Psychological problems

The incidence of mental health problems - incidence rates per 100 people.
Anxiety: 4.7
Depression: 2.6
Eating disorders:1.6
1 in 2 people experiences mental health problems in their lifetime. In 2007 24% of adults were accessing treatment. This rose to 37% in 2014. Estimated that by 2030 2 million more adults will have mental health problems than in 2013. More women are treated than men and this gap is widening. Those in lower income households more likely to have a mental health problem compared to higher income households. Greater social isolation due to city living increases loneliness and is linked to increased depression. In Western society, hearing voices is a symptom of a mental health problem e.g. schizophrenia. But is a positive experience in India and Africa. Some syndromes are culture-bound, occurring only in certain cultures. The signs and symptoms relating to mental illness are subjective - hard to measure. Signs and symptoms are focused on illness instead of health. Jahoda suggested we look for signs of mental health - she listed six characteristics to look for. Labelling a person develops expectations about their behaviour. These labels act as a stigma and can be harmful. The preferred term is 'mental health', which has less stigma and is focused on health.

Jahoda's list:

• Self-attitude: Having high self-esteem and a strong sense of identity.
• Personal growth and self-actualisation: The extent to which an individual develops their full capabilities.
• Integration: such as being able to cope with a stressful situation.
• Autonomy: being independent and self-regularity.
• Having an accurate perception of reality.
• Master of an environment: including the ability to love, function at work and in an interpersonal relationship, adjust to new situations and solve problems.

Individual effects - The way that Mental Health problems (MHP) affect the person who is experiencing them.
MHP:

• Affect the ability to talk to others, which affects relationship because communication is important.
• Are isolating as people avoid being social situations because they feel bad about themselves and fear judgement.

MHP is linked to difficulties with getting dressed, socialising, cleaning the house etc. This may cause a patient little distress but it could be distressing to others.
If you are anxious or stressed, the body produces cortisol. This prevents the immune system, so physical illness is more likely.

Social effects - The way MHP affect others in society.
Taxes are used to fund social care, offering people who are in need the basic necessities. Social care includes helping people to learn how to look after themselves and teaches new social and work skills. We should all feel more personally responsible.
There is an increased risk of violence in people with MHP. However, this may be explained by co-occurring problems. It was found that 1 in 20 crimes of violence was linked to MHP.
The McCrone report estimates that MH care costs £22 billion a year. Cheaper drug treatments should be researched more. Increase in dementia is also an issue.

Clinical depression is the name of depression as a medical condition.
Sadness is a 'normal' emotion where you can still function. Depression involves an enduring and all-encompassing sadness that stops the ability to function.
Unipolar depression - one emotional state (depression)
Bipolar depression - depression alternates with mania, and also periods of normal mood. Mania is an exaggerated state of intense well-being.

MHP is diagnosed in the same way as a physical illness. Symptoms are agreed by professionals. ICD-10 lists symptoms of different disorders and a person diagnosed with any one disorder if a clinician observes the symptoms.
A diagnosis of mild unipolar depression requires two of the three key symptoms plus two others. A diagnosis of 'moderate depression' requires five or six symptoms, 'severe depression' requires seven or more. Symptoms should be present at all or most of the time, and for longer than two weeks.
Symptoms: 1) Low mood. 2) Loss of interest and pleasure. 3) Reduced energy levels. 4) Changes in sleep patterns. 5) Changes in appetite. 7-10) Four further symptoms: guilt, pessimism, ideas of self-harm or suicide, reduced concentration

Biological - looking at physical influences (nature)
Messages travel along a neuron electrically and are transmitted chemically across the synapse via neurotransmitters. Serotonin is a neurotransmitter, linked to several behaviours including depression.
High levels of serotonin in a synaptic cleft stimulate postsynaptic neuron, improving mood. Low levels mean less stimulation resulting in a low mood.
Serotonin affects memory, sleep and appetite. These are linked to characteristics of depression. e.g. lack of concentration; disturbed sleep.
Genes may cause low levels of serotonin. Diet may cause low levels of tryptophan, an ingredient of serotonin.

Research support: Strength. Supporting research for biological explanations. McNeal and Cimbolic found lower levels of serotonin in people with depression. Suggests that there is a link between low levels of serotonin and depression.

Cause or effect?: Weakness. Low levels of serotonin could be an effect of being depressed. Thinking sad thoughts and having difficult experiences could cause low levels of serotonin. Therefore, low levels may be an effect of psychological experiences rather than a cause.

Alternative explanations: Weakness. Depression may not be solely caused by abnormal levels of neurotransmitters. Some people with low levels of serotonin don't have depression and some people with depression don't have low levels of serotonin. Therefore, the neurotransmitter explanation isn't enough on its own.

Psychological explanation - looks at other factors e.g. other people's influence (nurture).
The cognitive approach sees depression as caused by 'faulty' or irrational thinking. When a person is depressed they focus on the negative and ignore the positives. Creates feelings of hopelessness and depression.
Schemas are mental frameworks containing ideas and information developed through experiences. Having a negative self-schema means you are likely to interpret info about yourself in a negative way.
Attributions mean explaining the causes of behaviour. Seligman proposed that some people have negative attributional behaviour. They have negative internal, stable and global attributions which result in depression. (Internal - your fault, Stable - somethings fault, Global - you are bad at everything.)
Seligman suggested that a negative attributional style was learned. An unpleasant experience makes you try to escape but if you can't escape, you learn to give up. This is called 'learned helplessness'.

Research support: Strength. Support for learned helplessness. Seligman demonstrated the process using dogs, which learned to react to the challenge by 'giving up'. Therefore, research supports his explanation of depression due to negative attributions.

Real-world application: Strength. The cognitive explanation leads to ways of treating depression through CBT. People learn to replace faulty thinking with rational thinking to help relieve depression. Therefore, explanation leads to successful ways to help people with depression.

Negative beliefs may be realistic: Weakness. Negative beliefs may simply be realistic, not depressive. Alloy and Abramson found that depressed people gave more accurate estimates of the likelihood of a disaster than 'normal' people ('sadder but wiser'). So a negative attributional style may sometimes be good.

Low levels of serotonin may cause depression, so increasing it may treat depression. SSRIs selectively target serotonin at the synapse. SSRIs inhibit the reuptake of the serotonin molecules.
Serotonin is stored at the end of the presynaptic neuron in sacs called vesicles. The electrical signal travelling through the neuron causes the vesicles to release serotonin into the synaptic cleft.
Serotonin locks into the postsynaptic receptors, chemically transmitting the signal from the presynaptic neuron.
Normally, serotonin is taken back into the presynaptic neuron, broken down and reused. SSRIs block this reuptake so when new serotonin is released it adds to the amount in the synaptic cleft.

Side effects: Weakness. SSRIs have serious side effects including nausea, insomnia, dizziness, weight loss/gain, anxiety and suicidal thoughts. Side effects mean that people stop taking drugs, reducing the effectiveness of drug therapies.

Questionable evidence for effectiveness: Weakness. Research by Asbert shows that the serotonin levels of depressed people may not actually be that different from the normal population. Suggests that the effectiveness of the drug may not be related to serotonin. It may be the placebo effect.

Reductionist approach: Weakness. Medication is regarded as a reductionist explanation. It targets serotonin (sometimes noradrenaline) so focuses on only one kind of factor. Suggests that other treatments are not necessary but a more successful treatment might include both biological and psychological approaches (holistic).

CBT - Cognitive Behaviour Therapy - focuses on what the client thinks. Negative, irrational thinking causes depression. The aim of the therapist is to change this to rational thinking to reduce depression.
CBT aims to change behaviour indirectly through changing thinking. Behaviour also changed directly e.g. behavioural activation where a pleasant activity is planned each day.
'Disputing' is used to deal with negative thoughts experienced by a depressed person. More rational thinking leads to greater self-belief and self-liking.
Any negative emotions experienced are recorded in a 'thought diary', where the client also records the 'automatic' thoughts created by these emotions. The client rates how much they believe in these thoughts. A rational response to the automatic thoughts is then recorded and rated.

Lasting effectiveness: Strength. Using CBT to treat depression has a lasting effect. The 'tools' learned in CBT to help challenge irrational thoughts can help the client deal with future episodes of depression. Therefore, this therapy offers a long-term solution where the client can draw on the skills in the future.

Not for everyone: Weakness. Takes a lot of time and thought for CBT to be successful. Therapy takes months, homework is expected so a lot of effort is needed in comparison to medication. Therefore, many people drop out or fail to engage enough for it to work.

Holistic approach: Strength. CBT focuses on treating the whole person and what they think/feel. This may be preferable as it deals with the core symptoms of depression.

Only 30% of patients with depression respond fully to medication. 70% are 'treatment resistant'

Aim: Set up a CoBalT trial to test a holistic approach (CBT + antidepressants) for treatment-resistant patients.

Method: 469 patients with treatment-resistant depression were randomly allocated to one of two groups. Usual care (just antidepressants). Usual care + CBT. Improvements were assessed using the Beck Depression Index (BDI) before and after.

Results: After 6 months, the number who had more than 50% reduction in symptoms was 21.6% for Usual care and 46.1% for Usual care + CBT. After 12 months, those having Usual care + CBT continued to show greater levels of recovery.

Conclusion: CBT + antidepressants are more effective in reducing depressive symptoms.

Well designed study: Strength. Extraneous variables were carefully controlled. The two groups had the same average depression score at the start and ppts were randomly allocated to a group. Therefore, we can conclude that changes in the DV (reduction in symptoms) were not affected by EVs.

Assessment of depression: Weakness. Use of self-report methods to determine levels of depression. Some people may have over or underestimated how sad they felt. This questions the validity of the info collected about depression.

Real-world application: Strength. Focused on the development of useful therapy. The study shows that a more holistic approach to treating depression is more successful than a reductionist way. Therefore, real-world usefulness is one of the main reasons for conducting research.

Griffiths suggested that salience, dependence and substance abuse are key characteristics. (Salience means the substance/activity becomes the most important thing in a person's life).
Dependence is a characteristic of addiction but is not the same.
Dependence is doing something because of psychological reliance and to prevent withdrawal symptoms.
Addiction is where a person is dependent on the substance/activity but also does it for the 'buzz' or sense of escape.
Difference between substance misuse and substance abuse lies in the person's intentions.
Misuse is not following the 'rules' for usage like taking a substance more often than suggested or using it for something else.
Abuse is using the substance to get 'high' or to escape because a person's intentions are about the outcome of taking the drug.

International Classification of Disease (ICD-10) has a category called 'Mental and behavioural disorders due to psychoactive substance abuse disorders'. A diagnosis of addiction should be made only if three or more characteristics have been present together at some time in the previous year.

ICD-10 list:

• A strong desire to use the substance
• Persisting despite known harm
• Difficulty controlling use
• A higher priority is given to substance
• Withdrawal symptoms are substance/activity is stopped
• Evidence of tolerance i.e. needing more to achieve same effect

Hereditary factors - Research suggests that addictions are moderate to highly inherited.
Genetic vulnerability - Multiple genes create a vulnerability. Diathesis-stress proposes a genetic vulnerability is only expressed is a person's life stresses and experiences are a trigger

Kaij's Study
Aim: To see whether alcoholism could be explained in terms of heredity, using twins.

Method: Male twins from Sweden identified from twins registered with the temperance board. Twins and close relatives were interviewed, to collect info about drinking habits. 48 identified as MZ (Monozygotic) and 126 DZ (Dizygotic).

Results: 61% of MZ twins were both alcoholic whereas 39% of DZ twins were. Twins with social problems were overrepresented among the temperance board registrants.

Conclusion: Alcohol abuse is related to genetic vulnerability. If it was entirely genetic we would expect all MZ twins to be the same. If it was entirely due to the environment we would expect no difference between MZ and DZ twins.

Flawed study: Weakness. Temperance board data only includes drinkers who made a public display of their alcohol abuse. Therefore, conclusions lack validity.

Supported by later studies: Strength. Kendler et al. conducted a well-controlled study using a similar but larger sample. MZ twins were more likely to both be alcoholic than DZ twins. Therefore, research supports the role of heredity in alcoholism.

Misunderstanding genetic vulnerability: Weakness. Biological explanations of addiction are that they may be misleading. Peopled assume that if you inherit certain genes then the addiction is inevitable, ignoring nurture. Therefore, it is very important to fully understand the implications of genetic research.

'Nurture' refers to the influence of experience from the physical and/or social environment. Peers are people who are equal in terms of, for example, age or education.
Social Learning theory - Bandura states we learn how to behave and think by observing what others do. We imitate them especially if they are rewarded. We do it even more to those we identify with.
Social norms - We don't always how what behaviour is 'right'. We look at the behaviour of others to know what is 'normal' or acceptable (social norms).
Social Identity theory - You identify with your social groups. You want to be accepted by them, so behave like them. Adolescents particularly feel 'pressure' to act a certain way and conform to their social group.
Peers influence addictive behaviour because they provide opportunities. Peers may give direct instruction on how to act.

Supporting research: Strength. Peer influence - an explanation of addiction is that there is research support. Simons-Morton and Farhat reviewed 40 studies and found that all but one showed a positive correlation between peers and smoking. Therefore, there is a strong relationship between peers and addiction.

Maybe peer selection: Weakness. Peers may not be influencers. Individuals may actively select those who are like them, rather than conforming to the social norm. Therefore, addictive behaviour is a consequence of addiction rather than caused by a group.

Real-world application: Strength. Social norms programmes have had more success than just teaching resistance skills. Therefore, there is value in peer influence explanations.

Aversion therapy - based on clinical conditioning. Addict learns to associate addiction with something unpleasant, therefore avoids the addictive substance.
Treating alcoholism:
A drug is given to make them sick. Just before throwing up, the patient is given an alcoholic drink. Drug (UCS) leads to vomiting (UCR). Alcohol (NS) is associated with the drug (UCS). Alcohol becomes CS producing nausea (CR).
Treating gambling:
An addict writes phrases related or unrelated to gambling on cards. Gambler reads out each card and receives an electric shock every time they read a gambling phrase. Shock (UCS) leads to pain (UCR). Gambling phrases (NS) is associated with shock (UCS). Gambling phrases become a CS producing pain (CR).
Treating smoking:
The addicted smoker smokes rapidly in an enclosed room causing vomiting. Sickness becomes associated with smoking. Intensive smoking (UCS) leads to vomiting (UCR). Cigarette (NS) is associated with intensive smoking (UCS). Cigarette becomes a CS producing vomiting (CR)

Adherence issues: Weakness. Addicts may abandon the therapy as it's unpleasant. Makes it hard to assess effectiveness.

Poor long-term effectiveness: Weakness. Benefits seem short term rather than long-term. In a long-term follow up (nine years) McConaghy found aversion therapy was no more effective than a placebo. Suggests aversion therapy lacks effectiveness.

Holistic approach: Strength. Aversion therapy + CBT is effective. Aversion therapy rids them of urges to use the substance. CBT provides longer lasting support by changing the person's thinking. Therefore, provides a longer-term solution to addiction.

Self-management programmes require individuals to organise their treatment with no professional therapist. The 12-step recovery programme was developed over 65 years ago by a group of alcoholics. AA continues to offer a programme based on the same spiritual principles.
'Higher' power: One key element to the 12-step programme is giving control to a higher power and letting go of your own will.
Admitting and sharing guilt: Person accepts things they have done. Members of the group and the higher power listen to the confession to accept the 'sinner'.
Lifelong process: Recovery is a lifelong process where the group supports each other. They can call other members in case of relapse.
Self-help groups: A peer-sharing model to support each other. Some avoid the religious element of surrendering to a higher power. Some involve local cultural traditions.

Lack of clear evidence: Weakness. Poor quality research on effectiveness. AA reported in 2007 that 33% of its 8000 North American members have remained sober for 10 years or more but this doesn't include how many left without success. Therefore, it is difficult to get clear evidence on effectiveness.

Individual differences: Weakness. The 12-step programme may only be effective for certain types of people. Dropout rates are high, suggesting that the self-help approach is demanding and requires high motivation. This means this treatment is a limited approach.

Holistic approach: Strength. The 12-step programme focuses on the whole person. Many steps are concerned with emotions, particularly guilt, together with providing social support to help a person cope with their emotions. This can be contrasted with more reductionist programmes such as aversion therapy which just targets stimulus-response links.

12-step recovery programme:

• Admit powerlessness over the addiction.
• Find hope, believe that a higher power can help.
• Surrender control over to the higher power.
• Take a personal inventory, focusing on wrongs done.
• Share inventory with the higher power, oneself and another person, admitting wrongs done.
• Become ready to have the higher power correct any shortcomings in one's character.
• Ask the higher power to remove those shortcomings.
• Make a list of people who have been harmed.
• Make amends if possible for any past wrongs.
• Continue personal inventory and recognise immediately.
• Use prayer and meditation to continue the connection with the higher power.
• Carry the message of the 12-steps to others in need.