Abnormal Psychology

GENERAL FRAMEWORK

To what extent do biological, cognitive and sociocultural factors influence abnormal

behaviour?
1. Define abnormal behaviour
Abnormality: ‘Psychologically disordered behaviour involves that behaviour is atypical,
disturbing to oneself and/or others, maladaptive and unjustifiable to oneself or others’ — David
Meyers 1998. (to their particular culture)

State the abnormal behaviour:

- Depression
- OCD

2. Biological:
● Role of neurotransmitter
● Genes
● Hormones

3. Cognitive:
● Learned helplessness
● Depression

4. Sociocultural:
● Conditioning — fear
● Making mental health diagnosis
○ Kasamatsu and Hirai — Hallucinations is the norm not abnormal.

Evaluate psychological research (that is, theories and/or studies) relevant to the study of
abnormal behaviour.

[Described + evaluated]

Ms. K — ‘one of the theories related to diagnosis is... (refer to Q. if possible)

Before diagnosing, it is key that the terms ‘abnormality’ and ‘normality’ are defined. One
definition/some definitions are... Abnormality can be defined as atypical behaviour out of
social and cultural norms that are disturbing to oneself and others and that is maladaptive and
unjustifiable to themselves or others. The concept however is difficult to grasp as there may be
some exceptions. Therefore there are many problems with theories and studies in diagnosing
abnormality.

One theory is Jahoda’s mental health model. In her model, she tries to define normality,
rather than abnormality. It includes six categories: self positive attitude, self actualization
(potential), personal autonomy (independency), accurate reality of the world and self, ability to
adapt to change and resistance to stress. If one is able to check all six categories, they are
considered normal. In a way, it is useful as it criticises other models and psychologists for only
approaching ‘abnormality’ by the mental illnesses rather than what is considered healthy. Eval.
Some empirical evidence also supports her model such as research in unemployment. It was
found that those without jobs for a substantial amount of time were unhappy due to lack of
ability, not because they were poor or were in financial crisis. However, Jahoda’s model is too
idealistic and in some cases like personal autonomy, children and the elderly may not be able to
achieve this because they cannot be independent. Also, those that do fulfill each category may
not necessarily be normal. Due to the fact that it is really subjective, the model is not valid in
some cases, and because it was originally developed during the 1980s, it needs to be updated
and revised. Good desc. and eval.

Another theory is the DSM for classification. it stands for Diagnostic and Statistical
Manual of Mental Health and consists of 5 axes. In total, there are 16 categories for mental
illnesses, unlike Jahoda, it is a list of what defines abnormal mental health illnesses. This makes
it quite precise and accurate due to the well structured and categorized system. It is also
thought to be a better model compared to the ICD. Another good aspect about the model is that
it is often revised. The most recently updated model today is DSM-IV. However, the downside is
it does not consider gender and culture, therefore is biased. Another problem is that it does not
explain the mental illnesses and what exact treatment can be enforced. There is only short term
treatment. It does not explain stigmatization mental illnesses and one study by Rosenhan
highlights the impact of labelling and problems with diagnosing when patients are normal.

desc. of study
Rosenhan’s study aimed to investigate the effects of labelling. as well as... test existing
diagnostic systems. He had a total of 8 participants, who were to complain to different mental
hospitals that they were hearing voices. All were admitted and 7 were diagnosed with
schizophrenia. Participants were meant to take notes on any observations during the ward. After
being admitted they were to act normal, not take any medication given by staff and convince
them they were sane. As a result, none of the pseudo-patients were able to convince the staff.
The average number of days spent in the ward was 19 and the longest was 52. Patients and
staff were segregated and normal interaction was discouraged. The staff thought that normal
actions were symptoms of abnormality. For instance, waiting outside cafeteria for lunch was
termed as oral acquisition syndrome and pacing the corridors out of boredom was seen as
nervousness. The pseudo-patients had lost their rights and privacy. They were verbally and
physically abused by staff and felt a sense of powerlessness and because of the label, moulded
into the expectations of it. Hence self-fulfilling prophecy. An interesting point to note was that
some of the actual patients sensed normality and questioned pseudo patients if they were
reporters! Eval. Although this does give good insight to the problems with labelling, Kety
defended the staff saying that they did not expect normal people to be admitted and were only
basing actions with the related disorder. Thus this is not enough evidence to conclude that
scientific method for diagnosing is incorrect and inaccurate. This particular study also lacked
ethical considerations for the participants as they were not protected from mental and physical
harm. + deceit towards staff at hospital.
 Diagnosing for culture bound syndrome is also crucial, since the DSM does not consider
other cultures as it is a Western model. Culture bound syndrome are thought to exist in a
particular geographical location and not found in others. Such a case is Tseng’s study. His aim
was to investigate Neurasthenia, which is characterized with symptoms of lassitude and fatigue
based on emotional disturbances. It was found that over half of all out-patients have this
disorder and it can only be found in the CCMD-2 (the Chinese model of DSM). He also
compared the disorder with symptoms from DSM and found they were similar to anxiety
disorders. This has lead to considering culture and the different symptoms others experience.
Yet this diagnosis is not always accurate. For instance the study by Lopez and Hernandez
aimed to show too much consideration in culture can lead to inaccurate diagnosis Eval. of
disorder and less treatment given to other cultures. Eval. They surveyed psychologists in
California who considered culture when diagnosing. It was found that many of their clients were
not given proper treatment. In one case, a psychologist did not give any medication or
suggestion to an African-American woman who had symptoms of schizophrenia because he
thought that it was acceptable in her culture. Therefore this study highlighted a need to
understand more thoroughly the changing cultures and what is acceptable or not. A problem
with this study however is that it was only surveyed in California therefore we cannot completely
generalize the results but only bear them in mind. Eval.

In conclusion, it is difficult to diagnose what is abnormal and what isn’t because of the need to
keep track of development in a patient and their culture. There are a multitude of factors that
can affect abnormal behaviour and revising research, theories and studies would lead to a more
accurate and valid diagnosis.

Good description of Rosenhan, CBC, DSM and abnormality + Jahoda.

Good evals.

A-9
B-8
C-4

21/22. Fantastic!!!

Examine the concepts of normality and abnormality.

Concepts:
— Defining normal + Abnormal
— Criteria
— Change in norm (over time, culture)
— Variations (between groups of people)
more accurately:
● Statistical infrequency * Deviation from the norm does not address the desirability
● Deviation from social norms
● Dysfunctional behaviour
● Deviation from ideal mental health
Normality
Situational norm: behaviour accepted in given situation
Developmental norm: Behaviour accepted in certain age
(Jahoda’s mental health)
*Deviation from social norms

SOCIETY’S NORMS:
● Situational norm
● Developmental norm
Evaluation - Change in periods of time. [Change in view of homosexuality]
Because what’s acceptable and not is always changing.
They may be abnormal but not seen breaking any norms e.g. depression
Abnormal → labelled → stereotypes → discriminated against
PRESSURE to stick to norm (conform), even if you don’t agree

Abnormality
Psychologically disordered behaviour involving atypical behaviour, disturbing oneself and
others, maladaptive and unjustifiable to oneself/others.

Homosexuality — Used to be considered abnormal, but then it didn’t break rules of Jahoda.

Evaluation (Jahoda)
● Those unemployed for long periods of time cannot fulfill, but does that mean they are
abnormal?
● Some may fulfill but are abnormal
● Vague, difficult to measure
● 1958, needs updating.

Outline for abnormal behaviour — Rosenhan and Seligman dysfunction and distress.
● Suffering
● Maladaptiveness
● Irrationality
● Unpredictability
● Vividness and unconventionality
● Observer discomfort
● Violation of moral or standard ideals
* Rosenhan and Seligman suggested it should occur in combination, more than one element to
determine abnormality.

Statistical infrequency/deviation from the norm

E.g. measures of IQ, ability to sing (bell curve)
Those at high end (not normal) are desired.
But weight (anorexic, normal, obese) -- Out of normal = undesirable.

Subjective feelings associated with abnormality.

- Intense anxiety
- Unhappiness
- Distress
Some are unaware of their condition - individuals suffering from schizophrenia.

Overall
Evaluation points:
● Problems in defining abnormality
● Some behaviours outside mean are considered desirable... in this case abnormality is
seen as good. Contradicts
● Some cases, undesirable cases can be considered normal
● Specific to age, gender, cannot use one diagnosis for all
● Who decides to put deviation? Does it change over time!?

Discuss validity and reliability of diagnosis.

Reliability: Testing for reliability — replicating experiment to give same results.
Validity: Is it applicable in everyday life? Does it measure real pattern of symptoms and can
effective treatment be administered?
causes vs. symptoms, bias

Evaluating — Strengths: unable to make reliable diagnosis, studies raise awareness and thus
classification systems get revised often.

How people are diagnosed?

1. Patient:
○ People need to be aware of the problem (unable to function adequately)
○ Symptoms
2. Clinician
○ Brain scan
○ Blood tests
■ IQ tests
■ Personality tests
■ Cognitive tasks
3. Techniques of assessment
○ Behavioural observation
■ +ve: direct and detailed information.
■ -ve :inter-observer reliability and subject reactivity.. Some symptoms
cannot be observed
○ Clinical interview
■ +ve: Detailed, flexible, sensitive method
 ■ -ve: Lacks objectivity
○ Psychological tests
■ +ve: Objectively rated, quick and standardized
■ -ve: personality tests rely on self report and literacy
○ Physiological tests
■ +ve: Precise data on brain structure or activity
■ -ve: Expensive, cannot be used to diagnose disorders

*Jahoda? Rosenhan and Seligman?

Evaluation of Classification Systems

Purpose of classification:
- Involves identification of groups or patterns of behavioural or mental symptoms that reliably
occur together to form a type of disorder.
● Allows prognosis (prediction of future course of the disorder)
● Can investigate and determine the causes (aetiology) of disorder
● Develop a suitable treatment.

Classification systems of disorders:

● Operational diagnostic criteria - APA (American Psychiatric Association)
● Kraeplin (1981 [1896]) proposed the system consisting of two major groups of mental
diseases - formed the basis of Diagnostic and Statistical Manual of Mental Disorders
(DSM) used today.
● International Classification of Diseases (ICD) - World Health Organization

Strengths (of classification)

● Statistical diagnosis (Objective)
● Quantifiable (Objective)
● Can apply suitable treatment
● Uses 5 different axis (kinda well rounded, looking at all viewpoints. btw, welcome to the
5th dimension - seen below)

Weaknesses (of classification)

● Ethical implications
○ labels such as “mentally ill”, “criminal” or “foreigner”
■ People who are different are stigmatized (socially excluded)
■ The diagnosis provides the patient with a new identity, for example
“schizophrenic”
■ In DSM, this has been rectified by recommending psychiatrists to refer to
a patient by “an individual with schizophrenia”
■ A label is for life, and even if the patient no longer shows such symptoms,
the label “disorder on remission” still remains (remission: reduction of
seriousness or intensity)
■ Labelling can lead to the self-fulfilling prophecy, where people act as
they think they are expected to, and the number of symptoms increase as
a result of being labelled
■ People who are labelled have to endure discrimination and prejudice
 ● Langer and Abelson Study
● showed a video tape of a younger man telling an older man about
his job experience
● If the viewer was told beforehand that the man was a job
applicant, he was judged to be attractive and conventional-looking
● if the viewer was told that he was a patient, viewers responded
that he was tight, defensive, dependent, frightened of his own
aggressive impulses
● This demonstrates the power of schema processing
● Reliability
○ reliability is high when different psychiatrists agree on a patient’s diagnosis using
the same classification system (also know as inter-rater reliability)
Studies (Prove how poor the DSM II system was) … May be unreliable
○ Beck et al. (1962)
Found agreement on diagnosis for 153 patients (each patient was assessed by
two psychiatrists from a group of four), was only 54%.
○ Copper et al. (1972)
When shown the same video-taped clinical interviews New York psychiatrists
were twice as likely to diagnose schizophrenia compared to London psychiatrists
and they (London), were twice as likely to diagnose mania or depression.
○ Rosenhan (1973)
Found 8 normal people could get themselves admitted to mental hospitals as
schizophrenics merely by claiming to hear voices saying single words like ‘hollow’
and ‘thud’. Also found staff of a teaching hospital, when told to expect pseudo-
patients, suspected 41 out of 193 genuine patients of being fakers.
● Validity
○ The extent to which the diagnosis is accurate (how true it is)
○ the classification system should be able to classify a real pattern of symptoms
which can lead to an effective treatment
■ However the system is descriptive and therefore does not identify specific
causes for the disorders
■ It is therefore difficult to make a valid diagnosis due to the absence of
OBJECTIVE physical signs of such disorders
○ For a valid classification system, it should classify a real pattern of symptoms,
which result from a real underlying cause + suitable treatment. Only a few
underlying cause is known for current Classification systems + a wide range of
treatment for some disorders.
○ Some classifications (such as “undifferentiated schizophrenia”, which is for
symptoms that fit for the general, but none of the sub groups) are rather
meaningless as diagnostic categories.
○ A valid diagnosis is much harder than the physical disorder as it lacks quite a lot
in physical signs.
● BIAS D:
○ From expectations or prejudices of diagnostician
○ Confirmation bias
■ clinicians tend to have expectations about the person who consults them,
assuming that if the patient is there in the first place, there must be some
disorder to diagnosis. (Fundamental Attribution Error)
■ Since their job is to diagnose abnormality, they may overreact and see
abnormality wherever they look
■ Study: Rosenhan (1973)
 ● On Being Sane in Insane Places
● Aim: to illustrate the problems in determining normality and
abnormality
● Method:
○ 8 sane people (3 women 5 men from a small variety of
occupational backgrounds)
● Evaluation
○ Experiment done in 1973, the DSM was updated several
times after this, therefore the manual may have become
more reliable
○ FAE (Fundamental attribution error) - over emphasizing situational than
behaviour, thinking people seeking help are in fact disturbed... when they may
not be.

DSM IV - multi-axial classification system

● Axis 1 Clinical Syndromes
● Axis 2 Developmental and Personality Disorders
● Axis 3 Medical Conditions
● Axis 4 Psychosocial stressors
● Axis 5 Global assessment of functioning

Strength of DSM
- Revised often, therefore criteria becomes more accurate as time passes
- Operational diagnostic criteria
- Multi-disciplinary approach, this gives a broader diagnostic

Weaknesses of DSM
- Gender and culturally biased
- Does not look at causes (cures only short-term or visible symptoms, doesn’t necessarily cure
the disorder)

Accuracy
- Because of DSM’s precise way that disorders have been categorised, it increases the
accuracy of diagnosis made through the use of the DSM.
- DSM has Sixteen categories of mental disorders.

Reliability
- DSM is more reliable than ICD because of the difference in categories and the more precise
way that disorders have been categorised.

Where will there be mistakes made in diagnosis?

- Inter-observer reliability is tested (only for behavioural observation). Since they will find/notice
different particular traits, or behaviours, they will diagnose differently. [conformation bias could
also play a role, to make the psychiatrist believe in his/her diagnosis]
- The classification is not completely objective and reliable, bias may result from the
expectations. [Temerline 1970 - found that clinically trained psychiatrists and clinical
psychologists could be influenced in their diagnosis by hearing the opinion of a respected
authority. After watching that video of an interview with a mentally healthy man, their diagnosis
was influenced by the line “although the person seemed neurotic, he was actually psychotic]
- Criteria changes over time and it takes time for both the DSM and the ICD to be updated,
during the transitional time frame, one without a disorder may be diagnosed with a disorder.

Discuss cultural and ethical considerations in diagnosis (for example, cultural variation,
stigmatization).
INTRODUCTION
Why is it necessary to consider culture in diagnosis?
● An individual’s behaviour is governed to an extent by the culture they are brought up in
● What is perceived as acceptable in one culture may be seen as a severe social problem
in another
● Kaiser et al. (1998)
○ Claimed psychiatrists are now encouraged to be aware of cultural differences
when assessing patients.

How to diagnose?
● Use a manual to diagnose mental health problems
● DSM - outlines conditions that appear most often in specific cultures, as well as some
cultural variations in the way symptoms are described.
○ E.g. Some cultures, depression is expressed as a physical pain, while others
describe depression as a feeling like sadness.

PROBLEMS!
Cultural Bias
● A tendency to favour your own cultural view of the world!!!!!

Labeling, stereotyping

Racism (overlaps with ETHICS)

● In UK, black people are more likely than white to receive a diagnosis of a severe mental
illness e.g. schizophrenia (Littlewood and Lipsedge, 1989)
○ Assumption: consequence of stressful geographical and cultural relocation black
people have when undertaken as immigrants to a new country.
○ [Illusory correlation]
○ Counter: Littlewood and Lipsedge (1989) argue majority of immigrants to Britain
in recent history is actually white, process of immigration cannot account for
difference. Also examined rates of serious mental illness. Higher on average for
British-born black people rather than migrant parents or recent immigrants.
○ Further assumptions (problems) - claim black people are genetically more likely
to suffer from mental illness.
○ Counter: World Health Orgnaization (WHO) conducted study of rates of
schizophrenia in Europe, North America, Asia and Africa. Little difference in rates
of severe mental illness reported. For genetic argument to hold, higher rates
should have been seen in countries with largely black populations.
 ● Already at a disadvantage, with lack of money and the assumption that blacks have a
higher chance of getting disorders would result in discrimination, and they would
experience a range of disadvantages in areas of housing, education, health and
employment.
● Littlewood (1980) suggested what is judged as ‘insane’ behaviour by some mental health
practitioners may actually be a legitimate and understandable response to disadvantage
and racism.
● Littlewood and Cross (1980) found black people received higher doses of drugs and are
more frequently given electro convulsive therapy (ECT) compared to whites with same
diagnosis.

Medical model and cultural differences

Stirling and Hellewell (1999) - many psychiatrists in UK are middle class, male and white, thus
are subject to their own cultural bias. p. 10 (Lynda Turner)

STUDIES
● Lopez and Hernandez (1986)
● Lewis et al. (1990)
● Hirai and Kasamatsu

Cultural differences
● Lopez and Hernandez (1986)
● Aim: Investigate effectiveness of being aware of cultural diversity when making a mental
health diagnosis.
● Method: Surveyed large sample of mental health practitioners in California, who were
trying to avoid discrimination against minority groups by being culturally aware. They
examined clinical assessments and treatments offered to patients over a period of time.
● Result: Many practitioners minimized seriousness of patients’ problems by assuming
their behaviour was culturally different rather than abnormal. E.g. one clinician claimed
that an African-American woman, who was suffering from symptoms of schizophrenia,
did not require treatment. He believed hallucinations were a normal part of African-
American culture.
● Conclusion: Sensitivity about culture diversity may reduce changes of some cultural
groups receiving appropriate treatment.
○ Evaluation on research:
○ Being too culturally aware and making assumptions may reduce treatment to
cultural groups.

Comparison between Westernized and Non-westernized models

● Erinosho & Ayonrinde
○ The Yoruba tribe in Nigeria were presented with vignettes (packet of info)
describing case studies of mentally ill people, one of whom was a paranoid
schizophrenic.
○ Only 40% of the Yoruba tribe identified the patients as mentally ill
○ 30% said they would be willing to marry such a person
○ Shows importance of taking an emic approach
 ● Binitie 1970
○ Presented vignettes describing case studies of mentally ill people to the
Nigerians
○ Found that 31% of Nigerians agree that such a person should be expelled, and
16% said they should be shot
○ Education and westernization had led to a decrease in tolerance - link to ethical
issue
● The two studies show how the perception of behaviour as normal or abnormal is
subjective, and is largely dependent on cultural norms
● It appears that schizophrenia is a western model, because less westernized cultures
(Yoruba tribe) were less likely to view hallucinations as negative
● The idea of cultural relativism (an emic theory) suggests that beliefs about abnormality
differ between cultures and sub-cultures
○ Schemas are mental representations of the world influenced by our environment
and own experiences
○ Since the definition of abnormality for each individual is largely based upon his or
her schemas, abnormality itself is therefore subjective
○ As a result, diagnosis of abnormality is therefore subjective, and dependent on
cultural norms
● Hallucinations were also viewed in Kasamatsu & Hirai
○ researchers at Tokyo university studied a group of monks who went on a 3 day
journey to a holy mountain
○ the monks did not eat, did not sleep, did not speak, were cold
○ they saw "ancient ancestors" and "presence by their side"
● Hallucinations were a product of enlightenment

Link: It is culturally normal to be experiencing hallucinations during these pilgrimages - part of a

meditative experience, not negative (desirable).
Ethical

- Labels
● Indicates that once a diagnosis has been made, it tends to stick. and so Scheff (1966)
argues that receiving a psychiatric diagnosis will create a stigma (severe disapproval of
the member of the society) or mark of social disgrace
● Problems :
○ we are not convinced that such diagnosis is reliable or valid, even if this situation
is improving.
○ there are significant negative effects of such a diagnosis on a person’s
subsequent treatment by other people.
● Research :
● Scheff (1966) criticised the medical model of mental illness and in particular the
diagnosis of schizophrenia. Such as being known as a Schizophrenic does not mean
that they will break formal and obvious rules, but residual rule breaking (basically
breaking the norm i.e. talking to themselves). He argued that many people breaks
residual rules, but only those referred to a psychiatrist acquire a label, which influences
their behaviour (feeling discomfort etc.)
● Read (2007) summarized a large amount of research relating to stigma. The findings
showed that attitudes towards those diagnosed in a medical context tend to be
characterized by fears, especially regarding dangerousness and unpredictably; also that
 knowing some one has a diagnosis of mental illness increases reluctance to enter into
romantic relationships with them.
● Distortion of behaviour - Diagnosis of mental disorder tends to label the whole person
- once the label of diagnosis is attached, then all the individual ’s actions become
interpreted in the light of the label. Sometimes even normal behaviour is ignored or
interpreted as a sign of the individual ’s mental disorder
○ Rosenhan (1973) Although not exactly ecologically valid, Rosenhan ’s study
provided evidence that patients being diagnosed with mental illnesses are
treated differently as a result of labeling. The pseudo-patients, although without
any mental illnesses, were being treated differently solely because they have
been labeled as “mentally ill”.

- Depersonalisation & Powerlessness

● This is produced in institutions through a lack of rights, constructive activity, choice and
privacy, as well as frequent verbal and even physical abuse from attendants. This can be
seen from the first asylums for the patients suffering from mental disorders, it looks more
like a prison.
● Research :
○ Rosehan (1973) - Rosehan’s study found that institutionalisation can lead to
depersonalisation, dependency, and a loss of self care sills, thereby worsening
the disorder.

- Self-fulfilling prophecy
● Patients may begin to act as they think they are expected to act - Goffman argues that
they may internalise the role of ‘mentally ill patient’ and this could worsen their disorder
rather than improve it.
● Research :
● Scheff (1966) “Self-fulfilling prophecy” ^similar to above. Because they are being
labeled, they will act in the way they think they should be acting or the way they are
guided towards acting (fake symptoms might surface).
● Doherty (1975) found that the patients which reject the mental illness which they were
diagnosed of, they tend to improve more quickly than the others.

- Prejudice and discrimination

● Hogg and Vaughan (1995) Stereotyping is a widely help assumption about personalities,
attitudes and behaviour of people based on group membership. People suffering from
mental illnesses are often negatively stereotyped, in turn leading towards discrimination.
Don’t you ever wonder why “therapist” is so similar to “the rapist?” ← lol, why in
bold? cuz its kewl.
● Research :
○ Rosenhan (1973) talked of the ‘stickiness’ of diagnostic labels - when an
individual returns to society, their record of mental illness goes with them (the
pseudo-patients left with a diagnosis of ‘schizophrenia in remission’) This can
lead to stigmatisation, stereotyping and discrimination against those who have
been mentally disordered, making reintegration back into the community difficult.
- Changes in terminology / language
● Ever since Scheff (1966) proposed the self-fulfilling prophecy, the psychiatrists are
encouraged not sure use terms which labels the patients, instead it shows that they are
suffering from a mental disorder. An example is given below, with an extra set of
explanation
● DSM IV explicitly reject terms such as “schizophrenic” but instead to use terms such as
“patient diagnosed with schizophrenia”. This is done to remove the label which leads
towards stereotyping.

- Confirmation bias
● Psychiatrists have confirmation bias, and so it is possible that the diagnosis is invalid.
This leads to a problem in ethics, since it is possible that the patient is diagnosed
wrongly, and then they are labeled, when in fact that person may be ‘normal’.

- Stereotyping
● Research :
● Faulkner and Layzell (2000) provided evidence of stereotyping experienced by people
suffering mental health problems
○ Aim: To provide evidence of stereotyping experience by people suffering mental
health problems
○ Method: A total of 584 participants completed a questionnaire, designed to collect
information about discrimination. They were also asked how they thought
discrimination could be reduced.
○ Result: 70% of the participants had experienced stereotyping and discrimination;
66% said that they had not told people about their difficulties because of the
stigma attached to mental distress.
○ 30% experienced discrimination in the workplace, i.e. dismissal
○ 56% said that one of the main sources are from their families, and 52% from
friends.

Conclusion:
○ Mental health patients are negatively stereotyped and can experience
discrimination as a result of their diagnosis. This discrimination (and the fear of it)
adds to the difficulties of people with mental health problems. The figures also
reflect how severe the problem with discrimination and stereotyping is.
● Women are ore likely to be diagnosed with depression. While one vein of research
investigates the unique biological reasons why this might be the case, another argument
suggests that diagnostic criteria for depression are a description of normal female
response to social pressures, and as such should be pathologized but be understood
better and treated on a social rather than individual level.

- Schemas
 ● This relates to stereotypes, as from many places (gossips, media etc.) they may have
some negative connotations, and so whenever the terms “mental illness” or
“schizophrenic” is used, the schema will be activated and there will be stereotype.

- Racial / ethical Bias

● Morgan et al. (2006) found that in UK, the incidence of schizophrenia in nine times
higher for Afro-Caribeans and six times higher for those of black African descent, than
for while British people The researches argue that genetic differences cannot account for
this and it is more likely that diagnosis bias account for it. Migrants and ethic minorities in
many European countries and the Anglo-American world are over represented in mental
hospital populations (Read et al, 2004)
● Jenkins-Hall and Sacco (1991) Involved European American therapists being asked to
watch a video of a clinical interview and to evaluate the female patients. There was a
depressed and a non-depressed person in each of the race (only African American and
European American in the research). The non-depressed were evaluated in similar
ways, but the ratings for the African American woman had more negative terms, and saw
her as less socially competent.

- Changes / updates
● Homosexuality was removed from DSM since the DSM III (1980). These changes and
updates,

PSYCHOLOGICAL DISORDERS

Describe symptoms and prevalence of one disorder from the two groups:
— anxiety disorders
— affective disorders
Disorder: Depression + OCD

Depression - Symptoms, prevalence (gender, culture... general), etiologies (attempt

to explain the disorder) - bio, cog, sociocultural
Types: Unipolar and Bipolar; clinical depression (major depressive disorder); SAD
Unipolar - person’s mood changes from normal to depressed.
Bipolar - characterized by mood swings. When depression lifts, the person enters a period of
extreme elation known as mania.

Symptoms of unipolar disorder

● Cognitive - e.g. thought process is impaired, memory and concentration is affected.
Difficult to think positively about themselves. May be suicidal.
● Emotional - e.g. sadness, despair, absent feelings, ‘empty’, no interest in pleasure
● Behaviour - e.g. Stop socializing, stop taking care of themselves, handle everyday
activities slower, attempt suicide
● Physical (somatic) - e.g. Sleep disturbance, and loss of appetite and weight. Doctors
believe 40% of people suffering with depression visit their surgery for first time due to
 physical symptoms including aches, pain, lack of energy, palpitations, headaches,
stomach upsets.

Diagnosis of unipolar disorder

May appear gradually or suddenly.
Occurs in all social classes - all ages
Severe forms more common in middle and old, though there’s been steady increase in
depressive illnesses amongst people in their 20s and 30s.
Diagnosing depression - combinations of symptoms above must last for at least 2 weeks.

Evaluation points
● DSM and ICD can diagnose mood disorder on symptoms experienced not by physical
tests to establish it and are thus based on self reports from patient.
● Aetiology (cause of disease) - unclear

See gender and cultural variations of prevalence in depression in L.O. ‘Discuss cultural
and gender variations in prevalence of disorders.

OCD
Definition
- Obsessive - compulsive disorder
- An anxiety disorder characterized by intrusive thoughts that produce uneasiness, fear or worry,
by repetitive behaviours aimed at reducing the associated society or a combination of
obsessions and compulsions.

- An obsession is defined as an unwanted intrusive thought, image or urge, which

repeatedly enters the person’s mind (not imposed by an outside agency)
- Compulsions are repetitive behaviours or mental acts that the person feels
driven to perform. (can be either overt and observale by others)

Classification
- International Classification of Diseases (ICD-10)
- The essential feature of this disorder is recurrent obsessional thoughts or compulsive
acts.
- Obsessional thoughts are ideas, images or impulses that enter the individual’s mind
again and again in a stereotyped formed. They are almost invariably distressing and the sufferer
often tries, unsuccessfully to resist them.

- Compulsive acts or rituals are stereotyped behaviours that are repeated again and
again. They are not inherently enjoyable not do they result in the completion of inherently useful
tasks.
- Excessive washing or cleaning
- repeated checking
DSM - IV: Classification of OCD
Obsessions are defined as recurrent and persistent thoughts, impulses or images that are
experienced.
● preoccupation with sexual, violent or religious thoughts

Compulsions are repetitive behaviours that are aimed at preventing or reducing distress or
preventing some dreaded event or situation.
● extreme hoarding
● nervous rituals (e.g. opening and closing a door a certain number of times before
entering or leaving a room)
● Excessive washing or cleaning
● repeated checking
● aversion to particular numbers

* Specify if : with poor insight - for most of the time during the current episode, the person does
not recognize that the obsessions and compulsions are excessive or unreasonable.
(whether the patient knows that their behaviour is abnormal or not, might not search for
help)

Prevalence
- Fourth most common mental disorder
- In US, one in 50 adults suffers from OCD
- About one third to one half of adults with OCD report a childhood onset of the disorder
(suggests that the continuum of anxiety disorders across the life span)
- OCD is equally common in men and women. But the disorder’s onset is reported to occur
earlier in men than women.
- Lifetime prevalence in community surveys of about 2-3% (Robins et.al. 1984)
- (According to the WHO, only 1 - 2% of the whole population has OCD. It is more common
amongst young children, but increases as they advance into adolescence.) <- ?

Prevalence Bogetto et al. (2009) - Males are more prone towards OCD at a younger age.
– Gender 160 patients diagnosed with OCD were investigated. Patients were evaluated
with a semi-structured interview covering socio-demographic data, the first axis
of the DSM system (the display of certain mental disorders), clinical features of
OCD and social background. The researchers found that males had an earlier
development of obsessive compulsive symptoms and disorder. Females showed
more frequent acute symptoms of OCD and episodic courses of illness.
Throughout the whole investigation, males showed more common symptoms of
OCD whereas females frequently develop eating disorders. In conclusion to their
findings, they found traits in reference to gender and OCD:
- Males show and earlier age at onset with a lower impact of particular events in
triggering the disorder.
- OCD seems to occur in a relative high proportions of males who already have
 existing phobias.
- Excessive amount of chronic course of the illness in males when in comparison
with females.

Stirling and Hellewell (1999) found that OCD generally beings from early
adulthood, and can persist on for many years.

Prevalence Williams et al.

- Culture http://findarticles.com/p/articles/mi_hb4345/is_8_32/ai_n29117890/
(Originally African Americans were thought to have a higher percentage of the
population to have OCD, but apparently it’s now disproved)
Aim: To find out the difference between cultural factors and OCD prevelance
Method: 789 White Americans and 221 African Americans not diagnosed with
OCD. They used 4 common OCD instruments to measure their levels of OCD.
They were also questioned about attitudes towards hygiene, health, pets and
cultural mistrusts.
Findings:The OCD levels were similar, didn’t contrast too much between the 2
groups.
Conclusion: After many trials, they concluded that there is no strong correlation
between cultural factors and chances of getting OCD
Evaluation: Questionnaires might not be completely valid.

Zor et al.
http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=2682
(OCD looks alike in all cultures, compared to the differences in culture, the
symptoms of OCD are more coherent with each other, not much difference
between cultures – Israeli and British.

Aim: To find the difference between cultural factors and symptoms of OCD.
Method:9 Israeli and 9 British patients suffering from OCD were chosen after
signing the consent forms. For each patient, they found a healthy person with
the same age, gender and nationality, for control. (Matched pair)
They videotaped in their homes after briefing them about the videos, and asking
them to perform a Y-BOCS test. When they asked the OCD patient to perform a
task, they would also ask the healthy person to do the same (not at the same
time).
Findings: In both cases, the people suffering from OCD have exaggerated
repetitions in their rituals compared to their healthy matched pair.
Conclusion: The symptoms of OCD greatly outweights the difference between
cultures and so the symptoms of OCD will be similar in all cultures.

Analyse etiologies (in terms of biological, cognitive and/or sociocultural factors) of one
disorder from the two following groups:
— anxiety disorders
— affective disorders
Depression
Cognitive:
http://cranepsych2.edublogs.org/abnormal/abnormal-psychological-disorders/

(Seligman) Helplessness: Does not explain blame

(Abramson) Faulty Attributions [theory]:

E.g. Failure
Internal - explains guilt, shame, self-blame, affecting self-esteem → Hopeless External

Stable Unstable

Global Specific

Beck’s theory of depression - negative self schema

Self schema - expectations, knowledge of self.
- starts from ages 3-5 (parents are important)
-ve self schema → hard to interpret positively, regarding self

Becks cognitive triad of thinking

Future ← Ourselves → World
Event: Doing coursework
Ourselves: I can’t handle this coursework
World: Worried teacher would dislike it and give you a bad grade
Future: Whatever coursework you hand in, it will be bad
[Pessimistic people]
● Lewinsohn (1981) carried out a prospective study in which negative thoughts were assessed
before any of the participants became depressed. He concluded that there was no relationship
between negative thought and irrational beliefs and future depression.
● However Nolen-Hoeksma et al (1992) found that a negative attribution style in older children
predicted later depression, but only in the children who experienced stressful life events.

(social) Vulnerability model

- interaction of vulnerability factors and provoking agents
original factors:
● losing one’s mother at young age
● lack of confiding relationship
● more than 3 young children at home
● unemployment
US - lower prevalence of depression in Hispanic communities (Wu and Anthony, 2000)

Definition
- Obsessive - compulsive disorder

- An anxiety disorder characterized by intrusive thoughts that produce uneasiness, fear or worry,
by repetitive behaviours aimed at reducing the associated society or a combination of
obsessions and compulsions.
Biomedical Biological etiologies
Etiology/ Genetic predisposition:
Treatment McKeon and Murray found that relatives of OCD patients were more likely than
the rest of the population to suffer from anxiety disorders in general, but no more
likely to suffer specifically from OCD.
Black et al found in their large family study that relatives of OCD patients were
likely to suffer a variety of mental disorders, but no more likely than the general
population to suffer OCD.

twin and adoption studies********** :D*

Neurological factors:
It has been suggested that OCD is caused by abnormalities in the brain circuit.

A primitive brain circuit involving orbital-frontal cortex, thalamus and caudate

nucleus regulates aggression, sexuality and bodily excretions. The orbital-frontal
cortex notices something is wrong in the external environment, and sends a worry
signal to the thalamus. The thalamus directs signals back to the OFC in order to
react to the worry signal. The caudate nucleus lies between the orbital-frontal
cortex and the thalamus, and it regulates signals between the other two. Normally,
the caudate nucleus acts like the brake of a car, suppressing the worry signals
from the OFC to the thalamus. This prevents the thalamus from being hyperactive.

It has been suggested that OCD patients have damaged caudate nucleus, which
then causes increased signals between the OFC and thalamus, thereby resulting
in increased anxiety. Repetitive behavior called compulsions and obsessions are
the results of such anxiety. Obsessions are uncontrollable, worrying dangerous
thoughts which may lead to compulsive actions to soothe the obsessions.

In support of the circuit theory, obsessions and compulsions found in OCD

patients have themes related to sexuality, aggression and contamination, which
are exactly the themes that the above brain circuit deals with. Furthermore, the
brain circuit consists of primitive brain areas which do not deal with higher mental
functions such as reasoning. This supports the fact that OCD patients' obsessions
are often irrational, and patients cannot use reasoning to stop their obsessions.

Baxter et al. used PET scanning to observe the differences in brain function in
OCD patients before and after successful treatment. They found that the main
difference following treatment was that the right caudate nucleus became more
active, suggesting that the caudate nucleus does indeed correlate to OCD
(perhaps more activation means more compulsive acts).

Neurotransmitter (serotonin):
It has been suggested that an imbalance of the neurotransmitter serotonin causes
 dysregulation of the brain circuit, since OCD patients respond positively to SSRIs.
Low serotonin levels causes the brain to over-react and misinterpret stimulus,
leading to flawed cognition, which may develop into obsessions.
Hollander et al found that the drug M-CCP, which reduces serotonin levels, made
OCD symptoms worse.
Pigott et al found that anti-depressants, which increases serotonin levels, can
reduce OCD symptoms.

Biomedical treatment
● Drugs that affect neurotransmitter serotonin can significantly decrease
symptoms of OCD
○ Drugs like — SRI (serotonin re-uptake inhibitors), was the first to
be approved, followed by SSRI (selective serotonin re-uptake
inhibitors), approved by the Food and Drug Administration for
treating OCD e.g. flouxetine (Prozac), paroxetine (Paxil) etc.
● European psychiatrists reported in late 1960s early 1970s, medication
called clomipramine was effective in a series of cases of OCD.
○ Series of studies confirm behaviour therapy + serotonin reuptake
inhibitors (SRIs) are established as effective treatments for OCD.
○ Most broadly effective treatment for OCD appears to be a
combination of a SRI and behaviour therapy.
○ [http://psychcentral.com/lib/2006/treatments-for-obsessive-
compulsive-disorder/]

Effectiveness of medication:
● For more than half of patients, medications relieve symptoms of OCD,
diminishing frequency and intensity of obsessions and compulsions.
● Improvement usually takes at least 3 weeks or longer.
● If patient does not respond well to a particular medication, another SRI
may give better results.
● Medications help control symptoms of OCD, but like depression, if
medication is discontinued, relapse will follow because patients do not
know how to cope.

Cognitive Cognitive etiologies

Etiology/ In OCD patients, too much significance is attached to certain thoughts. This
Individual attachment is formed through flawed beliefs developed in earlier life. The following
Treatment are false beliefs which OCD patients often have:
● "exaggerated responsibility," or the belief that one is responsible for
preventing misfortunes or harm to others
● the belief that certain thoughts are very important and should be controlled
● the belief that somehow having a thought or an urge to do something will
increase the chances that it will come true
● the tendency to overestimate the likelihood of danger
● the belief that one should always be perfect and that mistakes are
unacceptable.

OCD patients' worrying obsessions are formed by these beliefs. Because patients
are conscious of their obsessions, confirmation bias further reinforces their
obsession is correct. Thus a vicious cycle is born.
It is argued that compulsions, which follow obsessions, are a learned process -
conditioning. In response to lowering the amount of stress due to the obsessions,
OCD patients will perform compulsive actions routinely. Since these compulsions
reduce worries, the soothing effect gives motivation to repeat the action.

Treatment:
● OCD was generally considered to be untreatable for over 50 years
● Until in 1966 Victor Meyer described successful treatment of 2 people with
OCD
○ His treatment is the forerunner of modern day CBT.
○ How it was done:
■ Changing cognitions
■ blocking compulsive rituals
○ Study (Meyer, 1966)
■ Applied experimentally established principles of learning
theory to treatment of OCD
■ Reported treating 15 patients with OCD using 2 behaviour
therapy procedures - ERP (exposure AND responses [ritual]
prevention)
■ He persuaded patients to confront (2 hours a day) situations
they’d normally avoid (e.g. bathrooms)
● Purpose was to induce obsessional fears and urges
to ritualize
● They were instructed to refrain from the rituals (e.g.
washing)
■ Result - 10 responded well and remainder was partial
improvement.
■ Evaluation point: Follow-up studies conducted several
years later found only 2 who had been successfully treated
relapsed (Meyer, Levy and Schnurer, 1974)
■ http://findarticles.com/p/articles/mi_6884/is_2_2/ai_n281280
28/]
○ His technique of behaviour therapy technique was later referred
to as exposure and response prevention
● From then onward, there had been many studies, experiments and
research to develop these behavioural techniques
● More than 30 years of published research and a large number of
authoritative accounts have led to a widely held consensus that
behavioural therapy is an effective treatment for OCD
● These experimentations based on behaviour procedures evolved into a
therapy central technique — ERP (exposure and response prevention)
○ Formats of ERP: book, computer-based self-help, group therapy,
individual therapy

Psychotherapy
Definition — A social interaction where a trained professional tries to help
another person feel or think differently.
(Purple book p. 113)
Behaviour Therapy
 Definition (wikipedia) - Treatment through techniques designed to reinforce
desired and eliminate undesired behaviours.
Cognitive Therapy
Definition (wikipedia) - Treatment through identifying and changing
dysfunctional thinking, behaviour and emotional responses by helping
patients develop skills or modifying beliefs, identifying distorted thinking
etc. to change behaviour.
Cognitive behavioural therapy
Definition — combination of both behaviour and cognitive therapy.
● Cognitive Behavioural Therapy (CBT) — most effective type of
psychotherapy for this disorder.
○ Patients are exposed to many difficult situations that trigger
obsessive thoughts. Through CBT, they gradually learn to tolerate
anxiety and resist urge to perform the compulsion.
○ Eclectic approach — Using medication and CBT together is
considered better than either treatment alone at reducing
symptoms.
○ At least 10-20 hours of treatment and practice are required to
achieve a favourable outcome - success rates as high as 80%
have been documented.
[http://psychcentral.com/lib/2006/treatments-for-obsessive-
compulsive-disorder/]
● Evaluation point: BT may not be suited for everyone - OCD patients with
depression, or those nearly convinced their fears are valid do less well with
BT alone.
● Exposure and response prevention — which is a specific behaviour
therapy
○ In this approach, patient deliberately and voluntarily confront feared
object/idea either directly or by imagination.
○ Individual is encourage to refrain from ritualizing
○ E.g. compulsive hand washer may be encouraged to touch an
object believed to be contaminated then urged not to wash for
several hours until anxiety provoked is greatly decreased.
○ As treatment progresses, most patients slowly experience less
anxiety from obsessive thoughts, then able to resist compulsive
urges.

Psychotherapy can also be used to provide effective ways of reducing

stress, anxiety and resolving inner conflicts.

Socio- Socio-cultural etiologies

cultural Cultural/social factors determine the kind of compulsions that manifest in OCD
Etiology/ patients. It is suggested that compulsions are filtered through culturally informed
Group expectations (social norms).
Treatment
Mahgoub and Abdel-Hafeiz 1991 studied the pattern of OCD in Saudi Arabia. Our
of 32 subjects, 87% had religious compulsions (repeating and washing), 9% had
compulsive avoidance and 9% had non-religious cleaning rituals.

Rasmussen and Eisen found that in western cultures, 50% had washing
 compulsions.

The two studies show that there is a difference in compulsion prevalence between
cultures, indicating that culture is an explanation for the type of compulsion shown
by a patient.
But, there are no indications that groups who are more heavily religious have
higher incidence of OCD.

Making treatment more effective:

● Group therapy
○ Sharing problems and achievements with others
● Talking with a trusted friend
● Stress management techniques and medication can help people with
anxiety disorders calm themselves and may enhance effects of therapy.

(STUDY) Group and individual treatment of OCD using CT and ERP (2 year
follow-up of 2 randomized trials) (Whittal et al. 2008)
[http://www.ncbi.nlm.nih.gov/pubmed/19045968]
● Study of follow-up results or participants who completed randomized trials
of group or individual treatment and received either CT or ERP.
● Yale-Brown Obsessive Compulsive Scale (YBOCS) scores for individual
ERP and CT were not significantly different over 2 years.
● YBOCS scores were consistently lower over time for group ERP
participants than group CT’s.
● *Single exception - in group treatment study, secondary cognitive and
depressions scores were stable, indicating that gains achieved during
acute treatment were maintained over 2 years.
● Less than 10% of treatment relapsed in each of treatment trials.
● Cross-study that CT was better tolerated and resulted in less dropout than
did ERP.

Another supporting study for OCD group therapy:

http://www.ncbi.nlm.nih.gov/pubmed/12792126

Treatment Summary 1. Psychotherapy

a. Behaviour Therapy (Individual)
b. CBT
c. Exposure and Response Prevention (ERP)
d. Cognitive therapy
2. Biomedical Treatment (Pharmacological)

Discuss cultural and gender variations in prevalence of disorders.

Gender Variations of Prevalence in Depression

 SIMILARITIES
● Symptoms of depression in both sexes are similar (but etiologies may be different)
○ Symptom 1: hopelessness and helplessness (Affective)
■ Which can be explained by Beck’s cognitive triad, and negative self-
schemas (dispositional attribution)
■ Similar faulty attribution in both sexes leads to depression
○ Symptom 2: insomnia or hypersomnia (Behavioural)
■ caused by the levels of melatonin (since melatonin is synthesized from
serotonin, therefore when serotonin levels change, as it does when one
has depression, melatonin levels will also be affected)
■ It can also explain fatigue and sleep disturbance as the body clock is
based on melatonin levels. (somatic)
● Females and males with similar heritage seem equally likely to develop depression
(Leibenluft)
○ This was found by studies tracing family histories of depression
○ The studies show that females are not more likely to inherit genes related to
depression than males
○ Therefore the increasing prevalence of depression in females may be related not
to genetic disposition, but rather environmental biases toward females
● They all respond to the same biological treatment
○ SSRIs (selective serotonin reuptake inhibitors) and MAOIs (monoamine oxidase
inhibitors) are most common to treat for depression. Both these drugs increase
the serotonin absorption.

DIFFERENCES
● Females are 3 times more likely to be diagnosed with depression (US National Institute
of Mental Health 2004)
○ Social Explanation
○ Men are reported to be less likely to report their feelings of depression, in order
to maintain their self-esteem, as the society which they live in may see having a
disorder as a sign of weakness
■ Conformity to group norms (that is the expected behaviour of genders in a
certain society) cause women to be better trained in recognizing their
feelings and seeking help, so they come to the attention of health
professionals more often than men
● Biological Explanations
○ Melatonin secretion in males can be based on artificial light (i.e. from fluorescent
lights), whereas females’ melatonin secretion is chiefly a response to natural light
(Wehr et al.)
■ According to Mental Health America, 3 out of 4 SAD patients are women
■ During winter, women would be more affected by the shortened length of
day compared to men (more melatonin in women due to shortened
daylight time).
■ Therefore women would feel more passive and lacking energy, which are
all symptoms of SAD
○ A PET study conducted by Diksic et al. has shown that males have an average
serotonin synthesis rate that is 52% higher than females.
■ There are studies suggesting that depression is correlated with low levels
of serotonin (Agren et al), therefore lower serotonin synthesis rate in
females suggests that they are more prone to depression
 ■ Since research has also suggested that melatonin is synthesized from
serotonin, and depression is correlated with lower levels of serotonin,
depression patients will have lower levels of melatonin too. Since
melatonin regulated the circadian rhythm, irregularly low levels of
melatonin will lead to insomnia, which is a symptom of depression.
Therefore, lower serotonin synthesis rate will cause symptoms of
depression.
○ Menstrual Cycle
■ Elevated levels of oestrogen in females during the menstrual cycle might
lead to more pronounced and longer lasting stress response, ultimately
leading to severe exhaustion (Selye’s General Adaptation Syndrome) and
depression.
● Chrousos et al found that increased levels of oestrogen
heightens levels of CRH
○ CRH makes the pituitary gland release ACTH, which
prompts the secretion of cortisol in the adrenal glands
● Increased levels of cortisol should prompt the hypothalamus to
decrease the levels of CRH and thus cortisol itself, however
Young et al have found that female rats are more resistant to this
system than male or spayed female rats
○ suggesting that oestrogen decreases cortisol’s ability to
shut down its own secretion
■ Young et al also found that women have longer-lasting cortisol responses
during the phase of the menstrual cycle when oestrogen and
progesterone levels are high
■ It is unclear as to whether depression is a cause or consequence of
elevated cortisol levels, but the two are definitely related.
● studies have shown that about half of all severely depressed
people, both men and women, have elevated cortisol levels
■ If oestrogen elevates the levels of cortisol, and prevents cortisol levels
from lowering, then oestrogen might render females more prone to
depression (especially after a stressful event)

Culture Variations of Prevalence in Depression

Depression
Around 15% of people experience at some point in their life (Charney and Weismann
1988).

Similarities
Prevalence
● World Health Organization (WHO, 1983)
○ The common symptoms of depression include sadness, loss of
enjoyment, anxiety, tension, lack of energy, loss of interest, inability to
concentrate, and ideas of insufficiency, inadequacy, and worthlessness.
○ These results came from research done in four different countries: Iran,
Japan, Canada, and Switzerland

Differences
● In USA - lower prevalence of depression in Hispanic communities (Wu and
Anthony, 2000)
○ Etiology: SCLOA, vulnerability model includes the factor of “lacking of a
confiding relationship”, Hispanic communities are closer and tend to share
their experiences more often.
● Countries with strong traditional roles of family and higher religiosity have a lower
prevalence in depression
● Prince (1968)
○ There was no depression in Africa and various regions in Asia, but found
that depression rates rose with the westernization of developing nations.
○ Correlation between Development and depression -> pressure, stress due
to work and increasing competition between individuals (social
comparison).
■ possibly from the need to learn a new language? new jobs, and to
work at the same time, compared to before when their job doesn’t
change?
■ Collectivitism and individualism
● Kleinman (1988)
○ Non-industrialised societies had higher recovery rates
○ Etiology: People from these societies experience less work related stress
therefore releases the pressure, providing them a suitable environment for
recovery.
● Kleinman (1982)
○ Somatization is mainly used as a typical channel of expression and as a
basic part of the depressive experience in China which is different from
other cultures in terms of the symptoms of depression.
○ Somatization - how depression is experienced through physical
discomfort.
○ Etiology
■ There are cultural preferences in the way that emotions are
experienced and communicated, with bodily complaints judged as
more socially acceptable than complaints of emotional distress.
● ( In a culture where ‘display rules ‘ govern emotional
expression, it is more acceptable to seek help for physical
than emotional problems.)
■ In Chinese culture, emotional messages are conveyed not in words
that designate emotions but usually through metaphors that are
related to physical body -> due to suppression of emotions, a lack
of distinction between the psychological and the physical or
constraints of vocabulary ->they often explain the word ‘depression’
somatically.
● Early studies suggested that the Chinese tended to complain of somatic
symptoms and avoid seeking psychiatric help (due to lack of medical and social
support services at that time.)
● Stigma of Mental Illness
 ○ Mental illness is stigmatized in traditional Chinese culture -> seen as
evidence of weakness of character and a cause for family shame, a
‘collective loss of face’ for the extended family
○ Stigmatization prevents individuals from approaching psychiatrists,
therefore rates of depression should be higher than actual statistics.
○ Chinese may have another systems for diagnosis, therefore Chinese may
be diagnosed as another mental illness rather than depression. Hence,
the actual statistics may be even higher.
● Parker, Gladstone and Chee (2001) -
http://cranepsych.edublogs.org/files/2009/07/depression-in-china.pdf
○ Reviewed evidence for claim that Chinese tended to deny depression or
express it somatically. They concluded it supported hypothesis of the
tendency for Chinese to deny depression. However Western influences on
Chinese society on detection and identification of depression are likely to
have been modified since early 1980s.
● Marsella (1979)
○ Individualist cultures are more likely to have affective symptoms (linked
with emotions), while collectivist cultures are more common to show
somatic symptoms (physical).

Prevalence:
● Gabilondo et al. (2010)
○ Depression occurs less frequently in Spain than in northern European
countries
○ Lower rate of suicide in Spain than European countries
■ Different cultures in Spain and European countries (Stronger
traditional roles of family [collectivistic cultures] and higher
religiousity were proposed as sociocultural variables)

IMPLEMENTING TREATMENT

Examine biomedical, individual and group approaches to treatment.

Biomedical approach to treatment

Focus : Changing the physiology of the individual through medical treatments.

1. What Biomedical treatments are available for depression and how do they work?
(see below!!)

2. What does the biomedical approach to treatment presume? i.e. what assumptions is the
approach based on?
● Mental disorders can be understood as illness in the same way as physical conditions.
They can be classified, diagnosed and treated by the medical profession in the same
way as physical disease.
● The emphasis is on physiology rather than behavorial, cognitive or emotional difficulties.
● It is assumed that scientific research will eventually discover the biological causes of all
types of mental disorder.
3. What are three important factors that clinicians need to consider when implementing
drug treatments?
● Dosage (dependency and withdrawal may result from overdose)
● Side-effects (allergies, other effects, developing physical tolerance towards drugs)
● Appropriate treatment for the occasion, alternative treatments may be a better option.
Longer lasting treatments such as CBT may be more beneficial for abnormalities that
crop up more often in daily life, i.e. OCD. Drug therapy will be more efficient in cases like
dental phobia.)

4. Evaluate the effectiveness of the biomedical approach to treatment with evidence.

(see below!!)

SSRIs (selective-serotonin re-uptake inhibitors)

How do they work?
● SSRI is a type of anti-depressant
● It aims to increase the amount of seratonin in the brain, since low seratonin levels are
associated with depression
● Specifically, SSRIs block the reabsorption (reuptake) of seratonin.
● Low levels of seratonin crossing the synaptic space means that the post synaptic neuron
does not have enough seratonin to start an impulse, therefore neurotransmission is
hindered. SSRIs inhibit the reuptake of seratonin so that there is more seratonin to be
attached to the post synaptic neuron, leading to higher efficiency of neurotransmission.

SSRI IS effective:
- When compared to previous anti-depressants, SSRIs are as effective, and have less side
effectives.
- They are also easier to administer (available in liquid form for young children)
- Alarcon: SSRIs are the most prescribed drugs for depression. This must mean that SSRIs
are more effective/accessible in comparison to other drugs or biomedical treatments.

SSRI ISN’T effective: (side effects)

- Healey (1999) claims that about 250,000 people worldwide have attempted suicide while
taking Prozac, with 25,000 succeeding. Survivors have described a strange, agitated
state of mind with unstoppable urges to commit violent acts. They had not felt
suicidal prior to taking Prozac.
- In response to these suicidal side effects, the Medicines and Healthcare Regulatory
Authority decided that SSRIs should not be prescribed to children under 18 in the UK
(MHRA 2003)
- Elkin
Procedure:
- 240 depressive patients
- 4 groups receiving different treatments: psychodynamic, cognitive, antidepressant
and placebo (control)
- groups monitored for 16 weeks
Results:
- all subjects NOT in the control showed signs of improvement
- after 16 weeks effects of all 3 treatments were about the same, however therapy
groups were less likely to experience relapses when compared to drug group
- suggests that SSRI is not THE best treatment to give
- Kirsch has suggested that placeboes work equally as well as SSRIs
ECT (Electro-convulsive therapy)
● Introduced by Cerletti and Bini in 1938.
○ They gave an electric shock to the brain of a psychiatric patient, believing that it
would eliminate symptoms of schizophrenia by producing an epileptic seizure.
○ However it was later found out that ECT’s more effective in treating severe
depression than schizophrenia.

● How do they function :

○ There are two types of ECT - bilateral and unilateral (depends on whether
electrodes are attached to both sides or one side.) Unilateral ECT has fewer side
effects but it is less effective with severe depression.
○ First, patients are given a fast-acting anaesthetic and a muscle relaxant, which
prevent them from getting injured during the seizure.
○ Electrodes are then attached to the patient’s temples and a 70 to 150 V shock is
given. (up to 1 s)
○ The shock produces a convulsion that lasts from 30s to 1 min.
○ The patient regains consciousness about 15 mins later.
○ ECT is usually given 2 or 3 times a week for up to 4 weeks.
● How do they work as a treatment for depression :
○ There is no precise explanation of how ECT works to help patients from
depression. There are different explanation suggested by psychologists :
■ Benton, 1981 suggested that ECT may alter some of the brain’s
electrochemical processes.
■ Milo et. al. 2001 suggested that ECT helps increasing blood flow in the
brain as he found out that the blood flow to the frontal lobes of the brain
increased immediately after ECT.
● Studies :
○ Ng et al. (2000)
■ Aim - to investigate the effectiveness of ECT with patients suffering from
severe depression.
■ Procedures - ECT (unilateral) treatment was given to 32 patients for over
six-week period.
■ Findings - Symptoms of depression decreased by around 50% following
the treatment. Over 30% of personal memories of participants were lost
after the treatment, but were recovered within the following month.
■ Conclusion - ECT was an effective treatment for severe depression.
● Effectiveness :
○ ECT IS effective :
■ Symptoms of depression decreases after ECT
● Ng et al. (above)
● ECT IS NOT effective :
○ Unethical
■ ECT can be administered against the person’s will, if the patient is
detained under the Mental Health Act.
■ Patients may suffer from memory loss that is associated with ECT, which
can cover the 6months prior to the treatment as well as up to 2 months
afterwards for some patients.
○ ECT may cause brain damage
■ Breggin (1991)
 ● presented two cases to support his claim that ECT causes brain
damage and is most often used with elderly women.
● argued that the treatment causes anosognosia, a condition where
the patient denies his or her own psychological difficulties.
■ Clare (1980)
● argued that as ECT treatment is relatively quick and easy to
administer, the psychiatrists have over used it which cause
unnecessary damage to patients.

General Evaluation for biomedical treatment

● Biomedical treatment often involves bringing about physical changes in the patients
using drugs, ECT or brain surgery rather than counselling or other forms of
psychological treatment. Biological approach is effective, to a certain extent, that it
decreases symptoms of depression. However, biomedical treatments have possible side
effects, like addiction, loss of memory, which can cause unnecessary damage and harm
to the patients.
● Ethical implications:
○ Loss of rights in consent (to ECT especially). There is an assumption that
mentally ill patients cannot be responsible for their actions due to their inept state
of mind, therefore therapy may be undertaken without their consent.
○ there is not clearly only ONE biological etiology for a disorder, which can then
lead to wrong diagnosis/treatment.

Individual therapy
1. What are the presumptions/assumptions of individual therapies?
A symptom of depression is distorted cognitions (e.g. self defeating thoughts)
By replacing negative cognitions with more realistic and positive ones can aid an
individual with depression. Aaron Beck in the 1960s developed his theory as the
pioneer of cognitive therapy. His theories were based on the idea of cognitive
restructuring. The principles to this approach are to: identify automatic negative,
self critical thoughts; note connections between negative thought and depression;
examine each negative thought and decide if it can be supported; and replace
distorted negative thoughts with realistic interpretations of each situation. According
to Beck, a person’s beliefs contribute to ‘automatic thoughts’ based on schemas. In
depression, negative self-schemas bias a persons thinking.
2. What does cognitive Behavioural therapy (CBT) aim to do?
CBT is a form of psychotherapy aimed to treat people with depression whilst focusing on
current issues and symptoms. The aim of the therapy is to identify faulty cognitions
and unhealthy behaviours, then correcting this. Other aims include helping clients
develop coping strategies and problem solving skills. Also to encourage them to
engage in behavioural action.
3. In what ways is individual therapy different to biomedical treatment?
Individual therapy focuses on symptoms rather than causes whilst biomedical treatment
focuses on the causes of the symptoms. For example in biomedical treatment,
depression involves imbalance in neurotransmission, drugs are used to restore the
balance. In addition, individual therapy does not require the intake of drugs or the
need to change biological aspects rather it focuses on the cognitive aspect and the
thought process of people.
4. What is the general picture in terms of the effectiveness of individual
therapies?
 The effectiveness of individual therapies can be examined through research. It has been
proved that cognitive therapy is superior to no treatment or to a placebo (e.g.
Dobson 1989). A study conducted by Elkin et al (1989) aimed to find the
effectiveness of various depression therapies. Subjects that were diagnosed with
major depressive disorder were randomly assigned to treatment using an
antidepressant drug, interpersonal therapy, CBT, and another form of therapy. They
found that over 50% of patients recovered from CBT/IPT/drug group and 29% from
the placebo group. The effectiveness between CBT, IPT and drug group were similar
thus in conclusion, it has more or less the same results and CBT can be compared
to other methods. Riggs et al. aimed to find out the effectiveness of CBT with either
placebo or SSRI. 76% of patients in CBT and SSRI group were judged as improved,
67% of patients in CBT and placebo group were judged as improved. Thus in
conclusion, CBT with drug is effective, CBT with placebo is also quite effective, but
CBT alone is quite reliable.ECLECTIC STUDY???

Group therapy
1. What group therapies are available for depression?
● couples therapy (for married couples, as most married couples have depression due to
the inability to communicate and problem-solve effectively) there is a strong link between
depression and marital problems.
● family therapy -
● psychodynamic - The group will each behave in a different way, and they are freely able
to talk about different things, the person will decide on the subconscious causes to them
based on their behaviour (i.e. how the group sets ‘rules’ even if it’s not spoken). It is
based on Freud’s transference, where their behaviour will be brought up from events in
the past, i.e. aggression for no reason.
● activity groups - engaging patients in a form of focused activity Ii.e. cooking, craft, art
work)
● psychoeducational (problem-solving) - interpersonal learning and ego support
● support groups - similar to psychoeducational, the patients talk about their experiences,
or problem solve some recent issues, which may be the cause of their depression. This
allows them to know how to deal with it.

2. What do clients do in group therapy? (give a brief explanation of the therapeutic process)
● Share experiences with other individuals who experiences depression.
● Group leader promotes healthy habits that group members could go home and put into
practice. They then can discuss their experiences between each other as well as the
leader.
● Leadership roles in a group allow individuals to identify with the leader as an idealised
figure.
● Support group allows a network for sharing experiences and showing support towards
other individuals establishing self esteem. This also build interpersonal skills
encouraging the individuals to communicate and share more often.

3. Give an example how group therapy could be used?

● To teach couples to communicate and problem solve more effectively, while increasing
positive interactions and reducing negative ones.
 ● Jacobsen et al. (1989) found that this type of treatment is just as effective as others in
treating the symptoms. It is even more effective when looking at the relationships. (This
may be because it goes into the cause and not just the symptoms).

4. What does group therapy allow the client and the therapist to do?
● Observe the client’s interactions, progress etc.
● Modify treatment according to progress in recovery

5. What are four advantages of the group therapy?

● It tends to be based on the causes (i.e. childhood repressed emotions, traumatic
experiences or bad relationships)
● Get support from not only the therapist, but from others who are in a similar situation as
the individual
● Toseland & Siporin (1986) reviewed 74 studies that compared individual and group
treatment, 32 of which met their criteria for inclusion. Group treatment was found to be
as effective as individual treatment in 75% of these studies and more effective in the
remaining 25%. In no case was individual treatment found to be more effective than
group treatment. Group treatment was more cost-effective than individual therapy in
31% of the studies.
● McDermut et al (2001) provides a meta- analytic review of the effectiveness of group
psychotherapy in the treatment of depression . Of the 48 studies examined, 43 showed
statistically significant reductions in depressive symptoms following group
psychotherapy; nine showed no difference in effectiveness between group and individual
therapy; and eight showed CBT to be more effective than psychodynamic group therapy.
● (Spiegal et al, 1981) Group therapy has also been shown to be effective in other patient
populations. Homogeneous groups for patients with chronic physical illness are
successful in treating symptoms of anxiety and depression and improving quality of life.
Particular interest has centered on patients with cancer, and some re- searchers have
found a significant improvement in survival rates following group therapy intervention. It
is postulated that this operates through an enhancement of immune functioning.

6. In what ways can group therapy help deal with the stigma of mental disorders?
● It allows the individual to realise that there are others that experience depression,
therefore accepting their own illness.
● Individuals feel free to discuss their own experiences with others.
● The environment allows them to feel comfortable.

7. What are some disadvantages of group therapy?

● If any of the factors in the group is not met, the therapy will not become as successful.
● Spontaneous Remission
● (Roback & Smith, 1987) The most important aspect of a successful outcome is
selecting the right patients for the group, i.e. getting the right mix of problems,
personalities and habitual defence style. Much of the literature on patient selection has
focused on its role in building cohesion. Careful patient-screening also serves to
minimise the drop- out rate resulting from patient–group mismatches.

Important factors to consider in a group therapy:

 1. Group Cohesion, no one should be different from the rest. They need to have a sense of
belonging (i.e. 5 males and 1 female, the female wouldn’t progress as well as the other 5
males)
2. Exclusion, certain characteristics should be excluded from a particular group, i.e. current
drug abusers might be a characteristic that most groups would do better if they were to
be excluded
3. confidentiality, they must trust the others to be able to talk freely and express themselves
4. relationship with therapist, the therapist is known to be not part of the group, and so
he/she must show empathy for the members of the group and attempt to understand
their reality.

Evaluate the use of biomedical, individual and group approaches to the treatment of one
disorder.

Measuring the Effectiveness of Treatments

LOs:
- Examine biomedical, individual and group approaches to treatment.
- Evaluate the use of biomedical, individual and group approaches to the
treatment of one disorder.
1. What issue did Eysenck (1961) highlight with regards to the measurement of treatment
success?
Eysenck argues that SPONTANEOUS REMISSION alone is responsible for the
individual's improved condition
● Even if the individual did not have therapy, he or she would have improved, simply
through the process of recovery, just like a common cold.
● Therefore Eysenck suggests that measuring the success of treatment is pointless,
because such a success may not be due to the effects of treatment, but rather the
results of our own bodies.
2. Measuring the effectiveness of therapy is problematic, what four criteria can be used
to assess whether a therapy has worked?
1. Relief of symptoms for a certain time period
2. Total absence of symptoms
3. Absence of observable traits and/or absence of non-observable traits (such as cognitive
processes)
4. Quantitative data (is it possible?) and qualitative data
3. What issues are faced when getting therapists/ the client themselves or family and
friends to report the success of treatment?
● Therapists are unlikely to state that their therapy was ineffective, especially when the
client has spent a lot of time and money on the sessions. (reporting bias)
● The client themselves is in a apposition to judge his or her own progress as they don’t
understand the aims / techniques of the treatment.
● Family and friends may be part of the problem or affected by the problem and may not
really objective observers (bias)
4. What type of research is used by psychologists to study the effectiveness of
treatment?
● Outcome studies
○ (focus on the results-did patients show improvements or not?)
● Example : Smith et al. (1980) meta analysis
5. What are important factors which influence the effectiveness of the above method?
 ● Drawbacks of outcome studies:
○ Can produce contradictory results e.g. Elkin et al (1985) found intervention did
contribute to recovery rates. Other research has been more dismissive of
psychological treatments.
○ It is highly unlikely that all patients experienced the disorder to the same degree.
○ No standardized procedure, therapy is highly individualized and personal. Must
continually be adapted to suit the patient.
6. What were the findings and conclusions of Smith et al. (1980) meta analysis?
● Smith et al. 1980 meta-analysis of 475 studies, he found that overall, therapeutic
approaches seemed to produce an improvement. However, when they were broken
down into specific disorders and found that there were significant differences in
efficiency of treatment.
● Concluded all methods are to some extent effective, it may not be the specific kind of
therapy that makes the difference but non-specific factors may play a role.
7. What statistics clearly demonstrate the popularity of the eclectic approach?
Glassman (2000) around 30 – 40% of Canadian and US psychologists describe
themselves as eclectic in orientation
8. What characteristics do most therapies have in common?
All therapies involve a warm interpersonal relationship, reassurance and
support, and the opportunity for the individual to gain insight into his or
her experience.
9. According to Bennun & Schindler (1988) what is the best indicator of success in
therapy?
Bennum and Schindler (1988) found that the best indicator of success in therapy
is how favourably clients rated their therapist during the initial session. Those
who liked their therapists more had more improvement.
10. Choosing the right treatment is an important step on the road to improved
psychological health. As a psychologist, what do you need to consider when deciding
which treatment is appropriate to your client?

Discuss the use of eclectic approaches to treatment.

Eclectic approaches: An approach that incorporates principles or techniques from various
systems or theories. Eclectic therapy recognizes the strengths and limitations of the various
therapies, and tailors sessions to the needs of the individual client or group.

Rush et al. (1977) suggest the higher relapse rate for those treated with drug arises because
patients in a cognitive therapy programme learn skills to cope with depression that the patients
given drugs do not.
Growing number of studies is showing that cognitive therapies are more effective than drug
treatment alone at preventing relapse or recurrence except when drug treatment is continued
long-term (Hollon and beck 1994).
Combination of psychotherapy (cognitive or interpersonal) and drugs appears to be moderately
more successful than either psychotherapy or drugs alone (Klerman et al. 1994)

AIM Eysenck (1952) investigated the effectiveness of talking cures such as psychoanalysis.
METHOD He reviewed recovery rates in five studies of psychoanalysis and 19 studies of
eclectic (mixed) psychotherapy. He compared these with the recovery rates of patients who had
received no therapy but were on a waiting list.
RESULT He claimed that approximately 44 per cent of patients treated with psychoanalysis
recovered and 64 per cent of those treated with eclectic methods improved. This compared
unfavourably with the 70 per cent who did not receive treatment, but nevertheless
spontaneously recovered!
CONCLUSION Eysenck concluded that psychotherapy was ineffective. It achieved nothing that
wouldn’t have happened naturally, without intervention.
EVALUATIVE COMMENT
Eysenck excluded the patients who dropped out of psychoanalysis. He argued they were
not cured, although he did not confirm this. If these patients stopped coming because
they were better, the success rate of psychoanalysis would have risen to 66 per cent.
Bergin and Lambert (1978) found that certain types of disorder, such as depression or
anxiety, were more likely to disappear with time. Other conditions, such as obsessive
compulsive disorder, were more likely to need some form of treatment. Further research
is needed to investigate whether different treatments are more successful with certain
disorders than others.

Advantages of using an eclectic approach

1. Eclectic approaches have a broader theoretical base and may be more sophisticated than
approaches using a single theory.
2. Eclectic approaches offer the clinician greater flexibility in treatment. Individual needs are
better matched to treatments when more options are available.
3. There are more chances for finding efficacious treatments if two or more treatments are
studied in combination.
4. The clinician using eclectic approaches is not biased toward one treatment and may have
greater objectivity about selecting different treatments

Disadvantages
1.Sometimes clinicians use eclectic approaches in place of a clear theory. Eclectic approaches
are not substitutes for having a clear orientation that is supplemented with other tested
treatments.
2. Sometimes eclectic approaches are applied inconsistently. It takes knowledge and skill to
deliver eclectic approaches effectively.
3. In general there are very few efficacy studies at this stage to support the approach, partly
because it is difficult to judge the relative value of each treatment in an eclectic approach.
4. However it is important to remember that eclectic approaches may be too complex for one
clinician. There is always a danger that clinicians might call themselves "eclectic" when they
really have no clear direction for treatment.

Discuss the relationship between etiology and therapeutic approach in relation to one
disorder.
Disorder: Depression
Treatments: Biomedical, individual, group

Etiologies:
● BLOA - genetic vulnerability, comorbidity, neurotransmitter malfunctioning,
● Diathesis Stress
● CLOA - Learned helplessness, psychological problems
● SCLOA - Beck’s theory of depression, life events/lifestyle factors

Biomedical
Assumption:
● If problem is based on biological malfunctioning, drugs should be used to restore the
biological system.
● The emphasis is on physiology rather than behavioural, cognitive or emotional
difficulties.
Physical symptoms:
● 40% of people suffering with depression visit their surgery for the first time because of
physical symptoms.
● Aches, pains, lack of energy, palpitations, headaches, stomach upsets, sleep
disturbance, loss of or gain in appetite and weight.
Etiology Possible Does Gender Research
treatment treatment + culture
address issues
etiology?

neuro- SSRI Yes Teuting et al 1981

transmitters Aim: Support for biochemical
noradrenaline and approach
serotonin imbalance.
Method
A compound, produced when
noradrenaline and serotonin are
broken down by enzymes, is
present in urine. Teuting analyzed
and compared urine samples
from depressed and non-
depressed patients.

Result:
Depressed patients’ urine had
lower than normal levels of the
compounds.

Conclusion:
Suggests depressed people have
lower than normal activity of the
neurotransmitters in the brain,
which causes depressed mood.
 Comorbidity

Genetics Allen (1976): Concordance

(However, there’s little rates for unipolar
evidence genetic depression: 40% for MZ
factor in unipolar twins, 11% for DZ twins.
Bertelsen, Harvald and
depresion, research
Hauge (1977): concordance
shows bipolar rates for unipolar depression
depression runs in 80% for MZ, 16% for DZ.
families) McGuffin et al. (1996)
studied a series of 177 pairs
sampled via the twin register
at the Maudsley Hospital,
London, and found an MZ
concordance of just over
40% and a DZ concordance
of 20%.

Stress

Individual
Etiolog Possible Does treatment address Gender + culture Research
y treatment etiology? issues

Group
Etiolog Possible Does treatment address Gender + culture Research
y treatment etiology? issues

Essay plan:
Introduction
Address abnormality - depression
Define ‘etiology’ and state 3 therapeutic approaches (biomedical, individual, group) and
their underlying assumptions.
Note: It is important to understand it is not possible for any doctor/psychologist to find
the cause of depression in any individual. Treatment of depression aims to alleviate
symptoms and consider possible psychosocial actors involved to help individual cope.

------------------------------------------------------------------------------------------------------------------

Biomedical treatments
Treatment based on assumption that problem is based on biological malfunctioning, drugs
should be used to restore the biological system.
Depression involves imbalance in neurotransmission. Drugs are used to restore appropriate
chemical balance in brain, but it’s unknown to why not all patients respond the same way to a
drug.
Antidepressant drugs help elevate mood of those suffering from depression
Most common drug group: selective serotonin re-uptake inhibitors (SSRIs)
Increase level of available serotonin by preventing re-uptake in synaptic gap
Most common SSRI is fluoxetine, brand name Prozac
Side effects: vomiting, nausea, insomnia, sexual dysfunction or headaches
Lacasse and Lee (2005) and Kirsch et al. (2008) are critical towards ‘over-
prescription’ of SSRIs.
Cognitive treatments
Individual approach
Symptom of depression: distorted cognitions (self defeating thoughts)
- lead cognitive psychologists to suggest replacing negative cognitions with more realistic and
positive ones can help
- Aaron Beck, pioneer in cognitive therapy
His theory in 1960s was based on the idea of cognitive reconstructing.
Group
‘couple’s therapy’

Historically, there have been different views on causes of psychological disorders and these
have all been influenced by knowledge and beliefs at the time. Some reflected the view that
psychological disorders were caused by biological factors. Others said that they were rooted in
the mind and yet others adopted an interactionist approach saying that it was a combination of
biological factors and the mind. No matter the approach to abnormal psychology, the treatment
of psychological disorders has generally linked what was thought to be the etiology — which
simply means the cause of the disorder.

Biological approaches and therapies

Biomedical approaches to treatment are based on the assumption that biological factors are
involved in the psychological disorder. This does not necessarily mean that biological factors
cause the psychological disorder but rather that they are associated with changes in brain
chemistry (neurotransmitters and hormones). A number of drugs are used to treat various
disorders based on theories of the brain chemistry involved, but this does not mean that there is
a full understanding of how neurotransmitters and symptoms are linked. Generally, however,
antidepressant drugs are an effective way to treat depression in the short term, significantly
helping 60-80 per cent of people, according to some reports (Bernstein et al. 1994).

However, it is argued that drugs do not target the problem but just address the symptoms, are
not equally effective in all cases and may not be better than psychotherapy in the long term,
according to some researchers. A controversial study by Kirsch and Sapirstein (1998) analysed
the results from 19 studies, covering 2318 patients who had been treated with the
antidepressant Prozac. They found that antidepressants were only 25 per cent more effective
than placebos, and no more effective than other kinds of drugs, such as tranquillizers.
Elkin et al. (1989) carried out one of the best controlled outcome studies in depression,
conducted by the National Institute of Mental health. This study included 28 clinicians who
worked with 280 patients diagnosed as having major depression. Individuals were randomly
assigned to treatment using either an antidepressant drug (imipramine), interpersonal therapy
(IPT), or cognitive-behavioural therapy (CBT) or another form of therapy. In addition, a control
group was given a placebo pill, together with weekly therapy sessions. The placebo/drug group
was conducted as a double-blind design - a form of experimental control, whereby both the
subject and experimenter are kept uninformed about the purpose of the experiment, to reduce
any forms of bias (in particular, experimenter bias). All patients were assessed at the start, after
16 weeks of treatment, and after 18 months.

The results showed that just over 50 per cent of patients recovered in each of the CBT and IPT
groups, as well as in the drug group. Only 29 per cent recovered in the placebo group. The drug
treatment produced faster results, but the NIMH study shows that there is no difference in the
effectiveness of CBT, IPT, and drug treatment. In other words, the study showed that it does not
matter which treatments patients received, all the treatments had the same result.

Cognitive approaches and therapies

Individual therapies are those in which a therapist works one –on- one with a client. Most
individual therapy today includes some kind of cognitive therapy, where a therapist helps a client
to change negative thought patterns. According to Beck (1976) people who develop depression
have cognitive distortions which centre around the cognitive triad (negative schema). This
consists of negative thoughts about themselves, the world and the future, and developed from
early negative experiences in early childhood.

Individual therapy is often seen as more personal than drug therapy, in which a person may feel
more like a patient. It can also be more highly individualized to meet the need of the client. The
aims of cognitive therapy are to help the client change faulty thinking patterns, to develop
coping strategies and to engage in more positive behaviours.

Individual therapy is the most commonly used form of treatment and research has shown that it
generally has a positive effect. A number of studies and meta-analyses have demonstrated that
cognitive therapy, including CBT, effectively treats patients with depression (e.g. Elkin et al
mentioned above).

Cognitive therapies are cost-effective because they do not usually involve prolonged treatment
and no negative effects have been found.

However cognitive therapies, similar to drug therapies, have been criticized for focusing on
symptoms than causes. We can be sure it is the cognitions causing the symptoms of depression
in the first place, they may be a consequence of depression.

Social approaches and therapies

We have already seen how life stressors and lack of social support can be contributing factors
to mental health problems. If social problems do trigger symptoms of depression then group
therapy may help alleviate the symptoms.

The group can provide support for the client in ways that are not possible in individual therapy.
Within the context of the group, clients realize they are not alone and that their problems are not
unique. Group therapy offers multiple relationships to assist an individual in growth and problem
solving. In group therapy sessions, members are encouraged to discuss the issues that brought
them into therapy openly and honestly. The therapist works to create an atmosphere of trust and
acceptance that encourages members to support one another. Since many disorders are either
caused by or promote poor social skills, group therapy allows clients to role-play and develop
social skills in a safe, supportive environment.

The beneficial effects that a therapy group can have on an individual have long been
recognized, but until recently there was a lack of quality studies comparing the effectiveness of
individual and group therapy for patients with similar characteristics. Toseland & Siporin (1 986)
reviewed 74 studies comparing individual and group treatment . Group treatment was found to
be as effective as individual treatment in 75% of these studies, and more effective in the
remaining 25%.

However there are also some possible disadvantages to group therapy. Some clients may be
less comfortable speaking openly in a group setting than in individual therapy, and some group
feedback may actually be harmful to members. In addition, the process of group interaction itself
may become a focal point of discussion, consuming a disproportionate amount of time
compared with that spent on the actual presenting problem.

Eclectic approaches and therapies

There is now a general belief that a multifaceted approach to treatment is the most efficient.
This is based on the biopsychosocial approach to mental disorders to treatment and involves a
combination of therapies.

The biopsychosocial model sees the person as a whole; it recognizes the complexity inherent in
psychological disorders. For example the cause of an individual’s depression may be inter-
related. Negative early childhood messages (psychological) and redundancy (social) may lead
to feelings of worthlessness (psychological). Negative self talk (psychological) may lead to
feeling stressed which leads to higher levels of cortisol (biological) and serotonin depletion
(biological). This may affect Patient X’s mood and coping mechanisms (psychological). This can
lead to decreased communication and social skills and rejection by friends and colleagues
(social). Thus, feeling unsupported, he feels more depressed, possibly further affecting
neurotransmitter levels.

A multifaceted approach is called an eclectic approach. it may include drug treatment, individual
therapy (e.g. cognitive therapy), or group therapy (e.g. family therapy) as well as help to handle
risk factors in the environment such as a stressful relationship.
An eclectic approach incorporates principles or techniques from various systems or theories. Ec
lectic therapy recognizes the strengths and limitations of the various therapies, and tailors
sessions to the needs of the individual client or group. For example, in the case of a depressive
patient who is suicidal, cognitive-behavioural therapy (CBT) may take too long to take effect, or
the individual may not be in a state that would allow for discussions about his or her cognitive
processes. Drug therapy may be used in order to lessen the symptomology of the disorder;
then, once the individual is stabilized, CBT might be used. Also, as the individual becomes more
self-reliant, group therapy may be recommended in order to help him or her develop strategies
to avoid future relapse, as well as a support system.

The argument for an eclectic approach comes from research demonstrating that drug therapies
alone often have significant relapse rates, that is the client begins to show symptoms of the
disorder after having been symptom-free. Rush et al. (1977) suggest the higher relapse rate for
those treated with drugs arises because patients in a cognitive therapy programme learn skills
to cope with depression that the patients given drugs do not. A growing number of studies is
showing that cognitive therapies are more effective than drug treatment alone at preventing
relapse or recurrence except when drug treatment is continued long-term (Hollon and Beck
1994). Furthermore, a combination of psychotherapy (cognitive or interpersonal) and drugs
appears to be moderately more successful than either psychotherapy or drugs alone (Klerman
et al., 1994).

However it is important to remember that eclectic approaches may be too complex for one
clinician. There is always a danger that clinicians might call themselves "eclectic" when they
really have no clear direction for treatment.

Conclusion
Finally, it is important to note that causation of disorders such as depression are not easy to
analyse, whilst an eclectic approach address the multi-faceted nature of depression, it can be
further complicated by the following;
• No one treatment works for everyone. Even if "causation" is established, the selected
therapeutic approach should take into account a client's cultural values, a client's ability to
tolerate drug treatments, a client's enthusiasm for group therapy, a client's willingness to
address negative cognitive style, or a client's ability to start and follow through (self-efficacy)
with the lifestyle changes necessary for dietary or exercise treatments.
• It is often difficult or impossible to identity a specific "cause" of any mental disorder.
Attempts to do, such as the biological approach, represent a singular, reductionist approach to
depression. However depression is a complex disorder caused by a number of factors.
• It is still possible to treat "symptoms." even when causes are unknown. For example,
antidepressants or cognitive therapy treat depressive symptoms. Many clinicians measure
symptoms before and after treatment with assessment instruments such as the Hamilton Rating
Scale for Depression and the Beck Depression Inventory. Many consider a treatment to "work" if
the symptoms are reduced, however not everyone agrees with this definition of "work."
Therefore etiology is not always a priority in treating depression.