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Abnormal Psychology

GENERAL FRAMEWORK To what extent do biological, cognitive and sociocultural factors influence abnormal behaviour? 1. Define abnormal behaviour Abnormality: Psychologically disordered behaviour involves that behaviour is atypical, disturbing to oneself and/or others, maladaptive and unjustifiable to oneself or others David Meyers 1998. (to their particular culture) State the abnormal behaviour: - Depression - OCD 2. Biological: Role of neurotransmitter Genes Hormones 3. Cognitive: Learned helplessness Depression 4. Sociocultural: Conditioning fear Making mental health diagnosis Kasamatsu and Hirai Hallucinations is the norm not abnormal. Evaluate psychological research (that is, theories and/or studies) relevant to the study of abnormal behaviour. [Described + evaluated] Ms. K one of the theories related to diagnosis is... (refer to Q. if possible) Before diagnosing, it is key that the terms abnormality and normality are defined. One definition/some definitions are... Abnormality can be defined as atypical behaviour out of social and cultural norms that are disturbing to oneself and others and that is maladaptive and unjustifiable to themselves or others. The concept however is difficult to grasp as there may be some exceptions. Therefore there are many problems with theories and studies in diagnosing abnormality. One theory is Jahodas mental health model. In her model, she tries to define normality, rather than abnormality. It includes six categories: self positive attitude, self actualization (potential), personal autonomy (independency), accurate reality of the world and self, ability to adapt to change and resistance to stress. If one is able to check all six categories, they are

considered normal. In a way, it is useful as it criticises other models and psychologists for only approaching abnormality by the mental illnesses rather than what is considered healthy. Eval. Some empirical evidence also supports her model such as research in unemployment. It was found that those without jobs for a substantial amount of time were unhappy due to lack of ability, not because they were poor or were in financial crisis. However, Jahodas model is too idealistic and in some cases like personal autonomy, children and the elderly may not be able to achieve this because they cannot be independent. Also, those that do fulfill each category may not necessarily be normal. Due to the fact that it is really subjective, the model is not valid in some cases, and because it was originally developed during the 1980s, it needs to be updated and revised. Good desc. and eval. Another theory is the DSM for classification. it stands for Diagnostic and Statistical Manual of Mental Health and consists of 5 axes. In total, there are 16 categories for mental illnesses, unlike Jahoda, it is a list of what defines abnormal mental health illnesses. This makes it quite precise and accurate due to the well structured and categorized system. It is also thought to be a better model compared to the ICD. Another good aspect about the model is that it is often revised. The most recently updated model today is DSM-IV. However, the downside is it does not consider gender and culture, therefore is biased. Another problem is that it does not explain the mental illnesses and what exact treatment can be enforced. There is only short term treatment. It does not explain stigmatization mental illnesses and one study by Rosenhan highlights the impact of labelling and problems with diagnosing when patients are normal. desc. of study Rosenhans study aimed to investigate the effects of labelling. as well as... test existing diagnostic systems. He had a total of 8 participants, who were to complain to different mental hospitals that they were hearing voices. All were admitted and 7 were diagnosed with schizophrenia. Participants were meant to take notes on any observations during the ward. After being admitted they were to act normal, not take any medication given by staff and convince them they were sane. As a result, none of the pseudo-patients were able to convince the staff. The average number of days spent in the ward was 19 and the longest was 52. Patients and staff were segregated and normal interaction was discouraged. The staff thought that normal actions were symptoms of abnormality. For instance, waiting outside cafeteria for lunch was termed as oral acquisition syndrome and pacing the corridors out of boredom was seen as nervousness. The pseudo-patients had lost their rights and privacy. They were verbally and physically abused by staff and felt a sense of powerlessness and because of the label, moulded into the expectations of it. Hence self-fulfilling prophecy. An interesting point to note was that some of the actual patients sensed normality and questioned pseudo patients if they were reporters! Eval. Although this does give good insight to the problems with labelling, Kety defended the staff saying that they did not expect normal people to be admitted and were only basing actions with the related disorder. Thus this is not enough evidence to conclude that scientific method for diagnosing is incorrect and inaccurate. This particular study also lacked ethical considerations for the participants as they were not protected from mental and physical harm. + deceit towards staff at hospital.

Diagnosing for culture bound syndrome is also crucial, since the DSM does not consider other cultures as it is a Western model. Culture bound syndrome are thought to exist in a particular geographical location and not found in others. Such a case is Tsengs study. His aim was to investigate Neurasthenia, which is characterized with symptoms of lassitude and fatigue based on emotional disturbances. It was found that over half of all out-patients have this disorder and it can only be found in the CCMD-2 (the Chinese model of DSM). He also compared the disorder with symptoms from DSM and found they were similar to anxiety disorders. This has lead to considering culture and the different symptoms others experience. Yet this diagnosis is not always accurate. For instance the study by Lopez and Hernandez aimed to show too much consideration in culture can lead to inaccurate diagnosis Eval. of disorder and less treatment given to other cultures. Eval. They surveyed psychologists in California who considered culture when diagnosing. It was found that many of their clients were not given proper treatment. In one case, a psychologist did not give any medication or suggestion to an African-American woman who had symptoms of schizophrenia because he thought that it was acceptable in her culture. Therefore this study highlighted a need to understand more thoroughly the changing cultures and what is acceptable or not. A problem with this study however is that it was only surveyed in California therefore we cannot completely generalize the results but only bear them in mind. Eval. In conclusion, it is difficult to diagnose what is abnormal and what isnt because of the need to keep track of development in a patient and their culture. There are a multitude of factors that can affect abnormal behaviour and revising research, theories and studies would lead to a more accurate and valid diagnosis. Good description of Rosenhan, CBC, DSM and abnormality + Jahoda. Good evals. A-9 B-8 C-4 21/22. Fantastic!!! Examine the concepts of normality and abnormality. Concepts: Defining normal + Abnormal Criteria Change in norm (over time, culture) Variations (between groups of people) more accurately: Statistical infrequency * Deviation from the norm does not address the desirability Deviation from social norms Dysfunctional behaviour Deviation from ideal mental health

Normality Situational norm: behaviour accepted in given situation Developmental norm: Behaviour accepted in certain age (Jahodas mental health) *Deviation from social norms SOCIETYS NORMS: Situational norm Developmental norm Evaluation - Change in periods of time. [Change in view of homosexuality] Because whats acceptable and not is always changing. They may be abnormal but not seen breaking any norms e.g. depression Abnormal labelled stereotypes discriminated against PRESSURE to stick to norm (conform), even if you dont agree

Abnormality Psychologically disordered behaviour involving atypical behaviour, disturbing oneself and others, maladaptive and unjustifiable to oneself/others. Homosexuality Used to be considered abnormal, but then it didnt break rules of Jahoda. Evaluation (Jahoda) Those unemployed for long periods of time cannot fulfill, but does that mean they are abnormal? Some may fulfill but are abnormal Vague, difficult to measure 1958, needs updating. Outline for abnormal behaviour Rosenhan and Seligman dysfunction and distress. Suffering Maladaptiveness Irrationality Unpredictability Vividness and unconventionality Observer discomfort Violation of moral or standard ideals * Rosenhan and Seligman suggested it should occur in combination, more than one element to determine abnormality. Statistical infrequency/deviation from the norm E.g. measures of IQ, ability to sing (bell curve) Those at high end (not normal) are desired.

But weight (anorexic, normal, obese) -- Out of normal = undesirable. Subjective feelings associated with abnormality. - Intense anxiety - Unhappiness - Distress Some are unaware of their condition - individuals suffering from schizophrenia. Overall Evaluation points: Problems in defining abnormality Some behaviours outside mean are considered desirable... in this case abnormality is seen as good. Contradicts Some cases, undesirable cases can be considered normal Specific to age, gender, cannot use one diagnosis for all Who decides to put deviation? Does it change over time!?

Discuss validity and reliability of diagnosis. Reliability: Testing for reliability replicating experiment to give same results. Validity: Is it applicable in everyday life? Does it measure real pattern of symptoms and can effective treatment be administered? causes vs. symptoms, bias Evaluating Strengths: unable to make reliable diagnosis, studies raise awareness and thus classification systems get revised often. How people are diagnosed? 1. Patient: People need to be aware of the problem (unable to function adequately) Symptoms 2. Clinician Brain scan Blood tests IQ tests Personality tests Cognitive tasks 3. Techniques of assessment Behavioural observation +ve: direct and detailed information. -ve :inter-observer reliability and subject reactivity.. Some symptoms cannot be observed Clinical interview +ve: Detailed, flexible, sensitive method

-ve: Lacks objectivity Psychological tests +ve: Objectively rated, quick and standardized -ve: personality tests rely on self report and literacy Physiological tests +ve: Precise data on brain structure or activity -ve: Expensive, cannot be used to diagnose disorders

*Jahoda? Rosenhan and Seligman? Evaluation of Classification Systems Purpose of classification: - Involves identification of groups or patterns of behavioural or mental symptoms that reliably occur together to form a type of disorder. Allows prognosis (prediction of future course of the disorder) Can investigate and determine the causes (aetiology) of disorder Develop a suitable treatment.

Classification systems of disorders: Operational diagnostic criteria - APA (American Psychiatric Association) Kraeplin (1981 [1896]) proposed the system consisting of two major groups of mental diseases - formed the basis of Diagnostic and Statistical Manual of Mental Disorders (DSM) used today. International Classification of Diseases (ICD) - World Health Organization Strengths (of classification) Statistical diagnosis (Objective) Quantifiable (Objective) Can apply suitable treatment Uses 5 different axis (kinda well rounded, looking at all viewpoints. btw, welcome to the 5th dimension - seen below) Weaknesses (of classification) Ethical implications labels such as mentally ill, criminal or foreigner People who are different are stigmatized (socially excluded) The diagnosis provides the patient with a new identity, for example schizophrenic In DSM, this has been rectified by recommending psychiatrists to refer to a patient by an individual with schizophrenia A label is for life, and even if the patient no longer shows such symptoms, the label disorder on remission still remains (remission: reduction of seriousness or intensity) Labelling can lead to the self-fulfilling prophecy, where people act as they think they are expected to, and the number of symptoms increase as a result of being labelled People who are labelled have to endure discrimination and prejudice Langer and Abelson Study

Reliability reliability is high when different psychiatrists agree on a patients diagnosis using the same classification system (also know as inter-rater reliability) Studies (Prove how poor the DSM II system was) May be unreliable Beck et al. (1962) Found agreement on diagnosis for 153 patients (each patient was assessed by two psychiatrists from a group of four), was only 54%. Copper et al. (1972) When shown the same video-taped clinical interviews New York psychiatrists were twice as likely to diagnose schizophrenia compared to London psychiatrists and they (London), were twice as likely to diagnose mania or depression. Rosenhan (1973) Found 8 normal people could get themselves admitted to mental hospitals as schizophrenics merely by claiming to hear voices saying single words like hollow and thud. Also found staff of a teaching hospital, when told to expect pseudo-patients, suspected 41 out of 193 genuine patients of being fakers. Validity The extent to which the diagnosis is accurate (how true it is) the classification system should be able to classify a real pattern of symptoms which can lead to an effective treatment However the system is descriptive and therefore does not identify specific causes for the disorders It is therefore difficult to make a valid diagnosis due to the absence of OBJECTIVE physical signs of such disorders For a valid classification system, it should classify a real pattern of symptoms, which result from a real underlying cause + suitable treatment. Only a few underlying cause is known for current Classification systems + a wide range of treatment for some disorders. Some classifications (such as undifferentiated schizophrenia, which is for symptoms that fit for the general, but none of the sub groups) are rather meaningless as diagnostic categories. A valid diagnosis is much harder than the physical disorder as it lacks quite a lot in physical signs. BIAS D: From expectations or prejudices of diagnostician Confirmation bias clinicians tend to have expectations about the person who consults them, assuming that if the patient is there in the first place, there must be some disorder to diagnosis. (Fundamental Attribution Error) Since their job is to diagnose abnormality, they may overreact and see abnormality wherever they look Study: Rosenhan (1973) On Being Sane in Insane Places

showed a video tape of a younger man telling an older man about his job experience If the viewer was told beforehand that the man was a job applicant, he was judged to be attractive and conventional-looking if the viewer was told that he was a patient, viewers responded that he was tight, defensive, dependent, frightened of his own aggressive impulses This demonstrates the power of schema processing

Aim: to illustrate the problems in determining normality and abnormality Method: 8 sane people (3 women 5 men from a small variety of occupational backgrounds) Evaluation Experiment done in 1973, the DSM was updated several times after this, therefore the manual may have become more reliable FAE (Fundamental attribution error) - over emphasizing situational than behaviour, thinking people seeking help are in fact disturbed... when they may not be.

DSM IV - multi-axial classification system Axis 1 Clinical Syndromes Axis 2 Developmental and Personality Disorders Axis 3 Medical Conditions Axis 4 Psychosocial stressors Axis 5 Global assessment of functioning Strength of DSM - Revised often, therefore criteria becomes more accurate as time passes - Operational diagnostic criteria - Multi-disciplinary approach, this gives a broader diagnostic Weaknesses of DSM - Gender and culturally biased - Does not look at causes (cures only short-term or visible symptoms, doesnt necessarily cure the disorder) Accuracy - Because of DSMs precise way that disorders have been categorised, it increases the accuracy of diagnosis made through the use of the DSM. - DSM has Sixteen categories of mental disorders. Reliability - DSM is more reliable than ICD because of the difference in categories and the more precise way that disorders have been categorised. Where will there be mistakes made in diagnosis? - Inter-observer reliability is tested (only for behavioural observation). Since they will find/notice different particular traits, or behaviours, they will diagnose differently. [conformation bias could also play a role, to make the psychiatrist believe in his/her diagnosis] - The classification is not completely objective and reliable, bias may result from the expectations. [Temerline 1970 - found that clinically trained psychiatrists and clinical psychologists could be influenced in their diagnosis by hearing the opinion of a respected

authority. After watching that video of an interview with a mentally healthy man, their diagnosis was influenced by the line although the person seemed neurotic, he was actually psychotic] - Criteria changes over time and it takes time for both the DSM and the ICD to be updated, during the transitional time frame, one without a disorder may be diagnosed with a disorder. Discuss cultural and ethical considerations in diagnosis (for example, cultural variation, stigmatization). INTRODUCTION Why is it necessary to consider culture in diagnosis? An individuals behaviour is governed to an extent by the culture they are brought up in What is perceived as acceptable in one culture may be seen as a severe social problem in another Kaiser et al. (1998) Claimed psychiatrists are now encouraged to be aware of cultural differences when assessing patients.

How to diagnose? Use a manual to diagnose mental health problems DSM - outlines conditions that appear most often in specific cultures, as well as some cultural variations in the way symptoms are described. E.g. Some cultures, depression is expressed as a physical pain, while others describe depression as a feeling like sadness.

PROBLEMS! Cultural Bias A tendency to favour your own cultural view of the world!!!!!

Labeling, stereotyping Racism (overlaps with ETHICS) In UK, black people are more likely than white to receive a diagnosis of a severe mental illness e.g. schizophrenia (Littlewood and Lipsedge, 1989) Assumption: consequence of stressful geographical and cultural relocation black people have when undertaken as immigrants to a new country. [Illusory correlation] Counter: Littlewood and Lipsedge (1989) argue majority of immigrants to Britain in recent history is actually white, process of immigration cannot account for difference. Also examined rates of serious mental illness. Higher on average for British-born black people rather than migrant parents or recent immigrants. Further assumptions (problems) - claim black people are genetically more likely to suffer from mental illness. Counter: World Health Orgnaization (WHO) conducted study of rates of schizophrenia in Europe, North America, Asia and Africa. Little difference in rates of severe mental illness reported. For genetic argument to hold, higher rates should have been seen in countries with largely black populations.

Already at a disadvantage, with lack of money and the assumption that blacks have a higher chance of getting disorders would result in discrimination, and they would experience a range of disadvantages in areas of housing, education, health and employment. Littlewood (1980) suggested what is judged as insane behaviour by some mental health practitioners may actually be a legitimate and understandable response to disadvantage and racism. Littlewood and Cross (1980) found black people received higher doses of drugs and are more frequently given electro convulsive therapy (ECT) compared to whites with same diagnosis.

Medical model and cultural differences Stirling and Hellewell (1999) - many psychiatrists in UK are middle class, male and white, thus are subject to their own cultural bias. p. 10 (Lynda Turner) STUDIES Lopez and Hernandez (1986) Lewis et al. (1990) Hirai and Kasamatsu

Cultural differences Lopez and Hernandez (1986) Aim: Investigate effectiveness of being aware of cultural diversity when making a mental health diagnosis. Method: Surveyed large sample of mental health practitioners in California, who were trying to avoid discrimination against minority groups by being culturally aware. They examined clinical assessments and treatments offered to patients over a period of time. Result: Many practitioners minimized seriousness of patients problems by assuming their behaviour was culturally different rather than abnormal. E.g. one clinician claimed that an African-American woman, who was suffering from symptoms of schizophrenia, did not require treatment. He believed hallucinations were a normal part of AfricanAmerican culture. Conclusion: Sensitivity about culture diversity may reduce changes of some cultural groups receiving appropriate treatment. Evaluation on research: Being too culturally aware and making assumptions may reduce treatment to cultural groups.

Comparison between Westernized and Non-westernized models Erinosho & Ayonrinde The Yoruba tribe in Nigeria were presented with vignettes (packet of info) describing case studies of mentally ill people, one of whom was a paranoid schizophrenic. Only 40% of the Yoruba tribe identified the patients as mentally ill 30% said they would be willing to marry such a person Shows importance of taking an emic approach

Binitie 1970 Presented vignettes describing case studies of mentally ill people to the Nigerians Found that 31% of Nigerians agree that such a person should be expelled, and 16% said they should be shot Education and westernization had led to a decrease in tolerance - link to ethical issue The two studies show how the perception of behaviour as normal or abnormal is subjective, and is largely dependent on cultural norms It appears that schizophrenia is a western model, because less westernized cultures (Yoruba tribe) were less likely to view hallucinations as negative The idea of cultural relativism (an emic theory) suggests that beliefs about abnormality differ between cultures and sub-cultures Schemas are mental representations of the world influenced by our environment and own experiences Since the definition of abnormality for each individual is largely based upon his or her schemas, abnormality itself is therefore subjective As a result, diagnosis of abnormality is therefore subjective, and dependent on cultural norms Hallucinations were also viewed in Kasamatsu & Hirai researchers at Tokyo university studied a group of monks who went on a 3 day journey to a holy mountain the monks did not eat, did not sleep, did not speak, were cold they saw "ancient ancestors" and "presence by their side" Hallucinations were a product of enlightenment

Link: It is culturally normal to be experiencing hallucinations during these pilgrimages - part of a meditative experience, not negative (desirable). Ethical - Labels Indicates that once a diagnosis has been made, it tends to stick. and so Scheff (1966) argues that receiving a psychiatric diagnosis will create a stigma (severe disapproval of the member of the society) or mark of social disgrace Problems : we are not convinced that such diagnosis is reliable or valid, even if this situation is improving. there are significant negative effects of such a diagnosis on a persons subsequent treatment by other people. Research : Scheff (1966) criticised the medical model of mental illness and in particular the diagnosis of schizophrenia. Such as being known as a Schizophrenic does not mean that they will break formal and obvious rules, but residual rule breaking (basically breaking the norm i.e. talking to themselves). He argued that many people breaks residual rules, but only those referred to a psychiatrist acquire a label, which influences their behaviour (feeling discomfort etc.) Read (2007) summarized a large amount of research relating to stigma. The findings showed that attitudes towards those diagnosed in a medical context tend to be characterized by fears, especially regarding dangerousness and unpredictably; also that

knowing some one has a diagnosis of mental illness increases reluctance to enter into romantic relationships with them. Distortion of behaviour - Diagnosis of mental disorder tends to label the whole person - once the label of diagnosis is attached, then all the individual s actions become interpreted in the light of the label. Sometimes even normal behaviour is ignored or interpreted as a sign of the individual s mental disorder Rosenhan (1973) Although not exactly ecologically valid, Rosenhan s study provided evidence that patients being diagnosed with mental illnesses are treated differently as a result of labeling. The pseudo-patients, although without any mental illnesses, were being treated differently solely because they have been labeled as mentally ill.

- Depersonalisation & Powerlessness This is produced in institutions through a lack of rights, constructive activity, choice and privacy, as well as frequent verbal and even physical abuse from attendants. This can be seen from the first asylums for the patients suffering from mental disorders, it looks more like a prison. Research : Rosehan (1973) - Rosehans study found that institutionalisation can lead to depersonalisation, dependency, and a loss of self care sills, thereby worsening the disorder.

- Self-fulfilling prophecy Patients may begin to act as they think they are expected to act - Goffman argues that they may internalise the role of mentally ill patient and this could worsen their disorder rather than improve it. Research : Scheff (1966) Self-fulfilling prophecy ^similar to above. Because they are being labeled, they will act in the way they think they should be acting or the way they are guided towards acting (fake symptoms might surface). Doherty (1975) found that the patients which reject the mental illness which they were diagnosed of, they tend to improve more quickly than the others.

- Prejudice and discrimination Hogg and Vaughan (1995) Stereotyping is a widely help assumption about personalities, attitudes and behaviour of people based on group membership. People suffering from mental illnesses are often negatively stereotyped, in turn leading towards discrimination. Dont you ever wonder why therapist is so similar to the rapist? lol, why in bold? cuz its kewl. Research : Rosenhan (1973) talked of the 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, making reintegration back into the community difficult.

- Changes in terminology / language Ever since Scheff (1966) proposed the self-fulfilling prophecy, the psychiatrists are encouraged not sure use terms which labels the patients, instead it shows that they are suffering from a mental disorder. An example is given below, with an extra set of explanation DSM IV explicitly reject terms such as schizophrenic but instead to use terms such as patient diagnosed with schizophrenia. This is done to remove the label which leads towards stereotyping.

- Confirmation bias Psychiatrists have confirmation bias, and so it is possible that the diagnosis is invalid. This leads to a problem in ethics, since it is possible that the patient is diagnosed wrongly, and then they are labeled, when in fact that person may be normal.

- Stereotyping Research : Faulkner and Layzell (2000) provided evidence of stereotyping experienced by people suffering mental health problems Aim: To provide evidence of stereotyping experience by people suffering mental health problems Method: A total of 584 participants completed a questionnaire, designed to collect information about discrimination. They were also asked how they thought discrimination could be reduced. Result: 70% of the participants had experienced stereotyping and discrimination; 66% said that they had not told people about their difficulties because of the stigma attached to mental distress. 30% experienced discrimination in the workplace, i.e. dismissal 56% said that one of the main sources are from their families, and 52% from friends. Conclusion:

Mental health patients are negatively stereotyped and can experience discrimination as a result of their diagnosis. This discrimination (and the fear of it) adds to the difficulties of people with mental health problems. The figures also reflect how severe the problem with discrimination and stereotyping is. Women are ore likely to be diagnosed with depression. While one vein of research investigates the unique biological reasons why this might be the case, another argument suggests that diagnostic criteria for depression are a description of normal female response to social pressures, and as such should be pathologized but be understood better and treated on a social rather than individual level.

- Schemas

This relates to stereotypes, as from many places (gossips, media etc.) they may have some negative connotations, and so whenever the terms mental illness or schizophrenic is used, the schema will be activated and there will be stereotype.

- Racial / ethical Bias Morgan et al. (2006) found that in UK, the incidence of schizophrenia in nine times higher for Afro-Caribeans and six times higher for those of black African descent, than for while British people The researches argue that genetic differences cannot account for this and it is more likely that diagnosis bias account for it. Migrants and ethic minorities in many European countries and the Anglo-American world are over represented in mental hospital populations (Read et al, 2004) Jenkins-Hall and Sacco (1991) Involved European American therapists being asked to watch a video of a clinical interview and to evaluate the female patients. There was a depressed and a non-depressed person in each of the race (only African American and European American in the research). The non-depressed were evaluated in similar ways, but the ratings for the African American woman had more negative terms, and saw her as less socially competent.

- Changes / updates Homosexuality was removed from DSM since the DSM III (1980). These changes and updates, PSYCHOLOGICAL DISORDERS Describe symptoms and prevalence of one disorder from the two groups: anxiety disorders affective disorders Disorder: Depression + OCD

Depression - Symptoms, prevalence (gender, culture... general), etiologies (attempt

to explain the disorder) - bio, cog, sociocultural Types: Unipolar and Bipolar; clinical depression (major depressive disorder); SAD Unipolar - persons mood changes from normal to depressed. Bipolar - characterized by mood swings. When depression lifts, the person enters a period of extreme elation known as mania. Symptoms of unipolar disorder Cognitive - e.g. thought process is impaired, memory and concentration is affected. Difficult to think positively about themselves. May be suicidal. Emotional - e.g. sadness, despair, absent feelings, empty, no interest in pleasure Behaviour - e.g. Stop socializing, stop taking care of themselves, handle everyday activities slower, attempt suicide Physical (somatic) - e.g. Sleep disturbance, and loss of appetite and weight. Doctors believe 40% of people suffering with depression visit their surgery for first time due to

physical symptoms including aches, pain, lack of energy, palpitations, headaches, stomach upsets. Diagnosis of unipolar disorder May appear gradually or suddenly. Occurs in all social classes - all ages Severe forms more common in middle and old, though theres been steady increase in depressive illnesses amongst people in their 20s and 30s. Diagnosing depression - combinations of symptoms above must last for at least 2 weeks. Evaluation points DSM and ICD can diagnose mood disorder on symptoms experienced not by physical tests to establish it and are thus based on self reports from patient. Aetiology (cause of disease) - unclear See gender and cultural variations of prevalence in depression in L.O. Discuss cultural and gender variations in prevalence of disorders.

Definition - Obsessive - compulsive disorder - An anxiety disorder characterized by intrusive thoughts that produce uneasiness, fear or worry, by repetitive behaviours aimed at reducing the associated society or a combination of obsessions and compulsions. - An obsession is defined as an unwanted intrusive thought, image or urge, which repeatedly enters the persons mind (not imposed by an outside agency) - Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. (can be either overt and observale by others)

Classification - International Classification of Diseases (ICD-10) - The essential feature of this disorder is recurrent obsessional thoughts or compulsive acts. - Obsessional thoughts are ideas, images or impulses that enter the individuals mind again and again in a stereotyped formed. They are almost invariably distressing and the sufferer often tries, unsuccessfully to resist them. - Compulsive acts or rituals are stereotyped behaviours that are repeated again and again. They are not inherently enjoyable not do they result in the completion of inherently useful tasks. - Excessive washing or cleaning - repeated checking

DSM - IV: Classification of OCD Obsessions are defined as recurrent and persistent thoughts, impulses or images that are experienced. preoccupation with sexual, violent or religious thoughts Compulsions are repetitive behaviours that are aimed at preventing or reducing distress or preventing some dreaded event or situation. extreme hoarding nervous rituals (e.g. opening and closing a door a certain number of times before entering or leaving a room) Excessive washing or cleaning repeated checking aversion to particular numbers * Specify if : with poor insight - for most of the time during the current episode, the person does not recognize that the obsessions and compulsions are excessive or unreasonable. (whether the patient knows that their behaviour is abnormal or not, might not search for help)

Prevalence - Fourth most common mental disorder - In US, one in 50 adults suffers from OCD - About one third to one half of adults with OCD report a childhood onset of the disorder (suggests that the continuum of anxiety disorders across the life span) - OCD is equally common in men and women. But the disorders onset is reported to occur earlier in men than women. - Lifetime prevalence in community surveys of about 2-3% (Robins et.al. 1984) - (According to the WHO, only 1 - 2% of the whole population has OCD. It is more common amongst young children, but increases as they advance into adolescence.) <- ?

Prevalence Gender

Bogetto et al. (2009) - Males are more prone towards OCD at a younger age. 160 patients diagnosed with OCD were investigated. Patients were evaluated with a semi-structured interview covering socio-demographic data, the first axis of the DSM system (the display of certain mental disorders), clinical features of OCD and social background. The researchers found that males had an earlier development of obsessive compulsive symptoms and disorder. Females showed more frequent acute symptoms of OCD and episodic courses of illness. Throughout the whole investigation, males showed more common symptoms of OCD whereas females frequently develop eating disorders. In conclusion to their findings, they found traits in reference to gender and OCD: - Males show and earlier age at onset with a lower impact of particular events in triggering the disorder. - OCD seems to occur in a relative high proportions of males who already have

existing phobias. - Excessive amount of chronic course of the illness in males when in comparison with females. Stirling and Hellewell (1999) found that OCD generally beings from early adulthood, and can persist on for many years. Prevalence - Culture Williams et al. http://findarticles.com/p/articles/mi_hb4345/is_8_32/ai_n29117890/ (Originally African Americans were thought to have a higher percentage of the population to have OCD, but apparently its now disproved) Aim: To find out the difference between cultural factors and OCD prevelance Method: 789 White Americans and 221 African Americans not diagnosed with OCD. They used 4 common OCD instruments to measure their levels of OCD. They were also questioned about attitudes towards hygiene, health, pets and cultural mistrusts. Findings:The OCD levels were similar, didnt contrast too much between the 2 groups. Conclusion: After many trials, they concluded that there is no strong correlation between cultural factors and chances of getting OCD Evaluation: Questionnaires might not be completely valid. Zor et al. http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=2682 (OCD looks alike in all cultures, compared to the differences in culture, the symptoms of OCD are more coherent with each other, not much difference between cultures Israeli and British. Aim: To find the difference between cultural factors and symptoms of OCD. Method:9 Israeli and 9 British patients suffering from OCD were chosen after signing the consent forms. For each patient, they found a healthy person with the same age, gender and nationality, for control. (Matched pair) They videotaped in their homes after briefing them about the videos, and asking them to perform a Y-BOCS test. When they asked the OCD patient to perform a task, they would also ask the healthy person to do the same (not at the same time). Findings: In both cases, the people suffering from OCD have exaggerated repetitions in their rituals compared to their healthy matched pair. Conclusion: The symptoms of OCD greatly outweights the difference between cultures and so the symptoms of OCD will be similar in all cultures.

Analyse etiologies (in terms of biological, cognitive and/or sociocultural factors) of one disorder from the two following groups: anxiety disorders affective disorders

Cognitive: http://cranepsych2.edublogs.org/abnormal/abnormal-psychological-disorders/ (Seligman) Helplessness: Does not explain blame (Abramson) Faulty Attributions [theory]: E.g. Failure Internal - explains guilt, shame, self-blame, affecting self-esteem Hopeless Stable Global External Unstable Specific

Becks theory of depression - negative self schema Self schema - expectations, knowledge of self. - starts from ages 3-5 (parents are important) -ve self schema hard to interpret positively, regarding self Becks cognitive triad of thinking Future Ourselves World Event: Doing coursework Ourselves: I cant handle this coursework World: Worried teacher would dislike it and give you a bad grade Future: Whatever coursework you hand in, it will be bad [Pessimistic people] Lewinsohn (1981) carried out a prospective study in which negative thoughts were assessed
before any of the participants became depressed. He concluded that there was no relationship between negative thought and irrational beliefs and future depression. However Nolen-Hoeksma et al (1992) found that a negative attribution style in older children predicted later depression, but only in the children who experienced stressful life events.

(social) Vulnerability model - interaction of vulnerability factors and provoking agents original factors: losing ones mother at young age lack of confiding relationship more than 3 young children at home unemployment US - lower prevalence of depression in Hispanic communities (Wu and Anthony, 2000)


- Obsessive - compulsive disorder - An anxiety disorder characterized by intrusive thoughts that produce uneasiness, fear or worry, by repetitive behaviours aimed at reducing the associated society or a combination of obsessions and compulsions. Biomedical Biological etiologies Etiology/ Genetic predisposition: Treatment McKeon and Murray found that relatives 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. Black et al found in their large family study that relatives of OCD patients were likely to suffer a variety of mental disorders, but no more likely than the general population to suffer OCD. twin and adoption studies********** :D* Neurological factors: It has been suggested that OCD is caused by abnormalities in the brain circuit. A primitive brain circuit involving orbital-frontal cortex, thalamus and caudate nucleus regulates aggression, sexuality and bodily excretions. The orbital-frontal cortex notices something is wrong in the external environment, and sends a worry signal to the thalamus. The thalamus directs signals back to the OFC in order to react to the worry signal. The caudate nucleus lies between the orbital-frontal cortex and the thalamus, and it regulates signals between the other two. Normally, the caudate nucleus acts like the brake of a car, suppressing the worry signals from the OFC to the thalamus. This prevents the thalamus from being hyperactive. It has been suggested that OCD patients have damaged caudate nucleus, which then causes increased signals between the OFC and thalamus, thereby resulting in increased anxiety. Repetitive behavior called compulsions and obsessions are the results of such anxiety. Obsessions are uncontrollable, worrying dangerous thoughts which may lead to compulsive actions to soothe the obsessions. In support of the circuit theory, obsessions and compulsions found in OCD patients have themes related to sexuality, aggression and contamination, which are exactly the themes that the above brain circuit deals with. Furthermore, the brain circuit consists of primitive brain areas which do not deal with higher mental functions such as reasoning. This supports the fact that OCD patients' obsessions are often irrational, and patients cannot use reasoning to stop their obsessions. Baxter et al. used PET scanning to observe the differences in brain function in OCD patients before and after successful treatment. They found that the main difference following treatment was that the right caudate nucleus became more active, suggesting that the caudate nucleus does indeed correlate to OCD (perhaps more activation means more compulsive acts). Neurotransmitter (serotonin): It has been suggested that an imbalance of the neurotransmitter serotonin causes

dysregulation of the brain circuit, since OCD patients respond positively to SSRIs. Low serotonin levels causes the brain to over-react and misinterpret stimulus, leading to flawed cognition, which may develop into obsessions. Hollander et al found that the drug M-CCP, which reduces serotonin levels, made OCD symptoms worse. Pigott et al found that anti-depressants, which increases serotonin levels, can reduce OCD symptoms. Biomedical treatment Drugs that affect neurotransmitter serotonin can significantly decrease symptoms of OCD Drugs like SRI (serotonin re-uptake inhibitors), was the first to be approved, followed by SSRI (selective serotonin re-uptake inhibitors), approved by the Food and Drug Administration for treating OCD e.g. flouxetine (Prozac), paroxetine (Paxil) etc. European psychiatrists reported in late 1960s early 1970s, medication called clomipramine was effective in a series of cases of OCD. Series of studies confirm behaviour therapy + serotonin reuptake inhibitors (SRIs) are established as effective treatments for OCD. Most broadly effective treatment for OCD appears to be a combination of a SRI and behaviour therapy. [http://psychcentral.com/lib/2006/ treatments-for-obsessivecompulsive-disorder/] Effectiveness of medication: For more than half of patients, medications relieve symptoms of OCD, diminishing frequency and intensity of obsessions and compulsions. Improvement usually takes at least 3 weeks or longer. If patient does not respond well to a particular medication, another SRI may give better results. Medications help control symptoms of OCD, but like depression, if medication is discontinued, relapse will follow because patients do not know how to cope. Cognitive Etiology/ Individual Treatment Cognitive etiologies In OCD patients, too much significance is attached to certain thoughts. This attachment is formed through flawed beliefs developed in earlier life. The following are false beliefs which OCD patients often have: "exaggerated responsibility," or the belief that one is responsible for preventing misfortunes or harm to others the belief that certain thoughts are very important and should be controlled the belief that somehow having a thought or an urge to do something will increase the chances that it will come true the tendency to overestimate the likelihood of danger the belief that one should always be perfect and that mistakes are unacceptable. OCD patients' worrying obsessions are formed by these beliefs. Because patients are conscious of their obsessions, confirmation bias further reinforces their

obsession is correct. Thus a vicious cycle is born. It is argued that compulsions, which follow obsessions, are a learned process conditioning. In response to lowering the amount of stress due to the obsessions, OCD patients will perform compulsive actions routinely. Since these compulsions reduce worries, the soothing effect gives motivation to repeat the action. Treatment: OCD was generally considered to be untreatable for over 50 years Until in 1966 Victor Meyer described successful treatment of 2 people with OCD His treatment is the forerunner of modern day CBT. How it was done: Changing cognitions blocking compulsive rituals Study (Meyer, 1966) Applied experimentally established principles of learning theory to treatment of OCD Reported treating 15 patients with OCD using 2 behaviour therapy procedures - ERP (exposure AND responses [ritual] prevention) He persuaded patients to confront (2 hours a day) situations theyd normally avoid (e.g. bathrooms) Purpose was to induce obsessional fears and urges to ritualize They were instructed to refrain from the rituals (e.g. washing) Result - 10 responded well and remainder was partial improvement. Evaluation point: Follow-up studies conducted several years later found only 2 who had been successfully treated relapsed (Meyer, Levy and Schnurer, 1974) http://findarticles.com/p/articles/mi_6884/is_2_2/ai_n28128028/] His technique of behaviour therapy technique was later referred to as exposure and response prevention From then onward, there had been many studies, experiments and research to develop these behavioural techniques More than 30 years of published research and a large number of authoritative accounts have led to a widely held consensus that behavioural therapy is an effective treatment for OCD These experimentations based on behaviour procedures evolved into a therapy central technique ERP (exposure and response prevention) Formats of ERP: book, computer-based self-help, group therapy, individual therapy Psychotherapy Definition A social interaction where a trained professional tries to help another person feel or think differently. (Purple book p. 113) Behaviour Therapy Definition (wikipedia) - Treatment through techniques designed to reinforce desired and eliminate undesired behaviours.

Cognitive Therapy Definition (wikipedia) - Treatment through identifying and changing dysfunctional thinking, behaviour and emotional responses by helping patients develop skills or modifying beliefs, identifying distorted thinking etc. to change behaviour. Cognitive behavioural therapy Definition combination of both behaviour and cognitive therapy. Cognitive Behavioural Therapy (CBT) most effective type of psychotherapy for this disorder. Patients are exposed to many difficult situations that trigger obsessive thoughts. Through CBT, they gradually learn to tolerate anxiety and resist urge to perform the compulsion. Eclectic approach Using medication and CBT together is considered better than either treatment alone at reducing symptoms. At least 10-20 hours of treatment and practice are required to achieve a favourable outcome - success rates as high as 80% have been documented. [http://psychcentral.com/lib/2006/treatments-for-obsessivecompulsive-disorder/] Evaluation point: BT may not be suited for everyone - OCD patients with depression, or those nearly convinced their fears are valid do less well with BT alone. Exposure and response prevention which is a specific behaviour therapy In this approach, patient deliberately and voluntarily confront feared object/idea either directly or by imagination. Individual is encourage to refrain from ritualizing E.g. compulsive hand washer may be encouraged to touch an object believed to be contaminated then urged not to wash for several hours until anxiety provoked is greatly decreased. As treatment progresses, most patients slowly experience less anxiety from obsessive thoughts, then able to resist compulsive urges. Psychotherapy can also be used to provide effective ways of reducing stress, anxiety and resolving inner conflicts. Sociocultural Etiology/ Group Treatment Socio-cultural etiologies Cultural/social factors determine the kind of compulsions that manifest in OCD patients. It is suggested that compulsions are filtered through culturally informed expectations (social norms). Mahgoub and Abdel-Hafeiz 1991 studied the pattern of OCD in Saudi Arabia. Our of 32 subjects, 87% had religious compulsions (repeating and washing), 9% had compulsive avoidance and 9% had non-religious cleaning rituals. Rasmussen and Eisen found that in western cultures, 50% had washing compulsions.

The two studies show that there is a difference in compulsion prevalence between cultures, indicating that culture is an explanation for the type of compulsion shown by a patient. But, there are no indications that groups who are more heavily religious have higher incidence of OCD. Making treatment more effective: Group therapy Sharing problems and achievements with others Talking with a trusted friend Stress management techniques and medication can help people with anxiety disorders calm themselves and may enhance effects of therapy. (STUDY) Group and individual treatment of OCD using CT and ERP (2 year follow-up of 2 randomized trials) (Whittal et al. 2008) [http://www.ncbi.nlm.nih.gov/pubmed/19045968 ] Study of follow-up results or participants who completed randomized trials of group or individual treatment and received either CT or ERP. Yale-Brown Obsessive Compulsive Scale (YBOCS) scores for individual ERP and CT were not significantly different over 2 years. YBOCS scores were consistently lower over time for group ERP participants than group CTs. *Single exception - in group treatment study, secondary cognitive and depressions scores were stable, indicating that gains achieved during acute treatment were maintained over 2 years. Less than 10% of treatment relapsed in each of treatment trials. Cross-study that CT was better tolerated and resulted in less dropout than did ERP. Another supporting study for OCD group therapy: http://www.ncbi.nlm.nih.gov/pubmed/12792126

Treatment Summary

1. Psychotherapy a. Behaviour Therapy (Individual) b. CBT c. Exposure and Response Prevention (ERP) d. Cognitive therapy 2. Biomedical Treatment (Pharmacological)

Discuss cultural and gender variations in prevalence of disorders. Gender Variations of Prevalence in Depression SIMILARITIES Symptoms of depression in both sexes are similar (but etiologies may be different)

Symptom 1: hopelessness and helplessness (Affective) Which can be explained by Becks cognitive triad, and negative self-schemas (dispositional attribution) Similar faulty attribution in both sexes leads to depression Symptom 2: insomnia or hypersomnia (Behavioural) caused by the levels of melatonin (since melatonin is synthesized from serotonin, therefore when serotonin levels change, as it does when one has depression, melatonin levels will also be affected) It can also explain fatigue and sleep disturbance as the body clock is based on melatonin levels. (somatic) Females and males with similar heritage seem equally likely to develop depression (Leibenluft) This was found by studies tracing family histories of depression The studies show that females are not more likely to inherit genes related to depression than males Therefore the increasing prevalence of depression in females may be related not to genetic disposition, but rather environmental biases toward females They all respond to the same biological treatment SSRIs (selective serotonin reuptake inhibitors) and MAOIs (monoamine oxidase inhibitors) are most common to treat for depression. Both these drugs increase the serotonin absorption. DIFFERENCES Females are 3 times more likely to be diagnosed with depression (US National Institute of Mental Health 2004) Social Explanation Men are reported to be less likely to report their feelings of depression, in order to maintain their self-esteem, as the society which they live in may see having a disorder as a sign of weakness Conformity to group norms (that is the expected behaviour of genders in a certain society) cause women to be better trained in recognizing their feelings and seeking help, so they come to the attention of health professionals more often than men Biological Explanations Melatonin secretion in males can be based on artificial light (i.e. from fluorescent lights), whereas females melatonin secretion is chiefly a response to natural light (Wehr et al.) According to Mental Health America, 3 out of 4 SAD patients are women During winter, women would be more affected by the shortened length of day compared to men (more melatonin in women due to shortened daylight time). Therefore women would feel more passive and lacking energy, which are all symptoms of SAD A PET study conducted by Diksic et al. has shown that males have an average serotonin synthesis rate that is 52% higher than females. There are studies suggesting that depression is correlated with low levels of serotonin (Agren et al), therefore lower serotonin synthesis rate in females suggests that they are more prone to depression Since research has also suggested that melatonin is synthesized from serotonin, and depression is correlated with lower levels of serotonin, depression patients will have lower levels of melatonin too. Since melatonin regulated the circadian rhythm, irregularly

low levels of melatonin will lead to insomnia, which is a symptom of depression. Therefore, lower serotonin synthesis rate will cause symptoms of depression. Menstrual Cycle Elevated levels of oestrogen in females during the menstrual cycle might lead to more pronounced and longer lasting stress response, ultimately leading to severe exhaustion (Selyes General Adaptation Syndrome) and depression. Chrousos et al found that increased levels of oestrogen heightens levels of CRH CRH makes the pituitary gland release ACTH, which prompts the secretion of cortisol in the adrenal glands Increased levels of cortisol should prompt the hypothalamus to decrease the levels of CRH and thus cortisol itself, however Young et al have found that female rats are more resistant to this system than male or spayed female rats suggesting that oestrogen decreases cortisols ability to shut down its own secretion Young et al also found that women have longer-lasting cortisol responses during the phase of the menstrual cycle when oestrogen and progesterone levels are high It is unclear as to whether depression is a cause or consequence of elevated cortisol levels, but the two are definitely related. studies have shown that about half of all severely depressed people, both men and women, have elevated cortisol levels If oestrogen elevates the levels of cortisol, and prevents cortisol levels from lowering, then oestrogen might render females more prone to depression (especially after a stressful event) Culture Variations of Prevalence in Depression

Around 15% of people experience at some point in their life (Charney and Weismann 1988). Similarities Prevalence World Health Organization (WHO, 1983) The common symptoms of depression include sadness, loss of enjoyment, anxiety, tension, lack of energy, loss of interest, inability to concentrate, and ideas of insufficiency, inadequacy, and worthlessness. These results came from research done in four different countries: Iran, Japan, Canada, and Switzerland Differences In USA - lower prevalence of depression in Hispanic communities (Wu and Anthony, 2000) Etiology: SCLOA, vulnerability model includes the factor of lacking of a confiding relationship, Hispanic communities are closer and tend to share their experiences more often. Countries with strong traditional roles of family and higher religiosity have a lower prevalence in depression

Prince (1968) There was no depression in Africa and various regions in Asia, but found that depression rates rose with the westernization of developing nations. Correlation between Development and depression -> pressure, stress due to work and increasing competition between individuals (social comparison). possibly from the need to learn a new language? new jobs, and to work at the same time, compared to before when their job doesnt change? Collectivitism and individualism Kleinman (1988) Non-industrialised societies had higher recovery rates Etiology: People from these societies experience less work related stress therefore releases the pressure, providing them a suitable environment for recovery. Kleinman (1982) Somatization is mainly used as a typical channel of expression and as a basic part of the depressive experience in China which is different from other cultures in terms of the symptoms of depression. Somatization - how depression is experienced through physical discomfort. Etiology There are cultural preferences in the way that emotions are experienced and communicated, with bodily complaints judged as more socially acceptable than complaints of emotional distress. ( In a culture where display rules govern emotional expression, it is more acceptable to seek help for physical than emotional problems.) In Chinese culture, emotional messages are conveyed not in words that designate emotions but usually through metaphors that are related to physical body -> due to suppression of emotions, a lack of distinction between the psychological and the physical or constraints of vocabulary ->they often explain the word depression somatically. Early studies suggested that the Chinese tended to complain of somatic symptoms and avoid seeking psychiatric help (due to lack of medical and social support services at that time.) Stigma of Mental Illness Mental illness is stigmatized in traditional Chinese culture -> seen as evidence of weakness of character and a cause for family shame, a collective loss of face for the extended family Stigmatization prevents individuals from approaching psychiatrists, therefore rates of depression should be higher than actual statistics. Chinese may have another systems for diagnosis, therefore Chinese may be diagnosed as another mental illness rather than depression. Hence, the actual statistics may be even higher. Parker, Gladstone and Chee (2001) http://cranepsych.edublogs.org/files/2009/07/depression-in-china.pdf

Reviewed evidence for claim that Chinese tended to deny depression or express it somatically. They concluded it supported hypothesis of the tendency for Chinese to deny depression. However Western influences on Chinese society on detection and identification of depression are likely to have been modified since early 1980s. Marsella (1979) Individualist cultures are more likely to have affective symptoms (linked with emotions), while collectivist cultures are more common to show somatic symptoms (physical).

Prevalence: Gabilondo et al. (2010) Depression occurs less frequently in Spain than in northern European countries Lower rate of suicide in Spain than European countries Different cultures in Spain and European countries (Stronger traditional roles of family [collectivistic cultures] and higher religiousity were proposed as sociocultural variables)
IMPLEMENTING TREATMENT Examine biomedical, individual and group approaches to treatment.

Biomedical approach to treatment

Focus : Changing the physiology of the individual through medical treatments. 1. 2. What Biomedical treatments are available for depression and how do they work? (see below!!) What does the biomedical approach to treatment presume? i.e. what assumptions is the approach based on? Mental disorders can be understood as illness in the same way as physical conditions. They can be classified, diagnosed and treated by the medical profession in the same way as physical disease. The emphasis is on physiology rather than behavorial, cognitive or emotional difficulties. It is assumed that scientific research will eventually discover the biological causes of all types of mental disorder. What are three important factors that clinicians need to consider when implementing drug treatments? Dosage (dependency and withdrawal may result from overdose) Side-effects (allergies, other effects, developing physical tolerance towards drugs) Appropriate treatment for the occasion, alternative treatments may be a better option. Longer lasting treatments such as CBT may be more beneficial for abnormalities that crop up more often in daily life, i.e. OCD. Drug therapy will be more efficient in cases like dental phobia.) Evaluate the effectiveness of the biomedical approach to treatment with evidence.



(see below!!) SSRIs (selective-serotonin re-uptake inhibitors) How do they work? SSRI is a type of anti-depressant It aims to increase the amount of seratonin in the brain, since low seratonin levels are associated with depression Specifically, SSRIs block the reabsorption (reuptake) of seratonin. Low levels of seratonin crossing the synaptic space means that the post synaptic neuron does not have enough seratonin to start an impulse, therefore neurotransmission is hindered. SSRIs inhibit the reuptake of seratonin so that there is more seratonin to be attached to the post synaptic neuron, leading to higher efficiency of neurotransmission. SSRI IS effective: - When compared to previous anti-depressants, SSRIs are as effective, and have less side effectives. - They are also easier to administer (available in liquid form for young children) - Alarcon: SSRIs are the most prescribed drugs for depression. This must mean that SSRIs are more effective/accessible in comparison to other drugs or biomedical treatments. SSRI ISNT effective: (side effects) - Healey (1999) claims that about 250,000 people worldwide have attempted suicide while taking Prozac, with 25,000 succeeding. Survivors have described a strange, agitated state of mind with unstoppable urges to commit violent acts. They had not felt suicidal prior to taking Prozac. - In response to these suicidal side effects, the Medicines and Healthcare Regulatory Authority decided that SSRIs should not be prescribed to children under 18 in the UK (MHRA 2003) - Elkin Procedure: - 240 depressive patients - 4 groups receiving different treatments: psychodynamic, cognitive, antidepressant and placebo (control) - groups monitored for 16 weeks Results: - all subjects NOT in the control showed signs of improvement - after 16 weeks effects of all 3 treatments were about the same, however therapy groups were less likely to experience relapses when compared to drug group - suggests that SSRI is not THE best treatment to give - Kirsch has suggested that placeboes work equally as well as SSRIs ECT (Electro-convulsive therapy) Introduced by Cerletti and Bini in 1938. They gave an electric shock to the brain of a psychiatric patient, believing that it would eliminate symptoms of schizophrenia by producing an epileptic seizure. However it was later found out that ECTs more effective in treating severe depression than schizophrenia. How do they function :

There are two types of ECT - bilateral and unilateral (depends on whether electrodes are attached to both sides or one side.) Unilateral ECT has fewer side effects but it is less effective with severe depression. First, patients are given a fast-acting anaesthetic and a muscle relaxant, which prevent them from getting injured during the seizure. Electrodes are then attached to the patients temples and a 70 to 150 V shock is given. (up to 1 s) The shock produces a convulsion that lasts from 30s to 1 min. The patient regains consciousness about 15 mins later. ECT is usually given 2 or 3 times a week for up to 4 weeks. How do they work as a treatment for depression : There is no precise explanation of how ECT works to help patients from depression. There are different explanation suggested by psychologists : Benton, 1981 suggested that ECT may alter some of the brains electrochemical processes. Milo et. al. 2001 suggested that ECT helps increasing blood flow in the brain as he found out that the blood flow to the frontal lobes of the brain increased immediately after ECT. Studies : Ng et al. (2000) Aim - to investigate the effectiveness of ECT with patients suffering from severe depression. Procedures - ECT (unilateral) treatment was given to 32 patients for over sixweek period. Findings - Symptoms of depression decreased by around 50% following the treatment. Over 30% of personal memories of participants were lost after the treatment, but were recovered within the following month. Conclusion - ECT was an effective treatment for severe depression. Effectiveness : ECT IS effective : Symptoms of depression decreases after ECT Ng et al. (above) ECT IS NOT effective : Unethical ECT can be administered against the persons will, if the patient is detained under the Mental Health Act. Patients may suffer from memory loss that is associated with ECT, which can cover the 6months prior to the treatment as well as up to 2 months afterwards for some patients. ECT may cause brain damage Breggin (1991) presented two cases to support his claim that ECT causes brain damage and is most often used with elderly women. argued that the treatment causes anosognosia, a condition where the patient denies his or her own psychological difficulties. Clare (1980) argued that as ECT treatment is relatively quick and easy to administer, the psychiatrists have over used it which cause unnecessary damage to patients. General Evaluation for biomedical treatment

Biomedical treatment often involves bringing about physical changes in the patients using drugs, ECT or brain surgery rather than counselling or other forms of psychological treatment. Biological approach is effective, to a certain extent, that it decreases symptoms of depression. However, biomedical treatments have possible side effects, like addiction, loss of memory, which can cause unnecessary damage and harm to the patients. Ethical implications: Loss of rights in consent (to ECT especially). There is an assumption that mentally ill patients cannot be responsible for their actions due to their inept state of mind, therefore therapy may be undertaken without their consent. there is not clearly only ONE biological etiology for a disorder, which can then lead to wrong diagnosis/treatment.

Individual therapy
1. What are the presumptions/assumptions of individual therapies? A symptom of depression is distorted cognitions (e.g. self defeating thoughts) By replacing negative cognitions with more realistic and positive ones can aid an individual with depression. Aaron Beck in the 1960s developed his theory as the pioneer of cognitive therapy. His theories were based on the idea of cognitive restructuring. The principles to this approach are to: identify automatic negative, self critical thoughts; note connections between negative thought and depression; examine each negative thought and decide if it can be supported; and replace distorted negative thoughts with realistic interpretations of each situation. According to Beck, a persons beliefs contribute to automatic thoughts based on schemas. In depression, negative self-schemas bias a persons thinking. 2. What does cognitive Behavioural therapy (CBT) aim to do? CBT is a form of psychotherapy aimed to treat people with depression whilst focusing on current issues and symptoms. The aim of the therapy is to identify faulty cognitions and unhealthy behaviours, then correcting this. Other aims include helping clients develop coping strategies and problem solving skills. Also to encourage them to engage in behavioural action. 3. In what ways is individual therapy different to biomedical treatment? Individual therapy focuses on symptoms rather than causes whilst biomedical treatment focuses on the causes of the symptoms. For example in biomedical treatment, depression involves imbalance in neurotransmission, drugs are used to restore the balance. In addition, individual therapy does not require the intake of drugs or the need to change biological aspects rather it focuses on the cognitive aspect and the thought process of people. 4. What is the general picture in terms of the effectiveness of individual therapies? The effectiveness of individual therapies can be examined through research. It has been proved that cognitive therapy is superior to no treatment or to a placebo (e.g. Dobson 1989). A study conducted by Elkin et al (1989) aimed to find the effectiveness of various depression therapies. Subjects that were diagnosed with major depressive disorder were randomly assigned to treatment using an antidepressant drug, interpersonal therapy, CBT, and another form of therapy. They found that over 50% of patients recovered from CBT/IPT/drug group and 29% from the placebo group. The effectiveness between CBT, IPT and drug group were similar thus in conclusion, it has more or less the same results and CBT can be compared to other methods. Riggs et al. aimed to find out the effectiveness of CBT with either

placebo or SSRI. 76% of patients in CBT and SSRI group were judged as improved, 67% of patients in CBT and placebo group were judged as improved. Thus in conclusion, CBT with drug is effective, CBT with placebo is also quite effective, but CBT alone is quite reliable.ECLECTIC STUDY???

Group therapy
1. What group therapies are available for depression? couples therapy (for married couples, as most married couples have depression due to the inability to communicate and problem-solve effectively) there is a strong link between depression and marital problems. family therapy psychodynamic - The group will each behave in a different way, and they are freely able to talk about different things, the person will decide on the subconscious causes to them based on their behaviour (i.e. how the group sets rules even if its not spoken). It is based on Freuds transference, where their behaviour will be brought up from events in the past, i.e. aggression for no reason. activity groups - engaging patients in a form of focused activity Ii.e. cooking, craft, art work) psychoeducational (problem-solving) - interpersonal learning and ego support support groups - similar to psychoeducational, the patients talk about their experiences, or problem solve some recent issues, which may be the cause of their depression. This allows them to know how to deal with it. 2. What do clients do in group therapy? (give a brief explanation of the therapeutic process) Share experiences with other individuals who experiences depression. Group leader promotes healthy habits that group members could go home and put into practice. They then can discuss their experiences between each other as well as the leader. Leadership roles in a group allow individuals to identify with the leader as an idealised figure. Support group allows a network for sharing experiences and showing support towards other individuals establishing self esteem. This also build interpersonal skills encouraging the individuals to communicate and share more often. 3. Give an example how group therapy could be used? To teach couples to communicate and problem solve more effectively, while increasing positive interactions and reducing negative ones. Jacobsen et al. (1989) found that this type of treatment is just as effective as others in treating the symptoms. It is even more effective when looking at the relationships. (This may be because it goes into the cause and not just the symptoms). 4. What does group therapy allow the client and the therapist to do? Observe the clients interactions, progress etc. Modify treatment according to progress in recovery

5. What are four advantages of the group therapy?

It tends to be based on the causes (i.e. childhood repressed emotions, traumatic experiences or bad relationships) Get support from not only the therapist, but from others who are in a similar situation as the individual Toseland & Siporin (1986) reviewed 74 studies that compared individual and group treatment, 32 of which met their criteria for inclusion. Group treatment was found to be as effective as individual treatment in 75% of these studies and more effective in the remaining 25%. In no case was individual treatment found to be more effective than group treatment. Group treatment was more cost-effective than individual therapy in 31% of the studies. McDermut et al (2001) provides a meta- analytic review of the effectiveness of group psychotherapy in the treatment of depression . Of the 48 studies examined, 43 showed statistically significant reductions in depressive symptoms following group psychotherapy; nine showed no difference in effectiveness between group and individual therapy; and eight showed CBT to be more effective than psychodynamic group therapy. (Spiegal et al, 1981) Group therapy has also been shown to be effective in other patient populations. Homogeneous groups for patients with chronic physical illness are successful in treating symptoms of anxiety and depression and improving quality of life. Particular interest has centered on patients with cancer, and some re- searchers have found a significant improvement in survival rates following group therapy intervention. It is postulated that this operates through an enhancement of immune functioning.

6. In what ways can group therapy help deal with the stigma of mental disorders? It allows the individual to realise that there are others that experience depression, therefore accepting their own illness. Individuals feel free to discuss their own experiences with others. The environment allows them to feel comfortable. 7. What are some disadvantages of group therapy? If any of the factors in the group is not met, the therapy will not become as successful. Spontaneous Remission (Roback & Smith, 1987) The most important aspect of a successful outcome is selecting the right patients for the group, i.e. getting the right mix of problems, personalities and habitual defence style. Much of the literature on patient selection has focused on its role in building cohesion. Careful patient-screening also serves to minimise the drop- out rate resulting from patientgroup mismatches. Important factors to consider in a group therapy: 1. Group Cohesion, no one should be different from the rest. They need to have a sense of belonging (i.e. 5 males and 1 female, the female wouldnt progress as well as the other 5 males) 2. Exclusion, certain characteristics should be excluded from a particular group, i.e. current drug abusers might be a characteristic that most groups would do better if they were to be excluded 3. confidentiality, they must trust the others to be able to talk freely and express themselves 4. relationship with therapist, the therapist is known to be not part of the group, and so he/she must show empathy for the members of the group and attempt to understand their reality.

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

Measuring the Effectiveness of Treatments

LOs: - Examine biomedical, individual and group approaches to treatment. - Evaluate the use of biomedical, individual and group approaches to the treatment of one disorder. 1. What issue did Eysenck (1961) highlight with regards to the measurement of treatment success? Eysenck argues that SPONTANEOUS REMISSION alone is responsible for the individual's improved condition Even if the individual did not have therapy, he or she would have improved, simply through the process of recovery, just like a common cold. Therefore Eysenck suggests that measuring the success of treatment is pointless, because such a success may not be due to the effects of treatment, but rather the results of our own bodies. 2. Measuring the effectiveness of therapy is problematic, what four criteria can be used to assess whether a therapy has worked? 1. Relief of symptoms for a certain time period 2. Total absence of symptoms 3. Absence of observable traits and/or absence of non-observable traits (such as cognitive processes) 4. Quantitative data (is it possible?) and qualitative data 3. What issues are faced when getting therapists/ the client themselves or family and friends to report the success of treatment? Therapists are unlikely to state that their therapy was ineffective, especially when the client has spent a lot of time and money on the sessions. (reporting bias) The client themselves is in a apposition to judge his or her own progress as they dont understand the aims / techniques of the treatment. Family and friends may be part of the problem or affected by the problem and may not really objective observers (bias) 4. What type of research is used by psychologists to study the effectiveness of treatment? Outcome studies (focus on the results-did patients show improvements or not?) Example : Smith et al. (1980) meta analysis 5. What are important factors which influence the effectiveness of the above method? Drawbacks of outcome studies: Can produce contradictory results e.g. Elkin et al (1985) found intervention did contribute to recovery rates. Other research has been more dismissive of psychological treatments. It is highly unlikely that all patients experienced the disorder to the same degree. No standardized procedure, therapy is highly individualized and personal. Must continually be adapted to suit the patient. 6. What were the findings and conclusions of Smith et al. (1980) meta analysis? Smith et al. 1980 meta-analysis of 475 studies, he found that overall, therapeutic approaches seemed to produce an improvement. However, when they were broken

down into specific disorders and found that there were significant differences in efficiency of treatment. Concluded all methods are to some extent effective, it may not be the specific kind of therapy that makes the difference but non-specific factors may play a role. 7. What statistics clearly demonstrate the popularity of the eclectic approach? Glassman (2000) around 30 40% of Canadian and US psychologists describe themselves as eclectic in orientation 8. What characteristics do most therapies have in common? All therapies involve a warm interpersonal relationship, reassurance and support, and the opportunity for the individual to gain insight into his or her experience. 9. According to Bennun & Schindler (1988) what is the best indicator of success in therapy? Bennum and Schindler (1988) found that the best indicator of success in therapy is how favourably clients rated their therapist during the initial session. Those who liked their therapists more had more improvement. 10. Choosing the right treatment is an important step on the road to improved psychological health. As a psychologist, what do you need to consider when deciding which treatment is appropriate to your client?

Discuss the use of eclectic approaches to treatment. Eclectic approaches: An approach that incorporates principles or techniques from various systems or theories. Eclectic therapy recognizes the strengths and limitations of the various therapies, and tailors sessions to the needs of the individual client or group. Rush et al. (1977) suggest the higher relapse rate for those treated with drug arises because patients in a cognitive therapy programme learn skills to cope with depression that the patients given drugs do not. Growing number of studies is showing that cognitive therapies are more effective than drug treatment alone at preventing relapse or recurrence except when drug treatment is continued long-term (Hollon and beck 1994). Combination of psychotherapy (cognitive or interpersonal) and drugs appears to be moderately more successful than either psychotherapy or drugs alone (Klerman et al. 1994) AIM Eysenck (1952) investigated the effectiveness of talking cures such as psychoanalysis. METHOD He reviewed recovery rates in five studies of psychoanalysis and 19 studies of eclectic (mixed) psychotherapy. He compared these with the recovery rates of patients who had received no therapy but were on a waiting list. RESULT He claimed that approximately 44 per cent of patients treated with psychoanalysis recovered and 64 per cent of those treated with eclectic methods improved. This compared unfavourably with the 70 per cent who did not receive treatment, but nevertheless spontaneously recovered! CONCLUSION Eysenck concluded that psychotherapy was ineffective. It achieved nothing that wouldnt have happened naturally, without intervention. EVALUATIVE COMMENT

Eysenck excluded the patients who dropped out of psychoanalysis. He argued they were not cured, although he did not confirm this. If these patients stopped coming because they were better, the success rate of psychoanalysis would have risen to 66 per cent. Bergin and Lambert (1978) found that certain types of disorder, such as depression or anxiety, were more likely to disappear with time. Other conditions, such as obsessive compulsive disorder, were more likely to need some form of treatment. Further research is needed to investigate whether different treatments are more successful with certain disorders than others. Advantages of using an eclectic approach 1. Eclectic approaches have a broader theoretical base and may be more sophisticated than approaches using a single theory. 2. Eclectic approaches offer the clinician greater flexibility in treatment. Individual needs are better matched to treatments when more options are available. 3. There are more chances for finding efficacious treatments if two or more treatments are studied in combination. 4. The clinician using eclectic approaches is not biased toward one treatment and may have greater objectivity about selecting different treatments Disadvantages 1.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. 2. Sometimes eclectic approaches are applied inconsistently. It takes knowledge and skill to deliver eclectic approaches effectively. 3. In general there are very few efficacy studies at this stage to support the approach, partly because it is difficult to judge the relative value of each treatment in an eclectic approach. 4. However it is important to remember that eclectic approaches may be too complex for one clinician. There is always a danger that clinicians might call themselves "eclectic" when they really have no clear direction for treatment.

Discuss the relationship between etiology and therapeutic approach in relation to one disorder. Disorder: Depression Treatments: Biomedical, individual, group Etiologies: BLOA - genetic vulnerability, comorbidity, neurotransmitter malfunctioning, Diathesis Stress CLOA - Learned helplessness, psychological problems SCLOA - Becks theory of depression, life events/lifestyle factors Biomedical

Assumption: If problem is based on biological malfunctioning, drugs should be used to restore the biological system. The emphasis is on physiology rather than behavioural, cognitive or emotional difficulties. Physical symptoms: 40% of people suffering with depression visit their surgery for the first time because of physical symptoms. Aches, pains, lack of energy, palpitations, headaches, stomach upsets, sleep disturbance, loss of or gain in appetite and weight. Etiology Possible treatment Does treatment address etiology? Yes Gender + culture issues Research

neurotransmitters noradrenaline and serotonin imbalance.


Teuting et al 1981 Aim: Support for biochemical approach Method A compound, produced when noradrenaline and serotonin are broken down by enzymes, is present in urine. Teuting analyzed and compared urine samples from depressed and non-depressed patients. Result: Depressed patients urine had lower than normal levels of the compounds. Conclusion: Suggests depressed people have lower than normal activity of the neurotransmitters in the brain, which causes depressed mood.

Comorbidity Genetics (However, theres little evidence genetic factor in unipolar depresion, research shows bipolar depression runs in families)
Allen (1976): Concordance rates for unipolar depression: 40% for MZ twins, 11% for DZ twins. Bertelsen, Harvald and Hauge (1977): concordance rates for unipolar depression 80% for MZ, 16% for DZ. McGuffin et al. (1996) studied a series of 177 pairs

sampled via the twin register at the Maudsley Hospital, London, and found an MZ concordance of just over 40% and a DZ concordance of 20%.


Individual Etiolog y 1 Possible treatment Does treatment address etiology? Gender + culture issues Research

Group Etiolog y 1 Possible treatment Does treatment address etiology? Gender + culture issues Research

Essay plan: Introduction Address abnormality - depression Define etiology and state 3 therapeutic approaches (biomedical, individual, group) and their underlying assumptions. Note: It is important to understand it is not possible for any doctor/psychologist to find the cause of depression in any individual. Treatment of depression aims to alleviate symptoms and consider possible psychosocial actors involved to help individual cope. -----------------------------------------------------------------------------------------------------------------Biomedical treatments Treatment based on assumption that problem is based on biological malfunctioning, drugs should be used to restore the biological system. Depression involves imbalance in neurotransmission. Drugs are used to restore appropriate chemical balance in brain, but its unknown to why not all patients respond the same way to a drug. Antidepressant drugs help elevate mood of those suffering from depression Most common drug group: selective serotonin re-uptake inhibitors (SSRIs) Increase level of available serotonin by preventing re-uptake in synaptic gap Most common SSRI is fluoxetine, brand name Prozac Side effects: vomiting, nausea, insomnia, sexual dysfunction or headaches

Lacasse and Lee (2005) and Kirsch et al. (2008) are critical towards overprescription of SSRIs. Cognitive treatments Individual approach Symptom of depression: distorted cognitions (self defeating thoughts) - lead cognitive psychologists to suggest replacing negative cognitions with more realistic and positive ones can help - Aaron Beck, pioneer in cognitive therapy His theory in 1960s was based on the idea of cognitive reconstructing. Group couples therapy

Historically, there have been different views on causes of psychological disorders and these have all been influenced by knowledge and beliefs at the time. Some reflected the view that psychological disorders were caused by biological factors. Others said that they were rooted in the mind and yet others adopted an interactionist approach saying that it was a combination of biological factors and the mind. No matter the approach to abnormal psychology, the treatment of psychological disorders has generally linked what was thought to be the etiology which simply means the cause of the disorder. Biological approaches and therapies Biomedical approaches to treatment are based on the assumption that biological factors are involved in the psychological disorder. This does not necessarily mean that biological factors cause the psychological disorder but rather that they are associated with changes in brain chemistry (neurotransmitters and hormones). 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. Generally, however, antidepressant drugs are an effective way to treat depression in the short term, significantly helping 60-80 per cent of people, according to some reports (Bernstein et al. 1994). However, it is argued that drugs do not target the problem but just address the symptoms, are not equally effective in all cases and may not be better than psychotherapy in the long term, according to some researchers. A controversial study by Kirsch and Sapirstein (1998) analysed the results from 19 studies, covering 2318 patients who had been treated with the antidepressant Prozac. They found that antidepressants were only 25 per cent more effective than placebos, and no more effective than other kinds of drugs, such as tranquillizers. Elkin et al. (1989) carried out one of the best controlled outcome studies in depression, conducted by the National Institute of Mental health. This study included 28 clinicians who worked with 280 patients diagnosed as having major depression. Individuals were randomly assigned to treatment using either an antidepressant drug (imipramine), interpersonal therapy (IPT), or cognitive-behavioural therapy (CBT) or another form of therapy. In addition, a control group was given a placebo pill, together with weekly therapy sessions. The placebo/drug group was conducted as a double-blind 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 (in particular, experimenter bias). All patients were assessed at the start, after 16 weeks of treatment, and after 18 months. The results showed that just over 50 per cent of patients recovered in each of the CBT and IPT groups, as well as in the drug group. Only 29 per cent recovered in the placebo group. The drug treatment produced faster results, but the NIMH study shows that there is no difference in the effectiveness of CBT, IPT, and drug treatment. In other words, the study showed that it does not matter which treatments patients received, all the treatments had the same result. Cognitive approaches and therapies Individual therapies are 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. According to Beck (1976) people who develop depression have cognitive distortions which centre around the cognitive triad (negative schema). This consists of negative thoughts about themselves, the world and the future, and developed from early negative experiences in early childhood. Individual therapy is often seen as more personal than drug therapy, in which a person may feel more like a patient. It can also be more highly individualized to meet the need of the client. The aims of cognitive therapy are to help the client change faulty thinking patterns, to develop coping strategies and to engage in more positive behaviours. Individual therapy is the most commonly used form of treatment and research has shown that it generally has a positive effect. A number of studies and meta-analyses have demonstrated that cognitive therapy, including CBT, effectively treats patients with depression (e.g. Elkin et al mentioned above). Cognitive therapies are cost-effective because they do not usually involve prolonged treatment and no negative effects have been found. However cognitive therapies, similar to drug therapies, have been criticized for focusing on symptoms than causes. We can be sure it is the cognitions causing the symptoms of depression in the first place, they may be a consequence of depression. Social approaches and therapies We have already seen how life stressors and lack of social support can be contributing factors to mental health problems. If social problems do trigger symptoms of depression then group therapy may help alleviate the symptoms. The group can provide support for the client in ways that are not possible in individual therapy. Within the context of the group, clients realize they are not alone and that their problems are not unique. Group therapy offers multiple relationships to assist an individual in growth and problem solving. In group therapy sessions, members are encouraged to discuss the issues that brought them into therapy openly and honestly. The therapist works to create an atmosphere of trust

and acceptance that encourages members to support one another. Since many disorders are either caused by or promote poor social skills, group therapy allows clients to role-play and develop social skills in a safe, supportive environment. The beneficial effects that a therapy group can have on an individual have long been recognized, but until recently there was a lack of quality studies comparing the effectiveness of individual and group therapy for patients with similar characteristics. Toseland & Siporin (1 986) reviewed 74 studies comparing individual and group treatment . Group treatment was found to be as effective as individual treatment in 75% of these studies, and more effective in the remaining 25%. However there are also some possible disadvantages to group therapy. Some clients may be less comfortable speaking openly in a group setting than in individual therapy, and some group feedback may actually be harmful to members. In addition, 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. Eclectic approaches and therapies There is now a general belief that a multifaceted approach to treatment is the most efficient. This is based on the biopsychosocial approach to mental disorders to treatment and involves a combination of therapies. The biopsychosocial model sees the person as a whole; it recognizes the complexity inherent in psychological disorders. For example the cause of an individuals depression may be interrelated. Negative early childhood messages (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). This may affect Patient Xs mood and coping mechanisms (psychological). This can lead to decreased communication and social skills and rejection by friends and colleagues (social). Thus, feeling unsupported, he feels more depressed, possibly further affecting neurotransmitter levels. A multifaceted approach is called an eclectic approach. it may include drug treatment, individual therapy (e.g. cognitive therapy), or group therapy (e.g. family therapy) as well as help to handle risk factors in the environment such as a stressful relationship. An eclectic approach incorporates principles or techniques from various systems or theories. Ec lectic therapy recognizes the strengths and limitations of the various therapies, and tailors sessions to the needs of the individual client or group. For example, in the case of a depressive patient who is suicidal, cognitive-behavioural therapy (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 stabilized, CBT might be used. Also, as the individual becomes more

self-reliant, group therapy may be recommended in order to help him or her develop strategies to avoid future relapse, as well as a support system. The argument for an eclectic approach comes from research demonstrating that drug therapies alone often have significant relapse rates, that is the client begins to show symptoms of the disorder after having been symptom-free. Rush et al. (1977) suggest the higher relapse rate for those treated with drugs arises because patients in a cognitive therapy programme learn skills to cope with depression that the patients given drugs do not. A growing number of studies is showing that cognitive therapies are more effective than drug treatment alone at preventing relapse or recurrence except when drug treatment is continued long-term (Hollon and Beck 1994). Furthermore, a combination of psychotherapy (cognitive or interpersonal) and drugs appears to be moderately more successful than either psychotherapy or drugs alone (Klerman et al., 1994). However it is important to remember that eclectic approaches may be too complex for one clinician. There is always a danger that clinicians might call themselves "eclectic" when they really have no clear direction for treatment. Conclusion Finally, it is important to note that causation of disorders such as depression are not easy to analyse, whilst an eclectic approach address the multi-faceted nature of depression, it can be further complicated by the following; No one treatment works for everyone. Even if "causation" is established, the selected therapeutic approach should take into account a client's cultural values, a client's ability to tolerate drug treatments, a client's enthusiasm for group therapy, a client's willingness to address negative cognitive style, or a client's ability to start and follow through (self-efficacy) with the lifestyle changes necessary for dietary or exercise treatments. It is often difficult or impossible to identity a specific "cause" of any mental disorder. Attempts to do, such as the biological approach, represent a singular, reductionist approach to depression. However depression is a complex disorder caused by a number of factors. It is still possible to treat "symptoms." even when causes are unknown. For example, antidepressants or cognitive therapy treat depressive symptoms. Many clinicians measure symptoms before and after treatment with assessment instruments such as the Hamilton Rating Scale for Depression and the Beck Depression Inventory. Many consider a treatment to "work" if the symptoms are reduced, however not everyone agrees with this definition of "work." Therefore etiology is not always a priority in treating depression.