Psychopathology

any behaviour seen as rare or different are 'abnormal', ie. statistically infrequent

IQ is normally distributed:

• the average IQ is 100 - most people have an IQ between 85 and 115
• only 2% have a score below 70 = statistically abnormal and diagnosed with intellectual disability disorder

real life applications - all assessment of patients with mental disorders includes some comparison to statistical norms - itellectual disability disorder demonstrates how statistical infrequency can be used - thus stat infrequency is a useful part of clinical assessment 

unusual characteristics can be positive - eg. IQ scores over 130 are just as unusual as those below 70, but not regarded as undesirable and requiring treatment - limitation of stat infrequency - should never be used as a diagnosis alone

being labelled as unusual - people living a happy and fulfilled life gain no benefit from being labelled as abnormal - being labelled as abnormal might have a negative effect on the way others view them and the way they view themselves

when a person behaves in a way that is different from how they are expected to behave, they may be defined as abnormal - societies / social groups make collective judgements about 'correct' behaviours in particular circumstances

definitions are related to cultural context, including historical differences within the same culture - eg. homosexuality is viewed as abnormal in some cultures but not others and was considered abnormal in our scoiety in the past

eg. antisocial personality disorder - one important symptom of APD is a failure to conform to culturally normative ethical behaviour - abnormal bcos they deviate from social norms

a strength is that the definition has real life applications in the diagnosis of APD

culturally relative - a person from one cultural group may label someone from another group as abnormal using their standards rather than the person's standards - this creates problems for people from one culture living within another culture group

human rights - too much reliance on deviation from social norms to understand abnormality can lead to a systematic abuse of human rights - some psychologists argue that some modern abnormal classifications are abuses of people's right to be different

inability to cope with everyday living, eg. not being able to hold down a job, maintain relationships or maintain basic standards of hygiene 

Rosenhan and Seligman proposed signs of failure to cope:

• no longer conforming to interpersonal rules, eg, maintaining personal space
• they experience personal distress
• behave in a way that is irrational or dangerous 

having a low IQ is statistically infrequent, but there would have to be clear signs that the person is not able to cope with demands of everyday living = intellectual diability disorder is an example of failure to function adequately

recognises patients perspective - definition acknowledges patient experience is important - captures experience of many people who need help and is useful for assessing abnormality

subjective to judgement - some patients may say they're stressed but be judged as not suffering - there are methods for making judgements as objective as possible eg. checklists, however principle remains whether the psychiatrist has the right to make this judgement

Jahoda listed 8 criteria for ideal mental health:

• no symptoms or distress
• rational and percieve ourselves accurately
• self-actualise
• can't cope with stress
• realistic view of the world
• good self-esteem and lack guilt
• independent of other people
• successfully work, love and enjoy our leisure

A limitation is that these are unrealistically high standards for mental health - very few will atain all Jahoda's criteria therefore, this approach sees most of us as abnormal

definition may be culturally relative - some of Jahoda's criteria are specific to Western (individualist) cultures, eg. emphasis on personal achievement would be considered self-indulgent in much of the world where the focus is on community rather than oneself

criteria covers most reasons someone would seek help from mental health - sheer range of factors in Jahoda's criteria make it a good tool for thinking about mental health

Behavioural

• Panic - may involve range of behaviours, eg. crying, screaming or running away from stimuli
• Avoidance - considerable effort to avoid coming to contact with stimuli - hard to go about everyday life, especially if phobic stimulus is often seen, eg. public places

Emotional

• Anxiety and fear - fear is the immediate experience when a phobic encounters / thinks about phobic stimulus - fear leads to anxiety
• Responses are unreasonable - response is widely disproportionate to the threat posed, eg. arachnophobic will have a strong emotional response to a small spider

Cognitive

• Selective attention to the phobic stimulus - the phobic finds it hard to look away from stimulus 
• Irrational beliefs - eg. 'if I blush, people will think I'm weak'

phobias are learned by classical conditioning and maintained by operant conditioning

Watson and Raynor showed how a fear of rats could be conditioned in 'Little Albert':

• UCS (noise)→UCR (fear)
• everytime little Albert played with a rat a loud noise was made close to his ear
• NS (rat) → no response
• UCS + NS → UCR
• rat (NS) did not create fear until the bang and the rat had been paired several times
• CS (rat) → CR (fear)
• Albert showed a fear response every time he came into contact with a rat

Generalisation of fear to other stimuli, eg. little Albert also showed a fear response to other white, furry objects including a fur coat and a Santa Claus mask

• maintenance by negative reinforcement (individual produces behaviour that avoids something unpleasant)
• when a phobic avoids a phobic stimulus they escape the anxiety that would have been experienced
• this reduction in fear negatively reinforces the avoidance behaviour and the phobia is maintained

example: if someone has a morbid fear of clowns they will avoid circuses and other situations where they may encounter clowns - the relief felt from avoiding clowns negatively reinforces the phobia and ensures it is maintained rather than confronted

has important implications for therapy - patient is prevented from avoidance behaviour, phobia declines = application to therapy is a strength of the two process model

alternative explanations for avoidance behaviour - in more complex behaviours eg. agoraphobia, there is evidence that some avoidance behaviours is motivated by feelings of safety - explains why agoraphobics can leave the house with a trusted friend - whereas two process model suggests avoidance is motivated by anxiety reduction = limitation

if we accept CC and OC are involved in the development/maintenance of phobias, there are some elements that need further explanation - we easily acquire phobias of things that were of risk to us in our evolutionary past, such as snakes - this is biological preparedness - shows there is more to acquiring phobias than just conditioning = incomplete explanation

sometimes phobias do appear following a bad experience, and it is easy to see how these can be the result of conditioning - however sometimes people have a bad experience, eg. bitten by a dog, and dont develop a phobia - conditioning alone cannot explain phobias, and may only develop where a vulnerability may exist

behavioural approach does not address the cognitive element of phobias

Systematic desensitisation is based on classical conditioning - the therapy aims to gradually reduce anxiety through counterconditioning:

• phobia is learned so that phobic stimulus (CS) produces fear (CR)
• CS is paired with relaxation and this becomes the new CR

Reciprocal inhibition: it is not possible to be afraid and relaxed at the same time, so one emotion prevents the other

Patient and therapist design an anxiety hierarchy - a list of fearful stimuli arranged in order from least to most frightening, eg. an arachnophobic will identify seeing a pic of a spider as low on their anxiety hierarchy and holding a tarantula at the very top

Relaxation is then practised at each level of the hierarchy:

• phobic is first taught relaxation techniques, eg. deep breathing, meditation
• patient then works through hierarchy - at each level phobic is exposed to phobic stimulus in relaxed state
• takes place over several sessions starting at bottom of the hierarchy

Gilroy followed up 42 patients who had SD for spider phobia in 3 45min sessions - at both 3 and 33 months, the SD group were less fearful than control group - helpful because reduces phobias and has long term effects

flooding and cognitive therapies are not well suited to some patients, eg. having learning difficulties can make it hard for some patients to understand what is happening during flooding or cog therapies which require reflection - SD most appropriate treatment for these/all patients

patients often prefer SD bcos does not cause the same degree of trauma as flooding, and includes pleasant elements, eg. time talking with therapist - reflected in low refusal rates

Flooding involves immediate exposure to the phobic stimulus, eg. an arachnophobic recieving flooding treatment may have a large spider crawl over their hand until they can relax fully

without the option of avoidance behaviour, the patient quickly learns the phobic object is harmless through exhaustion of their fear response - known as extinction 

Flooding is not unethical but it is an unpleasant experience, so it is important patients give informed consent - they must be fully prepared and know what to expect

less effective for complex phobias - highly effective for treating simple phobias but not for complex phobias like social phobias bcos of cognitive aspects, eg. sufferer of social phobia doesn't just experience anxiety but thinks unpleasant thoughts abiut the social situation - this type of phobia may benefit more from cog therapies to tackle irrational thinking

traumatic for parents - although parents do give informed consent, often parents don't see it through to the end bcos of the high traumatic experience - ultimately the treatment is not effective, and time and money is wasted

Behavioural

• Activity levels - sufferers of depression have reduced levels of energy making them lethargic
• Disruption to sleep - sufferers may experience reduced sleep (insomnia) or an increased need for sleep (hypersomnia)
• Disruption to eating behaviour - apetite may increase / decrease, leading to weight gain / loss

Emotional

• Lowered mood - more pronounced than the daily experience of feeling lethargic or sad
• Anger - on occassion, such emotions lead to aggression or self-harming behaviour

Cognitive

• Poor concentration - sufferers find themselves unable to stick with a task as they usually would, or they might find simple decision making difficult
• Absolutist thinking - when a situation is unfortunate it is seen as an absolute disaster

Beck (1967)

• suggested some people are more prone to depression becos of faulty info processing
• depressed people tend to look at the negative apects of a situation and ignore the positive, and also tend to blow small problems out of proportion and think in 'black and white' terms
• this is bcos depressed people are said to have negative self schemas - they interpret all info about themselves in a negative way

Beck's negative triad:

• negative view of the world
• negative view of the future
• negative view of oneself

Grazioli and Terry assessed 65 pregnant women for cog vulnerability and depression before and after birth - those with high vulnerability = more likely to suffer post-natal depression - cognitions noticed before depression develops - Beck may be right that cognition causes depression

forms the basis of CBT - the components of the negative triad can be easily identified and challenged in CBT - patient can test whether parts of the negative triad are true - practical application as a therapy

depression is a complex disorder - Beck's theory does not easily explain extreme anger emotion - Jarret 2013, some depression sufferers experience hallucinations, bizarre beliefs etc - Beck's cannot explain all cases of depression and just focuses on one aspect of the disorder

Ellis's ABC model:

A = activating event

• Ellis suggested that depression arises from irrational thoughts
• according to Ellis, depression occurs when we experience negative events, eg. failing an important test, or ending a relationship

B = beliefs - negative events trigger irrational beliefs:

• musterbation: we must always succeed
• I-can't-stand-it-itis: it is a disaster when something doesn't go smoothly
• utopianism: the world must always be fair

C = consequences

when an activating event triggers irrational beliefs there are emotinal and behavioural consequences, eg. if you believe you must always succeed, and you fail, the consequence may be depression

not all cases of depression follow 'activating events' - psychologists see that as a separate type of depression (reactive depression) - explanation only apply to some kinds of depression

cog explanation as a general issue

cog explanations are closely tied up with the concept of cognitive primacy - the idea that emotions are influenced by cognition (our thoughts) - not neccessarily always the case, eg. anxiety and distress can be stored as physical energy - cog theories do not explain all aspects of disorder

the aims behind Beck's version of CBT:

• patients and therapist work together toclarify the patients problemsand identify where there might be negative or irrational thoughts that will benefit from challenge
• The aim is to identify negative thoughts about the self, the world and the future - the negative triad

Patients are encouraged to test the reality of their irrational beliefs - this is done through, for example:

• setting homework to record when they enjoyed an event or when people were nice to them etc - reffered to as 'patient as a scientist'
• in future sessions if patients say that no-one is nice to them, the therapist can produce this evidence to prove the patients beliefs are incorrect

Ellis's rational emotive behaviour therapy (REBT) extends the ABC model to an ABCDE:

• D for dispute (challenge) irrational beliefs 
• E for effect 

Challenging irrational beliefs:

a patient might talk about how unlucky they have been or how unfair life is - an REBT therapist would identify this as utopianism and challenge it as an irrational belief:

• Empiracle argument - disputing whether there is evidence to support the irrational belief
• Logical argument - disputing whether the negative thought actually follows from the acts

Behavioural activation:

as individuals become depressed, they avoid difficult situations and become isolated, which maintains / worsens symptoms - therefore the goal of treatment is to work with avoidance and isolation and increase their engagement in activities that improve mood, eg. exercise, going out to dinner, etc.

large body of evidence to support effectiveness of CBT for depression, eg. March et al compared the effects of CBT with antidepressant drugs and a combination of the two in 327 adolescents - found CBT as effective as antidepressants and is helpful alongside medication

depression can be so severe that patients arent able to take on the hard cognitive work required for CBT - in this case, use antidepressants and commence CBT when they are more alert and motivated - limitation bcos cannot be used as a sole treatment for all depression

All psychotherapies contain one essential factor - the relationship between the patient and therapist - it might be the quality of this relationship that determines success rather than any particular technique

one aspect of CBT is to focus on the patients present and future, rather than past - some forms of psychotherapy patients make links between childhood experiences and current depression - this 'present focus' may ignore an important aspect of the depressed patients experience

patients living in poverty, suffers abuse etc need to change their circumstances - approaches that emphasise the patients mind rather than environment can prevent this = overemphasis on cognition - not used appropriately can demotivate people to change their situation

Behavioural

• Compulsions - actions that are carried out repeatedly to reduce anxiety, eg. handwashing
• Avoidance - OCD is managed by avoiding situations that trigger anxiety eg. coming into contact with germs

Emotional

• Anxiety and distress - obsessive thoughts are unpleasant and frightening, and the anxiety that goes with these can be overwhelming
• Guilt - eg. over a minor moral issue
• Disgust - directed towards oneself or something external, eg. dirt

Cognitive

• Obsessive thoughts - 90% of OCD sufferers have obessive thoughts, eg. about contaminated dirt / germs]
• Insight into excessive anxiety - sufferers experience catastrophic thoughts and are hypervigilant (over-aware of their obsession)

Candidate genes = specific genes which create a vulnerability for OCD

• Serotonin genes, eg. 5HT1-D beta, are implicated in the transmission of serotonin across synapses
• Dopamine genes are also implicated in OCD

Both serotonin and dopamine are neurotransmitters that have a role in regulating blood

OCD is polygenic = OCD is not caused by one single gene but several genes are involved

Taylor (2013) found evidence that up to 230 different genes may be involved in OCD

Different types of OCD: 

one group of genes may cause OCD in one person but a different group of genes may cause the disorder in another person - known as aetiologically heterogeneous

there is also evidence that different types of OCD may be result of particular genetic variations, such as hoarding disorder and religious obsession

Good supporting evidence, eg. Nestadt et al reviewed twin studies and found that 68% of MZ twins shared OCD as opposed to 31% of DZ twins - strongly supports genetic influence on OCD

although twin studies suggest OCD is largely genetic, psychologists have been less successful at pinning down all the genes involved bcos it appears that several genes are involved and that each genetic variation only increases the risk of OCD by a fraction - genetic explanation not very useful bcos provides little predictive value

seems some environmental risk factors can also trigger OCD - Cromer found that over half of OCD patients had traumatic event in their past, and OCD was more severe in these patients - supports diathesis stress model - focussing on envrionmental factors maybe more productive as we are able to do something about these

Low levels of serotonin:

Neurotransmitters are responsible for relaying info from one neuron to another

If a person has low levels of serotonin then normal transmission of mood-relevant info does not take place and mood (and sometimes other mental processes) is effected

Impaired frontal lobes:

OCD tends to be associated with impaired decision making, therefore may be associated with abnormal functioning of the lateral frontal lobes of the brain

The frontal lobes are responsible for logical thinking and decision making

Parahippocampal gyrus dysfuntion:

also evidence to suggest that an area called the left parahippocampal gyrus (associated with processing unpleasant emotions) functions abnormally in OCD

antidepressants that work purely on serotonin system are effective in reducing symptoms of OCD - suggests serotonin system is involved in OCD

OCD symptoms form part of biological conditions such as Parkinsons disease - suggests that the biological processes that cause the symptoms in those conditions may also be responsible for OCD

co-morbidity - many people who suffer from OCD also become depressed - depression probably involves disruption to the serotonin system - problem when it comes to using the serotonin system as a possible basis for OCD

drug therapy for mental disorders aims to increase / decrease levels of neurotransitters in the brain, or to increase / decrease their activity

Low levels of serotonin are associated with OCD, therefore drugs work in various ways to increase the level of serotonin in the brain

SSRIs

• prevent the reabsorption and breakdown of serotonin in the brain
• increases its levels in the synpase
• serotonin continues to stimulate the postsynaptic neuron

this compensates for whatever is wrong with the serotonin system in OCD

Typical dosage:

• typical dosage of Fluoxetine (SSRI) is 20mg
  
• takes 3 - 4 months of daily use for SSRIs to impact upon symptoms
• can be increased to eg. 60mg a day if not benefitting patient
  

Combining SSRIs with CBT

Drugs reduce a patient's emotional symptoms, such as feeling anxious or depressed - this means that patients can engage more with CBT

Alternatives to SSRIs:

1. Tricyclics - such as Clomipramine (older type of antidepressant) have the same effect on serotonin system as SSRIs, but have more severe side effects

2. SNRIs - (newer type of antidepressant) are like tricyclics, are second in line for patients who don't respond to SSRIs - they increase levels of noradrenaline as well as serotonin

Soomro reviewed 17 studies comparing SSRIs to placebos in the treatment of OCD - all 17 studies showed significantly better results for SSRIs than the placebo condition - effectiveness is greatest when SSRIs are combined with CBT - symptoms reduce around 70% when taking SSRIs, the rest are helped by alternative drugs or CBT+drugs = drugs can help most patients suffering from OCD

drug treatments usually preferred for these reasons:

• drugs are cheapter than psychological therapies = good value for NHS
• SSRIs are non-disruptive to patients lives - can just take drugs until symptoms decline and not engage with the hard work of psychological therapy

some patients gain no benefit from drug therapies at all, and others suffer side effects, such as indegestion, blurred vision and loss of sex drive - Clomipramine's side effects are more severe, eg. 1 in 10 men suffer erection problems and weight gain - reduces effectiveness bcos stop taking medication

OCD can occassionally be caused in response to traumatic life events - not appropriate to use drugs when treating these cases, psychological therapy is the best option