Abnormal Psychology

Paper 2: Options

Written by: Chris Ting 13H

Abnormal Psychology

Table of Contents
Concepts and diagnosis ............................................................. 3

Psychological disorders ............................................................ 21

Implementing treatment ......................................................... 41

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Concepts and diagnosis

Syllabus Question: Examine the concepts of normality and abnormality.

There are four definitions for abnormality:

I. Statistical Infrequency defines abnormality as deviation from the statistical norm

meaning infrequently occurring behavior.
II. Deviation from social norms defines abnormality as behavior which departs from what
is acceptable in a particular society
III. Dysfunctional behavior defines abnormality as psychological distress or discomfort that
causes a person to not be able to function properly
IV. Deviation from ideal mental health defines abnormality as behavior which departs
from that which is considered ideal

Statistical infrequency

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

Problems with measuring abnormality through statistical infrequency

I. Many behaviors that are statistically rare are desirable and healthy.
II. There are many behaviors that have been the norm in a particular society or culture yet
we wouldn’t really call it normal nor would it be appropriate to label those who
showed a different behavior as abnormal.
III. This approach equates normality with conformity yet many non-conformists are
valuable and without whom significant advances would never be made.
IV. There is no agreed definition of how much behavior must deviate from the norm before
it is considered abnormal.

Deviation from social norms

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

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abnormal as long as society accepts it. This definition means that abnormal behavior can
never have a universal meaning since it varies from culture to culture.
Problems with measuring abnormality through deviation from social norms
I. Through this approach abnormal behavior can never have a universal meaning as
judgments will vary from society to society.
II. This view assumes that if a behavior is social acceptable then it is normal that one set
of standards is as good as any other. But, same as statistical infrequency, there are
many behaviors that occur or occurred that were socially normal but many of us would
see it as normal. For example, behaviors shown in Nazi Germany were considered
normal and deviations from it were abnormal.
III. Standards within society change from time to time and vary between different
subgroups. Different sections within one society can set different standards by which to
judge abnormality.

Dysfunctional behavior

This approach states that behavior is abnormal if it is maladaptive, in that it hinders our
physical survival and/or the realization of our potential.

Rosenhan and Seligman (1989) suggest that dysfunctional behavior can be judged based on
seven criteria.
I. Personal distress: experiencing unpleasant emotional experiences such as guilt, anxiety
and depression to an excessive degree.
II. Maladaptiveness: behavior that interferes with the ability to meet everyday
responsibilities and cope with everyday demands
III. Irrationality: behavior which has no rational basis and is unconnected to reality
IV. Unpredictability: behavior which is impulsive and seemingly uncontrollable and
disrupts the lives of others
V. Statistically infrequent: abnormal behavior is shown by a minority and the majority
VI. Observer discomfort: breaking the unwritten and unspoken rules by which most
people abide and the violation of which makes others feel uncomfortable
VII. Violation of moral and ideal standards: behavior can be considered abnormal if it
violates moral standards even when most people in a particular group or culture
practice that behavior

This approach has the major advantage of recognizing a person’s subjective experience as a
means of helping to define who is abnormal. This approach includes statistical rarity and
deviations of social norms and therefore helps make this definition a more practical one in

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that it helps define which are in need.

Problems associated with failure to function adequately.

I. Some of the criteria depends on subjective judgments of other people. For example
observer discomfort may vary depending on the particular person doing the
observing. Violation of moral standards also involves subjectivity in judgement, who
moral standards are we using as the standard, it may different for each person.
II. The criteria of irrationality, unpredictability, loss of control and unconventionality
apply to people who choose an unconventional life. This does not mean they are
abnormal.
III. People who we consider as abnormal may feel no distress about the way they
behave. Distress is sometimes a very appropriate response to circumstances, for
example experiencing extreme distress because of the death of a loved one is
normal and so that person can’t be considered abnormal.

Deviation from ideal mental health

This approach considers abnormal behavior as what is the ideal mental health and deviations
from it as abnormal. The humanistic school of psychology believes that ideal health should
have a ultimate goal. Abraham Maslow and Carl Rogers suggested that this ideal goal is self
actualization.

Rogers argued that we all have a basic need to receive positive regard from important people
in our lives. People who receive unconditional positive regard early in life are likely to
develop a high self esteem and a feeling of self worth consequently they are comfortable
with themselves but recognize they are not perfect and are in a position to realize their
potential. Conversely, if people experience only conditional regard, which makes them feel
unworthy, they feel that they are only loved and accepted when they conform to the
imposed standards of others. It is impossible for such people to self-actualize because they
are no longer in touch with what values and goals would be meaningful for them. As a result
they have low self esteem that leads to problems of function and abnormal behavior.

Problems associated with judging abnormality based on deviation from ideal health
I. This definition means that the majority of people are considered abnormal as very
few people attain self-actualization.
II. What is the ideal standard? This criteria becomes a value judgement, different
cultures have different ideas on what is considered ideal. For example, in
collectivistic cultures working together is valued and ideal but in individualistic

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cultures autonomy is valued,

Jahoda’s positive mental health

Marie Jahoda (1958), instead of trying to define what is abnormal she tried to define what is
normal. Jahoda identified six components of ideal mental health based on a review of
literature.
I. Positive attitude toward own self
II. Growth, development and self actualization
III. Integration
IV. Autonomy
V. Accurate perception of reality
VI. Environmental mastery

The approach suggests that ideal mental health is achieved when a person has a realistic and
positive acceptance of who they are and are able to resist stress while acting voluntarily in
the interests of their own growth in the environment they live in.

Problems with Jahoda’s approach to positive mental health

According to this approach then very few people are able to say that they are in such a state
of ideal mental health. Taylor and Brown (1988) found that those with depression are more
accurate in their perception of reality, and that for the most of us, functioning adequately
requires an element of self-delusion. Also, unreasonable optimism seems to be beneficial for
many people.

But none of the above definitions of abnormality provide a complete definition of

abnormality as none of them are universe since all of the definitions are affected by
individual, social and cultural values systems.

Mental illness is a social construction

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

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

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demonstrable biological pathology, but psychiatric disorders are not.

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

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

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

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

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Syllabus Question : Discuss validity and reliability of diagnosis.

Classification of mental disorders involves the identification of groups or patterns of

behavioral or mental symptoms that reliably occur together to form a type of disorder. This
allows:
I. Psychiatrists, doctors and psychologists to more easily identify groups of similar
sufferers
II. Allows a prognosis to be made
III. Researchers to investigate these groups of people to determine what the aetiology of
the disorders are
IV. A suitable treatment to developed and administered to all those showing similar
symptoms

The major systems of diagnosis include the DSM and ICD.

The Diagnostic and Statistical Manual of Mental Disorder (DSM) defines a mental disorder
as a clinically significant syndrome associated with distress, a loss of functioning, an
increased risk of death/pain, or an important loss of freedom.

The manual attempts to describe any disorder in such terms that two clinicians referring to
the system would probably agree with the diagnosis it suggests. The DSM group’s disorders
into categories and then offers specific guidance to psychiatrists by listing the symptoms
required for a diagnosis to be given. The DSM consists of a multiaxial approach, where a
diagnosing clinician considers the individual under investigation under 5 axis’.

I. Axis 1: Clinical syndromes refers to the major diagnostic classification arrived by the
clinician.
II. Axis 2: Developmental and personality disorders consists of additional diagnostic
classifications that may contribute to an understanding of the Axis 1 Syndrome.
III. Axis 3: Medical conditions
IV. Axis 4: Psychosocial stressors, all potentially stressful events or enduring circumstances
that might be relevant to the disorder are rated for severity on a scale ranging from 1
(none) to 6 (catastrophic) for the past year.
V. Axis 5: Global assessment of functioning, rates the highest level of social, occupational
and psychological function on a scale of 1 (persistent danger) to 90 (good in all areas)
currently and during the past year.

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

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clinician to use a more holistic approach to understanding the person. The DSM also
undergoes constant revisions and it adapts to changes in thinking overtime.

The International Classification of Diseases (ICD) is more commonly used internationally

than the DSM and it covers a wide range of diseases and conditions for the sake of
classification rather than diagnosis. There is a chapter in the ICD that categorizes mental
disorders that is very similar to the DSM and the ICD has fewer categories than the DSM
because each category tends to be slightly broader. The biggest difference between the two
systems is that the ICD is intended primarily as a classification system but includes details of
what symptoms are required for diagnosis.

Conversely, the DSM is intended as a fully comprehensive manual for diagnosis and so
includes precise details of how to conduct diagnostic interviews, precise diagnostic details
and other tests.

Validity and reliability

In order for a diagnostic system to be reliable, those using it must consistently make the
same diagnoses. For it to be the valid, the diagnoses must identify a real pattern of
symptoms and therefore apply appropriate treatment.

Reliability

A major way of assessing reliability of psychiatric diagnosis is by inter-rater reliability, which

is by assessing the agreement with which different clinicians diagnose conditions in the same
patients. Studies of inter-rater reliability show that some diagnostic categories are much
more reliable than others and that procedures are more reliable for some types of patients
than others.

Nicholls et al. (2000) showed that neither ICD-10 nor DSM-IV demonstrates good inter-rater
reliability for the diagnosis of eating disorders in children, 81 patients aged 6-17 years with
some eat problem were classified using ICD-10, DSM-IV and a system developed for children
by the Great Ormond Street Hospital (GOS).

Over 50% of the children could not be diagnosed according to DSM criteria. Reliability was
0.64, i.e. 64% agreement between raters, but this figure was inflated by the fact that most
raters agreed that they couldn’t make a diagnosis. Using ICD-10 criteria there was 0.36
reliability and the GOS was the best with a 0.88% reliability. The success of the GOS was

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suggested to be due to it being specifically designed for young children. This shows that in
terms of eating disorders and possibly other disorders the reliability of well known diagnostic
systems such as the DSM or ICD may not be very reliable.

But, Pedersen et al. (2001) gave 10 Danish GPs one day’s training in the use of ICD-10 criteria
for diagnosing depression. Over the next 8 weeks they diagnosed a total of 116 patients with
a depressive episode. There was a 0.71 reliability with a diagnosis of depression, this
suggests that there is quite good inter-rater reliability for ICD-10 in the case of depression.

Beck et al. (1962) found that agreement on diagnosis for 153 patients between two
psychiatrist was only 54%.

Cooper et al. (1972) found that New York psychiatrists were twice more likely to diagnose
schizophrenia than London psychiatrists, who in turn were twice as likely to diagnose mania
or depression when shown the same videotaped clinical interviews.

Di Nardo et al (1993) studied the reliability of DSM-3 for anxiety disorders where two
clinicians separately diagnosed each of 267 people seeking for treatment for anxiety and
stress disorders. They found high reliability for OCD but very low for assessing generalized
anxiety disorder mainly due to problems with interpreting how excessive a person worries
are. This study used the DSM-III and has already undergone two revisions and is on the
DSM-IV already and so issues may have already been resolved. But even then, this study
shows the unreliability for certain disorders.

Lipton and Simon (1985) randomly selected 131 patients in a hospital in New York and
conducted various assessment procedures to arrive at a diagnosis for each patient. This
diagnosis was compared with the original diagnosis and found that of the original 89
diagnosis of schizophrenia; only 16 received this on re-evaluation. Fifty were diagnosed with
a mood disorder even though only 15 had been initially diagnosed with it in the first place.
But I could be argued that being misdiagnosed caused the mood disorder to develop.

Test-retest reliability is concern with whether the same person will receive the same
diagnosis if they are assessed more than once. Mary Seeman (2007) completed a literature
review examining evidence relating to the reliability of diagnosis over time. She found that
initial diagnosis of schizophrenia, especially in women, were susceptible to change as
clinicians found out more information about their patients. It was common for a number of
other conditions to cause the symptoms for which women were receiving the diagnosis of
schizophrenia. This indicates the problem of test-retest reliability with schizophrenia

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diagnoses.

Validity

Rosenhan et al. (1973)

Aim To test the reliability of diagnosis
Method and Results Rosenhan and a group of colleagues and
people with various occupations presented
themselves at 12 different hospitals across
the USA complaining of hearing voices, but
presented their life history and present state
as normal. All but one was admitted with a
diagnosis of schizophrenia. Once admitted to
the hospital they stopped complaining of
symptoms and try to get out.

All of the pseudo-patients could do this but

were diagnosed with a case of schizophrenia.
Thus, their sanity was never detected but
some patients and staff were suspicious. It
took between 7-52 days for the
pseudopatients to be released. This time was
used by the patients to conduct a participant
observation of life in the hospital. The staff
noticed this but assumed it was part of the
symptoms. This shows that an normal person
can receive a diagnosis.

Conversely, Rosenhan found that truly

abnormal people can be mistakenly assumed
to be healthy. In a follow up study, Rosenhan
told a hospital that they should expect
pseudo-patients over a 3 month period. But
none were sent instead 41 real patients were
sent and of these 41 patients 19 were
suspected to be fake.
Conclusion Shows the general inability and the lack of
reliability in telling the difference between

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normal and abnormal behavior.

This study shows very good reliability but

poor validity in that it shows that the
environment heavily affects the process of
diagnosis and therefore affecting its validity.
Evaluation This took place 30 years ago and used the
DSM-II and it has since undergone major
chances. Also, diagnostic procedures have
improved in response. This study showed
extremely good reliability and than in real
life doctors are not normally confronted with
people wishing to be admitted to psychiatric
hospitals. Therefore this should be seen as
an indicator of the current mental health
system.

Caetano (1973)
Method Conducted an experiment in which he
videoed a male psychiatrist carrying out
separate standardized interviews with a paid
university student and with a hospitalized
mental patient.

Two groups of people were shown these

interviews, a group of 77 psychology
students and a group of 36 psychiatrists.
They were asked to diagnose the
interviewees and rate their degree of mental
illness. With each sample of viewers, there
was random assignment to two different
groups, each of which received different
information about the interviewees:
1. either that both were volunteers
who were paid to participate,
2. or that both were patients in a
mental hospital.
Results Indicated that psychiatrists with clinical

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experience were more likely to be persuaded

by the information given about the two
interviewees and label them both as
mentally ill (if they were described as
patients) or both not mentally ill (if described
as volunteers).
Conclusion This study shows labeling theory, the theory
that the behavior of the person being
diagnosed is not the most important
component of diagnosis and, in the
ambiguous situation of a diagnostic
interview, any suggestion that the subject is
or has been mentally ill will be a strong
influence on any decision.

This research therefore shows that simply

being labeled as something affects the
validity of a diagnosis.

Wakefield et al. (2007) conducted a study which suggests that a wide range of other life
events can account for symptoms of depression and therefore the exclusion is
inappropriately narrow. This lack of clarity about when the symptoms of depression really
indicate a medical condition and when they indicate and understandable response to life
events is an example of the problems with validity.

Criterion-related validity is a form of validity based on whether a new system agrees with
existing measures of the phenomenon in question. Gavin Andrews published research using
DSM and ICD-10 systems, particularly in the diagnosis of anxiety disorders and found only
moderate agreement between them. When one person has been diagnosed according to
one system but cannot be diagnosed according to another system by the same psychiatrist or
group, this indicates poor validity.

Peters et al. (1999) found only moderate agreement between the two systems because
DSM-IV requires the presence of distress or impairment to functioning in the person being
diagnosed.

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Mental illness is a social construction

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

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

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

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

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

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

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Syllabus Question: Discuss cultural and ethical considerations in diagnosis.

Cultural factors

Culture bound syndromes (CBS) refers to syndromes that do not fit easily into the categories
and classifications of supposedly universal disorders. CBS occurs almost exclusively in specific
locations or populations and are indigenously regarded to be illness or afflictions and have
local names. Cultural universality maintains that all mental disorders are found worldwide
and that their causes and symptoms are very similar everywhere. Cultural relativism
maintains that mental disorders and their symptoms are universal but expressed differently
in different cultures. An explanation for these cultural differences was given by Weisz et al.
(1987)’s suppression facilitation model explains that forms of behavior discouraged within a
culture will be suppressed and therefore observed rarely. But behaviors that are rewarded in
a culture will be produced to an excess.

When there is such a huge variety of labels for behavior that shares its basis of either
dangerous or violation of social norms, it must be questioned whether the DSM criteria are
valid beyond the culture they were created in. An example that shows the possible role of
culture in diagnosis was found by Levav et al. (1997) in the United States. They compared
rates of alcoholism and depression across various religious groups and found that Jewish
males were more likely to have a diagnosis of depression and less likely to have a diagnosis
of alcoholism. This suggests there is some underlying issue that manifests itself differently
depending on cultural traditions and expectations. Therefore psychiatrists must be familiar
with these cultural traditions and expectations in order to accurately diagnosis.

In New Zealand studies have shown that there are differences in what is considered a mental
health issue among the Maori and Pacific Island population and other ethnic groups. Tapsell
and Mellsop (2007) found that affective disorders such as depression account for only 16%
of diagnoses given to Maori mental health service users compared with 30% for Europeans;
the majority of diagnoses were for schizophrenia, 60% compared to 40% for Europeans.
Maori mental health service users also report more experience of hallucinations and have
more records of aggression and problems of living. Arrol et al. (2002) found that the Maori
are less likely to be medicated for depression than Europeans in New Zealand. This suggests
that cultural and ethnical factors player a role into diagnosis and that between different
cultures and ethnicities there is different understanding of what is considered normal
behavior and what is considered a mental health disorder.

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In the UK, studies on ethnic minorities’ show that many factors affect mental health and the
way users of mental health services should be treated whether are aboriginal people,
immigrants, long-established residents or newly arrived refugees.

Palmer and Ward (2006) found in a content analysis of interviews that those who
experienced trauma in their previous locations are affected by difficulties in their new
environment as well as memories of their old one. For example among immigrants to
London from Somalia, Rwanda and Iran, experiences from their home country mix with new
problems in their new home. This shows that to properly diagnose people clinicians must
take into account of a person’s culture and previous experiences.

Examples of Culture Bound Syndromes

Description
Koro- thought to specifically occur in
Chinese cultures, involves:
I. Belief that penis is shrinking and will
withdraw to abdomen and cause
death
II. Physiological and emotional reactions
to this belief associated with fear and
anxiety
III. Behavioral countermeasures to
prevent penis retraction include
putting weights to it
Evaluation
Syndromes similar to Koro have been
identified in other cultures but they often
have shown that there are important
variations in symptoms such as lacking the
belief that death will occur. Also there are
different provoking cultural causes such as
outbreaks of Koro in China and India have
different beliefs. There are different
underlying mechanisms and responses to
treatment, Koro usually responds to
reassurance whereas the Koro-like
symptoms shown in other cultures have
often disappeared when other mental
disorders were treated.

Some Western psychiatrists regard Koro as

Dhat- thought to specifically occur in
Indian-Hindu cultures, involves
I. Belief that semen is leaking out of the
body and sapping the body of power
II. Excessive anxiety and concern in
reaction to this belief
III. Feelings of exhaustion, weakness and
just a particular form of hypochondria or
phobic anxiety disorder.
Syndromes similar to Dhat have been
identified in other cultures. Also the
symptoms shown and underlying beliefs
that trigger the disorder across cultures are
very similar in nature. It seems only culture
bound in terms of the prevalence of the
underlying beliefs, which in turn depend on

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lethargy access to and belief in scientific medical

knowledge.

Bias in diagnosis

Racial Bias

Diagnosis classification systems are not 100% objective and the diagnosis may be influenced
by the attitudes and prejudices of the psychiatrist or the diagnostic test itself. For example,
women and black people are more likely to be diagnosed mentally ill possibly because
psychiatrists expect them to be more prone to mental illness and are therefore keen to
diagnose them as such upon presentation of symptoms. But if presented by white men then
it would be interpreted as something other than a mental illness.

Kirov and Murray (1999) studied a group of patients taking lithium prophylaxis (sometimes
used for depression) and found that there were clear differences in symptoms and diagnoses
that had resulted in patients being medicated. They found that black patients were less likely
than white patients to have suicidal ideas of have attempted suicide and generally had more
manic symptoms, resulting in a diagnosis of bipolar disorder. It is suggested that because of
the difference in the manifestation of the underlying problem, many black patients in the UK
may be diagnosed with schizophrenia rather than affective disorder. Riodan et al. (2004)
found that compulsory hospitalization orders are more likely to be applied to black than
white patients.

In a study by Jenkins-Hall and Sacco (1991) they got white therapists to watch a video of a
clinical interview and then were asked to evaluate the female interviewee. There were four
conditions representing the possible combinations of race and depression.
I. African American woman and nondepressed
II. White American and nondepressed
III. African American woman and depressed
IV. White American and depressed

The therapists rated the nondepressed African American and the white American in the
same way but their ratings of the depressed women differed that they rated the African
American woman with more negative terms and saw her as less socially competent than the
depressed white American woman. This shows that there is racial bias in diagnosis.

Morgan et al. (2006) found that in the UK, the incidence of schizophrenia is nine times

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higher for Afro-Caribbean’s and six times higher for those of black African descent than for
white British people. Researchers argue that genetic differences cannot account for this and
it is more likely that diagnostic biases account for it.

Socioeconomic bias

There are various reasons for the apparent social class bias in diagnosing mental illness.
Mental health professionals have been found to make less encouraging clinical decisions with
patients from the lower classes and offering them less effective therapeutic interventions.
Another possibility is that those from higher social classes have more coping strategies at
their disposal.

Umbenhauer and DeWitte (1978) investigated the effects of social class on the attitudes of
mental health professionals and found that upper class people received more favorable
clinical judgments and were more likely to be offered. Luepnitz, Randolph and Gutsch (1982)
found that a given set of symptoms was much more likely to produce a diagnosis of
alcoholism for a lower-class African American than for a middle class white person. Bruce,
Takeuchi and Leaf (1991) found evidence of the impact of wealth. They found that people
around the poverty line who had no mental illness at first assessment and that were
assessed again 6 months later were more likely to be diagnosed with mental illnesses. For
example those living below the poverty line were more than twice as likely to have
developed alcohol abuse or dependence, bipolar disorder or major depression during that
period and 80 times more likely to have developed schizophrenia.

Barlow and Durand (1995) found that members of the lower social classes are much more
likely than those of higher social classes to be diagnosed as suffering from schizophrenia.
There are several explanations to this:

I. There actually is bias, with clinicians being more willing to use the diagnosis of
schizophrenia when considering the symptoms of individuals from lower social
classes. Johnstone (1989) reviewed several studies which showed that lower-class
patients were more likely than middle-class patients to be given serious diagnosis’s,
even when there were few if any differences in symptoms.
II. Social causation hypothesis, according to this hypothesis members of the lowest
classes in society tend to experience more stressful because of poverty,
unemployment, poorer physical health etc. Stress is also likely through
discrimination because ethnic and racial minorities in many cultures tend to belong
to the lower classes. The high level of stress makes them more vulnerable to

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schizophrenia than middle class.

III. Social drift hypothesis, according to this hypothesis, individuals who develop
schizophrenia are likely to lose their jobs and so their social status is reduced i.e.
schizophrenia reduces social status rather than low social status causing it. Turner
and Wagonfeld (1967) found that schizophrenics tend to belong to a lower social
class than their fathers. But the fathers also tended to belong to lower social classes
themselves, supporting the social causation hypothesis too.

Gender bias

An explanation for gender bias, terms of depression, are that women often have to cope
with sex discrimination and relative powerlessness and as a result it may explain that women
have the highest rates of depression. Physiologically, the menstrual cycle and menopause
may make women more vulnerable than compared to men.

Ford and Widger (1989) presented therapists with written cases of a patient with anti-social
personality disorder and another with histrionic personality disorder. Each patient was
sometimes identified as male and sometimes as female and the therapists had to decide on
the appropriate diagnosis. Anti-social personality disorder was correctly diagnosed over 40%
of the time when the patient was male, but fewer than 20% of the time when the patient
was female. In contrasts, histrionic personality disorder was correctly identified much more
when the patient was female: 80% vs 30%. The findings indicate a strong bias from
traditional sex role stereotypes. Broverman et al. (1981) found evidence sex-role stereotypes.
They asked clinicians to identify the characteristics of the healthy adult, man and woman.
The characteristics of the healthy adult and en were similar, including adjectives such
independent, decisive, and assertive. Conversely, the adjectives used to describe the healthy
woman included words such as dependent, submissive and emotional.

Ethical Considerations

Labeling theory as shown by Caetano and Rosehan indicates that one a diagnosis has been
made, it tends to stick and as a result there are significant negative effects of such diagnosis
on a person’s subsequent treatment by other people. Scheff (1966) points out that
diagnostic classification labels the individuals and therefore can cause adverse effects such
as:

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

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even if they weren’t initially. Goffman arugues that they may internalize the role of
“mentally ill patient” and could worsen their disorder rather than improve it. But
Doherty (1975) points out that those who reject the mental illness label tend to
improve more quickly than those who accept, although this is not always the case.

II. Distortion of behavior- Diagnosis of mental disorders tend to label the whole person
and once the label is attached, than the individual’s actions become interpreted in
the light of the label. For example in Rosenhan’s study, the pseudo-patients
behaviors were regarded as symptoms of their psychopathology.

III. Oversimplification- Labeling can lead to reification- making the classification a real,
physical disorder, rather than just a descriptive term to help diagnosticians talk about
patients or a hypothesis about what is troubling the person. Labeling may have a
major effect not on just the individual’s identity but also their self esteem.

Being diagnosed may lead to stigmatization, when a negative label is attached to someone,
and as a result they may receive prejudice from society. Langer and Abelson (1974) showed
a video tape of a younger man telling an older man about his job experience. If the viewers
were told that the man was a job applicant, he was judged to be attractive and conventional
looking, whereas if they were told that he was a patient, he was described negatively. Read
(2007) summarized a large amount of research related to stigmatization and found that
attitudes towards those diagnosed in a medical context tend to be characterized by fears and
that knowing someone has a diagnosis of mental illness increases reluctance to enter into
romantic relationships with them. Sato (2006) discusses how schizophrenia was renamed in
Japan because there was such a stigma attached to it that less than 40% of patients who had
been diagnosed with it had actually been informed of it. Farina et al (1980) conducted an
experiment in a naturalistic setting to illustrate the effects of stigma and prejudice towards
those labeled as mentally ill. When one pair of male college students was falsely led to
believe that the other had been a mental patient, he perceived the pseudo ex-patient to be
inadequate, incompetent and not likeable. In another experiment, they made one pair of
interacting males falsely believe he was perceived as stigmatized the naïve participant. Just
believing this was enough to lead him to behave in ways which caused the naïve participant
to reject him.

Also being diagnosed and then treated in a hospital may lead to institutionalization. This
when patients are so used to being cared for and not doing anything themselves they can’t
function independently in the outside world.

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Psychological disorders

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

Affective disorders are disorders related to mood, an example of this is major depressive
disorder.

The DSM-IV criteria for diagnosing major depressive disorder are:

I. Five or more of the following symptoms present during the same 2 week period and
represent a change from previous function and at least one of the symptoms is
either:
a. Depressed mood
i. Most of the day, nearly every day
b. Loss of interest or pleasure
i. Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day
c. Significant weight loss when not dieting or weight gain, or decrease or
increase in appetite nearly everyday
d. Insomnia or hypersomnia nearly everyday
e. Psychomotor agitation or retardation nearly every day
f. Fatigue or loss of energy nearly everyday
g. Feelings of worthlessness or excessive inappropriate guilt nearly every day
h. Diminished ability to think or concentrate, or indecisiveness, nearly every
day
i. Recurrent thoughts of death, recurrent suicidal ideation without a specific
plan, or a suicide attempt or a specific plan for committing suicide.

There are three main categories of clinical depression:

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

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calculated that 72% of people diagnosed as manic also suffered from

depression. The person does not have to depress to receive a diagnosis of
manic depression. Patients typically feel full of energy and may feel elated or
irritable. There is a reduced need for sleep and there may be an increased
sexual appetite. Patients are often extremely impulsive and their judgment is
impaired.

The United States National of Mental Health claims that major depressive disorder is the
leading cause of disability in the USA between the ages of 15-44 with a lifetime prevalence of
16.6%. Charney and Weismann (1988) found that major depressive disorder is relatively
common, affecting around 15% of people at some time in their life. It affects woman more
than men and that this difference appears to start around the age of 13 and results in up to
three times more women than men having a diagnosis of depression. Nicholson et al. (2008)
found that there is significant variation in the prevalence of depression in various countries.
They found that for example Polish men have a prevalence rate of 20.4% and both Polish and
Russian women were high at 32.9% and 33.7% respectively. Levav (1997) found the
prevalence rate to be above average in Jewish males and there is no difference in prevalence
between Jewish men and woman. The difference could suggest that some groups are more
vulnerable to depression.
Depression tends to be a recurrent disorder with about 80% experiencing a subsequent
episode, with an episode typically lasting for three to four months. The average number of
episodes is four and in approximately 12% of cases, depression becomes a chronic disorder
with duration of about two years.

Eating disorders include anorexia nervosa , where you eat very little, and bulimia nervosa
where you eat a lot and then vomit it out due to guilt.

The DSM- IV criteria for diagnosing this disorder are:

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

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has not regularly engaged in binge eating or purging behavior

b. Binge-eating/ purging type: during the current episode of anorexia nervosa,
the person has regularly engaged in binge-eating or purging behavior.
Eating disorders are known to affect females much more than males. The National Institute
of Mental Health in the United States suggests that females with anorexia have a death rate
12 times higher than the general female population. Zandian et al. (2007) found that the
disorder affects those from households with the above-average income to a greater extent
and that it affects around 0.3% of the population in the US.

The condition is far more common in Western and individualistic cultures. A possible
explanation is that there is a greater exposure to unreasonably thin models in television, film
and magazines, and social pressures to conform to a particular body weight, all of which
appear to affect females more than males. Another explanation is that there is a greater
focus on dieting since the 20th century in Europe and Anglo-American societies.

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Syllabus Question: Analyze etiologies (in terms of biological, cognitive and/or sociocultural
factors) of one disorder from two of the above groups. . And Discuss culture and gender
variations in prevalence of disorders. And To what extent do biological, cognitive and
sociocultural factors influence abnormal behavior.

Affective disorders such as depression can be split into three types of clinical depression
I. Major depressive disorder
II. Dysthymia
III. Manic or bipolar depression

Etiology of major depressive disorder

Biological factors

Hammen (1997) suggests four types of circumstantial evidence why we might believe that
depression is a biological condition:
I. Some symptoms of depression are physical, eg. Disruption to sleep and appetite
II. Depression runs in families
III. Antidepressant medication reduces the symptoms of depression
IV. We know that certain medical conditions and drugs induce depression

Evolution

Hagen et al. (2004) suggests that major depressive disorder has evolutionary origins. They
suggested that it is a psychological adaptation favored by natural selection and serves two
main purposes, to signal need and to elicit help from others in the social group.

It has also been suggested that depression and mania evolved from normal reactions and
attitudes towards loss and gain, failure and success. The feelings of sadness triggered by a
failure or loss may be adaptive since they would discourage the behavior that led to them,
preventing even greater losses. However behavior that resulted in gains and success would
be motivated by the feelings of self-confidence, optimism, high energy levels and euphoria
that are associated with happiness.

Rank theory suggests that losses or gains in dominance resulting from competition with
others would trigger these emotions. Depression would allow defeated individuals to display
yielding behavior and desist in further competition that might result in further loss, while
mania would allow victors to take advantage of their success and possibly gain further

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success.

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

Clinical depression and mania may be maladaptive because:

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

Evaluation of evolutionary explanations of depression:

I. Happiness and sadness are found cross culturally and genetic predispositions for
mood disorders have been proposed indicating there may be a biological adaptive
function.
II. Higher rates of female defeat in competition with males due to their greater
dominance generally, may explain the higher rates of female depression.
III. Evolutionary theories of depression and mania remain speculative and there are
many other explanations that do not assume these mood states are linked with
adaptive features.

Genetic factors

McGuffin et al. (1996) obtained a sample of 214 pairs of twins, at least one of whom was
being treated for major depression. They found that 46% of MZt and 20% of DZt of the
patients has also suffered major depression. This suggests moderate genetic influence but
identical twins may be reared more similarly to fraternal twins, therefore genes may not be
the only factor affecting this finding and it will be reductionist to believe so.

Kendler et al. (2006) conducted a large Swedish twin study with over 42 000 participants
using telephone interviews to diagnose depression on the basis of the presence of most of
the DSM-IV symptoms or having had a prescription for antidepressants . The researchers
found concordance rate among MZ twins of 0.44% for females and 0.31% for males,

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compared with 0.16% and 0.11% for female and male DZ twins respectively. Results suggest
a strong genetic component but not purely genetic as we would then expect the MZ rates to
be much higher.

Nurnberger and Gershon (1982) reviewed the results of seven twin studies and found that
the concordance rate for major depressive disorders was consistently higher for MZ twins
than for DZ twins. Across the seven studies reviewed, the average condorance rate for MZ
twins was 65% while for DZ twins it was 14%. This supports the theory that genetic factors
might predispose people to depression. However the fact that the concordance rate for MZ
twins is far below 100% indicates that depression may be a result of genetic predisposition
and that it is not purely genetic.

Silberg et al. (1999)

Aim Assess both the roles of genes and recent life
events on depression
Method 902 pairs of twins took part with:
I. 182 of pre-puberty girls
II. 314 pubertal girls
III. 234 puberty boys
IV. 171 of pubertal boys

Each adolescent completed a standard

psychiatric interview to assess depression.
Life events were measured both by a
questionnaire given to the young people and
an interview with their parents.
Results Girls suffered more depression than boys
and on average they more susceptible to
depression in response to life events.

There were wider individual different among

girls in response to life events and girls who
suffered depression after a negative life
event were often those whose twin also
suffered depression. Suggesting an
important role for genes in determining
individual differences in vulnerability to
depression in response to life events.

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Conclusion Study supports a role for genes and

environment.
Evaluation Method: The children could have lied about
life events or left out certain details.

Ethic: The interviews and questionnaires may

have caused unhappy memories to come
back and negatively affect the children and
their parents. This may therefore cause
unnecessary stress.

Gender: Both genders were used but they

don’t represent the older population and
may therefore be different.

Duenwald (2003) suggest that the short alleles of a gene known as 5-HTT affect the
transmission and reuptake of serotonin to increase the chances of a person suffering from
depression. But this finding between the gene and depression does not indicate a cause
since the data are co relational.

Kendler et al. (1992) carried out a twin study on sufferers of relatively mild major depressive
disorder and found little difference between the probability of identical and fraternal twins
sharing depression. This suggests that milder depression may have little genetic influence,
whereas severe cases have a substantial genetic component.

Research suggests that certain types of depression are more influenced by genetics than
others. Klein et al. (1995) examined depression in the families of 100 patients suffering from
dysthymia or major depression. They found that both dysthymia and major depression were
more common in the families of both groups of patients than in the general population.
Weissman (1984) found in the case of bipolar disorder, the families of patients of unipolar
disorder are at no increased risk from bipolar disorder than the rest of the population.
However, relatives of patients with bipolar disorder are at a greater risk from unipolar
disorder.

Neurobiological factors:

One explanation for neurobiological factors and its role on depression is the catecholamine
hypothesis suggested by Joseph Schildkraut (1965) according to this theory; depression is

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associated with low levels of noradrenaline. This theory was eventually developed in the
serotonin hypothesis: the idea that the neurotransmitter serotonin is involved.
Research has shown that there is evidence that drugs which decrease the level of
noradrenalin tend to produce depression like syndromes. Janowsky et al. (1972)
experimented on participants where they were given a drug called phygostigmine and
became profoundly depressed and experienced feelings of self-hate and suicidal wishes
within minutes of having taken the drug. This suggests that noradrenalin levels play a role in
depression. Since a depressed mood can be artificially induced by certain drugs it suggests
that some cases of depression might stem from a disturbance in neurotransmission.

Delgado and Moreno (2000) found abnormal levels of noradrenalin and serotonin in
patients suffering from major depression. However, abnormal levels of these
neurotransmitters might not cause depression, but merely indicate that depression may
influence the production of neurotransmitters.

Rampello et al. (2000) found that patients with major depressive disorder have an
imbalance of several neurotransmitters, including noradrenalin, dopamine, serotonin and
acetylcholine. But Burns (2003) states that although he has spent many years of his career
researching brain serotonin metabolism, he has never seen any convincing evidence that
depression results from a deficiency of brain serotonin. Lacasse and Leo (2005) support this
claim by stating that modern neuroscience research has failed to provide evidence that
depression is caused by neurotransmitter deficiency.

Another biological theory of depression is the cortisol hypothesis. Cortisol is a major

hormone the stress system. Burke et al. (2005) in a meta-analysis of studies connecting
cortisol with depression found that there seems to be a difference in reactivity to stress
between depressed and non-depressed people: when non-depressed people are put under
stress, cortisol levels rise and fall rapidly but depressed people have a more blunt reaction
and remain under stress for longer.

Cuteli et al. (2010) in a study of homeless children between the ages of 4 and 7 found a
significant correlation between high levels of cortisol and a history of many negative life
events. Fernald and Gunnar (2009) found that higher levels of cortisol were found in
children whose families were unable to participate in a poverty alleviation programme in
Mexico. The most significant group differences within the sample were between children
whose mothers were depressed, the results indicated that those that participated in the
programme helped reduce stress levels in children.

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Cognitive factors

Aaron Beck (1976)’s theory proposed three factors that contribute to a person’s cognitive
vulnerability to depression. These three factors are known as a cognitive triad and it
underlies the information-processing style of depressed individuals. The cognitive triad is a
cluster of negative thoughts grouped into three categories: the self, the world and the future.
A person develops and maintains these negative core beliefs through a set of cognitive bias
such as: over-generalization, selective abstraction (focusing on negative aspects of
something) and polar reason (not being able to appreciate ambiguity in interpretations of
life). These cognitive bias combine to give the person a negative self-schema which gives
them a fundamentally pessimistic attitude about themselves and making it very difficult for a
person to see anything positive in life. This can be contributed to by parents or peers early
on in life.

Alloy et al. (1999) followed a sample of young Americans in their twenties for six years. Their
thinking style was tested and they were placed in either the “positive thinking grup” or “the
negative thinking group”. After six year, the researchers found that only 1% of those in the
positive thinking group had developed depression compared to 17% in the negative thinking
group. The results indicate that there may be a link between cognitive style and
development of depression.

Grazioli and Terry (2000) assessed cognitive vulnerability in 65 woman in the third trimester
of their pregnancy and found that those with high levels of cognitive vulnerability were ore
likely suffer post-natal depression.

Perez et al. (1999) compared sufferers of major depression with non-depressed participants
in whom a sad mood had been induced by playing sad music and recalling unhappy
memories on a Stroop task involving unhappy stimuli. The major depressive group but not
the sad-mood participants paid significantly more attention to unhappy worlds in the Strrop
task. This phenomenon, where depressed people pay more attention to unhappy stimuli, is
called negative attention bias.

Parker et al. (2000) found that in 96 depressed patients whose self-reports of their
symptoms included the idea of a negative schema being activated under certain
circumstances were interviewed about their early experiences. There were significant
associations between reports of early experiences and the existence of maladaptive schemas
that were in turn associated with the experience of depression. This suggests that early
experiences do induce cognitive vulnerability.

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Albert Ellis (1962)’s theory focused on negative cognitive styles as the basis of depression.
Specifically, irrational and self-defeating beliefs affect an individual’s interpretation of
antecedent or activating events, leading to negative emotional consequences. Irrational
beliefs will lead to self defeating conclusions. This has been supported by Robins and Block
(1989) in which they found empirical support suggesting that depressed people do have
negative thinking styles. But Taylor and Brown (1988) research suggest that depressed
people are actually more realistic in their interpretations of events.

Abramson et al. (1989) put forward the hopelessness model, in which hopelessness is seen
as the main negative cognition underlying depression. Hopelessness consists of two
elements, negative expectations of the likelihood of positive events and negative beliefs
about the ability of the individual to influence events. When the vulnerable individual
experiences a negative life event they feel helpless to respond to it and this helplessness
leads to the sense of hopelessness and that directly causes depression. Once they are in the
pattern of experiencing negative events and not being able to respond positively to them., a
general sense of hopelessness results. This model doesn’t aim to explain all of depression but
to identify a particular group of people who are particularly vulnerable.

Rose et al. (1994) investigated the characteristics of people who displayed hopelessness.
They found that hopeless people were particularly likely have a diagnosis of personality
disorder, suffered sexual abuse and a highly controlling family. These two characteristics are
important as they are both circumstances in which they would have experienced
hopelessness in childhood. Therefore long term hopelessness in fact of negative events
during a childhood leads to learnt helpless and hopeless cognitive style.

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Sociocultural factors

Brown and Harris (1978) provided the vulnerability model based on the interaction of
vulnerability factors and provoking agents. In their vulnerability model of depression, they
based a number of factors that could increase the likelihood of depression. The vulnerability
factors are:
I. Losing one’s mother at an early age
II. Lack of a confiding relationship
III. More than three young children at home
IV. Unemployment

This vulnerability model was based on previous research by Brown and Harris (1978)

Brown and Harris (1978)

Aim They aimed to investigate the link between
depression and both current and past life
events in the lives of sufferers.
Method They focused on working-class women, as
women tend to experience more depression
than men and because working class people
tend to experience more stress than middle
class.

A interview called the Life events and

difficulties scale (LEDS) was developed and
interviewers were trained to use this. A
group of 539 women from London were
interviewed using the LEDS and asked details
of what stressful events had occurred in the
previous year along with background
circumstances in which they occurred. The
LEDS also aimed to uncover stressful
childhood events, interviewers prepared a
written account of each event of source of
stress which would then be rated by a panel
of researchers for how stressful it would be
for a typical person. To avoid bias, raters
didn’t know who suffered depression.

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Results Both recent high levels of stress and having

suffered a stressful childhood event left
people particularly vulnerable to depression.

80% of women who suffered depression had

had a major stressful life event in the
previous year as opposed to 40% of those
who didn’t suffer depression. The factors
that had the strongest associations with
depression involved recent level of stress,
they were lack of an intimate relation, lack of
paid employment and the presence of three
or more children and death of mother during
childhood.
Conclusion There is a link between recent negative life
events and the onset of depression.
Evaluation Method: The experiment used the LEDS
which was developed by the researchers for
the use of this experiment and was specific
for life events relating to depression
therefore the results would likely result in life
events leading to depression. Also even
though the raters didn’t know who was
depressed there may also be bias in the
interviewers.

Culture: The sample size was only London

people and culturally there may be different
results as many research have shown there
are different social and cultural factors in
depression. Therefore we don’t know how
well this will apply to other cultures.

Ethics: The LEDS aimed to uncover stressful

and possibly depressing events of people
during the childhood. Many of the details
uncovered involved high levels of stress on
the participants. This stress may have

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activated unhappy memories and therefore

cause negative emotions onto the
participants. Ethically this causes stress on
the participants.

Gender: This experiment aimed to focus on

woman, but research has shown that men
and women face depression differently so
the results of this experiment may not apply
to men as strongly as it would women.

The theory of social drift and social causation aims to explain how most mental disorders are
found more frequently in lower socioeconomic groups. Social drift is the idea that individuals
and families with mental disorders tend to drift into lower socioeconomic groups. Social
causation is the idea that low socioeconomic status causes psychopathology.

Ritsher et al. (2001) tested for social causation and drift effects in a study of 756 participants
across two generations. It was found that low parental education level was associated with
increases rates of depression in the following generation even when there was previously no
depression in the family history. Parental depression did not predict lower SES in offspring.
This study supports of the role of causation and fails to support a role for social drift in
depression.

Lupien et al. (2000) suggests that high levels of stress in parents affect children’s
development by affecting their own levels of stress. They test this theory on 139 mothers
and regularly assessed for stress and depression by telephone interview. Their children (217)
were assessed for salivary cortisol levels and for cognitive function. Low SES mothers
reported more stress which was reflected in the cortisol levels and cognitive functioning of
their children. This research suggests that stressed low SES mothers somehow transmitted
this stress for their children thus contributing to later depression.

Nicholson et al. (2008) found that men in the most socially disadvantaged groups in Poland,
Russia and the Czech Republic were 5 times more likely to report depressive symptoms than
their compatriots in higher socio-economic groups. Wu and Anthony (2000) found that in
the USA there appears to be lower prevalence of depression in Hispanic communities
supposedly because levels of social supports are higher and act as a preventative measure
against depression. Gabilondo et al. (2010) found that depression occurs less frequently in
Spain than in northern European countries and that there is lower rate of suicide. The reason

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for this is suggested to be due to stronger traditional roles of family and higher religiosity as
sociocultural variables that make the prevalence lower.

Culturally it was found that individualism was found to be associated with high rates of
depression. Chiao and Blizinsky (2010) found that depression was associated with
individualism and that this dimension has a negative correlation with the frequently of 5HTT.
The researchers suggest that cultural norms such as increase social support have developed
to protect the more biologically vulnerable groups. This suggests that collectivism is evidence
of biological vulnerability.

Brown and Harris (1978) have shown that there are gender variations in depression and that
women are more likely to experience depression. Koss et al. (1994) found that discrimination
against women begins early in their lives. Women are around twice as likely as men to suffer
sexual abuse in childhood and this pattern of victimization is maintained in adult hood,
where woman make up the majority of victims of physical assault.

Etiology of Eating Disorders

Eating disorders are split into two major ones

I. Anorexia nervosa
II. Bulimia nervosa

Biological factors

An evolutionary explanation was theorized by Surbey (1987) where his findings suggest that
weight loss usually comes after the amenorrhea (when menstruation stops) and that
anorexia often occurs in girls who are maturing early, the reproductive suppression model
suggests that starvation is an adaptive response to stress that deliberately delays the onset
of reproductive capabilities until a more appropriate time. A problem with this theory is that
it doesn’t address males but it does help explain the lack of obsession with food anorexics
have, adaptive behavior in times of food shortage and starvation is to shift attention to the
acquisition of food.

It is possible that physical illness may act as a factor in eating disorders. Park, Lawrie and
Freeman (1995) studied four females suffering from anorexia nervosa, all of whom had had
glandular fever or a similar disease shortly before the onset of the eating disorder, they
argued that the physical disease may have influenced the functioning of the hypothalamus
and this caused homeostatic imbalances. But this research fails to establish a casual link

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between anorexia and glandular fever as they used a small sample size and most people who
have had glandular fever do not go on to develop anorexia nervosa.

Zandian et al. (2007) suggest that anorexia is an expression of an underlying

obsessive-compulsive disorder as these disorders frequently precede anorexia. A hypothesis
is that there is a genetic base to this and the in male OCD does not usually manifest itself as
anorexia but female biology interacts with the OCD to transform it into an eating disorder.

Holland et al. (1988)

Aim Aimed to investigate whether there was a
higher concordance rate of anorexia nervosa
for MZ than DZ twins based on previous
research suggesting so.
Method An opportunity sample of 34 pairs of twins
(30 female and 4 male) and one set of
triplets because one of the pair had been
diagnosed with anorexia. This was a natural
experiment and a physical resemblance
questionnaire established genetic
relatedness. A blood test was also used. This
was a longitudinal study with the researchers
checking over time to establish whether the
other twin went on to develop anorexia. A
clinical interview and standard criteria were
used for diagnosis of anorexia.
Results Significant difference was found between the
concordance rates for MZ and DZ twins,
there was a much higher concordance rate of
anorexia for MZ than DZ 56% to 7%

Further findings revealed that in three cases

where the non-diagnosed twin did not have
anorexia they were diagnosed with other
psychiatric illnesses and two had minor
eating disorders.
Conclusion The results suggest a genetic basis for
anorexia and general psychiatric illness. The
fact that the percentage for MZ twins was

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well below 100% indicates that genes are not

wholly responsible, so genes can provide a
predisposition but do not directly trigger the
disorder.
Evaluation Study ignores the role of environmental
factors or nurture in causing anorexia. The
results clearly show that environment plays a
role.

This natural experiment lacks control of the

variables. The IV is not isolated and multiple
other factors may be implicated. Therefore
internal validity is low as factors other than
the IV may have caused the anorexia. Also
causation cannot be inferred as the IV is low.
This means that conclusions are limited as it
cannot be said that genes cause anorexia
and at best is strong implicates it.

The study is limited as it was carried in a

Western society and anorexia is much more
common in Western societies than others
parts of the world. These cultural factors
were not considered.

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

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Sociocultural factors

Anorexia nervosa can be explained through conditioning theory.

I. Classical Conditioning: Leitenerg, Agras, and Thompson (1968) suggest that

anorexics may have learned to associated eating with anxiety, because eating too
much makes people overweight and unattractive. Therefore they seek to lose weight
to reduce their anxiety. Weight loss is associated with relief from an unpleasant
stimulus.
II. Operant conditioning: Food avoidance can be rewarding or reinforcing because it is
a good way of gaining attention. It can also be reward or reinforcing in that those
who are slim are more likely to be admired by people. Rosen and Leitenberg (1985)
states that bingeing causes anxiety and the subsequent vomited or other
compensatory behavior reduces that anxiety. This reduction in anxiety is reinforcing
and helps to maintain the cycle of bingeing followed by vomiting.

Conditioning theory provides some reasons why anorexics and bulimics maintain their
disorders but it does not account for individual differences in vulnerability to eating
disorders.

Social Learning Theory

Cooper (1994) found that both bulimia and anorexia is considerably more common in
Western than in non-Western societies. This can be explained in terms of role mole models
available to young women. In society, women see other women rewarded for looking slim in
terms of the attention and admiration they receive. According to SIT this will lead many
women to imitate this rewarded behavior by striving to slim. This is known as vicarious
reinforcement. Nasser (1986) compared Egyptian women studying in Cairo and in London.
None of the women studying in Cairo developed an eating disorder, in contrast to 12% of
those studying in London. This shows evidence that there may the importance of Western
role models in the development of eating disorders. Lee, Hsu, and Wing (1992) noted that
bulimia was almost non-existent among the Chinese in Hong Kong and suggested that this
can largely be explain in terms of socio-cultural differences. Chinese girls are usually slim and
therefore don’t share the Western fear of fatness that can lead to excessive dieting behavior.
The Chinese regard thinness as a sign of ill-health rather than the Western view that it is a
sign of self-discipline and economic well being. Obesity is not seen as a sign of weak control
or moral impairment as in the West. It is seen as a sign of health and prosperity.

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Behar et al (2001)
Aim Aimed to investigate the effect of gender
identity on eating disorders to test behavior
explanations that gender identity on eating
disorders to test sociocultural explanations
that gender differences exist because
women experience more pressure to be thin
than men. They hypothesized that the
existence of role models with idealized body
images will develop into eating disorders and
aimed to see if the acceptance of female
gender roles was higher in females with
eating disorders than in controls.
Method 126 participants- 63 patients with eating
disorders and 63 control subjects were used.
A natural experiment as the IV could not be
controlled. A structured clinical interview
and DSM-IV criteria, a self report survey to
measure gender identity was used.
Results Significant differences were found in gender
identity. More eating disorder patients
classified as feminine gender identity- 43%
compared to only 23.8% of controls. More
controls were classified as androgynous:
31.7% of controls compared to only 19% of
patients. More controls were classified as
undifferentiated: 43% compared to 27%.
Evaluation Study ignores the role of genetics factors
even though there is strong evidence of role
of genetics. It is reductionist to only consider
one explanation.

This is a natural experience so the IV was not

controlled and so causation cannot be
inferred there it cannot be sad that eating
disorders and gender identities are casually
related. Gender identity was measured only
after eating disorders had developed, it is

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assumed that gender identity leads to eating

disorders but it is possibly the having an
eating disorder causes gender identity
changes.

This study was carried out in a western

society and eating disorders are far more
common there than in non-Western one.

Cognitive factors

Sufferers have eating disorders have cognitive bias. Garfinkel and Garner (1982) found that
anorexic patients typically overestimate their body and that it is greater than that found in
controls.

Jaeger et al. (2002) sampled 1751 medical and nursing students across 12 counties, including
a mixture of Western and non-Western ones. A self-report method was used to obtain data
on body dissatisfaction, self esteem and dieting behavior, BMI was also measured. A series of
10 body silhouettes, designed to be as culture free as possible, were shown to participants to
assess body dissatisfaction. Results showed that the most extreme body dissatisfaction was
found in Mediterranean counties, followed by northern European counties and counties in
process of Westernization, and finally non-Western countries which has the lowest levels.
Body dissatisfaction was independent of self-esteem and BMI; those with greatest body
dissatisfaction were very often not overweight. This research supports sociocultural
explanations of Western role models and shows us that body dissatisfaction may be
important vulnerability factor for eating disorders. Also since body dissatisfaction was
independent of BMI; it suggests the vulnerability to eating disorders depends on more
subjective factors than objective factors. This shows how fault cognitive processing
contributes to eating disorders.

Fairburn et al. (1999) provided a detail account of how low self-esteem and an extreme need
for self control are at the core the disorder. They suggest that for people with anorexia, the
need for control is easily met through eating. The idea that dieting and control go together is
a schema built and encouraged in Western society. The disordered eating patterns are
maintained because the person’s sense of control is increase to the point where control over
eating becomes a measure of self-worth. Also constant checking of body shape to obtain
objective information about success of dieting is made unreliable by distorted perceptions
cause by negative mood and the presence of thin women in the media. There is also an

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attention bias towards negative information about body.

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

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Implementing treatment

Syllabus Question: Examine biomedical, individual and group approaches to treatment.

And Evaluate the use of biomedical, individual and group approaches to the treatment of
one disorder.

Biomedical therapy

The biomedical approach to treatment is based on the assumption that if the problem is
based on biological malfunction, drugs should be used to restore the biological system.
Drugs are widely used to treat depression because we are aware of neurochemical activity
associated with the disorder. A biological theory that aims to explain major depressive
disorder is the serotonin hypothesis, it suggests that there is an inadequate amount of
serotonin available in the synaptic gap between neurons for effective transmission to occur.
Based on the assumption from research that serotonin plays a role in depression, medication
for major depressive disorder increase serotonin. Selective serotonin reuptake inhibitors
(SSRIs) aim to increase the amount of serotonin available by preventing the reuptake of
serotonin, making it stay in the synaptic gap longer and thereby increasing the efficiency of
the serotonin already present. These drugs include fluoxetine (Prozac).

Criticisms of Prozac are that it treats the symptoms but it does not cure the disorder and
there are significant side-effects. The effects include sexual problems, dry mouth, insomnia
and even an increase in suicidal thoughts. This drug seems to be more helpful for the most
serious cases of depression. Because only the symptoms are treated and because depressive
episodes usually recur, it is necessary for patients to continue taking the medication unless
the medication is used with therapy, it unlikely that the disorder will disappear permanently.
Therefore the effectiveness of drugs are limited without the use of other treatments.

A study by Kirsch and Sapirstein (1998) analyzed the results from 19 studies, covering 2318
patients who had been treated with Prozac and found that antidepressants were only 25%
more effective than placebos and no more effective than other kinds of drugs, such as
tranquillizers. Further research by Kirsch et al. (2008) reviewed 47 clinical trials published by
the US Food and Drug Administration on effectiveness of antidepressants. They claimed that
medical treatment was not more effective than a placebo and found that depressed patients
can improve without biomedical treatment. Blumenthal et al. (1999) found that exercise was
just as effective as SSRIs in treating depression in an elderly group of patients.

Leuchter and Witte (2002) found that depressive patients receiving drug treatments

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improved just as well as patients receiving a placebo. The researchers scanned the patients
and found changes in brain functioning in both cases but the changes were different.
Patients who got a placebo showed increased activity in the prefrontal cortex, whereas
patients who received the antidepressant showed decreased activity in the same brain area.
The researchers could see that brain changes happened within 48 hours of starting
treatment in the drug group, whereas changes began after one to two weeks in the placebo
group. It is not known why a placebo works but the results of this study clearly showed that
the placebo worked and was better than no treatment. The researchers argue that the brain
does not respond to the same way to a placebo and drugs but people’s mental health
improved in both groups indicating that medication is effective but there are other ways to
help people who suffer from depression.

Elkin et al. (1989) worked with 28 clinicians who worked with 280 patients diagnosed as
having major depression. Patients were randomly assigned to treatment using either an
antidepressant drug, interpersonal therapy, or CBT or another form of therapy. A control
group was given a placebo pill along with weekly therapy. The placebo/drug group was
conducted as a double blind design. All patients were assessed at the start, after 16 weeks of
treatment and after 18 months.

Results showed that 50% of patients recovered in each of the CBT and IPT groups as well as
the drug group. Only 29% recovered in the placebo group, the drug treatment produced
faster results but the study shows that there is no difference in the effectiveness of CBT, IPT
and drug treatment, i.e. it doesn’t matter which treatment patients receive.

But Bernstein et al. (1994) found that generally antidepressant drugs are an effective way to
treat depression in the short term, significantly helping 60-80 per cent of people.

Individual therapy

Assumptions of this form of treatment are that since one of the symptoms of depression is
distorted cognitions. This led to psychologists to suggest that replacing negative cognitions
by more realistic and positive ones can help the depressed person. Beck’s theory of cognitive
therapy is based on cognitive restructuring and aims to fix the cognitive bias identified
through his theory.

Cognitive behavioral therapy (CBT) is a brief form of psychotherapy used in the treatment of
adults and children. There are typically around 12-20 weekly sessions, combined with daily
practice exercises to specifically designed to help the patient use new skills on a day-to-day

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basis.

The therapy consists of identifying the automatic, negative thoughts assumed to underlie the
depression and helping the depressed person see and understand the connection between
these thoughts and their emotional state. By addressing these thoughts together, and
through individual exercises, the person in therapy and the therapist can gradually change
the negative self-schema and find more positive ways to interpret life events. Behaviors that
are rewarding for the individual and encouraging him or her to engage in them as one of the
key symptoms of depression is loss of interest in activities that used to give pleasure and its
aim of therapy to regain these levels of interest.

Interpersonal therapy (IPT) concentrates on helping the client develop and use any positive
social support networks they have in their life with improved communication skills.

Rush et al. (1997) found that cognitive therapy effectively treats patients with depression.
Dobson (1989) found that cognitive therapy is superior to not treatment or to a placebo. But
Elkin et al. (1989) found that there was no significant difference in the effectiveness of
individual therapy, CBT and another form of therapy in comparison with a drug and a
placebo. The two therapies were slightly less effective than the drug but more effective than
a placebo.

Riggs et al. (2007) studied effectiveness of CBT in combination with either a placebo or an
SSRI. This study was a randomized double blind study with 126 adolescents, aged 13-19, who
suffered from depression as well as a substance use disorder and conduct disorder. The
participants were rated by a physician who found that 67% of the patients in the CBT+
placebo group and 76% of the patients in the SSRI + CBT were judged as very much improved
or much improved after being treated for four months. The researchers concluded that
treatment with drugs and CBT is effective but that treatment with a placebo and CBT is
almost as effective. The participant’s self reports after the study showed that depression had
decreased and so had the other behavioral problems.

Nemeroff et al. (2003) found that CBT in combination with drugs was the most effective in
cases of chronic depression in people suffering from traumatic childhood experiences. This
group was better helped with either therapy alone or a combination of therapy and drugs,
rather than with drugs alone.

Parker et al. (2006) reviewed the effectiveness of CBT and IPT and it indicated that IPT alone
is not as quick as medication in relieving symptoms but it does provide substantial

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improvement at a slightly later point. Butler et al. (2006) reviewed several meta-analyses of
efficacy studies for CBT and concluded that CBT is extremely effective for depression,
although the effect is not usually greater than medication alone and outcomes are usually
better when CBT is combined without medication.

Group therapy

People who may not hear or share when they are alone with a therapist may be encouraged
to participate in discussion when they are surrounded by others. There is a chance that they
can vicariously through the experience of others become more optimistic about their own
chances for recovery if they meet others who have improved.

Hyun et al. (2005) randomly assigned depressed adolescents at a shelter for runaways to
group CBT or a group receiving no treatment. They found group CBT to be extremely
effective at relieving symptoms of depression. Meta-analyses by Toseland and Siporin (1986)
reviewed 74 studies comparing individual and group treatment. Group treatment was found
to be as effective as individual treatment 75% of the time in these studies and more effective
in 25% of it. In no case was individual treatment found to be more effective than group
treatment. Group treatment was also found to be more cost effective than IT in 31% of the
studies.

But McDermut et al. (2000) provided a meta-analytic review of the effectiveness of group
therapy in treating depression. Of the 48 studies examined, 43 showed statistically significant
reductions in depressive symptoms following group therapy, 9 showed no difference in
effectiveness between group and IT, and 8 showed CBT to be more effective than group
therapy.

But Traux (2001) states the most studies included in meta-analyses excluded the more
severely depressed people. Therefore we do not know if group CBT is effective for all
depressed people.

A problem with group therapy is that dissatisfaction with the group or any of its member
might lead to drop and Traux (2001) cites this as the main reason why people drop out from
studies like this.

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Abnormal Psychology

Syllabus Question: Discuss the use of eclectic approaches to treatment.

Eclectic approaches are treatments that use several approaches to treating a disorder, i.e.
using biomedical, individual and group approaches together.

State the strengths of limitations to each of these approaches for a disorder and then link
together on how they will be effective together.

Elkin et al. (1989) found that there was no significant difference in the effectiveness of
individual therapy, CBT and another form of therapy in comparison with a drug and a
placebo. The two therapies were slightly less effective than the drug but more effective than
a placebo.

Riggs et al. (2007) studied effectiveness of CBT in combination with either a placebo or an
SSRI. This study was a randomized double blind study with 126 adolescents, aged 13-19, who
suffered from depression as well as a substance use disorder and conduct disorder. The
participants were rated by a physician who found that 67% of the patients in the CBT+
placebo group and 76% of the patients in the SSRI + CBT were judged as very much improved
or much improved after being treated for four months. The researchers concluded that
treatment with drugs and CBT is effective but that treatment with a placebo and CBT is
almost as effective. The participant’s self reports after the study showed that depression had
decreased and so had the other behavioral problems.

Nemeroff et al. (2003) found that CBT in combination with drugs was the most effective in
cases of chronic depression in people suffering from traumatic childhood experiences. This
group was better helped with either therapy alone or a combination of therapy and drugs,
rather than with drugs alone.

Parker et al. (2006) reviewed the effectiveness of CBT and IPT and it indicated that IPT alone
is not as quick as medication in relieving symptoms but it does provide substantial
improvement at a slightly later point.

Cujipers et al. (2009) compared the effectiveness of various treatments for depression
through a meta-analysis of studies. They found that psychotherapy groups do significantly
better than control groups. Medication was found to be more effective than psychotherapy
in improving symptoms, especially when SSRIs were used. But the best results were found in
studies that used a combination of medication and psychotherapy.

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Syllabus Question: Discuss the relationship between etiology and therapeutic approach in
relation to one disorder.

Etiology are the origins of a disorder. Use info and research from depression about the
theories on the causes of it and then link it to the three treatment approaches and why they
are used. E.G. CBT is used because its theorized and shown that depression may be due to
faulty cognition.

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