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To what extent do biological, cognitive and sociocultural factors influence abnormal

behaviour?
Abnormal behaviour: Major Depressive Disorder
o Affective disorder
o Unipolar depression (fluctuates between normal to depressed)
o

Sociocultural etiologies of depression:


Diathesis stress model:
Claims that depression may be a result of inherited predisposition and
events from the environment (hence, diathesis: two explanations)

Brown and Harris (1978): Social origins of depression in women


Aim

Find out the social origins of depression in women

Process

Studied women who received hospital treatment for depression


Sampled 458 women in the general population aged between 1865

Findings

82% of those who became depressed had recently experienced


severe life-changing events
33% experienced severe life changing events in the non-depressed
group
23% working class women became depressed within the last year
3% in the middle class
Those with younger children were at higher risk of becoming
depressed

Lewinsohn et. Al. (2001): Sociocultural aspects of MDD


Description

Studied adolescents who experienced many negative life events


over a 12-month period
Those who had strongly negative attributions at the start of the
study were much more likely to develop MDD
Diathesis stress model (events from the environment)

Vulnerability model:
Losing either parent at a young age; lack of confiding relationship; more
than three young children at home; unemployment

Conclusion

Life events that resembled previous experience were more likely to


trigger depression

Evaluation

Relatively big sample group; representable of the general


population, results can be generalised
Cultural factors were not taken into consideration

Symptoms of depression in different cultures:


Affective symptoms (sadness, loneliness, isolation) are typical to
individualist countries
Collectivist cultures have a stronger and tighter network to support
individuals so somatic symptoms are more common

Prince (1968): Depression in Africa and Asia


Brief

Evaluation

Study claims that there were no signs of depression in Africa and


parts of Asia
Reported depression rose with westernisation in colonial countries
Researchers argue that depression is not exactly the same globally
Depression may be expressed differently and may escape the
attention of people from different countries
Asian and African countries tend to be more collectivist:
People from collectivist societies might not report depression
since it might affect others in the social network

Cognitive etiologies of depression:


Learned helplessness and hopelessness:
Learned that you are helpless, therefore lowering one's self-esteem;
explains withdrawal; link to faulty attributions

Teuting (1981): Depression and serotonin study


Description

Seligman (1967): Learned Helplessness in dogs


o

Faulty attributions (Abramson):


Negative mindset; explains self-blame/guilt; pessimists
Attributions of negative events to Internal, Stable, and Global, hence
affecting their self-esteem
Internal: dispositional attribution
Stable: happens every time
Global: happens all the time, every situation

Negative self-schema (Beck):


Develops early on in life
Relies heavily upon parental influences
Negative self-schema, new event interpreted negatively regarding
yourself

Cognitive triad (Beck):


Self <=> World <=> Future
Example:
Self: "I am going to do really bad in my coursework"
World: "Everyone probably thinks I suck"
Future: "I'm going to fail my course"
Biological etiologies of depression:
Neurotransmitters (serotonin):
Responsible for our mental wellbeing/depression
During process of neurotransmission, not all serotonin gets absorbed by
the post-synaptic neuron
o Extra serotonin is taking back into the pre-synaptic neuron
through active reuptake; or serotonin gets broken down by
monoamine oxidase (MAO), which cause a low level of
serotonin to be absorbed by the post-synaptic neuron
o Low level of serotonin in the post-synaptic neuron means the
impulse cannot be started
Diathesis stress model (physical vulnerability to stress)

Individuals with depression were asked to provide a urine sample


There was a significantly lower level of serotonin in the urine
sample of participants with depression
Result of MAO breaking down the serotonin, correlating to the
participant's depression

Genetics:
Monozygotic twins (identical twins)
o 100% same genes
o If twin A has something, twin B must have it
Dizygotic twin (fraternal twins)
o 50% similar genes
If there is a genetic aspect to behaviour, a high concordance rate would
be expected form monozygotic twins
Correlational study:
Genetics research is mostly done through this sort of study
o Concordance rate (presence of the same trait)
o Relationship/association
o To show to what extent two variables are related
Strengths:
o Shows how closely two variables relate
o High ecological validity, natural environments
o Allow study that could not be tested through experiments
ethically
o Representative sample
Weaknesses:
o Bidirectional ambiguity: cannot tell which caused which
o No manipulation of independent variable
Procedures of correlational genetic studies:
o Are all done in a similar manner
o Observation of pairs of twins or families
For twin studies, both monozygotic (MZ) and dizygotic
(DZ) twins, reared together and apart, will be used
Twin studies:
If it were a wholly genetic disorder, the concordance rate for MZ twins
should be 100% and for DZ twins should be 50%
Otherwise, other factors must be involved

Family studies:
Similarly to twin studies, if it was genetic, must run in families
The closer you are genetically to someone in the family, higher
probability you will have the disorder
Genetics studies grid

Rosenhan (1973): On being sane in insane places


Aim

Challenge the reliability and validity of diagnosis


Investigate the effects of labelling

Process

Eight participants, 5 male and 3 female, attempted to gain


admittance to a hospital's psychiatric ward
Participants phoned up the hospital for a diagnosis appointment
They all used a fake name and job (to protect their future health
and employment record [ethical considerations])
All the participants claimed they were hearing voices
These are existential symptoms which arise from concerns
about how meaningless your life is
They were chosen because there was no mention of
existential psychosis in the literature
After being admitted to the ward, they stopped showing the
pseudo-symptoms and acted like they would ordinarily
Participants started making notes about their life and the way they
were treated in the ward
Initially was done secretly, because they were scared
wardens might find out
Afterwards, however, they realised no one cared so they did
it publically
Participants asked the staff for a favour that tested the behaviour of
staff towards patients, which took the following form:
"Pardon me, Mr/Mrs/Doctor, could you tell me when I will be
presented at the staff meeting?" (or " when am I likely to
be discharged?")
Similar procedure was carried out with students at Stanford
University with students asking university staff a simple
question
Results were used to compare

Evaluate psychological research relevant to the study of abnormal behaviour.


Studies:

Rosenhan: On being sane in insane places II


Aim

Follow up study for Rosenhan (1973): On being sane in insane


places

Process

Falsely inform psychiatric institute that were aware of the first


study that during the next three months one or more pseudopatients would attempt to be admitted into their hospital
Staff members were asked to rate on a ten-point scale each new
patient as to the likelihood of them being a pseudo-patient
No pseudo-patients were sent

Findings

Conclusion

Evaluation

193 patients were judged


41 were confidently identified as a pseudo-patient by at least one
member of staff
23 were suspected as pseudo-patients by a psychiatrist
19 were suspected by a psychiatrist and a member of staff
Rosenhan claims that the study demonstrates that psychiatrists
cannot reliably tell the difference between people who are sane
and those who are insane
The main experiment (I) illustrated a failure to detect sanity, and
the secondary study (II) demonstrated a failure to detect insanity
Everything a patient does is interpreted in accordance with the
diagnostic label once it has been applied
The result of labelling/stigmatisation
Should focus on individual's specific problems regarding behaviour
rather than their sanity
Deception was involved, unethical
Research was done at the cost of misdiagnosis of patients with
actual mental disorders

Findings

All pseudo-patients disliked the environment and wanted to be


discharged immediately
All participants were 'diagnosed' with schizophrenia
No staff suspected their sanity
Patients in the ward, however, did suspect the sanity of some of
them, and reacted vigorously
E.g. "You're not crazy. You're a journalist, or a professor.
You're checking up on the hospital."
Patients were deprived of almost all human rights (e.g. privacy)
Medical records were not kept confidential

Conclusion

Evaluation

Hygiene was poor


Wardens would be brutal to patients when no other warden was
around
Indicates that patients had no credibility, but wardens did
Time spent with nurses, psychiatrists etc. averaged under 7 minutes
a day
There is an enormous overlap in the behaviours of the sane and the
insane
We all feel depressed sometimes, have moods, become angry; but
in the context of a psychiatric hospital, these everyday human
experiences and behaviours were interpreted as pathological
Regarding the favour asked, most pseudo-patients were ignored;
whereas all questions were addressed in the Stanford University
experiment
Experience of hospitalisation of the pseudo-patients was one of
depersonalisation and powerlessness
Field experiment/covert observation; high ecological validity
Can argue that the experiment is low in ecological validity as
psychiatrists don't usually diagnosis "pseudo-patients"
It is expected that the person will have some sort of disorder
if they seek diagnosis
Psychiatrists would normally play safe in their diagnosis
Because there is always an outcry when a patients is let out
of psychiatric care and gets into trouble
Always a higher likelihood of diagnosing an normal person sick than
a sick person normal
DSM-II was used then, an updated version of the DSM (DSM-IV)
used now has more sophisticated descriptions for diagnosis
Showed that patients suffering from psychological disorders
experienced:
Labelling and stigmatisation
Depersonalisation
Discrimination
Controversial study
Deception was involved, unethical

Jahoda's Mental Health Criteria


Conditions

Means

Positive self-attitude

Having a positive self-concept

Self-actualisation

Striving to fulfil potential

Personal autonomy

Being fairly self-reliant

Accurate perception of reality

Having a realistic view of ourselves/the world

Adapting to the environment

Being flexible and adaptive

Resistance to stress

Ability to tolerate anxiety

Seligman and Rosenhan's Seven Criteria of Abnormality


Conditions

Means

Suffering

Distress or discomfort

Maladaptiveness

Engage in behaviour that made life more difficult

Irrationality

Incomprehensible, cannot communicate in a


reasonable manner

Unpredictability

Act in ways that are unpredictable

Unconventionality

Experiencing things that are different

Violation of moral and ideal


standards

Breaking ethical and moral standards

Observer discomfort

Acting in ways that makes others feel discomfort

Theories:

Evaluation and criticism:


They value judgments about mental health, i.e. they reflect the ideals
and values of the person who constructed the list
A psychopath, for example, has a very positive attitude to self, but his
amoral behaviour is likely to be seen very negatively by others
Ambiguity and subjectivity in defining terms (e.g. reality and
positivity)
There are people who are normal that do not fulfil the characteristics
and people that are abnormal that fulfil the characteristics
Influenced by cultural attitudes
Too idealistic, only a few individuals can achieve the idealistic self
Too difficult to measure, too vague to diagnose

Classification/Diagnosis systems:
Classification systems are supposed to be objective
Traditional medical models in psychiatry are now assumed to be reductionist
Most psychiatrists use a biopsychosocial approach in diagnosis and treatment
Diagnosis is based on symptoms:
o Affective
o Behavioural
o Cognitive
o Somatic
Based heavily upon abnormal experienced and beliefs reported by patients that are
agreed upon by a team of professionals
Explains why classification/diagnosis systems are often updated and revised
Strengths:
o Statistical diagnosis
o Quantifiable
o Ability to identify disorders based on symptoms, therefore a suitable
treatment can be applied
Weaknesses:
o Ethical consideration is the main weakness of classification systems
o The effects of labelling:
Leads to stigmatisation
Prejudice and discrimination
Self-labelling can lead to self-fulfilling prophecy
Person diagnosed with disorder acts according to the label
DSM- Diagnostics and Statistical Manual of Mental Disorders:
A handbook used by psychiatrists in the US to identify and classify symptoms of
psychiatric disorders
A standardised system in diagnosis based upon:
o Patient's clinical and medical conditions
o Psychosocial stressors
o The extent that a person's mental state interfere with their daily life
Five axis of the DSM:
o Clinical syndromes
o Developmental and personality disorders
o Medical conditions
o Psychosocial stressors
o Global assessment of functioning

Ethical concerns regarding the DSM:


o Better to regard those suffering from mental disorders as 'sick' rather than
'morally defective'
Removes the responsibility from the patient
o Does not completely prevent patients from being labelled

Examine the concepts of normality and abnormality.

Deviation from the norm (statistical infrequency):


Unusual behaviours are sometimes desirable (e.g. geniuses)
Undesirable behaviour are sometimes normal (e.g. depression)
o Having disorders without breaking social norms
Norm differs due to culture, age; criteria are not universally applicable
Who decides the extent of deviation from the norm?
Causes ethical issues: social labelling; discrimination; violation of human rights
Social deviation:
Normality is defined by the standards of social behaviour
Variation of norms in different demographic/social groups
Situational norms: acceptable depending on the situation
Developmental norm: acceptable depending on development
Norms changing according to prevailing moral values: e.g. homosexuality, divorce
Pressure on becoming the norm:
o Conforming to the norm without internalising it
o Repressed to a point where one develops a disorder
Dysfunction and distress:
Behaviour disrupts that ability to work and/or to conduct satisfying relationship
with people
Not all mental disorders are accompanied by distress (antisocial personality
disorder)
Not all distress are disorders (grief)
Rosenhan and Seligman:
o Certain elements jointly determine abnormality, when they co-occur, then it
is symptomatic
What are positive and negative symptoms?

Diagnosis:

Deviation from mental health:


Jahoda's (1958) Mental Health Criteria
Seligman and Rosenhan's Seven Criteria of Abnormality

Discuss validity and reliability of diagnosis.

Purpose of diagnosis:
Identify abnormal disorders so treatment can be applied accordingly
Provides investigation opportunities into the etiologies of disorders
Method of diagnosis:
Biological tests:
o Brain scans
o Blood tests
Psychological tests:
o IQ test
o Personality test
o Cognitive tasks
o Interviews
o Observations
Reference to the classification system (e.g. DSM, ICD)
Classification/Diagnosis systems:
Classification systems are supposed to be objective
Traditional medical models in psychiatry are now assumed to be reductionist
Most psychiatrists use a biopsychosocial approach in diagnosis and treatment
Diagnosis is based on symptoms:
o Affective
o Behavioural
o Cognitive
o Somatic
Based heavily upon abnormal experienced and beliefs reported by patients that are
agreed upon by a team of professionals
Explains why classification/diagnosis systems are often updated and revised
Strengths:
o Statistical diagnosis
o Quantifiable
o Ability to identify disorders based on symptoms, therefore a suitable
treatment can be applied
Weaknesses:
o Ethical consideration is the main weakness of classification systems
o The effects of labelling:
Leads to stigmatisation
Prejudice and discrimination
Self-labelling can lead to self-fulfilling prophecy
Person diagnosed with disorder acts according to the label

Temerline (1970): Authority on diagnosis

Reliability:
Whether the same disorder is diagnosed every time
Inter-rater reliability: whether different diagnosticians get the same diagnosis (i.e.
how objective the diagnostic criteria is)
Test-retest: whether repeating the diagnosis will give a different result between
each time

Aim

Investigate the effect of authority on diagnosis

Process

2 groups of participants listened to the same taped interview of a


person describing their own life
The person talked about a seemingly normal life (i.e. happy
marriage, enjoyment at work)
A respected figure in psychiatry then told one group of participants
that he think the man was psychologically healthy
He told the other group that he thinks the person was psychotic
Participants were then asked to judge the person's mental health

Cooper et. Al. (1972): New York/London diagnosis


Description

And identical video clip of a patient was shown to psychiatrists


from New York and London
Psychiatrists from New York had a higher likelihood of diagnosing
schizophrenia
Psychiatrists from London were more likely to diagnose mania or
depression

Findings

Conclusion

Shows that someone with authority and expertise can have a strong
influence on the way people are perceived

Evaluation

The story of the taped person was hypothetical


Might have gave a different response if the person was
physically present
Difficult to gather information about real-life roles and interactions
between psychiatrists and patients
May break ethical guidelines (privacy and confidentiality)
Opinions on causes and treatment may different between
psychiatrists

Beck (1962): Psychiatrists agreement


Description

Agreement between two psychiatrists on diagnosis for 153


patients was 54%
This was due to the vagueness in criteria for diagnosis and a
different process for diagnosis

Validity:
Does the diagnosis process measure a real pattern of symptoms?
Can effective treatment be administered based on the diagnosis?
Are there biases in diagnostics?
o Confirmation bias: psychiatrists put emphasis on factors that hint patient's
disorders and overlooks other possible factors
o FAE: over attributing the causes to the dispositional factors
o Self-fulfilling prophecy: patient gets labelled as having a certain disorder and
acts according to the label

Those who were told the participant was normal gave a 'normal'
diagnosis
Those who were told that the participant was psychotic agreed with
that diagnosis

Discuss cultural and ethical considerations in diagnosis.


o
o
o
o

Rosenhan (1973): On being sane in insane places

o
o

Classification/Diagnosis systems:
Classification systems are supposed to be objective
Traditional medical models in psychiatry are now assumed to be reductionist
Most psychiatrists use a biopsychosocial approach in diagnosis and treatment
Diagnosis is based on symptoms:
o Affective
o Behavioural
o Cognitive
o Somatic
Based heavily upon abnormal experienced and beliefs reported by patients that are
agreed upon by a team of professionals
Explains why classification/diagnosis systems are often updated and revised

o
o
o
o

Strengths:
o Statistical diagnosis
o Quantifiable
o Ability to identify disorders based on symptoms, therefore a suitable
treatment can be applied
Weaknesses:
o Ethical consideration is the main weakness of classification systems
o The effects of labelling:
Leads to stigmatisation
Prejudice and discrimination
Self-labelling can lead to self-fulfilling prophecy
Person diagnosed with disorder acts according to the label

Binitie (1977): Schizophrenia in Nigeria

Investigate the cultural differences in criteria of normality and


abnormality

Process

Participants were tribesmen from the Yoruba tribe in Nigeria


Information of patients with schizophrenia were presented to the
people of the Yoruba tribe

Only 40% of the tribesmen from the Yoruba tribe identified the
patients as mentally ill
30% said they would marry such a person
This may be due to the cultural differences between the tribesmen
and the westernised world

Findings

Conclusion

Shows the importance of an emic approach to studies


The ability to identify the definition of 'abnormality' in different
cultures can only be done in culture-specific approaches to studies

Investigate the cultural differences in criteria of normality and


abnormality

Process

Participants were Nigerians living in the city


Information of patients with schizophrenia were presented to the
participants

Findings

Most participants correctly identified the patients as mentally ill


31% showed aggressive response to such patients (e.g. suggesting
that they should be expelled or shot)

o
o
o

Erinosho and Ayonrinde (1978): Nigeria Yoruba tribe study

Conclusion

Cultural considerations:
An individual's behaviour is governed to an extent by the culture they are brought
up in
There are likely to be different perceptions of behaviour in different cultures,
different cultural norms
A tendency to favour one's own cultural view of the world
Studies on psychological disorders originate from the west, hence the tendency
that the diagnosis systems favour the western culture

Aim

Aim

o
o
o
o
o

o
o
o

Shows how western culture has influenced the judgment of


normality

Overall conclusion:
Seems that schizophrenia is a western model; tribal Nigerians did not see
hallucinations as something negative
Cultural relativism suggests that abnormality is subjective cross-culturally
Hallucinations and cultural perspectives was also investigated in
Kasamatsu and Hirai (1999): Monk serotonin study
DSM vs. CCMD:
DSM: internationally recognised diagnosis system; westernised model
CCMD (Chinese Classification of Mental Disorders): China-specific diagnosis
system based upon the Chinese cultural background
The need for more than one classification system suggests that culture has
its effect on the criteria for abnormality and syndromes
Uses different criteria in the different classification systems
Takes care of certain culture-bound syndromes

Ethical considerations:
Ethical concerns regarding diagnosis mainly surround the issue of labelling and its
consequences
After diagnosis, the patient will inevitably be labelled with the diagnosed illness
Labelling will then causes stigmatisation
o Where the patient will have a negative persona attached to them because
they are labelled as mentally ill

o
o
o

o
o

o
o
o

Depersonalisation and powerlessness:


Removal of human rights; frequent verbal or physical abuse
Usually seen in mental institutes
Demonstrated in Rosenhan's study
Participants reported that cases of depersonalisation were observed in
the institute; this worsens the mental illness

Describe symptoms and prevalence of one anxiety/affective/eating disorder.

Self-fulfilling prophecy:
Patients may start to act according to the label they were given because they
think they should act that way
Demonstrated in Scheff's Labelling Theory
"Scheff (1966) argued that receiving a psychiatric diagnosis creates a
stigma or make of social disgrace."
Showed criticism toward the classification systems, in particular the
diagnosis of schizophrenia
Schizophrenic does not mean that they will break formal and obvious
rules; but residual rule breaking (basically breaking the norm)
He argued that many people break residual rules, but only those
referred to a psychiatrist acquire a label, which influences their
behaviour
Prejudice and discrimination:
Demonstrated in Rosenhan's study
Stickiness of diagnostic labels
When an individual returns to society, their record of mental illness goes
with them
The pseudo-patients left with a diagnosis of 'schizophrenia in remission'
This can lead to stigmatisation, stereotyping and discrimination against
those who have been mentally disordered

Depression (affective disorder):


Symptoms:
o Affective: The way people react emotionally and their ability to feel
emotions
Feeling of sadness and despair; or an absence of feeling (emptiness)
Fail to display interest and find pleasure in everyday activities
Feelings of guilt about a real or imagined event can also occur
o Cognitive: The ability to rationalise, remember and concentrate at their
usual level; the thoughts individuals have about themselves, other people
and their intentions
Impaired thought and logic process
Low levels of concentration
Negative self-schema
Paranoia
Thoughts of committing suicide
o Behavioural: The way that the individual behaves, activities they participate
in or withdraw from, and psychomotor movements
Severely depressed people can stop socialising, lose interest in sex
and stop taking care of themselves
Everyday activities may take much longer to complete
Withdrawal from friends and family members
Attempt suicide
o Physical (somatic): Physical changes that the individuals may experience
Headaches, stomach aches
Palpitations
Lack of energy
Loss of appetite, leading to weight loss
Sleep disturbance, insomnia
Prevalence:
o Affecting 15% of the population; 80% who get it are more likely to get it
more than once
o 2 weeks or more of continuous low mood to be considered as depression
o Women are 70% more likely than men to develop depression in their
lifetime
o SAD is likely to happen between the ages of 18-30
o 90% of people who have a type of depression are unipolar, not bipolar
o Men are less likely to report feelings of depression

Obsessive compulsive disorder (OCD) (anxiety disorder):


Symptoms:
o International Classification of Diseases 10th edition (ICD 10)
Recurrent obsessional thoughts or compulsive acts
Obsessional thoughts:
Ideas, images, impulses that enter the individual's mind
repeatedly in a stereotyped form
Extremely distressing, the sufferer often tries, unsuccessfully,
to resist them
Compulsive acts:
Stereotyped behaviours that are repeated
They are not inherently enjoyable neither do they result in the
completion of particularly useful tasks
o Diagnostics and Statistical Manual of Mental Disorders 5th edition (DSM V)
Obsessions:
Recurrent and persistent thoughts, impulses or images that are
experienced
Preoccupation with sexual, violent or religious thoughts
Compulsions:
Repetitive behaviours that are aimed at reducing distress or
preventing dreaded event or situation
Extreme hoarding
Nervous rituals
o Most of the time during the episode, the sufferer does not recognise that
the obsessions and compulsions are excessive or unreasonable
Prevalence:
o Fourth most common mental disorder
o In the US, 1/50 adults suffers from OCD
o About 1/3 to 1/2 of adults with OCD report a childhood onset of the disorder
(suggests that the continuum of anxiety disorder across the lifespan)
o OCD is equally common in men and women; onset is reported to occur
earlier in men, though
o Lifetime prevalence in community surveys of about 2-3%

Analyse etiologies of one anxiety/affective/eating disorder.


Depression:
Biological etiologies of depression:
o Neurotransmitter - Serotonin:
Responsible for our mental wellbeing
During process of neurotransmission, not all serotonin gets absorbed by
the post-synaptic neuron
o Extra serotonin is taking back into the pre-synaptic neuron
through active reuptake; or serotonin gets broken down by
monoamine oxidase (MAO), which cause a low level of
serotonin to be absorbed by the post-synaptic neuron
o Low level of serotonin in the post-synaptic neuron means the
impulse cannot be started
Diathesis stress model (physical vulnerability to stress)
Teuting (1981): Depression and serotonin study
Cognitive etiologies of depression:
o Learned helplessness and hopelessness:
Learn that you are helpless, therefore lowering one's self-esteem
Explains withdrawal
Link to faulty attributions
Seligman (1967): Learned Helplessness in dogs
o

Faulty attributions (Abramson):


Negative mindset; explains self-blame/guilt; pessimists
Attributions of negative events to Internal, Stable, and Global, hence
affecting their self-esteem
o Internal: dispositional attribution
o Stable: happens every time
o Global: happens all the time, every situation

Negative self-schema (Beck):


Develops early on in life
Relies heavily upon parental influences
Negative self-schema, new event interpreted negatively regarding
yourself

Cognitive triad (Beck):


Self <=> World <=> Future
Example:
o Self: "I am going to do really bad in my coursework"
o World: "Everyone probably thinks I suck"
o Future: "I'm going to fail my course"

Sociocultural etiologies of depression:


o Diathesis stress model:
Claims that depression may be a result of inherited predisposition and
events from the environment (hence, diathesis: two explanations)
Lewinsohn et. Al. (2001): Sociocultural aspects of MDD
o

Vulnerability model:
Losing either parent at a young age; lack of confiding relationship; more
than three young children at home; unemployment

Brown and Harris (1978): Social origins of depression in women


o

Symptoms of depression in different cultures:


Affective symptoms (sadness, loneliness, isolation) are typical to
individualist countries
Collectivist cultures have a stronger and tighter network to support
individuals so somatic symptoms are more common

Prince (1968): Depression in Africa and Asia


Obsessive compulsive disorder (OCD):
Biological etiologies of OCD:
o Genetic predisposition:
McKeon and Murray (1987): OCD prevalence
Description

Relative of OCD patients were more likely than the rest of the
population to suffer from anxiety disorders in general, but no
more likely to suffer specifically from OCD

Neurological factor:
An affected neurological pathway that regulates aggression, sexuality
and bodily secretions
The pathway includes the following three regions of the brain:
o Orbital frontal cortex (OFC)
o Thalamus
o Caudate nucleus
Caudate nucleus acts as a break, suppressing signals that trigger anxiety
("worry signals") from the OFC to the thalamus, preventing it from
hyperactivity
Damaged
caudate nucleus therefore increases signals between the OFC

and thalamus, resulting in increased anxiety


Patients with OCD display obsessions and compulsions related to
aggression, sexuality, and combination, much like what this
neurological pathway deals with
The primitive natural of this particular neurological pathway explains
why patients with OCD are often irrational

Baxter, et. Al. (1992): Caudate nucleus and OCD


Aim

Observe the differences in brain function in patients with OCD


before and after successful treatment

Process

PET scanning was used to identify active areas of the brain

Findings

The right caudate nucleus became more active in patients after


treatment

Conclusion

There is a correlation between the activity of the caudate nucleus


and OCD

Neurotransmission:
Patients with OCD response positively to SSRI, suggesting that an
imbalance of serotonin may be the cause of dysregulation of the
neurological pathway
Low serotonin levels may cause misinterpretation and overreaction to
external stimulus
o Leading to flawed cognition, developing into obsession
Lowering serotonin levels with M-CCP (meta-Chlorophenylpiperazine)
made the symptoms worse (Hollander et al.)
Antidepressants, which increase serotonin levels, can reduce OCD
symptoms (Pigott et al.)

Cognitive etiologies of OCD:


o Distorted cognition formed during early stages of life may have led to OCD
o The following are false beliefs/schemas which patients with OCD often have:
Exaggerated responsibility in preventing misfortunes or harm to others
The belief that certain thoughts should be controlled
The belief that having a thought or urge to do something will increase its
chances of becoming true
Tendency to overestimate danger
Perfectionist
o Compulsive routines are responses for the anxiety caused by these
obsessions:
Argued to be a learned, conditioned process to neutralise anxiety
The relaxing feeling motivates the repetition of the compulsive routines
Patients with OCD believe that there will be negative consequences if
compulsive routines are not carried out
o

Cognitive triad (Beck):


Self <=> World <=> Future
Example:
o Self: "I am going to do really bad in my coursework"
o World: "Everyone probably thinks I suck"
o Future: "I'm going to fail my course"
Beck's cognitive triad suggest that patients with OCD have chosen to
generate their own obsessive thoughts
o Since decision-making is a cognitive process, it can be seen that
OCD may primarily be caused by cognitive distortion; leading to
compulsive acts as a method of neutralisation

Sociocultural etiologies of OCD:


o Few people believe that the etiology of OCD is based on sociocultural
factors; hence very few studies have been done to investigate this area
o There are studies that focus on whether or not "demographic factors and
personal characteristics [have] an impact on the development of OCD"

Sullivan (2008): Factors related to OCD


Aim

Examining the relation between academic majors/minors of college


students, birth order, level of stress, locus of control, and the
amount of obsessive-compulsive behaviours

Process

All participants were selected through convenience sampling


A sample of 75 undergraduate students were surveys
51 females, 24 males
46 students with science/business majors/minors
26 students with liberal arts/humanities majors/minors
30 first-born or only children
43 standing lower in the birth order
Questionnaires assessing OC behaviour using a 1-7 Likert scale were
administered to participants
Questions were based on the Yale-Brown Obsessive Compulsive
Scale (Y-BOCS); including 26 questions measuring obsessive
thoughts and compulsive behaviours
Relationships between the different demographics and OCD
behaviour were determined using a t-test

Findings

Conclusion

Results supports the following hypothesis:


Females reported more OC behaviours
Participants with greater stress levels reported more OC
behaviours
Results do not support the following hypothesis:
First-born and only children reporting more OC behaviours
Students with external locus of control reporting more OC
behaviours
Difference in the amount of OC behaviours among students
of science/business majors/minors vs. liberal arts/humanities
majors/minors
Greater stress levels means higher level of anxiety
Prevalence of OC behaviour in this demographic can arguably
be a response to sooth the high anxiety levels
Most demographics chosen were not equally sampled, and this
sample size is not representative of the population

Discuss cultural and gender variations in prevalence of disorders.


Kleinman (1982): China somatisation
Cultural variations: China and depression
o The apparent rarity of depression in China was noted by Western observers
in the early 1980s
Psychiatric survey of mental disorders was undertaken in seven regions
in 1993
Lifetime prevalence of affective disorder was 0.08%, point prevalence
was 0.05%
Reasons for this include:
o Psychological symptoms are primarily reported as physical symptoms:
Party because of a long-standing attachment to the diagnosis of
shenjing shuairuo (neurasthenia)
o Translates as 'neurological weakness'
o Patients presenting with a clinical picture of insomnia,
dizziness, headache, poor concentration
o Got the diagnosis of neurasthenia because patients prefer to
interpret their illness as physical in origin and report only
somatic discomforts to their doctors
There has been a shift towards more diagnoses of depression, because
of a shift towards Western criteria
o Stigma:
Mental illness is stigmatised in traditional Chinese culture
It is seen as evidence of weakness of character and a cause for family
shame
o Differences in diagnostic practice:
E.g. Chinese psychiatrists have tended to take a broad diagnostic view of
schizophrenia and in some case, depression may be diagnosed as
schizophrenia
Murphy, et. Al. (1967): Cultural considerations linked to depression
Aim

Findings

Looking at cultural considerations linked to depression to identify


common symptoms of depression in 30+ countries
Symptoms were: sad, loss of enjoyment, anxiety, tension, lack of
energy, loss of interest, inability to concentrate, ideas of insufficiency,
inadequacy, worthlessness, loss of sexual interest, loss of appetite,
weight reduction, fatigue, self-accusatory ideas

Prince (1968): Depression in Africa and Asia

Description

China somatisation is a typical channel of expression of a basic


component of depressive experience
Chinese had the body as a medium of their distress

Marsella (1985): Symptoms of depression in different cultures


Description

Individualist cultures: present affective symptoms (sadness,


loneliness, isolation)
Collectivist cultures: cultures are larger, more stable social
networks, support the individual more, somatic symptoms such as
headaches are common

Parker (1988): DSM-III vs. CDC


Description

In a study comparing DSM-III diagnoses with diagnoses made by


Chinese psychiatrists using the Chinese diagnostic criteria in 116
patients in Shanghai, 12 of those who received a DSM-III diagnoses
of depression received a different diagnosis, including
schizophrenia, from Chinese psychiatrists

Gender variations: Depression


o Women are twice as likely as men to experience depression
20-25% lifetime rate in women compared to 7-12% for men
o Artifactual explanations:
Much research has assumed that the different rates are the result of an
artifact (a misleading result that occurs when an apparent gender
difference is due to some other variable that is associated with
gender)
Reporting bias:
o Critics point out that women may be more willing to seek
treatment for emotional problems, or more likely to admit that
they are depressed

Genetics:

Chevron, Quinlan and Blatt (1978): Reporting bias in depression


Description

There is a hypothesis that hold that men and women experience


depression symptoms equally frequently, and to the same degree,
but because depressive symptoms are perceived as feminine, men
are less likely to admit to them

Genetics studies grid (TWINS)


Nazroo and Edwards (1998): X-linkage theory of depression (HYPOTHESIS)

Prove that there is a possible x-linkage in the susceptibility towards


depression

Description

The position of the relevant locus on the x-chromosome


If the gene for depression is located in the x-chromosome and the
trait is dominant, females, who have two x-chromosomes, will be
more often affected than males, who only have one x-chromosome

Aim

Expression of symptoms:

Hammen and Peters (1977): Gender differences in self-reports of depression


Description

Men and women are equally susceptible to depression, but


depression in men often takes the form of "acting-out" behaviours
instead of sadness, passivity and crying, which are symptoms
commonly included in self-report inventories

Stress and chronic strain:


Women face a number of chronic burdens in everyday life as a result of
their social status and roles relative to men; these strains could
contribute to their higher rates of depression

Biopsychosocial model:

Williams and Spitzer (1983): Men, depression and alcoholism


Description

Suggested that the male equivalent of depression is alcoholism


Proponents of this argument point to statistics showing that twice
as many men as women are diagnosed as alcoholics
Suggest that rates of alcoholism in men make up for the absence
of depression in men

Weiss, et. Al. (1999): Role of hypothalamic-pituitary-adrenal (HPA) axis in


depression
Description

Egeland and Hostetter (1983): Depression rates among Amish men


Description

It is evident in cultures, such as Amish culture, where alcohol is


strictly prohibited, that there are no sex differences in rates of
depression found

Biological explanations:
Hormones:
o Women's reproductive events include the menstrual cycle,
pregnancy, the post-pregnancy period, infertility, menopause,
and sometimes the decision not to have children
o Events bring fluctuations in mood that, for some women,
includes depression
o Researchers have confirmed that hormones have an effect on
brain chemistry; so changes in emotions and mood often result

HPA axis plays a major role in regulating stress responses, in part


by regulating levels of a number of hormones (including cortisol)
Cortisol levels can affect other biochemicals known to
influence moods
People with MDD often show elevated cortisol responses to
stress, indicated dysregulation of the HPA responses
Women are more likely than men to have deregulated HPA
response to stress, which makes them more likely to develop
depression in response to stress

Examine biomedical, individual and group approaches to treatment.


Evaluate biomedical, individual and group approaches in the treatment of one disorder
(DEPRESSION).

Biomedical treatments:
o Based on the assumption that a neurotransmitter imbalance is implicated in
disorders such as depression
o The serotonin hypothesis suggest that there is a lack of serotonin in the
synaptic gaps for effective transmission
Most medications aim to increase the amount of serotonin available
by preventing the reuptake of serotonin, making it stay in the synaptic
gap longer, and thereby increasing the efficiency of the serotonin
already present
o

Evaluation:
Generally antidepressants are an effective way to treat depression

Elkin, et. Al. (1989): Effectiveness of antidepressants


Aim

To determine the effectiveness of antidepressants in treating


depression

Process

Conducted by the NIMH


Double-blind experiment design: a form of experimental control,
whereby both the subject and experimenter are kept uninformed
about the purpose of the experiment, to reduce any forms of bias
Included 28 clinicians who worked with 280 patients diagnosed as
having MDD
Randomly assigned patients to drug therapy or cognitive therapies
(IPT or CBT)
The control group was given a placebo pill
All patients were assessed at the start, after 16 weeks, and after 18
months of treatment

Findings

Evaluation

Showed the drug group showed the fastest results, but no other
difference in the effectiveness of treatment between drug therapy
and cognitive therapies such as CBT
Just over 50% of patients recovered in each of the CBT and IPT
groups, as well as in the drug group
Only 29% recovered in the placebo group
Ethical issues: in that lying to patients about the kind of treatment
they receive is not only deceptive, but also possibly dangerous if the
patient is having frequent suicidal thoughts

Kirsch and Sapirstein (1998): Effectiveness of antidepressants (meta-study)


Description

Results from 19 studies, covering 2318 patients who had been


treated with the antidepressant Prozac
A meta-analysis of 19 studies found that anti-depressants were
only 25% more effective than placebos
Were no more effective than other kinds of drugs, such as
tranquilisers

Individual approaches-- Cognitive therapy:


o Rationale is to identify faulty patterns of thinking, and to replace them with
more positive ways of thinking
o CBT for depression:
Based on the idea that how e think (cognition), how we feel (emotion)
and how we act (behaviour) all interact together; specifically, our
thoughts determine our feelings and our behaviour
CBT then aims to identify these negative thoughts, challenge them
and replace them with positive thoughts
The emphasis is on the client meta-awareness-- that is, the ability to
think about their own thoughts

Cognitive restructuring:
Involves teaching clients to become aware of their automatic
negative thoughts, to evaluate the extent to which these
thoughts are accurate or rational, and to replace irrational
thoughts with more reasonable interpretations, evaluations
and assumptions
Some cognitive distortions that clients learn to identify are:
All-or-nothing thinking
Magnifying or minimising the important of an event
Overgeneralisations (drawing extensive conclusions from
a single event)
Personalisation (taking things too personally)
Selective abstraction (giving disproportionate weight to
negative events)
Arbitrary inference (drawing illogical conclusions from an
event

Once negative ways of thinking have been identified, therapist


helps client work on replacing them with more
adaptive/positive ones; this process involves a repertoire of
techniques:
Self-evaluation
Positive self-talk
Control of negative thoughts and feelings
Accurate assessment of both external situations and of
the client's own emotional state

Behavioural activation:
Require clients to behave in new ways in order to alter
maladaptive patterns of interpreting and interacting with their
environments
Novel interventions and activities are developed and
performed b the client in-session and beyond in an attempt to
address and eventually modify dysfunctional distortions,
behaviours and beliefs

Bolton, et. Al. (2003): IPT in Uganda


Aim

Process

Findings

o
Evaluation:
CBT is as effective as drug treatment
CBT focuses only on symptoms and strategies and does address the
causes of depression

Group approaches-- Group therapy:


o Interpersonal group therapy for depression:
IPT examines the person's past and current social roles and assumes
that mental illnesses such as depression occur within a social system
and that one's own social (interpersonal) roles are of the keys to
recover
I.e. Depression can be treated by improving the communication
patterns and how people relate to others

Deduce the success rate of IPT in Uganda


Conducted a randomised controlled trial comparing group
interpersonal psychotherapy with treatment as usual among rural
Ugandans meeting the criteria for MDD
Therapy was conducted in single-gender group of 5-8 participants,
with one group per participating village
Groups met for approx. 90 minutes per week for 16 weeks
Each group was led by a local Ugandan of the same gender with no
previous mental health or counselling experience other than training
in IPT by members of the study team
IPT proved highly effective in reducing depression
Post-therapy, only 6% of the treated group met the criteria for
MD, compared with more than half of the untreated control
group

Evaluation:
Strengths:
Therapist's knowledge about the clients offers an added
dimension through the opportunity of observing them interact
with each other
Clients are helped by listening to others discuss their problems,
and by realising that they are not alone
Also gain hope by watching the progress of other members and
experience the satisfaction of being helpful to others
Can model positive behaviour they observe in others
The trust and cohesiveness developed within the group can
bolster each member's self-confidence and interpersonal skills
Group therapy gives clients an opportunity to test these new
skills in a safe environment
Cost-effective
Weaknesses:
Some clients may be less comfortable speaking openly in a
group setting than in individual therapy
Some group feedback may actually be harmful to members
The process of group interaction itself may become a focal
point of discussion, consuming a disproportionate amount of
time compared with that spent on the actual presenting
problem

Discuss the use of eclectic approaches to treatment.

Incorporates principles or techniques from various theories


Recognises the strengths and limitations of the varies therapies, and tailors
sessions to the needs of the individual client or group
o E.g. in the case of a depressive patient who is suicidal, CBT may take too long
to take effect, or the individual may not be in a state that would allow for
discussions about his or her cognitive processes; drug therapy may be used
in order to lessen the symptomology of the disorder; then, once the
individual is stabilised, CBT might be used; also, as the individual becomes
more self-reliant, group therapy may be recommended in order to help
him/her develop strategies to avoid future relapse, as well as a support
system
Advantages:
o Have a broader theoretical base and may be more sophisticated than
approaches using a single theory
o Offer the clinician greater flexibility in treatment; individual needs are better
matched to treatments when more options are available
o More chances for finding efficacious treatments if two or more treatments
are studied in combination
o Clinician using eclectic approaches is not biased toward one treatment and
may have greater objectivity about selecting different treatments
Disadvantages:
o Sometimes clinicians use eclectic approaches in place of a clear theory;
eclectic approaches are not substitutes for having a clear orientation that is
supplemented with other tested treatments
o Are applied inconsistently; takes knowledge and skill to deliver eclectic
approaches effectively
o Very few efficacy studies at this stage that support the approach, partly
because it is difficult to judge the relative value of each treatment in an
eclectic approach
o May be too complex for one clinician

Discuss the relationship between etiology and therapeutic approach to one disorder.

Biological approaches and therapies:


o Based on the assumption that biological factors are involved in the
psychological disorder
Does not necessarily mean that biological factors cause the
physiological disorder, but rather that they are associated with
changes in brain chemistry

A number of drugs are used to treat various disorders based on theories of


the brain chemistry involved, but this does not mean that there is a full
understanding of how neurotransmitters and symptoms are linked

Bernstein et al. (1994): Efficiency of antidepressants in treating depression


Description

Antidepressant drugs are an effective way to treat depression in


the short term
Significantly helping 60-80% of people

Kirsch and Sapirstein (1998): Effectiveness of antidepressants (meta-study)


Elkin, et. Al. (1989): Effectiveness of antidepressants

Cognitive approaches and therapies:


o Individual therapies:
Those in which a therapist works one-on-one with a client
Most individual therapy today includes some kind of cognitive
therapy, where a therapist helps a client to change negative thought
patterns
Beck's cognitive triad
IT is often seen as more personal than drug therapy, in which a person
may feel more like a patient
Can also be highly individualised to meet the need of the client
The aims are to help the client change faulty thinking patterns, to
develop coping strategies and to engage in more positive behaviours
Have a tendency to focus more on symptoms than causes, though-- a
negative

Social approaches and therapies:


o If social problems are the trigger, group therapy may alleviate the symptoms
Toseland and Siporin (1986): Comparison of group and individual therapies
Description

Reviewed 74 studies comparing individual and group treatment


Group treatment was found to be as effective as individual
treatment in 75% of these cases, and more effective in the
remaining 25%

Eclectic approaches and therapies:


o Biopsychosocial model sees the person as a whole; it recognises the
complexity inherent in psychological disorders
E.g. the cause of an individual's depression may be inter-related:
Negative early childhood message s(psychological) and
redundancy (social) may lead to feelings of worthlessness
(psychological)
Negative self-talk (psychological) may lead to feeling stressed
which leads to higher levels of cortisol (biological) and
serotonin depletion (biological)