Clinical Psychology

     Describe

• Generated first hand  
•  Produced for a purpose to test a hypothesis
• Usually correlated into graphs, charts or statistics.
• It can come from methods such as observations and content analysis.
•  E.g Milgram generated his experiment to test obedience.

 Evaluation

• Usually replicable
•   Mostly time valid as it is current data so is more relevant.
•  Its population specific and is highly representative of the population under study.
• Generated first hand so carries authenticity and credibility as it uses original documents and sources.
• May be subject to researcher bias.
• To get large samples it may be costly and time consuming.

Describe          

• Analysis of existing primary data after its been collected.
• Data used to answer a different research question.
• Focus is on analysis of the results that were originally generated as a comment, explanation or evaluation
•  E.g if you wanted to investigate cross cultural difference in obedience  you may look at all the published studies of obedience in different parts if the world and then analyse the data to interpret the results .

        Evaluation

•  It is inexpensive as data is already collected.
• Can be in the form of large amounts of data (census data).
• For some types of research it is the only viable way of collecting data.
• There may be issues of reliability as the researcher can not check the original data which may be bias
• The researcher has no control of the methods that were used to collect the original data

Describe the statistical norm method of defining abnormal

•  Std dev – how far each score is away from the average.
•  Someone who falls into the 3^rd standard deviation isn’t normal.
•  Measured on a bell curve on the normal distribution curve.
•  Looking for outlying behaviour (statistically rare/infrequent)
•  If a few people show a certain behaviour it is described as abormals

Evaluate

• A person may be one score above what is classed as normal according to the definition but may still need help e.g An IQ score of 71 (70 is normal).
• It over looks the issue of desirability where some abnormal behaviours are desirable.
•  Cultural variations have different definitions of normal.
•  Some types of mental illnesses are thought to be increasing including depression and therefore are no longer statistically rare.

Examples

•  In western society we have a concept of personal space whereas in other cultures (Arabic) they stand very close to each other when talking
•  It us usual to wear clothes and only acceptable to be naked on designated beaches but in some cultures it is usual.
• In some countries its usual for men to greet by kissing each other.
•  Hearing voices can be a symptom of sz but in some religions they believe it is the voice of god

 Evaluate

• There are cultural differences that might explain behavioural abnormalities which makes the definition of social norms ethnocentric.
• Social norms change over time.
•  This definition is more flexible and subjective so allows us to consider behaviours in context e.g someone who has been bereaved may exhibit unusual behaviours that don’t fit the social norms.

The DSM is the diagnostic and statistical manual of mental disorders.

Axis 1 – Clinical disorders – major types of illness

Axis 2 – personality disorders and mental retardation

Axis 3 – General medical conditions

Axis 4 – Psychosocial and environmental issues

Axis 5 – Global assessment of functioning – 100 excellent and 0 extreme danger of hurting self/others. 

Reliability

• Inter-rater – Do other people agree with the findings.
• Test- Retest – If when tested again does it give the same results.
• Beck et al – He gave the same 2 psychiatrists 252 patients and found they only agreed 54% of the time – Inter-rater

• Morey & Orchoa – They concluded that diagnosis will always be affected by both patient + clinician variables – test-retest

Validity

• Etiological – Same causes for the category should be found in all people with the disorder.
• Concurrent – Several kinds of evidence support a diagnosis. Similar symptoms to be found in all people with the disorder.
• Predictive – When people who have the same diagnosis can expect the same course of illness.

Aim: To illustrate the problems in defining abnormality and  to demonstrate the poor validity of categories on early classification systems using DSM.

 Method – field study using covert observation

 Procedure:

• He was one of 8 people trying to gain admission into 12 institutions.
• They were told not to wash, shave or brush there hair and to dress scruffy.
• They gave a false name and occupation.
• Complained of hearing voices.
• They were admitted to a psychiatric ward.
•  Once inside stopped complaining about the symptoms.
• During there stay they observed and recorded behaviour of staff and other patients.They were allowed to say they felt better and to ask when they could go home.
•   They were allowed to say they felt better and to ask when they could go home.

Results;

• They received a diagnosis of schizophrenia.
• There sanity wasn’t detected by staff but was by other patients.
•  The note taking was seen as a symptom.
•  Length of stay ranged from 7-52 days.
• All except one received a diagnosis of sz in remission.
•   In 3 of the institutions 37/118 patients detected the pseudo patients were lying.

Conclusion;

• Demonstrates a lack of validity.
•   Unable to distinguish the sane from the insane.
• Lack of rights, choice and privacy and experienced verbal and physical abuse from staff.
• Highlights unreliability of diagnosis for mental illnesses.

Strengths

• High ecological because it was undertaken at an actual institution therefore its likely to reflect real life.
•  Good construct validity as it was designed and conducted in a way to test the actual process of diagnosis.

Weaknesses;

•  The fact the pseudo patients insisted to be admitted could be argued to be a symptom of sz.
•  The DSM has been revised since the study so its unlikely that the same study would get results if conducted today as diagnosis would be more valid.

Culture needs to be taken into account when making a diagnosis. If not they may be guilty of ethnocentrism which makes there diagnosis invalid and unreliable.

 Cooper:

• They asked American and British psychiatrists to watch a number of filmed clinical interviews and make a diagnosis.
• He found that the new York diagnosis’s were twice as likely to decided on sz whereas the London diagnosis’s were more likely to diagnose mania and depression.
• This clearly demonstrates cultural variations.

 Littlewood & Lipsedge

•   Found that black afro Caribbean’s only reflect 5% of the population but 25% of people on psychiatric wards are black.
• In a group of black people who were diagnosed with sz only 15% showed the classic symptoms.
• This shows that black afro Caribbean’s are being over diagnosed with sz

Diagnosing Sz

• First third – patient responds well to treatment and may only have one episode in there life.
•   Second third – Need treatment on and off for a long period of time.
•   Third third – Condition is chronic, don’t respond to treatment and they will need permanent and often institutional care.

Types of schizophrenia

• Paranoid – Patients have delusions.
•  Catatonic – Psychomotor disturbances such as excessive motor activity.
•  Disorganised – Extreme disorganisation in thought, speech and behaviour.
•  Residual – A prevalence of negative symptoms

 Positive symptoms – behaviours such as hearing voices, hallucinations and excessive motor movement.

Negative symptoms – Behaviours that are absent or missing in a person such as a lack of emotion and social withdrawal. 

Symptoms;

•  Delusions – Mistaken beliefs
• Hallucinations – auditory such as hearing voices or visual seeing things.
• Disorganised thinking/speech – slipping off track not making sense.
• Grossly disorganised behaviour – ranges from childlike silliness to unpredictable agitation.
• Negative symptoms – reduced body language, appearing frozen, social withdrawal.

• The dopamine hypothesis says that the symptoms happen because patients with sz have too much dopamine in the brain and have oversensitive pathways.
•  This is supported by post-mortem examinations as people who have had sz have a higher density of dopamine receptors.
• Randrup and monkvad support as they found raising dopamine levels in rats brains resulted in psychotic behaviour.
• Anti-psychotic medication suggests it only works on about 33% of patients, partially helps 33% and has no effect on the final third. This suggests that in some cases high levels of dopamine are not the cause of the disorder.

The biological explanations – Genes

•  You inherit your genetic makeup from your parents.
•  So far the evidence suggests  that there is no single gene responsible
•  SZ occurs when the individual inherits a number of these genes.
•  Evidence suggests that genes alone cant explain sz because if it was purely genetic the concordance rate between mz twins would be 100%  so it is only a partial explanation.
•  Supported by gottesman who found a positive correlation between the risk rate of sz and the amount of genes a person has in common with a family member with sz.

• Aim – To draw a conclusion about the heritability of sz by using data from existing family studies.
• Procedure – Combined data from 40 European studies  conducted between 1920 and 1980.The concordance rate was calculated according to the amount of shared genes to calculate the risk rate.
•  Results – Much higher concordance rate for MZ twins.

-          Mz twins was 48% and DZ was 17%

-          31% increased risk for an identical twin of them developing the disorder too.

• Conclusion – The reason MZ showed a higher concordance rate was because of their shared genes.

Evaluation

• Sample size will be large and its drawn from 40 studies which increases the generalisability.
•  The reliability will be increased by the researchers removing data that no longer met the diagnostic criteria.
•  The nature of a Meta analysis opens it up to criticism of its reliability as they are using secondary data which they have no control over.
•   MZ twins look alike and would be treated as if they were more alike so this could be a factor of them developing sz.

 Aim – To see  if the symptoms of sz could be created in animals by giving them amphetamine to raise the dopamine levels in there brain.

Procedure – Different species of animals injected with amphetamine and there behaviour monitored and recorded.

Results – The animals showed behaviour that was stereotypical for their species but they became more aggressive and socially isolated.

Conclusion – The animals showed behaviour consistent with psychosis which was caused by the injection of amphetamine.

Describe

•  Used when the procedure is too invasive and unethical to do on humans
• Most research requires a similar central nervous system (generalisation)
• Can be designed to test the effects of genetic inheritance through breeding specific characteristics.

Evaluation

• Using animals means the variables are easy to control
• They have a similar but simpler nervous system which makes it possible to extrapolate results.
• Wide diversity of responses within species e.g if you give morphine to rats it calms them down but if you give it to mice they behave in a frantic and maniacal way.

Takes the view that mental illness is caused through maladaptive functioning of the brain and it seeks to restore functioning by changing the chemical environment within the brain.

• Prescribed the drug
• Then stay in institution until condition is stabilized and the effectiveness of treatment has been established.
• The level of drugs is manipulated.
• The medication will be needed to be taken for several weeks before the symptoms are reduced.
• Neuroleptic drugs have their best effect within the first 6 months.
• If they stop taking the medication they will relapse very quickly.
• Side effects may take place which can be very damaging.

• They are a palliative treatment not a curative one. Therefore they simply alleviate the symptoms and don't remove the underlying cause.
• Some patients which are in the third third are resistant to the drug treatment so dont respond to medication.
• The side effects can be very severe or sometimes fatal. Windgassen reported that over 83% of patients reported some side effects.
• A benefit is that it allows patients to lead a relatively normal life.
• It also has a rapid effect compared to some other types of therapy.

This focuses on the workings of the mind rather than the mechanics of brain function

• Frith suggested that the symptoms can be well explained by examining failures in normal cognitive function.
• He said there was a breakdown in the meta representation system

Positive Symptoms

• It can help explain hallucinations and delusions for example the inner source of speech can be misinterpreted as hearing voices. Thoughts and intentions can be mistaken for external experiences.

Negative symptoms

• People with schizophrenia cannot self initiate easily because of the breakdown in the meta-representation system. This explains social withdrawal

• Experiments by McGuigan found that during an episode of auditory hallucinations activation of the larynx was detected which suggests that they misinterpreted there inner voice as being somebody else s.
• Bentall et al did a study and found patients with audiotry hallucinations are unable to differentiate effectively between internal and external verbal stimuli and are incorrectly attributing self generated inner thoughts as coming from an external source.
• However,     this is not a complete explanation as it focuses on the symptoms themselves not the underlying causes, so doesn't tell us how cognitive function becomes impaired.
• Also the approach has problems with the direction of cause and effect. Is it a lack of cognitive function causing schizophrenia or that schizophrenia causes an inhibitions in mental functioning?

Cognitive Behavioural therapy is a product of both cognitive and behaviorist approaches. It focuses on present thoughts and behavior rather than past events .

• It uses coping strategy enhancement.
• Involves detailed conversations with the therapist to identify the trigger and try to develop coping strategies for dealing with them.
• Secondly the patients learn to accept that these thoughts are part of their illness.
• Thirdly, one specific delusion or hallucination is chosen for treatment.
• Fourthly, the patient is given work to do outside of the sessions.
• Lastly, they explore more ways of making the coping strategies more effective.

• Not be successful with patients suffering from extreme positive symptoms because they were unable to perceive reality due to their psychosis.
• Tarrier tested coping strategies with patients and they showed a higher level of reduction in symptoms that lasted for over 6 months.
• CBT is ineffective in helping deal with he negative symptoms of schizophrenia only the positive ones so the therapy cant help everyone.
• Turkington identifies that we should be cautious in interpreting the results from comparative studies or treatments on the succes and effectiveness of CBT. This is due to many of the control treatments not being adequately monitored. This makes the results look more effective than the actually are.

There are 2 types reactive which is a response to a negative life event such as divorce and endogenous which is where the causes are internal i.e chemical inbalance.

• Can be an episode lasting only a few months of a condtion that can last a lifetime.
• Its the most common types of mental disorder with an estimate of 120 million people worldwide. No longer statistically rare at 10% of people.
• Women are more likely to be diagnosed and also more common to start in early adolescence.

• Depression tends to run in families suggesting a genetic factor.
• Role of genes - The children of depressed people are more vulnerable . The data shows that they inherit an increased risk suggesting a partial role for genetic makeup in the development of the disorder
• Twin studies find a higher concordance rate for depression in mz twins compared to dz. Mcguffin found 46% for MZ and 20% for dz.
• The role of brain structure - Differences have been identified in the brains of people with depression compared to those without.
• Scanning studies such as Milo found that the frontal lobes in depressed people dont use as much blood.
• It is impossible to separate the biological factors out as one thing affects another so pinpointing causality is impossible.

• women more likely to visit the doctor and also womens chemicals fluctuate compared to mens which could explain why women suffer more
• The somatic and motivational symptoms can be explained by cortisol increasing which is present in the stress response. This response impacts on processes like digestion, blood sugar levels and the immune system.
• The emotional symptoms can be explained by an increase in o estrogen and progesterone  which is responsible for changes in the body such as irritability, mood swings, impaired concentration, poor memory and headaches.
• The motivational symptoms can be explained by nor-adrenaline decreasing which affect mood and motivation as they inhibit message transmission.

It was originally given without muscle relaxant or anesthetic which often caused physical injury or even death.

Procedure

• Full medical examination is carried out.
• The patient is then given a muscle relaxant and sleep drug.
• In bilateral ECT electrodes are attached to each temple
• In unilateral they are attached to one temple.
• A current of between 65-110 vaults is passed through the brain for around 2-5 seconds which causes a convulsion that can last between 25 seconds to several minutes.

It stimulates biochemical changes in the neural activity in the brain. Long term memory loss has been known in some patients. They also usually experience some confusion, headaches, nausea and have no memory of events surrounding treatment. 

It is used as a treatment of choice for patients who are at serious risk of suicide and for whom drug therapy has proved inaffective.

• It has a 60-90% success rate for treating cases of chronic depression.
• Gagne did a follow up study of 58 depressed patients and found 93% of patients who continued to have ECT and drugs remained symptom free 2 years later. This compared to 52% who had the drugs alone.
• The use of any form of anesthetic always carries a risk but it is important to remember there is a death rate of 3 in 10,000
• There are ethical issues to be addressed which are the lack of ability to consent if they are medically ill and they can be compulsorily admitted to a psychiatric hospital and recieve therapy against their wishes.

The learning approach argues that mental illness comes about through a maladaptive learning process in our environment.

Lewinsonn linked depression to the processes of operant conditioning dpecifically to a lack of positive reinforcement. This is often triggered by a negative life event.

• The theory is based of Seligman who found that dogs showed learned helplessness which is now used as an explanation for clinical depression.
• Seligman and Overmeir showed that learned helplessness could be induced in dogs when confronted with inescapable shocks the dogs passively accepted the situation and failed to escape thus showing the motivational symptoms of depression.
• However the study was done on animals which may not be generalisable to humans.
• A useful application of the theory comes as a treatment for some types of depression e.g therapies based on providing opportunities for positive reinforcement like the pleasent avents schedule.
• The learning approach is only a partial explanation as it ignores the role of cognition.

• The aim was to investigate the role of operant conditioning specifically reinforcement in learning to be helpless.
• The procedure included 150 dogs being gathered from local shelters. The dogs were pretested where they were put in the box and allowed free movement which allowed them to jump the barrier to escape the shock. The dogs were then separated into 2 groups control and experimental. The control dogs were strapped in a harness during the learning phase but suffered no shocks. Experimental dogs were strapped in but were given inescapable shocks. In the 2nd phase they were put into the box and given free movement so they could escape the shock.
• The results showed 95% of the control dogs showed the avoidance response of jumping the barrier. 2/3 of the experimental dogs gave up and didnt try to escape. Some dogs had to be pushed over the barrier 200 times before they learnt to do it by there selves.
• In conclusion the dogs in the experimental condition learned they couldnt escape the shocks and learned they were helpless. This was so powerful that when they were put into a condition where they could escape the shock they didnt try because they had formed the expectation that they couldnt control their environment.

Negative

• The study breaches many ethical guidelines
• Giving the animals electric shocks will induce anxiety which is diffucult to extinguish from the intended effects of the experiment. But human depression can sometimes be experienced without anxiety which means this behavior may not be true for all types of depression.
• The results are subject to anthropomorphism because we cant generalise the findings to humans.

Positive

• The theory has been used to develop an explanation for why some people become depressed when in similar situations.
• The findings have proven to be reliable as he carried out further studies with similar results and it has been replicated on humans suggesting that the effect is particularly robust.

According to Lewinson therpy needs to focus on encouraging people to become more engaged and involved in events that will positively reinforce them.

Procedure

• The therapist meets the patient and they discuss the issues affecting them.
• The focus is to work on the persons social skills.
• The therapist praises the patients constructive, positive, active behaviors and ideas but ignores the depressive behaviors and actions.
• The therapist uses the patients responses as a measure on pleasant events and activity schedule to determine their pleasurable activities
• They are encouraged to set up weekly schedules for engaging in the pleasurable activities to improve their opportunity for positive reinforcement.
• This is then discussed with the therapist and positive feedback is rewarded.

This therapy is based on operant conditioning and works by encouraging and rewarding desirable, non depressive behavior and ignoring undesirable behaviors.

Positive

• Appropriate and effective as some of the main symptoms relate to issues of motivation. The majority of patients see the value in increasing their involvement in pleasurable activities and so are motivated to continue.
• A study by Dimidijan was done and he found full recovery was achieved by 56% of people receiving behavior therapy, 36% by cognitive and 23% drug.

Negative

• It can be argued that it only treats the symptoms and not the causes of depression. The focus is on changing the persons behavior rather than understanding why they were in a depressed state in the first place.
• It addresses the behavioral aspects of the depression but not the cognitive or affective aspects such as emotional disturbances, feelings of hopelessness and a negative self view.

• This involves the therapist and patient communicating so it is often referred to as the talking cure. It focuses on the influences of early childhood believing that the first 5 years of life are essential in the forming of the adult.
• Freud believed that psychoanalysis gained an insight into the unconscious mind but different methods such as free association where the patient says the first thing that comes into their mind.Another popular method is dream analysis where the therapist looks for the symbolic content from what is described by the patient.
• Psychoanalysis tries to uncover any conflict that exists within the unconscious. Once the patient has been through the therapy the interpretation made by the therapist should help them gain an insight  which releases tension. 
• The patient often rejects the interpretation but freud argues this an a type of defence mechanism . Once the patient has brought the issues into the conscious mind and dealt with them they accept these feelings and then should be relieved of their symptoms.

• Storr suggests that the approach is too lengthy to be effective with 3-6 sessions needed a week at around £50 a session. This is a huge investment and people may feel they have to justify this by claiming they feel better.
• There are ethical considerations as people with depression have a tendency to depend on others and as transference to the therapist is actively encouraged this could exaggerate the problem.
• It raises social issues about equality and availability of treatments as it is only available to the affluent.
• Bergin stated that the criteria being used to judge patients may bring the rates of improvement for psychosis to 83% which is very high.

• The therapist uses many techniques within the therapy such as circular questioning (where questions are asked from different perspectives) , producing a genogram (picture to trace relationships).
• The goal is to understand the family unit and change dysfunctional patterns of behavior to help family member develop better communication, coping and problem solving skills.
• It focuses on the social dynamics within the family as they have been prove to have a profound effect on the relapse and recovery rates of patients.
• They work collaboratively with other colleagues and family therapy is often combined with other treatments such as drugs or counselling.

Evaluation

• Mcfarlane reviewed literature looking at the effects of family therapy and found it improved family well ebing, reduced relapse rates and improved recovery.
• Birchwood found the relapse rates for patients was 60% over 12 months for patients which routine treatments but only 25% for family therapy.
• It doesnt consider other factors that may be relevant for example biochemical imbalances and genetic elements. Its not regarded as a cure.
• It makes the assumption patients have families who can be supportive when many patients with schizophrenia are unmarried and dont have supporting families.

• It is based upon the principals of operant conditioning that any behavior rewarded will be strengthened.
• The process starts with a baseline measure where target behaviors are chosen that the therapist wants the patient to do. Some form of token is used as a secondary reinforcer which is given when they perform a target behavior. The tokens then can be exchanged for the primary reinforcer which can be trips, goods from a shop or additional privileges. A schedule of events is designed allowing different levels of motivation and ability for example it may start with continuous reinforcement then move onto fixed ratio. When the target behaviors have been achieved the patients are weaned off the programme.

• It doesn't require specialist knowledge so it can be undertaken by anyone who has received basic training.
• Useful in helping patients re-learn or re-engage with behaviors that are necessary to cope socially in society.
• Not succesful with all patients as it needs to take into account a persons motivation and people with depression and schizophrenia may suffer from a lack of motivation.
• It only treats the symptoms not the underlying cause.
• May wear off if they know they are not going to get the tokens anymore.