Psychopathology

Abnormality - Statistical infrequency

Statistical infrequency - Occurs when an individual has a less common characteristic, for example being more depressed or less intellegent than most of the population.

(http://static1.mbtfiles.co.uk/media/docs/newdocs/as_and_a_level/psychology/the_psychology_of_individual_differences/758621/html/images/image03.png)

In the distribution curve the highest 2.28% and lowest 2.28% can be defined as abnormal as it is statistically infrequent. 

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Statistical infrequency - evaluation

Strengths 

  • Can be appropriate - In many situations statistical criteria can define abnormality, eg. mental retardation. 
  • Overall view - Gives an overview of what behaviours and characteristics are infrequent within a good population. 
  • Based on real data - Definition relies on real, unbiased data and so again is an objective means of defining abnormality. 

Weakness

  • Cultural relativity - What is statistically normal in one culture is not normal in another eg. Britain wouldn't take an extended rest period during the workday.
  • Not all infrequent behaviours are abnormal - some infrequent behaviours are desirable eg. being highly intellegent. 
  • Not all abnormal behaviours are infrequent - some statistically frequent normal behaviours are actually abnormal. 10% of the population have been chronically depressed at some point in their lives. 
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Abnormality - Deviation from social norms

Concerns behaviour that is different from the accepted standards of behaviour in a community or society. 

Strengths 

  • Developmental norms - establishing what is normal depending on your age.
  • Protects society - seeks to protect society from the effects of an individual's abnormal behaviour. 
  • Social dimension - a behaviour in one setting is abnormal but not in another.
  • Clearly distinguishes between normal and abnormal behaviour. 

Weaknesses

  • Cultural relativity - one behaviour may be seen as abnormal in one culture but not in another. 
  • Changes over time - society's views change over time.
  • Individualism - those who do not wish to conform may not be abnormal but merely eccentric. 
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Abnormality - Failure to function adequately

When a person fails to meet the expectations of day-to-day life and begins to cause distress. 'Acting in a way that prevents the person from living a normal life and doing the things that most normal people are able to do'.

Rosenhan & Seligman's 7 features of personal dysfunction 

  • Personal distress 
  • Maladaptive behaviour 
  • Unpredictability 
  • Irrationality 
  • Observer discomfort
  • Violation of moral standards
  • Unconventionality.

Displaying one of these is not a problem, when you have several of them it means that you may have a problem. 

The Global Assessment of Functioning Scale ( GAF) is a method of measuring how well individuals function in everyday life and it considers Rosenhan and Seligman’s sections plus occupational functioning.

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Failure to function adequately - evaluation

Strengths

  • Matches sufferer's perceptions
  • Assesses degree of abnormality 
  • Checklist
  • Personal perspective - recognises the personal experience of the sufferer and thus allows disorder to be regarded from the perception of the individual's suffering from them.

Weaknesses 

  • Cultural relativism
  • Subjective nature of the features of dysfunction - what is normal for an eccentric is not normal for an introvert
  • Normal abnormality -  everyone goes through abnormality eg. we suffer personal distress when someone dies
  • Distress to others
  • Personally rewarding abnormality - individuals dysfunction behaviour may be rewarding. 
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Abnormality - Deviation from ideal mental health

Failure to meet the criteria for perfect psychological wellbeing according to Jahoda's characteristics of ideal mental health. 

Jahoda (1958) suggested that we are in good mental health if we meet the following criteria:

  • Positive attitude to oneself - positive self respect & positive self concept 
  • Self actualisation - experiencing personal growth and development 
  • Resisting stress - having effective coping strategies and being able to cope with everyday anxiety provoking situations
  • Accurate perception of reality - Percieving the world in a non-distorted fashion & having and objective and realistic view of the world 
  • Autonomy - being independent, self-reliant & able to make personal decisions
  • Environmental mastery - being competent in all aspects of life and able to meet the demands of any situation. Having the flexibility to adapt to changing life circumstances.
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Deviation from ideal mental health - evaluation

Strengths 

  • Positivity - definition emphasises achievements rather than failure, distress and stresses a positive approach to what is desirable
  • Holistic - considers an individual as a whole person rather than focusing on individual areas of behaviour 
  • Goal setting - permits identification of exactly what is needed to achieve normality, allowing creation of personal goals to work towards and achieve, thus facilitating self-growth. 

Weaknesses 

  • Cultutral relativity 
  • Overdemanding criteria - most people do not meet all the ideals, eg. not everyone reaches self actualisation. 
  • Subjective criteria - many of the criteria are vague & difficult to measure. Measuring physical health is much more objective. Diagnosing mental health is more subjective, largely self-reports from patients. 
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Phobias

An irrational fear of an object or situation.

Specific phobia: phobia of an object, such as an animal or body part, or a situation such as flying or having an injection

Social anxiety (social phobia): phobia of a social situation such as public speaking or using a public toilet. 

Agoraphobia: phobia of being outside or a public space. 

Behavioural characteristics of phobias

Panic: a phobic may panic in response to the presence of the phobic stimulus. Panic may involve a range of behaviours including crying, screaming or running away. 

Avoidance: Unless the sufferer is making a concious effort to face their fear they tend to go to a lot of effort to avoid coming into contact with the phobic stimulus. Hard to go about everyday life. 

Endurance: remains in the presence of the phobic stimulus but continues to experience anxiety.

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Emotional characteristics of phobias

Anxiety: Phobias are classified as anxiety disorders. By definition then they involve an emotional response of anxiety and fear. Anxiety is an unpleasant state of high arousal. This prevents the sufferer relaxing anf makes it very difficult to experience any positive emotion. Anxiety can be long term. Fear is the immediate and extremely unpleasant response we experience when we encounter or think about the phobic stimulus. 

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Cognitive characteristics of phobias

The cognitive element is concerned with the ways in which people process information. Peopple with phobias process information about phobic stimuli differently from other objects or situations.

Selective attention to the phobic stimulus: If a sufferer can see the phobic stimulus it is hard to look away from it. Keeping our attention on something really dangerous is not a good thing as it gives us the best chance of reacting quickly to a threat, but this is not so useful when the fear is irrational. 

Irrational beliefs: A phobic may hold irrational beliefs in relation to phobic stimuli. This kind of belief increases the pressure on the sufferer to perform well in social situations. 

Cognitive distortions: The phobic's perceptions of the phobic stimulus may be distorted. 

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Depression

A mental disprder characterised by low mood and low energy levels.

DSM-5 categories of depression:

  • Major depressive disorder: severe but often short-term depression
  • Persistant depressive disorder: long-term or recurring depression, including sustained major depression and what used to be called dysthymia.
  • Distuptive mood dysregulation disorder: childhood temper tantrums
  • Premenstural dysphoric disorder: disruption to mood prior to and/or during menstruation..
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Behavioural characteristics of depression

Anxiety levels: Typically sufferers of depression have reduced levels of energy making them lethargic. This has a knock-on effect, with sufferers tending to withdraw from work, education and social life. In extreme cases this can be so severe that the sufferer cannot get out of bed. 

In some cases depression can lead to the opposite effect - known as psychometer agaitation. Agitated individuals struggle to relax and may end up pacing up and down. 

Disruption to sleep and eating behaviour: Depression is associated with changes to sleeping behaviour. Sufferers may experience insomnia, particularly premature making, or an increased need for sleep. Similarly, appetite and eating may increase or decrease, leading to weight gain or loss. 

Aggression and self-harm: Sufferers of depression are often irritable, and in some cases they can become verbally or physically aggressive. This can have serious knock-on effects on a number of aspects of their life. 

Depression can also lead to physical aggression directed against the self. This includes self-harm, often in the form of cutting, or suicide attempts. 

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Emotional characteristics of depression

Lowered mood: Lowered mood is still a defining emotional element of depression but it is more pronounced than in the dailt kind of experience of feeling lethargic and sad. Patients often describe themsekves as 'wothless' and 'empty'.

Anger: Although sufferers tend to experience more negative emotions and fewer positive ones during episodes of depression, this experience of negative emotion is not limited to sadness. Sufferers of depression also frequently experience anger, sometimes extreme anger. This can be directed at the self or others. On occasion such emotions lead to aggressive or self-harming behaviour.

Lowered self-esteem: Self-esteem is the emotional experience of how much we like ourselves. Sufferers of depression tend to report reduced self-esteem, in other words they like themselves less than usual. This can be quite extreme, with some sufferers describing a sense of self-loathing. 

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Cognitive characteristics of depression

Poor concentration: Depression is associated with poor levels of concentration. The sufferer may find themselves unable to stick with a task as they usually would, ot they might find it hard to make decisions that they would normally find straightforward. Poor concentration and poor decision making are likely to interfere with the individual's work. 

Attending to and dwelling on the negative: When suffereing a depressive episode people are inclined to pay more attention to negative aspects of a situation and ignore the positives In other words they tend to see a glass half empty. 

Sufferers also have a bias towards recalling unhappy events rather than happy ones.

Absolutist thinking: Most situations are not all-goor or all-bad, but when a sufferer is depressed they tend to think in these terms. They sometimes call this 'black and white thinking'. This means that when a situation is unfortunate they tend to see it as an absolute disaster. 

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OCD

 Condition characterised by obsessions and/or compulsive behaviour. 

DSM-5 categories of OCD:

  • OCD - characterised by either obsessions and/or compulsions. Most people with OCD have both obsessions and characteristics.
  • Trichotillomania - compulsive hair pulling
  • hoarding disorder - the compulsive gathering of possessions and the inability to part with anything, regardless of its value
  • Excoriation disorder - compulsive skin picking 
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Behavioural characteristics of OCD

Compulsions 

  • Compulsions are repetitive - Typically sufferers of OCD feel compelled to repeat a behaviour. A common example is hand washing. 
  • Compulsions reduce anxiety - The vast majority of compulsive behaviours are performed in an attempt to manage the anxiety produced by obsessions.

Avoidance

The behaviour of OCD sufferers may also be characterised by their avoidance as they attempt to reduce anxiety by keeping it away from situations that trigger it. 

(http://www.biggiesboxers.com/wp-content/uploads/2016/05/OCD-pg5_499x305.jpg.png)- Cycle of OCD

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Emotional characteristics of OCD

Anxiety and distress

OCD is regarded as a particularly unpleasant emotional experience because of the powerful anxiety that accompanies both obsessions and compulsions. Obsessive thoughts are unpleasant and frightening, and the anxiety that goes with these can be overwhelming. The urge to repeat a behaviour (compulsion) creates anxiety.

Accompanying depression

Ocd is often accompanied by depression, so anxiety can be accompanied by low mood and lack of enjoyment in activities. Compulsive behaviour tends to bring some relief from anxiety but this is temporary. 

Guilt and disgust

As well as anxiety and depression, OCD sometimes involves other negative emotions such as irrational guilt.

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Cognitive characteristics of OCD

Obsessive thoughts

These vary considerably from person to person but are always unpleasant. 

Cognitive strategies to deal with obsessions 

Obsessions are the major cognitive aspects of OCD, but people also respond by adopting cognitive coping strategies eg. praying or meditating - distracts them from everyday thoughts. 

Insight into excessive anxiety

People with OCD are aware that their obsessions and compulsions are not rational. In fact this is necessary for a diagnosis of OCD. If someone really believed their obsessive thoughts were based on reality that would be a symptom of a quite different form of mental disorder. However, in spite of this insight, OCD sufferers experience catastrophic thoughts about the worst case scenarios that might result if their anxieties were justified. They also tend to be hypervigilant. 

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The behavioural approach to explaining phobias

The two-process model 

The behavioural approach emphasises the role of learning in the acquisition of behaviour. The approach focuses on behaviour - what we can see. The behavioural approach is geared towards explaining these rather than the cognitive and emotional aspects of phobias. 

Mowrer (1960) proposed the two-process model based on the behavioural approach to phobias. This states thst phobias are acquired by classical conditioning and then continue because of operat conditioning. 

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The two-process model

Acquisition by classical conditioning 

Classical conditioning involves learnign to associate something of which we initially have no fear with something that already triggers a fear response. 

Watson & Raynor (1920) created a phobia in 9 month old - Little Albert. 

  • He showed no unusual anxiety at the start of the study. 
  • When shown a white rat he tried to play with it. Whenever the rat was presented they made a loud noise. This noise is an UCS which created an UCR of fear. 
  • When the rat (NS), and the unconditioned stimulus are encountered close together in time the NS becomes associated with the UCS and now produce the fear response. 
  • Rat is now a learned conditioned stimulus that produces a conditioned response. 
  • Conditioning then generalised to similar objects. 
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The two-process model

Maintenance by operant conditioning 

Responses acquired by classical conditioning usually tend to decline over time. However, phobias are often long lasting. Mowrer has explained this as a result of operant conditioning. 

Operant conditioning takes place when our behaviour is reinforced or punished. Reinforcement tends to increase the frequency of a behaviour. This is true of both negative reinforcement and positive reinforcement. In the case of negative reinforcement an individual avoids a situation that is unpleasant. Such a behaviour results in a desirable consequence, which means the behaviour will be repeated. 

Mowrer suggested that whehever we avoid a phobic stimulus we successfully escape the fear and anxiety that we would have suffered if we had remained there. This reduction in fear reinforces the avoidance behaviour and so the phobia is maintained. 

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Two process model - evaluation

Good explanatory power

The two-process model was a deifninate step forward when it was proposed in 1960 as it went beyond Watson and Rayner's concept of classical conditioning. It explaine how phobias could be maintained over time and this had implicationsfor therapies because it explains why patients need to be exposed to the feared stimulus. Once a patient is prevented from practising their avoidance behaviour the behaviour ceases to be reinforced and so it declines. 

Alternative explanation for avoidance behaviour 

Not all avoidance behaviour associated with phobias seems to be the result of anxiety reduction, at least in more complex phobias like agoraphobia. There is evidence to suggest that at least some avoidance behaviour appears to be motivated more by positive feelings of safety. In other words the motivating factor in choosing an action like not leaving the house is not so much to avoid the phobic stimulus but to stick with the safety factor.  This explains why some patients with agoraphobia are able to leave their house with a trusted person with relatively little anxiety but not alone. 

This is a problem for the two-process model, which suggests that avoidance is motivated by anxiety reduction. 

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Two process model - evaluation

An incomplete explanation of phobias

Even if we accept that classical and operant conditioning are involves in the development and maintenance of phobias, there are some aspects of phobic behaviour that require further explaining. Bounton (2007) points out, that evolutionary factors probably have an important role in phobias but th two-factor theory does not mention this. 

For example, we easily acquire phobias of things that have been a source of danger in our evolutionary past, such as snakes and the dark. It is adaptive to acquire phobias of such fears. Seligman (1971) called this biological preparedness - the innate predisposition to acquire certain fears. However, it's quite rare to develop a fear of carn or guns, which are actually much more dangerous to us today than snakes. Presumably this is because they have only existed very recently and so we are not biologically prepared to learn fear responses towards them. 

This shows there is more to acquiring phobias than simple conditioning. 

Phobias that don't follow trauma

Sometimes phobias appear following a bad experience and it is easy to see how they could be the result of conditioning. However, someone who has never seen a snake can still be phobic. 

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Behavioural approach to treating phobias

Systematic desensitisation - A behavioural therapy designed to reduce an unwanted response, such as anxiety, to a stimulus. SD involves drawing up a hierarcy of anxiety-provoking situations related to the phobis stimulus, teaching the patient to relax, and then exposing them to phobic situations. The patient works their way through the hierarchy whilst maintaining relaxation.

Essentially a new response to the phobic stimulus is learned. This learning of a different response is called counterconditioning. 

In additionit is impossible to be afraid and relaxed at the same time, so one emotion prevents the other. This is called reciprocal inhibition. 

Three processes in SD:

  • Anxiety hierarchy
  • Relatation - breathe deeply and slowly, muscle relaxation.
  • Exposure. 
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Systematic desensitisation - Strengths

It is effective - Research shows that SD is effective in the treatment of specific phobias. Gilroy et al (2003) followed up 42 patients who has been treated for spider phobia using SD. Spider phobia was assessed on several measures including the Spider Questionnaire and by assessing response to a spider. A control group was treated by relaxation without exposure. At both 3 months and 33 months after the treatment the SD group were less fearful than the relaxation group.

Suitable for a diverse range of patients - The alternatives to SD - flooding and cognitive therapies - are not well suited to some patients. For example, some sufferers of anxiety disorders like phobias also have learning difficulties. Learning difficulties can make it hard for some patients to understand what it happening duing flooding or to engage with cognitive therapies that require the abilty to reflect on what you are thinking - For these patients SD is probably the most appropriate treatment.

SD has a solid theoretical foundation based on the notion that through conditioning pateints could learn to replace the anxiety response to feared stimuli with a relaxation response. 

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Standard desensitisation - Weaknesses

Many phobias treated by SD are relatively trivial in that they don't have the crippling effects on everyday life of other mental disorders. However, SD has been used successfully to treat social phobi, and social phobia that can disrupt people's everyday life. 

Most evidence (Choy et al 2007) indicates that flooding or exposure therapy is more effective than SD in the treatment of phobias. This helps to explain why there has been a large reduction in the use of SD in recent years (McGlynn et al 2004).

There is a lack of clarity about precisley why SD is effective. However, Wolpe probably exaggerated the importance of muscle relaxation. Muscle relatation often adds nothing to the effectiveness of SD. Flooding is effective without making any use of muscle relaxation. 

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Behavioural approach to treating phobias

Flooding - A behavioural therapy in which a phobic patient is exposed to an extreme form of a phobic stimulus in order to reduce anxiety trigered by that stimulus. This takes place across a small number of long therapy sessions.

How does flooding work?

Flooding stops phobic responses very quickly. This may be because, without the option of avoidance behaviour, the patient quickly learns that the phobic stimulus is harmless. In classical conditioning terms this process is called extinction. A learned response is extinguished when the conditioned stimulus. The result is that the conditioned stimulus no longer produces the conditioned response. 

In some cases the patient may achieve relaxation in the presence of the phobic stimulus because they become exhausted by their own fear response. 

Ethical safeguards

Flooding is not unethical, but it is an enpleasant experience so it is important that patients give fully informed consent to this traumatic procedure and that they are fully prepared before the flooding session. 

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Flooding - Evaluation

+ Cost effective.  Flooding is at least as effective as other treatments for specific phobias. Studies comparing flooding to cognitive therapies have found that flooding is highly effective and quicker than alternatives. 

+ Based on the theoretical foundation that exposure to phobic stimuli should produce extinction or habituation of the fear response.

- Less effective for some types of phobia. Although flooding is highly effective for treating simple phobias it appears to be less so for more complex phobias like social phobias. This may be because social phobias have cognitive aspects as it has irrational thinking. 

- Traumatic for the patient. The problem is not that flooding is unethical but that patients are often unwilling to see it through to the end. This is a limitation of flooding because time and money are sometimes wasted preparing patients only to have them refuse to start or complete treatment. 

- Flooding raises ethical issues concerning acceptable levels of suffering by patients. 

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The cognitive approach to explaining depression

Beck's cognitive theory of depression 

Beck (1967) suggested a cognitive approach to explaning why some people are more vulnerable to depression than others. in particular it is a person's cognitions that create this vulnerability. He suggested three parts to this cognitive vulnerability.

Faulty information processing - When depressed we attent to the negative aspects of a situation and ignore positives. We also tend to blow small problems out of proportion and think in 'black and white terms'.

Negative self-schemas - A schema is a 'package' of ideas and information developed through experience. They act as a mental framework for the interpretation of sensory information. A self schema is the package of information we have about ourselves. We use schemas to interpret the world, so if we have a negative self schema we interpret all information about ourselves in a negative way. 

The negative triad (on next card).

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The cognitive approach to explaining depression

The negative triad - A person develops a dysfunctional view of themselves because of three types of negative thinking that occur automatically, regardless of the reality of what is happening at the time. These three elements are called the negative triad. When we are depressed, negative thoughts about the world, the future and onself often come to us. 

  • Negative view of the world 
  • Negative view of the future
  • Negative view of the self.

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Beck's theory - Evaluation

+ A range of evidence supports the idea that depression is associated with faulty information processing, negative self-schemas and the cognitive triad of negative automatic thinking. Grazioli & Terry (2000) assessed 65 pregnant women for cognitive vulnerability and depression before and after birth. They found that those women judged to have been high in cognitivevulnerability were more likely to suffer post-natal depression. 

Clark and Beck (1999) reviewed research on this topic and concluded that there was solid support for all these cognitive vulnerability factors. Critically, these cognitions can be seen before depression devlope, suggesting that Beck may be right about cognition causing depression, at least in some cases. 

+ Forms the basis of a CBT. All cognitive aspects of depression can be identified and challenged in CBT. These include the components of the negative triad that are easily identifiable. This means a therapist can challenge them and encourage the patient to test whether they are true. This is a strength of the explanation because it translates well into a successful theory.

- It doesn't explain all aspects of depression. Beck's thory explains the basic symptoms of depression, however depression is complex. Some depressed patients are deeply angry and Beck cannot explain this. 

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The cognitive approach to explaining depression

Ellis's ABC model 

Ellis (1962) suggested a different cognitive explanation of depression. He proposed that good mental health is the result of rational thinking, he defined as thinking in ways that allow people to be happy and free of pain. To Ellis, conditions like anxiety and depression result from irrational thoughts. Ellis defined irrational thoughts, not as illogical or unrealistic thoughts, but as any thoughts that interfere with us being happy and free of pain.  Ellis used the ABC model to explain how irrational thoughts affect our behaviour and emotional state. 

A - Activating event: Whereas Beck's emphasis wason automatic thoughts, Ellis focused on situations in which irrational thoughts are triggered by external events. According to Ellis we get depressed when we experience negative events and these trigger irrational beliefs. 

B - Beliefs: Ellis identified a range of irrational beliefs. He called the belief that we must always succeed or achieve perfection 'mustabatory thinking' is the idea that it is a major disaster whenever something does not go smoothly. 

C - Consequences: When an activating event trigers irrational beliefs there are emotional & behavioural consequences. 

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The cognitive approach to explaining depression

Ellis's ABC model 

Ellis (1962) suggested a different cognitive explanation of depression. He proposed that good mental health is the result of rational thinking, he defined as thinking in ways that allow people to be happy and free of pain. To Ellis, conditions like anxiety and depression result from irrational thoughts. Ellis defined irrational thoughts, not as illogical or unrealistic thoughts, but as any thoughts that interfere with us being happy and free of pain.  Ellis used the ABC model to explain how irrational thoughts affect our behaviour and emotional state. 

A - Activating event: Whereas Beck's emphasis wason automatic thoughts, Ellis focused on situations in which irrational thoughts are triggered by external events. According to Ellis we get depressed when we experience negative events and these trigger irrational beliefs. 

B - Beliefs: Ellis identified a range of irrational beliefs. He called the belief that we must always succeed or achieve perfection 'mustabatory thinking' is the idea that it is a major disaster whenever something does not go smoothly. 

C - Consequences: When an activating event trigers irrational beliefs there are emotional & behavioural consequences. 

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Ellis's ABC model - Evaluation

A partial explanation - There is no doubt that some cases of depression follow activating events. Psychologists call this reactive depression and see it as different from the kind of depression that arises without an obvious cause. This means that Ellis's explanation only applies to some kinds of depression and therefore only a partial explanation for depression.

It has a practical appilcation in CBT - A strength of Ellis's explanation, like Beck's, it has led to a succefful therapy. The idea that, by challenging irrational negative beliefs, a person can reduce their depression is supported by research evidence. This in turn supports the basic theory because it suggests that the irrational beliefs had some role in the depression.

It doesn't explain all aspects of depression - Although Ellis explains why some people appear to be more vulnerable to depression than others of their cognitions, his approach has very much the same limitation as Beck's. It doesn't easily explain the anger associated with depression or the fact that some patients sufer hallucinations and delusions. 

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The cognitive approach to treating depression

CBT beings with an assessment in which the patient and the cognitive behaviour therapist work together to clarify the patient's problems.They jointly identify goals for the therapy and put together a plan to achieve them. One of the central tasks is to identify where there might be negative or irrational thoughts that will benefit from challenge.

CBT then involves working to change negative and irrational thoughts and finally put more effective behaviours into place. Some CBT therapists do this using techniques purely from Beck's cognitive therapy, or some rely exclusively on Ellis's rational emotive behaviour therapy. Most draw on both.

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CBT: Beck's cognitive therapy

Cognitive therapy is the application of Beck's cognitive theory of depression. The idea behind cognitive therapy is to identify automatic thoughts about the world, the self and the future - this is the negative triad. Once identified these thoughts must be challenged. This is the central component of the therapy. 

As well as chalenging these thougts directly, cognitive therapy aims to help patients test the reality of their negative beliefs. They might therefore be set homework such as to record when they enjoyed an event or when people were nice to them.  This sometimes referred to as the patient as scientist, investigating the reality of their negative beliefs in the way a scientist would. In future sessions if patients say that no one is nice to them or there is no point in going to events, the therapist can then produce this evidence and use it to prove the patient's statements are incorrect. 

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REBT

CBT: Ellis's rational emotive behaviour therapy (REBT)

REBT extends the ABC model to an ABCDE model - D stands for dispute and E for effect. The central technique of REBT is to identify and dispute irrational thoughts. 

The vigorous argument is the hallmark of REBT. Vigorous argument intends to change the irrational belief and so break the link between negative life events and depression. 

Ellis identified different methods of disputing. For example, emperical argument involves disputing whether there is actual evidence to support the negative belief. Logical argument involves disputing whether the negative thought logically follows from the facts. 

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Behavioural activation

Alongside the purely cognitive aspects of CBT the therapist may also work to encourage a depressed patient to be more active and engage in enjoyable activities. This behavioural activation will provide more evidence for their irrational nature of beliefs. 

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Cognitive approach to treating depression - Eval

It is effective - There is a large body of evidence to support the effectiveness of CBT for depression. March et al (2007) compared the effects of CBT with antidepressant drugs and a combination of the two in 327 adolescents with a main diagnosis of depression. After 36 weeks 81% of the CBT group, 81% of the antidepressants group and 86% of the CBT plus antidepressants group were significantly improved. Thus CBT emerged as just as effective as medication and helpful alongside medication. 

This suggests there is a good case for making CBT the first choice of treatment in the NHS.

CBT may not work for the most severe cases - In some cases depression can be so severe patients cannot motivate themselves to engage with the hard cognitive work of CBT. They may not even be able to pay attention to what is happening in a session. Where this is the case it is possible to treat patients with antidepressant medication and commence CBT when they are more alert and motivated.

Although it is possible to work around this by using medication, this is  limitation of CBT because it means CBT cannot be used as the sole treatment for all cases of depression. 

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Cognitive approach to treating depression - Eval

Success may be due to the therapist-patient relationship

Rosenzweig (1936) suggested that the differences between different methods of psychotherapy, such as betwen CBT and SD, might actually be quite small. All psychotherapies share one essential ingredient - the therapist-patient relationship. It may be the quality of this relationship that determines success rather than any particular technique that is used. 

Many comparative reviewa find very small differences, which supports the view that simply having an opportunity to talk to someone who will listen could be what matters most. 

Some patients really want to explore their past

One of the basic principles of CBT is that the focus in therapy is on the present and future, not the patient's past. This is in contrast to some other forms of psychological therapy. Some patients are aware of the like between their childhood experiences  and current depression and want to talk about their experiences. They can find the 'present-focus' very frustrating.

Overemphasis on cognition - There's a risk that because of its emphasis on what is happening in the mind of the individual patient CBT may end up minimising the importance of the ircumstances in which a patient is living, eg. suffering abuse or living in poverty.

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Biological approach to explaining OCD

Some mental disorders appear to have a stronger biological component than others, and OCD is a good example of this. One form of biological explanation is the genetic explanation

Genes are involved in individual vulnerability to OCD. Lewis (1936) observed that of his OCD patients 37% had parents with OCD and 21% had siblings with OCD. This suggests that OCD runs in families, although what is probably passed on from one generation to the next is genetic vulnerability not the certainty of OCD. According to the diathesis-stress model certain genes leave some people more likely to suffer a mental disorder but it is not certain - some environmental stress is necessary to trigger the condition. 

Candidate genes - Researchers have identified genes, which create vulnerability for OCD, called candidate genes. Some of these genes are involved in regulating the development of the seratonin system.

OCD is polygenic - Taylor (2013) analysed findings of previous studies and found evidence that up to 230 genes may be involved in OCD. Genes that have been studied in relation to OCD include those associated with the action of dopamine as well as seratonin, both neurotransmitters believed to have a role in regulating mood. 

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Genetic explanation - Evaluation

  • + Nesdadt (2000) found that people with a first degree relative with OCD had a 5x greater risk of having the illness themselves in the future. 
  • + Nesdadt et al (2010) reviewed previous twin studies and found that 68% of identical twins shared OCD as opposed to 31% of non-identical twins. This strongly suggests a genetic influence on OCD.
  • - Although twin studies suggest that OCD is largely under genetic control, psychologists have been much less successful at pinning down all the genes involved. One reason for this is becaude it appears that several genes are involved and that each genetic variation only increases the rick of OCD by a fraction. The conseuence is that a genetic explanation is unlikely to ever be very useful because it provides little predictive value.
  • - Environmental risk factors. It seems that environmental factors can also trigger or increase the risk of developing OCD (the diathesis-stress model). Cromer et al (2007) found that over half the OCD patients in their sample has a traumatic event in their past, and that OCD was more severe in those with more than one trauma. This suggests that OCD cannot be easily genetic in origin, at least not in all cases. It may be more productive to focus on the environmental causes because be are more able to do something about these. 
  • - Concordance rates are not 100% in twin studies so OCD is not completely genetic. 
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Biological approach to explaining OCD

Neural explanations

The role of seratonin: One explanation for OCD concerns seratonin - believed to regulate mood. Neurotransmitters are responsible for relaying information from one neuron to another. If a person has low levels of seratonin then normal transmission of mood-relevant information does not take place and mood - and sometimes other mental processes - are affected. At least some cases of OCD may be explained by recuced  functioning of the seratonin system in the brain. 

The neurotransmitter dopamine has also been implicated in OCD, with higher levels of dopamine being associated with some of the symptoms of OCD, in particular the compulsive behaviours.

The basal ganglia is a brain structure involved in multiple processes, including the coordination of movement. Patients who suffer head injuries in this region often develop OCD-like symptoms, following their recovery. Another brain region associated with OCD is the orbitofrontal cortex, a region which converts sensory information into thoughts and actions. PET scans have found higher activity in the orbitofrontal cortex in patients with. One suggestion is that the heightened activity in the orbitofrontal cortex increases the conversion of sensory information to actions (behaviours) which results in compulsions. The increased activity also prevents patients from stopping their behaviours.

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Neural explanations - Evaluation

  • + Some antidepressants work purely on the seratonin system, increasign levels of this neurotransmitter. Such drugs are effective in reducing OCD symptoms and this suggests that the seratonin system is involves in OCD. Also, OCD systems form part of a number of other conditions that are biological in origin, for example Parkinson's Disease (Nesdadt et al 2010). This suggests that the biological processes that cause the symptoms in those conditions may also be responsible for OCD.
  • - It is not clear exactly what neural mechanisms are involved. Studies of decision making have shown that these neural systems are the same systems that function abnormally in OCD (Cavedini et al 2002). However, reseaerch has also identified other brsin systems that may be involved sometimes but nor system has ben found that always plays a role in OCD. We cannot therefore claim to understand the neural mechanisms involved. 
  • - There is evidence to suggest that various neurotransmitters and structures of the brain do not function normally in patient with OCD. However, this is not the same as saying that this abnormal functioning causes the OCD. These biological abnormalities could be a result of OCD rather thsn it's cause. 
  • - Many people who suffer OCD become depressed. Having two disorders together is called co-morbidity. This depression probably involves disruption to the seratonin system. This leaves us with a logical problem when it comes to the seratonin system as a possible basis for OCD. It could be thst the S system is disrupted in many patients with OCD as depressed.
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Biological approach to explaining OCD

Overall evaluation:

  • + Scientific basis in biology
  • + Twin studies
  • + Ethical - people aren't blamed for their disorders
  • - Doesn't take into account the effect of environment, family, childhood experiences or social influences. 
  • - Biological therapies raise ethical concerns - drugs cause addiction. 
  • - Reductionist - doesn't accept other explanation or approaches. 
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Biological approach to treating OCD

Drug therapy for mental disorders aims to incresse or decrease levels of neurotransmitters in th brain or to increase/decrease their activity. 

SSRIs: The standard medical treatment used to tackle the symptom of OCD involves a particular type of antidepressant drug called s selective seratonin reuptake inhibitor. SSRIs work on the seratonin system in the brain. Seratonin is released by certain neurons in the brain. It is relessed by the presynsptic neurons and travels across a synapse. The neurotransmitter chemically conveys the signal from the presynaptic neuron to the postsynaptic neuron and then it is reabsorbed by the presynaptic neuron where it is broken down and re-used. 

By preventing the re-absorption and breakdown of seratonin SSRIs effectively incresse its levels in the synapse and thus continue to stimulate the postsynaptic neuron. This compensates for whatever is wrong with the seratonin system in OCD. 

Combining SSRIs: Drugs are often used alongide CBT to treat OCD. The drugs reduce a patient's emotionsl symptoms, such as feeling anxious or depressed. This means that patients can engage more effectively with CBT.

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Biological approach to treating OCD

Alternatives to SSRIs

Where an SSRI is not effective after 3-4 months the dose can be increased or it can be combined with other drugs. Sometimes different antidepressants are tired. Patients respond very differently to different drugs and alternatives work well for some people and not all for others.

Tricyclics (older type of antidepressanrt) are sometimes used, such as Clomiprsmine. These have the same effect on the seratonin system as SSRIs. Clompiramine has more severe side-effects than SSRIs so it is generally kept in reserve for patients who do not respond to SSRIs.

SNRIs (seratonin-noradrenaline reuptake inhibitors). In the last 5 years a different class of antidepressant drugs called SNRIs has also been used to treat OCD. These are, like Clomipramine, a second line of defence for patients who don't respond to SSRIs, SNRIs incresse levels of seratonin as well as another different neurotransmitter - noradrenaline. 

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Drug therapy - Evaluation

  • + Effective. There is clear evidence for the effectiveness of SSRIs in reducing the severity of OCD symptoms and so improving quality of life for OCD patients. Soomro et al (2009) reviewed studies comparing SSRIs to placebos in the treatment of OCD and concluded that all 17 studies reviewed showed significantly better results for the SSRIs than for placebo conditions. Effectiveness is greatest when SSRIs are combined with a psychological treatment, usually CBT. Typically symptoms decline significantly for around 70% of patients taking SSRIs. 
  • + An advantage of drug treatment in general is that they are cheap compared to psychological treatments. Using drugs to treat OCD is therefore good value for a public health system like the NHS. 
  • - Drugs have side effects - such factors reduce effectiveness because people stop taking the medication.
  • - Unreliable evidence for drug treatments. Although SSRIs are fairly effective and at any side-effects will probably be short term, like all drug treatments is biased because the research is sponsored by drug companies who do not report all the evidence (Goldacre 2013).
  • - Some cases of OCD follow trauma. OCD is widely believed to be biologcal in origin. It makes sense, therefore, that the standard treatment should be biological. However, it is acknowledged that OCD can have a range of other causes, and that in some cases it is a response to a traumatic life event. 
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