Clinical psych

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Key Terms

Clinical psychology: about the study of mental health and mental disorders.

Statistical definition of abnormality:
refers to statistical infrequency. If a behaviour is statistically rare, according to the statistical definition of abnormality, it is abnormal. IQ is an example of this, as IQ is normally distributed across the population and anyone outside of the normal limits of this can be said to be abnormal.

Social norms of definition of abnormality: behaviour that conforms to social norms is ‘normal’ and behaviour that doesn’t is ‘abnormal’. However, there are aspects of society to be taken into account when judging someone as ‘abnormal’, such as age, gender, situation etc.

Schizophrenia: mental illness that can affect the way someone thinks, speaks or feels to such a degree that they lose focus on reality. Characteristics include first-rank symptoms such as hearing voices, and second-rank symptoms such as flattered emotions.

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Key Terms

Reliability: reliability is found when what was done in one study is repeated and the same results are found.

Validity: validity is found in studies where what is measured is what is claimed to be measured. For example, if someone is studying anxiety and draws conclusion, only to discover that people being studied have depression, conclusions wouldn’t be valid.

Primary data: gathered first hand from source, directly by researcher. Ways to gather primary data include observations, questionnaires and experiments. For example, Milgram collected primary data in his study of obedience in a lab.

Secondary data: has already been gathered by someone and are used by someone else for further research. For example, government statistics from a census can inform researchers about number of females living alone.

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Primary data gathered first hand from source, directly by researcher e.g. Milgram collected primary data in lab exp. on obedience. Psychological studies usually gather primary data in ways like surveys and questionnaires.

Secondary data already gathered and used by someone else e.g. govt stats from census can inform researchers about number of females living alone.

Evaluating use of primary and secondary data in research
Relative cost: primary data = expensive because researcher starts from beginning, finds participants etc. Secondary data cheaper - already exists.

Validity: primary data gathered first hand following careful operationalisation of variables and careful procedures - more valid as study is designed and carried out for main purpose of research. Secondary data more likely gathered for another purpose and already analysed (subjectivity).

Time period: primary data gathered at time of study and conclusions can be drawn. Secondary data maybe gathered some time ago so conclusions might not be valid e.g. because cultures change over time. 

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Issues of reliability and validity in primary research

Validity: found where what is measured is what is claimed to be measured e.g. if someone is studying anxiety and draws conclusions about it, then finds the participants are suffering from depression, conclusions might not be valid. If two doctors are all using same symptoms and manual to diagnose the same person with different mental disorders, then the diagnosis is neither reliable nor valid. For a diagnosis to be valid it has to be measuring what it claims to measure and if a patient’s set of symptoms can be interpreted to be different disorders, then the manual being used is not a valid measure.

Reliability: found when what was done in one study is repeated and the same results are found e.g. if someone links depression with loss in early childhood and then the study is repeated with different participants and no link is found, the findings lack reliability. If one doctor gave a diagnosis of depression and another gives a diagnosis of schizophrenia, the patient would not think that they had been reliably diagnosed. Reliability is important for the individual as treatment depends on diagnosis. If someone is not being treated for the correct disorder, the individual’s condition will not improve.

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Two methods used to study schizophrenia

Twin studies involve comparing MZ and DZ twins to see what differences there are in the incidence of a certain characteristic. MZ twins = identical (100%) and DZ twins = non-identical (50%). If a characteristic is completely genetically given (nature), MZ twins would both show the characteristic.

If a characteristic comes from environmental influences, MZ twins won’t share it any more than DZ twins. If one twin has schizophrenia and condition is inherited, MZ twins would more likely both have schizophrenia, it's less for DZ.

Evaluation of twin studies research method
+ No other way to study genetic influences so clearly, because no other humans share 100% of DNA.

+ Twins share environment - natural control over environmental effects.

- MZ, even in womb, experience different environments = develop differently.

- MZ twins may be treated differently and share gender - environments might not be as controlled as might be thought. 

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Two methods used to study schizophrenia

Study using twin studies - Gottesman & Shields

Aim: see if any relationship between genetic make-up and development of schizophrenia, by looking at concordance rate for disorder in groups of twins.

Procedure: 57 twin pairs chosen (24 MZ and 33 DZ). Blood tests used to find if MZ or DZ. Data collected through hospital notes, case histories, tape recordings of verbal behaviour through semi-structured interviews.

Results: in MZ twins there was concordance rate of 42%. In DZ it was 9%.

Conclusions: genes do play role in development of schizophrenia.

+ Inoyue found 74% CR for progressive chronic schizophrenics.
+ Careful sampling made sure twins were accurately designated as MZ or DZ.
- Disorder maybe from shared pre-natal environment (illness in mother).
- Only gives concordance rates, so cause and effect conclusions cannot be drawn.


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Two methods used to study schizophrenia

Interviews can take form of questionnaires where interviews are structured and questions remain same, so each is asked same questions in same format. Semi-structured is where set questions but interview can explore issues. When unstructured, no set questions, but schedule/areas to cover.

Interviewer will find out about personal data required for study (gender, age, marital status). Interviewer will use some standard instructions at start so respondent is aware of ethical issues such as confidentiality. Respondent will be told something abou interview and what purpose is.

Evaluation of interview research method
+ Unstructured interviews useful for obtaining qualitative data because can be exploration of issues and respondent can use own words and ideas (which makes it more valid). Qualitative data offered is more depth and detail.

- Interviewer may affect findings - interviewer bias.

- Subjectivity in analysing interviews. When categories/themes are identified from detailed data, research may allow personal judgments to affect analysis.

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Two methods used to study schizophrenia

Study using interviewing - Goldstein

Aim: compare course of schizophrenia in men and women for first 10 years of condition, in particular regarding hospitalisation.

Procedure: 90 Ps (32 women, 58 men). Mean age of Ps = 24. Goldstein used trained interviewers to get data about symptoms of patients and questionnaires to get info about premorbid functioning (dealing with isolation and peer relationships). Overall ratings for premorbid functioning then found.

All Ps hospitalised with diagnosis of schizophrenia for 1st or 2nd time at start of study, with diagnosis confirmed by 2 independent psychiatrists. Course of schizophrenia measured by number and length of hospitalisations over 10yrs.

Results: men hospitalised average 2.24 times over 10yrs, 1.12 times for women. Mean number of days in hospital for men were double that of women.

Conclusion: men with schizo are typically admitted more times for longer periods, appears to be related to worse premorbid functioning (socially and interpersonally).

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Two methods used to study schizophrenia

Evaluation of Goldstein
+ Men and women well matched in marital status, age, socio-economic background.

+ Data is objective and unbiased in number of hospital stays and length of them. This quantitative data is testable for reliability. Inter-rater reliability as schizo diagnoses checked.

- Although men and women matched for employment status, type of employment varied – women mostly held clerical or sales jobs whereas men had more blue-collar jobs. There were also more unemployed men than women.

- Problem with sample is that age limit was 45 years. 9% of schizo women have first schizophrenia episode after 45, whilst very few men do. This may have biased the sample in favour of finding the gender differences. 

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Two definitions of abnormality

Statistical definition of abnormality - if behaviour is statistically rare = abnormal. Majority of scores will cluster around average. As we move from average, fewer people will attain this score (normal distribution). 

Standard deviation of scores shows how far someone has to be from average to be abnormal. It's calculated by finding how far each score is from average, expressing spread of scores around mean. 2SDs away = abnormal on CND.

+ Quantitative measure - objective, so more likely reliable and suitable: administering same test will get same result and draw same conclusion.

+ Some areas of functioning highlight abnormality as lack of ‘normal’ functioning - can support requests for assistance as number = scientific.

- Statistically frequent behaviours still considered to be abnormal. Depression is frequent in UK but considered mental health disorder and abnormal.

- Statistically infrequent is not necessarily bad (IQ) so ‘undesirability’ is not a valid measure of what is thought of in society as abnormality.

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Two definitions of abnormality

Social norms definition of abnormality states behaviour that conforms to social norms is 'normal' and behaviour that doesn't is 'abnormal'.

Context: someone shopping in bee outfit = abnormal. If for charity = normal.
Age/gender: a child stripping in public = normal. A 40yr old = abnormal.
Culture: in one culture, hearing voices is normal and means you're connected to spirits, in another it's abnormal/symptom of a mental disorder.

+ Idea of abnormality as behaviour that goes against social norms matches what is expected in daily life when talking about abnormality.

+ Explains why different cultures have alternative ideas of what's abnormal and that there’s no universal rule about what’s abnormal.

- Different aspects have to be considered so hard to have reliable idea of what's abnormal, so diagnosis is difficult as no set symptoms to rely on.

- Diagnosis lacks validity except in specific culture, gender etc. Difficult to measure abnormality objectively/scientifically - many subjective issues.

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The DSM - classification of a mental disorder involves taking set of symptoms and categorising them so person showing these symptoms has disorder. With set of abnormal symptoms into disorders, can diagnose people by symptoms, assessing symptoms and seeing whether they meet criteria.

DSM was first used in 1952, currently on version 5. It's standard criteria for classifying mental disorders, and used to determine and help communicate a patients’ diagnosis. Can also be used to help categorise patients. It's multi-axial system split into 5 levels to relate to different aspects of the disorder.

Axis 1 – all disorders apart from mental retardation and personality disorders
Axis 2 – personality disorders and mental retardation
Axis 3 – general medical conditions
Axis 4 – psychosocial and environmental factors
Axis 5 – assessment of global functioning (GAFscore/100, higher the better).

Purpose involves identification system of groups/patterns of behaviour that reliably occur together to form type of disorder. Researchers identify group of similar sufferers and determine course of disorder/suitable treatment.

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Evaluation of the DSM
+ Allows a common diagnosis. Has been revised many times and stood test of time. Is perhaps best attempt at diagnosis. When 2+ doctors use it, should have similar diagnosis.

+ Goldstein tested the reliability of the DSM in her study of schizophrenia, and found evidence to suggest its reliability.

- DSM is seen as confirmation of medical state of mental disorder, as sufferers are ‘patients’ and ‘treatment’ is suggested. It might be said mental illnesses are simply ways of living, and who is to say whether they are ‘illnesses’ or not. Laing said schizophrenia is just another way of living where a person is trying to get back to their true self, so it isn’t a medical illness.

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Reliability, diagnosis and the DSM

A classification system used to diagnose mental disorders must be reliable, so different psychiatrists reach the same diagnosis and offer same treatment. Reliability means something is done again and same results are found.

Inter-rater reliability: 2+ psychiatrists give same diagnosis for same symptoms. 
Test-retest reliability: same clinician found same diagnosis with same symptoms on different occasions, after a time gap of weeks or months.

Beck et al used 2 psychiatrists and found 54% agreement on the diagnosis of 153 patients, though newer versions of DSM have been released since.

Goldstein used single-blind technique, and found 80% inter-rater reliability and high levels of agreement in 190 diagnoses of schizophrenia.

Davidson & Neale found 92% agreement for psychosexual disorders.

Nicholls et al compared reliability of DSM4 for children with eating disorders and found 64% agreement, as only half the raters were able to make a diagnosis. 

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Validity issues in the diagnosis of disorders

A diagnosis must be valid. If diagnosis predicts course of illness and symptoms, it's useful. It's also useful if it leads to right treatment. If DSM isn't reliable, it's not valid as different diagnosis given at different times by different doctors, so DSM isn’t measuring what it's supposed to.

Feature of diagnosis is that disorders have to be operationalised (measurable) and categorised - might not be suitable for diagnosing mental disorders (complex symptoms and features e.g. depression is hard to diagnose - list of symptoms mightn't account for whole experience so diagnosis lacks validity).

DSM accounts for personal and social factors and how person is functioning but factors might not link to disorder e.g. someone might be diagnosed with depression partly based on social functioning, but that might come from some other cause such as unemployment, making the diagnosis lack validity.

Etiological validity: (same cause) found when diagnosed problem is said to have the same cause for all those diagnosed e.g. if schizophrenia is caused by too much dopamine, all schizophrenics should have excess dopamine. 

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Validity issues in the diagnosis of disorders

Concurrent validity: (symptoms) when other symptoms or factors found in one person, but not seen as part of diagnosis, are found in others with same diagnosis e.g. if all people with schizophrenia had problems relating to others.

Predictive validity: (future path) those with particular diagnosis progress in same way and course of illness is the same e.g. at a later date, the person would be diagnosed with same disorder using different way of measuring it.

Criterion validity: (different measures, same diagnosis) compare one system with another known to be valid – if they agree, system being is valid.

Rosenhan concluded that the DSM-III wasn’t valid, as it could not distinguish between those who did have mental disorders and those who did not.

Lahey found good predictive validity in relation to social and academic functioning over a 6-year period, when looking at children with ADHD.

Andrews looked at how much DSM-IV agreed with ICD-10 - found good agreement for depression + substance abuse but poor agreement for PTSD. 

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Validity issues in the diagnosis of disorders

Evaluation of the DSM regarding validity
+ Andrews’ and Lahey’s suggest DSM, particularly later versions, are valid.

+ The claim that DSM is valid is supported by claim that it is reliable (as reliability and validity go together).

+ Great efforts have been made to make the DSM-IV more valid, such as adding culture-bound syndromes.

- It's claimed that splitting mental disorders into symptoms and features is reductionist and a holistic approach would be more valid e.g. in a counselling situation, symptoms are treated as aspects of the whole person and mental health is the focus, not a mental disorder, so treatment is more important than a diagnosis.

- It’s difficult to diagnose more than one mental disorder (co-morbidity) using the DSM, so a clinician might go for the closest match.

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Cultural issues, diagnosis and the DSM

Culture can affect diagnosis and treatment of mental disorders, as different cultures have different attitudes to mental disorders e.g. in Morocco mental disorders are viewed as to come from sorcery. DSM was developed in the USA and is used widely. Some disorders are culture-bound, such as:

Dhat – men from Indian subcontinents. Main symptoms are severe anxiety and obsessive concern over discharge of *****. Koro – South Chinese men, worry their penis will shrink and disappear into abdomen, leading to death.

Culture-bound syndromes: mental health problems with set of symptoms found/recognised in one culture. Many psychiatrists reject idea but most commonly recognised ones are listed in DSM-IV. Examples include ‘penis panics’, mainly found in African/Asian cultures, where males think their penis might retract. DSM deals with diagnostic tool developing in one culture not being valid in others by including category of culture-bound syndrome.

One cultural issue is that some cultures are spiritual and some scientific. DSM is scientific and uses medical model which is scientifically defined. In non-Western cultures mental health issues can be linked to spirits.

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Cultural issues, diagnosis and the DSM

Burham found in Mexican-born Americans, more reports of auditory hallucinations than non-Mexican Americans, maybe cultural differences.

Lee conducted a study to see if DSM-IV diagnosis of ADHD would be suitable for Korean children. Findings showed DSM to be valid.

Banyard found in Britain, 25% of patients on psychiatric wards were black, whilst they only made up 5% of general population. Cultural bias in diagnosis?

What can be done to overcome cultural issues in diagnosis? 
For greater reliability and validity, less emphasis on symptoms showing cultural differences (judged bizarre behaviour) and more on universal ones (social functioning difficulties/distress).

Flaum said negative symptoms (apathy, lack of energy) are more objectively measured than positive ones (hallucinations), so should be focused on more.

Including culture-bound syndromes such as Koro in DSM ensures clinicians are aware of cultural differences/issues when diagnosing. 

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Cultural issues, diagnosis and the DSM

Evaluation of cultural issues, diagnosis and the DSM
+ The DSM-IV accounts for cultural issues in acknowledging culture-bound syndromes.

+ There has been an attempt to remove focus from bizarre symptoms in schizophrenia, as it was acknowledged that such symptoms are open to interpretation and that there are cultural issues in such interpretations.

- Other features of symptoms of schizophrenia that are listed in the DSM could lead to cultural bias. ‘First rank’ symptoms (like ‘bizarreness’) should perhaps receive less emphasis.

- Negative symptoms of schizophrenia are more objectively measured and so should be given greater attention. In practice, focus is more on positive ones.

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Symptoms and features of schizophrenia

Features of a mental illness usually involve stats about disorder or aspects of it such as how illness develops. Symptoms are what characterise the disorder with regard to how the person thinks, feel or behaves. First-rank symptoms = hearing voices, second-rank = flattened emotions.

Positive symptoms are additions to behaviour and actual symptoms that can be noted. 2 or more must be present for 1+month to diagnose schizophrenia.

Hallucinations: seeing/hearing things that are not there. Hearing voices in some cultures is not seen as a mental disorder but a spiritual capability.

Delusions – false beliefs, someone thinking their movements are being controlled by someone else. Cmmon form of delusion is paranoid delusion; sufferer believes someone is trying to harm them. Someone is suffering with delusions of grandeur when they think they are in a position of power.  Positive symptoms tend to have greater weight in diagnosing schizophrenia but can be affected by cultural differences so perhaps shouldn't be weighted as strongly as negative ones, which might be more objectively measured.

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Symptoms and features of schizophrenia

Negative symptoms are when normal functioning isn't present and often start before positive ones, sometimes years before schizo develops (prodromal period).

Lack of energy/apathy: no motivation to do daily chores.
Poverty of speech: sufferer uses as few words as possible.
Flattening of emotions: face becomes emotionless and voice dull and flat.

Negative symptoms seem less affected by cultural factor and more objectively measurable. Hearing voices is hard to measure but lack of energy can be monitored. Prodromal features have been found in teens - can't indicate schizophrenia on their own.

Types of schizophrenia
Paranoid: suspicious of others, delusions of grandeur, often hallucinations.

Disorganised: speech disorganised and hard to follow, inappropriate moods.

Catatonic: someone is withdrawn and isolated, has little physical movement. 

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Two explanations for schizophrenia

The dopamine hypothesis is a biological explanation for schizo related to neurotransmitter functioning. Research suggests the presence of excess number of dopamine receptors at synapse can contribute to schizo. It's possible that increases in dopamine in one site in brain (mesolimbic pathway) contributes to positive symptoms and in another (mesocortical pathway) it contributes to negative symptoms.

Evaluation of dopamine hypothesis
Ampethamines give similar symptoms to excess dopamine.
Some evidence comes from effect of drugs like amphetamines which cause excess dopamine and result in symptoms of psychosis similar to symptoms of schizo. However, excess dopamine also has stimulant effect like overconfidence, which are more symptoms of mania so explanation doesn't fit exactly.

Brain differences might link with dopamine sensitivity.
Brains of schizos seem different (grey matter different in front and temporal lobes). Such brain changes, at early age, link with sensitivity to dopamine.

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Two explanations for schizophrenia

Evaluation of dopamine hypothesis continued
PET scans show blocking dopamine receptors doesn't always remove symptoms.
PET scans have suggested drug that block dopamine didn't reduce symptoms of schizo in patients who had it more than 10yrs, even if block was 90% effective. However, if anti-psychotic drugs administered early in disorder, more than 90% patients respond.

Blocking dopamine receptors takes few days to work.
Anti-schizo drugs block dopamine receptors almost immediately but any calming effect isn't noticed for days, suggesting something other than excess dopamine causes psychotic symptoms.

Social and environmental factors also involved.
Social and environmental factors seem to trigger schizo, so biological explanation not sufficient. Perhaps stressful events in life can trigger production of excess dopamine. There's also link between social class and schizophrenia, suggesting environmental factors do play role.

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Two explanations for schizophrenia

Social class: ‘environmental breeder’ hypothesis: evidence that people in lowest classes, and groups such as immigrants, have highest incidences of schizo than others in UK. It looks as if social class might be cause for schizo or at least be involved in development. In UK, incidence of about 4 in 1000 people has been found. Studies regularly show schizo is found more in lower class, amongst unemployed and those in deprived city areas. Those in lower classes also experience different course and receive different medical care.

Social drift: has been suggested those with schizo become lower class because of difficulties that arise from having schizo. Study compared social class of schizo men with father’s social class found that, though schizo men were in lower classes, fathers generally weren't. Those with schizo didn't achieve well in education, had problems in teens and difficulties keeping job.

Social adversity: schizo is more associated with cities than rural communities, might be something in city life that leads to schizo (Eaton et al 2000). There are people in lower classes in rural areas, so social drift hypothesis does not explain country/city split. Schizo shows clustering in declining inner-city areas, perhaps being brought up there leads to schizo.

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Two explanations for schizophrenia

Evaluation of the environmental breeder hypothesis
+ Not everyone with certain environmental circumstances develops schizo, though might be environmental triggers. Other causes possible; genetic and neurotransmitter functioning (evidence dopamine receptors are involved).

+ Idea helps to explain fact that though more people with schizo in the lower classes, they are concentrated in the inner-city areas, and black immigrants are more likely to be diagnosed than white lower-class groups. Hypothesis helps explain these two pieces of evidence better than social drift.

- Those in lower socio-economic groups, living alone, unemployed and living in poverty might be more likely to be diagnosed, suggesting diagnosis, not environmental, problem.

- Might be that poverty, unemployment and lack of social support are stressors and that this stress that causes schizo, not the environment itself.

- It's hard to separate environmental factors to see if they cause schizo, as they could be the result of schizo, as the social drift hypothesis suggests.

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Two treatments for schizophrenia

Biological approach: drug treatment: will in many cases allow some form of normal functioning. If neurotransmitter functioning causes symptoms, drug treatments that affect such functioning can help to treat them. Drugs such as Chlorpromazine block dopamine receptors so that there is no excess.

Drugs used in treatment of schizos are called ‘anti-psychotic’. They work to suppress hallucinations/delusions. Usually first psychotic episode results in prescription. Drugs are known as ‘typical’ (well-established) and ‘a-typical’ (newer/less widely used, tend to have fewer side effects and act in different ways to ‘typical’).

Effectiveness of drug treatment: Meltzer et al 2004 looked at effectiveness of drug treatment in schizo. 481 patients with schizo randomly assigned them into groups. Groups had a placebo, 1 of 4 new anti-psychotic investigational drugs or haloperidol. Study gathered info about positive and negative symptoms, severity of illness and a score from a psychiatric rating scale. Haloperidol gave significant improvements in all areas of functioning compared with placebo group, so study has validity. 2 of new drugs also showed improvements compared with placebo group, whilst the other 2 didn't. This is evidence that drug treatment works to an extent.

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Two treatments for schizophrenia

Side effects of anti-psychotic drugs
Chlorpromazine is an example of an anti-psychotic drug. Side effects can include shaking, muscle spasms, low blood pressure, weight gain and lethargy.

Evaluation of drug treatment
+ Thought to be more ethical and effective than former (pre-1950s) treatments.

+ Treatment rests on strong biological evidence about causes of schizo so is underpinned by theory, which helps in considering its effectiveness.

- Schizo patients often don’t continue to take prescription (est. 50%).

- Ethics - ‘chemical straitjacket’, some think such control by society is unacceptable.

- Don’t account for environmental or social problems, which might contribute to re-hospitalisation and relapses. Social treatments, such as ACTs, do.

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Two treatments for schizophrenia

A social approach: psychosocial treatment
Assertive Community Therapy used to help schizophrenic patients who have frequent relapses and bouts of hospitalisation. Used by community mental health services with clients who have difficulties meeting personal goals, getting on with people, making and keeping friends and living independently.

Characteristics of ACT
- A focus on those who need the most help from the community health service.

- Helping with independence, rehabilitation and recovery, and to avoid homelessness and re-hospitalisation.

- Treatment in real-life setting – visiting them and helping, rather than offering therapies, with enough staff to offer this support and related treatment.

- Whole team can focus on the individual in question. Commitment to spend as much time as necessary to rehabilitate and support patients, offering holistic treatment looking at all needs in multidisciplinary approach.


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Two treatments for schizophrenia

Evaluating ACT
+ Good for those who have many relapses, might be problems with living outside the hospital that lead to such episodes. Social skills training such as family therapy can improve interactions. Treatments based on improving individual to function in society shown to help and can be incorporated into ACT programmes.

+ Bond (2002) found ACT extremely effective in most mental health disorders and suggests it allows client choice. About 11% clients say it's restricting.

- Although ACT prevents relapses, doesn't seem to have an effect on actual functioning, such as reducing positive and negative symptoms of schizophrenia or helping with employment prospects.

- ACT works best in heavily populated areas with high incidence of schizophrenics needing care in the community because of the effort and intensive focus required as part of treatment.

- Gomory (2001) pointed out that the client is offered little choice and surrenders all responsibility in making decisions and taking care of themselves.

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Symptoms and features of anorexia nervosa

Sufferers maintain weight at as low a level as possible by controlling what they eat. They starve themselves because they think they are fat or have strong fear of being fat. Sufferers become extremely thin and their weight dangerously low, but continue to want to lose weight. Sometimes they vomit to get rid of food: the cycle of binge eating and vomiting characterises bulimia nervosa.

Anorexia is more common in developed countries and in females than in males. It tends to start in the mid-teens. Among teenagers and young adults, about 1 in 250 females have anorexia and 1 in 2000 males. It is a serious condition and can be life threatening if not treated.

DSM-IV criteria for diagnosing anorexia include:
- The body weight must be less than 85% of what would be expected.
- There is an intense fear of being overweight, despite being underweight.
- Focus on weight is distorted, either through minimising the dangers of being thin or exaggerating the importance of weight on self-esteem.
- In females, menstruation has been absent for 3 months or more.

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Two explanations of anorexia nervosa

Biochemistry explanation
Anorexia may be linked with chemical imbalances in the brain. For example, low levels of neurotransmitters like serotonin and noradrenaline are found in those very ill with anorexia. Serotonin is linked with suppression of appetite. Anorexia is also linked with high levels of cortisol, a hormone related to stress.

Evaluation of the biochemistry explanation for anorexia
+ Can be tested using animal studies. Information that serotonin is involved in the action of appetite comes from animal studies, which are objective.

+ The explanation is strengthened by the fact that different findings, such as serotonin being linked with appetite and low levels of serotonin being found in anorexics, support one another.

- Findings from animal studies may not relate well to humans, as there are differences in functioning, including the use of problem solving.

- Not clear whether neurotransmitter differences in anorexics cause condition or are a result of it.

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Two explanations of anorexia nervosa

Genetics explanation
As eating disorders run in families, it is likely that there is a genetic explanation. Twin studies have shown a higher concordance for anorexia in MZ twins than in DZ twins which suggests a genetic link. Anorexia is more common in white people, which might be taken as evidence for a genetic link although there is no actual evidence. It may be that there is a genetic link that makes someone likely to develop an eating disorder, rather than a gene for the disorder itself.

+ Holland et al found concordance rates for anorexia in MZ twins were higher than DZ twins (50% vs. 7%) which is evidence for a genetic link as MZ twins share 100% of DNA and DZ twins share 50% of their genes, just like any other siblings.

- Identical twins aren’t identical in developing anorexia (there is only a 50% concordance) so there must also be an element of environmental influence.

- A study in Fiji (Fearn 1999) suggests that eating disorders in young women in Fiji after the introduction of TV in 1995 has risen - eating disorders are learnt rather than inherited.

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Two treatments for anorexia

Medical treatment
Medical treatment involves visits to hospital, where specialist help can be offered to encourage someone to put on weight if they are dangerously thin.

Some patients can be treated as outpatients, but some have to be treated against their will. Those enter hospital as inpatients and a treatment plan is put into place. The treatment plan can include education regarding nutrition where a dietician helps the patient to learn about healthy eating and proper nutrition.

Evaluation of medical treatment for anorexia nervosa
+ Outpatient programmes can allow the person to continue with their daily schedules, allowing them to continue to function relatively normally. These patients are not institutionalised by a prolonged stay in hospital.

- It is widely thought that good treatment requires many different treatment options ranging from education about nutrition to therapy to help improve negative thinking. This suggests that an effective medical intervention is a multidisciplinary one, which can be hard to set up and monitor.

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Two treatments for anorexia

Anorexia can be treated by means of counselling, which allows patients to identify negative thoughts and feelings about weight. They can explore their view of self and see what thoughts are behind the maladaptive views of their weight. Emotions can be addressed, as can issues with stress.

Cognitive therapy can be used so that unhealthy thoughts are recognised and coping strategies identified. Behaviour therapy can be used to reward healthy eating and reinforce good practices with regard to eating.

+ A more holistic therapy which assess the route of the problem and equips patients with long term skills to cope. More effective in long term.

- Psychotherapy by itself may not be enough as a treatment. Anorexics may need to be in hospital to get help to raise their weight to safe standards before psychotherapy can start. Someone with severe anorexia may not see they have a problem and so may not be willing to work with a therapist in the collaborative way that many therapies require.

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Study in detail: Rosenhan

Rosenhan 'sent' people into mental hospitals posing as mentally ill people to see if their sanity would be identified and the patients distinguished from the 'insane context in which they are found'.

Aim: to see if 8 sane people who gained admission to 12 different hospitals would be 'found out' as sane.

Procedure: 8 pseudo-patients (5 men and 3 women). All used pseudonyms to avoid diagnoses giving any later embarassment and those employed in mental health gave different occupatioons to avoid being treated differently. Settings varied to give generalisability. 12 hospitals were located in 5 different states of USA and varied in character.

Patients called for an appt and arrived at admissions office saying they had been hearing voices. Voices were unclear but seemed to be saying 'empty', 'hollow' and 'thud'. On admission, patients stopped simulating symptoms and behaved 'normally'. They were given meds they didn't swallow, chatted to other patients and responded to instructions from staff. All but 1 wanted to be discharged immediately.

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Study in detail: Rosenhan

Results: patients were never detected. All but 1 admitted with a diagnosis of 'schizophrenia in remission'. No records show any doubts over the authenticity of the patients. Between 7 and 52 days were spent in hospital, an average of 19 days. 35 out of 118 patients on the admissions ward voiced suspicion.

Conclusions: in general, doctors are more likely to err on the side of caution and call a healthy person sick than a sick person healthy.

+ Using 8 patients in 12 different hospitals, with similar results, means that there is replication to test for reliability.
- Over 30 years old, not necessarily true now.

+ The kinds of hospitals used were varied so there is generalisation of findings. 12 hospitals were involved, strengthening this as if it was just 1 hospital, it might be that hospital alone that 'labelled' mental illness.
- Patients said they heard voices (standard symptom of schizo) so not a surprising diagnosis although doesn't explain why they weren't released after symptoms stopped. 'Lies' guided research so invalid findings.

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Study in detail: Goldstein

Aim: to compare the course of schizophrenia in men and women for the first 10 years of the condition, in particular with regard to hospitalisation.

Procedure: Goldstein used trained interviewers to gather data about the symptoms of the patient and questionnaires to gather info about their premorbid functioning e.g. dealing with isolation and peer relationships. Overall ratings for premorbid functioning were then found.

90 patients took part – 32 women and 58 men. The mean age of the participants was 24 years old.

All were hospitalised with a diagnosis of schizophrenia for the 1st or 2nd time at the start of the study. The diagnosis was confirmed by 2 independent psychiatrists.

The course of schizophrenia was measured by a number and length of hospitalisations over a 10-year period.

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Study in detail: Goldstein

Results: significant differences between men and women. Men hospitalised an 2.24 times over 10 years, as opposed to 1.12 times for women.

Mean number of days spent in hospital for men more than double of women's.

Conclusion: men with schizophrenia are typically admitted more times to hospital for longer periods. This appears related to worse  premorbid functioning.

+ Participants well matched in marital status, age and socio-economic background

+ Data is objective and unbiased in terms of number and length of hospital stays. This quantitative data is testable for reliability. Also inter-rater reliability.

- Although matched for employment status, type of employment varied – women held clerical/sales jobs, men had more blue-collar jobs. More unemployed men.

- Sample age limit was 45 years. 9% schizophrenic women have first schizophrenia episode after 45, whilst very few men do - bias. 

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Study in detail: Holland

Aim: to study if there is a genetic basis to anorexia by looking at concordance rates of the illness in MZ and DZ twins.


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Fantastic revision cards, thank you!

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