PSYC A232

Introduction to Abnormal Psychology

Study Guide
Unit 2

236
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236
Contents

Unit 2 Anxiety, mood disorders and suicide

Introduction...................................................................................................................... 1
Unit 2 outline ................................................................................................................... 2
Module 1: Anxiety, obsessive-compulsive, trauma and stressor-related disorders ........ 4
Activity 2.1 ................................................................................................................ 4
Panic disorder .......................................................................................................... 4
Separation anxiety disorder ..................................................................................... 6
Generalised anxiety disorder ................................................................................... 7
Reading 2.1 (E-Library) ............................................................................................ 8
Activity 2.2 ................................................................................................................ 9
Social anxiety disorder ............................................................................................. 9
Phobias .................................................................................................................. 10
Obsessive-compulsive disorder ............................................................................. 11
Activity 2.3 .............................................................................................................. 13
Posttraumatic stress disorder................................................................................. 13
Self-test 2.1 ............................................................................................................ 15
Module 2: Mood disorders and suicide.......................................................................... 15
Mood disorders ...................................................................................................... 16
Characteristics of depression ................................................................................. 16
Characteristics of bipolar disorder.......................................................................... 17
Activity 2.4 .............................................................................................................. 17
Theories of depression and bipolar disorder .......................................................... 17
Reading 2.2 (E-Library) .......................................................................................... 19
Activity 2.5 .............................................................................................................. 20
Treatment of mood disorders ................................................................................. 20
Self-test 2.2 ............................................................................................................ 21
Suicide ................................................................................................................... 21
Activity 2.6 .............................................................................................................. 23
Self-test 2.3 ............................................................................................................ 23
Summary ....................................................................................................................... 23
References .................................................................................................................... 24
Feedback on activities and self-tests ............................................................................ 25
 Unit 2 1

Unit 2
Anxiety, mood disorders and
suicide

Introduction
In Unit 1 we covered the basic overview, history and assessment methods in abnormal
psychology. Starting from this unit onwards, we will delve into various aspects of specific
disorders.
This unit includes two modules: the first module investigates anxiety, obsessive-compulsive,
and trauma and stressor-related disorders. Feelings of anxiety are normal reactions to stress
that we all experience, but they exist along a continuum that can reach dysfunctional levels
when they profoundly interfere with our capacity to lead a normal life.
The second module explores mood disorders and suicide. Suicidal behaviour is closely
connected not only with mood disorders but also the anxiety disorders covered in Module 1.
People affected by these disorders carry an increased risk of suicidal ideation, suicide
attempt, and completed suicide.
In short, this unit:
• identifies and distinguishes the characteristics, theories, and treatment of anxiety
disorders;
• illustrates and explains the characteristics, theories, and treatment of mood disorders;
and
• defines suicide and describes the treatment and prevention of suicide.
All the learning tasks are clearly outlined in this Study Guide, and it is highly recommended
you follow this guide in your study. In this unit, you will need to cover the following
materials:
• Unit 2 of the custom textbook, entitled ‘Anxiety, mood disorders and suicide’
• Two assigned readings.
2 PSYC A232 Introduction to Abnormal Psychology

Unit 2 outline
The following provides you with an outline for working through Unit 2. The page numbers
refer to the page numbers of your custom textbook. The activities and self-tests are shown in
italics. The assigned readings are available in the University’s E-Library. Remember to refer
also to the Online Learning Environment (OLE) as you work through the unit.

Module 1: Anxiety, obsessive-compulsive, trauma and stressor-related disorders

Activity 2.1
Fear and anxiety along the continuum [p. 87]
Panic disorder [p. 90]
Theories of panic disorder
Treatments for panic disorder
Separation anxiety disorder [p. 95]
Theories of separation anxiety disorder
Treatments for separation anxiety disorder
Generalised anxiety disorder [p. 99]
Theories of generalised anxiety disorder
Treatments for generalised anxiety disorder
Reading 2.1 (E-Library)
Activity 2.2
Social anxiety disorder [p. 103]
Theories of social anxiety disorder
Treatments for social anxiety disorder
Specific phobias and agoraphobia [p. 107]
Specific phobias
Agoraphobia
Theories of phobias
Treatments for phobias
Obsessive-compulsive disorder [p. 112]
Theories of OCD and related disorders
Treatments for OCD and related disorders
Activity 2.3
Posttraumatic stress disorder and acute stress disorder [p. 122]
Traumas leading to PTSD
 Unit 2 3

Theories of PTSD
Treatments for PTSD
Self-test 2.1
Module 2: Mood disorders and suicide
Mood disorders along the continuum [p. 139]
Characteristics of depressive disorders [p. 140]
Symptoms of depression
Prevalence and course of depressive disorders
Characteristics of bipolar disorders [p. 148]
Mania: The opposite of depression
Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder
Rapid cycling bipolar disorder
Bipolar disorder in children
Prevalence and course of bipolar disorder
Creativity and the mood disorders
Activity 2.4
Theories of depression [p. 154]
Biological theories of depression
Psychological theories of depression
Reading 2.2 (E-Library)
Theories of bipolar disorder [p. 164]
Biological theories of bipolar disorder
Psychosocial contributors to bipolar disorder
Activity 2.5
Treatment of mood disorders [p. 166]
Biological treatments for mood disorders
Psychological treatments for mood disorders
Interpersonal and social rhythm therapy and family-focused therapy
Comparison of treatments
Self-test 2.2
Suicide [p. 176]
Defining and measuring suicide
4 PSYC A232 Introduction to Abnormal Psychology

Understanding suicide
Treatment and prevention
Activity 2.6
Self-test 2.3
Summary

Module 1: Anxiety, obsessive-compulsive,

trauma and stressor-related disorders
In this module, we will cover abnormal forms of fear and anxiety, including panic, separation
anxiety, generalised anxiety, and social anxiety disorders, and various kinds of phobia. We
will also learn about obsessive-compulsive disorder, as well as posttraumatic stress disorder
and acute stress disorder.
Let’s begin with a reflective activity on the nature of anxiety in our daily lives. The feedback
to this and all the activities and self-tests in this unit is available at the end of this Study
Guide and in the interactive ePub version on the OLE.

Activity 2.1
The COVID-19 pandemic was a period of great stress, profoundly impacting our lives. Think
back on your experiences during this period of time. Were there any aspects of life during the
pandemic that made you feel anxious? How did this anxiety, and COVID-19 more broadly,
affect your daily life physiologically, psychologically, cognitively, behaviourally and/or
socially?

The term ‘anxiety’ is typically related to negative feelings, but recognising it as a normal
feeling or reaction towards stress is helpful in many ways. From a physiological perspective,
our fight-or-flight mode comes on when facing threatening situations. In this mode, there are
two systems being activated, namely the autonomic nervous system and the adrenal-cortical
system (page 88 of the textbook). On an emotional level, we also experience feelings of dread
or apprehension that might cause us irritability or restlessness. Cognitively, we evaluate the
situation for the degree of potential threat in both a conscious and unconscious manner. Taken
together, these elements prompt us to take appropriate actions (behaviour) to either confront
the threat or to escape from it.

Panic disorder
Let’s now dive into different disorders related to fear and anxiety. Our first topic is panic
disorder. Please now read the following sections of your custom textbook.
 Unit 2 5

Textbook topics
Fear and anxiety along the continuum [p. 87]
Panic disorder [p. 90]
Theories of panic disorder
Treatments for panic disorder

All of the anxiety disorders have anxiety, panic, or both at their core. Panic disorder can be
defined and characterised by the occurrence of panic attacks that often come ‘out of the blue’.
Panic attacks are short but intense and an individual might experience symptoms like heart
palpitations, trembling, shortness of breath, dizziness and so on. Most symptoms are physical,
although three are cognitive: feelings of unreality, fear of ‘going crazy’ and fear of dying
(refer to Table 2 on page 91 of the textbook for the detailed DSM symptom list). Panic attacks
do not appear to be provoked by identifiable aspects of the immediate situation. People
having a panic attack may show up repeatedly at emergency departments or doctors’ clinics
for what they are convinced is a medical problem.

Theories of panic disorder

We can explain panic disorder using biological and cognitive theories and identify various
factors contributing to a person’s vulnerability. This disorder has a moderate heritable
component — it is estimated that 43 to 48 per cent of the variance in liability to panic
symptoms is due to genetic factors. Environmental factors may also play a role in the
pathogenesis of panic disorder. Psychological factors such as anxiety sensitivity influence
one’s thoughts, emotions and interpretation of physiological changes, and therefore
contribute to symptoms of panic disorder.
Biological factors
The amygdala is a collection of nuclei in front of the hippocampus in the limbic system of the
brain that is critically involved in the emotion of fear and thus the experience of panic
attacks. The amygdala is the central area involved in what has been called a ‘fear network’,
with connections not only to lower areas in the brain but also to higher brain areas like the
prefrontal cortex.
From a biochemical perspective, different neurotransmitters such as gamma-aminobutyric
acid (GABA) and cholecystokinin (CCK) play a role in the fight-or-flight response, and in
panic disorder these may be poorly regulated.
Individuals with panic disorder are more likely to experience panic attacks when exposed to
various biological challenges (such as breath holding, hyperventilation, or ingesting caffeine)
as compared to normal individuals. Biological challenge procedures suggest that no single
neurobiological mechanism is implicated in panic disorder.
Cognitive factors
The cognitive theory of panic proposes that people with panic disorder are hypersensitive to
their bodily sensations and very prone to giving them the most dire interpretation possible.
Initial panic attacks become associated with initially neutral internal cues such as physical
sensations (interoceptive cues) and external cues in the environment (exteroceptive cues).
These processes are known as interoceptive conditioning and exteroceptive conditioning
respectively. Anxiety conditioned to these internal and external cues sets the stage for
6 PSYC A232 Introduction to Abnormal Psychology

anticipatory anxiety to arise and sometimes agoraphobic fears (you will learn more about
agoraphobia later in this unit) which may grow into a full-blown attack.

Treatments for panic disorder

Although there are different treatments available for panic disorder, there is no ‘one-size-fits-
all’ solution. The most common biological treatment is prescription of antidepressants —
primarily tricyclics, selective serotonin reuptake inhibitors (SSRIs), and, most recently,
serotonin-norepinephrine reuptake inhibitors (SNRIs). These drugs take about four weeks to
take effect, but they do not create physiological dependence, and they can also alleviate
comorbid depressive symptoms or disorders (i.e. symptoms or disorders occurring alongside
panic disorder). Undesirable side effects mean that many people refuse to take these
medications or discontinue their use. SSRIs are more widely prescribed than tricyclics
because they are generally better tolerated by most patients.
Another type of treatment is cognitive-behavioural treatment (CBT). For example, therapists
may ask clients to keep diaries of their thoughts surrounding their panic attacks and then
work through these in therapy sessions, or use systematic desensitisation to deliberately
expose clients to their feared internal sensations gradually. CBT is commonly used alongside
medication.

Separation anxiety disorder

Please now turn back to your textbook to read the following sections about separation anxiety
disorder.

Textbook topics
Separation anxiety disorder [p. 95]
Theories of separation anxiety disorder
Treatments for separation anxiety disorder

The earliest interpersonal relationships we build are with our caregivers. Many infants may
become anxious and upset when they have to be separated from their primary caregivers. You
may have memories of crying when you had to say goodbye to your parents at the entrance of
the kindergarten or a new primary school. It is not uncommon for children to display
symptoms of separation anxiety, but these may not be a cause for concern unless the
symptoms persist for at least four weeks and significantly impair functioning. If the
separation anxiety disorder is left untreated, it may continue to significantly interfere with a
child’s academic progress and peer relationships throughout childhood and adolescence.

Theories and treatment of separation anxiety disorder

Separation anxiety disorder (SAD) in childhood is the child’s disproportionate and
maladaptive anxiety when they are separated from their primary caregivers (such as parents)
and/or when they anticipate separation. The disorder can be explained through the presence
of a family history of anxiety and depressive disorders. From a genetic point of view, the
disorder is estimated to be 70 per cent heritable, with a greater tendency in girls than in boys.
Psychologically, the trait of behavioural inhibition might be inherited. Children with this trait
are shy, fearful and irritable. They tend to avoid or withdraw from novel situations, are clingy
with their parents, and become even excessively aroused in unfamiliar situations. Beyond
 Unit 2 7

genetic factors, children may learn to be anxious by modelling the behaviours of an anxious
parent by observational learning. An overprotective parenting style is a significant family
factor associated with levels of maternal anxiety and child separation anxiety in dyadic social
interactions.
Separation anxiety disorder can occur in adults (adult separation anxiety disorder, or ASAD).
It takes two different forms, each with slightly different diagnostic criteria in the DSM-5:
• Adult-onset ASAD refers to an adult separation anxiety disorder diagnosis without a
documented history of childhood separation anxiety disorder.
• Childhood-onset ASAD refers to an adult separation anxiety disorder diagnosis in
individuals who have also met the criteria of separation anxiety disorder in childhood
(Bögels et al., 2013).
The existing understanding and prevalence of ASAD could be underestimated, and more
research is needed into this form of the disorder.
Similar to panic disorder, the most empirically effective treatments are pharmacotherapy
(such as SSRIs), together with cognitive-behavioural therapy. During CBT sessions,
maladaptive thoughts and anxiety about separation are challenged and replaced by more
helpful and rational thoughts on separation. Besides, a CBT therapist can also offer guidance
to the children and parents for dealing with the separation anxiety in a healthier way. In
clinical practice, pharmacological and psychological treatments are often combined to
achieve the best treatment outcomes.

Generalised anxiety disorder

Please now turn to the following sections in your custom textbook to explore generalised
anxiety disorder.

Textbook topics
Generalised anxiety disorder [p. 99]
Theories of generalised anxiety disorder
Treatments for generalised anxiety disorder

For some people, worrying can become chronic, excessive, and unreasonable. Occasional
anxiety is absolutely normal and is part of life. It is not unusual to worry about one’s health,
career, finances, relationships or family issues. However, individuals with generalised anxiety
disorder (GAD) feel extremely and more frequently worried about these and/or other things
— even when there is little or no cause for concern. In GAD, a person has chronic and
excessively high levels of worry and responds to stress with high levels of psychic and
muscle tension. Generalised anxiety disorder may occur in people who have had extensive
experience with unpredictable or uncontrollable life events. People with generalised anxiety
may have danger schemas (mental structures about information and concepts) which
automatically conceptualise commonplace situations as dangerous and the individual as
unable to cope. This promotes worries focused on possible future threats.

Theories and treatment of generalised anxiety disorder

A person’s history of control over important aspects of their environment is a significant
factor affecting their reactions to anxiety-provoking situations. Parents’ responsiveness to
8 PSYC A232 Introduction to Abnormal Psychology

their children’s needs directly influences children’s development of a sense of mastery.

People with GAD also show marked vigilance (sustained attention) for possible signs of
threat in the environment. They frequently engage in subtle avoidance activities such as
procrastination, checking, or calling a loved one frequently to see if they are safe. Most of
these assumptions or acts reflect their concerns about losing of control or being unable to
tolerate uncertainty and uncontrollable life experiences.
GAD is one of the most common mental disorders. The worries of GAD individuals have
reinforcing properties which help sufferers to avoid bad events as well as to engage in
problem solving. People with GAD perceive the following benefits from worrying:
• superstitious avoidance of catastrophe;
• avoidance of deeper emotional topics; and
• coping and preparation.
In fact, research shows that when people with GAD worry, their emotional and physiological
responses to aversive imagery are actually suppressed (Ji et al., 2016).
The neurobiological factor most implicated in generalised anxiety is a functional deficiency
in the neurotransmitter GABA, which is involved in inhibiting anxiety in stressful situations;
the limbic system is the brain area most involved.
Echoing the activity you did at the start of the unit, a study conducted in China revealed that
participants who were more concerned about the COVID-19 outbreak (for example,
participants who spent three hours or more per day focussing on COVID-19 issues) were
more likely to develop GAD than those who were less concerned. The study also found that
healthcare workers were at high risk of mental illness, which was linked to poor sleep quality
(Huang & Zhao, 2020).
Treatments for GAD include cognitive-behavioural treatment and biological treatment using
medications. It usually involves a combination of behavioural techniques, such as training in
applied muscle relaxation, emotion regulation therapy, and cognitive restructuring. Research
has found that CBT approaches can result in substantial changes on most symptoms
measured. The magnitude of the changes seen with cognitive-behavioural treatment was at
least as large as those seen with benzodiazepines (anti-anxiety medication). Most often,
benzodiazepines are used for temporary tension relief, reduction of other somatic symptoms,
and relaxation. However, they are addictive, so long-term use is not an option. Several
categories of antidepressants are also useful in the treatment of GAD.
So far, we have looked at several categories of anxiety disorders. Please now read the
following review article which aims to shed some light on the interaction between
environmental experiences and genetic susceptibility in explaining the origins of anxiety.

Reading 2.1 (E-Library)

Gross, C., & Hen, R. (2004). The developmental origins of anxiety. Nature Reviews
Neuroscience, 5, 545–552.
This article is available in the University’s E-Library → E-Reserve.

This article attempts to explain abnormal anxiety-related behaviours from perspectives of

physiology, gene-environment interactions and molecular mechanisms of anxiety circuits in
the brain. The article explains how animal research shows that genetic and environmental
influences act on the maturation of neurons to determine susceptibility to anxiety. It suggests
 Unit 2 9

that anxiety circuits are particularly vulnerable to these influences during developmental
periods when synaptic connections are being made in the developing brain, i.e. when brain
circuits are highly plastic.

Activity 2.2
Although people with GAD worry excessively and uncontrollably about daily life events and
activities, the worrying serves a purpose. What potential benefits/functions do those with
generalised anxiety disorder derive from worrying? (If you need a hint, turn back to pages
101–102 of the textbook.)

Social anxiety disorder

Please now turn to the topic of social anxiety disorder in your custom textbook.

Textbook topics
Social anxiety disorder [p. 103]
Theories of social anxiety disorder
Treatments for social anxiety disorder

Have you ever felt anxious when you need to present your ideas in unfamiliar social
situations? Have you ever worried about being rejected, judged or humiliated? In social
anxiety disorder (also known as social phobia) a person has disabling fears of one or more
social situations, usually because of fears of negative evaluation by others or of acting in an
embarrassing or humiliating manner. In some cases a person with social anxiety disorder may
actually experience panic attacks in social situations. People with social anxiety disorder also
have prominent perceptions of unpredictability and uncontrollability and are preoccupied
with negative self-evaluative thoughts that tend to interfere with their ability to interact in a
socially skilful fashion.
In some extreme forms, adolescents and young adults might avoid social contact and become
recluses in their parents’ homes, unable to work or go to school for months or years. This
severe social withdrawal is called hikikomori (defined as isolation lasting more than six
months and not due to an apparent mental disorder) and it serves as a proxy for a severe form
of social anxiety disorder. The prevalence of hikikomori of more than six months’ social
withdrawal among young people in Japan is 1.9% (Koyama et al., 2010) while that of Hong
Kong is 1.2% (Wong et al., 2015).

Theories and treatment of social anxiety disorder

While there is a modest genetic contribution to social phobia, cognitive explanations for the
disorder dominate. One suggestion is that socially anxious people have formed danger
schemas which lead them to expect that they will behave in an awkward and unacceptable
fashion, resulting in rejection and loss of status. Individuals may be preoccupied with bodily
responses and with stereotyped, negative self-images in social situations. A vicious cycle
may evolve in which the inward attention and potentially awkward interactions may lead
others to react to the individual in a less friendly fashion, confirming their expectations.
10 PSYC A232 Introduction to Abnormal Psychology

Another cognitive bias is the interpretation of ambiguous social information in a negative

rather than a benign manner.
Effective treatments for social anxiety disorder are (1) SSRIs and SNRIs and (2) cognitive-
behavioural therapy. Prolonged and graduated exposure to the feared situation has been
proven to be a very effective treatment. Cognitive restructuring is a therapy technique in
which the therapist attempts to help clients with social anxiety identify their underlying
negative, automatic thoughts and then change these inner thoughts and beliefs through logical
re-analysis. Many studies over the years have shown that exposure therapy and cognitive-
behavioural therapy produce comparable results.

Phobias
Please now turn to the following topics in your custom textbook.

Textbook topics
Specific phobias and agoraphobia [p. 107]
Specific phobias
Agoraphobia
Theories of phobias
Treatments for phobias

In specific phobias, an individual has an intense and irrational fear of specific objects or
situations that leads to a great deal of avoidance behaviour; when confronted with a feared
object, the person with a phobia often shows activation of the fight-or-flight response, which
is also associated with panic. There are five types of phobic stimulus in the DSM-5 as
summarised in the table below.
Table 2.1 Types of phobic stimulus in the DSM-5

Type of phobic stimulus in Examples

the DSM-5
Animal Spiders, insects, dogs
Natural environment Heights, storms, water
Situational Aeroplanes, elevators, enclosed places
Blood-injection-injury Needles, invasive medical procedures
Others Situations that may lead to choking, vomiting, etc.

A specific phobia is said to be present if a person shows a strong and persistent fear that is
triggered by the presence of a specific object or situation which leads to significant distress
and/or impairment in a person’s ability to function. Most phobias develop during childhood
but will persist across the lifespan if untreated.
Your textbook highlights agoraphobia. People with agoraphobia are anxious about being in
places or situations from which escape would be difficult or embarrassing, or in which
immediate help would be unavailable. In very severe cases, agoraphobia is an utterly
debilitating disorder in which a person cannot go beyond the narrow confines of their home
 Unit 2 11

— or even particular parts of the home. Agoraphobia is a frequent complication of panic

disorder; however, many agoraphobic individuals do not experience panic.

Theories and treatment of phobias

Two types of theories can help us to understand phobias:
• Behavioural theories: As you will remember from previous courses, through classical
conditioning, a fear response can be conditioned to previously neutral stimuli when
paired with traumatic or painful events. However, direct conditioning, in which a person
has a terrifying experience in the presence of a neutral object or situation, is not the only
way that people can learn irrational fears — observational learning may also play a role.
Simply watching a phobic person acting frightened towards the object of their phobia
can be distressing to the observer and can result in fear being transmitted from one
person to another. Prepared classical conditioning is the idea that primates and humans
have evolved to rapidly associate certain objects with frightening or unpleasant events. It
can explain why phobias of snakes and spiders, which could have delivered a nasty bite
to our distant ancestors, are common.
• Biological theories: Genetic and temperamental variables may affect the speed and
strength of the conditioning of fear. Twin studies show that monozygotic twins (i.e.
identical twins) are more likely to share animal phobias and situational phobias than
dizygotic twins (non-identical twins).
Behavioural therapies are generally used to treat phobias. These therapies involve exposure to
the phobic object. Systematic desensitisation, which we mentioned earlier as a treatment for
panic disorder, involves helping clients to form a list of situations from least to most
frightening, and then gradually exposing the client to these stimuli while using relaxation
techniques. Other effective approaches include modelling (the therapist calmly models ways
of interacting with the phobic stimulus or situation) and flooding (the intensive exposure to a
client’s feared objects until anxiety is extinguished). Medications such as benzodiazepines
may have beneficial effects (e.g. to allow a phobic person to travel by plane), yet their effects
are temporary and they do not eliminate the phobia.

Obsessive-compulsive disorder
Please now read the following topics about obsessive-compulsive disorder (OCD) in your
custom textbook.

Textbook topics
Obsessive-compulsive disorder [p. 112]
Theories of OCD and related disorders
Treatments for OCD and related disorders

Obsessive-compulsive disorder is defined by the occurrence of both obsessive thoughts and

compulsive behaviours performed in an attempt to neutralise such thoughts. The following
table provides a summary of these two characteristics.
12 PSYC A232 Introduction to Abnormal Psychology

Table 2.2 Overview of obsessions and compulsions in OCD

Description Remarks Examples

Obsessions Persistent and People with obsessions Contamination fears

recurrent intrusive actively try to resist or (e.g. ‘I could have sat
thoughts, images, or suppress them, or on something dirty’),
impulses that are neutralise them with fears of harming
experienced as some other thoughts or oneself and others, and
disturbing, actions. pathological doubt
inappropriate, and (e.g. ‘This spot could
uncontrollable be skin cancer; what if
the doctor made a
mistake?’)

Compulsions • Overt repetitive Compulsive Cleaning (e.g. hand

behaviours that are behaviours are washing), repeated
performed as performed with the checking (e.g. whether
lengthy rituals goal of preventing or the gas stove has been
reducing distress, or turned off), ordering,
• Covert mental
preventing some arranging or counting
rituals, such as
dreaded event or items, and repeatedly
counting, praying,
situation. asking others for
or saying certain
reassurance (e.g. ‘Is
words silently over
this spot on my skin
and over again
OK?’)

OCD is characterised by irrational beliefs but individuals with OCD vary in terms of their
‘insight’ into their obsessions and compulsions. Some OCD sufferers can see that their
obsessions and compulsions are irrational, senseless and excessive, while others cannot, or
can only perceive this to a certain extent.

Theories and treatment of OCD

Obsessive-compulsive disorder (OCD) is a complex condition that can be influenced by
multiple factors. Genetics is one factor, as revealed from family history studies. People with
OCD show abnormally high levels of activity in the basil ganglia, thalamus, anterior
cingulate cortex (ACC), and frontal cortex. The orbital frontal cortex seems to be where
primitive urges regarding sex, aggression, hygiene, and danger come from.
Medications that affect the serotonin system, i.e. SSRIs, can be effective in providing relief to
OCD sufferers. These drugs tend to be used alongside exposure and response prevention
(ERP) therapy, which involves having patients encounter the source of their obsessions and
preventing them from engaging in compulsive behaviours. Clients may be given homework
that helps them confront their obsessions and compulsions. For example, a client might be
instructed not to immediately sanitise their hands after touching an escalator handrail, and to
complete this exercise several times a week. Exposure and response prevention may be
enhanced by the addition of cognitive therapy to challenge the thoughts associated with the
compulsions. For example, the client is guided to conclude that there were no disastrous
consequences when they did not immediately sanitise their hands after riding the escalator.
This therapeutic approach results in a reduction in symptoms, as well as improvement in
quality of life of OCD sufferers.
 Unit 2 13

A recent systematic review by Linde et al. (2022) found that people both with and without a
diagnosis of OCD before the COVID-19 pandemic experienced a worsening of their
symptoms of OCD during the pandemic period. During this period, personal hygiene
practices that might previously have been considered excessive were strongly encouraged
(frequent hand washing, using hand sanitiser, etc.). It is probable that fears of contamination
and disproportionate concern about getting infected by the disease became widespread in
society, which could have amplified the obsessions and compulsions of OCD sufferers.

Activity 2.3
One of the most influential ideas in explaining the origin of specific phobias is preparedness
theory. The theory proposes that people are more likely to develop fears of stimuli that were
potentially dangerous to our ancestors.
1. According to this theory, would it be accurate to say ‘I inherited my fear of snakes from
my great-grandparents’? Please explain.
2. Could you use the theory of evolutionary preparedness to explain any aspects of
a) social anxiety disorder and b) obsessive-compulsive disorder?

Posttraumatic stress disorder

Please now turn to the following sections of your custom textbook.

Textbook topics
Posttraumatic stress disorder and acute stress disorder [p. 122]
Traumas leading to PTSD
Theories of PTSD
Treatments for PTSD

Have you ever had an experience that you consider to be traumatic? Say, a bad break-up, or a
major loss in childhood? While experiencing various types of trauma is an unavoidable part
of life, some people experience minimal and short-term effects, while in others trauma has
pathological consequences.
There are two kinds of psychological disorders related to trauma: posttraumatic stress
disorder (PTSD) and acute stress disorder (ASD). In the DSM-5, posttraumatic stress
disorder is grouped with other disorders in a new diagnostic category called trauma- and
stressor-related disorders. Adjustment disorder and acute stress disorder are also part of this
diagnostic category.
A variety of events can cause PTSD, as long as they expose the individual to the risk of
death, serious injury, or sexual violence. Examples of such traumatic events include serious
accidents, catastrophic events such as terrorist attacks, war, physical or sexual assault, abuse,
including childhood or domestic abuse, and childbirth experiences, such as losing a baby. In
PTSD, stress symptoms fail to abate, even when the traumatic event has passed and the
danger is over. A diagnosis of PTSD would require four types of symptoms (see Table 10 on
page 123 of the textbook for the detailed criteria):
14 PSYC A232 Introduction to Abnormal Psychology

• re-experiencing of the traumatic event in a recurrent, distressing way;

• avoidance of stimuli associated with the traumatic event;
• negative changes in thought or mood; and
• hypervigilance (increased alertness) or chronic arousal.
Acute stress disorder is a diagnostic category that can be used when symptoms develop
shortly after experiencing a traumatic event and last for at least two days. If symptoms persist
beyond four weeks, the diagnosis can be changed to PTSD.
In the DSM-5, the diagnostic criteria for PTSD were tightened as compared to previous
versions:
• The traumatic event must be experienced by the person directly, either because it
happened to them or because, in person, they witnessed it happening to someone else.
• It is no longer possible to experience trauma indirectly through electronic media.
• A provision now exists for experiencing trauma by learning of the death of another
person: the person must be a close friend or relative and their death must have been
violent or accidental.
• The requirement that the person respond in a particular way — i.e. with fear,
helplessness, or horror — was removed.
Being a member of a minority group seems to place people at higher risk for developing
PTSD. Returning to a negative and unsupportive social environment can also increase
vulnerability to posttraumatic stress. Being female is a risk factor for developing PTSD due
to the fact that women are more likely to be victims of sexual violence. Other risk factors
include low levels of social support, higher levels of neuroticism, having preexisting
problems with depression and anxiety, and having a family history of depression, anxiety, and
substance abuse.

Treatment of PTSD
CBT has been proven effective in treating PTSD. As in the treatment of other anxiety
disorders discussed previously, systematic desensitisation plays a part here. The therapist
guides the client in vividly recounting the traumatic event in a safe environment, until there is
a decrease in their emotional responses. This type of treatment has been shown to be an
effective treatment for PTSD and can be supplemented with other behavioural techniques.
Because this therapy involves persuading clients to confront traumatic memories that they
fear, the therapeutic relationship is of great importance in this kind of clinical intervention.
The cognitive aspects of therapy for PTSD aim to modify excessively negative appraisals of
the trauma or its consequences, decrease the threat that patients experience when they have
memories of the traumatic event, and remove problematic cognitive and behavioural
strategies. Additionally, medications such as SSRIs and benzodiazepines are often used to
tackle sleep problems and irritability in PTSD sufferers, although evidence for their
effectiveness in treating this disorder is mixed.
Before moving on to Module 2, please attempt the following self-test to assess your grasp of
some of the key ideas in this unit so far.
 Unit 2 15

Self-test 2.1
1. What are obsessions? What are compulsions? Please define them and give an example
of each.
2. Compare and contrast the flooding and systematic desensitisation techniques in exposure
therapy for specific phobias.
3. What is necessary for a diagnosis of generalised anxiety disorder?

Module 2: Mood disorders and suicide

Anxiety and depression often co-occur, so individuals who experience one condition are
more likely to experience the other. In this module, you will see that some of the
characteristic symptoms of the anxiety disorders you learnt about in Module 1, such as
negative thoughts, feelings of hopelessness, and sleep disturbances, are also present in
depression and other mood disorders.
The two mood disorders covered in this module are depression and bipolar disorder. Please
now turn to the following sections in your custom textbook for an overview of these disorders
and an in-depth discussion of their characteristics.

Textbook topics
Mood disorders along the continuum [p. 139]
Characteristics of depressive disorders [p. 140]
Symptoms of depression
Prevalence and course of depressive disorders
Characteristics of bipolar disorders [p. 148]
Mania: The opposite of depression
Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder
Rapid cycling bipolar disorder
Bipolar disorder in children
Prevalence and course of bipolar disorder
Creativity and the mood disorders
16 PSYC A232 Introduction to Abnormal Psychology

Mood disorders
Have you ever listened to the song ‘Bad Day’ by Daniel Powter? How would you describe
your ‘bad day’? We all experience mood swings and changes throughout our days, and
everyone has bad days from time to time. Mood disorders are characterised by extreme
variations in mood — either low or high — and these moods have disruptive impacts on a
person’s ability to function. Firstly, let’s familiarise ourselves with some key terms relating to
mood disorders and their diagnosis:
• In unipolar depressive disorders, a person experiences only depressive episodes.
• In bipolar disorder, a person experiences both depressive and manic episodes.
• A depressive episode is one in which a person is markedly depressed or loses interest in
formerly pleasurable activities (or both) for at least two weeks. Other symptoms include
a change in sleep or appetite, or feelings of worthlessness.
• A manic episode is one in which a person shows a markedly elevated, euphoric, or
expansive mood, often interrupted by occasional outbursts of intense irritability or even
violence. This mood is called mania.
• A hypomanic episode is one in which a person experiences abnormally elevated,
expansive, or irritable mood for at least four days; in addition, the person must have at
least three other symptoms similar to those involved in mania, but to a lesser degree.
From the above, you can see that the two key moods involved in mood disorders are
depression and mania. Let’s focus on depression first.

Characteristics of depression
Li et al. (2020) recruited 2,312 college students in Hong Kong, Macau and mainland China to
fill out the Beck Depression Inventory-II and found that 41% of respondents in Hong Kong,
35.2 % of respondents in Macau and 16.8% of respondents in mainland China had
depression. Due to the fact that it is so common, depression, specifically major depression, is
often referred to as the psychological ‘common cold’ of mental disorders.
Major depressive disorder (MDD, also known as major depression) requires that a person
must be in a major depressive episode and never have had a manic, hypomanic, or mixed
episode. The main characteristic of depression is a loss of joy or pleasure in daily life, which
can in turn affect a person’s thoughts, energy levels, eating and sleep patterns. Meanwhile,
persistent depressive disorder (formerly called dysthymic disorder or dysthymia) is a disorder
characterised by persistently depressed mood most of the day, for more days than not, for at
least two years (one year for children and adolescents).
Rates for unipolar major depression tend to be much higher for women than for men, as well
as individuals in lower socioeconomic groups. Depression is nearly always precipitated by
stressful life events. Some of the most stressful events possible are those involving the loss of
life, as well as the creation of new life. Psychologists have struggled with how to
appropriately diagnose (or not) a person’s response to such events. There is also research
evidence that people with negative social media behaviours (such as social comparison,
addiction to social media, etc.) may have a higher chance of developing MDD (Robinson
et al., 2019). Depression among children and adolescents has become a significant public
health concern nowadays and early intervention is critical and essential to get them treated
effectively.
 Unit 2 17

Characteristics of bipolar disorder

As you have read, bipolar and related disorders are those in which a person experiences both
depressive and manic episodes. The mood involved in manic episodes is mania. Mania is the
opposite of depression, so individuals experiencing mania feel very good, or ‘high’, have
elevated energy levels, inflated self-esteem, and may engage in risky behaviour. According to
Ng et al. (2021), a total of 17,247 patients were diagnosed with bipolar and related disorders
in Hong Kong from 2001 to 2018.
Variations in manic symptoms can lead to one of four bipolar disorder diagnoses: (1) bipolar
I disorder, (2) bipolar II disorder, (3) cyclothymic disorder and (4) rapid cycling bipolar
disorder (see Table 2.3 below). All these variations of bipolar disorder involve different
degrees of alternation between mania and depressive states.
Table 2.3 Variations of bipolar disorder and their characteristics

Type of bipolar disorder Characteristics

Bipolar I disorder • More time in depressed state

• At least one manic episode
• Long periods of normality

Bipolar II disorder • Long episodes of depression, occasional hypomania

• Virtually no time of wellness

Cyclothymic disorder • Many episodes of hypomania

• Occasional mild depression
• Mood swings are less dramatic and milder

Rapid cycling bipolar • Many cycles of mania and depression each year
disorder
• Four or more episodes a year

Activity 2.4
What is the difference between the diagnoses of bipolar I and bipolar II disorders?

Theories of depression and bipolar disorder

Please now turn to the following topics in your custom textbook, to explore how depression
and bipolar disorders can be understood.
18 PSYC A232 Introduction to Abnormal Psychology

Textbook topics
Theories of depression [p. 154]
Biological theories of depression
Psychological theories of depression
Theories of bipolar disorder [p. 164]
Biological theories of bipolar disorder
Psychosocial contributors to bipolar disorder

Theories of depression
The diathesis-stress model can help provide an overarching understanding of depression.
Recall from Unit 1 that this model understands psychological disorders as the result of the
interaction between inherent vulnerability (diathesis) and environmental stressors. For
example, children who have a family history of depression (an inherent vulnerability) are
generally more vulnerable to developing a depressive disorder themselves under
environmental stressors (a set of challenging life circumstances which then trigger the
development of the disorder).
One implication of this model is that depression involves the interaction of different factors,
including biological and psychosocial ones. Let’s recap the key biological and psychological
theories of depression.
Biological theories
Among biological causal factors, there is evidence of a moderate genetic contribution to the
vulnerability for major depression and probably also for dysthymia. Moreover, major
depression is clearly associated with multiple interacting disturbances in the neurochemical,
neuroendocrine, and neurophysiological systems. Disruptions in circadian and seasonal
rhythms are also prominent features of depression.
Neurotransmitters of the monoamine class such as norepinephrine and serotonin play a
significant role in depression at synaptic junctions in the limbic system. Depression may be
the outcome of absolute or relative depletion of one or both of these neurotransmitters at
important receptor sites in the brain. A number of integrative theories of depression have
been proposed that include a role for neurotransmitters, not alone but rather as they interact
with other disturbed hormonal and neurophysiological patterns and biological rhythms.
Hormones also play a crucial role in mood disorders. Research has largely focused on the
hypothalamic-pituitary-adrenal (HPA) axis, and in particular on the hormone cortisol. In
people with major depression, there is abnormal cortisol functioning which suggests
dysregulation in the HPA axis.
New directions in research have explored the gut microbiome, which can play a role in
depression by influencing the gut-brain axis. Changes in the gut microbiome can lead to
alterations in the production and regulation of neurotransmitters and inflammatory markers,
which are both involved in the development of depression.
Psychological theories
Among the cognitive theories of the causes of depressive disorders are Beck’s cognitive
theory and the reformulated learned helplessness theory. In these theories, the diathesis
(vulnerability) is cognitive in nature (e.g. dysfunctional beliefs and pessimistic attributional
 Unit 2 19

style, respectively), and stressful life events are often important in determining when those
diatheses actually lead to depression. Personality variables such as neuroticism may also
serve as diatheses for depression.
Meanwhile, psychodynamic and interpersonal theories of unipolar depression emphasise the
importance of early experiences (especially early losses and the quality of the parent-child
relationship) as setting up a predisposition for depression. Indeed, some research has
particularly focused on the association between early attachment and vulnerability to
depression in later life. Please now read the following article for further details of these
mechanisms.

Reading 2.2 (E-Library)

Morley, T. E., & Moran, G. (2011). The origins of cognitive vulnerability in early
childhood: Mechanisms linking early attachment to later depression. Clinical
Psychology Review, 31(7), 1071–1082.
This article is available in the University’s E-Library → E-Reserve.

This article proposes the existence of links between early attachment experiences and later
depression based on recent research. Early non-secure attachment leads to processes linked to
depressive vulnerability. These emerging models help us to understand the role that early
attachment experiences play in depressive vulnerability from perspectives of epigenetics and
gene-environment interactions. These findings can help to guide therapeutic interventions to
reduce the risk of depression, such as providing psychoeducation for parents to build their
parenting and childcare skills so as to guide children in challenging situations.

Theories of bipolar disorder

Biological causal factors probably play an even more prominent role for bipolar disorders
than for unipolar disorders. The genetic contribution to bipolar disorder is among the
strongest of such contributions among the major psychiatric disorders. Abnormalities in the
structure and function in the amygdala and prefrontal cortex, as well as alternations in the
size or functioning of the hippocampus all play important roles in bipolar disorders.
Additionally, monoamine neurotransmitters have also been implicated in bipolar disorder.
Stressful life events may be involved in precipitating manic or depressive episodes. Factors
such as differing rates of stigma, stressors, criticism and conflicts may trigger symptoms and
may also help explain the different rates and expressions of mood disorders across cultures.
Personality variables and cognitive styles related to goal striving, drive, and incentive
motivation have been associated with bipolar disorder.
20 PSYC A232 Introduction to Abnormal Psychology

Activity 2.5
Neuroimaging studies have revealed structural and functional brain abnormalities in people
with mood disorders. Based on your learning from the textbook, please indicate the changes
which occur in the following brain regions by checking the boxes.

Mood Brain region affected As compared to healthy people,

disorder the following changes are seen
Depression Left prefrontal cortex Metabolic activity is:
Increased ☐
Decreased ☐
Hippocampus The volume is:
Increased ☐
Decreased ☐
Amygdala Activation is:
Increased ☐
Decreased ☐
Bipolar disorder Striatum Activation is:
Increased ☐
Decreased ☐
Hippocampus The volume is:
Increased ☐
Decreased ☐
Amygdala Activation is:
Increased ☐
Decreased ☐

Treatment of mood disorders

Please now read about the treatment of mood disorders in the following sections of your
textbook.

Textbook topics
Treatment of mood disorders [p. 166]
Biological treatments for mood disorders
Psychological treatments for mood disorders
Interpersonal and social rhythm therapy and family-focused therapy
Comparison of treatments

Biologically-based treatments such as medications (e.g. SSRIs, SNRIs) are often the first-line
treatments for the more severe depressive disorders, with electroconvulsive therapy as an
alternative treatment option for treatment-resistant cases. New methods of brain stimulation
without applying electric current (such as repetitive transcranial magnetic stimulation
(rTMS)) are also found to be effective in treating depression. The biological treatment of
 Unit 2 21

bipolar disorder through the use of lithium can be very effective in stabilising mood, despite
the risk of severe side effects.
Increasingly, however, specific psychosocial treatments such as behavioural therapy,
cognitive-behavioural therapy, and interpersonal therapy are being used to good effect in
many cases of these more severe disorders as well as in the milder forms of mood disorder.
Considerable evidence suggests that recurrent depression is best treated by specialised forms
of psychotherapy or by maintenance on medications for prolonged periods.
Table 2.4 Summary of treatment approaches for mood disorders

Approach Treatments Disorder

Biological • Antidepressant medications: SSRIs, SNRIs, Depression

bupropion, tricyclics, MAOIs
• Electroconvulsive therapy (ECT)
• Brain stimulation: rTMS, VNS, deep brain
stimulation

• Light therapy Seasonal affective

disorder (SAD)

• Mood stabilising medications: lithium, Bipolar disorder

anticonvulsants, atypical antipsychotics

Psychological • Behavioural therapy Depression

• Cognitive-behavioural therapy
• Interpersonal therapy

• Interpersonal and social rhythm therapy Bipolar disorder

• Family-focused therapy

Self-test 2.2
1. Discuss Beck’s cognitive theory of depression. In particular, what are the roles of
dysfunctional beliefs and the negative cognitive triad in Beck’s theory?
2. Nancy has been feeling somewhat depressed for several months. She is considering
seeking help from a therapist. What kind of therapy would you suggest that Nancy seek
out?

Suicide
The last major topic of this unit is suicide. Suicide is associated with mood disorders, but the
risk of suicide is elevated in people with any mental disorder. Please read the following
textbook topics to learn more.
22 PSYC A232 Introduction to Abnormal Psychology

Textbook topics
Suicide [p. 176]
Defining and measuring suicide
Understanding suicide
Treatment and prevention

Suicide is the intentional taking of one’s own life. Suicide is among the three leading causes
of death globally for people aged 15–44. A completed suicide ends in death, a suicide attempt
may or may not end in death, while suicidal ideation refers to thoughts about suicide. Suicide
attempts are up to 20 times more common than completed suicides.
According to HKU CSRP Centre for Suicide Research and Prevention (2022), the estimated
overall suicide rate1 in 2021 is 16.8 for males and 8.5 for females. For individuals aged 60
years or above, the estimated suicide rate in 2021 is 27.3 for males and 14.6 for females. For
youths, the estimated suicide rate in 2021 for 15 to 24-year-olds is 9.3.
One remarkable trend has been the increased risk among adolescents and young adults over
the past several decades. Possible reasons for this surge include the following: (1) this is a
period during which depression, anxiety, alcohol and drug use, and conduct disorder
problems show increased prevalence; (2) (in the US context) the availability of firearms; and
(3) exposure to suicides (especially those of celebrities) through the media, where they are
often portrayed in dramatic terms. In Hong Kong, suicide prevention strategies have been
implemented with reference to prevention guidelines published by regional organisations or
the World Health Organization, such as high-quality mental health services to at-risk
populations or school-based prevention programmes (awareness and screening, and
gatekeeper training) (Siu, 2019).
Most people who attempt suicide are likely to be suffering from a psychological disorder.
Individuals who are at higher risk of suicide often come from backgrounds with some
combination of the life stressors of family psychopathology, child maltreatment, and family
instability. People who have a strong implicit association between the self and death or
suicide are at elevated risk for future suicide attempts. Suicide can be contagious if attempts
or ideation are widely spread and supported in social media or other forms of media.
In terms of genetic predisposition, the concordance rate for suicide in identical twins is about
three times higher than it is in fraternal twins. Suicide victims often have alternations in
serotonin functioning, with reduced serotonergic activity. Many researchers explain suicide
using diathesis-stress models in which underlying vulnerabilities (e.g. genetic,
neurobiological) interact with stressful life events to produce suicidal thoughts and
behaviours. Joiner’s 2005 interpersonal-psychological model of suicide suggests that two
factors — perceived burdensomeness and low belonging/social alienation — interact to
produce suicidal thoughts and desires, and it is only in the presence of a third factor, the
acquired ability for lethal self-injury, that a person may make a suicide attempt (Joiner,
2009).
One way to help prevent suicide is through treating the underlying mental disorder(s) of the
potentially suicidal person. In emergencies, hospitalisation might be required for high-risk
individuals. Prevention can be achieved through crisis interventions which aim to help a
person cope with an immediate problem as quickly as possible as well as the availability of

1. All suicide rates are calculated as per 100,000 people. So for example, a suicide rate of 13 means there were 13 among 100,000
people in the region who died by suicide.
 Unit 2 23

suicide hotlines providing competent assistance. These are usually staffed primarily by non-
professionals who are supervised by psychologists and psychiatrists.

Activity 2.6
Imagine you are a volunteer at a university counselling unit and the unit is running a suicide
prevention campaign. You have been asked to help with some tasks.
1. Your team needs to prepare a leaflet for the campaign. You are going to have a
brainstorming meeting about what to include in the leaflet. What suggestions would you
make at the meeting?
2. You are asked by the volunteer coordinator to prepare a PowerPoint slide listing the
warning signs for student suicide at university. What points would you list on the slide?
(You may include ideas from your textbook reading or from online research.)

You have come to the end of Module 2. Before moving on to the summary, please attempt the
following self-test question.

Self-test 2.3
In what way do the symptoms of depression in Western and non-Western societies differ?

Summary
This unit has covered some of the most common psychological disorders: anxiety, obsessive-
compulsive, trauma and stressor-related disorders in Module 1, and the mood disorders of
depression, bipolar disorder and suicide in Module 2. All these disorders involve disturbances
in emotions and affective states.
You will have learnt that anxiety disorders all are characterised by unrealistic, irrational fears
or anxieties that cause significant distress and/or impairments in functioning. Among the
anxiety disorders recognised in the DSM-5 are panic disorder, generalised anxiety disorder,
social anxiety disorder, specific phobias, and agoraphobia. People with these varied disorders
differ from one another both in terms of the amount of fear or panic versus anxiety symptoms
that they experience and in the kinds of objects or situations that most concern them.
Major mood disorders occur at almost the same rate as all the anxiety disorders taken
together. Major depressive disorder is the most common condition among the depressive
disorders and is characterised by discrete episodes of depressed mood and loss of interest or
pleasure. In the bipolar disorders (cyclothymia and bipolar I and II disorders), the sufferer
experiences episodes of both depression and hypomania or mania. During manic or
hypomanic episodes, the mood symptoms are essentially the opposite of those experienced
during a depressive episode.
Suicide is one of the leading causes of death worldwide. The rate of suicidal thoughts and
behaviour increases drastically during adolescent and young adult years, and psychological
disorders such as mood and bipolar disorders are especially strong risk factors for these
outcomes. Suicide prevention (or intervention) programmes generally consist of crisis
intervention in the form of suicide hotlines. Although these programmes undoubtedly avert
24 PSYC A232 Introduction to Abnormal Psychology

fatal suicide attempts in some cases, the long-term efficacy of treatment aimed at preventing
suicide in high-risk individuals is much less clear at present.

References
Bögels, S. M., Knappe, S., & Clark, L. A. (2013). Adult separation anxiety disorder in

DSM-5. Clinical Psychology Review, 33(5), 663–674.

HKU CSRP Centre for Suicide Research and Prevention. (2022, September 10). Moving

forward together [Press release]. https://www.hku.hk/press/press-releases/detail/

25024.html#:~:text=Latest%20Suicide%20Figures%20and%20Trends&text=Since%20ag

eing%20in%20Hong%20Kong,World%20Health%20Organization%2C%202021

Huang, Y., & Zhao, N. (2020). Generalized anxiety disorder, depressive symptoms and sleep

quality during COVID-19 outbreak in China: A web-based cross-sectional survey.

Psychiatry Research, 288, 112954.

Ji, J. L., Heyes, S. B., MacLeod, C., & Holmes, E. A. (2016). Emotional mental imagery as

simulation of reality: Fear and beyond — A tribute to Peter Lang. Behaviour Therapy,

47(5), 702–719.

Joiner, T. (2009, June). The interpersonal-psychological theory of suicidal behavior: Current

empirical status. American Psychological Association. https://www.apa.org/science/

about/psa/2009/06/sci-brief

Koyama, A., Miyake, Y., Kawakami, N., Tsuchiya, M., Tachimori, H., Takeshima, T., &

World Mental Health Japan Survey Group. (2010). Lifetime prevalence, psychiatric

comorbidity and demographic correlates of ‘hikikomori’ in a community population in

Japan. Psychiatry Research, 176(1), 69–74.

Li, L., Lok, G. K. I., Mei, S. L., Cui, X. L., An, F. R., Li, L., Cheung, T., Ungvari, G. S., &

Xiang, Y. T. (2020). Prevalence of depression and its relationship with quality of life

among university students in Macau, Hong Kong and mainland China. Scientific Reports,

10(1), 1–8.
 Unit 2 25

Linde, E. S., Varga, T. V., & Clotworthy, A. (2022). Obsessive-compulsive disorder during

the COVID-19 pandemic — a systematic review. Frontiers in Psychiatry, 13, Article

806872.

Ng, V. W., Man, K. K., Gao, L., Chan, E. W., Lee, E. H., Hayes, J. F., & Wong, I. C. (2021).

Bipolar disorder prevalence and psychotropic medication utilisation in Hong Kong and

the United Kingdom. Pharmacoepidemiology and Drug Safety, 30(11), 1588–1600.

Robinson, A., Bonnette, A., Howard, K., Ceballos, N., Dailey, S., Lu, Y., & Grimes, T.

(2019). Social comparisons, social media addiction, and social interaction: An

examination of specific social media behaviours related to major depressive disorder in a

millennial population. Journal of Applied Biobehavioural Research, 24(1), e12158.

Siu, A. M. (2019). Self-Harm and suicide among children and adolescents in Hong Kong: A

review of prevalence, risk factors, and prevention strategies. Journal of Adolescent

Health, 64(6), S59–S64.

Wong, P. W. C., Li, T. M. H., Chan, M., Law, Y. W., Chau, M., Cheng, C., Fu, K. W., Bacon-

Shone, J., & Yip, P. S. F. (2015). The prevalence and correlates of severe social

withdrawal (hikikomori) in Hong Kong: A cross-sectional telephone-based survey

study. International Journal of Social Psychiatry, 61(4), 330–342.

Feedback on activities and self-tests

Activity 2.1
During the COVID-19 pandemic period, you might have experienced different dimensions of
anxiety, manifested as a variety of emotions, thoughts and physiological sensations, which
may have prompted certain behaviours. The public health measures that were put in place
may have also had different effects on your actions and states of mind. This is a reflective
activity and your responses will be unique. The below are some general remarks to get you
thinking and making connections with ideas from abnormal psychology:
• Physiologically: On a practical level, the pandemic had a physiological impact on many
people due to restrictions and lockdowns limiting certain outdoor activities and resulting
in reduced frequency of exercises. These factors may complicate or aggravate feelings
of anxiety, which also have a physiological dimension, as you will read about in your
textbook (p. 88).
• Psychologically: COVID-19 precipitated a wide variety of mental health problems in the
population. People have reported psychological distress and symptoms of depression,
anxiety or post-traumatic stress. Widespread public health messaging about hand
26 PSYC A232 Introduction to Abnormal Psychology

hygiene and sanitisation, while important to the broader population, may have
compounded the difficulties experienced by some with obsessive-compulsive disorder.
Furthermore, reports of suicidal thoughts and behaviours among vulnerable young
people studying at home and unable to socialise were a further cause for concern.
• Cognitively: Some people who caught COVID-19 reported symptoms involving various
deficits in cognitive functioning such as attention, executive functioning, language,
processing speed, and memory. The collective term for these symptoms was colloquially
known as ‘brain fog’.
• Behaviourally and socially: Social distancing measures during the pandemic forced
individuals to adapt to isolation in different extents. This may have had the impact of
increasing the prevalence of conflicts or violence in the family, depression, anxiety, and
different mood disorders.

Activity 2.2
Research has revealed that worrying does have a positive effect on those with GAD. While it
does not prevent catastrophe, when those with GAD worry, emotional and physiological
responses to negative stimuli are suppressed. In other words, the act of worrying about an
event lessens the impact of that event if and when it does occur.
Researchers have suggested that people with GAD prefer to deal with this tolerable, chronic
anxiety rather than the possibility of sudden peaks of negative emotion, therefore the chronic
worrying is reinforced.

Activity 2.3
1. The statement is not entirely accurate. According to preparedness theory, the fear itself
is not inherited, but the tendency to quickly make certain connections is. Our
evolutionary history may dictate the stimuli we are most likely to fear. People and
primates seem genetically prepared to quickly associate certain objects with fear. While
there are many types of specific phobias, most involve animals and situations that were a
threat to our ancestors. Those primates and humans who had this rapid acquisition of
fear were more likely to survive and pass on their genes.
2. From an evolutionary standpoint, it may have been advantageous to acquire fears of
social stimuli that signalled danger (e.g. angry or contemptuous faces). So you could
argue that social anxiety disorder may have an evolutionary basis. In OCD, a common
obsession is contamination and dirt — so you could argue that developing a fear of dirt
could have protected our ancestors against disease and infection, although there is little
scientific evidence at present to support this idea.

Activity 2.4
A diagnosis of bipolar I is made when there has been a manic episode. This diagnosis is made
with or without the occurrence of a bout of major depression. In bipolar II, there is at least
one episode of major depression and a hypomanic episode. If the individual with bipolar II
exhibits a manic episode, a diagnosis of bipolar I is warranted.
 Unit 2 27

Activity 2.5

Mood Brain region affected As compared to healthy people,

disorder the following changes are seen
Depression Left prefrontal cortex Metabolic activity is:
Increased ☐
Decreased ☑
Hippocampus The volume is:
Increased ☐
Decreased ☑
Amygdala Activation is:
Increased ☑
Decreased ☐
Bipolar disorder Striatum Activation is:
Increased ☑
Decreased ☐
Hippocampus The volume is:
Increased ☐
Decreased ☑
Amygdala Activation is:
Increased ☑
Decreased ☐

For more information on these brain abnormalities, please turn back to your custom textbook
(p. 156 — depression; p. 165 — bipolar).

Activity 2.6
1. Your suggestions should focus on the elements of effective campaigns for suicide
prevention: emphasising help-seeking, reducing stigma, encouraging positive behaviour
change, informing the audience of available resources, and highlighting effective
treatments and support. Your leaflet may include messages and information to this
effect, including practical details of crisis hotlines and support in your areas. You may
also wish to include suggestions for friends of suicidal people in emergencies, in which
case the list on page 188 of the textbook can provide some pointers.
2. The warning signs for student suicide at university may include: marked change in mood
and behaviour, especially withdrawal; decline in self-esteem; not taking care of personal
hygiene; uncharacteristically impulsive behaviours; not attending classes. Many students
communicate their impulses. Often the behaviour is a reaction to the break-up of a
romance.
Here are some links you can explore for more information about warning signs:
• For people in general: https://sprc.org/warning-signs-for-suicide/
• With more details about university students: https://wmich.edu/suicideprevention/basics/
warning-signs
28 PSYC A232 Introduction to Abnormal Psychology

Self-test 2.1
Obsessions are persistent, recurrent, intrusive thoughts. Examples include concerns about
contamination or fear of harming oneself or others. Compulsions are repetitive behaviours or
mental acts that a person feels driven to perform in a ritualistic way. They are usually in
response to an obsession and done to reduce anxiety. Examples include cleaning (e.g.
surfaces, hands) and checking (e.g. doors being locked, household appliances being off).
Both flooding and systematic desensitisation are examples of exposure therapy for phobias,
the purpose of which is to place people in the situation they fear for long enough that
extinction occurs and their fear subsides. In terms of the difference between flooding and
systematic desensitisation, systematic desensitisation usually exposes the client with the least
feared stimulus first (e.g. an image of a cartoon reptile), then gradually proceeds towards the
most feared stimulus (e.g. a reptile in a pet store) which is usually followed by relaxation
training after the gradual exposure. On the contrary, flooding involves immediate exposure to
the most frightening stimulus.
In order to be diagnosed with generalised anxiety disorder, an individual must exhibit worry
on a majority of days over at least a six-month period. The worry must not be associated with
another disorder and it must be perceived as difficult to control. In addition to the experience
of worry, at least three of the following six symptoms must be present: (1) restlessness or
edginess, (2) a feeling of being easily tired, (3) problems concentrating, (4) irritability,
(5) muscle tension, and (6) sleep disturbances.

Self-test 2.2
1. Beck’s theory is a cognitive model that suggests that thinking precedes and causes
depression. First, people hold dysfunctional beliefs that predispose them to depression.
These are rigid, extreme, and unhelpful beliefs about the world. People with depression
create automatic, negative thoughts that centre around the cognitive triad, i.e.:
• negative views about oneself, such as feeling worthless or incompetent;
• negative views about the world, such as seeing the world as unfair or dangerous; and
• negative views about the future, such as feeling hopeless or believing that things will
never get better.
This triad of negative beliefs and feelings is maintained by cognitive errors such as all-
or-none reasoning and arbitrary inference. Beck’s theory has been well supported as an
explanation for many aspects of depression, and is the basis for cognitive-behavioural
therapy (CBT).
2. To answer this question, you may briefly describe one of the psychological approaches
to treating depression that are covered in the textbook, i.e. behavioural therapy,
cognitive-behavioural therapy, or interpersonal therapy. Many studies have shown the
usefulness of cognitive-behavioural therapy, and it seems to prevent relapse and
recurrence of depression. However, studies which have compared different therapeutic
approaches to treating depression have found them to be equally effective in treating
depression. From the question, we don’t know much about Nancy’s depression, but the
best therapy could be the one that best fits her personal circumstances as well as one that
provides a good therapist-client match.

Self-test 2.3
While the Western constellation of depressive symptoms is primarily psychological, in many
cultures the symptoms tend to be more somatic. In those cultures in which there is great
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stigma associated with mental illness and/or a lack of emotional expressiveness (this may
include Asian collectivist societies including Hong Kong), depression may manifest itself in
symptoms such as weight loss, sleep disturbances, and sexual dysfunction. In addition, the
feelings of guilt and worthlessness that characterise depression in individualistic cultures may
not be seen in more communal cultures.