Health and Clinical Psychology

Theories of Health Belief:

• Health Belief Model - (Becker)
• Locus of Control - (Wallston)
• Self Efficacy - (Bandura)

Methods of Health Promotion:

• Media Campagins - (Cowpe)
• Legislation - (Dannenberg)
• Fear Arousal - (Janis & Feshbeck)

Features of Adherence:

• Reasons for Non-Adherence - (Bullpit) (can also relate to HBM)
• Measures of Non-Adherence - (Becker) (Watt et al)
• Improving Adherence Through Behavioural Methods (Watt et al)

A cognitive decision making model - helps explain why people failed to take part in preventative health campaigns (e.g. free tuberculosis screening).

Smoking:

• Perceived Benefits - e.g. to be cool, stress relief, weight loss.
• Perceived Costs - e.g. money, health.
• Sociodemographic - e.g. age, gender religion, knowledge, education, social support.
• Perceived Threat of Disease
  - Seriousness: understanding consequences, e.g. cancer.
  - Susceptibility: if you are young you feel invincible "it won't happen to you/now"
• Cues to Action:
  Social: - Media, campaigns. Social Cognition (smoking ban). The presence of other people (showing you someone who has died).
  Physiological: if you start getting ill, you may start thinking you are more susceptible.

Conclusion: HBM helps us identify gaps in peoples' health beliefs, and then change them - e.g. adverts so gaps don't exist. if the benefits outweigh the costs, they will keep doing unhealthy behaviours, So we can get try to get rid of the benefits/increase the risks.

• Asked 111 mothers to complete self report on their adherence to child's asthma regime.
  Also did blood tests on children for validity check.
• Positive correlation found between mother's HBM (perceieved threat and seriousness of child's asthma) and compliance with medical regime (administering the asthma medication as perscribed).
  Costs & Benefits also taken into account - disruption to daily life, accessibility of chemists, etc.
• Demographic variables influenced health belief were marital status and education - (those who were married were more likely to adhere).

The way in which a person explains (attributes) responsibility to either themselves or other ouside forces. Similar to attribution theory with internal or external attributions.

Study: Wallston
Locus of Control scale measures extent to which people perceive their state of health as being under external or internal control. 18 questions w/ likert scale.

Multidimensional Health Locus of Control (MHLC) identifies 3 distinct ways in which people attribute their health status.

• Internal Health Locus of Control - feels responsible for their health and takes action to improve it. Takes blame when ill, so tends to lead a healthy lifestyle (e.g. "i am in control of my health")
• Powerful Others Health Locus of Control - other people are responsible. Less likely to take blame, won't change on their own (e.g. "health professionals control my health").
• Chance Health Locus of Control - fatalisitc about health, least likely to do anything about health (e.g. "no matter what i do, i'm likely to get sick")

Self Efficacy - The belief that you can perform adequately in a situation. Confidence.
A sense of 'personal competence' - likely to impact your perception, motivation, and performance in the task.

In relation to Health, self efficacy = the individual's belief they have the ability/confidence to carry out a behaviour successfully (e.g. maintaining a healthy lifestyle or giving up unhealthy behaviours; like how confident they feel they can commit to a diet/give up smoking...)

Study: Bandura's Theory of Planned Behaviour
4 influences of Self Efficacy (S.E)

• Enactive Influences: past experiences and successes/failures.
  Past successes = future successes. S.E = high
  Past failures = future failures. S.E = low.
• Vicarious Influences: comparing ourselves to others and judging our ability accordingly.
  If others around us succeed, we will succeed. S.E. = high.
  modeled behaviour, imitation, etc. Sometimes can be negative.
• Persuasory Influences: positive feedback that we can succeed.
  high S.E. - e.g. family and friends telling you you can do it and succeed.
• Emotive Influences: over-anxiety may lead to lower S.E. In order to improve, it must not be over anxious of the consequences.
  Over emotive = lower S.E. Needs just the right amount.

Different forms: social networks, adverts (TV), websites, parents/drs., education.
Methods to protray message: emotional shock, facts, make it fun, simplicty, stories.
HBM - helps enhance the perceived risks and trigger cues to action.

Various Media Campaigns in this country:
The F.A.S.T. Campaign (for stroke)

• Gives very factual instructions.
• Acronym - memorable and simple.
• Aimed at everyone (even young children can understand).
  • 2 months later, 24% rise to calling 999. 16% rise in stroke sufferers seen quicker.

The "Truth" Anti-Smoking

• Fun, musical, more likely to pay attention. Catchy, BUT - could be off putting as less serious.
• Humour, facts, sarcastic.
  • When released, nationwide fall in young smokers. 5% rise = 1 million people.
  • Longitudinal Study showed florida teens who had seen campaign were less likely to smoke.

Study: Cowpe
Tested effectiveness of an advertising campaign about the dangers of chip pan fires. 

Method and Procedure: Longitudinal study. Quasi experiment and Self-Report questionnaires. (triangulation of data increases validity). TV adverts of how to prevent & put out chip pan fires. Shown to 10 different British TV regions. Effectiveness measured by asking viewers in these regions to complete questionnaire about safe use of chip pan fires. 

Results: Decline in chip pan fires over 12 months: -7% (in central TV area). -25% (in Granada area).
Decline during the campaign:    - 33% (in Tyne Tees area).

Questionnaire data: increased awareness + 34%.
However, people overexposed to the campaign were less impacted/had less of an influence on them. Due to loss of chock factor, boredom, de-sensitized if you see things more than once.  

Legislation = a law produced by a governing body to regulate, authorise, sanction, declare, or restrict.
Legislations are effecctive in behaviour change b/c they act as an external reminder/cue (linking to health belief model), and it forces people to follow a particular behaviour change.

Laws passed to protect our health:
- Smoking bans - age limits, warnings on packaging, changing the packaging/shops (all behind the counter).
- Alcohol - age limits (18), asked for ID if look under 25.
- Driving - seatbelt, criminal offences.
                  Ethnocentric

Study: Dannenberg (reviews the impact of the passing of a law requiring cycle helmet wearing in children. Maryland US).

Method: Quasi Experiment (children naturally falling into one of 3 counties).
             Self Report - questionnaires

Sample: Children from 47 schools in Howard County
               2 control groups - one from Montgomery County, other Baltimore County
               Aged 9-10 yrs, 12-13 yrs, 14-15 yrs.
               7322 children were sent questionnaires

Procedure: Questionnaires containing 4 point likert scale. Topics - bicycle use, helmet ownership, peer pressure, etc. Parents helped w/ questionnaire (informed consent).

Findings: Response rates  = 41-53% across the 3 age groups and counties.
- Howard County = helmet usage increased by 26.1%
- Montgomery County = helmet usage increased by 4.2%
- Baltimore County = helmet usage increased by 4.4%
      Most children (87%) were aware of the law, 14% were not (in howard county).

Conclusions: The Howard County legislation showed a large increase in the reported rate of cycle helmet wearing.
- Slight rise in the area w/ educational programme campaign compared to area w/out campaign, BUT not significantly different.

- passing legislation has more effect than the educational campaign.
- educational campagins are not necessarily effective at all in increasing healthy behaviours.

Study: Dannenberg (reviews the impact of the passing of a law requiring cycle helmet wearing in children. Maryland US).

Method: Quasi Experiment (children naturally falling into one of 3 counties).
             Self Report - questionnaires

Sample: Children from 47 schools in Howard County
               2 control groups - one from Montgomery County, other Baltimore County
               Aged 9-10 yrs, 12-13 yrs, 14-15 yrs.
               7322 children were sent questionnaires

Procedure: Questionnaires containing 4 point likert scale. Topics - bicycle use, helmet ownership, peer pressure, etc. Parents helped w/ questionnaire (informed consent).

Findings: Response rates  = 41-53% across the 3 age groups and counties.
- Howard County = helmet usage increased by 26.1%
- Montgomery County = helmet usage increased by 4.2%
- Baltimore County = helmet usage increased by 4.4%
      Most children (87%) were aware of the law, 14% were not (in howard county).

Conclusions: The Howard County legislation showed a large increase in the reported rate of cycle helmet wearing.
- Slight rise in the area w/ educational programme campaign compared to area w/out campaign, BUT not significantly different.

- passing legislation has more effect than the educational campaign.
- educational campagins are not necessarily effective at all in increasing healthy behaviours.

what effect will invoking fear have on a person's behaviour? how does it change their actions? real life examples of where fear arousal is used within a health campaign?

Fears: Looks - (e.g. getting fat- caloric counter for alcohol).
     Death - (ecstasy advertisement - dead person). 
--> Promote fear enough to make them change to avoid unpleasant consequences.
> Negative Reinforcement (behaviourism).
--> Problems = unethical.
= based on individual emotional responses. will not change/influence everyone in the same way. 
--> Fear Arousal will only work if perceived susceptibility of extreme outcomes is high (persuasive, believable. HBM link.)

Study: Janis & Feshbeck
 Sample: Students at US high school. 14-15yrs old.

Method & Design: Lab experiment. Self-Report questionnaires. Independent measures design.
Group 1 = strong fear appeal; painful consequences of poor dental hygiene were emphasized. “This could happen to you” statements.

Group 2 = moderate fear appeal; little information. Factual statements.

Group 3 = minimal fear arousal; neutral information.

Group 4 = control – had a lecture on eye.

Procedure: ★ 1 week before lecture = questionnaire was given. Questions on dental health practices. ★ 15 minute lecture (same lecturer). ★ immediately after lecture, questionnaire given. ★ 1 week later, follow up questionnaire on long-term effects.

Net increase in conformity

Strong fear appeal

8%

Moderate fear appeal

22%

Minimal fear appeal

36%

Control group

0% change

Findings: Strong fear appeal lecture seen more positively and more disliked (more interesting but slides were unpleasant).

Conclusion: fear appeals are helpful, but levels must be adjusted according to audience.

reasons why people may not adhere to various medical regimes? any unique reasons for certain regimes? 

Why do we not follow advice given to us? - laziness, expensive, naive, peer pressure not to, difficult, lack of effect (can't see any negatives in your own health), when costs out weigh the benefits (e.g. chemotherapy). 

Study: Bulpitt
reviewed research into adherence of medication to reduce high blood pressure (hypertension) given to males and females. Research analysed the physical and psychological effects of the drug. 
Costs: (side effects of drug)
- sleepiness, dizziness, erectile dysfunction, minor cognitive functioning, swollen face long life medication.
Benefits: (of taking drug)
- avoid heart disease/stroke/diabetes/kidney disease.

Findings: 1985 study reviewed = 8% of males discontinued treatment due to erectile dysfunction.
  1981 study reviewed =  15% withdrew due to side effects. 
Conclusion: erectile dysfunction is a short term problem, men are more concerned with short term gain (good sex) than long term reward (no stroke!). evolutionary - want to attract a female, reproduce, and shorter life expectancy. Also no outward effects; low perceived threats/seriousness. 

HBM: perceived threat and perceived seriousness and lack of effect à if a person believes there is a lack of negative effect, their perceived threat & seriousness is low. Costs & Benefits.

 Locus of Control:
“Internal” – may think they know better, so won’t follow.
“Chance” – are least likely to adhere, will just let nature run its course.

Self-Efficacy:
Vicarious Influences – if someone else has not had luck with regime, you will think the same for yourself.
Enactive Influences – bad past experiences can influence your adherence behaviour. 

what are various measures for non-adherence and how do they work?

Self Report - asking the patients how adherent they have been.
Biochemical Tests - blood tests/urine tests to estimate adherence. (e.g. adherence to a diet can be measured in renal patients by the levels of potassium in their blood.) 
Pill and Bottle Counts - count the number of pills left in the bottle and compare it with what should be there.  

Study: Becker
- self reports on 111 mothers of kids with asthma.
- were interviewed on their reasons for adherence/non-adherence to child's asthma regime.
Results for reasons of non-adherence: child complaining, single, disruption to daily life.
- also did blood tests to check validity of self report --> Triangulation.

Study: Watt et al
- after children used diff. types of inhaler, after 1 week, each parent completed questionnaire about usage. 

how might classical conditioning, operant conditioning and social learning improve someone's adherence? who might it work best for? will it work in this way for all health behaviours?

• Classical Conditioning (Pavlov's dog)
  - learning through association. associate the medicine with something positive.
  - use an existing association, then paired learning of a new association (stimulus-response).
• Operant Conditioning (Skinner's rat)
  - learning through positive or negative reinforcement
  - POSITIVE = reward desired behaviour (e.g. give them sticker when they take medication/general praise). NEGATIVE = encourage desired behaviour in order to avoid unpleasant consequence (e.g. take toy away if you don't take medicine). PUNISH = punish bad behaviour (e.g. take toy away).
• Social Learning
  - learn through observing others; imitate.
  - parents model behaviour. cartoon characters can model behaviour.  

Why children may not adhere?
- may not see the benefits, ruining their day/interruption, fear?, time consuming, don't understand how to take it, friends don't do it? feel different, taste, no fun! 

Study: Funhaler 

• 32 Australian children (aged 6 or under). Had asthma.
• Child used normal inhaler for 1 week, then funhaler for the next week. Parents were given a questionnaire after each week w/ matched questions.
• Positive Reinforcement - rewarded with whistle and spinner (fun) if correct behaviour was done.
  - OPERANT Conditioning.

Findings: 38% more parents medicated children the previous day when using funhaler compared to normal inhaler.

Conclusion: Improved adherence as medical regime was made fun, enjoyable, interactive. Eliminated boredom and apathy. Could help them better understand breathing technique.

Causes of Stress

• Work as a cause of stress - (Johansson)
• Hassles and Uplifts - (Kanner et al.)
• Lack of Control - (Geer and Maisel)

Methods of Measuring Stress

• Physiological - (Johansson)
• Self-Report Measures - (Kanner
• Combined Approach - (Johansson)

Techniques of Managing Stress

• Cognitive - (S.I.T. - Meichenbaum)
• Behavioural - (Meichenbaum/Mcgrath)
• Social Support - Waxler Morrison

list various jobs that may be stressful, what makes them stressful jobs? what is it about our society that makes work one of the most primary causes of stress?

- Builders: environment/conditions they have to work in.
- Lack of interaction; isolating. lack of support.
- Competition - pressure to always do well/perform. consequences of not performing well (e.g. doctors)
- Work environment - lack of personal space, noise, temperature. Colleagues.
- Unflexibility of hours. Dealing with demands of others.
- Repetitive work. boring not challenging.
- Time, deadlines for work. cannot control.
- Money - culture biased. 

Study: Johansson
Sample: 24 workers at Swedish saw mill.
14 High Risk = set paced work, governed by production line, complex & extensive     knowledge, danger, responsible for salary of others.  
10 Control = maintenance/cleaners.
Design: Independent Measures. Quasi Experiment.
Results: Control group's adrenaline level decreased throughout the day.
High risk group's adrenaline levels increased throughout the day.
Self-Report showed high risk group reported lower levels of wellbeing and satisfaction. 

examples of daily hassles? why do these things cause us stress? is the stress short/long term? prolonged result of too many hassles?

Examples of Daily Stressors - concerns about weight, health of a family member, too many things to do, etc. 
--> there is evidence to suggest that minor stressors (hassles) can combine to become one large cause of stress.
--> there are also things that happen in our lives that give us uplift, e.g. holidays, having a good night's sleep, etc.

Study: Kanner
Sample: 100 participants (mostly white, protestant, above average income, fairly well educated). Had previously completed Health Survey in 1965 from California.
Method & Procedure: Repeated Measures. P's completed:
Hassles Rating Scale every month for 9 months.
Life Events Scale after 10 months.
Then, psychological symptoms of stress were measured using Hopkins System Checklist & Bradborn Morale Scale every month for 9 months. 
Findngs: Hassles scale = better predictor of psychological and physiological symptoms (compared to life events scores). Also more consistent month on month.
Hassles & Symptoms were significantly correlated - the more hassles reported, the more symptoms of stress reported.
Conclusion: Daily Hassles and Uplifts may be a better approach to the prediction and cause of stress and ill health, compared to the life events approach. 

why might perceived (lack of) control make someone feel more or less stressed? differences between people that make internal attributions about their lives to those that make external attributions? 

This subsection looks at a more individual and physiological response to stress (as opposed to Work and Hassles & Uplifts which are often situational causes of stress) The idea here is that if we have, or think we have, a certain level of perceived control over what happens in our lives, then we will feel less stressed or fearful of it. 
Things we have a lack of control over: 
- Public Transport - unreliable. Consequences of it being late, e.g. getting told off.
- Money - never enough, always something to pay.
- Death - predictable but unavoidable, uncertain & the after effects.
- Exams - can't control the questions, examiner, time..leading to the Results.
--> the Results and Consequences are what makes us stressed.
- Stressed about the anticipation of stress - predictable. 

Sample: 60 psychology students from New York.

Method & Design: Independent measures design, lab experiment.
Group 1 = control + predictability
Group 2 = no control + predictability
Group 3 = no control + no predictability 

2 IV’s:
Control = could press buzzer if they wanted picture gone.

Predictability = 10 second warning tone before car crash victim pic was shown.
Physiological Measures of Stress: P’s wired up to GSR (measures stress), and Heart Rate Monitor (not used – inaccurate). GSR tone taken on the start of warning tone, during warning tone, and in response to the photograph.

Results: Group 2 (no control, predictability) showed most stress with the tone – they knew what was coming, but could not control the photograph. (anticipation of the stress, concerned about their perceived lack of control. Build up=more physical stress).
Group 1 (control&predictability) showed least stress in response to the photograph. 

summarise the various physiological measues that can be used to measure stress, including Heart Rate monitors, GSR and biochemical analysis.

Johansson: physiological measures
- Urine Samples = measures levels of adrenaline.
   collected when the workers arrived at work, and four times during the working day.
   baseline was taken at home.
- Body Temperature = taken at same time + place + thermometer.
   temperature drops when stressed.  
- Galvanic Skin Response (GSR) = measures sweat as an indication of stress. Anxiety causes sweating and therefore increases the moisture on the skin.  

outline what self report measures aim to find out about stress, how they are usually administered, name some specific self report tests that are used to measure stress. 

Self Reports are used to find out how the individual is feeling. They provide indepth detail and understanding into their minds and thoughts.
In regards to stress, it can help tell us if the physiological signs of stress are actually happening because of stress and not something else (like excitement which can produce similar outwardly signs). Self Reports can also tell us causes of stress to gain a fuller understanding. 

Kanner: Self Report Measures
All tests were sent out via post, 1 month before the study began. P's asked to complete:
Hassles & Uplifts Rating Scale - every month for 9 months to complete. P's scored the severity of their stress on daily hassles. The greater the score, the greater the hassle. (e.g. misplacing or losing things, score 1-3?)
The Hopkins Symptom and Bradburn Morale Scale - every month for 9 months. Measured psychological symptoms of stress. 
Life Events Scale - after 10 months.  

Hassles scale = better predictor of psychological and physiological symptoms (compared to life events scores). Also more consistent month on month.
Hassles & Symptoms were significantly correlated - the more hassles reported, the more symptoms of stress reported. 

Self Report. Half of the people didn't send back.
Social Desirability & Order effects could have occurred because the study was conducted over a long period of time.  

what does a combined approach to measuring stress involve? why would this approach be used as opposed to a single measure?

Johansson: combined approach (physiological + self-report measures)
- When urine was tested, P's given rating scale of mood & wakefulness/wellbeing (e.g. sleepiness, well-being, efficiency, being rushed, etc). This gave quantitative estimates.
> used in order to increase validity.
> self-report should correlate positively with physiological tests (They did).
- Physiological results could be due to other reasons (e.g. excitement) - self reports show what is happening to body, and why.
- Self-Reports may be invald - social desirability (e.g. managers might read it)

> all of this data put together increases validity and shows triangulation of data.  

outline how cognitive therapies work such as SIT

Cognitive research assumes an internal process influences our behaviour (such as memory, language, thinking, etc). Therefore stress might be caused by irrational or faulty thinking.
Using cognitive principles, we can attempt to modify the irrational thoughts and behaviours individual's suffer, and enable them to cope with stress and anxiety more.
Cognitive Symptoms of Stress: lack of concentration, mood - angry, poor memory, spontaneous decisions, irrational/impulsive decisions, negative thoughts. 
CBT:
cognitive - identifying cog. symptoms of stress (thoughts, feelings, etc).
  - understanding they're irrational. 
  - learning new techniques/coping skills.
behavioural - application of new skills - often hypothetical.  

Treatment: Stress Inoculation Therapy (S.I.T.)
Cognitive technique designed to help an individual repair their faulty thinking. Makes patient aware of the nature of their stress. Coping strategies are helped to be developed, new skills are rehearsed.
3 phases:
1.) Initial Conceptualization Phase:
- identify the stressors & emotions attached.
- identify the irrational/negative thinking (could be done through "homework"; patient keeps a diary). (e.g. "you're useless" - bad, disappointed, worthless).
- educate patient.
>> can take 3+ sessions. 
2.) Skills Acquisition and Rehearsal:
-  skills acquisition - only when client is ready to learn new coping strategies. Positive Reframing.    Tailored to the client. e.g. relaxation, emotion regulation. 
- rehearsal - practise, e.g. say positive things about yourself.
3.) Application and Follow Through: 
- therapist provides patient w/ opportunities to practise coping skills, e.g. role playing,   visualization exercises. 

Behaviourist perspective assumes that all behaviour is learned from the environment. --> believes stress is caused by environmental factors/learning through past experiences.
To manage it, the stress response can simply be "un-learned" by helping the patient associate stress with something unpleasant.  

Classical Conditioning - unlearning the anxiety 
- Unconditioned Stimulus (e.g. relaxation techniques) --> Unconditioned Response (calm, happy)
- Fearful Stimulus (e.g. snakes) + Unconditioned Stimulus (relaxation technique) --> Unconditioned Response (calm, happy)
- Conditioned Stimulus (e.g. snakes) --> Condtioned Response (calm, happy)

Systematic Desensitization
process uses classical conditioning.
1.) Create a Fear Heirarchy. (5 point heirarchy of fearful situations, 1=least fearful situation of your fear, e.g. looking at pic of fear. 5=most fearful situation of your fear, e.g. in a room full of it). Combating each stage allows for gradual exposure to fear.
2.) Find the positive association to teach relaxation. gradual exposure to fear with learning associations of relaxation and calmness.
3.) Start the association. 

outline diff. types of social support and how they could be used to reduce stress

Social Support - other people/environment. Examples and How they support stress?
- Friends - listen, understand, relate, advise.
- Family - more realisitc, bigger picture.
- Social Networks - comparison, easy to offload, accessible, internet.
- Teachers - academic/specific support.
- Financial - benefits, physical support. 

Study: Waxler Morrison
looks at how a woman's social networks influence her response to breast cancer.
Sample: 133 women, Vancouver. Confirmed diagnoses of breast cancer. 
Method & Procedure: Self-report questionnaires (on their demographic, existing social networks, contact w/ friends & family etc.) and psychometric tests (marital status, contact w/friends, church membership).
Findings: Aspects of their social network were significantly linked to their survival. These aspects included, Marital Status, Support From Friends, Contact With Friends, Total Support, Social Network, Employment. 
Conclusion: the more social networks and support, higher survival rate of women with breast cancer.

Companionship: - it reduces stress as being part of a group may bring friendships, but also distractions from stressors.
Easy to access as surrouneded by groups (friends, etc.) all the time. Belonging may increase understanding of each other.
Biological Drive to belong to groups (survive, attachment, etc.) 
(long term and most often used... but what if they die?)

Emotional: - e.g. trust, advice, love, empathy. Helps to understand the situation you are in.
Easy to access as those we trust are often friends/family.
Supporitve as there may be more trust in a better relationship.
(long term and most often used) 

Tangible: - e.g. money. Doesn't have to be extravagant items, but simple everyday support like clothing.
Having something physical is a constant reminder that there is support and this can be linked to companionship.
Makes you feel more comfortable and helps manage your stress. Easy to access?
(short term) 

Informational: - e.g. internet. look to as a fallback. 

Diagnosis of Dysfunctional Behaviour:

• Categorising - (ICD/DSM)
• Definitions of Abnormality - (Rosenhan & Seligman)
• Biases in Diagnosis - (Ford and Widiger)

Explanations of Dysfunctional Behaviour (phobia):

• Behavioural - (Watson & Raynor)
• Biological - (Kendler, Gottesman)
• Cognitive - (clark & Wells)

Treatments of Dysfunctional Behaviour (phobia):

• Behavioural - (McGrath)
• Biological - (Leibowitz)
• Cognitive - (Ost & Westling)

Two main diagnostic manuals designed to enable practitioners to identify and treat a particular disorder. 

Key Features
(incl. brief history and classification types)     
ICD – 10/(11^th edition released Jan 2014) 
    - Published by WHO and used in WHO linked countries.

- Mostly used outside of the USA.
- Initially developed as a medical manual (more scientific).
- Disorders are grouped by common symptoms.
- Diagnostic section indicates how many of each feature is needed for an accurate diagnosis.
- Criteria all based on real life evidence.
- Diagnosis is flexible and open to clinician’s discretion.

DSM – 4/(5^th edition released May 2013) 
- APA (American). Used in USA & in western countries.
- Only developed for mental health (this makes mental health seem more abnormal).
- Criteria based on empirical research.
- Multi-Axial Model:
   > Axis 1 – diagnostic categories.
   > Axis II – personality disorders & Mental retardation.
   > Axis III – general medical conditions.
   > Axis IV – psychosocial and environmental problems.
   > Axis V – current level of functioning.    

e.g. Hitler – going against human nature/social norms/unnecessary behavior/extreme behavior.
“unnatural”
“obsessive”?
different to the average/norm.
à no concrete definition as it is constantly changing throughout time and culture. (study into dysfunctional behavior can never be reliable).
time: e.g. Ÿ Homosexuality used to be considered a mental disorder & dysfunctional. Ÿ Underage sex – in older times, people used to get married much earlier. Ÿ Throughout history, religions preachers have been considered “insane” yet we now hold these ideas as truth.
culture: e.g. Ÿ symptoms of tiredness, sores in head and neck and blurred vision à Brain Fog – a clinical condition linked to depression in west Africa. Ÿ A period of violent and murderous outbursts à Amok – dissociative disorder found in Malaysia.

*study into dysfunctional behavior is always ethnocentric, timelocked, and low reliability.

your understanding of what is normal/abnormal? why might defining abnormality be a problem? what might be the benefits of it? 

Study: Rosenhan & Seligman
4 ways in which abnormality may be defined: 
1.) Statistical Infrequency: - a person's trait, thinking or behaviour is classified as abnormal if it is rare or statistically unusual, e.g. schizophrenia. 
2.) Deviation from Social Norms: - social norms are expected approved ways of behaving.
3.) Failure to Function Adequately: - under this definition, a person is considered abnormal if they are unable to cope with the demands of everyday life, e.g. feeding yourself, dressing yourself, interacting with people (autism).  
4.) Deviation from Ideal Mental Health: - under this definition, rather than defining what is abnormal, we define what is normal and why anything that deviates from this is regarded as abnormal. 
To have an ideal mental health, the patient should: Have a positive view of self (e.g. depression, anorexia). Be capable of some personal growth (e.g. down syndrome). Be independent and self-regulating (e.g. depression). Have an accurate view of reality (eg. schizophrenia). Be resistant to stress *e.g. anxiety disorders). Be able to adapt to your environment (e.g. autism).  

what various forms of bias seem to exist when discussing or diagnosing mental health? who do they affect?
Biases:
Gender - women are more emotional, neurotic, depressed/mentally ill.
      - men less likely to discuss mental problems.
      - men less likely in therapy/diagnosed with eating disorder.
Ethnic  - african americans less likely to be diagnosed with depression.
Age       - children & elderly seen as more vulnerable and maybe more diagnosed. 
      - however, elderly might not be seen as mentally ill ("you're just old") same for the young. 

Histrionic Personality Disorder
- over excessive attention seeking. inappropriate seduction. emotionless. dramatic.
--> gender bias: towards female, female attributes. occurs four times more in females. 

Anti-Social Personality Disorder
- lack empathy. deceitful. impulsive. exploit, manipulate or violate the rights of others. not able to control their anger.
--> gender bias: male attributes.  

Looked at sex biases in diagnosis.
Sample: Clinical psychologists, randomly selected from National Register in 1983.
Method: Self-Report – health practitioners given scenarios and asked to make diagnosis based on information.
Independent measures design – clinician given male/female/sex unspecified case study.
IV = gender of patient in case study. DV = diagnosis made by clinician.

Procedure:
- clinicians presented with 1 of 9 case histories. Case studies of patients with antisocial personality disorder (ASPD) or histrionic personality disorder (HPD), or an equal balance of symptoms from both disorders.
- therapists asked to diagnose the illness on a 7 point scale, the extent to which the patient appeared to have each of nine disorders.
Results:
Sex unspecified cases were diagnosed most often with borderline personality disorder.
When it was a female case, a case of ASPD was misdiagnosed as HPD 46% of the time, and 76% of HPD cases were correctly identified.

Conclusion: gender bias occurs due to schemas (we need to make sense of what we do/the world). Diagnosis can be made “blind” to their gender.

description can be applied to both an explanation of dysfunctional behaviour and an explanation of disorders (as long as the disorder chosen is an anxiety disorder - phobia)
different ways behaviourism can explain learning abnormal behaviour? details about classical conditioning.

Learned (e.g. phobias)
Operant Conditioning: - positively reinforced to act a certain way to create a fear of whatever is avoided.
      > punishment - punished for doing something, won't do it agian = avoidance.
     > e.g. teacher screams; phobia of teachers.
Classical Conditioning: - negative experinece in the past + fear stimulus = fear. Association.
Social Learning: - see others' fear, we imitate (we pick up on fear responses of other people).

Study: Watson & Raynor
Participant: Little Albert. Initially unafraid of rats, rabbits, dogs, a mask with hair and cotton wool.
Method: Case study, undertaken on one child "Little Albert". Controlled Laboratory Conditions.
Procedure & Findings: 5 sessions in total, spanned a total of 5 months.
Session 1) Albert was presented with rat in lab, steel bar struck. This was repeated as he reached for the rat. --> Albert fell forward first time he heard sound. Second time, he whimpered. After this, Albert was given a week off
Session 2) Next week, rat presented alone, then 3 times with the loud noise. Then rat alone, then 2 more times with noise. Then finally rat alone again. --> After 5 paired presentations, Albert reacted to the rat alone by immediately crying, crawling and turning away.
Session 3) Albert tested 3 days later to test transference of fear. Given toy blocks (neutral), then rat, rabbit, dog, fur coat, cotton wool, Santa Claus mask. --> Albert reacted negatively to each presentation, crying/moving away. Showed less negativity to cotton wool.
Session 4) 5 days later, Albert shown rat alone, fear response was weaker. So, his fear was refreshed again by hitting steel bar. Also moved to a different location to test if location was important. --> fear response was high, Albert cried and crawled away. In different location, fear response was only slight.
Session 5) One month later, Albert tested with various stimuli including Santa Claus mask, rat, rabbit, and dog. --> Albert showed fear responses to a varying degree of all stimuli. Rabbit not scared of, wanted to play with it.

different ways biology could explain why we develop behaviours & phobia? what do twin studies focus on?

Human Instinct - to avoid anything that threatens survival (individual to our perceptions) e.g. snakes, fire, heights, germs - quite logical to fear them.
     > Fight or Flight. a phobic person = flight.
Biological Disorders (root disorders) e.g. allergic reactions.
Hormone imbalance - making the sufferer more anxious.
Gender - female (hormone)
Genetics - fear inherited?
Brain Dysfunction = amygdala functioning.

Genetic Research on Twins:
MZ = monozygotic twins (identical, same DNA)
DZ = dizygotic twins (non-identical, different DNA)
Concordance Rates = expressed as a %; the probability of one twin having the disorder if the other already has it.
--> when interpreting twin study data, the following features will be observed.
- MZ concordance significantly higher than DZ concordance = disorder has genetic component.
- MZ concordance same or similar to DZ concordance = disorder environmentally caused.
- MZ concordance is 100% = disorder is genetically caused.
- MZ concordance significantly less than 100% = disorder has an environmental component.

Looked at concordance rates of Animal Phobia.
MZ twins = 25.9%. DZ twins = 11%. --> suggesting a strong genetic component playing a role in developing animal phobia.

Challenging Evidence:
Kendler et al looked at concordance rates of Situational Phobia:
MZ twins = 22.2%. DZ twins = 23.7%. --> Dz concordance is higher, suggesting a greater environmental component.

cognitive assumption about behaviour? how might it explain why mental disorders such as anxiety develop?

Cognitive research assumes an internal process influences our behaviour (such as memory, language, thinking, etc). Therefore mental disorders such as anxiety might be caused by irrational or faulty thinking.

We can attempt to modify the irrational thoughts and behaviours individual's suffer, and enable them to cope with their anxiety more.
Features of phobic cognitive thought processes: - irrational, unrealistc, low possibility, over excessive thinking. 

Study: Clark & Wells cognitive model

outline how behavioural techniques work such as systematic desnsitization in the treatment of abnormal behaviour.

Systematic Desensitization (SD) - classical conditioning
- Create fear heirarchy - scale from 1-10 (1 least, 10 most fearful)
- Identify an unconditioned positive stimulus = response of calm relaxation.
- Classical conditioning = pair fearful stimulus with unconditioned stimulus. Gradually expose from lowest to highest fear.
- 8-12 sessions. Fearful response replaced with relaxation. --> Conditioned response.
Flooding (exposure in heaviest form)
Aversion Therapy (punishment or unpleasant consequences)
Token Economy (rewards) --> modify behaviours in institution = operant.

Study: McGrath
Case study - one participant called Lucy, 9 year old girl.
Phobia - fear of sudden loud noises, e.g. balloons popping, cap guns, party poppers, fireworks, etc.
Procedure - Therapy session. Systematic Desensitization. Gradual exposure to fearful stimulus + loud noises.
Informed consent gained from her and her parents.
Lucy's first session fear heirarchy was established. Taught breathing techniques, imagined being at home w/toys relaxed.
Hypothetical fear thermometer. Rate fear from 1-10.
Results - end of 1st session, Lucy cried after baloon popped, but by end of 4th session, Lucy able to burst balloon 10cm away. 10th/final session, fear thermometer scores for party popper dropped from 9/10 to 3/10... but for cap gun from 8/10 to 5/10 (didn't work as effectively)

Psychometric tests on Lucy showed she had lower than average IQ but was not depressed. --> She is dysfunctional/abnormal --> confounding variable?

various forms of biological treatments used to treat different disorders? how do they work?

Drugs/Medication (only been available past 50 years)
- hormone replacement/therpay/treatment - gene therapy.
- psychosurgery (labotomies)
- electroconvulsive therapy (shock therapy/ECT)
   --> rarely used today.. only when medication fails.
Change or treat the symptoms (most drugs do!) drugs only attack symptoms - not the cause of disorder.
   --> reduction of undesired symptoms.

Types of Drugs:
- Antidepressants - increase/regulate levels of neurotransmitters, e.g. serotonin (mood) and noradrenaline.
- Antipsychotics - block dopamine (and serotonin) receptors in the brain to drecrease levels.
                            - higher levels of dopamine = manic, paranoia.
                            - lower levels of deopamine = depression + parkinsons.
- Anti-anxiety - different classes.
                        - antidepressants - slows down central nervous system, forced calm. e.g. Vallium, Dizepam.
                        - betablockers (heart)
                        - Tri-cyclics.

Study: Leibowitz - to see if the drug phenelzine can help treat patients w/social phobia.

Sample: 80 patients, 18-50yrs, meeting DSM criteria for social phobia. Had not received phenelzine for at least 2 weeks before trial. Medically healthy. Had no other disorders, signed consent.

Method & Procedure: Controlled lab experiment & Self-Report scales. One group treated with phenelzine (anti-anxiety drug), one control group given a matching placebo. Second treatment group given atenolol (a beta blocker used to treat high blood pressure), another control group given a matching placebo.
Patients assessed by Hamilton Rating scale for Anxiety and Leibowitz Social Phobia scale, before and after drug administering. Gradual increases in dosage of phenelzine or atenolol in the treatment groups.

Findings: After 8 weeks, significant differences. Phenelzine is effective in treating social phobia - had better scores on tests for anxiety compared with placebo groups. No significant difference between patients taking atenolol and placebo.

outline process of CBT and hw it might reduce someone's anxiety about their phobia.

Cognitive Behaviour Therapy : CBT
Stress Inoculation Therapy : SIT
--> involves changing thoughts + irrational/negative thinking.

CBT is a combination of behaviour modification and cognition theraphy. Cognitive thought = emotion. going to the root cause (perception) targets cause of irrational behaviour.
CBT can help to make sense of overwhelming problems by breaking them down into smaller parts - makes it easier to see how they are connected and hwo they affect you. Parts include:
- A situation (a problem, event or difficult situation). From this can follow: thoughts, emotions, physical feelings, actions.
Change the cycle that a negative thought can trigger negative, irrational thoughts. Reframing negative thoughts to positive, rationalise their beliefs through open discussion.
Between 8-12 sessions/therapy. Behavioural strategies, repractised (role play)

shows how CBT can be used to help treat panic attacks (although not a phobia, panic attacks are another form of anxiety disorder). compares CBT with applied relaxation.
Sample: 38 patients with DSM diagnosis of panic disorder w/without agoraphobia (develops as a complication of panic disorder). 26 females, 12 males, around age 32, variety of occupations, some married, some single/divorced.
Method & Procedure: Longitudinal study. Patients undergoing therapy for panic disorder. P's assigned randomly to cognitive therapy or applied relaxation.
Findings: CBT showed 74% panic free patients after treatment and 89% panic free after 1 year. Applied relaxation showed 65% panic free patients after treatment and 82% panic free after 1 year.
Conclusion: Both cognitive therapy and applied relaxation worked at reducing panic attacks.

Characteristics of Disorders:

• ·         Anxiety Disorders – (Phobia)
• ·         Affective Disorders – (Depression)
• ·         Psychotic Disorders – (Schizophrenia)

Explanations of Disorders:

• ·         Behavioural – (Watson & Raynor)
• ·         Biological – (Kandler)
• ·         Cognitive – (Clark & Wells)

Treatments of Disorders:

•  Behavioural – (McGrath)
• Biological – (Leibowitz)
• Cognitive – (Ost & Westling)

These give a continuous feeling of fear and anxiety, which is disabling and can impose on daily functioning. They can be triggered by something that may seem trivial to others.
Example include: phobias, (e.g. fear of pickles), panic attacks, post-traumatic stress disorder, generalised anxiety disorders.

Example: Phobia
Definition: Phobias have a definite, persistent fear of a particular object/situation. Stimulus will provoke an immediate response - may include physical symptoms (shortness of breath), may feel intense terror and begin to lose control. Fear must result in disrupting everyday life for it to be considered a phobia.
Characteristics from ICD: phobias restricted to highly specific situations. Specific phobias usually arise in childhood/early adult life. Fear tends not to fluctuate.  Anxiety must be restricted to the presence of the particular phobic object/situation. Phobic situation is avoided wherever possible.
Characteristics from DSM: marked and persistent fear that is excessive or unreasonable. Exposure to phobic stimulus provokes immediate anxiety response. Person recognises fear as excessive. Phobic situation is avoided. Phobia disrupts normal person's life. Phobia lasted 6 months+ in people over 18 years old.

Characterisitcs of mood or affective disorders are disabling moods. The disorder prevents the individual from leading a normal life, at work, socially, or within their family.
Types of Affective Disorders: Depression (most commonly), Bipolar Disorder, Dysthymic Disorder, Cyclothymic Disorder, Hypomania.

Example: Depression
Definition: depression can be seen as a continuum with patients having some or all of the symptoms to a different degree. Common symptoms = reduced concentation, lack of self esteem, pessimism, etc. Sometimes in children, irritability is seen rather than a sad mood.
Characteristics from ICD: usually suffer from depressed mood, reduced self esteem, reduced enjoyment and energy, leading to increased fatigue and diminished activity. Pessimistic point of view, ideas and acts of self harm/suicide. Differentiation between severity of symptoms rests upon clinical judgement.
Characteristics from DSM: classification for depression. 4 symptoms present for same 2 week period: feelings of guilt or worthlessness, inability to concentrate, recurrent thoughts of death, insomnia most nights, fidgeting or lethargy, tiredness.

Psychosis is the general term for disorders involving loss of contact w/ reality. Often are characterised by delusions and disorganised speech or behaviour. Can lead to withdrawal from the outside world.
Examples include: Schizophrenia, Schizo-affective Disorders, Brief Psychotic Episodes, Polymorphic Psychotic Disorder.

Example: Schizophrenia
Definition: Positive Symtpoms = delusions, auditory hallucinations, thought disorder. There is an underlying problem with conscious thought that has an effect on a person's language.
Negative Symptoms = loss or absence of normal characteristics, losing emotional responses, inability to feel pleasure, lack of motivation. Disorganised aspect shown in chaotic speech.
Characteristics from ICD: one clear symptom for a period of 1 month or more. 9 subtypes (paranoid schizophrenia, catatonic schizophrenia, post-schizo depression, simple schiz., schiz. unspecified, hebephrenic schiz., undifferentiated schiz., residual schiz., cenesthopathic schiz).
Characteristics from DSM: 5 subtypes, atleast one for 6  months. Two from: delusions, hallucinations, disorganised speech, disorgnanised behaviour, negative symptoms (disorganised speech, etc) social or occupational dysfunctional, no other explanations such as developmental disorder or medication side effects.