THE CLINICAL APPROACH - KEY STUDIES

Question 1

What was Rosenhan’s aim?

Answer 1

To investigate whether the characteristics of abnormality exist in the patient or in the environment in which they are observed
To investigate the reliability of the diagnoses of schizophrenia and abnormality, and whether the same symptoms will always be diagnosed in the same way

Question 2

What Rosenhan’s procedure?

Answer 2

Eight ‘sane’ people (one graduate student, three psychologists, a paediatrician, a painter and two housewives) were used as confederates
They telephoned 12 psychiatric hospitals for urgent appointments in five USA states, one hospital was private and all the others were public
They arrived at admissions, gave false names and addresses but gave their other ‘life’ details correctly
They all complained of hearing unclear voices (saying empty, hollow, thud) and said the voice was unfamiliar but was the same sec
They were all admitted to hospital, and all were diagnosed with schizophrenia
Once they admitted, the ‘pseudo-patients’ stopped simulating any symptoms and took part in the ward activities

Question 3

What were Rosenhan’s results?

Answer 3

The pseudo-patients were never detected and they wish to be discharged immediately, but they waited until they were diagnosed as ‘fit to leave’
Normal behaviour was misinterpreted (eg writing notes in a diary was described as ‘the patient engaged in writing behaviour, which is pathological’)
If they approach staff with simple requests (based on 1283 attempts)
88% ignored them, 10% made eye contact and 2% stopped for a chat
The shortest stay was 7 days and the longest was 52 days (mean of 19 days)
They were given a total of 2100 medication tablets
Each ‘real patient’ spent less than 7 minutes per day with psychiatric staff
25/118 patients voiced their suspicions about the pseudo-patients but none of the hospital staff did

Question 4

What was Rosenhan’s follow up study?

Answer 4

A teaching and research hospital was told of the first study and were warned that over the next 3 months, one or more pseudopatients will attempt to be admitted
Staff members rated ‘new patients’ on a scale of 1-10 as ‘how likely to be a fraud’
193 patients were ‘assessed’, 41 rated as pseudo patient by staff, 23 by psychiatriss and 19 by both
However no pseudopatients were sent and the staff were rating their regular intake of ‘mentally ill patients’

Question 5

What were the conclusions of Rosenhan’s study?

Answer 5

‘It is clear that we are unable to distinguish the sane from the insane in psychiatric hospitals’
The behaviour is interpreted according to the expectations of staff and these expectations are created by the labels of ‘sanity’ and ‘insanity’
In the first study they were unable to detect ‘sanity’
In the second study they were unable to detect ‘insanity’

Question 6

What are the strengths of Rosenhan’s study?

Answer 6

The confederates consisted of people of different genders and occupations, making it more generalisable because it represents whether the environment affects how abnormal behaviour is interpreted for the whole population
The fact they used one private hospital makes the results more generalisable, as it represents the different environments of psychiatric hospitals so more representative
The fact all the confederates gave the same symptoms of hearing voices makes it more reliable as it was a standardised procedure, and each psychiatrist was given the same information (easy to repeat)
There was no chance of demand characteristics as the staff were unaware they were being observed which makes it more valid as their behaviour reflected the natural environment
It had high ecological validity as the confederates and participants were in a natural environment of a psychiatric hospital and therefore how they interpreted abnormal behaviour reflected real life situations

Question 7

What are the weaknesses of Rosenhan’s study?

Answer 7

The doctors weren’t looking for people with fake symptoms so therefore weren’t looking out for them (they’re trained to assess the symptoms infront of them) so reducing the validity of the study
Although the pseudo-patients had negative experiences in the psychiatric hospitals, their accounts do not deprive the experiences of real patients who did not have the comfort of knowing their diagnosis was false
The current system of clinical classification that is most widely used (DSM 5) requires diagnosis to be made across 5 different categories which contrasts from tehe study (outdated)
In the second study, people were sent away when they were seeking treatmenr just in case they were the possible pseudo-patient which is an ethical issue
With the follow up study, they didn’t know whether the patients they assessed actually had mental health issues, and therefore there was no way to isolate the cause and effect of if the staff wrongly diagnosed the patients

Question 8

What was Williams et al’s aim?

Answer 8

To investigate the impact of a seven day internet delivered ‘imagery based cognitive bias modification’ on negative thinking, distress and depressive symptoms
Also aimed to see whether this intervention would improve the effectiveness of online CBT

Question 9

What was William’s et al procedure?

Answer 9

Participants were recruited by a clinic based in Sydney, Australia and completed an online screening questionnaire and diagnostic interview by telephone
Resulted in 69 participants who were randomly allocated to the intervention group (38) or the ‘wait-list’ control group (31)
Baseline measures were taken of depressive symptoms, distress, degree if disability, anxiety and repetitive negative thinking for all the participants and there were no significant differences between the groups
This was done via short, structured telephone interviews and a variety of questionnaires (eg the Beck Depression Inventory)
Following an explanation of the treatment programme, all participants rated how logical the programmes seemed and the extent to which they thought it would be useful (using a 4 point scale)
The intervention group completed 7 days of CBM-I while the control group had no intervention, they then completed the questionnaires again
The intervention group then completed the 10 week iCBT course and were assessed, while the control group continued to ‘wait’ for their treatment - did the questionnaires
The control group did the 10 week iCBT but without the initial week of CBM-I
There was no face-to-face contact in the treatment or assessments and at the end participants rated their satisfaction with the programme
CBM-I involved daily 20 minute sessions for one week, where individuals are repeatedly presented with ambiguous scenarios which resolved positively
iCBT comprised of six online lessons of CBT including regular homework assignments and access to additional resources

Question 10

What were the results of Williams et al’s study?

Answer 10

Following CBM-I, the mean BDI score from the questionnaire went down by 9 points from the first questionnaire for the intervention group, compared to 3 for the control
Following iCBT, the mean BDI score dropped nearly 18 points for the intervention group and 7.5 for the control group
Average distress scores decreased by nearly 12 points for the intervention group, but only 4 for the control group

Question 11

What were the conclusions of Williams et al’s study?

Answer 11

Suggests that a brief, online CBM-I course can lead to significant symptom reduction in just one week, and the integrated of a ‘bottom-up’ approach into more traditional ‘top-down’ iCBT may be a useful addition

Question 12

What were the strengths of Williams et al’s study?

Answer 12

The control group provided a baseline comparison to isolate the cause and effect, and ensured it was the CBM-I treating depression, improving validity
The control group completed the same set of questionnaires as the intervention group which allowed the researchers to establish the extent to which changes in depressive symptoms were due to the intervention and not just passing of time
Results telling us that CBM-I further helps to reduce depressive symptoms has an important role in the future of treatments, as many people who waiting months or years on NHS waiting lists may be able to access support in their own homes
It was standardised and therefore reliable, as every participant completed the same questionnaire and were measured using the same measures (eg BDI)
The screening process made the study more reliable (eg those over 65 and with severe depression were not included)
No ethical issues as the participants were not harmed
High ecological validity as the people were in their own homes, meaning it reflected how online therapy would be in the real world

Question 13

What are the weaknesses of Williams et al’s study?

Answer 13

They used self report scales yet people may not answer honestly about their symptoms or ma tend towards overestimating their improvements as they knew they were in therapy, lowering the validity
The quantitative data tells us nothing about why symptoms have improved, although it was objective, whereas semi-structured interviews may have done this
The data collected might be bias and the research fails to provide more than a superficial understanding of how therapy works
No comparison was made to an alternative therapy which means it is not possible to attribute clinical change to the techniques that were used as other factors might have lead to the change in symptoms (eg attention from the therapist)
Quite a small sample making it less generalisable as it may not reflect all personality types within the whole population
Bias sample as all from a clinic meaning they’re more likely to seek help and be open and willing to therapy

Question 14

What was the aim of Carlsson’s study?

Answer 14

To present a review of the evidence for and against the dopamine hypothesis of schizophrenia
Also aimed to include a consideration of the role of other neurotransmitters
Wanted to explore new antipsychotics, especially for people who are ‘treatment-resistant’ or who experience extreme side effects

Question 15

What was the procedure of Carlsson’s study?

Answer 15

Conducted a review and analysis of literature/studied (secondary data) looking into schizophrenia
Involved looking at a range of studies and evidence to compare their results and bring together their findings to create a bigger picture of causes and treatments

Question 16

What were the basic results of Carlsson’s study?

Answer 16

supported the dopamine hypothesis
Found that other neurotransmitters are also involved in schizophrenia
Revealed two different models of schizophrenia (hypodopaminergic model and hypoglutamergic model)
Opposing models can be tested by comparing the effectiveness of different drugs

Question 17

What did Carlsson find about the dopamine hypothesis?

Answer 17

found continuing evidence to support it (eg PET studies show that amphetamines enhance schizophrenia as they increase dopamine levels) yet doesn’t apply to everyone with schizophrenia

Question 18

What did Carlsson find about the role of other neurotransmitters?

Answer 18

PCP (anaesthetic) induces schizophrenic symptoms and is a powerful antagonist of NDMA receptors (type of glutamate receptor) and decreases glutamate which increases dopamine, acting as an ‘accelerator’
Glutamate molecules also affect the release of GABA, which produces the opposite effect and acts like a ‘brake’ reducing dopamine activity - hypoglutamergia
There is normally a balance between the brake and accelerator, but when this is disrupted it can produce schizophrenic symptoms
Hypoglutamergia (glutamate failure) in the cerebral cortex may lead to negative symptoms, but in the basal ganglia (contains stratium at the base of the brain) it can lead to positive symptoms

Question 19

What two different models of schizophrenia did Carlsson find?

Answer 19

Hypodopaminergic model (traditional view of dopamine) - increased dopamine leads to psychotic symptoms
Hypoglutamergic model - glutamate can produce an increase or decrease in dopamine activity, depending on whether the accelerator (PCP) or brake (GABA) is applied

Question 20

What drug treatments did Carlsson suggest?

Answer 20

Haloperidol tackles hypodopaminergia and was better for treating amphetamine induced activity
M100907 tackles hypoglutamergia (affecting GABA via serotonin) and was better than haloperidol for treating hyperactivity

Question 21

What was Carlsson’s conclusions?

Answer 21

The dopamine hypothesis may be too simplistic to explain all the experienced symptoms of schizophrenia
Other types of neurotransmitters may also be implicated in the disorder
This has implications for the development of future drugs, like developing targeted drugs that can have an affect on specific neurotransmitters and receptors

Question 22

What were the strengths of Carlsson’s study?

Answer 22

The link between low levels of glutamate and elevated dopamine levels is supported by various experiments
Eg mice were given a drug to reduce motor activity then MK-801, which reduces glutamate and increases serotonin and dopamine which restarted motor activity
Using secondary data allows for the collection of a large amount of data that would have been difficult and time consuming to generate using primary data, this allowed the researchers to see the findings of lots of research and draw valid conclusions
Much of the research in the study were scientifically credible
Secondary data is more ethical as it doesn’t involve any manipulation of participants and refers to research that has already been done
However the researcher cannot personally check the data so reliability and validity may be questioned, the researcher may have no knowledge of how the data was collected, the data may be out of data so doesn’t reflect current social and cultural norms and the data is likely to be gathered to suit another aim
The research has led to the development of new drug treatments which reduce both positive and negative symptoms, and have less side effects as they act specifically on the disturbance in the neurotransmitter systems
Sendt et al has written a review of studies which supports these findings

Question 23

What were the weaknesses of Carlsson’s study?

Answer 23

They used evidence from studies involving rodents, primates, people with Parkinson’s disease, Huntington’s disease and schizophrenia - this is a wide range of evidence that supports the study, yet it may not be generalisable to the whole population
May not be as valid as animals have different brain functioning and levels of neurotransmitters so may not relate to human behaviour
animal studies fail to take account of cultural effects of schizophrenia, for example a study by Luhrmann found that participants in the US were more likely to experience violent and frightening voice whereas Ghanian and Indian people have more positive experiences
shows how animal models fail to capture the more holistic experience of schizophrenia which can be different for each individual

Question 24

What was the aim of the clinical practical?

Answer 24

To investigate whether tabloid newspapers and broadsheet newspapers present mental health disorders in different ways, and if it’s negative

Question 25

What was the procedure of the clinical practical?

Answer 25

The sample was two newspaper articles from February 2021, one from the Daily Mail, and one from the Guardian
Chose the research question ‘How do different media sources report mental health issues?’
We defined the categories for the content analysis by devising a list of seven words with negative connotations towards mental health, such as vulnerable
To ensure high validity, a practising psychotherapist has confirmed for us that these terms were used in the field of clinical research into mental health and illness
We recorded the frequency of the words used in an article from each newspaper reporting on mental health from February 2023 to find our manifest content
We also recorded who said the word, for example, if it was the reporter or a quote in the article, to reveal the latent content
As multiple coders were used we were able to check inter-rater reliability of the coding, which was high

Question 26

What were the results of the clinical practical?

Answer 26

The use of words with negative connotations towards mental health were used less in the broadsheet newspaper (12) than the tabloid newspaper (38)
Analysis of the latent content reveals that in both newspapers the reporter used the most negative connotations, but in the tabloid paper, the doctor who was quoted throughout used the most words associated as a negative connotation

Question 27

What were the conclusions of the clinical practical?

Answer 27

Overall, the use of words with negative connotations towards mental health were less common in the broadsheet newspaper, suggesting a difference in the negativity of depiction of mental health in different types of newspapers
However, use of terms with negative connotations were still frequently used in both newspapers, suggesting that there is still a negative bias on how mental health is reported
Our results are not consistent with Chen and Lawrie’s study suggesting that more research should be conducted to investigate this further

Question 28

What were the strengths of the clinical practical?

Answer 28

After coding the frequency of key words and noting the latent content, I checked my analysis with another researcher - as our frequency tables were consistent this established high inter-rater reliability
The content analysis follows a standardised procedure with pre-determined categories and a predetermined latent content to record
The newspaper articles could easily be analysed again by other researchers, using the same categories, to further check the consistency of the analysis
I took steps to ensure validity of the categories by using words that a psychotherapist had confirmed were used in the field of clinical research into mental health and illness

Question 29

What were the weaknesses of the clinical practical

Answer 29

Only two newspaper articles were selected as the sample (The Daily Mail and The Guardian)
other newspapers may use a different frequency of words with a negative connotation to mental health disorders - with such a small sample, the results have poor generalisability to the media’s depiction of mental health disorders in general
Our findings are inconsistent with the study by Chen and Lawrie as they found no difference between types of newspaper and negative reporting of mental health issues
This suggests that our research would need to be repeated to see whether the results are consistent in other studies
There may have been subjectivity when selecting keywords used to be included as categories for analysis - what one researcher believes to be a key word with a negative connotation may differ to what another researcher believes