Anxiety Disorders and Depression: Emotional, Behavioral, and Cognitive Characteristics, Study notes of Psychology

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AS PSYCHOLOGY REVISION PSYCHOPATHOLOGY 3.2.2 Psychopathology Specification • Definitions of abnormality, including deviation from social norms, failure to function adequately, statistical infrequency and deviation from ideal mental health. • The behavioural, emotional and cognitive characteristics of phobias, depression and obsessive compulsive disorder (OCD). • The behavioural approach to explaining and treating phobias: the two-process model, including classical and operant conditioning; systematic desensitisation, including relaxation and use of hierarchy; flooding. • The cognitive approach to explaining and treating depression: Beck’s negative triad and Ellis’s ABC model; cognitive behaviour therapy (CBT), including challenging irrational thoughts. • The biological approach to explaining and treating OCD: genetic and neural explanations; drug therapy. DEFINITIONS OF ABNORMALITY FAILURE TO FUNCTION ADEQUATELY • People are judged on their ability to go about daily life – E.g. eating regularly, washing clothes, being able to communicate with others, etc • If they cannot do this and are also experiencing distress (or others distressed by their behaviour) then it is considered a sign of abnormality EVALUATION OF FtFA • Who judges? – A patient may recognise that their behaviour is undesirable and become distressed – Or they may be content in their situation but others are uncomfortable and judge them to be abnormal – The weakness of FtFA is that it depends on who is making the judgement on abnormality • The behaviour may be quite functional – Some dysfunctional behaviour may actually be functional (e.g. cross-dressing is regarded as abnormal but people make money out of it) • Strengths of this definition – FtFA does recognise the subjective experience of the patient (allowing us to see the point of view of the person experiencing it) – Failure to Function is quite easy to judge objectively as we can list behaviours DEFINITIONS OF ABNORMALITY DEVIATION FROM IDEAL MENTAL HEALTH • Abnormality is defined in terms of mental health, behaviours that are associated with competence and happiness • IMH would include a positive attitude towards the self, resistance to stress and an accurate perception of reality • I.e. looking at the absence of signs of mental health (Jahoda, 1958) • Jahoda identified 6 categories commonly referred to self- attitudes (having high self- esteem), personal growth, integration (coping with stress), autonomy (being independent), having accurate perception of reality, mastery of the environment EVALUATION OF DfIMH • Unrealistic Criteria – According to these criteria, most of us are abnormal – We need to ask how many need to be lacking to be judged as abnormal – Criteria are difficult to measure • Suggests that mental health is the same as physical health – It is possible that some mental disorders also have physical causes (e.g. brain injury) but many do not – It is unlikely that we could diagnose mental abnormality in the same way that we can diagnose physical abnormality • It is a positive approach – DfIMH offers an alternative perspective on mental disorders by focusing on the positives rather than negatives and what is desirable rather than undesirable EVALUATION FOR DEFINITIONS OF ABNORMALITY – CULTURAL RELATIVISM • Cultural relativism (the view that all beliefs, customs, and ethics are relative to the individual within his own social context. I.e. behaviour cannot be judged properly unless it is viewed in the context of the culture in which it originates) • SI = Behaviours that are statistically infrequent in one culture may be statistically frequent in another • DfSN = What is socially normal in one culture is not normal in another culture. The classification system was based on the social norms of the dominant culture in the West (white and middle class), yet the same criteria are applied to subcultures in the West • FtFA = FtFA criteria is likely to result in different diagnoses when applied to people from different cultures (as the standard of one culture is being used to measure another) – This could be why lower-class and non-white patients are more often diagnosed with a mental disorder (due to their lifestyles being different from the dominant culture) • DfIMH = The criteria here are also culture-bound. If we apply the criteria to non-Western or non-middle-class then there may be more incidence of abnormality DEPRESSION • Is classified as a mood disorder Emotional Characteristics • At least 5 symptoms must be present to diagnose – Including sadness (most common description given such as feeling worthless or empty) or loss of interest and pleasure in normal activities (activities associated with feelings of despair and lack of control) – Also anger is associated with depression (towards self or others) Behavioural Characteristics • Reduced energy (being tired or wanting to sleep all the time) • Being agitated and restless (pace around the room, tear at skin) • Some sleep more, others may experience insomnia • Some may lose appetite and other may eat considerably more Cognitive Characteristics • Negative thoughts like negative self-belief, guilt, sense of worthlessness • Negative view on the world (expect things to turn out badly) • Negative expectations about their lives, relationships and the world – These can be self-fulfilling (if you believe you will fail you may reduce effort or increase your anxiety and so will fail) OCD • Is classified as an anxiety disorder broken into: – Obsessions (persistent thoughts) – Compulsions (repetitive behaviour) Emotional Characteristics • Obsessions and compulsions are a source of considerable anxiety and distress • Sufferers are aware that their behaviour is excessive and this causes feelings of embarrassment and shame • A common obsession concerns germ which leads to feelings of disgust Behavioural Characteristics • Compulsive behaviours are performed to reduce the anxiety created by the obsessions • They are repetitive and unconcealed (e.g. hand washing) • Patients feel compelled to carry out these actions or something bad will happen – This creates anxiety • Some patients only experience compulsive behaviours with no particular obsession Cognitive Characteristics • Obsessions are recurrent, intrusive thoughts or impulses that are perceived as inappropriate or forbidden • These thoughts, impulses or images are not simply excessive worries about everyday problems; but are seen as uncontrollable, which creates anxiety • They recognise that the obsessional thoughts or impulses are a product of their own mind • They also, at some point, recognise that the obsessions or compulsions are excessive or unreasonable 3.2.2 Psychopathology Specification • Definitions of abnormality, including deviation from social norms, failure to function adequately, statistical infrequency and deviation from ideal mental health. • The behavioural, emotional and cognitive characteristics of phobias, depression and obsessive compulsive disorder (OCD). • The behavioural approach to explaining and treating phobias: the two-process model, including classical and operant conditioning; systematic desensitisation, including relaxation and use of hierarchy; flooding. • The cognitive approach to explaining and treating depression: Beck’s negative triad and Ellis’s ABC model; cognitive behaviour therapy (CBT), including challenging irrational thoughts. • The biological approach to explaining and treating OCD: genetic and neural explanations; drug therapy. BEHAVIOURAL APPROACH TO EXPLAINING PHOBIAS TWO-PROCESS MODEL EVALUATION BIOLOGICAL PREPAREDNESS • Humans are genetically programmed to rapidly learn an association between potentially life-threatening stimuli and fear (Seligman, 1970) • These stimuli are called ancient fears (things that would have been dangerous in our evolutionary past, e.g. snakes, heights, strangers) – It would have been adaptive to rapidly learn to avoid these • Biological preparedness can explain why people are less likely to develop fears of modern objects (e.g. toasters) as they were not a threat in our evolutionary past • Behavioural explanations alone cannot be used to explain the development of phobias TWO-PROCESS MODEL IGNORES COGNITIVE FACTORS • There are cognitive aspects to phobias that behaviourist frameworks cannot explain • Cognitive approach suggests phobias may develop as a consequence of irrational thinking – E.g. thinking “I could be trapped in this lift and suffocate” (an irrational thought) which creates extreme anxiety and may trigger a phobia • This leads to cognitive therapies like CBT which may be a more successful treatment (as social phobias respond better to CBT – Engles et al, 1993) BEHAVIOURAL APPROACH TO TREATING PHOBIAS SYSTEMATIC DESENSITISATION (SD) • Patient is taught to associate the phobic stimulus with a new response (relaxation) so their anxiety is reduced and they are desensitised – The response of relaxation inhibits the response of anxiety • Therapist teaches the patient relaxation techniques (focus on breathing, visualising on a peaceful scene, progressive muscle relaxation) • Desensitisation Hierarchy used FLOODING • This is applied in one session in the presence of the patient’s most feared situation (lasting around 2-3 hours) • When adrenaline levels naturally decrease, a new stimulus- response link can be learned between feared stimulus and relaxation BEHAVIOURAL APPROACH TO TREATING PHOBIAS SYSTEMATIC DESENSITISATION (SD) EVALUATION EFFECTIVENESS • SD is successful for a range of phobic disorders (McGrath et al, 1990, found that 75% of patients with phobias responded to SD) • The key to success is having contact with the feared stimulus (in vivo techniques being more successful then in vitro – imaging) NOT APPROPRIATE FOR ALL PHOBIAS • Ohman et al (1975) suggest that SD is not as effective in treating phobias that have an evolutionary survival link (e.g. dark, heights, dangerous animals), than those as a result from personal experience STRENGTHS OF BEHAVIOURAL THERAPIES • Behavioural therapies are generally fast and require less effort from the patients than other psychotherapies (e.g. CBT) • This lack of “thinking” means the technique is useful for people who lack insight to their emotions (e.g. children, people with learning difficulties) • SD can also be self-administered, making it also cheaper 3.2.2 Psychopathology Specification • Definitions of abnormality, including deviation from social norms, failure to function adequately, statistical infrequency and deviation from ideal mental health. • The behavioural, emotional and cognitive characteristics of phobias, depression and obsessive compulsive disorder (OCD). • The behavioural approach to explaining and treating phobias: the two-process model, including classical and operant conditioning; systematic desensitisation, including relaxation and use of hierarchy; flooding. • The cognitive approach to explaining and treating depression: Beck’s negative triad and Ellis’s ABC model; cognitive behaviour therapy (CBT), including challenging irrational thoughts. • The biological approach to explaining and treating OCD: genetic and neural explanations; drug therapy. COGNITIVE APPROACH TO EXPLAINING DEPRESSION ELLIS’ ABC MODEL (1962) Negative Event (4) Negative Event (A) Rational Belief (B) Irrational Belief (B) Healthy Negative Unhealthy Negative Emation (C) Emotion {C) COGNITIVE APPROACH TO EXPLAINING DEPRESSION ELLIS’ ABC MODEL (1962) • A = an activating event (e.g. getting fired at work) • B = the belief; which could be rational or irrational (e.g. “the company was overstaffed” or “I was sacked because they’ve always had it in for me”) • C = the consequence – rational beliefs lead to healthy emotions (e.g. acceptance) but irrational beliefs lead to unhealthy emotions (e.g. depression) MUSTABATORY THINKING • The source of irrational beliefs lie in mustabatory thinking (thinking that certain ideas/assumptions must be true in order for an individual to be happy • Ellis identified the three most important irrational beliefs: – I must be approved of or accepted by people I find important – I must do well or very well, or I am worthless – The world must give me happiness, or I will die • An individual who holds such assumptions is bound to be, at the very least disappointed, at worst, depressed • Someone who fails an exam becomes depressed due to an irrational belief about that failure (e.g. “I must always do well, so failing the exam means I am stupid”), not because they have failed the exam • Such “musts” need to be challenged in order for mental healthiness to prevail COGNITIVE APPROACH TO EXPLAINING DEPRESSION EVALUATION PRACTICAL APPLICATIONS IN THERAPY • Cognitive explanations led to the development of CBT (which is consistently the best treatment for depression) • Cognitive explanations have specific implications for the success of the therapy and the therapy supports the explanation – E.g. If depression is alleviated by challenging irrational thinking then this suggests these thoughts had a role in depression in the first place IRRATIONAL BELIEFS MAY BE REALISTIC • Not all irrational beliefs are “irrational” – Alloy and Abrahmson (1979) suggest that depressive realists tend to see things for what they are and they found that depressed individuals gave more accurate estimates of the likelihood of a disaster than “normal” controls (they called this the sadder but wiser effect) ALTERNATIVE EXPLANATIONS • The biological approach suggests genes and neurotransmitters may cause depression • The success of drug therapies for treating depression suggest that neurotransmitters do play an important role • At the very least a diathesis-stress approach might be advisabe COGNITIVE APPROACH TO TREATING DEPRESSION COGNITIVE BEHAVIOUR THERAPY (CBT) • Developed by Ellis; CBT challenges irrational thoughts and changes them into rational ones • Ellis renamed it Rational Emotional Behaviour Therapy (REBT) • Ellis extended his ABC model to ABCDEF: COGNITIVE APPROACH TO TREATING DEPRESSION COGNITIVE BEHAVIOUR THERAPY (CBT) CHALLENGING IRRATIONAL THOUGHTS • Ellis extended the ABC model to ABCDEF where: – D = disputing irrational thoughts/beliefs – E = effects of disputing and effective attitude to life – F = the new feelings (emotions) that are produced • It is not the activating event that cause unproductive consequences (it is the beliefs) • REBT focuses on challenging/disputing the irrational thoughts/beliefs and replacing them with effective ones – Logical disputing (does it make sense?) – Empirical disputing (where is the proof/evidence?) – Pragmatic disputing (how is this helping?) • Effective disputing changes self-defeating beliefs into more rational beliefs • This makes the client feel better and become more self-accepting COGNITIVE APPROACH TO TREATING DEPRESSION CBT EVALUATION SUPPORT FOR BEHAVIOURAL ACTIVATION • The belief that changing behaviour can go some way to alleviating depression is supported by a study on the beneficial effects of exercise (Babyak et al, 2000) – Where all clients who exercised exhibited significant improvements at the end of 4 months of exercise and also had lower relapse rates than clients in the medication group ALTERNATIVE TREATMENTS • The most popular treatment for depression is the use of antidepressants like SSRI’s • Drug therapy requires less effort from the client and can be used in conjunction with CBT – This may be useful as the drugs treat the symptoms and so the client can focus/cope better on the CBT (which treats the cause of depression) – Cuijpers et al found that CBT was more effective when used with drugs THE DODO BIRD EFFECT • Rosenzweig (1936) argued that all methods of treatment for mental disorders were equally effective (called the Dodo Bird Effect – everyone wins) • Research does find fairly small differences in success rates (e.g. Luborsky et al, 1975 and 2002) • Rosenzweig argued that the lack of difference was due to so many common factors in the various psychotherapies (like being able to talk to a sympathetic person) 3.2.2 Psychopathology Specification • Definitions of abnormality, including deviation from social norms, failure to function adequately, statistical infrequency and deviation from ideal mental health. • The behavioural, emotional and cognitive characteristics of phobias, depression and obsessive compulsive disorder (OCD). • The behavioural approach to explaining and treating phobias: the two-process model, including classical and operant conditioning; systematic desensitisation, including relaxation and use of hierarchy; flooding. • The cognitive approach to explaining and treating depression: Beck’s negative triad and Ellis’s ABC model; cognitive behaviour therapy (CBT), including challenging irrational thoughts. • The biological approach to explaining and treating OCD: genetic and neural explanations; drug therapy. BIOLOGICAL APPROACH TO EXPLAINING OCD GENETICS EXPLANATIONS • COMT Gene – OCD patients have found to have a variation of this gene that produces a lower activity of COMT and higher levels of dopamine = linked to OCD • SERT Gene – This affects the transportation of serotonin (creating lower levels of this neurotransmitter) – Higher levels of SERT (and so lower levels of Serotonin) have been linked to OCD • Diathesis-Stress – Each individual gene creates a vulnerability for OCD as well as other conditions, but this does not mean that they will develop NEURAL EXPLANATIONS • Abnormal levels of neurotransmitters – Abnormally high levels of dopamine are linked to OCD – Lower levels of serotonin are associated with OCD • Abnormal brain circuits – The caudate nucleus suppresses signals from the orbitofrontal cortex (OFC) – OFC sends signals of worry to the thalamus – If caudate nucleus is damaged it fails to suppress minor worry signals and the thalamus is alerted (which sends signals back to the OFC acting as a worry circuit) BIOLOGICAL APPROACH TO EXPLAINING OCD EVALUATION ALTERNATIVE EXPLANATIONS • The two-process model can be applied to OCD – Initial learning occurs when a neutral stimulus (like dirt) is associated with anxiety – The association is maintained as the anxiety-provoking stimulus is avoided – Thus an obsession is formed and a link is learned with compulsive behaviours (e.g. washing hands) which appears to reduce the anxiety • These explanations are supported by the success of a treatment for OCD called “exposure response preventions” (ERP) which is similar to SD – Patients have to experience their feared stimulus and at the same time are prevented from performing their compulsive behaviour – Albucher et al (1998) reported a high success rate (60-90% of adults with OCD improved considerably by using ERP BIOLOGICAL APPROACH TO TREATING OCD ANTIDEPRESSANTS: SSRI’s • SSRI’s are the preferred drug for treating anxiety disorders • SSRI’s increase the levels of serotonin in the synapse by inhibiting the re-uptake process ANTIDEPRESSANTS: TRICYCLICS • Tricyclics block the re-absorption of serotonin and noradrenaline into the pre-synaptic neuron after it fires • This prolongs their activity in the synapse (same as SSRI’s) • There are greater side effects associated with tricyclics than SSRI’s ANTI-ANXIETY DRUGS • BZ’z reduce anxiety by slowing down the activity of the central nervous system by enhancing the activity of the neurotransmitter GABA • GABA opens up channels on the receiving neuron and increase the flow of chloride ions into this neuron • Chloride ions make it harder for the neuron to be stimulated by other neurotransmitters (therefore slowing down its activity and making them feel relaxed) OTHER DRUGS • D-Cycloserine reduces anxiety • It is an antibiotic used to treat tuberculosis and enhances the transmission of GABA and so reduces anxiety BIOLOGICAL APPROACH TO TREATING OCD EVALUATION EFFECTIVENESS • Soomro et al’s (2008) review of 17 studies found that using SSRI’s with OCD patients was more effective than using a placebo in reducing the symptoms of OCD up to 3 months after treatment (i.e. in the short term) • One issue regarding the evaluation of treatment is that most studies are only 3-4 months in duration (so little long-term data exists) DRUG THERAPIES ARE PREFERRED TO OTHER TREATMENTS • It is preferred as it requires little effort and little time (much less than CBT) • This is also cost-effective for the health service as they require little monitoring and cheaper than psychological treatments • They may still benefit from simply talking with a doctor during consultations (“Dodo Bird Effect”)