-term benefits when individuals can complete the process. This highlights its potential as a valuable treatment option

52
Q

How is having an effective and timely nature a strength of flooding?

A

P - A strength of flooding is its effective and timely nature.
E - Flooding is highly effective and quicker than alternatives; however, a meta-analysis by Craske found SD is equally effective.
E - This means phobias are treated efficiently, allowing individuals to resume their lives faster.
L - Therefore, flooding can successfully treat phobias in most people.
C.P - However, SD is less traumatic than flooding, making it a preferable choice for some individuals.

53
Q

How is recalling the activating event a strength of the 2 process model?

A

P - A strength of the two-process model is that individuals often recall an activating event.
E - For example, recalling a dog bite suggests phobias form through association.
E - This supports therapies where exposure to fear stimuli is used.
L - The model can explain how phobias develop through such associations.
C.P - However, some individuals can’t remember an activating event.
E - This implies phobias may form without a clear initiating event.
L - Therefore, the two-process model may not explain phobia formation for everyone.

54
Q

What are the evaluation points for the 2 process model?

A

+) recall activating event
C.P-> not everyone experienced an activating event
-) not everyone with activating event will get phobia

55
Q

How is an not everyone who experiences an activating event developing a phobia a limitation of the 2 process model?

A

P - A limitation is that not everyone who experiences an activating event will develop a phobia.
Ev - Research shows that not everyone bitten by a dog develops a dog phobia, and some with phobias can’t identify the exact moment they began. The diathesis-stress model suggests we inherit a genetic vulnerability, which is triggered by life events.
E - This indicates a biological component in the development of phobias.
L - Therefore, behaviourism alone cannot explain the formation of all phobias.

56
Q

What are the evaluations of statistical infrequency as a definition of abnormality\?

A

+) RWA
-) some abnormal behaviour is desirable

57
Q

How is real life application a strength of statistical infrequency?

A

Point: Statistical infrequency has real-life application.
Evidence: It is used to assess intellectual ability, such as IQ, in clinical diagnosis.
Explanation: This helps measure how extreme a behavior is compared to others.
Link: It’s useful in clinical assessments but doesn’t distinguish between desirable and undesirable behavior.

58
Q

How is abnormal behaviour being desirable a limitation of SI?

A

Point: some abnormal behaviour is desirable
Evidence: IQ over 150 is desirable and rare`
Explanation: The definition doesn’t differentiate between desirable and undesirable behavior.
Link: We need a system to identify both frequent and undesirable behaviors.

59
Q

How is attempting to include the subjective experience a strength of failure to function?

A

Point: Recognizes individual distress.
Evidence: It focuses on the person’s experience, which is essential in diagnosing abnormality.
Explanation: Though difficult to assess, it highlights the importance of the individual’s perspective.
Link: This definition is limited by cultural relativism.

60
Q

What are the evaluation points for failure to function adequately?

A

+) attempts to include subjective experience of individual
-) cultural relativism

61
Q

How is cultural relativism a limitation of failure to function adequately?

A

Point: Cultural relativism is a limitation.
Evidence: definitions are based on Western cultural ideas and beliefs.
Explanation: Applying these definitions to non-Western cultures may be inappropriate, as they may not align with different cultural norms.
Link: This means the definition is culture-bound and may not be universally applicable.

62
Q

How is social norms varying across time and cultures a limitation of deviation from social norms?

A

Point: Social norms vary across time and cultures.
Evidence: Homosexuality was once considered a mental disorder in Western societies but is now accepted.
Explanation: This shows that what is considered abnormal can change over time and across cultures.
Link: Therefore, this definition is culture-bound and not universally applicable, as social norms differ globally.

63
Q

Evaluation points for deviation from social norms?

A

-) vary over time and culture
-) culture bound

64
Q

How is being culture bound a limitation of deviation from social norms?

A

P: The concept of abnormality can be seen as culture-bound.
Ev: Classifications like the DSM are based on Western cultures; however, cultures differ in terms of social norms.
Ex: This means there are no universal standards or rules for labeling behaviors as normal or abnormal.
L: As a result, behaviours considered abnormal in one culture may be seen as normal in another, limiting the universality and validity of these classifications.

65
Q

What are evaluation points for deviation from ideal mental health?

A

+) comprehensive
-) unrealistic

66
Q

How is being comprehensive a strength of deviation from ideal mental health?

A

P: The definition of mental health is comprehensive.
Ev: It covers a broad range of criteria for mental health, including most reasons someone would seek help from mental health services or be referred for support.
Ex: This makes it a good tool for thinking about mental health and establishing a threshold for when someone might need to seek help.
L: As a result, it provides a practical framework for identifying and addressing mental health concerns.

67
Q

What is systematic desensitisation?

A

client is gradually exposed to the source of their fear while practising relaxation techniques

68
Q

What are the steps in SD?

A

1) patients is taught relaxation techniques
2) desensitisation hieracrchy formed, each situation with fear stimuli causes more anxiety that the previous
3) patient gradually works through hierarchy and master phobia

69
Q

What is the 2process model?

A

Classical conditioning is the intiation of the phobia- aquired
Operant coditioning is the maintenance of phobias - maintained

70
Q

What is the imitation through classical conditioning?

A

association between an NS (object if fear) and UCS (something unpleasant) causing CR (fear)

71
Q

What is the maintenance of ohobias through operant conditioning?

A

maintained when individual avoids situations where the object of their phobia might be present
Negative reinforcement - individual avoids unpleasant sensation of fear
Positive reinforcement - individual avoids unpleasant sensation of fear

72
Q

What is a phobias?

A

anxiety disorder
characterised by an excessive and irrational fear of a specific object, situation or activity

73
Q

What is depression?

A

mood disorder
characterised by persisitent feelings of sadness, hopelessness and a lack of pleasire and interest in activities

74
Q

What is OCD?

A

anxiety disorder
marked by presence of intrusive and unwanted thoughts
leads to repetitive behaviours or mental acts

75
Q

What are emotional characterisitcs of phobias?

A

persistent fear
feelings of anxiety and panic

76
Q

What are emotional characteristics of depression?

A

lack of self-esteem
feelings of worthlessness and embarassment
possible feelings of anger

77
Q

What are emotional characterisitcs of ocd?

A

possible disgust and guilt
feelings of embarassment / shame

78
Q

What is the behaviourial charcaterisitcs of phobias?

A

avoidance of object of fear
freezing as an adaptive response

79
Q

What are behaiourial characteristics of depression?

A

change in sleep and appetite
aggression / irritability

80
Q

What ar ebehavioural characterisitcs of OCD?

A

repetitive compulsions / rituals

81
Q

What are cognitive factors of phobias?

A

negative distorted irrational thinking
selective attention
insight - person knows fear is excessive or unreasonable

82
Q

What are cognitive characterisitcs of depression?

A

negative distorted irrational thinking
inability to concentrate

83
Q

What are cognitive characteristics of OCD?

A

obsessions and compulsions lead to anxiety and stress
intrusive thoughts and impulses are percieved as innapropiate or forbidden
hypervigilance
insight

84
Q

What is floding?

A

client is exposed o feared situation in 1 long session at phobias worst while patient practises relaxation techniques, leads to extinction of phobia

85
Q

What is statistical infrequency?

A

normal distribution curve shows most people as being in the middle, these people are defined as normal
outliers can be considered abnormal

85
Q

What is failure to function adequately?

A

day to day inability to cope with everyday tasks
distress leads to dysfunction

85
Q

What is deviation from social norms>?

A

BEHAVIOUR IS ABNORMAL WHEN IT DOES NOTfit with what is socially acceptable

85
Q

What is deviation from ideal mental health?

A

Jahoda’s criteria
a perosn must fulfil to have ideal mental health those who deviate considered abnormal
self-attitudes - high self oesteem
personal growth and seld-actualisation
integration
autonomy
accurate perception of reality

85
Q

What are the evaluation points for Statistical Infrequency?

A

+)RWA
-) abnormal behaviour is desirable

85
Q

How is real life application a strength of statistical infrequeny?

A

P: The statistical infrequency definition has real-life applications.
Ev: It is used in the diagnosis of intellectual ability and in assessments where the severity of symptoms is measured against statistical norms.
Ex: This makes it a useful part of clinical assessment, helping professionals identify individuals who may need support.
L: Therefore, it is a practical and useful definition of abnormality in clinical settings.

85
Q

How is abnormal behaviour desirable a limitation of statistical infrequency?

A

P: Not all abnormal behavior is undesirable.
Ev: For example, an IQ over 150 is statistically rare but highly desirable.
Ex: The statistical infrequency definition fails to distinguish between desirable and undesirable behaviors, which limits its usefulness.
L: This means the definition may label positive traits, like high intelligence, as abnormal, highlighting the need for a more accurate way to identify undesirable rare behaviours

85
Q

What are the evaluation points for failure to function adequately?

A

+) attempts to include subjective experience of experience
-) cultural relativism

85
Q

How is attempting to include the subjective experience of the individual a strength of failure to function adequately?

A

P: The failure to function adequately definition includes the subjective experience of individuals.
Ev: While assessing distress can be difficult, it acknowledges the importance of the individual’s perspective.
Ex: This makes it a more personal and humane approach to defining abnormality.
L: Therefore, it is a useful and practical definition for understanding real-life mental health issues.

85
Q

How is cultural relativism a liitation f the failure to function adequately?

A

P: The failure to function adequately definition is affected by cultural relativism.
Ev: It is based on Western norms and beliefs, which may not apply universally.
Ex: Using this definition in non-Western cultures is inappropriate, as ideas of normal functioning differ across societies.
L: This makes the definition culture-bound, limiting its usefulness outside the West.

85
Q

What are the evaluation points of deviation from social norms?

A

-) vary over time
-) culture bound

85
Q

How is varying over time a limitation of deviation from social norms?

A

P - vary over time
Ev - homosexuality considered a mental disorder in DSM however now it is socially-acceptable
Ex - this definition is based on prevailing social norms and attitudes which may change over time
L - lacks tmeporal validity, outdated with evolving societal values

85
Q

How is culture-bound a limitaiton of deviation from social norms?

A

P - culture bound
Ev - classifications like DSM based on western cultures but cultures differ in their social norms
Ex - no universal standards for labelling behaviour as abnormal
L- This highlights the need for culturally sensitive approaches to defining abnormality.

85
Q

What are the evaluation points fordeviation from ideal mental health?

A

+) comprehensive
-) unrealistic

85
Q

How is being comprehensive a strength of deviation from ideal mental health?

A

P: The definition of mental health is comprehensive.
Ev: It covers a broad range of criteria and addresses the main reasons someone might seek mental health services.
Ex: This makes it a useful tool for understanding mental health and determining when intervention is needed.
L: Therefore, it offers a practical and thorough framework for assessing mental health issues.

85
Q

How is being unrealistic a limitation of deviation from idea mental health?

A

P: The definition of ideal mental health is unrealistic.
Ev: Very few people satisfy the criteria all the time.
Ex: This means almost everyone would be described as abnormal to some degree, raising the question of how many criteria need to be absent before someone is judged as abnormal.
L: As a result, the definition lacks practicality, as it sets an overly high standard for mental health.

Psychology (12 decks)

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