IB Psychology- Abnormal Psychology Revision Guide

Abnormal Psychology Paper 2: Options

Written by: Chris Ting 13H

Abnormal Psychology

Table of Contents Concepts and diagnosis ............................................................. 3 Psychological disorders ............................................................ 21 Implementing treatment ......................................................... 41

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Concepts and diagnosis Syllabus Question: Examine the concepts of normality and abnormality. There are four definitions for abnormality: I.

Statistical Infrequency defines abnormality as deviation from the statistical norm meaning infrequently occurring behavior.

II.

Deviation from social norms defines abnormality as behavior which departs from what is acceptable in a particular society

III.

Dysfunctional behavior defines abnormality as psychological distress or discomfort that causes a person to not be able to function properly

IV.

Deviation from ideal mental health defines abnormality as behavior which departs from that which is considered ideal

Statistical infrequency Using this definition behavior that occurs frequently is normal and that that is rare as abnormal. Some behaviors can be measure quantitatively such as the level of anxiety, but for other more subjective behaviors it is harder to measure it quantitatively and therefore hard to measure it statistically. Problems with measuring abnormality through statistical infrequency I.

Many behaviors that are statistically rare are desirable and healthy.

II.

There are many behaviors that have been the norm in a particular society or culture yet we wouldn’t really call it normal nor would it be appropriate to label those who showed a different behavior as abnormal.

III.

This approach equates normality with conformity yet many non-conformists are valuable and without whom significant advances would never be made.

IV.

There is no agreed definition of how much behavior must deviate from the norm before it is considered abnormal.

Deviation from social norms Social norms are standards that society sets according to which it expects its members to behave. These standards are the explicit and implicit rules for appropriate conduct. This approach known as cultural relativism is to classify anyone who violates these conventional rules of conduct as abnormal. According to this view, behavior cannot be considered

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abnormal as long as society accepts it. This definition means that abnormal behavior can never have a universal meaning since it varies from culture to culture. Problems with measuring abnormality through deviation from social norms I.

Through this approach abnormal behavior can never have a universal meaning as judgments will vary from society to society.

II.

This view assumes that if a behavior is social acceptable then it is normal that one set of standards is as good as any other. But, same as statistical infrequency, there are many behaviors that occur or occurred that were socially normal but many of us would see it as normal. For example, behaviors shown in Nazi Germany were considered normal and deviations from it were abnormal.

III.

Standards within society change from time to time and vary between different subgroups. Different sections within one society can set different standards by which to judge abnormality.

Dysfunctional behavior This approach states that behavior is abnormal if it is maladaptive, in that it hinders our physical survival and/or the realization of our potential. Rosenhan and Seligman (1989) suggest that dysfunctional behavior can be judged based on seven criteria. I.

Personal distress: experiencing unpleasant emotional experiences such as guilt, anxiety and depression to an excessive degree.

II.

Maladaptiveness: behavior that interferes with the ability to meet everyday responsibilities and cope with everyday demands

III.

Irrationality: behavior which has no rational basis and is unconnected to reality

IV.

Unpredictability: behavior which is impulsive and seemingly uncontrollable and disrupts the lives of others

V.

Statistically infrequent: abnormal behavior is shown by a minority and the majority

VI.

Observer discomfort: breaking the unwritten and unspoken rules by which most people abide and the violation of which makes others feel uncomfortable

VII. Violation of moral and ideal standards: behavior can be considered abnormal if it violates moral standards even when most people in a particular group or culture practice that behavior This approach has the major advantage of recognizing a person’s subjective experience as a means of helping to define who is abnormal. This approach includes statistical rarity and deviations of social norms and therefore helps make this definition a more practical one in

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that it helps define which are in need. Problems associated with failure to function adequately. I.

Some of the criteria depends on subjective judgments of other people. For example observer discomfort may vary depending on the particular person doing the observing. Violation of moral standards also involves subjectivity in judgement, who moral standards are we using as the standard, it may different for each person.

II.

The criteria of irrationality, unpredictability, loss of control and unconventionality apply to people who choose an unconventional life. This does not mean they are abnormal.

III.

People who we consider as abnormal may feel no distress about the way they behave. Distress is sometimes a very appropriate response to circumstances, for example experiencing extreme distress because of the death of a loved one is normal and so that person can’t be considered abnormal.

Deviation from ideal mental health This approach considers abnormal behavior as what is the ideal mental health and deviations from it as abnormal. The humanistic school of psychology believes that ideal health should have a ultimate goal. Abraham Maslow and Carl Rogers suggested that this ideal goal is self actualization. Rogers argued that we all have a basic need to receive positive regard from important people in our lives. People who receive unconditional positive regard early in life are likely to develop a high self esteem and a feeling of self worth consequently they are comfortable with themselves but recognize they are not perfect and are in a position to realize their potential. Conversely, if people experience only conditional regard, which makes them feel unworthy, they feel that they are only loved and accepted when they conform to the imposed standards of others. It is impossible for such people to self-actualize because they are no longer in touch with what values and goals would be meaningful for them. As a result they have low self esteem that leads to problems of function and abnormal behavior. Problems associated with judging abnormality based on deviation from ideal health I.

This definition means that the majority of people are considered abnormal as very few people attain self-actualization.

II.

What is the ideal standard? This criteria becomes a value judgement, different cultures have different ideas on what is considered ideal. For example, in collectivistic cultures working together is valued and ideal but in individualistic

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cultures autonomy is valued, Jahoda’s positive mental health Marie Jahoda (1958), instead of trying to define what is abnormal she tried to define what is normal. Jahoda identified six components of ideal mental health based on a review of literature. I.

Positive attitude toward own self

II.

Growth, development and self actualization

III.

Integration

IV.

Autonomy

V.

Accurate perception of reality

VI.

Environmental mastery

The approach suggests that ideal mental health is achieved when a person has a realistic and positive acceptance of who they are and are able to resist stress while acting voluntarily in the interests of their own growth in the environment they live in. Problems with Jahoda’s approach to positive mental health According to this approach then very few people are able to say that they are in such a state of ideal mental health. Taylor and Brown (1988) found that those with depression are more accurate in their perception of reality, and that for the most of us, functioning adequately requires an element of self-delusion. Also, unreasonable optimism seems to be beneficial for many people. But none of the above definitions of abnormality provide a complete definition of abnormality as none of them are universe since all of the definitions are affected by individual, social and cultural values systems. Mental illness is a social construction Since the 1960’s it has been argued by anti-psychiatrists that the entire notion of abnormality or mental disorder is merely a social construction used by society. Notable anti-psychiatrists were Michel Foucault, R.D. Laing, Thomas Szasz and Franco Basaglia. Some observations made are: I.

Mental illness is a social construct created by doctors. An illness must be an objectively

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demonstrable biological pathology, but psychiatric disorders are not. II.

Criteria for mental illness is vague, subjective and open to misinterpretation criteria

III.

The medical profession uses various labels eg. depressed, schizophrenic to exclude those whose behavior fails to conform to society’s norms

IV.

Labels and consequently treatment can be used as a form of social control and represent an abuse of power

V.

Compromise to medical and ethical integrity because of financial and professional links with pharmaceutical companies and insurance companies

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Syllabus Question : Discuss validity and reliability of diagnosis. Classification of mental disorders involves the identification of groups or patterns of behavioral or mental symptoms that reliably occur together to form a type of disorder. This allows: I.

Psychiatrists, doctors and psychologists to more easily identify groups of similar sufferers

II.

Allows a prognosis to be made

III.

Researchers to investigate these groups of people to determine what the aetiology of the disorders are

IV.

A suitable treatment to developed and administered to all those showing similar symptoms

The major systems of diagnosis include the DSM and ICD. The Diagnostic and Statistical Manual of Mental Disorder (DSM) defines a mental disorder as a clinically significant syndrome associated with distress, a loss of functioning, an increased risk of death/pain, or an important loss of freedom. The manual attempts to describe any disorder in such terms that two clinicians referring to the system would probably agree with the diagnosis it suggests. The DSM group’s disorders into categories and then offers specific guidance to psychiatrists by listing the symptoms required for a diagnosis to be given. The DSM consists of a multiaxial approach, where a diagnosing clinician considers the individual under investigation under 5 axis’. I.

Axis 1: Clinical syndromes refers to the major diagnostic classification arrived by the clinician.

II.

Axis 2: Developmental and personality disorders consists of additional diagnostic classifications that may contribute to an understanding of the Axis 1 Syndrome.

III.

Axis 3: Medical conditions

IV.

Axis 4: Psychosocial stressors, all potentially stressful events or enduring circumstances that might be relevant to the disorder are rated for severity on a scale ranging from 1 (none) to 6 (catastrophic) for the past year.

V.

Axis 5: Global assessment of functioning, rates the highest level of social, occupational and psychological function on a scale of 1 (persistent danger) to 90 (good in all areas) currently and during the past year.

The strength of the DSM is that it utilizes multi-axial diagnosis and it encourages a diagnosing

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clinician to use a more holistic approach to understanding the person. The DSM also undergoes constant revisions and it adapts to changes in thinking overtime. The International Classification of Diseases (ICD) is more commonly used internationally than the DSM and it covers a wide range of diseases and conditions for the sake of classification rather than diagnosis. There is a chapter in the ICD that categorizes mental disorders that is very similar to the DSM and the ICD has fewer categories than the DSM because each category tends to be slightly broader. The biggest difference between the two systems is that the ICD is intended primarily as a classification system but includes details of what symptoms are required for diagnosis. Conversely, the DSM is intended as a fully comprehensive manual for diagnosis and so includes precise details of how to conduct diagnostic interviews, precise diagnostic details and other tests. Validity and reliability In order for a diagnostic system to be reliable, those using it must consistently make the same diagnoses. For it to be the valid, the diagnoses must identify a real pattern of symptoms and therefore apply appropriate treatment. Reliability A major way of assessing reliability of psychiatric diagnosis is by inter-rater reliability, which is by assessing the agreement with which different clinicians diagnose conditions in the same patients. Studies of inter-rater reliability show that some diagnostic categories are much more reliable than others and that procedures are more reliable for some types of patients than others. Nicholls et al. (2000) showed that neither ICD-10 nor DSM-IV demonstrates good inter-rater reliability for the diagnosis of eating disorders in children, 81 patients aged 6-17 years with some eat problem were classified using ICD-10, DSM-IV and a system developed for children by the Great Ormond Street Hospital (GOS). Over 50% of the children could not be diagnosed according to DSM criteria. Reliability was 0.64, i.e. 64% agreement between raters, but this figure was inflated by the fact that most raters agreed that they couldn’t make a diagnosis. Using ICD-10 criteria there was 0.36 reliability and the GOS was the best with a 0.88% reliability. The success of the GOS was

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suggested to be due to it being specifically designed for young children. This shows that in terms of eating disorders and possibly other disorders the reliability of well known diagnostic systems such as the DSM or ICD may not be very reliable. But, Pedersen et al. (2001) gave 10 Danish GPs one day’s training in the use of ICD-10 criteria for diagnosing depression. Over the next 8 weeks they diagnosed a total of 116 patients with a depressive episode. There was a 0.71 reliability with a diagnosis of depression, this suggests that there is quite good inter-rater reliability for ICD-10 in the case of depression. Beck et al. (1962) found that agreement on diagnosis for 153 patients between two psychiatrist was only 54%. Cooper et al. (1972) found that New York psychiatrists were twice more likely to diagnose schizophrenia than London psychiatrists, who in turn were twice as likely to diagnose mania or depression when shown the same videotaped clinical interviews. Di Nardo et al (1993) studied the reliability of DSM-3 for anxiety disorders where two clinicians separately diagnosed each of 267 people seeking for treatment for anxiety and stress disorders. They found high reliability for OCD but very low for assessing generalized anxiety disorder mainly due to problems with interpreting how excessive a person worries are. This study used the DSM-III and has already undergone two revisions and is on the DSM-IV already and so issues may have already been resolved. But even then, this study shows the unreliability for certain disorders. Lipton and Simon (1985) randomly selected 131 patients in a hospital in New York and conducted various assessment procedures to arrive at a diagnosis for each patient. This diagnosis was compared with the original diagnosis and found that of the original 89 diagnosis of schizophrenia; only 16 received this on re-evaluation. Fifty were diagnosed with a mood disorder even though only 15 had been initially diagnosed with it in the first place. But I could be argued that being misdiagnosed caused the mood disorder to develop. Test-retest reliability is concern with whether the same person will receive the same diagnosis if they are assessed more than once. Mary Seeman (2007) completed a literature review examining evidence relating to the reliability of diagnosis over time. She found that initial diagnosis of schizophrenia, especially in women, were susceptible to change as clinicians found out more information about their patients. It was common for a number of other conditions to cause the symptoms for which women were receiving the diagnosis of schizophrenia. This indicates the problem of test-retest reliability with schizophrenia

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diagnoses. Validity Rosenhan et al. (1973) Aim

To test the reliability of diagnosis

Method and Results

Rosenhan and a group of colleagues and people with various occupations presented themselves at 12 different hospitals across the USA complaining of hearing voices, but presented their life history and present state as normal. All but one was admitted with a diagnosis of schizophrenia. Once admitted to the hospital they stopped complaining of symptoms and try to get out. All of the pseudo-patients could do this but were diagnosed with a case of schizophrenia. Thus, their sanity was never detected but some patients and staff were suspicious. It took between 7-52 days for the pseudopatients to be released. This time was used by the patients to conduct a participant observation of life in the hospital. The staff noticed this but assumed it was part of the symptoms. This shows that an normal person can receive a diagnosis. Conversely, Rosenhan found that truly abnormal people can be mistakenly assumed to be healthy. In a follow up study, Rosenhan told a hospital that they should expect pseudo-patients over a 3 month period. But none were sent instead 41 real patients were sent and of these 41 patients 19 were suspected to be fake.

Conclusion

Shows the general inability and the lack of reliability in telling the difference between Page 11

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normal and abnormal behavior. This study shows very good reliability but poor validity in that it shows that the environment heavily affects the process of diagnosis and therefore affecting its validity. Evaluation

This took place 30 years ago and used the DSM-II and it has since undergone major chances. Also, diagnostic procedures have improved in response. This study showed extremely good reliability and than in real life doctors are not normally confronted with people wishing to be admitted to psychiatric hospitals. Therefore this should be seen as an indicator of the current mental health system. Caetano (1973)

Method

Conducted an experiment in which he videoed a male psychiatrist carrying out separate standardized interviews with a paid university student and with a hospitalized mental patient. Two groups of people were shown these interviews, a group of 77 psychology students and a group of 36 psychiatrists. They were asked to diagnose the interviewees and rate their degree of mental illness. With each sample of viewers, there was random assignment to two different groups, each of which received different information about the interviewees: 1. either that both were volunteers who were paid to participate, 2. or that both were patients in a mental hospital.

Results

Indicated that psychiatrists with clinical Page 12

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experience were more likely to be persuaded by the information given about the two interviewees and label them both as mentally ill (if they were described as patients) or both not mentally ill (if described as volunteers). Conclusion

This study shows labeling theory, the theory that the behavior of the person being diagnosed is not the most important component of diagnosis and, in the ambiguous situation of a diagnostic interview, any suggestion that the subject is or has been mentally ill will be a strong influence on any decision. This research therefore shows that simply being labeled as something affects the validity of a diagnosis.

Wakefield et al. (2007) conducted a study which suggests that a wide range of other life events can account for symptoms of depression and therefore the exclusion is inappropriately narrow. This lack of clarity about when the symptoms of depression really indicate a medical condition and when they indicate and understandable response to life events is an example of the problems with validity. Criterion-related validity is a form of validity based on whether a new system agrees with existing measures of the phenomenon in question. Gavin Andrews published research using DSM and ICD-10 systems, particularly in the diagnosis of anxiety disorders and found only moderate agreement between them. When one person has been diagnosed according to one system but cannot be diagnosed according to another system by the same psychiatrist or group, this indicates poor validity. Peters et al. (1999) found only moderate agreement between the two systems because DSM-IV requires the presence of distress or impairment to functioning in the person being diagnosed.

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Mental illness is a social construction Since the 1960’s it has been argued by anti-psychiatrists that the entire notion of abnormality or mental disorder is merely a social construction used by society. Notable anti-psychiatrists were Michel Foucault, R.D. Laing, Thomas Szasz and Franco Basaglia. Some observations made are: VI.

Mental illness is a social construct created by doctors. An illness must be an objectively demonstrable biological pathology, but psychiatric disorders are not.

VII. Criteria for mental illness is vague, subjective and open to misinterpretation criteria VIII. The medical profession uses various labels eg. depressed, schizophrenic to exclude those whose behavior fails to conform to society’s norms IX.

Labels and consequently treatment can be used as a form of social control and represent an abuse of power

X.

Compromise to medical and ethical integrity because of financial and professional links with pharmaceutical companies and insurance companies

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Syllabus Question: Discuss cultural and ethical considerations in diagnosis.

Cultural factors Culture bound syndromes (CBS) refers to syndromes that do not fit easily into the categories and classifications of supposedly universal disorders. CBS occurs almost exclusively in specific locations or populations and are indigenously regarded to be illness or afflictions and have local names. Cultural universality maintains that all mental disorders are found worldwide and that their causes and symptoms are very similar everywhere. Cultural relativism maintains that mental disorders and their symptoms are universal but expressed differently in different cultures. An explanation for these cultural differences was given by Weisz et al. (1987)’s suppression facilitation model explains that forms of behavior discouraged within a culture will be suppressed and therefore observed rarely. But behaviors that are rewarded in a culture will be produced to an excess. When there is such a huge variety of labels for behavior that shares its basis of either dangerous or violation of social norms, it must be questioned whether the DSM criteria are valid beyond the culture they were created in. An example that shows the possible role of culture in diagnosis was found by Levav et al. (1997) in the United States. They compared rates of alcoholism and depression across various religious groups and found that Jewish males were more likely to have a diagnosis of depression and less likely to have a diagnosis of alcoholism. This suggests there is some underlying issue that manifests itself differently depending on cultural traditions and expectations. Therefore psychiatrists must be familiar with these cultural traditions and expectations in order to accurately diagnosis. In New Zealand studies have shown that there are differences in what is considered a mental health issue among the Maori and Pacific Island population and other ethnic groups. Tapsell and Mellsop (2007) found that affective disorders such as depression account for only 16% of diagnoses given to Maori mental health service users compared with 30% for Europeans; the majority of diagnoses were for schizophrenia, 60% compared to 40% for Europeans. Maori mental health service users also report more experience of hallucinations and have more records of aggression and problems of living. Arrol et al. (2002) found that the Maori are less likely to be medicated for depression than Europeans in New Zealand. This suggests that cultural and ethnical factors player a role into diagnosis and that between different cultures and ethnicities there is different understanding of what is considered normal behavior and what is considered a mental health disorder.

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In the UK, studies on ethnic minorities’ show that many factors affect mental health and the way users of mental health services should be treated whether are aboriginal people, immigrants, long-established residents or newly arrived refugees. Palmer and Ward (2006) found in a content analysis of interviews that those who experienced trauma in their previous locations are affected by difficulties in their new environment as well as memories of their old one. For example among immigrants to London from Somalia, Rwanda and Iran, experiences from their home country mix with new problems in their new home. This shows that to properly diagnose people clinicians must take into account of a person’s culture and previous experiences. Examples of Culture Bound Syndromes Description

Evaluation

Koro- thought to specifically occur in

Syndromes similar to Koro have been

Chinese cultures, involves:

identified in other cultures but they often

I.

Belief that penis is shrinking and will

have shown that there are important

withdraw to abdomen and cause

variations in symptoms such as lacking the

death

belief that death will occur. Also there are

Physiological and emotional reactions

different provoking cultural causes such as

to this belief associated with fear and

outbreaks of Koro in China and India have

anxiety

different beliefs. There are different

Behavioral countermeasures to

underlying mechanisms and responses to

prevent penis retraction include

treatment, Koro usually responds to

putting weights to it

reassurance whereas the Koro-like

II.

III.

symptoms shown in other cultures have often disappeared when other mental disorders were treated. Some Western psychiatrists regard Koro as just a particular form of hypochondria or phobic anxiety disorder. Dhat- thought to specifically occur in

Syndromes similar to Dhat have been

Indian-Hindu cultures, involves

identified in other cultures. Also the

I.

Belief that semen is leaking out of the

symptoms shown and underlying beliefs

body and sapping the body of power

that trigger the disorder across cultures are

Excessive anxiety and concern in

very similar in nature. It seems only culture

reaction to this belief

bound in terms of the prevalence of the

Feelings of exhaustion, weakness and

underlying beliefs, which in turn depend on

II. III.

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lethargy

access to and belief in scientific medical knowledge.

Bias in diagnosis Racial Bias Diagnosis classification systems are not 100% objective and the diagnosis may be influenced by the attitudes and prejudices of the psychiatrist or the diagnostic test itself. For example, women and black people are more likely to be diagnosed mentally ill possibly because psychiatrists expect them to be more prone to mental illness and are therefore keen to diagnose them as such upon presentation of symptoms. But if presented by white men then it would be interpreted as something other than a mental illness. Kirov and Murray (1999) studied a group of patients taking lithium prophylaxis (sometimes used for depression) and found that there were clear differences in symptoms and diagnoses that had resulted in patients being medicated. They found that black patients were less likely than white patients to have suicidal ideas of have attempted suicide and generally had more manic symptoms, resulting in a diagnosis of bipolar disorder. It is suggested that because of the difference in the manifestation of the underlying problem, many black patients in the UK may be diagnosed with schizophrenia rather than affective disorder. Riodan et al. (2004) found that compulsory hospitalization orders are more likely to be applied to black than white patients. In a study by Jenkins-Hall and Sacco (1991) they got white therapists to watch a video of a clinical interview and then were asked to evaluate the female interviewee. There were four conditions representing the possible combinations of race and depression. I.

African American woman and nondepressed

II. White American and nondepressed III. African American woman and depressed IV. White American and depressed The therapists rated the nondepressed African American and the white American in the same way but their ratings of the depressed women differed that they rated the African American woman with more negative terms and saw her as less socially competent than the depressed white American woman. This shows that there is racial bias in diagnosis. Morgan et al. (2006) found that in the UK, the incidence of schizophrenia is nine times

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higher for Afro-Caribbean’s and six times higher for those of black African descent than for white British people. Researchers argue that genetic differences cannot account for this and it is more likely that diagnostic biases account for it. Socioeconomic bias There are various reasons for the apparent social class bias in diagnosing mental illness. Mental health professionals have been found to make less encouraging clinical decisions with patients from the lower classes and offering them less effective therapeutic interventions. Another possibility is that those from higher social classes have more coping strategies at their disposal. Umbenhauer and DeWitte (1978) investigated the effects of social class on the attitudes of mental health professionals and found that upper class people received more favorable clinical judgments and were more likely to be offered. Luepnitz, Randolph and Gutsch (1982) found that a given set of symptoms was much more likely to produce a diagnosis of alcoholism for a lower-class African American than for a middle class white person. Bruce, Takeuchi and Leaf (1991) found evidence of the impact of wealth. They found that people around the poverty line who had no mental illness at first assessment and that were assessed again 6 months later were more likely to be diagnosed with mental illnesses. For example those living below the poverty line were more than twice as likely to have developed alcohol abuse or dependence, bipolar disorder or major depression during that period and 80 times more likely to have developed schizophrenia. Barlow and Durand (1995) found that members of the lower social classes are much more likely than those of higher social classes to be diagnosed as suffering from schizophrenia. There are several explanations to this: I.

There actually is bias, with clinicians being more willing to use the diagnosis of schizophrenia when considering the symptoms of individuals from lower social classes. Johnstone (1989) reviewed several studies which showed that lower-class patients were more likely than middle-class patients to be given serious diagnosis’s, even when there were few if any differences in symptoms.

II. Social causation hypothesis, according to this hypothesis members of the lowest classes in society tend to experience more stressful because of poverty, unemployment, poorer physical health etc. Stress is also likely through discrimination because ethnic and racial minorities in many cultures tend to belong to the lower classes. The high level of stress makes them more vulnerable to

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schizophrenia than middle class. III. Social drift hypothesis, according to this hypothesis, individuals who develop schizophrenia are likely to lose their jobs and so their social status is reduced i.e. schizophrenia reduces social status rather than low social status causing it. Turner and Wagonfeld (1967) found that schizophrenics tend to belong to a lower social class than their fathers. But the fathers also tended to belong to lower social classes themselves, supporting the social causation hypothesis too. Gender bias An explanation for gender bias, terms of depression, are that women often have to cope with sex discrimination and relative powerlessness and as a result it may explain that women have the highest rates of depression. Physiologically, the menstrual cycle and menopause may make women more vulnerable than compared to men. Ford and Widger (1989) presented therapists with written cases of a patient with anti-social personality disorder and another with histrionic personality disorder. Each patient was sometimes identified as male and sometimes as female and the therapists had to decide on the appropriate diagnosis. Anti-social personality disorder was correctly diagnosed over 40% of the time when the patient was male, but fewer than 20% of the time when the patient was female. In contrasts, histrionic personality disorder was correctly identified much more when the patient was female: 80% vs 30%. The findings indicate a strong bias from traditional sex role stereotypes. Broverman et al. (1981) found evidence sex-role stereotypes. They asked clinicians to identify the characteristics of the healthy adult, man and woman. The characteristics of the healthy adult and en were similar, including adjectives such independent, decisive, and assertive. Conversely, the adjectives used to describe the healthy woman included words such as dependent, submissive and emotional. Ethical Considerations Labeling theory as shown by Caetano and Rosehan indicates that one a diagnosis has been made, it tends to stick and as a result there are significant negative effects of such diagnosis on a person’s subsequent treatment by other people. Scheff (1966) points out that diagnostic classification labels the individuals and therefore can cause adverse effects such as: I.

Self-fulfilling prophecy- Patients may begin to act as they think they are expected to act, i.e. if someone is diagnosed with depression than that person act depressed

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even if they weren’t initially. Goffman arugues that they may internalize the role of “mentally ill patient” and could worsen their disorder rather than improve it. But Doherty (1975) points out that those who reject the mental illness label tend to improve more quickly than those who accept, although this is not always the case. II. Distortion of behavior- Diagnosis of mental disorders tend to label the whole person and once the label is attached, than the individual’s actions become interpreted in the light of the label. For example in Rosenhan’s study, the pseudo-patients behaviors were regarded as symptoms of their psychopathology. III. Oversimplification- Labeling can lead to reification- making the classification a real, physical disorder, rather than just a descriptive term to help diagnosticians talk about patients or a hypothesis about what is troubling the person. Labeling may have a major effect not on just the individual’s identity but also their self esteem. Being diagnosed may lead to stigmatization, when a negative label is attached to someone, and as a result they may receive prejudice from society. Langer and Abelson (1974) showed a video tape of a younger man telling an older man about his job experience. If the viewers were told that the man was a job applicant, he was judged to be attractive and conventional looking, whereas if they were told that he was a patient, he was described negatively. Read (2007) summarized a large amount of research related to stigmatization and found that attitudes towards those diagnosed in a medical context tend to be characterized by fears and that knowing someone has a diagnosis of mental illness increases reluctance to enter into romantic relationships with them. Sato (2006) discusses how schizophrenia was renamed in Japan because there was such a stigma attached to it that less than 40% of patients who had been diagnosed with it had actually been informed of it. Farina et al (1980) conducted an experiment in a naturalistic setting to illustrate the effects of stigma and prejudice towards those labeled as mentally ill. When one pair of male college students was falsely led to believe that the other had been a mental patient, he perceived the pseudo ex-patient to be inadequate, incompetent and not likeable. In another experiment, they made one pair of interacting males falsely believe he was perceived as stigmatized the naïve participant. Just believing this was enough to lead him to behave in ways which caused the naïve participant to reject him. Also being diagnosed and then treated in a hospital may lead to institutionalization. This when patients are so used to being cared for and not doing anything themselves they can’t function independently in the outside world.

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Psychological disorders Syllabus Question: Describe symptoms and prevalence of one disorder from two of the following groups: anxiety disorders, affective disorders and eating disorders

Affective disorders are disorders related to mood, an example of this is major depressive disorder. The DSM-IV criteria for diagnosing major depressive disorder are: I.

Five or more of the following symptoms present during the same 2 week period and represent a change from previous function and at least one of the symptoms is either: a. Depressed mood i. Most of the day, nearly every day b. Loss of interest or pleasure i. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day c. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly everyday d. Insomnia or hypersomnia nearly everyday e. Psychomotor agitation or retardation nearly every day f.

Fatigue or loss of energy nearly everyday

g. Feelings of worthlessness or excessive inappropriate guilt nearly every day h. Diminished ability to think or concentrate, or indecisiveness, nearly every day i.

Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

There are three main categories of clinical depression: I.

Major depressive disorder

II. Dysthymia a. Involves constant but generally less severe symptoms. Depression must last for longer than two years for dysthymia to be diagnosed and it tends to be most severe in those in which it begins at 21. III. Bipolar disorder aka manic depression a. Diagnosed when patients suffer from episodes of mania, ie states of high arousal and irritability or excitement. Goodwin and Jamison (1990)

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calculated that 72% of people diagnosed as manic also suffered from depression. The person does not have to depress to receive a diagnosis of manic depression. Patients typically feel full of energy and may feel elated or irritable. There is a reduced need for sleep and there may be an increased sexual appetite. Patients are often extremely impulsive and their judgment is impaired. The United States National of Mental Health claims that major depressive disorder is the leading cause of disability in the USA between the ages of 15-44 with a lifetime prevalence of 16.6%. Charney and Weismann (1988) found that major depressive disorder is relatively common, affecting around 15% of people at some time in their life. It affects woman more than men and that this difference appears to start around the age of 13 and results in up to three times more women than men having a diagnosis of depression. Nicholson et al. (2008) found that there is significant variation in the prevalence of depression in various countries. They found that for example Polish men have a prevalence rate of 20.4% and both Polish and Russian women were high at 32.9% and 33.7% respectively. Levav (1997) found the prevalence rate to be above average in Jewish males and there is no difference in prevalence between Jewish men and woman. The difference could suggest that some groups are more vulnerable to depression. Depression tends to be a recurrent disorder with about 80% experiencing a subsequent episode, with an episode typically lasting for three to four months. The average number of episodes is four and in approximately 12% of cases, depression becomes a chronic disorder with duration of about two years. Eating disorders include anorexia nervosa , where you eat very little, and bulimia nervosa where you eat a lot and then vomit it out due to guilt. The DSM- IV criteria for diagnosing this disorder are: I.

Refusal to maintain body weight at or above minimally normal weight for age and height.

II. Intense fear of gaining weight or becoming fat, even though underweight III. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight IV. In postmenarcheal female, amenorrhea, i.e. the absence of at least three consecutive menstrual cycles V. Type of eating disorder a. Restricting type: during the current episode of anorexia nervosa, the person

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has not regularly engaged in binge eating or purging behavior b. Binge-eating/ purging type: during the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior. Eating disorders are known to affect females much more than males. The National Institute of Mental Health in the United States suggests that females with anorexia have a death rate 12 times higher than the general female population. Zandian et al. (2007) found that the disorder affects those from households with the above-average income to a greater extent and that it affects around 0.3% of the population in the US. The condition is far more common in Western and individualistic cultures. A possible explanation is that there is a greater exposure to unreasonably thin models in television, film and magazines, and social pressures to conform to a particular body weight, all of which appear to affect females more than males. Another explanation is that there is a greater focus on dieting since the 20th century in Europe and Anglo-American societies.

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Syllabus Question: Analyze etiologies (in terms of biological, cognitive and/or sociocultural factors) of one disorder from two of the above groups. . And Discuss culture and gender variations in prevalence of disorders. And To what extent do biological, cognitive and sociocultural factors influence abnormal behavior. Affective disorders such as depression can be split into three types of clinical depression I.

Major depressive disorder

II. Dysthymia III. Manic or bipolar depression Etiology of major depressive disorder Biological factors Hammen (1997) suggests four types of circumstantial evidence why we might believe that depression is a biological condition: I.

Some symptoms of depression are physical, eg. Disruption to sleep and appetite

II. Depression runs in families III. Antidepressant medication reduces the symptoms of depression IV. We know that certain medical conditions and drugs induce depression Evolution Hagen et al. (2004) suggests that major depressive disorder has evolutionary origins. They suggested that it is a psychological adaptation favored by natural selection and serves two main purposes, to signal need and to elicit help from others in the social group. It has also been suggested that depression and mania evolved from normal reactions and attitudes towards loss and gain, failure and success. The feelings of sadness triggered by a failure or loss may be adaptive since they would discourage the behavior that led to them, preventing even greater losses. However behavior that resulted in gains and success would be motivated by the feelings of self-confidence, optimism, high energy levels and euphoria that are associated with happiness. Rank theory suggests that losses or gains in dominance resulting from competition with others would trigger these emotions. Depression would allow defeated individuals to display yielding behavior and desist in further competition that might result in further loss, while mania would allow victors to take advantage of their success and possibly gain further

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success. Inclusive fitness theory suggests that depression and suicide may have evolved as a strategy of individuals who feel they are unsuccessful or a burden to others to promote the inclusive fitness of their relatives by not reproducing and passing on these traits or removing themselves completely. Clinical depression and mania may be maladaptive because: I.

They developed as pathological exaggerations of normal adaptive emotional reactions or became too easily triggered. Depressed feelings that are triggered by consistent failure and major losses are maladaptive. These emotions involve a general lack of motivation for all behaviors not just those associated with failure or loss, which consequently could leave to even greater loss, which is adaptive. Similarly, the behaviors and emotions associated with mania may lead to unrealistic goals which may actually cause future loss.

Evaluation of evolutionary explanations of depression: I.

Happiness and sadness are found cross culturally and genetic predispositions for mood disorders have been proposed indicating there may be a biological adaptive function.

II. Higher rates of female defeat in competition with males due to their greater dominance generally, may explain the higher rates of female depression. III. Evolutionary theories of depression and mania remain speculative and there are many other explanations that do not assume these mood states are linked with adaptive features. Genetic factors McGuffin et al. (1996) obtained a sample of 214 pairs of twins, at least one of whom was being treated for major depression. They found that 46% of MZt and 20% of DZt of the patients has also suffered major depression. This suggests moderate genetic influence but identical twins may be reared more similarly to fraternal twins, therefore genes may not be the only factor affecting this finding and it will be reductionist to believe so. Kendler et al. (2006) conducted a large Swedish twin study with over 42 000 participants using telephone interviews to diagnose depression on the basis of the presence of most of the DSM-IV symptoms or having had a prescription for antidepressants . The researchers found concordance rate among MZ twins of 0.44% for females and 0.31% for males,

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compared with 0.16% and 0.11% for female and male DZ twins respectively. Results suggest a strong genetic component but not purely genetic as we would then expect the MZ rates to be much higher. Nurnberger and Gershon (1982) reviewed the results of seven twin studies and found that the concordance rate for major depressive disorders was consistently higher for MZ twins than for DZ twins. Across the seven studies reviewed, the average condorance rate for MZ twins was 65% while for DZ twins it was 14%. This supports the theory that genetic factors might predispose people to depression. However the fact that the concordance rate for MZ twins is far below 100% indicates that depression may be a result of genetic predisposition and that it is not purely genetic. Silberg et al. (1999) Aim

Assess both the roles of genes and recent life events on depression

Method

902 pairs of twins took part with: I.

182 of pre-puberty girls

II. 314 pubertal girls III. 234 puberty boys IV. 171 of pubertal boys Each adolescent completed a standard psychiatric interview to assess depression. Life events were measured both by a questionnaire given to the young people and an interview with their parents. Results

Girls suffered more depression than boys and on average they more susceptible to depression in response to life events. There were wider individual different among girls in response to life events and girls who suffered depression after a negative life event were often those whose twin also suffered depression. Suggesting an important role for genes in determining individual differences in vulnerability to depression in response to life events. Page 26

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Conclusion

Study supports a role for genes and environment.

Evaluation

Method: The children could have lied about life events or left out certain details. Ethic: The interviews and questionnaires may have caused unhappy memories to come back and negatively affect the children and their parents. This may therefore cause unnecessary stress. Gender: Both genders were used but they don’t represent the older population and may therefore be different.

Duenwald (2003) suggest that the short alleles of a gene known as 5-HTT affect the transmission and reuptake of serotonin to increase the chances of a person suffering from depression. But this finding between the gene and depression does not indicate a cause since the data are co relational. Kendler et al. (1992) carried out a twin study on sufferers of relatively mild major depressive disorder and found little difference between the probability of identical and fraternal twins sharing depression. This suggests that milder depression may have little genetic influence, whereas severe cases have a substantial genetic component. Research suggests that certain types of depression are more influenced by genetics than others. Klein et al. (1995) examined depression in the families of 100 patients suffering from dysthymia or major depression. They found that both dysthymia and major depression were more common in the families of both groups of patients than in the general population. Weissman (1984) found in the case of bipolar disorder, the families of patients of unipolar disorder are at no increased risk from bipolar disorder than the rest of the population. However, relatives of patients with bipolar disorder are at a greater risk from unipolar disorder. Neurobiological factors: One explanation for neurobiological factors and its role on depression is the catecholamine hypothesis suggested by Joseph Schildkraut (1965) according to this theory; depression is Page 27

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associated with low levels of noradrenaline. This theory was eventually developed in the serotonin hypothesis: the idea that the neurotransmitter serotonin is involved. Research has shown that there is evidence that drugs which decrease the level of noradrenalin tend to produce depression like syndromes. Janowsky et al. (1972) experimented on participants where they were given a drug called phygostigmine and became profoundly depressed and experienced feelings of self-hate and suicidal wishes within minutes of having taken the drug. This suggests that noradrenalin levels play a role in depression. Since a depressed mood can be artificially induced by certain drugs it suggests that some cases of depression might stem from a disturbance in neurotransmission. Delgado and Moreno (2000) found abnormal levels of noradrenalin and serotonin in patients suffering from major depression. However, abnormal levels of these neurotransmitters might not cause depression, but merely indicate that depression may influence the production of neurotransmitters. Rampello et al. (2000) found that patients with major depressive disorder have an imbalance of several neurotransmitters, including noradrenalin, dopamine, serotonin and acetylcholine. But Burns (2003) states that although he has spent many years of his career researching brain serotonin metabolism, he has never seen any convincing evidence that depression results from a deficiency of brain serotonin. Lacasse and Leo (2005) support this claim by stating that modern neuroscience research has failed to provide evidence that depression is caused by neurotransmitter deficiency. Another biological theory of depression is the cortisol hypothesis. Cortisol is a major hormone the stress system. Burke et al. (2005) in a meta-analysis of studies connecting cortisol with depression found that there seems to be a difference in reactivity to stress between depressed and non-depressed people: when non-depressed people are put under stress, cortisol levels rise and fall rapidly but depressed people have a more blunt reaction and remain under stress for longer. Cuteli et al. (2010) in a study of homeless children between the ages of 4 and 7 found a significant correlation between high levels of cortisol and a history of many negative life events. Fernald and Gunnar (2009) found that higher levels of cortisol were found in children whose families were unable to participate in a poverty alleviation programme in Mexico. The most significant group differences within the sample were between children whose mothers were depressed, the results indicated that those that participated in the programme helped reduce stress levels in children.

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Cognitive factors Aaron Beck (1976)’s theory proposed three factors that contribute to a person’s cognitive vulnerability to depression. These three factors are known as a cognitive triad and it underlies the information-processing style of depressed individuals. The cognitive triad is a cluster of negative thoughts grouped into three categories: the self, the world and the future. A person develops and maintains these negative core beliefs through a set of cognitive bias such as: over-generalization, selective abstraction (focusing on negative aspects of something) and polar reason (not being able to appreciate ambiguity in interpretations of life). These cognitive bias combine to give the person a negative self-schema which gives them a fundamentally pessimistic attitude about themselves and making it very difficult for a person to see anything positive in life. This can be contributed to by parents or peers early on in life. Alloy et al. (1999) followed a sample of young Americans in their twenties for six years. Their thinking style was tested and they were placed in either the “positive thinking grup” or “the negative thinking group”. After six year, the researchers found that only 1% of those in the positive thinking group had developed depression compared to 17% in the negative thinking group. The results indicate that there may be a link between cognitive style and development of depression. Grazioli and Terry (2000) assessed cognitive vulnerability in 65 woman in the third trimester of their pregnancy and found that those with high levels of cognitive vulnerability were ore likely suffer post-natal depression. Perez et al. (1999) compared sufferers of major depression with non-depressed participants in whom a sad mood had been induced by playing sad music and recalling unhappy memories on a Stroop task involving unhappy stimuli. The major depressive group but not the sad-mood participants paid significantly more attention to unhappy worlds in the Strrop task. This phenomenon, where depressed people pay more attention to unhappy stimuli, is called negative attention bias. Parker et al. (2000) found that in 96 depressed patients whose self-reports of their symptoms included the idea of a negative schema being activated under certain circumstances were interviewed about their early experiences. There were significant associations between reports of early experiences and the existence of maladaptive schemas that were in turn associated with the experience of depression. This suggests that early experiences do induce cognitive vulnerability.

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Albert Ellis (1962)’s theory focused on negative cognitive styles as the basis of depression. Specifically, irrational and self-defeating beliefs affect an individual’s interpretation of antecedent or activating events, leading to negative emotional consequences. Irrational beliefs will lead to self defeating conclusions. This has been supported by Robins and Block (1989) in which they found empirical support suggesting that depressed people do have negative thinking styles. But Taylor and Brown (1988) research suggest that depressed people are actually more realistic in their interpretations of events. Abramson et al. (1989) put forward the hopelessness model, in which hopelessness is seen as the main negative cognition underlying depression. Hopelessness consists of two elements, negative expectations of the likelihood of positive events and negative beliefs about the ability of the individual to influence events. When the vulnerable individual experiences a negative life event they feel helpless to respond to it and this helplessness leads to the sense of hopelessness and that directly causes depression. Once they are in the pattern of experiencing negative events and not being able to respond positively to them., a general sense of hopelessness results. This model doesn’t aim to explain all of depression but to identify a particular group of people who are particularly vulnerable. Rose et al. (1994) investigated the characteristics of people who displayed hopelessness. They found that hopeless people were particularly likely have a diagnosis of personality disorder, suffered sexual abuse and a highly controlling family. These two characteristics are important as they are both circumstances in which they would have experienced hopelessness in childhood. Therefore long term hopelessness in fact of negative events during a childhood leads to learnt helpless and hopeless cognitive style.

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Sociocultural factors Brown and Harris (1978) provided the vulnerability model based on the interaction of vulnerability factors and provoking agents. In their vulnerability model of depression, they based a number of factors that could increase the likelihood of depression. The vulnerability factors are: I.

Losing one’s mother at an early age

II. Lack of a confiding relationship III. More than three young children at home IV. Unemployment This vulnerability model was based on previous research by Brown and Harris (1978) Brown and Harris (1978) Aim

They aimed to investigate the link between depression and both current and past life events in the lives of sufferers.

Method

They focused on working-class women, as women tend to experience more depression than men and because working class people tend to experience more stress than middle class. A interview called the Life events and difficulties scale (LEDS) was developed and interviewers were trained to use this. A group of 539 women from London were interviewed using the LEDS and asked details of what stressful events had occurred in the previous year along with background circumstances in which they occurred. The LEDS also aimed to uncover stressful childhood events, interviewers prepared a written account of each event of source of stress which would then be rated by a panel of researchers for how stressful it would be for a typical person. To avoid bias, raters didn’t know who suffered depression. Page 31

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Results

Both recent high levels of stress and having suffered a stressful childhood event left people particularly vulnerable to depression. 80% of women who suffered depression had had a major stressful life event in the previous year as opposed to 40% of those who didn’t suffer depression. The factors that had the strongest associations with depression involved recent level of stress, they were lack of an intimate relation, lack of paid employment and the presence of three or more children and death of mother during childhood.

Conclusion

There is a link between recent negative life events and the onset of depression.

Evaluation

Method: The experiment used the LEDS which was developed by the researchers for the use of this experiment and was specific for life events relating to depression therefore the results would likely result in life events leading to depression. Also even though the raters didn’t know who was depressed there may also be bias in the interviewers. Culture: The sample size was only London people and culturally there may be different results as many research have shown there are different social and cultural factors in depression. Therefore we don’t know how well this will apply to other cultures. Ethics: The LEDS aimed to uncover stressful and possibly depressing events of people during the childhood. Many of the details uncovered involved high levels of stress on the participants. This stress may have Page 32

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activated unhappy memories and therefore cause negative emotions onto the participants. Ethically this causes stress on the participants. Gender: This experiment aimed to focus on woman, but research has shown that men and women face depression differently so the results of this experiment may not apply to men as strongly as it would women. The theory of social drift and social causation aims to explain how most mental disorders are found more frequently in lower socioeconomic groups. Social drift is the idea that individuals and families with mental disorders tend to drift into lower socioeconomic groups. Social causation is the idea that low socioeconomic status causes psychopathology. Ritsher et al. (2001) tested for social causation and drift effects in a study of 756 participants across two generations. It was found that low parental education level was associated with increases rates of depression in the following generation even when there was previously no depression in the family history. Parental depression did not predict lower SES in offspring. This study supports of the role of causation and fails to support a role for social drift in depression. Lupien et al. (2000) suggests that high levels of stress in parents affect children’s development by affecting their own levels of stress. They test this theory on 139 mothers and regularly assessed for stress and depression by telephone interview. Their children (217) were assessed for salivary cortisol levels and for cognitive function. Low SES mothers reported more stress which was reflected in the cortisol levels and cognitive functioning of their children. This research suggests that stressed low SES mothers somehow transmitted this stress for their children thus contributing to later depression. Nicholson et al. (2008) found that men in the most socially disadvantaged groups in Poland, Russia and the Czech Republic were 5 times more likely to report depressive symptoms than their compatriots in higher socio-economic groups. Wu and Anthony (2000) found that in the USA there appears to be lower prevalence of depression in Hispanic communities supposedly because levels of social supports are higher and act as a preventative measure against depression. Gabilondo et al. (2010) found that depression occurs less frequently in Spain than in northern European countries and that there is lower rate of suicide. The reason

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for this is suggested to be due to stronger traditional roles of family and higher religiosity as sociocultural variables that make the prevalence lower. Culturally it was found that individualism was found to be associated with high rates of depression. Chiao and Blizinsky (2010) found that depression was associated with individualism and that this dimension has a negative correlation with the frequently of 5HTT. The researchers suggest that cultural norms such as increase social support have developed to protect the more biologically vulnerable groups. This suggests that collectivism is evidence of biological vulnerability. Brown and Harris (1978) have shown that there are gender variations in depression and that women are more likely to experience depression. Koss et al. (1994) found that discrimination against women begins early in their lives. Women are around twice as likely as men to suffer sexual abuse in childhood and this pattern of victimization is maintained in adult hood, where woman make up the majority of victims of physical assault. Etiology of Eating Disorders Eating disorders are split into two major ones I.

Anorexia nervosa

II. Bulimia nervosa Biological factors An evolutionary explanation was theorized by Surbey (1987) where his findings suggest that weight loss usually comes after the amenorrhea (when menstruation stops) and that anorexia often occurs in girls who are maturing early, the reproductive suppression model suggests that starvation is an adaptive response to stress that deliberately delays the onset of reproductive capabilities until a more appropriate time. A problem with this theory is that it doesn’t address males but it does help explain the lack of obsession with food anorexics have, adaptive behavior in times of food shortage and starvation is to shift attention to the acquisition of food. It is possible that physical illness may act as a factor in eating disorders. Park, Lawrie and Freeman (1995) studied four females suffering from anorexia nervosa, all of whom had had glandular fever or a similar disease shortly before the onset of the eating disorder, they argued that the physical disease may have influenced the functioning of the hypothalamus and this caused homeostatic imbalances. But this research fails to establish a casual link

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between anorexia and glandular fever as they used a small sample size and most people who have had glandular fever do not go on to develop anorexia nervosa. Zandian et al. (2007) suggest that anorexia is an expression of an underlying obsessive-compulsive disorder as these disorders frequently precede anorexia. A hypothesis is that there is a genetic base to this and the in male OCD does not usually manifest itself as anorexia but female biology interacts with the OCD to transform it into an eating disorder. Holland et al. (1988) Aim

Aimed to investigate whether there was a higher concordance rate of anorexia nervosa for MZ than DZ twins based on previous research suggesting so.

Method

An opportunity sample of 34 pairs of twins (30 female and 4 male) and one set of triplets because one of the pair had been diagnosed with anorexia. This was a natural experiment and a physical resemblance questionnaire established genetic relatedness. A blood test was also used. This was a longitudinal study with the researchers checking over time to establish whether the other twin went on to develop anorexia. A clinical interview and standard criteria were used for diagnosis of anorexia.

Results

Significant difference was found between the concordance rates for MZ and DZ twins, there was a much higher concordance rate of anorexia for MZ than DZ 56% to 7% Further findings revealed that in three cases where the non-diagnosed twin did not have anorexia they were diagnosed with other psychiatric illnesses and two had minor eating disorders.

Conclusion

The results suggest a genetic basis for anorexia and general psychiatric illness. The fact that the percentage for MZ twins was Page 35

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well below 100% indicates that genes are not wholly responsible, so genes can provide a predisposition but do not directly trigger the disorder. Evaluation

Study ignores the role of environmental factors or nurture in causing anorexia. The results clearly show that environment plays a role. This natural experiment lacks control of the variables. The IV is not isolated and multiple other factors may be implicated. Therefore internal validity is low as factors other than the IV may have caused the anorexia. Also causation cannot be inferred as the IV is low. This means that conclusions are limited as it cannot be said that genes cause anorexia and at best is strong implicates it. The study is limited as it was carried in a Western society and anorexia is much more common in Western societies than others parts of the world. These cultural factors were not considered.

Kendler et al. (1991) did a similar twin study except they focused on bulimia in female twins. They investigated whether there was a higher concordance for bulimia nervosa in MZ than in DZ twins. The study used a sample of 2163 female twins in which at least one pair had been diagnosed with bulimia. Results showed that the concordance rate for MZ twin was 23% to 9% for DZ. The difference is statistically significant and suggests that genetic factors play some part in bulimia but the evidence is less strong than for anorexia. Since the concordance rate is way below 100% it suggests environmental factors play a role and the results also show that genetic factors are much less important in the development of bulimia than in the development of anorexia.

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Sociocultural factors Anorexia nervosa can be explained through conditioning theory. I.

Classical Conditioning: Leitenerg, Agras, and Thompson (1968) suggest that anorexics may have learned to associated eating with anxiety, because eating too much makes people overweight and unattractive. Therefore they seek to lose weight to reduce their anxiety. Weight loss is associated with relief from an unpleasant stimulus.

II. Operant conditioning: Food avoidance can be rewarding or reinforcing because it is a good way of gaining attention. It can also be reward or reinforcing in that those who are slim are more likely to be admired by people. Rosen and Leitenberg (1985) states that bingeing causes anxiety and the subsequent vomited or other compensatory behavior reduces that anxiety. This reduction in anxiety is reinforcing and helps to maintain the cycle of bingeing followed by vomiting. Conditioning theory provides some reasons why anorexics and bulimics maintain their disorders but it does not account for individual differences in vulnerability to eating disorders. Social Learning Theory Cooper (1994) found that both bulimia and anorexia is considerably more common in Western than in non-Western societies. This can be explained in terms of role mole models available to young women. In society, women see other women rewarded for looking slim in terms of the attention and admiration they receive. According to SIT this will lead many women to imitate this rewarded behavior by striving to slim. This is known as vicarious reinforcement. Nasser (1986) compared Egyptian women studying in Cairo and in London. None of the women studying in Cairo developed an eating disorder, in contrast to 12% of those studying in London. This shows evidence that there may the importance of Western role models in the development of eating disorders. Lee, Hsu, and Wing (1992) noted that bulimia was almost non-existent among the Chinese in Hong Kong and suggested that this can largely be explain in terms of socio-cultural differences. Chinese girls are usually slim and therefore don’t share the Western fear of fatness that can lead to excessive dieting behavior. The Chinese regard thinness as a sign of ill-health rather than the Western view that it is a sign of self-discipline and economic well being. Obesity is not seen as a sign of weak control or moral impairment as in the West. It is seen as a sign of health and prosperity.

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Behar et al (2001) Aim

Aimed to investigate the effect of gender identity on eating disorders to test behavior explanations that gender identity on eating disorders to test sociocultural explanations that gender differences exist because women experience more pressure to be thin than men. They hypothesized that the existence of role models with idealized body images will develop into eating disorders and aimed to see if the acceptance of female gender roles was higher in females with eating disorders than in controls.

Method

126 participants- 63 patients with eating disorders and 63 control subjects were used. A natural experiment as the IV could not be controlled. A structured clinical interview and DSM-IV criteria, a self report survey to measure gender identity was used.

Results

Significant differences were found in gender identity. More eating disorder patients classified as feminine gender identity- 43% compared to only 23.8% of controls. More controls were classified as androgynous: 31.7% of controls compared to only 19% of patients. More controls were classified as undifferentiated: 43% compared to 27%.

Evaluation

Study ignores the role of genetics factors even though there is strong evidence of role of genetics. It is reductionist to only consider one explanation. This is a natural experience so the IV was not controlled and so causation cannot be inferred there it cannot be sad that eating disorders and gender identities are casually related. Gender identity was measured only after eating disorders had developed, it is Page 38

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assumed that gender identity leads to eating disorders but it is possibly the having an eating disorder causes gender identity changes. This study was carried out in a western society and eating disorders are far more common there than in non-Western one. Cognitive factors Sufferers have eating disorders have cognitive bias. Garfinkel and Garner (1982) found that anorexic patients typically overestimate their body and that it is greater than that found in controls. Jaeger et al. (2002) sampled 1751 medical and nursing students across 12 counties, including a mixture of Western and non-Western ones. A self-report method was used to obtain data on body dissatisfaction, self esteem and dieting behavior, BMI was also measured. A series of 10 body silhouettes, designed to be as culture free as possible, were shown to participants to assess body dissatisfaction. Results showed that the most extreme body dissatisfaction was found in Mediterranean counties, followed by northern European counties and counties in process of Westernization, and finally non-Western countries which has the lowest levels. Body dissatisfaction was independent of self-esteem and BMI; those with greatest body dissatisfaction were very often not overweight. This research supports sociocultural explanations of Western role models and shows us that body dissatisfaction may be important vulnerability factor for eating disorders. Also since body dissatisfaction was independent of BMI; it suggests the vulnerability to eating disorders depends on more subjective factors than objective factors. This shows how fault cognitive processing contributes to eating disorders. Fairburn et al. (1999) provided a detail account of how low self-esteem and an extreme need for self control are at the core the disorder. They suggest that for people with anorexia, the need for control is easily met through eating. The idea that dieting and control go together is a schema built and encouraged in Western society. The disordered eating patterns are maintained because the person’s sense of control is increase to the point where control over eating becomes a measure of self-worth. Also constant checking of body shape to obtain objective information about success of dieting is made unreliable by distorted perceptions cause by negative mood and the presence of thin women in the media. There is also an

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attention bias towards negative information about body. Fallon and Rozin (1988) found that when families were asked to compare their body shape to their ideal body, only the sons reported that their body shape was acceptable. Both mothers and daughters in the sample believe that men prefer thinner women than they actually do.

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Implementing treatment Syllabus Question: Examine biomedical, individual and group approaches to treatment. And Evaluate the use of biomedical, individual and group approaches to the treatment of one disorder. Biomedical therapy The biomedical approach to treatment is based on the assumption that if the problem is based on biological malfunction, drugs should be used to restore the biological system. Drugs are widely used to treat depression because we are aware of neurochemical activity associated with the disorder. A biological theory that aims to explain major depressive disorder is the serotonin hypothesis, it suggests that there is an inadequate amount of serotonin available in the synaptic gap between neurons for effective transmission to occur. Based on the assumption from research that serotonin plays a role in depression, medication for major depressive disorder increase serotonin. Selective serotonin reuptake inhibitors (SSRIs) aim to increase the amount of serotonin available by preventing the reuptake of serotonin, making it stay in the synaptic gap longer and thereby increasing the efficiency of the serotonin already present. These drugs include fluoxetine (Prozac). Criticisms of Prozac are that it treats the symptoms but it does not cure the disorder and there are significant side-effects. The effects include sexual problems, dry mouth, insomnia and even an increase in suicidal thoughts. This drug seems to be more helpful for the most serious cases of depression. Because only the symptoms are treated and because depressive episodes usually recur, it is necessary for patients to continue taking the medication unless the medication is used with therapy, it unlikely that the disorder will disappear permanently. Therefore the effectiveness of drugs are limited without the use of other treatments. A study by Kirsch and Sapirstein (1998) analyzed the results from 19 studies, covering 2318 patients who had been treated with Prozac and found that antidepressants were only 25% more effective than placebos and no more effective than other kinds of drugs, such as tranquillizers. Further research by Kirsch et al. (2008) reviewed 47 clinical trials published by the US Food and Drug Administration on effectiveness of antidepressants. They claimed that medical treatment was not more effective than a placebo and found that depressed patients can improve without biomedical treatment. Blumenthal et al. (1999) found that exercise was just as effective as SSRIs in treating depression in an elderly group of patients. Leuchter and Witte (2002) found that depressive patients receiving drug treatments

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improved just as well as patients receiving a placebo. The researchers scanned the patients and found changes in brain functioning in both cases but the changes were different. Patients who got a placebo showed increased activity in the prefrontal cortex, whereas patients who received the antidepressant showed decreased activity in the same brain area. The researchers could see that brain changes happened within 48 hours of starting treatment in the drug group, whereas changes began after one to two weeks in the placebo group. It is not known why a placebo works but the results of this study clearly showed that the placebo worked and was better than no treatment. The researchers argue that the brain does not respond to the same way to a placebo and drugs but people’s mental health improved in both groups indicating that medication is effective but there are other ways to help people who suffer from depression. Elkin et al. (1989) worked with 28 clinicians who worked with 280 patients diagnosed as having major depression. Patients were randomly assigned to treatment using either an antidepressant drug, interpersonal therapy, or CBT or another form of therapy. A control group was given a placebo pill along with weekly therapy. The placebo/drug group was conducted as a double blind design. All patients were assessed at the start, after 16 weeks of treatment and after 18 months. Results showed that 50% of patients recovered in each of the CBT and IPT groups as well as the drug group. Only 29% recovered in the placebo group, the drug treatment produced faster results but the study shows that there is no difference in the effectiveness of CBT, IPT and drug treatment, i.e. it doesn’t matter which treatment patients receive. But Bernstein et al. (1994) found that generally antidepressant drugs are an effective way to treat depression in the short term, significantly helping 60-80 per cent of people. Individual therapy Assumptions of this form of treatment are that since one of the symptoms of depression is distorted cognitions. This led to psychologists to suggest that replacing negative cognitions by more realistic and positive ones can help the depressed person. Beck’s theory of cognitive therapy is based on cognitive restructuring and aims to fix the cognitive bias identified through his theory. Cognitive behavioral therapy (CBT) is a brief form of psychotherapy used in the treatment of adults and children. There are typically around 12-20 weekly sessions, combined with daily practice exercises to specifically designed to help the patient use new skills on a day-to-day

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basis. The therapy consists of identifying the automatic, negative thoughts assumed to underlie the depression and helping the depressed person see and understand the connection between these thoughts and their emotional state. By addressing these thoughts together, and through individual exercises, the person in therapy and the therapist can gradually change the negative self-schema and find more positive ways to interpret life events. Behaviors that are rewarding for the individual and encouraging him or her to engage in them as one of the key symptoms of depression is loss of interest in activities that used to give pleasure and its aim of therapy to regain these levels of interest. Interpersonal therapy (IPT) concentrates on helping the client develop and use any positive social support networks they have in their life with improved communication skills. Rush et al. (1997) found that cognitive therapy effectively treats patients with depression. Dobson (1989) found that cognitive therapy is superior to not treatment or to a placebo. But Elkin et al. (1989) found that there was no significant difference in the effectiveness of individual therapy, CBT and another form of therapy in comparison with a drug and a placebo. The two therapies were slightly less effective than the drug but more effective than a placebo. Riggs et al. (2007) studied effectiveness of CBT in combination with either a placebo or an SSRI. This study was a randomized double blind study with 126 adolescents, aged 13-19, who suffered from depression as well as a substance use disorder and conduct disorder. The participants were rated by a physician who found that 67% of the patients in the CBT+ placebo group and 76% of the patients in the SSRI + CBT were judged as very much improved or much improved after being treated for four months. The researchers concluded that treatment with drugs and CBT is effective but that treatment with a placebo and CBT is almost as effective. The participant’s self reports after the study showed that depression had decreased and so had the other behavioral problems. Nemeroff et al. (2003) found that CBT in combination with drugs was the most effective in cases of chronic depression in people suffering from traumatic childhood experiences. This group was better helped with either therapy alone or a combination of therapy and drugs, rather than with drugs alone. Parker et al. (2006) reviewed the effectiveness of CBT and IPT and it indicated that IPT alone is not as quick as medication in relieving symptoms but it does provide substantial

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improvement at a slightly later point. Butler et al. (2006) reviewed several meta-analyses of efficacy studies for CBT and concluded that CBT is extremely effective for depression, although the effect is not usually greater than medication alone and outcomes are usually better when CBT is combined without medication. Group therapy People who may not hear or share when they are alone with a therapist may be encouraged to participate in discussion when they are surrounded by others. There is a chance that they can vicariously through the experience of others become more optimistic about their own chances for recovery if they meet others who have improved. Hyun et al. (2005) randomly assigned depressed adolescents at a shelter for runaways to group CBT or a group receiving no treatment. They found group CBT to be extremely effective at relieving symptoms of depression. Meta-analyses by Toseland and Siporin (1986) reviewed 74 studies comparing individual and group treatment. Group treatment was found to be as effective as individual treatment 75% of the time in these studies and more effective in 25% of it. In no case was individual treatment found to be more effective than group treatment. Group treatment was also found to be more cost effective than IT in 31% of the studies. But McDermut et al. (2000) provided a meta-analytic review of the effectiveness of group therapy in treating depression. Of the 48 studies examined, 43 showed statistically significant reductions in depressive symptoms following group therapy, 9 showed no difference in effectiveness between group and IT, and 8 showed CBT to be more effective than group therapy. But Traux (2001) states the most studies included in meta-analyses excluded the more severely depressed people. Therefore we do not know if group CBT is effective for all depressed people. A problem with group therapy is that dissatisfaction with the group or any of its member might lead to drop and Traux (2001) cites this as the main reason why people drop out from studies like this.

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Syllabus Question: Discuss the use of eclectic approaches to treatment. Eclectic approaches are treatments that use several approaches to treating a disorder, i.e. using biomedical, individual and group approaches together. State the strengths of limitations to each of these approaches for a disorder and then link together on how they will be effective together. Elkin et al. (1989) found that there was no significant difference in the effectiveness of individual therapy, CBT and another form of therapy in comparison with a drug and a placebo. The two therapies were slightly less effective than the drug but more effective than a placebo. Riggs et al. (2007) studied effectiveness of CBT in combination with either a placebo or an SSRI. This study was a randomized double blind study with 126 adolescents, aged 13-19, who suffered from depression as well as a substance use disorder and conduct disorder. The participants were rated by a physician who found that 67% of the patients in the CBT+ placebo group and 76% of the patients in the SSRI + CBT were judged as very much improved or much improved after being treated for four months. The researchers concluded that treatment with drugs and CBT is effective but that treatment with a placebo and CBT is almost as effective. The participant’s self reports after the study showed that depression had decreased and so had the other behavioral problems. Nemeroff et al. (2003) found that CBT in combination with drugs was the most effective in cases of chronic depression in people suffering from traumatic childhood experiences. This group was better helped with either therapy alone or a combination of therapy and drugs, rather than with drugs alone. Parker et al. (2006) reviewed the effectiveness of CBT and IPT and it indicated that IPT alone is not as quick as medication in relieving symptoms but it does provide substantial improvement at a slightly later point. Cujipers et al. (2009) compared the effectiveness of various treatments for depression through a meta-analysis of studies. They found that psychotherapy groups do significantly better than control groups. Medication was found to be more effective than psychotherapy in improving symptoms, especially when SSRIs were used. But the best results were found in studies that used a combination of medication and psychotherapy.

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Syllabus Question: Discuss the relationship between etiology and therapeutic approach in relation to one disorder. Etiology are the origins of a disorder. Use info and research from depression about the theories on the causes of it and then link it to the three treatment approaches and why they are used. E.G. CBT is used because its theorized and shown that depression may be due to faulty cognition.

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