What do I need to learn?

Content Define what is meant by Clinical Psychology understanding it is about explaining and treating mental illness Number of marks (Rough guide) 3 marks you should define the term and elaborate or give an example 4 marks you should define the term and elaborate or give an example 4 marks

Define the following key terms: statistical definition of mental illness, social norm definition of mental illness, schizophrenia, reliability, validity, primary and secondary data

Describe what is meant by primary and secondary data when doing research Evaluate the use of primary and secondary 4 marks data when doing research Explain how issues of reliability and validity 4 marks arise in clinical psychology

Describe and evaluate how animal 4 marks each experiments and twins studies are used as research methods for schizophrenia. Be able to describe one study as a research method example Using studies, describe and evaluate Description issues of reliability, validity and culture evaluation with regard to the diagnosis of mental (each issue) illness 4, 4

Describe the symptoms and features of Description 6 schizophrenia Describe and evaluate a biological (dopamine hypothesis) and social (environmental breeder) explanation for schizophrenia Describe and evaluate two treatments for schizophrenia, a biological (drug therapy) and social (assertive community therapy) Describe the features and symptoms of anorexia Describe and evaluate two explanations for anorexia, biological (genetic explanation), cognitive (faulty perceptions) Describe and evaluate two treatments for anorexia, psychodynamic (free association) and cognitive (rational emotive therapy) Description evaluation 6 Description evaluation 6 Description 6 6

Description 6, evaluation 6 Description 6, evaluation 6

Describe and evaluate a social treatment 6 des, 6 eval for mental illness (Care in the community) Describe and evaluate a biological 6 des, 6 eval treatment for mental illness (drug therapy) Describe and evaluate a cognitive 6 des, 6 eval treatment for mental illness (cognitive behaviour therapy) Describe and evaluate a behavioural treatment for mental illness (systematic desensitization) Describe and evaluate a psychodynamic treatment for mental illness (dream analysis) Describe and evaluate Rosenhans 1973 study on being sane in insane places Describe and evaluate Goldsteins 1988 study Gender differences in the course of schizophrenia Describe and evaluate Mumford and Whitehouses 1988 study on Increased prevalence of bulimia nervosa among Asian school girls Evidence in practice describe one key 6 des, 6 eval

6 des, 6 eval 6 des, 6 eval 6 des, 6 eval

issue in Clinical Psychology Understanding a mental health disorder Prepare a leaflet using secondary data for families of someone diagnosed with your chosen disorder Include a commentary on the leaflet explaining why decisions were made, who the audience were and what outcomes were intended

There is a lot to learn, but it is not impossible! Use your knowledge from the Cognitive Approach to help you revise:
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Revise in chunks do not try to learn too much at once it is easy to get confused Deep processing is best do not simply read the information, do something with it. Spider diagrams, flash cards, post-it notes for definitions are all helpful. If you know something well enough to explain it to someone else without notes then you will be fine in the exam Use cues to help you remember such as mnemonics or includes pictures on your spider diagrams which can act as a visual cue in the exam Test yourself especially with past exam questions, use past papers, you know the style of question that will be asked so make them up, you have my email address so you can email me questions that you complete and I will mark them and send them back to you with comments (jkirk@pensbyhigh.wirral.sch.uk) Use the Learning Environment there is extra information on there, including podcasts for auditory learners Follow PensbyPsycho on Twitter I will share tips in the run up to the exam

o It sounds obvious but read the question! If it asks for a theory do not describe a study you will get no marks o If you are asked to describe, do not evaluate and vice versa o Remember to PEE!! Make your point and provide an example or further explanation 3

o When evaluating make sure the points you make are specific to that study e.g. lots of studies lack ecological validity you need to say what this is and explain how the study you are evaluating lacks ecological validity (if this is the point you are making) o When describing a study remember Nasty Awful Mothers Ruin Children (Name Aim Method Results Conclusion). This should be the first thing you write on your question paper as a cue to help you remember as you will not have time to plan any answers except possibly the 12 mark essay question o Watch out with the multiple choice questions they are not as easy as they look and can often catch people out o Always write in full sentences never ever ever use bullet points even for evaluating and do not divide evaluation into sub headings such as strengths and weaknesses I have done this here to make it easier for you to read (and also because a question could only ask for strengths etc..) o Use the language of the mark scheme to answer your question. When describing a study use word such as the aim of the study was to, the results of the study were o Use connectives in your writing One strength of Rosehans study of is In addition to this, the study has been praised because of o You will be given marks for spelling, punctuation and grammar in the essay question so take care on this question especially o If you are asked to compare, refer to both things you are comparing in each sentence. o If a question asks you to assess something you need to weigh up the strengths and weaknesses If a question asks you to describe something for a parent for example, you should use laymens terms (language which a non-psychologist would understand).

The specification states that you need to learn the following key terms off by heart: o statistical definition of mental illness, social norm definition of mental illness, schizophrenia, reliability, validity, primary and secondary data

These are discussed in detail throughout this revision guide, however, it would be a useful revision exercise to make your own cards/ list of these key terms (and the many other new words you came across in this unit e.g. anorexia)

Primary and Secondary Data

Primary Data Original data collected by those who witnessed the event first hand or carried out an experiment and collected the data themselves It can be qualitative or quantitative Observed aggression levels in a playground is an example of primary data An example of a study from Clinical Psychology which uses primary data is Rosenhan he noted whether the pseudopatients were admitted to the psychiatric hospital. The researchers also noted who they were treated by staff once they had been admitted Secondary Data This is second-hand analysis of pre-existing primary data The data can be analysed in a different way or used to answer a different question than that used in the primary research Secondary data usually comments, evaluates and or analyses primary data Sometimes secondary data is gathered before primary data at the beginning of a study the researchers may want to gather all relevant secondary data on the topic in order to develop their hypotheses An example of a study in Clinical Psychology which uses secondary data is Goldstein 1988 she analysed data already held on schizophrenic patients to see whether females differed in their experience of the disorder to males Evaluation Strengths It saves time and expense that is involved when collecting secondary data In some cases, secondary data 5

Evaluation Strengths In general, primary data is reliable because the researcher can adopt controls and the procedures can be replicated to

see whether similar results are is the only way to examine found trends in the past It is more likely to be up-to- Weaknesses date than secondary data The researcher cannot which could have been personally check the data so its gathered years before reliability can be questionable It is more likely to gather Because they did not gather credibility and respect from the data the researcher cannot others as it is founded on always be sure that appropriate authentic evidence and controls were taken and empirical data therefore how accurate the Weaknesses data is Researchers may be subjective The data may be out-of-date in which data they decide to and therefore not suitable for collect so that it is more likely the research to fit their hypotheses It is costly and time-consuming as the data has to be gathered from scratch using a large population Remember when describing research methods it is important to refer to their use in Clinical Psychology when describing and evaluating

Use of Animal Learning Studies to Study Schizophrenia

Although, it is thought that schizophrenia is a condition only found in humans, it is possible to model this disorder and test possible treatments. For example, the dopamine hypothesis can be tested using animals. Animals can be given amphetamines (which increases dopamine levels) and then their behaviour observed to see whether they develop schizophrenia symptoms. In addition to this their brains can be leisioned to see what effect this has on their behaviour e.g. it is believed that enlarged ventricles in the brain are linked with schizophrenia. Brains can also be damaged prenatally to see what effect this has on behaviour (see the Caster et al study below).

Evaluation Strengths of using animals as participants in schizophrenia research:

1. Evolutionary continuity: Non-human animals are similar enough to humans to extrapolate results from one species to another; Green (1994) basic physiology of brain and nervous system are similar enough to warrant comparisons internal biochemistry works in same way through release of same basic hormones and similar chemical transmitters animal models are therefore useful in exploring areas in which it would not be possible to use humans (practical and ethical reasons) and can help to reduce human suffering 2. Greater objectivity and control of confounding variables can be attained by using animals animals do not show demand characteristics and evaluation apprehension in same way as humans; increased internal validity can control for genetic inheritance across a sample through selective breeding can keep animals in controlled environments so all experiences are documented and taken account of 3. Can use species with short life spans full progress of disease can be seen quickly breeding can occur quickly and inheritance of symptoms monitored

Weaknesses of using animal experiments in schizophrenia research:

1. Subtle differences between non-human animal species are revealed every day extrapolating to humans must be done with caution; researchers are findings differences between the way male and female brains work and with such differences within the same species this emphasises the possible errors that could be made from generalising from one species to another 2. Just because a part of the brain is used for a certain skills in one species does not necessarily mean it is used for the same function in another; Also human brains are much bigger relative to our body size to any other species and the amount of cortex( the outer layer) is far more developed 7

3. Only possible to look at behavioural indicators of schizophrenia such as lack of goal-directed activity and social withdrawal (negative symptoms may be more detectable?) No language so cannot diagnose in same way difficult to operationalise whether a creature if suffering with hallucinations from behaviour alone they cannot speak and tell you they are hallucinating need to invent ways of assessing possibilities of thought disorder as cannot detect this through disordered language use could assess stereotypical/impaired movements etc

4. Anthropomorphism: this term means attributing human qualities to animals and means that we might assume that an animal is behaving in a certain way for the same reasons as a human would behave in a certain way, thus we might believe that an animal appears apathetic because it is wandering around its cage in a seemingly purposeless manner however it just be getting some exercise we might perceive that an animal is confused due to some behavioural sign whereas actually this is not the case

5. Being in captivity (confined, handled and isolated) will alter their natural behaviour (thus affecting internal validity); it can be stressful for animals and can lead to increased autonomic nervous system activity; this could in fact enhance schizophrenic symptoms as in humans there is evidence that environmental stressors may trigger underlying genetic predispositions

Example of animal study of schizophrenia

Name: Caster et al, (1998)

Aim: To investigate the effects of pre-natal brain damage, via exposure to radiation, on the behaviour of rhesus monkeys They specifically aimed to investigate whether brain damage was a causal factor in the development of schizophrenic-like behaviour To explore why schizophrenic symptoms do not seem to appear until puberty and the possible role of the increased level of sex hormones at this life stage in triggering the onset of schizophrenia

Method: Laboratory experiment using two groups of irradiated monkeys: half experienced radiation at 70-80 days gestation, the others at 33-40 days (8 monkeys in total) They were exposed to selective brain damage caused by X-rays during the critical early weeks of fetal development They were either exposed to a high dose (three to six times with 100 Rads) or low dose of radiation (four times with 50 Rads) Irradiated monkeys were compared with an age matched control group tested on a battery of cognitive tests at 6-18 months of age (prepuberty) and again after puberty (3-7 years of age) tests included cognitive skills such as matching, selecting, spatial tasks and visual discrimination amongst others

Results: Tests showed normal development up until adolescence (puberty) and no significant difference between experimental and control groups Following puberty, irradiated monkeys developed hallucinations and difficulties on memory and problem-solving tests the nature and degree of impairment depended on the stage of embryonic development in which the damage occurred and the brain regions affected. Monkeys suffering brain damage between 70 and 80 days of fetal development showed more pronounced abnormalities than monkeys irradiated between 33 and 40 days of gestation

Conclusions:

"This is the first evidence suggesting that schizophrenia in humans might be caused by damage to neurons in the cortex or thalamus during fetal development," "The study also demonstrated that early loss of neurons may not be detected until later in life." It is possible that brain damage sustained in other ways, e .g. viruses, drugs and other mutagens could lead to similar outcomes Further research is now required to look at the possibility of reversing the effects of the brain damage using neuroleptic/anti-psychotic drugs, e.g. clozapine or haloperidol

Use of Twin Studies to Study Schizophrenia

One way of finding out whether a disorder has a genetic component is to see whether it runs in families. If relatives of sufferers have a higher than average risk of getting the disorder themselves, then it may be that the disorder has a genetic component. However, family members typically share similar environments. Consequently, increased risk amongst close relative may simply indicate that that are exposed to the same set of environmental risks. An alternative approach is to do a twin study. This looks at the concordance rate (degree of similarity) of twins with respect to the disorder being considered. Concordance rates means the probability of one twin having the disorder if the other already has it expressed as a percentage. In a twin study, MZ (identical) and DZ (non-identical) twins are compared. Whilst MZ twins have a greater degree of genetic similarity, both types of twin pair grow up in identical environments. So if we discover that MZ twins have a higher concordance, this cannot be because their environments are more similar than those of DZ twins; it must therefore be because their genes are more similar. When interpreting twin study data, we look for the following features: Feature Interpretation has a genetic

MZ concordance is significantly higher The disorder than DZ concordance component

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MZ concordance is same or similar to DZ concordance MZ concordance is 100% MZ concordance is significantly less than 100%

The disorder caused.

is

environmentally

The disorder is genetically caused The disorder has an environmental component

Evaluation

Strengths of twin studies o Twins provide a perfect way of controlling for genetic inheritance as MZs always share 100% and DZ share 50%, a naturally occurring manipulation of an independent variable, yet both have the same environmental experience (control of confounding variables) meaning that the effect of nature over nurture can be studied effectively. o With increasing numbers of multiple births, it is possible to replicate the findings of twin studies with large samples in many different world cultures, increasing the reliability and generalisability of the findings; records of multiple births means that researchers can easily find large sample with which to test their hypotheses. DNA analysis can then isolate the gene/ genes involved. Weaknesses of twin studies o One of the grounding assumptions of the twin study methodology concerns the degree of similarity between the environments of MZ and DZ twins. Because both types of twin pair are born at the same time into the same environment it is assumed that each member of a twin pair is exposed to exactly the same set of environmental influences, regardless of zygosity. However, this not strictly true as ... o MZ twins can experience differences in terms of environmental experiences, even in the womb o MZ twins are typically closer than DZ twins, their parents are more likely to dress them similarly and they are always the same sex; all these factors mean that people will treat them more similarly and therefore it may not be right to assume that both MZ and DZ twin pair share equally similar environments; MZ environments may be more similar than DZs o Even though genetically identical, MZ twins are not exactly the same; their fingerprints are different. One twin is typically larger and more robust than the other; first observable during pre-natal development. 11

o Genes turn on and off at different point in life and in interaction with differing environmental experiences (epigenetic modification); therefore MZ twins may both share a gene or cluster of genes which predispose them to schizophrenia however, only one twin may be exposed to the environmental circumstances which trigger that gene to start affecting the persons thinking and behaviour (cross reference to nature-nurture debate) o Rosenthal (1963) commented on a case where 4 identical quadruplet sisters were born in the 1930s. They all developed schizophrenia, but all at different stages in their lives and the form of schizophrenia differed from quad to quad. Therefore all of them inherited a predisposition to the disorder, but their differing experiences meant they each had a different experience and onset. o In studies of separated twins, whereby similarity in developmental outcomes must be due to genes and not to similar environments are problematic as often the environments that they are placed in are actually more similar than the researches have credited o Genetic inheritance in schizophrenia may be a more complex issue than twin studies would at first have us believe; Boklage (1977) noted that if MZ twins were both right handed, the concordance rate for schizophrenia was 92% but if one was right handed and the other left-handed, the concordance rate was only 25%!

Example of Twin Study of Schizophrenia

Name: Gottesman & Shields (1966) Aim: To investigate the relative i m p o r t a n c e o f g e n e t i c a n d environmental influences on schizophrenia by comparing MZ and DZ twins. Method: Records of twins from the Maudsley and Bethlehem Royal Joint Hospital 12

provided a sample of 392 patients with twins of the same sex, born between 1893 and 1945 who had survived to age 15 (from a total of about 45,000 psychiatric patients). Sample: 57 twin pairs In addition to the hospital diagnosis, the following information was obtained: case histories based on a self-report questionnaire and interview with the twins and their parents to provide a record of verbal behaviour a personality test a test used to measure disordered thinking conducted on twins and parents. Results: Analysis of the data looked for similarities between each client and their twin. Concordance was assessed in three different ways: Grade 1: both client and co-twin have been hospitalised and diagnoses with schizophrenia. Grade 2: both client and co-twin have had psychiatric hospitalisation but the co-twin has a different diagnosis. Grade 3: The co-twin has some psychiatric abnormality (e.g. out-patient care, Same sex Tota DZ l Female 11 16 27 Male 13 17 30 Total 24 33 57 GP care, neurotic or psychotic personality profile or being abnormal on interview) Normal: The co-twin did not suffer from any psychological abnormality MZ

Grade 1 2 3 Normal

MZ(% ) 42 12 25 21

DZ( %) 9 9 27 55

Conclusion: Genes appear to play an important role in schizophrenia because the concordance rate is higher in MZ twins than DZ twins. However environmental factors must also be important. 13

Gottesman (1991) went on to investigate the influence of genes on schizophrenia by combining the results of 40 investigations (doing a metaanalysis) of European studies spanning over 60 years. Concordance rate for schizophrenia (%) MZ 48 DZ 17

These studies show that while there seems to be a genetic component for schizophrenia, the environment cannot be ruled out as a contributory factor

Defining and Classifying Abnormality

It is extremely difficult to classify whether a person is normal or abnormal. Psychologists have decided upon a number of criteria which they use to determine abnormality.

1. Deviation from Social Norms

These are beliefs about what is normal behaviour, and anyone who does not show them is abnormal. There are two types of social norm: Descriptive norms these are the common behaviours that most people have. These norms tell us what is the correct conduct for a particular situation. In the main it is about conforming. Injunctive norms these are the shared expectations within a society, culture or group regarding what is acceptable/ unacceptable behaviours. A group/ society automatically works to maintain the norms by putting conformity pressure on deviants.

Different societies have different norms, they also depend on time, culture and environment. Under deviation from social norms there is a continuum of acceptability 14

Evaluation: Too much reliance on deviation from social norms to define someone as abnormal can lead to the abuse of peoples rights. The following are examples of mental disorders defined according to social conventions in the 19th century: Classificati on Drapetoman ia Nymphoma nia Moral insanity Symptoms Slaves experienced an irrational desire to run away Middle class women were sexually attracted to working class men Women who inherited money and spent in on themselves rather than male relatives

o Looking at the table above it is clear that one reason for defining behaviour as abnormal is to maintain control over a group. Thus defining atypically by social deviation has ethical issues as well as the practical issue of different cultures having different norms. o Homosexuality used to be illegal and also classed as a mental illness, this was removed and replaced in DSM III (1980) with the concept of ego dystonic homosexuality (someone who is distressed by the fact they are attracted to the same sex. DSM IV (1994) removed this and has included it in the category sexual disorders not otherwise specified. The American view contrasts with part of Melanesia (Pacific Islands) where adolescents are encouraged by their fathers to have relationships with older men. o Most importantly this definition is subjective because in practice the norms of society of based on what the elites (including the government) deem to be acceptable. In practice there are different types of deviancy: Individuals who do good with their deviancy e.g. suffragettes Individuals who do bad with their deviancy Harmless deviancy individuals who do not fit in with norms but are not harming others e.g. naturism

2. Statistically Unusual People

Because of the subjective nature of social norms it is felt more objective criteria are needed. The most literal way of defining something as atypical or abnormal is according to how often it occurs. According to this definition anything that occurs relatively rarely can be thought of as abnormal. This 15

approach is most useful when dealing with characteristics that can be reliably measured e.g. IQ. We know that most peoples scores will cluster around the mean, and as we move away from this point fewer and fewer people will attain that score. This is called the normal distribution. The normal distribution of IQ scores across the population The average IQ is set at 100. 65% of people will fall between 85 and 115; 95% will fall between 70 and 130% (between 2 and + 2 standard deviations). If someone has an IQ of less than 70, this is one of the criteria for diagnosing mental retardation. Evaluation: o Just because something is statistically infrequent does not make it abnormal. For example an IQ of 130+ is statistically infrequent but we would not call this person abnormal or give them a diagnosis just because they were very bright. o Secondly the decision to establish the normal range as 2 to +2 is a subjective one and many IQ tests have different standard deviations. o Hasset and White (1989) suggest that more than half of the US population have experienced some sort of abuse as a child. This may be statistically normal, but not desirable. o Many behaviours are not easily statistically measurable, for example neurotic behaviour or psychoses. o In some sub-cultures deviant behaviour may be the statistical norm. Belson (1975) surveyed 1445 London schoolboys and found that over half admitted to minor offences such as shoplifting. o There is also the problem that there are no universal statistical norms. Cultural differences are important.

Systems for the Abnormality

Classification

and

Diagnosis

of

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There are systems in place that are used to aid the diagnosis of mental disorders. The two most widely used systems of classification are the Diagnostic & Statistical Manual of Mental Disorder (DSM) produced by the American Psychiatric Association and the International Classification of the Causes of Disease & Death (ICD), produced by the World Health Organisation. THE DSM SYSTEM: Some categories of DSMIt was first published in 1952 and is VR-TR now in its fourth edition Substance related DSM-IV-TR (The 4th edition with text disorders revisions) was published in 2000) and Schizophrenia and other contains over 200 distinct mental psychotic disorders disorders Mood disorders Each version of the DSM has tightened Eating disorders up the criteria for identifying mental disorders, e.g. DSM-IV specifies how long symptoms are required to last before a diagnosis is made Some disorders have been removed e.g. homosexuality and new ones have been added e.g. bulimia in DSM-III and binge-eating disorder in DSM-IV.

DSM As a Multi-Axial Tool:

The five axes of DSM-IV-TR Axis I: Clinical Disorder; the disorder or disorders from which the patient is suffering. In addition any other circumstances that may require intervention are noted here, including stress related physical symptoms and a history of sexual abuse. Axis II: Personality Disorders and Retardation; because these chronic conditions often go alongside axis I disorders they are looked at separately. Axis III: General Medical Conditions: medical conditions that are of relevance to the condition or its treatment. Axis IV: Psychosocial and environmental problems; life problems that influence the psychological well-being of the individual, e.g. homelessness Axis V: Global Assessment of Functioning Since DSM-III-R in 1987, diagnosis takes place on five different bases or axes multiaxial diagnosis Clinicians are advised that it is helpful to use all five axes when making a diagnosis

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Evaluation of classification systems for reliability and validity

For a system like DSM to work effectively if must be reliable and valid. A system is reliable if those using it consistently make the same diagnosis A system is valid if the diagnoses identify something real in the sense of being a distinct condition that has different symptoms from other conditions and that is likely to progress in a certain way and respond to one treatment rather than another.

RELIABILITY It is possible to test whether a diagnostic tool is reliable by assessing the agreement with which different clinicians diagnose conditions in the same patients e.g. if they are diagnosed as depression by one clinician will a different clinician make the same diagnosis. This is known as inter-rater reliability. Studies of inter-rater reliability reveal that some diagnostic categories are much more reliable than others, and that procedures are more reliable for some types of patient than others. Nicholls et al (2000) shows that neither ICD-10 (the European system) nor DSMIV demonstrates good interrater reliability for the diagnosis of eating disorders in children. 81 patients aged 7-16 years with some eating problem were classified using ICD-10 and DSM-IV. Over 50% of children could not be diagnosed using DSM criteria. Reliability was 0.64 (64%) agreement between raters, but this figure is inflated because most people agreed they that they could not make a diagnosis. + reliability and validity of DSM has increased with each new version. + agreement on diagnosis using DSMIV is quite good for most conditions + the inter-rater and test-retest reliability of some disorders are very good. +Great efforts have been made to make DSM-IV-TR more valid for example by including culture bound disorders the reliability of some disorders e.g. PTSD is much lower. inter-rater reliability for diagnosing childhood conditions using DSM-IV is poor. It has been said that co-morbidity, the state of having more than one mental disorder is had to diagnose using DSM It could de said that splitting a mental disorder into symptoms is reductionist

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Goldstein (1988) found DSM III had high inter-rater reliability in the diagnosis of schizophrenia Brown et al (1996) found there was a 67% agreement rate for major depression Davison and Neale (1994) found a variable reliability rate for different disorders, 92% for psychosexual disorders and 54% for somatoform disorders Some people argue that the reliability rate for the diagnosis of metal disorders is similar to that of medical disorders

VALIDITY Validity tests the extent to which a test measures what it is supposed to measure. A study by Rosenhan (1973) demonstrated how diagnosis could have good reliability but poor validity, as doctors consistently but wrongly diagnosed pseudopatients whose symptoms. (See separate notes). Etiological validity refers to whether a group a patients diagnosed with the same disorder have the same factors causing it. If schizophrenia is caused by an excess of dopamine, then the people diagnosed should all have an excess of dopamine in their brain Concurrent validity looks at whether a person diagnosed with one disorder using DSM is given the same diagnosis by another person using the same system at the same time Predictive validity is the same as concurrent validity except the retest is carried out at some time in the future o Lahey et al (2006) found there was good predictive validity in relation to their social and academic functioning over a six-year period for children diagnosed with ADHD Validity can also be tested by diagnosing people with DSM and ICD, and then examine the extent to which the two diagnoses agree. This is known as criterion validity. Of course this can only tell us the validity of DSM if we are sure ICD is valid. Andrews et al (1999) assessed 1500 people using ICD-10 and DSM-IV. They found good agreement on diagnoses of depression, substance dependence and generalised anxiety. Moderate agreement was found for other anxiety disorders. There was only 35% for diagnoses of PTSD; ICD-10 identified twice as many cases as DSM-IV. Overall agreement was 68% Generally people were more likely to be diagnosed using ICD10; this was expected as the criteria for diagnosis are tighter with DSM19

IV. This result suggests that either the criteria in DSM-IV are too narrow or ICD-10 are too broad. Clusa et al (1990) compared DSM IV and the Portuguese classification for dependence disorders and found good agreement for measuring the severity of dependence on cocaine, cannabis and alcohol. o The problem with studies such as this is that the assume the classification system DSM is being compared to is valid itself

Key Studys 1. Study chosen by the specification

Name: Rosenhan , 1973, On being sane in insane places Aim: To test the hypothesis that psychiatrists cannot reliably tell the difference between people who are sane and those who are insane using the DSM classification system. Method: The study actually consisted of two parts. The main study is an example of a field experiment. The study also involved participant observation, since, once admitted, the pseudopatients kept written records of how the ward as a whole operated, as well as how they personally were treated. The participants were hospital staff in 12 different hospitals. The first part of the study involved eight sane people (pseudo-patients) attempting to gain admission to 12 different hospitals, in five different states in the USA. There were three women and five men. These pseudo-patients telephoned the hospital for an appointment, and arrived at the admissions office complaining that they had been hearing voices. They said the voice, which was unfamiliar and the same sex as themselves, was often unclear but it said 'empty', 'hollow', 'thud'. The pseudo patients gave a false name and job, but all other details they gave were true including general ups and downs of life, relationships, events of life history and so on. After they had been admitted to the psychiatric ward, the pseudo patients stopped simulating any symptoms of abnormality. The pseudo patients took part in ward activities, speaking to patients and staff as they might ordinarily. When asked how they were feeling by staff they said they were fine and no longer experienced symptoms. Each pseudo patient had been told they would have to get out by their own devices by convincing staff they were sane. 20

The pseudo patients spent time writing notes about their observations. Initially this was done secretly although as it became clear that no one was bothered the note taking was done more openly.

Results: None of the pseudo patients was detected and all but one were admitted with a diagnosis of schizophrenia and were eventually discharged with a diagnosis of 'schizophrenia in remission' The pseudo-patients remained in hospital for 7 to 52 days (average 19 days), Although they were not detected by the staff, many of the other patients suspected their sanity (35 out of the 118 patients voiced their suspicions). The pseudo patients normal behaviours were often seen as aspects of their supposed illness. For example, nursing records for three of the pseudo patients showed that their writing was seen as an aspect of their pathological behaviour. 'Patient engages in writing behaviour'. In four of the hospitals the pseudo patients carried out an observation of behaviour of staff towards patients that illustrate the experience of being hospitalised on a psychiatric ward. The results were compared with a university study. In the university study, nearly all the requests were acknowledged and responded to unlike the psychiatric hospital where the pseudo patients were treated as if they were invisible. See table 1.

Table 1: Responses of staff towards pseudo patients requests Response Moves on with averted Makes eye contact Pauses and chats Stops and talks Percentage making contact with patient Psychiatrists Nurses head 71 88 23 2 4 10 4 0.5

Conclusions: Rosenhan concluded that staff in psychiatric hospitals were unable to distinguish between the sane and insane Therefore DSM was not a valid measure of mental illness 21

Rosenhan concluded that psychiatric labels tend to stick in a way that medical labels do not and that everything a patient does is interpreted in accordance with the diagnostic label once it has been applied.

Secondary Study: In the secondary study, staff of a teaching and research hospital, which was aware of the first study, was falsely informed that during the next three months one or more pseudo patients would attempt to be admitted into their hospital. Staff members were asked to rate on a 10-point scale each new patient as to the likelihood of them being a pseudo patient The table shows that many patients of the hospitals regular intake were judged to be pseudo patients. For example, around ten per cent of their regular intake were judged by one psychiatrist and another staff member to be pseudo patients

Table 2: Judgement of all admissions patients as to the likelihood that they are pseudo patients Number of patients judged Number of patients confidently judged as pseudo patients by at least one staff member Number of patients suspected by one psychiatrist Number of patients suspected by one psychiatrist AND one other staff member Evaluation: Strengths: Ecologically valid, because done in real environment the study was carried out in actual psychiatric hospitals using real staff who were unaware they were taking part in a study Generalisation possible, as different hospitals were used located in 5 different States (12 hospitals). The hospitals were a mixture of older and newer ones and were funded in different ways The number of days stay in hospital was an objective measure. In addition to this the observations made by the pseudo-patients while they were in hospital gave validity to their findings concerning treatment of hospitalized patients by staff 193 41 23 19

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Weaknesses: Staff were misinformed about any symptoms pseudo-patients experienced, hence one could argue that the psychiatrists were playing safe. This reduces the validity of the results. Psychiatrists have to be careful about not admitting people as if they go on to pose a risk to others there can be severe repercussions The emotions of the pseudo-patients could have influenced their observation notes allowing subjectivity to creep in The pseudo-patients insisted on being admitted to hospital which is in itself a symptom of mental illness Study took place over 30 years ago, and DSM is changing constantly, hence results may not be generalised to psychiatric hospitals today

2. Studies chosen by Mrs Kavanagh

Name: Goldstein, 1988, Gender Differences in the course of Schizophrenia Aims: To see if there were gender differences with regard to the rehospitalisation of schizophrenic patients and the length of their hospital stays (to see if there was a difference in symptom severity between the sexes) To see if there is a significant difference in the age of onset of schizophrenia between the two sexes To look at social factors present before diagnosis to see if they had an impact on the course of the disorder with regard to gender Method: The original sample size was 199 men and women who had been diagnosed with schizophrenia between 1972 and 1973 at a private psychiatric teaching hospital in New York using DSM-II The patients had to meet the following criteria o A hospital stay of less than 6 months o Expected to return to their families after hospitalization o No brain abnormality o No drug or alcohol abuse o Aged between 18 and 45 All patients were re-diagnosed using DSM-III (by using the patients case histories) by Goldstein and experts who did not know Goldsteins hypotheses 169 out of the original 199 met the criteria for schizophrenia. Goldstein was interested in patients who were either first time admissions (52) or had only one previous admission (38), giving a total sample size of 90. 23

Males and females did not differ much in terms of age, education, religion or class, but there were more females than males in white collar jobs The study gathered information about symptoms, functioning before the diagnosis was made (premorbid functioning) by a questionnaire focused upon feelings of isolation, peer relationships and interests, employment and marital status was also considered and the course of the illness was measured by looking at the number of rehospitalisations and the length of hospital stays over a ten year period ending in 1983 Results: Men had more re-hospitalisations than women (a mean of 2.24 compared to 1.12 over a 10 year period) Men had longer hospital stays than women (a mean of 417.83 days compared to 206.81 over a 10 year period) Differences in premorbid functioning, such as isolation and peer relationships affected re-hospitalisations Social functioning such as occupation and marital status affected length of hospital stays Conclusions: Gender differences in the course of schizophrenia are present in the early stages of the disorder, with poorer premorbid functioning in men being responsible for a poorer outcome

Evaluation: Strengths: German study with larger sample (Angermeyer 1987) obtained the same results The reliability of the hypothesis of her study was checked by experts who were not aware of the aim The study supports DSM-III. It is used as evidence to support the reliability of DSM-III The men and women were well matched in terms of their age, education and religion The data is objective the dependent variable of length of hospital stays and number of readmissions came from an outside agency which accurately recorded these details Weaknesses: Findings may have been affected by the samples age limit of 45. Some studies have shown that for 9% of women experience more severe 24

o o o o

course of schizophrenia after the age of 45. The results may only be valid if considering women under 45. There are several limitations that might prevent generalisation of the results: Limited area choice Limited sample size (around New York) Similar background of participants Study was carried out in 70s/80s using DSM-III.

Name: Mumford and Whitehouse, 1988, Increased prevalence of Bulimia Nervosa among Asian schoolgirls Aim: To test the fact that fewer cases of anorexia and bulimia were reported in non-white, they investigated whether British Asian schoolgirls do have fewer occurrences of eating disorders than their white counterparts Method: The sample included girls from 4 different schools in Bradford, aged between 14 and 16 The total sample size was 559, 204 Asians and 355 white schoolgirls The girls were given an eating attitudes test and a body shape questionnaire Those who appeared abnormal from the tests (scoring over 20 on the eating attitudes test or 140 on the body shape questionnaire) were interviewed and examined to see if they had an eating disorder. This included 22 Asian and 32 white girls. An eating disorder was only diagnosed after discussions between researchers

Results: There was a significant difference in the mean scores from the eating attitudes test (10.6 Asian girls, 7.7 white girls) There was no significant difference in the responses from the body shape questionnaire Of the girls interviewed, 7 Asians and 2 white girls were diagnosed with bulimia (a significant difference), 1 Asian girl and no white girls were diagnosed with anorexia

25

Conclusions: Bulimia nervosa is more prevalent among Asian than white school girls (not what they expected to find) Asian school girls more concerned about the amount of food they ate Evaluation Strengths: A large sample size means the results can be generalised to other schoolgirls The reliability of the diagnosis of an eating disorder was high as an agreement had to be made between researchers before a diagnosis could be made Weaknesses A very limited age range was used the same findings may not have been seen with an older or younger sample The original questionnaires were given by the girls teachers in the classroom. This may have affected results perhaps because eating disorders are seen as more of a white issue, white girls with eating problems may have been more careful about how they answered There was no independent verification of the diagnosis of an eating disorder by a person who did not know what the study was about, although the fact that they expected to find the opposite the likelihood of experimenter effects is reduced Nicholls et al (2000) found that DSM was not a reliable measure of eating disorders in children

Culture and Abnormality

Many of the studies looking at DSM-IV-TR suggest it is largely reliable and valid in the diagnosis of mental health. One area where the system is still criticised is its usefulness across cultures. As mental disorders are meant to be scientific culture should not affect diagnosis some disorders e.g. depression present as the same illness all over the world. Lee (2006) found that DSM was valid for identifying ADHD in Korea Culture can affect diagnosis hearing voices in the West is seen as a symptom of schizophrenia whereas in some cultures (e.g. Haiti) hearing voices is seen as possession by a spirit, something which is desirable. A clinician from one culture must be aware that a patient from another culture is guided by their own frame of reference 26

Burnham et al found that Mexican-born patients diagnosed with schizophrenia living in America were more likely to report auditory hallucinations than non-Mexican born Americans Culture can affect the likelihood a diagnosis is given. Berry et al reported that in Japan a diagnosis of schizophrenia is less likely to be given because the name translates as disorganised mind which is seen as a shameful thing in Asian cultures Culture can affect the amount of information a patient will disclose Sue and Sue (1992) found many Asian Americans do not like to talk about their emotional problems Cinnerella and Lowenthal (1999) found that Black Christians and Muslim Pakistanis felt there was a social stigma attached to depression and believed prayer could help alleviate symptoms Banyard (1996) found that black people make up 5% of the British population yet 25% of the population on the ward of a psychiatric hospital Littlewood and Lipsedge (1989) found that black patients were more likely to be seen by a junior doctor There are some culture bound syndromes Koro is the belief that the penis or breasts are retracting into the body

Evaluation of cultural issues, diagnosis and DSM Strengths DSM-IV-TR acknowledges culture-bound syndrome There has been an attempt to tighten up diagnosis by placing less emphasis on bizarre symptoms such as hallucinations in schizophrenia which can be affected by culture Weaknesses In practice the focus is on positive symptoms when diagnosing schizophrenia

Symptoms and Features of Schizophrenia

Symptoms Positive symptoms (Excesses of behaviour present in someone with schizophrenia) Hallucinations (hears or sees things that do not exist e.g. voices commenting on their behaviour) Delusions (e.g. delusions of control where the patient believes someone else is controlling their actions) Thought insertions (where the patient believes that the thoughts in their head Features Usually diagnosed in men in mid-20s and women in mid-30s Some people recover completely, others need drugs for the rest of their lives (15%). 15% do not respond to treatment 1% of the population 27

have been put there by someone else) Thought broadcasting (where the patient believes their thoughts are being broadcast to others) Negative symptoms (behaviour which is missing in someone diagnosed with schizophrenia often seen before positive symptoms) Poverty of speech (the patient uses as few words as possible) Social withdrawal (lack of interaction with friends and family) The flattening effect (lack of expression in the voice and emotion in the face) Lack of care for appearance

are affected schizophrenia, effects men women equally

by it and

There are five different types of schizophrenia: catatonic, paranoid, disorganised, residual and undifferentiated. Different symptoms present in the different types of schizophrenia

Biological Explanation of Schizophrenia

Neurons Biological explanation of schizophrenia Neuronal cell bodies Axons Synapses occur at the junctions

Neurons transmit signals electrically along their axons The synapses (junctions between neurons) transmit signals chemically For more in depth information see o http://www.bristol.ac.uk/synaptic/basics/basics-3.html 28

*Also

look at the PowerPoint on Biological treatments Schizophrenia for a detailed explanation of how neurons work Biochemical factors

for

The dopamine hypothesis argues that high levels of dopamine causes schizophrenia or that the presence of an excess number of receptors at the synapse contributes to schizophrenia Postmortems of schizophrenics show unusually high levels of dopamine, especially in the limbic system (Iverso, 1979) It is possible that an increase in dopamine in one site in the brain contributes to positive symptoms and in another site negative symptoms Sensitivity to dopamine could be due to genetic inheritance or brain lesioning- people with schizophrenia also have enlarged ventricles and a higher incidence of head injury during childhood

Biochemical explanation evidence and evaluation Scanning techniques show that those with schizophrenia who are given amphetamines (which cause excess dopamine) show a greater release of dopamine than non-schizophrenics People given Levodopa (which adds to dopamine production) for Parkinsons show symptoms similar to schizophrenia Lindstroem et al (1999) used PET scan to investigate the uptake of IDOPA (used to make dopamine) in 10 schizophrenics who had not received treatment and 10 normal people. They found that IDOPA was used more quickly in the schizophrenics, suggesting they make more dopamine Homovanillic acid is a waste product of dopamine, Donnelly et al (1996) found that schizophrenics have more homovanillic acid than nonschizophrenics suggesting they make more dopamine Depatie and Lal (2001) found that apomorphine, a drug that increases the effect of dopamine, did not create schizophrenic symptoms in their patients Cause and effect does high levels of dopamine cause schizophrenia or schizophrenia cause high levels of dopamine? Drugs which block the dopamine receptors work immediately upon blocking the receptors but the calming effect on schizophrenics is not noticed for a few days Antipsychotic drugs used to treat schizophrenia seem to be effective in controlling positive symptoms, but much less effective for negative symptoms these may stem from reduced levels of dopamine in certain parts of the brain 29

Social Explanation of Schizophrenia

Social Class hypothesis the environmental

Another neurotransmittor, glutamate is thought to cause psychotic symptoms if there is excess present this was found from people taking the drug PCP or Angel dust it could be that the cause involves several neurotransmitters rather than just dopamine

breeder

The

The

There is evidence that people from the lowest social classes and immigrants have a higher incidence of schizophrenia than others in the UK There is an incidence rate of 4 in 1000 for the lowest social class in whites and in black immigrant groups Studies show that schizophrenia is found more among the unemployed and those living in deprived city areas The lower classes also experience a different course for the illness and receive different medical care idea of social drift: It has been suggested that those with schizophrenia become lower class because of the difficulties of having schizophrenia One study found that while men with schizophrenia tended to be among the lower social classes, their fathers generally did not Those who developed schizophrenia did not do well in school and difficulties keeping a job The idea of social drift is widely accepted, however, recent studies have suggested there may also be an environmental cause for schizophrenia in that the environment increases the chance of schizophrenia developing idea of social adversity: Eaton et al 2000 argue that there may be something in city life which leads to schizophrenia There are lower social classes in rural areas so the social drift idea cannot fully explain the city/ country split seen with schizophrenia Harrison et al argue that there are clusters of schizophrenia in declining inner city areas, so perhaps being brought up in these areas leads to schizophrenia In the UK, the 2001 census showed that there is a significantly higher incidence of schizophrenia in the black immigrant population, these groups were already lower class and therefore this figure cannot be explained by social drift It is not thought that there is a genetic reason for higher levels of schizophrenia in black immigrants this is because incidence rates for 30

schizophrenia in the Caribbean are similar to the UK general rate. Also the rate for second generation immigrants is higher than the first Features in the environment that might affect the development of schizophrenia seem to be poverty, social isolation, poor housing, high crime and drug use

Evaluation: Not everyone with certain environmental circumstances develops schizophrenia although there may be environmental triggers. Other explanations are probable such as genetics and there is a lot of evidence for the dopamine hypothesis its is better to see the two explanations as complementing each other The idea explains why there are more people with schizophrenia in the lower social classes living in inner city areas Those from lower social groups might be more likely to be diagnosed with schizophrenia, suggesting a diagnosis rather than an environmental problem It might be that poverty, unemployment and lack of social support are stressors and it is the stress which causes the schizophrenia and not the environment itself It is hard to separate environmental factors to see if they cause schizophrenia it could be the result as the social drift hypothesis suggests

Biological Treatment for Schizophrenia

Antipsychotic medication Antipsychotic drugs are also known as Neuroleptics (e.g. chlorpromazine) were first developed in the 1950s they helped to sedate the person and reduce the frequency and intensity of hallucinations, delusions and other symptoms It follows that if an excess of neurotransmitter (dopamine) causes the symptoms of schizophrenia, prescribing a drug which lessens the levels of neurotransmitter will reduce the schizophrenic symptoms Other antipsychotic drugs have been developed which bind to the dopamine receptors in the brain, stopping the dopamine being picked up so minimizing the effects Clozapine, developed in the 1970s also appears to reduce negative effects of schizophrenia Different clinicians prefer different drugs, patients may be prescribed anti-depressants alongside them

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Anti-psychotic drugs

Side effects * NB just listing side effects will only get you 1 evaluation mark Tightening of the muscles, especially neck and jaw Decrease in emotionally spontaneity and motivation Fidgeting Sedation Dry mouth Constipation Weight gain Sleepiness Low blood pressure Low sex drive

Evaluation- Strengths Older (typical) drugs (e.g. chlorpromazine) o Short term beneficial effect in 75% of patients (Davis et al, 1989) o Long term beneficial effect in 55-60% (Davis et al, 1993) o Most effective against positive symptoms Newer (atypical) drugs (e.g. clozapine) o As effective as typical drugs on positive symptoms; better for negative symptoms (Bilder et al, 2002) o More effective with treatment-resistant patients (DeNayer et al, 2003) Drugs allow the patient to recover in society, avoid being institutionalised and gain access to other treatments Pickar et al (1992) compared the effectiveness of clozapine with other antipsychotics and a placebo. He found clozapine was the most effective and the placebo the least 32

Drug therapy rests on strong biological evidence so is underpinned by theory

Evaluation Weaknesses Older drugs have quite a lot of side effects Schizophrenic patients often do not continue to take the drugs either because of the side effects or because their syndrome means they forget to take them Rosa et al found that only 50% comply with their drug therapy Ethically, drugs are seen as a chemical strait-jacket and some people think such control by society is unacceptable Drugs do not take into account a patients environmental or social problems which may contribute to re-hospitalisation and relapse. Social treatments such as assertive community therapy address this

Social Treatment for Schizophrenia

Assertive Community Therapy ACT is used to help patients who have frequent relapses and bouts of hospitalisations It is used by community mental health services with clients who have difficulty meeting personal goals, such as making friends and living independently It was developed in Madison Wisconsin by Leonard Stein and Mary Ann Test ACT links with deinstitutionalisation and the creation of care in the community in the 1970s where large amounts of people were discharged from hospitals

Characteristics of ACT A focus on those most in need Help with independence, rehabilitation and recovery and avoidance of homelessness and re-hospitatlisation Treatment of the patient in real life settings A whole team is focussed on the individual including psychiatrists, nurses, social workers and people with whom the treatment has worked Offers a holistic treatment that looks at an individuals needs in a multidisciplinary approach ACT is used in many countries, mainly USA, Australia, the UK and Canada 33

It is used mainly in urban areas with other interventions such as social skills training and family therapy

Evaluation - strengths Dixon (2002) since 1980s ACT seen as the model for mental health practice Bond et al (2001) looked at 25 studies into the effectiveness of ACT and found that ACT was more effective than traditional community care ACT seems to work with all age groups, genders and across cultures Surveys tend to suggest clients appreciate ACT (Mueser et al 1998) Evaluation weaknesses Gomery (2001) suggests ACT is coercive in that the client does not have the choice of whether or not to undergo such treatment about 11% feel forced into it. Also they surrender all responsibility for making decisions and taking care of themselves Although ACT helps reduce relapses, it does not have an effect on actual functioning such as reducing positive and negative symptoms ACT works best in highly populated areas where there are the services in place to cope

Symptoms and Features of Anorexia

Symptoms Refusal to eat and maintain a minimum average expected body weight Fear of gaining weight or becoming fat Distorted perception of body weight and shape Amenorrhea (absence of at least 3 consecutive periods) Weight less than 85% of expected body weight Features 90% of cases are females between 13 and 18 Rarely seen before puberty Occurs in between 0.5-1% of females in adolescence and early adulthood 20% have one episode and complete recovery 60% gain weight and then relapse 20% continue to be affected, often requiring hospitalisation Of those hospitalised 10% die of starvation or suicide

Biological Explanation of Anorexia

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Genetic Explanation Family History Studies We inherit our genes from our parents, and members of the same family have similar genetic profiles. For this reason, disorders with a genetic component tend to run in families. Following from this, if eating disorders are influenced by genetics, we would expect to find that people closely related to anorexics would have a higher chance of getting it themselves. Strober & Humphrey (1987) found that relatives of eating disorder patients were between four and five times more likely than members of the general population to develop an eating disorder themselves. Twin Studies There are two sorts of twin. A monozygotic (MZ or identical) twin pair have exactly the same genes, whereas a dizygotic (DZ or non-identical) twin pair share only about 50% of their genetic material. If a disorder is completely genetic, then if one half of an MZ twin pair gets it, then the other is guaranteed to. In other words, the concordance or similarity between the twins for getting the disorder is 100%. On the other hand, if one half of a DZ twin pair gets a genetic disorder, then the other only has a 50% chance of getting it (the concordance is 50%). However, both MZ and DZ twins have highly similar environments both halves of the twin pair receive the same environmental influences and learning experiences. This means that if we compare concordance rates for anorexia in MZ and DZ twins: If we find that MZ concordance is 100% and DZ concordance about 50% then the disorder is likely to be wholly genetic. If MZ concordance is significantly less than 100%, then although genes might play a role, the environment must play a part too. If we find that MZ concordance is markedly higher than DZ concordance, then it is likely that the disorder has a genetic influence. If we find that MZ and DZ concordance are similar, then it is unlikely that genes play much of a role, and the environment is likely. Studies MZ concordance DZ concordance Holland et al (1984) Anorexia MZ twins = 56% DZ twins =5% Kortegaard et al (2001) Anorexia MZ Twins = 25% DZ twins =13% Other studies which show a genetic basis for Anorexia: Collier et al (1999) examined the gene that controls serotonin brain systems. They found that women with eating disorders were twice as likely as a control group to have an abnormal version of the gene. Hook et al (2000) examined medical records of 144,000 people on the island of Curacao, where it is considered attractive to be fat. They 35

found that the prevalence of eating disorders was the same as in Europe and the US. Evaluation: Strengths The person suffering from anorexia is not seen as being responsible for their behaviour and is seen as a victim of a disorder of which they have little or no control. This removes issues of blame and labelling the person Research does prove that anorexia does have a least a degree of biological basis. Genetic abnormalities have been found using scientific methods which have been tested for reliability Weaknesses It is argued that twin studies assume twins have an identical environment and this may not be the case MZ twins are not totally identical (finger prints, size, handedness) The concordance rates for MZ twins, while higher than DZ are not 100%. This means that the environment must also play a role The genetic explanation is not helpful in seeking a treatment for someone suffering from anorexia It is argued that genes and environment cause anorexia the stressdiathesis model assumes a person inherits a predisposition to developing a disorder and this may lay dormant until an environmental event triggers this this could be pressure from the media or peers to be thin, rape etc...

Cognitive Explanation of Anorexia

Psychological disorders are the result of faulty or maladaptive thinking processes Anorexia may involve misperception of the body They will also involve faulty reasoning about the self, the body and food/eating

Cognitive Distortions in AN Faulty thinking in AN typically includes: o Misperceiving the body as overweight when it is actually underweight o Basing feelings of self worth unduly on physical appearance 36

o Basing sense of self on control over eating/ AN symptoms o Irrational/mistaken beliefs about food/fat/dieting behaviours Cognitive Errors in AN All or nothing thinking o I ate one biscuitthats blown everything! Overgeneralising o If I fail at controlling my eating I fail in life. Magnifying/minimising o My weight loss isnt serious. Magical thinking o If I reach size 6 then my life will be perfect. Evidence and evaluation

Fallon & Rozin (1985) o Male & female students rated themselves on current and ideal body shape o Compared to males, females rated themselves as heavier than what was attractive, and much heavier than their ideal McKenzie et al (1993) o Female ED patients overestimated their own body size in relation to other women o They judged their ideal weight to be lower than comparable nonED patients o Following a sugary snack, they judged their body size to have increased. Controls did not.

Evaluation (Strengths and Weaknesses) Women are generally more dissatisfied than men with their bodies AN patients misperceive their own bodies and have more unrealistic body ideals In AN patients, minor events related to eating activate fear of weight gain o Plenty of evidence to show that thinking processes are biased/distorted in AN sufferers 37

o Some evidence (but not all) shows that altering thought processes is an effective treatment o Less evidence to show that cognitive biases are the cause of AN Not much evidence for the view that faulty thinking precedes other psychological symptoms (cause or effect?) People who are clinically normal also think irrationally so whats the difference? All the cognitive model does is state the obvious e.g. depressed people think gloomy thoughts. No! Really? Ethical issues: o By locating psychological problems in faulty thinking processes, the cognitive model sometimes blames the victim o E.g. a person might be anorexic because they have suffered an extreme trauma but the cognitive model implies that the problem is their perceptions AN and BN are certainly associated with biases and distortions in thinking However, most women are dissatisfied with their bodies, not all of them develop EDs A good account of what helps to maintain EDS, but not of what causes them in the first place.

Psychodynamic Treatment for Anorexia

Free Association Free Association is a technique used as part of Psychoanalysis (a technique developed by Freud) The psychodynamic approach maintains that mental illness is caused by conflict occurring in the unconscious mind The aim of free association is for the patient to reveal these unconscious conflicts in the comfort and safety of the therapy room. The therapists job is to uncover these conflicts, explain them to the patient and help the patient come to terms with the conflict During free association the patient lies on a couch and the therapist sits in a place out of view of the patient The patient is asked to talk freely about their childhood, their earliest memories and the relationships they have/ had with loved ones If the patient stopped talking the therapist would ask the patient to reflect on things they had said (How did the divorce make you feel), or things they did not talk about (tell me about your father)

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Freud believed that a patients answer to direct questions were often predictable so he would give the patient give words (fear, love) and ask the patient to say whatever comes into their head. He believed this would catch the patient offguard and would glean a more honest answer

Evaluation: Strengths It is in depth and takes into account early experiences as well as current symptoms (looks at the whole person rather than the illness they are suffering from) It is a unique method as it is needed to gain access to the unconscious mind and this allows subsequent interpretation by the therapist. This allows the patient to uncover things which were bothering them yet they were consciously unaware of Weaknesses Free association may not be applicable for everyone or for all mental disorders. Encouraging the patient to talk at length about their problems may reinforce the disorder. For example someone with anorexia talking about why they do not eat may reinforce their avoidance of food The therapists interpretation of what the client says is subjective and therefore clearly unscientific. Another therapist may come up with a different interpretation making the findings of free association unreliable Free association and psychoanalysis is not a cure for a disorder. By uncovering the unconscious conflicts it just allows the patient to be more aware of the causes of their symptoms, allowing the patient more control and a way in which to deal with the conflicts, lessening their symptoms Free association takes a long time before the therapist can interpret the unconscious conflicts. Someone with anorexia who is so thin that they are in immediate danger of destroying their health would be better suited to another programme

Cognitive Treatment for Anorexia

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Rational Emotive Behavioural Therapy: Ellis (1991) developed the ABC model to explain how irrational thinking can lead to maladaptive behaviour Activating Event Consequences (of B) Occurrence of an unpleasant event: One of your friends asks if you have put on weight Beliefs (About A)

Cognitive reaction to the unpleasant event: You must stop eating and lose weight

State of anxiety: You feel isolated and worthless

THE

THE

From this, Ellis developed Rational Emotive Behaviour Therapy (REBT) to help the client identify their faulty thinking and replace this with irrational thinking There is a cognitive and a behavioural part of the therapy COGNITIVE PART: The therapist will get the client to reflect upon the activating event and will ask questions in such a way that the client will recognise their thoughts are irrational (they will not simply tell the client they are being irrational)!e.g. o Are there any reasons why your friend thought you had put on weight? o Why is it important what your friend thinks about you BEHAVIOURAL PART: The therapist and client decide how to reality test the hypotheses through experimentation either as role-plays within the sessions or as homework tasks By testing out the hypotheses the aim is to dispute (D) the irrational thinking (B) For example the irrational belief may be that eating a bar of chocolate will mean that the anorexia sufferer will put on weight the client could then eat the bar of chocolate and the weigh themselves to see that the weight is not any different and thus challenge the irrational thought Clients are encourage to come up with their own goals so that they feel in control and part of the treatment process

Evaluation: Strengths 40

 The client is in control of their treatment and empowering them in this way raises their self-esteem Brandsma et al (1978) reported that REBT is useful for changing behaviour in clients who are self-demanding and who feel guilty for not living up to their own high standards (something common is anorexia sufferers) REBT is more effective than psychoanalysis as it helps people get better rather than just feel better Weaknesses The argumentative nature of the therapy has been questioned, especially by those who emphasise the use of empathy in therapy It is difficult to identify faulty thinking as what is foolish to the therapist may be entirely logical to the therapist * For your key issue you need to be able to outline and explain a disorder (use the information for anorexia or schizophrenia in this booklet) and also design a leaflet explaining the disorder. Be prepared in the exam to justify the design of your leaflet

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Therapies Notebook

The evaluation points are in bullet point format for us to discuss and revision, you are only likely to need four or five evaluation points per therapy but some point must be explained in more depth than you have here. You must never use bullet points for your evaluation in the exam. Also not all the suggested evaluation points may be relevant to the question you are asked. Practice putting together a number of linked points to give an in depth answer.

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Biological Treatments/therapies Drugs/ Chemotherapy Drug therapy was begun during the 1950s and dominates treatments given by the medical profession. It is based on the belief that problems in neurotransmitter functioning are the root of mental illness. Seretonin is implicated in mood disorders and eating disorders, noradrenaline and GABA in anxiety disorders and dopamine in schizophrenia. Currently there are typical and atypical types of drugs. Typical are the well established types and atypical are newer less tried and tested options (new drugs mainly try to reduce the side effects). There are three major groups of psychoactive drugs used in treatment of mental illness: 1. The anti-depressants 2. The major tranquillizers (anti-schizophrenic drugs) 3. The minor tranquillizers (anti-anxiety drugs) The anti-depressants can help restore emotional balance; the drugs are commonly used for psychotic depression, manic depressive disorder and obsessive disorders. Newer antidepressants include Selection Serotonin Reuptake Inhibitors (including Prozac) they work by stopped the reuptake of serotonin back into the presynaptic neuron, making more serotonin available. Major tranquillizers, eg chlorpromazine becomes concentrated in the brain stem and is secreted only very slowly, so that the effect on the brain is prolonged. At first there is a sedation effect, which wears off after a few days; there will be a reduced responsiveness to external stimulation and gross motor activity but without reducing motor power or co-ordination. Minor tranquillizers reduce anxiety and cause drowsiness by depressing neural activity, especially in the brain stem and the limbic system. They are mainly used for neurotic disorder where

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there is acute anxiety. Valium. Evaluation of drugs Strengths

Common anti-anxiety drugs include

It has enabled the care in the community programme to go ahead drugs can allow someone who may have been a danger to themselves or others integrate back into the community For some people they are very effective and can help them lead a normal life Drugs are cheaper than long term therapies and the effects are usually quicker It takes the problem of the mental illness away from the patient it is therefore more ethical as it does not blame the patient for their illness mental illnesses are seen as the same as other illnesses Weaknesses Risk of addiction tricyclical drugs are not meant to be physiologically addictive because they start to work a couple of weeks later and so people dont attribute the good feeling to the drug. But anything that you think has made you better is going to be prone to the person having a psychological dependency. Benzodiazepine withdrawal syndrome is often seen with people who have taken drugs such as Valium over a long period of time. A doctor might insist that you come off them which may cause distress or relapse With sleeping tablets or tranquillizers you become immune so need a higher dosage, because they are physiologically addictive Diazepam (valium) can tamper with the heart rate and cause death. Lithium can cause kidney failure, coma and death. COUNTER CRITICISM we cannot be sure that anything doesnt
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have bad effects over a long period of time and nut allergies cause far more fatalities. They dont cure they only treat the symptoms Is it ethical to treat something we dont understand? E.g. we know for example that some drugs are effective but not the full reasons why they work in the way they do on the brain Drugs can have minor side effects which can impair quality of life such as twitching Promotes the idea of an easy answer, which stops people sorting out their lives for themselves. This has become part of our culture, over prescription is a major problem. The patient has no role in their own cure Laing and other humanists believe that we contaminate the patients, which stops the progression of the illness, so we cant see how it would have ended without this intervention, which means we have been unable to learn more that could have been of more long term benefit The drugs are often seen as Chemical Straight Jackets Prozac can actually increase the risk of suicide for depressive patients when the drug is first taken Studies According to Stevenson and Backer (1996) MAOIs are linked to cardiac problems, dry mouth, blurred vision and water retention Meltzer et al (2004) Carried out a study on 481 schizophrenic patients. They were given either a placebo, one of 4 investigational drugs, or Haloperidol (an established drug).The results indicated that haloperidol and 2 of the other drugs showed improvement Rose et al 1984 prolonged use of drugs can cause a whole range of disorders e.g. a major tranquilliser can cause tardive dyskinesia (uncontrollable mouth movements) which doesnt stop when they come of the drugs Meta-analysis studies indicate that drug therapy works better with minor illnesses Lithium used on depression and show 70/80% improvements within 2 weeks General Point Over prescription is a huge problem
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Behavioural Treatment/ Therapy

Systematic Desensitisation Systematic Desensitisation is based upon classical conditioning and is used to treat mainly phobias. The idea is that the object is associated with fear and SD aims to replace fear with relaxation. This is based on the notion of reciprocal inhibition the idea that you cannot feel two incompatible emotions at once (fear and relaxation). Treatment takes place over a number of sessions and can be either in vivo (exposure to the real object) or in vitro (imagining the object) There are four stages 1. Functional Analysis questioning to uncover the nature of the anxiety and any triggers

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2. Creation of an anxiety hierarchy from the least to the most fearful thing (see below) 3. Relaxation training music, selfhypnosis (depends on the client) 4. Gradual exposure the client and therapist work through the fear hierarchy

Hold the Spider

Be in the same room as the spider

Look at a picture of a spider

A shortened version of a typical fear hierarchy

The systematic part of the procedure involves the gradual, stepby-step contact with the phobic object (usually by imagining it) based in a hierarchy running from least to the most feared possible contact, drawn up together by the therapist and the patient. Starting with the least feared contact, the patient while relaxing imagines it until this can be done without feeling any anxiety al all; then and only then will the next least feared contact

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be dealt with in the same way until the most frightening contact can be imagined with no anxiety. Many believe that SD is beyond doubt effective although it is most effective for the treatment of minor phobias (e.g. animal phobias) as opposed to say agoraphobia and for patients who are able to learn relaxation skills and have sufficiently vivid imaginations to be able to conjure up the sources of their fear. Another limitation of SD is that some patients may have difficulty transferring from imaginary stimulus to real-life situations. Evaluation of Systematic Desensitisation Strengths Effective in treating simple phobias McGrath et al (1990) showed a 75% of patients showed significant improvements In S/D the patient has control of the hierarchy and the progression that the therapy has. It is a gradual step-by-step process with much communication between the therapist and the patient. This is more ethical than flooding Rachman and Wilson (1980) and Mcglynn et al (1981) believe that SD is beyond doubt effective although it is most effective for the treatment of minor phobias (e.g. animal phobias) as opposed to say agoraphobia and for patients who are able to learn relaxation skills and have sufficiently vivid imaginations to be able to conjure up the sources of their fear. Another limitation of SD is that some patients may have difficulty transferring from imaginary stimulus to real-life situations. Wolpe (1958) defined behaviour therapy as a whole, as the use of experimentally established principles of learning for the purpose of changing un-adaptive behaviour. This means there is a scientific basis behind the therapy

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Weaknesses It only treats the symptoms and not the cause so, after a while the condition tends to come back.(spontaneous recovery) There is debate as to whether or not the use of relaxation or a hierarchy is necessary. Combined studies suggest that what is probably the essential ingredient is the exposure to the feared object. In SD patients must have sufficient imagination to picture their fears. Some patients have trouble relating imaginary stimulus to real life situations. With S/D it takes a long period of time for it to work does not have an immediate effect due to the use of gradual progression. Flooding has an immediate effect and is more effective than SD according to Matthews (1981) and Emmelkamp (1975).

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Psychodynamic Treatment/ Therapy

Dream analysis as a therapy The Psychodynamic Approach sees mental disorders as coming from the unconscious mind, due to repressed thoughts or emotional problems in childhood. In order to treat the disorder the therapist must access the unconscious mind. The basis of Freuds theory of dreams is that dreams are a way for anxiety and other emotions to manifest themselves. When we sleep material that would usually remain in the unconscious enters the consciousness in the form of a dream Dreamwork This is when the ego turns the Latent Content (underlying wish) into the Manifest Content (the reported dream). If we dreamt about our problems we would not a good nights sleep. FREUD SAW DREAMS AS THE ROYAL ROAD TO THE UNCONSCIOUS i.e. the best way to get to the unconscious Freud thinks the unconscious has ways of hiding the truth even in dreams & thats why dreams are mainly symbolic. And so through analyzing persons dreams they can be helped in a therapeutic way Latent Content Underlying wish, desire or emotion, e.g. fear of being left alone so dream of a boat sailing away from you Manifest Content What we actually remember from the dream - the story, i.e. remembering that you dreamt of a boat sailing away Displacement When we turn the object of anger into something else. e.g. using a cow as a symbol for your annoying mother
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 Condensation When you combine all the things that youre angry at into one. Secondary Elaboration This is stringing together the symbols to make a story. This logical version of the symbols may further confuse analysis Doing dream analysis Only a highly qualified/experienced psychoanalysts are supposed practise psycho-therapy and therefore use dream interpretation as part of their diagnostic armour and therapeutic practice. One way they can analyse the dreams is by using free association where the patient talks about the thoughts and emotions that the dream created. The analyst would normally see the client 3 times a week and a session lasts 50 minutes and would cost at least 50 making this one of the most expensive therapies. It is reasoned that as the analyst knows so much about the client they will be able to properly interpret the symbols of the dream in the context of the clients history and defence strategies. Evaluation Strengths The case study of Y backs up dream analysis theory that anxiety can manifest itself in dreams, because she was pregnant which is probably an anxious time and she reported having more vivid dreams. Freud does back up his theory with a number of case studies such as Dora and little Hans. Such case studies are rich in detail and are valid in the sense that they were collected in real life interactions that would have been taking place whether or not they were used as research evidence. Also in everyday life many people report having dreams that are clearly linked to anxieties e.g. missing an exam or having no paper or pen in an exam the night before. And so it is reasonable to think that dream analysis may well uncover deep rooted problems.
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 Heaton et al (1988) found that 88% of clients undergoing psychoanalysis preferred it when their dreams were analysed and felt they got insight when they analysed their dreams Many people feel that if we do not dream in symbolic forms as suggested by Freud then it is difficult to explain why dreams should often be so bizarre Weaknesses There are Psychologists that disagree with Freud with regard to the purpose of dreams e.g. Crick and Mitchison claim that we dream to forget and get rid of all the unwanted memories that we have collected as the day has gone on. If this is the case then analyzing the meanings seems a fairly pointless exercise Other than case studies there is very little evidence that dreams are a way of getting rid of unwanted desires fears and anxieties, and we can not really generalize from this type of evidence Epostio et al (1999) analysed the dream content of 18 Vietnam Veterans who had PTSD. They found that half of the veterans dreamt about conflict and battle, disputing the theory we symbolize material which would distress us in our dreams According to Freud, dreams can be interpreted by trained Psychoanalysts but many psychologists feel that even if they are a way of accessing the unconscious, it is far too subjective for one person to try to interpret anothers dream; the dream may not be retold exactly as it was experienced at the time and the analyst may misinterpret the meaning as he /she could never know everything about a persons life. Storr 87 says that analysts use their own subjective personal opinion in analysis. Others may go further and suggest that a psychoanalytic interpretation is totally contaminated by the analysts indoctrination with Freudian theory causing a bias towards sexual motivation at every opportunity

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Social approach Treatment/ Therapy

Care in the community Meaning/History/Background Based on the social approach and humanist theory, care in the community came into operation around 1985. It replaced taking care of mentally ill people in asylums and hospitals by making provisions within the community, such provisions include home care, day centers, crisis intervention centers, and counseling drop in centers, help lines, halfway houses and respite help. It is an extremely controversial area because while most psychologists would agree that care in the community is preferable to the isolation of a large asylum, many saw the closure of such institutions as an attempt to save money in the short term.

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 Homecare Help in the home, feeding, dressing, grooming, reminders. Few qualifications if any needed for those giving the care. Day Centers This is a lot cheaper then residential care, they may look after people for up to 7 days a week but are not residential. Crisis intervention centres based on the idea that it is best to keep people out of hospital there are 24 hour facilities, mainly phone lines which can connect you to various other services i.e. GP or Psychiatrist the Samaritans. help lines after controversial TV programs. Counseling drop in sessions Drop in places Help lines Half way houses a type of warden assisted or shared home where a person can get used to independent living with support. Residential homes help and assist the people. Live in.

Evaluation Strengths Encourages integration which will help people to adjust to the norms of the wider community Reduces isolation and the stigma that people felt It enables society to reduce their own fear and learn more about the nature and variety of mental health problems It is far more ethical because nobody is forced into an institution against their will. However this is partly dependant on finances and adequate facilities being available. Many doctors feel that it is more ethical for some people to be hospitalized as they are not in a fit mind to make their own choices. Theoretically it is more ethical, no civilized country can justify locking people up against their will when they have not committed a crime. But in the real world it is perhaps unethical; it is kinder to look after people properly because there are many cases of mentally ill people not coping and becoming homeless or ending up in prison.
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 It helps people stay with their family, which gives them more of an emotional support than a hospital Leff (1997) found that schizophrenics in long-term sheltered accommodation had less severe symptoms than those still in hospital Trauer et al (2001) found that care in the community improved the quality of life for people suffering from mental illness Weaknesses Care in the community programmes are under-funded this impacts on a patientss recovery. Leff (1994) found that the balance between hospital beds and community care was inappropriate Private companies are often used for home care, such companies tend to under pay their staff. ( Toynby 2003) Causing high staff turn-over when consistency of care and positive interpersonal relationships between the client and carer are essential for such vulnerable people. Many in the medical profession feel that things have swung too far towards the rights of the individual; they feel that this system badly lets down many seriously ill schizophrenics who need the regime of the hospital to help them to take the drugs that can help them in a properly prescribed way. Disastrous effects Two cases of schizophrenics being found in a lions den. o Micheal argyle stabbed George Harrison because voices told him to only six weeks after being released from a mental institution. o Johnatan Zito a diagnosed schizophrenic stabbed a man to death shortly after his release. A lot of schizophrenics can end up in prison. There is a lack of community between the different services community care sometimes not being informed when a patient is released from hospital

Cognitive Approach Treatment/ Therapy

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Rational Emotive Behaviour Therapy One set of therapeutic techniques is called cognitive behaviour therapy. As its name suggests, this therapy combines elements of the behavioural model of abnormality. The therapy has two parts. o The cognitive part - The cognitive part of the therapy involves identifying the faulty or irrational thinking processes that are affecting the client. This is done through questioning and getting the client to give examples of situations, what they would think and what they would do. During the cognitive part, the therapist develops ideas about what the clients irrational beliefs are but does not challenge these directly. o The behaviour part - The behaviour part of the therapy involves setting homework for the client to do. The therapist gives the client tasks that will help them challenge their own irrational beliefs. The idea is that the client identifies their own unhelpful beliefs and them proves them wrong. As a result, their beliefs begin to change.

Evaluation Strengths The main strengths of the therapy are that it is structured, has clear goals, is measurable and as a consequence is the most widely used by clinical psychologists. Butler and Beck (2001) carried out a meta-analysis of studies across a range of disorders and therapies. They found that cognitive therapy was successful for a wide range of disorders and very effective for bulimia, depression, GAD and social phobias For depression, the relapse rate with CBT is 29.5% whereas it is 60% with anti-depressive medication
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 Beck himself argues that Cognitive therapies have been equally ore more effective than drug therapies when treating depression Weaknesses Guthrie criticises meta-analysis as they only use monosymptomatic conditions, meaning they fit the diagnostic criteria for a disorder exactly. It is questionable whether it will work as well with those without a pure disorder. It does not have a curative element for treating all mental illnesses but can be used in conjunction with other treatments to help treat Schizophrenia for example. The treatment works best for those with good problem solving skills

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