CLINICAL PSYCHOLOGY

WORKBOOK

NAME:

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DEFINITIONS

You need to be able to define clinical psychology and terms associated with clinical psychologyWhat is clinical psychology about?Clinical psychology is concerned with abnormal behaviour and seeks to define what makes a behaviour abnormal and then diagnose the problem so that that it can be treated.

What is meant by abnormality?Abnormality is defined through two different definitions. Abnormality according to the ststistical definition is any behaviour that does not occur within the ‘normal’ behaviour of 95% of the population – i.e. the behaviour of 5% of the population. According to the social norm definition, any behaviour which deviates from what society sees as desirable behaviour is classed as abnormal.

Why is it difficult to define abnormality?Even amongst psychologists there is disagreement about the causes of abnormal behaviour and depending on the approach the psychologist comes from, they will have different views of the causes of the mental disorder, the reasons behind this and what the correct treatment is.

Define the following termsStatistical definition of abnormality

Abnormality refers to behaviours which are statistically infrequent. Behaviours that deviate significantly from the average, or normal distribution, are abnormal. Schizophrenia is suffered by 1% of population so therefore statistically abnormal.

Social norms definition of abnormality

Abnormality is the breaking of society’s standards or norms. Abnormal behaviour is behaviour that deviates from or explicit rules and moral standards. For example, always talking to trees instead people.

Validity Measuring what you claim to measure, and having findings about real-life situations and behaviours.

Reliability The consistency of a method as it is applied to the Pps, measurable by the ability to replicate the study and also by the consistency of the results found.

Primary data Primary data is gathered first hand from a source directly by the researcher. This could be through a study employing questionnaires, observations, content analyses and experiments.

Secondary data Secondary data has already been gathered by someone else and is then used for further research. This may be a meta-analysis which employs data that has already been gathered before being studied.

Schizophrenia Schizophrenia is a psychotic disorder that affects about 1% of the population. It can cause disturbances in a person’s thoughts emotions and behaviours that can lead to the person withdrawing from social life.

METHODOLOGY

Describe what is meant by ‘primary data’Primary data is original data that has been collected by those who witnessed and event first hand or who collected the data themselves for a specific purpose. Data can be either quantitative or qualitative coming from questionnaires, experiments or

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observations, and is usual in psychological studies. An example of a study using primary data is Rosenhan (1973) who collected primary data from mental institutions in the US to study treatment of mental conditions.

Evaluate the use of primary data in researchOperationalisation is done with the research aim in mind, so there is likely to be validity with regard to the aim.Data is usually more up to date that secondary data and so be more reliable.Usually more credible than secondary data because they are gathered for the purpose with the chosen research method.Expensive compared with secondary data because data is gathered from the start.Limited to the time, place and no. of Ppts whereas secondary can come from multiple sources to give more range and detail.Researchers may be subjective in what kinds of data they look for, for example data which fits their hypothesis.

Describe what is meant by ‘secondary data’Secondary data is sencond hand analysis of pre-existing (primary) data which was collected by someone else. It is used for further research by the researcher. A meta-analysis is a common example of where secondary data is used where researchers pool data on a particular topic but which they themselves have not collected. An example of a study using secondary data is Gottesman and Shields (1966) who collected secondary data from hospital records and conducted further research regarding schizophrenia.

Evaluate the use of secondary data in researchRelatively cheap and quick in comparison to primary data as it is already collected.Can be in good quantity so there is likely to be detail.Can be from different sources so there is a possibility of comparing data to check for reliability and validity.In some circumstances, secondary data, in the form of historical documents, may be the only way of researching trends of the past.Likely to be gathered to suit some other aim, so may not be valid for the purpose of the study.May have been gathered some time before and so not in the relevant time period.The researcher cannot personally check the data or how it was collected calling into doubt its reliability and accuracy.

In clinical psychology the goal of diagnosis can only be achieved if it is both consistent (i.e. clinicians must agree) = Reliability, and it reflects an actual disorder (and cause/possible treatment) = Validity

Explain how issues of reliability and validity arise in clinical psychology (ensure you use evidence i.e. research in your answer)Validity is found in studies where what is measured is what is claimed to be measured. For example if someone is studying anxiety and then finds out the people studied are suffering from depression, the study would lack validity. Validity of diagnosis refers to the extent to which the diagnosis reflects the actual disorder and therefore enables a suitable treatment.Reliability is found when what was done in one study is repeated and the same results are found in another. For example if a researcher links depression with loss in early childhood and then the study is repeated and no such link is found, the results lack validity.These issues are important in clinical psychology, particularly with regard to

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diagnosing a mental disorder. A diagnosis is considered reliable if more than one psychologist gives the same diagnosis to the same individual – they must be consistent.Heather (1976) found that there is only a 50% chance of correctly predicating the treatment a patient will receive on the basis of diagnosis, suggesting a lack of predictive validity in diagnosis.Beck et al. (1961) found that two psychiatrists only agreed 54% of the time over diagnosis, suggesting it is highly unreliable.

You need to be able to describe and evaluate TWO research methods (Animal studies and Twin Studies) used in the study of schizophrenia AND include ONE study for each of the two methods

Describe animal experiments:Although it is thought that schizophrenia is a condition only found in humans, it is possible to model the disorder and test treatments on animals.Humans and animals have similar hormonal system, nervous system and brain with rats sharing humans’ hind-, mid- and fore-brain.This means that experiments can be conducted that would be unethical to conduct on humans.Researchers attempt to ‘induce’ schizophrenia in animals; perhaps by administering drugs (e.g. amphetamine) producing symptoms similar to positive symptoms of schizophrenia.Medication is then administered (e.g. Haldol) is administered which reduce symptoms, helping the understanding and development of anti-psychotic medication.Findings are generalised from animals to humans to help treating conditions in humans.

Describe how animals have been used in the study of schizophrenia (ensure you include ONE study in your answer)Randrup and Munkvad (1966) aimed to see whether schizophrenia-like symptoms could be induced in non-human animals by giving them amphetamines.The researchers injected rats with doses of 1-20mg/kg of amphetamines.They found that all the known symptoms of schizophrenia were reported, including stereotypical activity.The conclusions show that stereotypical schizophrenic activity can be produced by amphetamines in non-human animals.

Evaluate the use of animal studies in the study of schizophreniaAnimals are similar enough to humans to extrapolate results from one species to another. Green (1994) stated the basic physiology of brain and nervous system are similar enough to warrant comparisons between humans and animals.Animal studies are important in developing new drugs that can be used to treat schizophrenia in humans.Animal studies are useful in exploring areas in which it would not be possible to use humans for practical and/or ethical reasons, such as inducing schizophrenic symptoms.There may be problems with anthropomorphism (meaning attributing human qualities to animals) because we might assume that an animal is behaving in a certain way for the same reasons as a human would behave in a certain way.The nervous system in rats (used primarily in animal studies on schizophrenia) is not identical to humans and different parts of the brain are different sizes thus leading to difficulties in extrapolating results.

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Animals studies cannot replicate schizophrenia in animals, only the symptoms meaning there may be problems in the application of animal studies.It may be unethical to use animals in research, particularly inducing schizophrenic symptoms.

Describe twin studies:Twin studies test whether there is a genetic component to schizophrenia or whether it is triggered by environmental factors. They look at concordance rates which is the probability of one twin having schizophrenia if the other already has it. Twins are genetically tested to ensure they are identical and hospital records are used identify a diagnosis of schizophrenia in one twin.Monozygotic (MZ - identical) twins share 100% of their genes while Dizygotic (DZ – non-identical) share 50%. They share the same environment meaning that environmental factors can be discounted. If it is found that MZ twins have a higher concordance rate than DZ twins, it must be because the disorder has a genetic component, but anything less than a 100% concordance rate in MZ twins shows schizophrenia must have an environmental factor. Describe how twin studies have been used in the study of schizophrenia (ensure you include ONE study in your answer)Gottesman & Shields (1966) aimed to investigate the relative importance of genetic and environmental influences on schizophrenia by comparing MZ and DZ twins. They collected secondary data from the Maudsley & Bethlem Royal Joint Hospital records of twins. From a sample of 392 patients with twins of the same sex, 57 twin pairs were selected; 24 were MZ and 33 were DZ. The concordance rate of MZ twins both diagnosed with schizophrenia was 42% and for two schizophrenic DZ twins it was 9%. With only one twin diagnosed with schizophrenia and the other another psychiatric diagnosis, the concordance rate is 12% for MZ twins and 9% for DZ twins. Gottesman & Shields concluded that genes appear to play an important role in schizophrenia because the concordance rate is higher in MZ twins than DZ twins.

Evaluate the use of twin studies in the study of schizophreniaTwin studies provide a naturally occurring independent variable in that MZ twins always share 100% of their genes whilst DZ twins share 50%. This means researchers can clearly study genetic influences on a disorder.As twins both have the same environment, the nature vs nurture debate can be perfectly tested. As multiple births around the world are growing in number, and medical/birth records getting better, researchers are able to gain large samples and replicate their studies to gain generalisability and reliability. MZ and DZ twins may not share as similar an environment as would be first thought meaning environmental factors may not be able to be ruled out. MZ twins may be treated more alike than DZ twins because they are identical and the same gender. Twin studies can be criticised for not showing cause and effect. For example, a 50% concordance rates suggests schizophrenia runs in families but this may not be due to genes as families share similar environments which the concordance rate may refer to.Genetic inheritance in Schizophrenia may be more complex that would be first believe, with Boklage (1977) finding that the concordance rate of two right-handed MZ twins was 92% while in MZ twins where one was left-handed, the concordance rate was only 25%.

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CONTENT

You have to be able to describe and evaluate (in terms of their suitability) the statistical and social norms definitions of abnormality

Describe the statistical infrequency definition of abnormalityThe statistical infrequency definition of abnormality defines behaviours that are very infrequent as abnormal.Both ends of the normal distribution are included in the definition.An example is schizophrenia which has a 1% incidence rate and so according to the definition would be classed as abnormal. However, depression which has a roughly 10% incidence rate would be seen as less abnormal.

Evaluate the statistical definition of abnormalityThe cut off between what is normal and abnormal is arbitrary and adds not context to the behaviour.The dividing line between behaviour is sudden. For example IQ scores for which one score would be classed as normal while another would be considered abnormal.The definition does not account for whether the behaviour is desirable or not. For example a high IQ score, which would be classed as abnormal may well be desirable.This means that high functioning individuals such as geniuses are classified as abnormal. This links to the fact that the definition does not allow the clinician to judge whether the individual is coping.Some mental problems, e.g. depression at 10% incidence rate are not statistically rare so not encompassed by the definition.

Describe the deviation from social norms definition of abnormalityThe deviation from social norms definition of abnormality defines behaviour that is different from what is normally acceptable and can make people feel uneasy as abnormal.This could include behaviour that is bizarre and/or extreme.An example would be people always talking to trees instead of people.It has to be clear to everyone in a particular society what the social norms are so that the abnormal behaviour is seen as such by everyone in that society.

Evaluate the social norms definition of abnormalitySocial norms vary over time and between cultures so are hard to accurately define.The definition lacks objectivity as to what are classed as socially abnormal.The lack firm objectivity means that the definition could be open to abuse of diagnosis, possibly for social convenience or political ends.Within the definition, the behaviour is judged within social context e.g. hearing voices in some parts of Asia may be considered the desirable occurrence of ancestors’ communications but a sign of schizophrenia in the UK.In the past, homosexuality was treated as abnormal mental illness in the UK but this now seem absurd showing the social norms can change over a relatively short space of time.

You have to be able to use studies to describe: the use of the DSM; issues of validity, issues of reliability, cultural issues in the diagnosis of disorders:

What is the DSM?It is the most commonly used classification and diagnostic system and is published by the American Psychological Association (APA). It groups symptoms together in syndromes which relates to specific mental health conditions and contains criteria to help psychiatrists to make diagnoses relating to around 400 disorders.

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Describe the DSMThe DSM is a multi-axial system where the individual is rated on five axes to help with the process of diagnosis:Axis 1 (disorders): looks at the diagnosis of all mental disorders, except for personality disorders and mental retardation – problems which need immediate attention. Examples include; clinical disorders, developmental disorders, schizophrenia.Axis 2 (personality disorders): concerned with all major mental disorders, including personality disorder and mental retardation. Often accompanied with something from axis 1. Examples include; OCD, autism.Axis 3 (medical conditions): looks at general medical conditions, as the symptoms of some medical disorders are similar to mental disorders. For example, hypothyroidism has the same symptoms as depression. Examples include existing brain injuries and liver damage.Axis 4 (environmental problems): looks at psychosocial and environmental problems, which may have an effect on the disorder. This includes problems such as family problems with employment and social problems.Axis 5 (GAF): is the global assessment of functioning scale, which ranges from 100-0; 0 being in danger of hurting oneself and 100 being a superior level of functioning.

Briefly outline the changes to the DSM and explain why revisions have been necessary:An example of a revision came in 1974 when homosexuality was removed as a form of mental disorder and replaced with sexual orientation disturbance. By 1980 this category was changed to ego-dystonic homosexuality, later removed and replaced with persistent and marked distress about one’s sexual orientation.

RELIABILITY, diagnosis and the DSMAny classification system used to diagnose mental disorders must be reliable, so that different psychiatrists studying the same patient or symptoms come to the same diagnosis and therefore offer the same (correct) treatment

Describe and evaluate research studies looking at the reliability of the DSMBeck et al. (1961) found that two psychiatrists only agreed 54% of the time over diagnosis in 153 patients, suggesting it can be highly unreliable.Zeigler and Phillips found between 54% and 84% reliability which although good, still leaves for 16% unreliability.Davison and Neale found variable reliability with different disorders – 92% for psychosexual disorders but only 54% for somatoform (psychological conditions that have the characteristics of physical disease) disorders.Brown et al. (2001) found there was a 67% agreement rate for major depression.

Evaluate the reliability of diagnosis and the DSMThe studies seems to indicate that reliability of diagnoses using the DSM is not very reliable. Figures around 50-60% reliability are common, which is clearly leaving at least 40% of unreliable diagnoses. Results also vary reducing reliability.Differences in reliability appear to be between different disorders, with some much higher than others.Issues with reliability may come from patient’s’ descriptions themselves which can affect diagnosis from different clinicians.

VALIDITY, diagnosis and the DSMA classification system must also be valid to diagnose the mental disorder the person is suffering from, how the disorder will develop and how effective treatments will be

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Outline construct (1), etiological (2), concurrent (3) and predictive validity (4):(1) Constructs attempt to operationalise mental disorders through a list of symptoms and behaviours. If the constructs drawn up are not representative enough, there is a lack of construct validity.(2) Etiological validity is achieved when the diagnoses of the same disorder result in the same symptoms or factors causing it.(3) For a diagnosis to have concurrent validity, symptoms that form part of the disorder, but are not part of the actual diagnosis, should be found in those diagnosed.(4) Predictive validity is present if diagnosis can lead to a prediction of future behaviours caused by a disorder as well as how those diagnosed will respond to treatments.

Describe and evaluate studies looking at the validity of the DSMLahey et al (2006) found that there was good predictive validity in relation to ADHD diagnosed children’s social and academic functioning over a six year period. Andrews et al (1999) looked at how far DSM IV agreed with ICD 10. They found good agreement on disorders such as depression but poor agreement on PTSD; so validity appears to depend on the disorder.Rosenhan (1973) concluded DSM III wasn't valid, as it couldn't tell those who did have mental disorders from those who did not in that pseudo-patients sent to psychiatric hospitals by Rosenhan were diagnosed as having mental disorders.Hoffmann (2002) found DSM IV to be valid when he compared structured interview data with DSM criteria in relation to alcohol abuse, dependence and cocaine dependence.

Evaluate the validity of diagnosis and the DSMIt appears that later versions of DSM are valid in diagnoses. Given tht the DSM has had many revision to date, this is unsurprising.Great efforts have been made to make the DSM IV (text revisions) more valid, for example, by including culture bound syndromes.However validity still seems to vary between disorders and is certainly not totally valid.It could be claimed that splitting a mental disorder into symptoms and feature is reductionist and that a holistic approach may be more valid.Studies such as Andrews above, assume the alternative classification system (ICD in this case) is valid, which may not be the case.

CULTURE – One criticism of the DSM is of its usefulness across different cultures. Remember, some mental disorders are specific to certain cultures (what does this suggest?)

Outline the argument ‘culture does not affect diagnosis’ with reference to evidenceCulture should not affect diagnosis as mental disorders are scientific. The symptoms and features of a certain disorder are the same the world over so the diagnosis should match.Mental disorders are scientifically defined illnesses that are explained in a scientific way. This means that culture should not affect diagnosis.The DSM was developed in the USA but is used widely in many other cultures. Therefore the DSM should be valid if the mental disorders are clearly defined with specific features and symptoms.Lee (2006) was conducted in Korea to check the DSM III (text revisions)’s validity in a non-Western culture. It was found to be valid in the case of ADHD.

Outline the argument ‘culture does affect diagnosis’ with reference to evidenceCulture can affect the diagnosis and treatment of mental disorders, as different cultures habe different attitudes to mental disorders. For example, symptoms that

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are seen in Western countries as characterising schizophrenia (such as hearing voices) are interpreted in other countries as showing possession by spirits which is seen in a positive way rather than as a disorder.Culture can also affect how much information a patient is likely to disclose. This can affect diagnosis, as not all symptoms may have been mentioned. Casas (1995) found that a lot of African Americans do not like to share their personal information with people of a different race.Culture can also affect one’s expectation of the diagnosis process. Cinnerella and Loewenthal (1999) found black Christians and Muslim Pakistanis both felt there was a social stigma associated with depression, possibly making them less likely to seek medical help.

Evaluate cultural issues, diagnosis and the DSMThe DSM III (text revisions) takes account of cultural issues in acknowledging culture bound syndromes.There has been an attempt to remove focus from bizarre symptoms in schizophrenia, as it was acknowledged that such symptoms are open to interpretation and that there are cultural issues in such interpretation.Other features/symptoms of schizophrenia that are listed in DSM could lead to cultural bias. ‘First-rank’ symptoms (like ‘bizarreness’) should perhaps receive less emphasis.Negative symptoms of schizophrenia are more objectivity measured and so should be given greater attention. In practice, the focus is on positive symptoms (including bizarreness, because this includes hallucinations).There might be some cultural differences in the symptoms of schizophrenia (such as grandiosity and auditory hallucinations) so these should be considered separately rather than elements of a range of symptoms.

SCHIZOPHRENIA

You have to be able to 1) Describe the features and main symptoms of schizophrenia.2) Describe and evaluate a biological explanation (Dopamine hypothesis) PLUS one other explanation – we covered the cognitive explanation of schizophrenia.3) Describe and evaluate two treatments – from two different AS approaches – for schizophrenia; we studied Drug treatment (biological approach) and CBT (cognitive approach).

Describe the main symptoms (1) and features (2) of schizophrenia(1) Delusions are common such as of persecution or grandeur.Person is likely to suffer from hallucinations, may be auditory or visual.Negative symptoms such as poverty of speech means cannot express selves effectively.May show either a lack of emotion or inappropriate emotions such as laughing at something distressing.Person may enter a catatonic stupor where they remain immobile for lengthy periods.(2) There are many types of schizophrenia such as paranoid, disorganised and catatonic schizophrenia.Paranoid schizophrenia has such symptoms as hallucinations and visions of grandeur

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as well as feelings of paranoia.Schizophrenia’s common age of onset is from late adolescence to late 20’s.It is prevalent in about 1% of the population, equal gender balance, with 15% of sufferers requiring help and support for the rest of their life.Symptoms can be split into categories of positive and negative symptoms. These are excesses in behaviour, present in the patient, and behaviours which should be present but are missing, respectively.

Describe a biological explanation (Dopamine hypothesis) of schizophrenia Research suggests the presence of an excess number of dopamine receptors at the synapse contributes to schizophrenia.There is an increase of activity at dopamine synapses which is associated with increased feelings of paranoia and explains why hallucinations may occur as the brain is too active.It is possible that an increase in dopamine in one site in the brain (the mesolimbic pathway) contributes to positive symptoms of schizophreniaProblems with dopamine functioning in another site (the mesocortial pathway) contributes to negative symptoms.There are many ways in which such dopamine sensitivity can arise, such as genetic inheritance, so, according to the hypothesis, there are many ways to develop schizophrenia.The drugs used to treat schizophrenia cause symptoms similar to Parkinson’s disease which is known to be caused by low levels of dopamine. As the drugs treat schizophrenia by lowering the levels of dopamine, the hypothesis argues schizophrenia must be caused by high levels of dopamine.

Evaluate a biological explanation (Dopamine hypothesis) of schizophrenia Dopamine receptors are implicated in many different studies, which give the hypothesis reliability. An example of one is Lindstroem et al (1999) used a PET scan to study the uptake of IDOPA (used to make dopamine) and found it was used more quickly in schizophrenics suggesting they make more dopamine.Genes that are likely to increase sensitivity to dopamine are found in those who develop symptoms of schizophrenia, suggesting not only that dopamine has an effect, but also genes.PET scans show that blocking dopamine receptors does not always remove the symptoms of schizophrenia. The block was 90% effective in patients of 10 years or more, still leaving 10% which cannot be accounted for by dopamine receptors.Depatie and Lal (2001) found that apomorphine, a drug that increases the effect of dopamine, did not create schizophrenic symptoms in their Ppts, suggesting that dopamine may not have such an effect on schizophrenia.Social and environmental factors seem to trigger schizophrenia, so a biological explanation is not sufficient.It is also hard to know whether the excess dopamine causes schizophrenia or if schizophrenia causes excess dopamine as excess dopamine is only measured after onset.

Describe the cognitive explanation of schizophrenia Sees the cause of schizophrenia as a problem with processing information.These information processing difficulties may disrupt self-awareness by producing difficulties in the ability to recognise one’s own actions and thoughts as being carried out by ‘me’. The sufferer may think that they are from an outside agency. Frith (1992) proposes a deficit in the Central Monitoring System which is responsible for labelling actions and thoughts as having been done by ‘me’.Shallice (1998) found patients with negative symptoms may have a deficit in the cognitive processes responsible for generating self-initiated actions – e.g. poverty of speech or thought, social withdrawal, flattening affect.

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Maher (1968) sees bizarre use of language as being the fault of the way in which information is processed. Pickering (1981) proposed that catatonic schizophrenia may be caused by a breakdown in auditory selective attention, making social interaction difficult when the individual is overloaded with auditory information.

Evaluate the cognitive explanation of schizophrenia Frith and Done (1989) found that schizophrenia sufferers have difficulties monitoring their own actions. They asked participants to follow a target on a video game with a joystick. schizophrenia sufferers performed worse when their errors were not shown to them.The approach does not attempt to explain schizophrenia as a whole but specific symptoms – this means that we do not need to change diagnostic criteria.Some patients have been treated with anti-psychotic medication for some time and so it is difficult to interpret results from studies as the results could be due to either cognitive deficits or the effects of the medication. The cognitive explanation for schizophrenia focuses on the symptoms and does not study the cause of the disorder – in effect it says that the symptoms are the cause. This means the explanation is not that useful as we do not know where the faulty processing comes from. Frith and Done found that cognitive functioning differs in schizophrenia sufferers compared to non-sufferers when sufferers with negative symptoms had more difficulty in creating their own responsesThere is no explanation as to what causes the cognitive changes – the disorder is typically diagnosed in adulthood and, as yet, there is no scientific evidence to link childhood difficulties in information processing with later onset of schizophrenia.

Describe Drug treatment (biological approach) for schizophrenia Drugs aim to change the level of dopamine availability with in the brain to reduce symptoms.It is important the patient takes their medication regularly.Once established, drug regimes are straightforward to administer and dosage rates are clear.Drug levels manipulated to ensure appropriate dose level for patient.There is a time delay from starting a course of treatment and feeling any benefit.Usually the patient will be kept in an institution until their condition has stabilised.

Evaluate Drug treatment (biological approach) for schizophrenia It can take considerable time to find the right drug/level for individual patients.Sometimes changes in the patient’s lifestyle or metabolism may mean the dosage rate is no longer appropriate, and this can cause problems.Compliance is often a problems especially in outpatients.This is because anti-psychotic drugs have unpleasant side effects, such as lethargy, drowsiness and Parkinsonism including a shuffling walk, though modern drugs are better. Not all forms of schizophrenia respond to drug treatments, so is not a universal treatment.Drugs have allowed schizophrenia, previously seen as untreatable, to be dealt with in the community.

Describe CBT (cognitive approach) for schizophrenia The therapist accepts a patient’s perception of reality and uses this misperception to help the patient manage through making adaptive rather than maladaptive decisions.The aims of this therapy are to challenge and modify delusionary beliefs, to help the patient identify delusions, to challenge those delusions and to kelp the patient to understand how to test the reality of evidence.

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This therapy does not try to cure the patient but rather to help them function relatively normally.The process may begin by asking the patient to focus on the nature of the voices that they hear – for example are they male or female, what tone is used etc.The therapist help the patient to recognise that the voices represent part of their own thought processes, e.g. an evil voice may represent their own desire for self-harm.Patients are encourages to develop strategies to protect them against the wishes of these inner voices – for example relaxation techniques, talking to a supportive other or only paying attention at a certain time of the day.

Evaluate CBT (cognitive approach) for schizophrenia Chadwick and Lowe (1993) found that CBT reduced delusions in 10/12 of the patients in their study showing that this therapy has a good success rate.However, whilst it may help around 70% of patients, it has made the other 30% deteriorate (Kingdom and Turkington (1996))Many psychiatrists are concerned that the approach may encourage and support delusional thinking in their patients. Paying attention to the content of the voices may result in the client doing what the voice instructs, rather than controlling it.Romme and Escher (2000) claim that focusing on the voices actually reduces the likelihood of harm to the self or others.Until recently it was thought that CBT would not be effective for schizophrenics as their whole perception of reality is different. This makes it difficult to get them to challenge their beliefs, which to them are rational. However, Chadwick (2000) studied 22 schizophrenics who all heard voices and had eight hours of CBT. They all had reduced negative beliefs about how the voice controlled them and thus could live with the voices better. (2 marks)

You need to be able to describe and evaluate one treatment or therapy from EACH of the 5 AS approaches:BIOLOGICAL APPROACH – ECT (Electro-Convulsive Treatement)Describe ECT (Biological Approach)Electro-Convulsive therapy involves inducing a convulsive seizureThe patient receives anaesthetic and muscle relaxant to minimize the danger of physical injury and oxygen to guard against brain damage.Two electrodes are attached to the patient’s head and an electrical current of between 65 and 140v is passed through their brain for up to half a second causing a convulsion lasting from 25 seconds to 3 minutes.The shock can be delivered through one temple (unilateral ECT) or both temples simultaneously (bilateral ECT).Bilateral ECT acts more quickly and requires fewer treatments so it preferred for severely depressed patents however unilateral ECT has fewer side-effects particularly with regard to memory disruption so is used wherever possible.Typically a person with depression receives 6-9 treatments over a 2-4 week period.

Evaluate ECT (Biological Approach)It is widely acknowledged by psychiatrics that the relapse rate is high and there is no evidence that the effects last more than four weeks. This clearly limits the effectiveness of the treatment.Sackheim et al (2001) found that 84% of patients relapsed within 6 months, weakening the effective of ECT as a treatment.Comer (2002) found that 60-70% of ECT patients improve after treatment showing that it is effective in the majority of cases.Datto (2000) found ECT is distressing to receive and results in side-effects such as memory loss, cardiovascular changes and headaches which is a weakness of the treatment.When compared to ‘sham ECT’ where the same procedure, minus the shock, is given

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a number of patients recover suggesting that the attention of the treatment rather than ECT may cause the recovers.ECT cannot be a cure is we have not establish the cause of depression or how ECT works. This has prompted MIND to make ethical objections, especially since many patients are unable to give informed consent.The biological treatment is reductionist (too simplistic) as it focusses only on one explanation and ignores all others. To fully explain complex disorders it would be better to take a multi-dimensional approach that accounts for both nature and nurture.

COGNITIVE APPROACH – REBT (Rational Emotive Behavioural Therapy)Describe REBT (Cognitive Approach)According to the social approach, mental disorders can be triggered by factors in the environment and thus can be treated by provisions within the community.This treatment came into operation around the 1985 replacing asylums and hospitals where the mentally ill were previously placed, leading, according to social psychologists, to institutionalisation.In the 1970s and 80s there were closures of a number of psychiatric hospitals and wards and community based care programmers being set up instead.The aim of community care is to rehabilitate the patient and ensure they can function normally within society.An example of such care is within the home where helped is given in feeding, dressing and grooming.Those who do need to be hospitalised are admitted to psychiatric wards, usually on a short-term basis with the aim of returning them to the community as soon as possible.

Evaluate REBT (Cognitive Approach)REBT is seen as more effective than psychoanalytic therapies as they aim to help people to get better by viewing their problems in a different light rather than only feel better within the sessions by understanding their dreams. It attempts to empower clients by educating them into self-help strategies.The therapy ignores the fact that irrational environments continue after the therapy which can continue to reinforce irrational beliefs and behaviours.The argumentative nature has been questioned by some, particularly by those who stress the importance of empathy in therapy.Unlike psychoanalytic therapies, the therapist and client are equal so REBT cannot be criticised in the respect of the therapist taking too much control.Fancher (1995) argues that therapists may not be able to identify faulty thinking. What is irrational to the therapist may not be to the client, especially given their own experiences.Hollon et al (1992) found REBT is at least as effective as drugs at treating depression strengthening it as a therapy especially as it is non-invasive and does not lead to side effects.The cognitive treatment is reductionist (too simplistic) as it focusses only on one explanation and ignores all others. To fully explain complex disorders it would be better to take a multi-dimensional approach that accounts for both nature and nurture.

LEARNING APPROACH – TEPs (Token Economy Programmes)Describe TEPs (Learning Approach)Desired behaviour(s) are reinforced by giving tokens.Tokens are a secondary reinforcer while the privileges/rewards may be primary reinforcers.The tokens can be exchanged for privileges/rewards.As behaviour improves the standard required to achieve a token may become higher.

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Tokens are awarded by staff on the wards.TEPs are designed to increase desirable behaviour in those with disorders.

Evaluate TEPs (Learning Approach)Token economies can be open to abuse because they rely on the staff being fair and consistent.Patients can become mercenary and change their behaviour to achieve the tokens though there is no underlying change in behaviour.Only tends to work effectively within institutions as behaviour needs to be constantly monitored.This means that behaviour may not generalise to real life once the individual leaves the institution.Paul and Lentz found token economies worked more effectively than other programmes to manage in-patient behaviour.Allyon and Azrin showed effectiveness of token economies in producing socially desirable behaviours in long term psychiatric unit patients.The biological treatment is reductionist (too simplistic) as it focusses only on one explanation and ignores all others. To fully explain complex disorders it would be better to take a multi-dimensional approach that accounts for both nature and nurture.

PSYCHODYNAMIC APPROACH – Dream AnalysisDescribe Dream Analysis (Psychodynamic Approach)Dream analysis is a therapy from the psychodynamic approach which believes in the importance of the unconscious mind. This is shown to the conscious through latent content in dreams. Freud said ‘Dreams are the royal road to the unconscious’.The therapy investigates the symbols within the manifest content to reveal the latent content which is supposed to show the unconscious.The approach is based two levels. Catharsis is the process is talking through ones negative feelings and in doing so getting them out of the unconscious and this feeling better.Insight involves making the conscious aware of the unconscious and thus making the person able to confront and deal with their negative feelings.The psychodynamic approach focussed on the importance on the Id being the source of people’s wishes. In the conscious mind this is repressed to protect the conscious mind. However in dreams the Id has more freedom and thus the primary process thought can be shown.Dreamwork is the method used by the conscious mind to transform the unacceptable wished of the unconscious into symbols expressed in dreams. The therapist tries to reverse the process of dreamwork to get to the latent content of the dream and help the patient decipher their dream.

Evaluate Dream Analysis (Psychodynamic Approach)Solms (2000) used PET scans to discover that while dreaming the parts of the brain involved with memory was very active while areas concerned with rational thought were inactive. Freud would say this showed that the conscious Ego was dormant and the unconscious Id was given free reign.Heaton et al (1998) found that clients who had therapists interpreting their dreams felt they gained more insight than when interpreting their own dreams suggesting that dream analysis does offer some help to clients.Dream analysis is subjective with the interpretation dependent of the interpreter. This means that different interpreters could analyse the same dream differently.The client may not tell the therapist the whole dream, either through forgetting or deliberate editing. The missed parts could be important and lead to inaccurate interpretation of the dream and thus not reflect what was actually in the unconscious.The Eysenck (1952) review found that psychoanalysis therapy, including dream

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analysis, was no more effective than having no treatment at all.Espostio et al (1999) analysed the dreams of 18 Vietnam veterans suffering PTSD. The found about half had combat elements in their dreams disputing the theory of symbolism within dreams.The psychodynamic treatment is reductionist (too simplistic) as it focusses only on one explanation and ignores all others. To fully explain complex disorders it would be better to take a multi-dimensional approach that accounts for both nature and nurture.

SOCIAL APPROACH – Care in the CommunityDescribe Care in the Community (Social Approach)According to the social approach, mental disorders can be triggered by factors in the environment and thus can be treated by provisions within the community.This treatment came into operation around the 1985 replacing asylums and hospitals where the mentally ill were previously placed, leading, according to social psychologists, to institutionalisation.In the 1970s and 80s there were closures of a number of psychiatric hospitals and wards and community based care programmers being set up instead.The aim of community care is to rehabilitate the patient and ensure they can function normally within society.An example of such care is within the home where helped is given in feeding, dressing and grooming.Those who do need to be hospitalised are admitted to psychiatric wards, usually on a short-term basis with the aim of returning them to the community as soon as possible.

Evaluate Care in the Community (Social Approach)Studies have found that patients who refer care in the community prefer it to being in hospital indicating that in a civilised country community care may be a better treatment than hospitalisation.Trauer et al (2001) found that in patients released from hospital a year earlier, quality of life improved.Care in the community will encourage the patient to integrate into the community and thus helps them to adjust to society’s norms.Care in the community provision are often led by private companies which will be profit driven. This may lead to lack of funding and thus a lack of provision or over-stretched staff.Real life examples of where community care has led to negative effects on innocent third parties include Michael Argyle who stabbed George Harrison because vices told him to do so just six weeks after being released from a mental institution.Many in the medical profession feel that the rights of the individual (patient) are held too highly believing that the system has let down many seriously ill schizophrenics who needed hospitalization.The social approach treatment is reductionist (too simplistic) as it focusses only on one explanation and ignores all others. To fully explain complex disorders it would be better to take a multi-dimensional approach that accounts for both nature and nurture.

INCLUDE COMPARISON TABLE WHEN PRINTING

STUDIES IN DETAILYou need to cover (Describe and evaluate) 3 studies in detail. One must be Rosenhan’s (1973) study – ‘On being sane in insane places’. The second must be on Schizophrenia – Gottesmann and Shields (1966) - investigating whether there is a genetic basis for schizophrenia. The third needs to be on Anorexia Nervosa – Mumford and Whitehouse (1988).

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Describe the APRC for Rosenhan’s (1973) study ‘On being sane in insane places’ Experiment 1Aim – Rosenhan examined how clear cut the diagnoses of sanity/insanity are and whether psychiatric staff can distinguish sanity and insanity.Procedure – Eight pseudopatients (confederates) (three women, five men) were sent to 12 different hospitals in the USA.The real participants were the hospital staff who did not know that the pseudopatients, who mixed with the participants, were observing them.All gave false details, such as names and occupations, as well as pretend symptoms; mainly hearing voices of the same gender saying “empty”, “hollow” and “thud”.Upon admission, the pseudopatients immediately stopped any abnormal symptoms although at the start they were nervous. They told staff they felt fine and asked when they would be discharged.The pseudopatients spent time writing observations about the ward patients and staff.Results – All the pseudopatients were admitted and none detected as sane with all but one (manic-depressive) were diagnosed with schizophreniaThe pseudopatients’ normal behaviours were interpreted in the context of being mentally ill, for example, turning up at the cafeteria 30 mins early was described as ‘oral-acquisative nature of the syndrome’Hospitalisation time ranged from 7 to 52 days, with the average being 19 days.Real patients could detect the pseudopatients’ sanity, with 35 of 118 patients voiced suspicions.Conclusion – Rosenhan concluded that staff in psychiatric hospitals were unable to distinguish those who were sane from those who were insane, and that DSM was therefore not a valid measurement of mental illness at that time.Experiment 2In a second experiment conducted by Rosenhan, staff, who knew about Rosenhan’s findings of Experiment 1, at a different hospital, were told that more pseudopatients would be admitted sometime in the following three months. In fact no pseudopatients were admitted, but staff incorrectly rated 83 of the 193 new admissions as pseudopatients showing that a diagnosis can be reversed; those who really were mentally ill were not diagnosed as such.

Evaluate Rosenhan’s (1973) study ‘On being sane in insane places’ Clinicians wouldn't expect those presenting as apparently mentally ill not to be so, so wouldn't doubt the report of symptoms.The pseudopatients did say they heard a voice so there was deception albeit briefly.The study has high ecological validity as it was conducted within real psychiatric hospitals.Several different hospitals were used in several different states so there is evidence of some generalisability and reliability.All institutions were within the USA so whether the findings would have been the same in other countries is unclear, possibly limiting generalisability.The ability of the pseudopatients to observe and record their experiences enhances the validity of the findings.Objectivity of the pseudopatients may have been affected as they were unable to leave the institutions when they wanted to.

Describe the APRC for Gottesmann and Shields (1966) investigating whether there is a genetic basis for schizophrenia Aim – To see whether schizophrenia has a genetic basis, by investigating the importance of genetic and environmental influences on schizophrenia by comparing MZ and DZ twins.Procedure – Records of twins from the Maudslet and Bethlem Royal Joint Hospital

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provided a sample of 392 patients with twins of the same sex. 68 had a diagnosis of schizophrenia or other related psychosis. 6 were then discounted as their twin was overseas or it was not clear whether they were one of MZ or DZ twins and 5 twin pairs were discounted as both already had a diagnosis of schizophrenia. This left 57 participants – 30 were male and 27 female; 24 were one of MZ twins and 33 one of same sex DZ twins; their ages ranged from 19 to 64, with the average being 32.Zygocity was determined using three methods: fingerprinting, blood testing and resemblance assessments (the study was pre-DNA).The researchers used multiple data collection methods including hospital notes, case histories based on self-report questionnaires and interviews, personality testing and a test to measure disordered thinking.Results – The data was analysed and categorised in four ways. Of those affected with schizophrenia (categories 1 and 2) 42% of MZ twins were both diagnosed with schizophrenia and 9% of DZ twins. Where the second twin was diagnosed with a different schizophrenic related disorder there was 12% concordance rate for MZ twins and 9% for DZ twins. Gottesmann and Shields also found a 75% concordance rate for severe (meaning over two years’ hospitalisation) schizophrenia in MZ twins but only a 22% concordance rate in DZ twins. In a 1991 meta-analysis combining 40 studies spanning 60 years, Gottesmann found a 48% concordance rate for schizophrenia in MZ twins and a 17% concordance rate in DZ twins.Conclusions – Genes appear to play an important role in schizophrenia because the concordance rate is higher in MZ twins than DZ twins. However, environmental factors must also be important as the concordance rate for MZ twins was not 100%.

Evaluate Gottesmann and Shields (1966) investigating whether there is a genetic basis for schizophreniaThe results are supported by other studies which have produced similar findings, such as Inouye (1961) who found a 74% concordance rate of twins with a progressive chronic schizophrenia disorder, and a 39% concordance rate for mild schizophrenia.The sampling was carefully controlled using multiple measures to make sure that twins were correctly allocated either MZ or DZ twin status, and a lot of data was gathered using multiple research methods increasing internal reliability.The MZ and DZ twins both shared the same environment meaning that these factors could be discounted. As the was investigating a genetic basis for schizophrenia, this increases validity.However MZ twins may be treated more alike than DZ twins because they are identical and the same gender. This means environmental factors may not be able to be ruled out. It would have been useful to know more about what ‘related psychosis’ meant and the severity of the disorder suffered by the twin, as they failed to make this clear. The concordance rate shows some genetic link, but it fails to give any other explanations for schizophrenia despite Gottesmann and Shields arguing some types of schizophrenia being caused by life events (environmental stimuli).

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