Schizophrenic and Psychotic

Disorders
Schizophrenia
 Schizophrenia: a range of psychotic disorders that affect all aspects of a person’s

thinking, emotions, and actions, along with a major break from reality. Personal,

social, and occupational functioning deteriorates because of disturbed thought

processes, unusual emotions, and motor abnormalities.

Types and Characteristics

Types

 Simple: gradual withdrawal from reality

 Paranoid: having delusional thoughts and hallucinations

 Catatonic: no response to the environment; would remain rigid/unmoving or would

engage in constant repetitive movements.

 Disorganised: thoughts and speech are jumbled and impossible to understand

(word salad).

 Undifferentiated: has symptoms but doesn’t fit into the above categories

The DSM-5 outlines the following psychotic symptoms:

 Positive symptoms: additional symptoms to normal behaviour, e.g:

o Delusions: non-realistic beliefs, e.g. believing someone will harm/kill you.

o Hallucinations: false sensory experiences e.g. hearing voices.

o Disorganised thoughts and catatonic behaviour

 Negative Symptoms: symptoms that lack normal behaviour, e.g. loss of speech,

withdrawal from society, or loss of typical facial expressions (flat affect).

Case Studies: Conrad (Male Aged 23)

 First psychotic episode at 22 and later diagnosed with schizoaffective disorder

(symptoms of schizophrenia + mood disorder).

 After 8 months of being admitted to a psychiatric hospital, treatment was eventually

found through trial and error, although maintaining a healthy weight was challenging.

Delusional Disorder

 When a person experiences persistent delusion (for a month or longer) but otherwise

has normal behaviour.

 It excludes positive or negative psychotic symptoms.

 Types of delusional disorder:

o Erotomanic: belief someone is in love with you.

o Grandiose: the belief that they have great unrecognised skill or status.

o Jealous: belief that partner is unfaithful (paranoia).

o Persecutory: the belief that people conspire against or want to harm you (paranoia).

 Bizarre Delusion: logically impossible.

 Non-Bizarre: possible but unlikely.

Symptom Assessment Using Virtual Reality (Freeman, 2008)

 Freeman explores the potential for VR to eliminate challenges such as

misinterpretations of social interaction (leading to paranoia, withdrawal, etc) when

checking symptoms and developing treatment for schizophrenia.

 Typically, symptom assessment involves the interviewer and patient sitting in a

clinical room, discussing behaviour over the past week/month – however, this heavily

relies on the patient answering truthfully.

 Using VR:

o The assessment can be novel and standardised

o Patients are presented with an artificial and neutral social situation with unresponsive

avatars so that any paranoid thought is unfounded (having no basis) and genuine.

This allows us to assess the severity of paranoid delusions.

o The situation can easily be manipulated, and the patient’s behaviour monitored

o It can be used to develop a treatment as:

 Factors that worsen/improve the patient’s condition can be identified

 Patients can be exposed to persecutory fears in the environment via VR so that they

can learn to cope with it (or with the symptoms) in reality

 Procedure in Freeman’s Study: the user takes a walk or a ride in a specifically

designed library or underground train scene amongst neutral avatars whilst wearing

VR headgear.

 Sample: trialled in library scene of Freeman’s study is 12 males and 12 females

from university college London with an average age of 26 years

 Before the test: multiple validated measurement tools (such as the 16-item Green

Et al. Paranoid Thoughts Scale (GPTS) Part B) were used to assess the user’s

paranoid thinking, emotional distress and other social and cognitive traits.
 After the test: persecutory thinking, visual analogue rating scale (used to measure

frequency of symptoms) and degree of immersion in a virtual environment were

taken.

 Result:

o High scores on the paranoia assessment questionnaire had high levels of

persecutory ideation.

o Individuals who experience auditory hallucinations in the real world experience them

in VR, too.

Evaluation:

 Large sample but no clinical population.

 VR used a standardised approach to assessing symptoms, hence increasing

reliability of measurement.

 Low ecological validity as the environment is simulated.

 The use of self-reports may lead to response bias.

Issues and debates:

 Relevance to everyday life: identify symptoms, causal factors and treatment

strategies.

o It is not used extensively in clinical populations, so it is yet to be determined whether

it can replace clinical interviews and questionnaires in diagnosis.

 Cultural Bias: relies on culturally based expectations of what determines normal

social behaviour. Different cultures have different interpretations of normal

behaviour, so these factors must be considered when diagnosing symptoms and

behaviour to avoid biased results.

Explanations
Genetic (Gottesman & Shields, 1972)
 They believe that there is a genetic relationship with a person with schizophrenia,

which can be inherited.

 They believed that a series of genetic abnormalities caused symptoms like

psychosis, and these have genetic origins called endophenotypes (genetic markers

with known locations used to identify individuals) that could be inherited.

 To test this, they carried out a longitudinal twin study in monozygotic (identical twins

sharing all their DNA) and dizygotic (fraternal sharing 50% of DNA) twins to test

genetic concordance of schizophrenia.

 Sample: 57 pairs of twins (24 MZ, 33 DZ) were drawn from 467 twins registered at

Maudsley Hospital (London).

o Twins were identified as MZ/DZ through blood group and fingerprint analysis.

o Parents and twins were interviewed, some of whom were diagnosed with

schizophrenia.

 Participants took cognitive tests like object sorting (?)

 External judges independently evaluated case summaries of each participant to find

co-twin schizophrenic concordance.

 Results:

o MZ twins share 50% schizophrenic concordance; DZ have only 9% concordance.

 Concordance: the presence of observable trait/disorder in both co-twins.

o In MZ twins, twin 1 was more likely to be schizophrenic if the illness of twin 2 was

severe.

o In mild illness, co-twin concordance is far lower.

Evaluation:

 Large sample; generalisable to twins but not to non-twins.

 Assessment made by independent judges, reducing researcher bias.

 Qualitative data collected, such as interviews (in-depth), although it is more

subjective.

Biochemical (Dopamine Hypothesis) (Lindstrom et al., 1999)

 The hypothesis states that the brains of schizophrenic patients produce/transmit

excess dopamine, have increased amounts of dopamine receptors, or have

receptors with increased sensitivity to dopamine, which disrupt the normal

transmission of nerve impulses and are linked to positive symptoms.

 It is thought that excess dopamine in specific brain areas, e.g. Broca’s region

(responsible for the formation of language), can lead to certain symptoms, e.g.

impaired logical speech.

 Drugs that increase dopamine levels (amphetamine and cocaine) are correlated with

hallucinations and delusions.

 Parkinson’s disease is treated with a synthetic form of dopamine called ‘L-dopa’. If

the dosage is too high, it creates symptoms identical to schizophrenia, e.g.

hallucinations.

 Post-mortem studies, brain scans and autopsies have shown that schizophrenic

patients have a larger number of dopamine receptors than usual.

o Wise et al. (1974) found low enzyme levels that break down dopamine in brain fluid,

thus increasing its quantity.

 Positron Emission Tomography (PET): gamma cameras to detect radioactive

tracers, e.g. glucose in blood. Tracer accumulates in areas of high activity, showing

visibility during analysis.

o High dopamine receptors in the striatum, limbic system and cortex indicate high

dopamine activity contributing to positive symptoms; low levels in the prefrontal

cortex indicate negative symptoms (flat affect).

 Cognitive (Frith, 1992)

 Frith emphasises the importance of faulty mental processing rather than relying

solely on physiological explanations.

 He describes schizophrenia as an abnormality of self-monitoring.

 He wanted to test the idea that schizophrenic patients confused inner talk with

hallucinations.

 Thus, he asked patients to decide whether items read aloud were done by an

experimenter or computer.

 Patients with incoherent speech performed worst, which may be linked to memory

and attention difficulties, crucial to self-monitoring.

 Delusional thinking may be an outcome of misinterpretation of perception

o E.g. traffic lights turning red may be interpreted as the Martians are about to land.

 Applying logical reasoning to hallucinations results in delusions.

o If you have an auditory hallucination where you constantly hear ‘die’ – adding logical

reasoning to it: ‘I stole his girlfriend, so he’s out to kill me’ leads to paranoia and

persecutory ideation.

 Failure in monitoring results in auditory hallucinations, alien control and

thought insertion.
o Alien Control: misattributes self-generated actions to an external source.

o Thought Insertion: feeling as if one's self-generated thoughts are not one's own but

rather have come from an external source and have been inserted into one's mind.

o Auditory Hallucination: inner speech is not recognised as self-generated but

instead attributed to an external source.

 The inability to monitor the intentions of others, perhaps due to impaired theory of

mind, can lead to paranoia and incoherence.

 Frith says that negative symptoms are a result of the individual's impairment to

produce spontaneous actions and that external stimuli are required for a response to

be produced

 Flat affect, social withdrawal and lack of speech result from difficulty in monitoring

mental state.

Issues and Debates:

 Nature vs Nurture:

o A longitudinal twin study found a causal link between genes (nature) and mental

disorders.

o However, MZ twins are treated more similarly than DZ twins as they are always the

same gender and look more alike, unlike DZ twins, who are treated like ordinary non-

twin siblings. Thus, differences between MZ and DZ could also be due to nurture.

 Biological and biochemical explanations are considered reductionists, as they

attribute the cause of schizophrenia to a specific biological origin.

o For biological explanation, it is genes or gene combinations.

o For biochemical explanation, it disrupts the normal uptake of a specific

neurotransmitter – dopamine.

o However, they consider environmental factors important to the onset of the disorder.
 Cognitive by Frith is more holistic as it considers both mental processing and

biological causes but could still be said to ignore environmental and social causes.

 Unlike psychologists from social or psychodynamic traditions, these all point towards

individual explanations. They would look towards situational factors such as

traumatic events or difficulty forming early relationships.

Treatment and Management

Biochemical

 Antipsychotic drugs: 1st generation antipsychotics (1950s), such as

chlorpromazine/Thorazin, block dopamine and serotonin receptors in the cortical and

limbic areas of the brain. They also have an impact on neurotransmitters such as

serotonin and norepinephrine, depending on the antipsychotic.

o Their effectiveness has been researched via randomised control trials (RCT);

each participant is randomly allocated to the control or experimental group, and

results are compared.

o These trials are double-blind placebo-controlled, meaning neither the groups nor

the researchers know who gets the treatment and who gets the placebo.

o 50% of patients taking antipsychotic drugs show significant improvement after 4-6

weeks, 30-40% show partial improvement, and a minority show no improvement

(treatment-resistant schizophrenics).

o High Relapse Rate: patients are directed to take (low dosage) medications even in

periods of remission; as the symptoms start reducing; they stop taking medication to

prevent side effects, leading to relapse.

o Unpleasant Side Effects: weight gain, drowsiness, extrapyramidal symptoms (EPS)

and tardive dyskinesia (TB). The latter two affect motor control, resulting in
 involuntary spasms and abnormal face and body movement. These side effects may

result in non-adherence to medication.

 Atypical antipsychotic drugs: 2nd generation antipsychotics (1990s), which are as

effective as 1st generation antipsychotics but are less likely to produce EPS and TB.

Instead, they increase the risk of weight gain and obesity, which can lead to heart

disease and diabetes.

Electro-Convulsive Therapy (ECT)

 Using electricity via electrodes to pass on a small current to induce seizures to treat

psychiatric problems.

o This would, however, be without the use of anti-anxiety drugs or anaesthesia; thus,

patients would be traumatised and suffer from broken bones.

o Modern ECT: passes electricity to induce seizures, which is the treatment rather

than the electricity itself, as it aims to ‘restart’ the nervous system and affects the

release of neurotransmitters in the brain.

 Treatment ranges from 6-12 sessions, typically given twice a week, or less

commonly at longer intervals to prevent relapse.

 It is applied unilaterally to the non-dominant hemisphere to reduce memory loss.

 Risks: Affecting the central nervous system (CNS) and cardiovascular system can

lead to memory loss (usually temporary), neurological damage, and even death.

o Use of ECT:

 It can be effective during acute episodes of psychosis where fast, short-term

improvement of severe symptoms is needed.

 It is most effective for individuals with catatonic symptoms.

Token Economy (Paul and Lentz, 1977)

 Behaviourists consider schizophrenic symptoms as a learned response which can be

unlearnt via operant conditioning (learning through consequences).

o 84 individuals with chronic (long-term/ongoing occurrence) admission to psychiatric

institutions were split into different treatment groups.

o Independent group design was used to compare the outcomes of 3 different forms of

treatment over 4.5 years:

 Milieu Therapy: a therapeutic community where patients live collectively and are

encouraged to look after one another, promoting social well-being. 71% of this group

could live independently.

 Traditional Existing Hospital Management: 45% of the group could live

independently.

 Token Economy System: Patients were given a token for appropriate behaviours,

e.g. self-care, attending therapy and engaging socially. The tokens had no value but

could be exchanged for luxury items, e.g. clothing, sweets, TV use. This system

reinforced desirable behaviours. 97% of this group could live independently.

o The behaviour of the groups was monitored through time-sampled observations,

standardised questionnaire scales and individual interviews.

o The system was most effective at reducing catatonic behaviour and social

withdrawal but less successful in reducing hallucinations and delusional thinking.

Cognitive-Behavioural Therapy (Sensky, 2000)

 Talking therapy is designed to improve the person’s ability to function independently,

manage/cope with schizophrenia, and reduce stress by identifying thoughts which

underline their behaviour and the emergence of their disorder. It mainly targets

treatment-resistant schizophrenics and incorporates both cognitive and behaviourist

approaches.
o Randomised control trial (RCT): patients were randomly allocated to the CBT

group or the ‘befriending’ control group, making it an independent group design.

 Befriending Sessions: one-to-one discussions about hobbies, sports or

current affairs.

o Sample: 90 treatment-resistant schizophrenics from 5 clinical services received a

mean average of 19 sessions of CBT/befriending.

o Procedure: CBT treatment included experienced nurses engaging with the patient,

discussing the emergence of the disorder before tackling symptoms, e.g. patients

experiencing auditory hallucination engaged in joint critical analysis with nurses to

challenge beliefs about the nature and origin of voices.

o Patients kept voice diaries to record what they were hearing to generate coping

strategies.

o Participants were assessed via blind raters before treatment at treatment completion

and a 9-month follow-up.

 Blind raters: those rating the treatment group were blind to the treatment.

o Comprehensive Psychiatric Rating Scale (CPRS) and Scale for Assessment of

Negative Symptoms (SANS) were used to assess the positive and negative

symptoms.

o Results: both groups showed a reduction in positive and negative symptoms, but at

the follow-up stage, CBT continued to show improvements in positive symptoms,

unlike the befriending group.

Evaluation

 Token Economy (Paul and Lentz):

o Involved in intensive staff training to ensure rewards were administered reliably.

o Staff were monitored and issued with a manual to ensure procedures

were standardised.

o Stern and consistent enforcement in other hospitals and outside the world may not

be possible, lowering ecological validity.

o Good behaviour ceases when rewards disappear, making therapy hard to apply to

reality.

o Ethical Issues: denying privileges to patients who behave poorly will demotivate and

distress them.

 CBT (Sensky et al.):

o The use of RCT reduces bias and increases validity.

o Assessors were blind to the treatment they were assessing, reducing any bias.

o Representative samples obtained all over the UK

o Both nurses were highly trained, increasing standardisation.

Issues and Debates:

 There is an application to real life.

o Biochemical treatment (antipsychotics) is the primary treatment for the disorder and

is effective in reducing positive symptoms.

o Reduces hospitalisation and improves quality of life.

o ECT is less effective and is mostly used in urgent, acute cases with primarily

catatonic symptoms.

o The token system requires specific conditions, training, and enforcement by clinical

staff.

o The effectiveness of CBT is significant and may be used when patients don’t

respond to antipsychotics.
 Bipolar and Related Disorders
Characteristics
 Abnormal affect: abnormal disorders such as unipolar depression and bipolar disorder that

are classified as mood disorders in DSM-5.

 Characteristics: emotions are amplified beyond the normal ups and downs, in either

extreme (positive or negative), for a long period of time (at least 2 weeks) and not allowed to

function normally. It should not be related to another disorder caused by grief or substance

abuse.

o At times, they may experience strong feelings of despair and emptiness, other times, they

may feel anger or euphoria.

 Depression (unipolar):

o A long period of sadness, despair and a pessimistic spirit

o Loss of interest in enjoyable activities

o Struggling to concentrate or remember easily

o Withdrawing from activities or friends

o Fatigue or lethargy

o Finding it difficult to make decisions

o Change in appetite (including weight loss or gain) or sleeping patterns (insomnia or

excessive sleeping)

o Considering or attempting suicide

o Psychomotor agitation like pacing and hand-wringing.

 Mania (bipolar): having swings between depressive and manic symptoms. The feelings of

happiness that are accompanied by a manic state may not lead them to believe anything is

wrong.

o A long period of feeling euphoric or ‘high.’

o Rage; irritability
o Becoming easily distracted, having racing thoughts

o Sudden interest in new activities or projects

o Overconfidence in one’s abilities

o Social

o Delusional ideas

o Speaking quickly

o Sleeping less or appearing not to need sleep

o Engaging in risky behaviours (gambling, multiple sexual relationships)

 Beck Depression Inventory: a form of psychometric testing to measure depression.

o Consists of a 21-item questionnaire to assess attitudes and symptoms of depression.

o Each item consists of at least four statements, of which one can be chosen that best fits how

they’ve been feeling during a recent period.

o Example item: satisfaction

 I get as much satisfaction out of things as I used to (0)

 I don’t enjoy things the way I used to (1)

 I don’t get real satisfaction out of anything anymore (2)

 I am dissatisfied and bored with everything (3)

o After scoring each item from 0-3, the results are totalled and evaluated as:

 Mild depression: score of 10

 Moderate depression: 19-29

 Severe depression: >30

Evaluation:

 It has high validity and reliability as it is an accurate and consistent measure of depression.

 Quantitative measurement as it provides a numerical score, increasing objectivity.

 Allows clinicians to measure deterioration or improvement of depression with treatment.

 It cannot capture the detail and richness that a less structured approach could.

 Validity may be at risk as there could be response bias.

 Depressive patients may exaggerate their responses, which will not be an accurate

representation of how they are feeling.

Issues and debates:

 BDI is an important diagnostic tool and has applications.

o It can be used to diagnose and treat depression.

o It can help identify patients with a high risk of suicidal thoughts and death.

o Adapted for use with children below age 13 who suffer from depression.

Explanations of Depression
Biological: Genetic and Neurochemical (Oruc et al. 1997)

 Genetic: some illnesses have a genetic basis and can be transmitted from generation to

generation. First-degree relatives (parents and siblings) share 50% of their DNA.

o MZ and DZ twins can be used to investigate whether there is a genetic link in depression.

 Neurochemical: An imbalance of chemicals affects the brain's functioning and,

consequently, the mood. Depressed individuals have low activity of serotonin and

norepinephrine neurotransmitters.

 Sample: 42 participants (25F, 17M) diagnosed with bipolar disorder, aged between 31-70,

were drawn from two psychiatric hospitals in Croatia.

o A healthy control group of 40 participants with no personal/family history of mental disorders

were also included (they were also matched for sex and age).

 Sixteen of the bipolar participants had a first-degree relative with major disorders.

o Participants and their families gathered this information and medical records.

 Procedure: DNA testing was carried out to test for polymorphisms (gene variation) in

serotonin receptor 2c (5-HTR2C) and serotonin transporter (SERT/5-HTT) genes.

 Results:

o There were no significant differences between the two groups.

o However, serotonin (5-HT) is sexually dimorphic, and females had trends of polymorphism in

the serotonin genes, which could be responsible for the increased risk of bipolar in females.

 Sexually dimorphic: any differences in males and females of a species, excluding organs

and genitalia.

Cognitive (Beck, 1979)

 Beck was interested in investigating the irrational thought processes in depression.

 The reason for an individual’s low mood is due to incorrect information processing.

 The negative views of a depressed person form a reality for them.

 This form of irrational thinking is called cognitive distortion, which is an automatic process

that develops as a result of earlier life experiences through schemas (knowledge/memory)

o Negative events and schemas activate the underlying negative assumptions and create

pessimistic thoughts and beliefs about the future.

 Cognitive triad:

 This leads to impairment in perception, memory, and problem-solving- the person is

constantly overwhelmed with negative thoughts.

Learned Helplessness and Attributional Style (Seligman et al. 1988)

 A behaviour that occurs as a result of a person having to endure an unpleasant situation

which they perceive as inescapable.

 Seligman et al.’s view is that depression is a direct result of a real/perceived lack of control

over the outcome of one’s situation – one feels helpless.

 The individual learns that they cannot control the situation and cannot prevent suffering, and

eventually ceases to resist it.

 For example, in Seligman’s 1974 research on dogs, they received electric shocks

preventing them from escaping (experiencing a lack of control). They accepted the situation

and eventually stopped trying to escape. In future trials, they had an opportunity to escape,

but due to experience, they did not try.

 Attribution: the cognitive process wherein individuals explain the causes of events and

behaviour. It may be faulty/biased based on previous life experiences.

 A person who has had a difficult upbringing/experienced parental loss, e.g., will have learned

helplessness and ∴ be inclined towards a negative attributional style.

 A negative event can be attributed to:

o Internal (personal)/ external (environment)

o Stable (constant)/unstable (occasional)

o Global (affecting many aspects)/ specific (affecting one aspect)

 Investigation: how well attributional style could predict depressive symptoms.

 Sample:

o 39 patients with unipolar depression

o 12 with bipolar disorder during a depressive episode from the same clinic.

o Included a mix of genders with a mean age of 36.

o They were compared with a control group of 10 participants.

 Procedure:

o All participants completed BDI to assess the severity of symptoms

o Then, completed an Attributional Style Questionnaire (ASQ) consisting of 12 hypothetical

good and bad situations.

o They had to make causal attributions for each event and rate the cause on a 7-point scale

for internality, stability, and globality.

 Note: question 2 is about internal/external, Q3 is about stable/unstable, and Q4 is

about global/specific.

 Results:

o Bipolar and unipolar patients had more pessimistic, negative attributional styles than the

control group.

o The more severe the score on BDI, the worse the pessimism on ASQ.

o For those with unipolar depression undergoing cognitive therapy, an improvement in

attributional style correlated with an improvement in BDI score.

o Thus, the way we make attributions is an important underlying mechanism of depression.

Evaluation

 BDI and ASQ:

o Standardised measures used e.g. using the BDI and ASQ, which are both valid.

o A positive correlation between BDI and ASQ does not indicate a causal relationship.

 Oruc et al. (biological explanation):

o Limited sample size so difficult to generalise; genetic studies require a large sample to be

valid and accurate.

 Establishing the importance of serotonin-linked genes in increasing risk of depressive illness

in females requires a large sample.

o DNA samples were collected and analysed in a lab with automatic equipment,

increasing validity and removing researcher bias.

 Nature vs nurture:

o A biological explanation for depression reflects nature, e.g. Oruc et al.

o Other explanations for depression e.g. adverse life events, are more nurture based e.g.

learned helplessness.

 Individual vs situational:

o Individual: cognitive explanation assumes that depression arises due to the dysfunctional

thinking of the individual rather than as a result of situational variables, e.g., a difficult

childhood.

o Situational: learned helplessness arises due to the individual’s interaction with their

environment.

 Reductionist: genetic explanation is reductionist as it only considers a narrow set of genes

(e.g. those relating to serotonin). It doesn’t feel all instances of depression or why not all

first-degree relatives develop the same disorder.

 Deterministic: as we can’t change our DNA, and individuals who have a family history of

depression are automatically at more risk, it makes the genetic cause of depression

deterministic. However, as there is only a small genetic variation in females, there could be

other non-genetic causes (non-deterministic).

 BDI: application to real life as useful for clinicians, but subject to bias and social desirability.
 Treatment and Management
Biochemical: MAOIs and SSRIs

 Numerous anti-depressant drugs are available which affect neurotransmitter levels in the

brain.

 Monoamine Oxidase Inhibitors (MAOIs)

o Inhibits the work of an enzyme known as monoamine oxidase.

o Monoamine oxidase breaks down and removes neurotransmitters like norepinephrine,

serotonin and dopamine.

o Thus, MAOI prevents monoamine oxidase from breaking these neurotransmitters down,

maintaining them at high levels in the synapse for the postsynaptic neurone.

o Side effects:

 Headaches/drowsiness

 Insomnia

 Nausea

 Diarrhoea

 Constipation

 Addiction

 Suicidal thoughts

o It can cause issues with withdrawal and may interact with other medications – thus, MAOI is

reserved for atypical depression (difficult to treat) when other treatments have been

unsuccessful.

 Selective Serotonin Reuptake Inhibitors (SSRIs).

o Acts on the neurotransmitter serotonin to stop it from being reabsorbed into the pre-

synaptic neurone, keeping it at high levels in the synapse for the post-synaptic

neurone.
o However, fewer and less severe side effects than MAOIs depend on the patient’s

response.

 Both MAOIs and SSRIs are more effective than placebos, although the impact is more

noticeable for patients with moderate to severe symptoms and less with mild depression

(Fournier et al., 2010).

Electro-Convulsive Therapy

 Last resort: if biochemical and CBT are non-responsive.

 A study by Dierckx et al. (2012) included 1000 patients with unipolar or bipolar depression. It

showed that ECT has similar effectiveness as antidepressants, resulting in around 50%

remission (reduction in severity) rate.

 The benefits of ECT are short-term as it is administered in short sessions, in contrast to the

maintenance effect created by ongoing drug therapy.

 Thus, relapse rates are just as high as those that stop antidepressant use; patient will have a

reoccurrence of symptoms, requiring further treatment (Jelovac et al., 2013).

 Cognitive Restructuring (Beck, 1979)

 Talking therapy: one-to-one interactions between depressed patients and therapist.

 Techniques like questioning and identifying illogical

 thinking are involved in determining and changing patients’ thinking.

 Begins with explaining the theory of depression using a cognitive triad so the patient knows

that their thinking contributes to their depression.

 Further, patients are trained to observe and record their thoughts to help them recognise

irrational/inaccurate beliefs.

 Once patients recognise their cognition, they can understand the link between their thoughts

and their effect on behaviour and vice versa.

 Patients are trained to record dysfunctional thoughts to identify their occurrence in reality.

They are then discussed in therapy to explore whether they really are an accurate reflection

of reality.

 Purpose of this reality testing:

o For patients to realise negative distortions in thinking for themselves.

o Reattribution: a technique that tests automatic thoughts and assumptions by considering

alternative causes of events.

o Therapists can help reattribute patients' thoughts by identifying whether the causes of

problems are internal or external to make them realise they were not responsible.

o The therapy is completed when the patient can employ cognitive restructuring for

themselves and see a reduction in depressive symptoms.

 A study by Wiles et al. (2013): showed that depressive symptoms reduce using CR in

those that don’t respond to antidepressants.

o A group of 469 depressed patients were randomly allocated to either the ongoing

medications group or CBT.

o Those who received therapy were 3 times more likely to show a reduction in depressive

symptoms.
 Rational Emotive Behavioural Therapy (REBT) (Ellis, 1962)

 Based on the principles of Stoicism.

o Stoicism is a philosophy based on a theory by Albert Ellis (1962) that an individual is not

directly affected by external things but rather by their own perception of how they affect

them.

o According to Ellis, this is how depression should be identified and treated.

 Process of ABC model of psychological change:

Components Example Description

Adversity in one’s life (not

A -Unsuccessful at a
directly the cause of emotional
Activating event job interview
upset or negative thinking)

-I’ll never get Beliefs about the activating

B anywhere event which lead to emotional
Beliefs about event -I’m just not good and behavioural problems
enough

-Feeling sad,
C tearful or angry
Consequences: -Withdrawal from
emotional and friends and family
behavioural responses -Refusal to apply
for other work
 Impulse Control Disorders and
Non-Substance Addictive Disorder
Characteristics
Definitions (Griffiths, 2005)

 ICDs are characterised by failure to resist temptation/urge/impulse - individuals find it difficult

to regulate thought and behaviour connected to a certain behaviour.

 According to Griffiths, there are 6 components to any addiction disorder:

o Salience: the addiction becomes the single most important activity in their life. It dominates

their thoughts, feelings and behaviour.

o Euphoria: the addictive behaviour creates mood modification – feelings of being ‘high’ or

escape and peace.

o Tolerance: gradually, the person has to do more addictive behaviour to get the same effect.

o Withdrawal: unpleasant feelings or physical effects when the behaviour is reduced or

stopped.

o Conflict: conflict can occur between the person and surroundings. They may compromise

their personal relationships, work, education or other social activities.

 They may face internal conflict when they are unable to stop the addiction despite wanting

to.

o Relapse: the chances of returning to addictive behaviour despite reduction efforts.

Types

 Kleptomania: an impulse control disorder that involves an urge to steal – the items are not

needed for personal use or monetary gain.

o The more difficult the challenge of gaining the objects, the more thrilling and addictive it

becomes.

o Intrusive thoughts characterise it and urge it to steal.

o More women seem to have the disorder, perhaps because they are more likely to seek

treatment.

o Occurs between 0.3% and 0.6% of the population, and they are diagnosed with other

disorders such as anxiety and substance misuse.

o Can lead to arrest, prosecution, embarrassment and loss of employment.

 Pyromania (Burton et al. 2012): an impulse control disorder characterised by an impulse to

start fires and deliberately doing so on more than one occasion.

o These individuals are fascinated with fires, their accelerants, etc - they feel a sense of

satisfaction and arousal once the fire has started.

o Some pyromaniacs are indifferent to the destructive consequences. However, some report

feelings of severe distress.

 Note: pyromaniacs and kleptomaniacs may feel tension before the act, then gratification

afterwards.

 Gambling disorder: a non-substance addictive disorder that is characterised by constant

and troubled gambling behaviour, difficulty withdrawing even if big money is lost, lying to

conceal involvement with gambling and loss of significant relationships.

o Gambling is shown to activate the brain’s reward system in a way that is similar to substance

abuse.

Measures (Kleptomania Symptom Assessment Scale-KSAS)

 The 11-item self-rated scale measures impulses, thoughts, feelings and behaviours related

to stealing in the last 7 days.

 Each item is rated on a 0-4 or 0-5 point-based scale (0=no symptoms, 4 or 5= severe,

frequent or enduring symptoms)

 Evaluation of K-SAS

 High score on test-retest reliability.

 Good concurrent validity when compared to other validation tools, such as the Global

Assessment of Functioning Scale.

 It could have response bias as it is a self-report.

 Provides quantitative data, which makes it easy to compare the outcomes of interventions.

Issues and debates

 Relevant to everyday life as it can be used in monitoring symptoms, to gain insight into

patients’ thoughts and feelings to develop treatments and help person with disorder to

understand their behaviour.

Explanation
Biochemical: Dopamine

 Rewarding stimuli such as stealing or gambling stimulates reward centres and releases

dopamine.

 When behaviours become compulsive, you develop tolerance, and dopamine levels in the

striatum reduce.

o Striatum is responsible for the reward and behavioural control.

o A deficiency of dopamine in the striatum leads to the continuation of compulsions and

addictions, increasing stealing behaviours.

 This is known as ‘Reward deficiency syndrome’ (Comings & Blum, 2000) and can be

used to explain other forms of addiction.

 Kleptomania is a possible side effect of using synthetic dopamine for treatment of disorders

such as Parkinson’s.

 Evidence shows that symptoms of gambling disorder and compulsive shopping emerge

alongside the use of dopamine drugs, proving the relationship between dopamine and

impulse control disorders.

Behavioural: Positive Reinforcement

 When you receive a reward for doing a certain activity, you tend to repeat the activity to

achieve more rewards – this is positive reinforcement; it occurs when learned behaviour

results from previous trials.

o E.g. the enjoyment gained by winning in poker

 Gamblers don’t stop playing once they start losing because of Schedules of

reinforcement.

o Gamblers don’t win every time they play, and so don’t feel 100% satisfied. Thus, they

continue to play repeatedly, believing that playing just one more time will make up for the

loss/lead to victory. This is partial reinforcement.

Cognitive: Feeling-State Theory (Miller, 2010)

 Miller explains how positive feelings can be linked to behaviours like

gambling. The ‘feeling state theory’ proposes how underlying thoughts about

such behaviours can then lead to obsession.

 ICD can be created because the links form a ‘state-dependent memory’ known as

the feeling state.

Feeling states are created by an intense desire to do an activity, the positive

experience associated with it (psycho-physiological arousal), and the memory of the

behaviour.

o A pyromaniac who has feelings stating ‘I am powerful’, combined with positive emotions,

physiological arousal and memory of setting the fire, leads to compulsions of fire-setting

behaviour.

 Underlying negative thoughts or experiences are the most likely cause of the feeling

states that lead to impulse control disorders.

o For example, the pyromaniac with the feeling-state ‘I am powerful’ when setting a fire may

have an underlying set of negative beliefs (e.g., I’m weak), making the act more intense and

desirable.

 Further negative beliefs occur when behaviour becomes out of control, such as

gambling, stealing, etc, and have negative consequences for the individual and

those around them.

 Note: normal behaviours in moderation only become problematic because of fixated,

intense feeling-states.

Belief type Example of belief

Negative belief about oneself or the world ‘I’m a loser’

Positive belief created during the event (e.g. gambling) ‘I’m a winner’

Negative beliefs created from out-of-control behaviour ‘I mess up everything’

Issues and debates

 Application to everyday life to treat addictive behaviours; understating the role of

dopamine has led to biochemical treatments.

 Individual versus situational debate

o Biochemical explanation relates to individual impairment of brain function.

o Cognitive explanation is more balanced: naturally, experiences will be

stimulating/rewarding/upsetting, but as individuals, we develop our own feeling-states

in relation to the experiences, leading to overall change in patterns of behaviour.

 Nature versus nurture debate:

o The behaviourist approach to positive reinforcement (Skinner, 1938) is based on nurture

factors. The satisfaction gained from compulsive behaviours (in the environment) reinforces

subsequent behaviour.

o The biological approach (effect of dopamine uptake) is based on nature factors.

 Treatment and Management
Biochemical (Grant et al., 2008)

 Research suggests that drugs like opiates (painkillers) can be successful in treating

gambling disorders.

 Sample:

o 284 participants (roughly equal split of both genders) participated in a double-blind

experiment.

o They were divided to take either the 16-week course of opiate nalmefene or the 18-week

course of naltrexone, a placebo.

 Measures: Yale-Brown Obsessive Compulsive (Y-BOCS) scale to measure gambling

severity.

 Aim: whether taking opiates would reduce gambling behaviour, which was operationalised

as a ≥35% reduction in their Y-BOCS scores for at least one month after the study.

o Note: participants’ depression, anxiety and psychosocial functioning were considered in their

response to treatment.

 Results:

o The opiate group had a significant reduction in gambling symptoms.

o Also, significant individual differences contributed to a greater reduction in Y-BOCS scores.

 Participants with a family history of alcoholism and those who received higher doses of

opiates showed a greater reduction in symptoms. This suggests it’s more effective in some

addicts than others.

 Cognitive-Behavioural

Changing distortions in thoughts and feelings to enact behavioural changes.

Covert Sensitisation (Glover, 2011)

 Uses classical conditioning by combining an undesirable behavior with an unpleasant

stimulus to change the behaviour

 Background of Kleptomaniac study:

o A 56-year-old woman had a 14-year history of daily shoplifting without any purposeful gain,

e.g. stealing baby shoes despite not having anyone to give them to.

o Several compulsive thoughts occurred to her, which were disgusting but hard to resist.

 The Procedure of Treatment: imagery of nausea and vomiting while stealing.

o The woman underwent 4 sessions at 2-week intervals.

o For the first 2 weeks, muscle relaxation was used to enhance her

 Muscle Relaxation: used to relieve tension from within the body and mind. It can be

induced through medication, visualisation exercises or repetition of calming phrases. In turn,

progressive muscle relaxation is achieved by systematically tensing and relaxing the body

muscles.

o Visualisation ability.

o Increasing nausea visualisation was used over each session; she imagined vomiting as she

stole, which attracted attention and disgust from those around her.

o She practised these visualisation exercises as homework after each session.

o During the last session, she imagined the sickness going away as she walked away without

shoplifting.

o At the 19-month check-up, she had decreased desire and avoidance of stealing, with 1

relapse, along with improvements in self-esteem and social life.

Imaginal Desensitisation (Blaszczynski & Nower, 2003)

 Relies on the use of images to help individuals with impulse control disorders.

 First, a progressive muscle relaxation technique is taught.

 Then, clients visualise themselves in a triggering situation (e.g., a gambling venue) and are

asked to think about acting on their impulse and all the psycho-physiological arousals

associated with it.

 Finally, they have to mentally leave the situation while maintaining a state of relaxation and

not having acted upon the impulse.

 The sessions are often audio-recorded to assist in practising outside therapy.

 Found to be effective as it reduces the strength of a compulsive drive. This is done by

reducing levels of psycho-physiological arousal associated with these disorders.

 In gambling, it was found to decrease arousal and anxiety levels associated with gambling

impulses even at a 5-year follow-up.

Impulse Control Therapy (Miller, 2010)

 Doesn’t aim to eliminate behaviour but to establish normal behaviour, e.g.: compulsive

shoppers can still shop, but without triggering problematic behaviours, i.e. overspending,

hoarding, etc.

 It involves changing distorted thoughts about their behaviour, linked to feeling-state

explanation.

 First, the aspect of behaviour that produces the most intense feelings, the intense positive

feelings, and the physical sensations are all identified.

o Measured on a standardised scale known as the ‘Positive Feelings Scale’ for comparisons.

 The client is then asked to combine images of the compulsive act, positive feelings and

physical sensations (recreating the feeling state in their mind) while performing eye

movement desensitisation and reprocessing (EDMR) exercises.

o EDMR- individual recalls behaviour or memories while the therapist directs eye movement

patterns using hands or other stimuli.

 In between sessions, clients re-evaluate their impulsive feelings using the feeling scale.

 Usually, 3 to 5 sessions are conducted, alternating between visualisation and eye

movements until compulsive behaviour is reduced.

 Case study of John, a compulsive gambler:

o After losing their first marriage, he got depressed because of the debt that was caused by

gambling.

o With the help of his therapist, he identified his feeling-state memory to be “winning”, which

was connected to his compulsive behaviour.

o After visualisation and EDMR, he noticed a reduction in the urge to gamble as his behaviour

and feelings changed over the course of 4 sessions.

o During his follow-up interview, he stated that he is healthy now.

Evaluation

 Biochemical:

o Grant used a double-blind trial, so no researcher bias, increasing validity.

o The data collected was quantitative, using objective data in the standardised Y-BOCS

tool.

o Ethical issues such as placebos would deceive participants.

 Cognitive-behavioural:

o Glover shows that covert sensitisation can be used effectively to reduce symptoms of

kleptomania, but it used a case study specifically for kleptomaniacs, which won’t

be generalisable to other impulse control disorders.

o The same goes for Miller, who also uses a case study of John.

o In both cases, the follow-up treatments occurred within a year post-treatment, which could

check for relapse.

o However, the therapist is assessing the participants, which would make it biased

 In-depth qualitative data obtained via case studies.

Issues and debates

 Applied to real life:

o A study by Grant et al. showed the effectiveness of opiates in treating gambling disorder; it

also shows in what circumstances opiates will be most effective.

o Cognitive-behavioural treatments can be used alongside drug therapy or to improve the

symptoms of those with treatment-resistant impulse control disorders.

 Reductionist: The management of disorders is somewhat reductionist, e.g., the use of

opiates showed effectiveness. However, it ignores the circumstances in a person’s life, like

the problem that triggered the disorder.

 Individual vs Situational: cognitive and behavioural approaches to treatment, like covert

sensitisation, don’t focus on the person’s social and emotional situation- they rely on an

individualistic approach.
 Anxiety Disorders
Characteristics
 Anxiety is classified as a pattern of frequent, persistent worry and apprehension about a

perceived threat in the environment.

 It is minor or non-existent, but the person perceives it as highly threatening.

 A phobia is an extreme and irrational fear towards a stimulus and is disproportionate to the

actual danger.

 Common symptoms of Anxiety:

o Muscle tension

o Restlessness

o Feeling constantly ‘on edge’

o Difficulty concentrating (due to being preoccupied with their worry)

o Tiredness and irritation (due to sleep disturbance).

 Generalised Anxiety Disorder (GAD): a long-term condition wherein feelings of anxiety

may be generalised over multiple situations and things (money, health, family, work, etc)

rather than a specific stimulus (phobia).

 Panic attacks are a common feature and can last minutes or hours. Its symptoms are:

o Fear of dying or losing control

o The sensation of shortness of breath or choking

o Nausea

o Feeling dizzy or light-headed

o Sweating

o Accelerated heart rate

Case Study: Kimya (female aged 39)

 Kimya is afraid of birds, not knowing what caused her extreme anxiety.
 She can’t even look at photographs of birds; the thought of looking or touching birds makes

her sick

 She finds the sounds of wings flapping rather upsetting.

 She avoids places where she might be exposed to birds: beaches, town centres or

woodlands, limiting her social life.

Types and Examples

 Agoraphobia- fear of public places.

o Characterised by a fear of two or more of:

 standing in line or in a crowd

 being in open spaces

 using public transport

 being outside the home by oneself

 being in enclosed spaces

o Agoraphobic individuals will actively avoid such situations or experience severe distress

while enduring them. Depending on the nature of the phobic stimulus, the anxiety can cause

significant impairment to social and working life.

 Haemophobia: an irrational fear of blood but can also extend to needles, injections or other

invasive medical procedures.

o Individuals experience an increased heart rate, combined with a drop in blood pressure, they

can fain.

 Animal Phobias: commonly include dog, insect, bird and spider phobias.

o Individuals feel distress and panic attacks when faced with them.

 Koumpounophobia: fear of buttons.

o Individuals can’t touch or look at them.

Measures (BIPI, GAD-7)

 The Blood-Injury Phobia Inventory (BIPI) measures haemophobia.

o Self-report measure that lists 18 situations involving blood and injections to find cognitive,

physiological and behavioural responses.

o Example situation: when I see someone injured, bleeding on the road

o Example response:

 Cognitive: I think I’m going to faint

 Physiological: my heartbeat speeds up

 Behavioural: I escape from the situation immediately.

o Asked to rate on a scale of 0-3 the frequency of each symptom (0=never, 1=sometimes,

2=almost always, 3=always).

 Generalised Anxiety Disorder 7 (GAD-7) questionnaire is a screening test often used by

general practitioners to enable further referral to a psychiatrist.

o It has 7 items that measure the severity of anxiety.

o Example items:

 Feeling nervous, anxious or on edge

 Being so restless that it is hard to sit still

 Feeling afraid as if something awful might happen

o A score between 0-3 to measure the frequency of symptoms (0=not at all, 1=several days,

2=more than half the days, 3=nearly every day).

Evaluation of GAD-7 and BIPI:

 High concurrent validity with other measures, thus valid and reliable instruments.

 Response Bias: inaccurate response can distort results, e.g. the, the person had a ‘bad’

day (had a finger cut)

Issues and Debates

 Reductionist: these psychometric tests rely on a single quantitative measurement of a

complex patient experience. They do not consider qualitative data, e.g., what it is like to

have a phobia.
 Cultural Bias: Cross-cultural differences influence BIPI and GAD-7 results, e.g., cultures

that promote well-being and reassure those around them will have low diagnostic rates of

social phobia.

Explanations
Behavioural (Classical Conditioning, Watson, 1920)

 Phobia may result from classical conditioning, where when a neutral stimulus is paired with a

frightening stimulus, future association with the neutral stimulus will produce a fearful

conditioned response.

 Watson and Rayner wanted to check whether fear could be learned via classical

conditioning and whether it could be transferable to other objects and individuals.

 They used the principles of classical conditioning to create a phobia in a young and healthy

11-month-old infant, ‘Little Albert’.

 Before conditioning, he was shown a range of stimuli: white rat, rabbit, dog, monkey, masks,

cotton wool, etc, to which he reacted neutrally.

 The table below proves that fear can be learned through classical conditioning.

Before Unconditioned response

Unconditioned stimulus (UCS)
conditioning (UCR)

Fearful crying and

Loud noise of metal bar
avoidance

During Neutral stimulus + Unconditioned response

conditioning unconditioned stimulus (UCR)

(NS) + (UCS) Fearful crying and

White rat + loud noise avoidance

After Conditioned response

Conditioned stimulus (CS)
conditioning (CR)

Fearful crying and

White rat or similar animal/item
avoidance

Treatment and Management

 Systematic Desensitisation (Wolpe, 1958)

 It is a way of reducing undesirable responses to a particular situation.

 It holds the assumption that nearly all behaviour is a conditional response to stimuli in the

environment.

 If a phobia can be learned, it can be unlearned.

 Systematically desensitising a patient requires that once the frightening stimulus should

eventually become neutral and provoke no anxiety.

 Reciprocal inhibition: the impossibility of feeling two strong and opposing emotions

simultaneously.

 The key to unlearning phobic reactions through SD is to put the fearful feelings associated

with phobic stimulus directly in conflict with feelings of deep relaxation.

 Stages in SD:

o Teach patient relaxation techniques: progressive muscle relaxation exercises,

visualisation or even anti-anxiety drugs.

o Creating an anxiety hierarchy: a list of anxiety-provoking situations in relation to specific

phobias that increase in severity.

 The patient works through each hierarchy stage via in vivo (direct) or in vitro (imagined)

exposures.

Stage Situation relating to Spider Phobia

1 Looking at a drawing of a spider

2 Looking at a detailed photo of a spider

3 Watching a spider making a web on a video

4 Being in the same room as a spider

5 Standing in front of a spider’s cage

6 Standing next to another person holding a spider

 Stage Situation relating to Spider Phobia

7 Touching a spider whilst someone else holds it

8 Holding a spider in their own hand

 At each stage of the hierarchy, the patient is assisted to remain calm and relaxed using their

chosen technique. The patient does not proceed to the next stage until they report no feeling

of anxiety in the current stage.

Principles of Classical Conditioning Linked to SD

 As both feelings of fear and calm are incompatible, a fearful response to a stimulus is

unlearned, and no more anxiety is produced.

 Good evidence supports the effectiveness of SD in agoraphobia and fear of snakes,

however treatments involving more direct forms of exposure is now more commonly used.

Applied Tension (Ost et al., 1989)

 Involves applying tension to muscles to increase blood pressure throughout certain areas.
 For example blood phobia is associated with drops in blood pressure and, consequently,

fainting. Using increased muscle tension, blood pressure can be raised, and fainting

prevented

In a study by Ost et al.:

 Sample:

o 30 patients (19M:11F) from the same hospital with a phobia of blood, wounds and injuries

o 18-60 years

o Using an independent design, they were divided into 3 groups: Applied tension, applied

relaxation or a combination

 Aim: establish which treatment was the most effective, including applied tension.

 Procedure: participants were part of either group below and underwent the following 45-60

min sessions:

o Applied tension group: 5 sessions

 Participants learned to tense their arm, chest, and leg muscles until they experienced a

feeling of warmth rising to their face. Once mastered, they would practice it during exposure

to several blood-related situations.

o Applied relaxation group: 9 sessions.

 The applied relaxation technique involved progressive muscle relaxation during exposure to

the same stimuli.

o Combined group: 10 sessions.

o Before treatment:

 Participants were assessed by self-report, along with behavioural and physiological

measures to establish tendencies towards anxiety and fainting.

 This included being observed while watching videos involving surgical operations and having

their heart rate and blood pressure measured.

 Results: After treatment and 6 months post-treatment, participants were given the same set

of measures to establish any changes

o Across all groups: 73% of participants showed a noticeable improvement in behavioural

and physiological responses to blood.

o Applied tension: As effective as other forms of treatment in half the time, it was, therefore,

the most appropriate treatment for haemophobia.

Cognitive-Behavioural Therapy (Ost and Westling, 1995)

 CBT considers the need to change an individual’s thoughts and beliefs about the source of

their anxiety.

In the study by Ost and Westling

 Aim: compare the effectiveness of CBT with applied relaxation (AR) in patients with panic

disorder (characterised by spontaneous/unexpected panic attacks)

 Sample:

o 38 patients were recruited via newspaper advertisement and psychiatrist referrals.

o They were treated individually across 12 weekly sessions.

o They were assessed before, after and in a one-year follow-up by a self-report scale and self-

observations of panic attacks which included noting panic attacks and their severity in a

diary.

 Procedure:

o Steps in CBT:

1. Identifying the misinterpretation of bodily sensations i.e. thinking that when the heart beats

fast, they are having a heart attack

2. Participants were encouraged to generate alternative, non-catastrophic interpretations of

their bodily sensations.

3. The therapist challenged the patient’s evidence for their beliefs.

o Steps in AR: progressive muscle relaxation techniques were taught, which were

then practised in both panic and non-panic situations.

 Results: no significant difference nor relapse between AR and CBT, suggesting both

methods were successful in short to medium-term alleviation of panic attack symptoms.

 Evaluation

 A study by Ost et al. (1989):

o The sample was from the same hospital, limiting generalisability

o Both sexes were part of the sample so that results could be applied to both

o An independent measures design was used; thus, participant variables could have

affected the outcome, reducing the validity

 A study by Ost and Westling (1995):

o More ethical as participants kept diaries of naturally occurring panic attacks instead of

triggering it

o Well-controlled as therapists were given standardised training, increasing validity and

removing extraneous variables

o One-year follow-up shows a long-term effect of treatment rather than a 6-month follow-up

in Ost et al. (1989)

Issues and Debates

o Treatments apply to real life and are the most effective treatment found, e.g. applied

tension was more effective for hemophobia than AR, reducing waiting times for therapy

o Nature vs Nurture

 In the case of SD, behaviourists assume that individuals are born (nature) a ‘blank

state’ with few specific behaviour tendencies, and further behaviours such as phobia are

developed via classical conditioning (nurture)

 However, not all phobias develop from negative associations with traumatic events. Some

are believed to have served an evolutionary purpose (nurture).

 Thus, systematic desensitisation and other behavioural treatments are most effective for

phobias that are learned.

OBSESSIONS COMPULSIONS
Fear of deliberately harming oneself, illness/infection,
Frequent and excessive
harming/killing others, accidentally injuring
handwashing
oneself/others

Strong desire for order and symmetry Putting things in order

Repetitive checking

Repeating words to
oneself/repetitive counting.
 Obsessive Compulsive and
Related Disorders
Characteristics
 Obsessions: intrusive, recurrent thoughts and unwanted urges.

 Compulsions: repetitive actions that impair normal functioning.

 Patients with OCD will often be compelled to suppress obsessions to reduce anxiety and

gain temporary relief. However, these compulsions are excessive and unrealistic – e.g., a

person having a fearful obsession of accidentally hitting someone may be compelled to

engage in continuous counting.

 Hoarding: experiencing great difficulty and distress getting rid of possessions negatively

affecting their social life. Their homes may be unsafe due to hygiene or access issues.

 Body dysmorphic disorder (BDD): obsessive thoughts regarding perceived faults in one’s

physical appearance.

o These faults are slight or not apparent to others.

o The obsessions are often focused on imagined flaws/defects on the face.

o The anxiety caused by obsession leads to compulsive, repetitive behaviour, e.g. frequent

mirror-checking, excessive grooming (hair-washing, shaving etc.) and comparing one’s self

to others.

Case Studies: (‘Charles’ by Rappaport, 1989)

 14-year-old boy with OCD who spent >3 hours showering and 2 hours getting dressed.

 He had repetitive routines for holding soap in one hand, putting it underwater, switching

hands, etc.

 His mother contacted Rappaport after the child exhibited this behaviour for around 2 years.

 He was utterly obsessed with the thought that he had something sticky on his skin that had

to be washed off, causing him to leave school.

 He also had trips to the hospital, where he received standard treatments of medication,

behavioural therapy and psychotherapy.

 He was socially isolated as his rituals left him little time outside the house.

 He underwent a drug trial for clomipramine (antidepressant) giving him effective relief of his

symptoms; however, he developed tolerance to it and relapsed.

Measures: Maudsley Obsessive-Compulsive Inventory (MOCI),

Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)

 MOCI: quick assessment tool (takes around 5 mins to complete) and is scored between 0-

30.

o Consists of 30 items that are scored either ‘true’ or ‘false’, which assesses symptoms related

to checking, washing, slowness and doubting e.g.

 I frequently have to check things (Checking).

 I am excessively concerned about germs and diseases (Washing)

 I don’t take a long time to dress (Slowness)

 Despite doing something carefully, I often feel it is not quite right (Doubting)

 Y-BOCS (Goodman et al., 1989): consists of a 30-min semi-structured interview and a

checklist of different obsessions and compulsions.

o The checklist includes a 10-item severity scale, allowing individuals to rate (between 0-4)

time spent on obsessions and compulsions, how hard they resist, and how much distress

they cause.

o Total scores range from 0-40, where >16 is in the range for OCD.

Aggressive, Contamination, Sexual, Hoarding, Religious, Symmetry,

Obsessions
Body focus, Other

Cleaning, Washing, Checking, Repeating, Counting,

Compulsions
Ordering/arranging, Hoarding, Other
 Explanations of OCD
Biomedical (Genetic, Biochemical, Neurological)

 Genetic: suggests that patients with OCD inherit specific genes that cause OCD.

o A large-scale study by Mattheisen et al., 2015 involving 1406 people both with and without

OCD were analysed.

o 2 genes (PTPRD and SLITRK3) interact to regulate particular synapses in the brain (the

irregularity of these synapses lead to neurological disorders like OCD)

o DRD4 (dopamine receptor D4) is related to the uptake of dopamine (its abnormal levels are

implicated in OCD, e.g. high levels of dopamine associated with compulsive behaviour)

o SERT (onin transporter) gene can cause low levels of serotonin, which is associated with

OCD (and depression).

o Biochemical: ‘oxytocin’ or love hormone, is known to enhance trust and attachment, but can

also increase distrust and fear of certain stimuli, especially those that pose a threat to

survival.

o By analysing cerebral spinal fluid and patient behaviour, Leckman et al., 1994 found that

oxytocin levels are higher in patients with OCD and found a positive correlation with a higher

frequency of repetitive behaviour.

o OCD behaviours could be at the extreme end of a normal range of behaviours moderated by

oxytocin.

 Neurological: abnormalities in brain structure and function.

o The basal ganglia and two associated regions (orbitofrontal cortex and cingulate gyrus) work

together to send and check warning messages about threatening stimuli.

o In brain-damaged (case study) patients, the checking ‘loop’ doesn’t work as it should, so the

basal ganglia continue receiving worrying messages relating to the obsessive thinking

symptom of OCD.
o Note: heightened activity in the orbitofrontal cortex increases conversion of sensory

information into thoughts (obsessions) and actions (behaviours), leading to compulsions.

PET scans have found higher activity in the orbitofrontal cortex in patients with OCD.

Cognitive and Behavioural

 OCD consists of cognitive obsessions and behavioural compulsions.

 Obsessive thinking is based on faulty reasoning, e.g., believing that hands covered in germs

could kill.

 Compulsive behaviours are outcomes of erroneous thinking, attempts to alleviate

obsessions and the associated anxiety.

 Such behaviours can be explained via operant conditioning:

o Hand washing is the negative reinforcement as it has relieved something unpleasant

(obsessive thoughts)

o It is also a positive reinforcement as the person is rewarded by knowing they have cleaner

hands.

Psychodynamic

 Freud emphasises the unconscious beliefs and desires to explain OCD, and how childhood

experiences shape personality.

 OCD symptoms result from an internal conflict between the id and the ego.

 Freud suggests that conflicts arise in the anal stage of psychosexual development,

around the time most children begin toilet training.

 There’s a tension between parents and children, as the parent may want to control when the

child defecates/urinates against the child’s wishes.

 The child may soil themselves to regain control, upsetting their parents (leads to anally

expulsive behaviour: being messy and careless)

 Alternatively, they may fear harsh responses from parents and retain faeces/urine to regain

control (leads to anally retentive behaviour: the compulsive need for order and tidiness)
 Anally retentive/expulsive behaviours can lead to behavioural disturbances as the individual

has become ‘fixated’ in this stage.

o Fixation: when conflict at the psychosexual stage remains unresolved, and the person is

unable to move on to the next stage.

 Obsessive thoughts coming from the id disturb the rational part of the self, the ego, to the

extent that it leads to compulsive cleaning and tidying rituals later in life to deal with

childhood trauma.

 Evaluation:

o Genetic: objective and usually controlled under lab conditions, making it highly replicable.

 However, it doesn’t explain why some individuals may carry genes that are implicated in

OCD but never develop symptoms.

o Biochemical: The oxytocin hypothesis is supported by lab-based studies; however, it is

difficult to establish a causal relationship between hormones and OCD symptoms.

o Neurological: supported by case studies on brain-damaged individuals, but this lacks

generalisability to other OCD patients.

o Psychodynamic: not supported by research as you can’t mention or control variables

involved, so no causal relationship was found, e.g. between harsh toilet training and later

compulsive washing.

 Issues and Debates:

o Biomedical Explanations are potential areas for research into treating and managing OCD.

o Individual Explanation: biomedical, cognitive and behavioural explanations focus on the

individual, e.g. hormonal abnormalities and faulty thought processes, making it reductionist.

o Situational Explanation: psychodynamic explanation emphasises the effect of early social

relationships on an individual’s development.

o Nature: biomedical explanation (genes, hormones, brain structure)

o Nurture: behavioural (learnt behaviours)

o Both nature and nurture: psychodynamic (natural urges we are born with vs childhood

experiences)

o Deterministic: no free will to influence genetic makeup or automatic learning process

leading to OCD.

Treatment and Management

Biomedical (SSRIs)

 SSRI acts on the serotonin transporter, increasing its level and acting as a treatment.

 Soomro et al. (2008) reviewed the results of 17 studies comparing the effectiveness of

SSRIs with placebo.

 In all studies, totalling 3097 participants, the SSRI group was more effective at reducing

OCD symptoms shown using Y-BOCS 6-13 weeks after treatment.

 SSRIs reduce the severity of OCD as they seem to lessen the anxiety associated with it.

Psychological Therapies: Cognitive (Lovell et al., 2006) and

Exposure and Response Prevention (Lehmkuhl et al., 2008)

 Cognitive:

o Aim: to compare the effectiveness of CBT delivered by telephone vs. the same face-to-face

therapy.

o Sample: 72 patients from 2 different hospitals

o Procedure: Lovell et al. used RCT wherein participants underwent 10 weekly therapy

sessions either by telephone or face-to-face.

o Changes in well-being were measured via Y-BOCS, BDI, and a client satisfaction

questionnaire.

o Result: 6 months after treatment, Y-BOCS scores significantly improved in both groups,

along with high participant satisfaction, suggesting patients may benefit equally from both

forms of CBT.
 Exposure and Response Prevention (ERP): Lehmkuhl researched the application of this

form of CBT with a 12-year-old boy, Jason, who had both OCD and autism spectrum

disorder (ASD).

o Jason experienced contamination fear, excessive hand-washing, counting and checking.

o He spent several hours daily in compulsive behaviour, having anxiety when prevented from

his rituals.

o ERP consists of gathering information about existing symptoms, therapist-initiated ERP and

generalisation and relapse training.

o Procedure: Jason attended ten 50-minute CBT sessions over 16 weeks, and ERP

techniques were modified to fit Jason’s needs.

o Identification and Coping: Jason first identified feelings of distress and, with the help of the

therapist, learned coping statements when he felt anxious.

 Some ERP techniques were modified to fit Jason’s needs; he was not asked to do

visualisation exercises as he would find it impossible to imagine pretend situations.

o Exposure: he was exposed to stimuli which he felt were contaminated and produced

feelings of anxiety/disgust (door handles, elevator buttons)

 He was asked to touch them repeatedly until he became habituated, and his anxiety levels

dropped.

 Mid-sessions, he was exposed to specific tasks in his normal environment – handing out

papers in classes or using ‘contaminated’ items at home.

o Results: Jason’s score on Y-BOCS dropped from a severely high pre-therapy score of 18 to

just 3 (normal).

 At a 3-month follow-up, his score remained low, and he showed improvement in both OCD

symptoms and participation in social activities.

 Evaluation:

o Cognitive therapy (Lovell et al. ):. An independent measures design was used where

participants were randomly allocated to two conditions, removing researcher bias.

o The Face-to-face CBT group acted as the control group so that researchers could compare

the results and effectiveness of ERP with the control group.

 Validity and reliability: The duration of therapy in both groups was the same, and

outcomes were measured using the same validated scales.

 Limited Generalisability: A case study was used, and the participant had ASD too, thus

unrepresentative of the general OCD population.

 Ethical Issues: Jason was a child with additional needs and issues regarding briefing,

consent and risk of psychological harm.

 Qualitative and Quantitative: in-depth qualitative data through ERP and interviews, along

with quantitative data via Y-BOCS scores.

 Issues and Debates:

o Use of children in psychology:

 SSRIs are generally considered safe but sometimes restricted in the case of children with

OCD due to the risks of harmful side effects.

 Ethics: Jason’s parents would have had to give consent on his behalf; some procedures of

ERP were altered to accommodate his age and ASD needs.

o Application to everyday life: CBT and SSRIs are frequently used OCD treatments.

o Individual explanation: SSRIs only treat one aspect: the individual’s serotonin uptake,

ignoring what may have caused the OCD symptoms to emerge, thus also being

a reductionist approach for treatment.

o Situational Explanation: CBT considers the environment in which the compulsive

behaviour takes place, e.g. Jason’s therapy addressed triggers in home and school

environments to help prevent relapse.