Chapter 7: Abnormal Psychology
Essential Questions
What is the difference between normal and abnormal behaviour?
How reliable and valid is a diagnosis of a psychological disorder?
What causes abnormal behaviour?
How can psychological disorders be treated?
Myths and Misconceptions
People with mental illnesses are often violent.
This is a myth. People with mental illness are more likely to be the victims of violence rather than being violent themselves. There is a growing body of evidence that:
The vast majority of people with mental illness are not violent.
The public is misinformed about the link between mental illness and violence.
Inaccurate beliefs about mental illness and violence lead to widespread stigma and discrimination.
The link between mental illness and violence is promoted by the entertainment and news media.
See this fact sheet from Sane Australia.
Mental illnesses are not really illnesses.
This is another myth. The Canadian Mental Health Association (CMHA) argues that mental illnesses create distress, don’t go away on their own and are real health problems with effective treatments. When someone breaks their arm, we wouldn’t expect them to just ‘get over it.’ Nor would we blame them if they needed a cast, sling, or other help in their daily life while they recovered.
People with mental illness cannot work.
This is a myth. People with mental illness successfully work across the full spectrum of workplaces. Some people disclose their mental illness and some do not. Most importantly, people with mental illness can succeed or fail, just like any other worker. You may be surprised at the list of celebrities who are open about their mental illnesses.
The study of abnormal behaviour has a long and tragic history. People suffering from a mental disorder were seen as possessed by evil spirits that needed to be driven out by whatever means.
A more humane approach developed in the 18th and 19th centuries and mental illness was seen as a physical disease. The discovery that the infection syphilis would bring on delusions and changes in personality lent support to this perspective. However, not all abnormal behaviours could be linked to a physical disease or injury. One example was the condition known as hysteria which was prevalent in the late 19th and early 20th centuries. Sigmund Freud, the founder of psychoanalysis, argued hysteria was caused by psychological issues to do with unconscious conflict. Treatment consisted of a ‘talking cure’ that helped the patient resolve inner conflicts, many of which stemmed from early childhood. In the mid-20th century, some psychological disorders were seen as the result of faulty learning and later faulty thinking.
Modern approaches have attempted to understand both the biological and the psychological causes of abnormal behaviour. A diathesis-stress model was proposed. This theory contended some individuals may have a biological predisposition to develop a mental disorder but it would only be triggered by a stressful psychological event. Building on this model, most mental health professionals now argue a biopsychosocial perspective should be adopted to understand mental illness. For example, this perspective would explain depression in terms of biological factors such as genetics, a tendency to engage in faulty cognition and a lack of social support.
In our study of depression, we will investigate the interaction of biological, cognitive and sociocultural approaches to diagnosis, as well as etiology (etiology = study of causes) and treatment. We will also examine approaches to research and ethical considerations.
1. Factors Influencing Diagnosis
Abnormal psychology focuses on diagnosing, explaining and treating humans suffering from psychological disorders. Psychologists and psychiatrists are two of the professionals most associated with the processes of diagnosis and treatment. Psychologists have a post-graduate degree in clinical psychology. Psychiatrists are trained as medical doctors and then study a speciality in psychiatry. They adopt different approaches and have different opinions and beliefs about the relative influence of biological, cognitive or sociocultural factors. All would agree however that it is often an interaction of all three that affect abnormal behaviour.
Biological Approach
Psychologists or psychiatrists taking a biological approach will look at the role of inheritance in abnormal behaviour, will explore brain structure and function to see if this is related to abnormal behaviour and will examine animal research into abnormal behaviour to see if the results can inform us about human abnormal behaviour.
Cognitive Approach
Psychologists or psychiatrists taking a cognitive approach will look at faulty schemas (mental representations), types of thinking and beliefs (mental processes) and how these are influenced by social and cultural factors.
Sociocultural Approach
Psychologists or psychiatrists taking a sociocultural approach will look at people’s social needs, how their culture affects what is defined as normal and abnormal and how this influences their behaviour and the whole process of labelling and being labelled.
Ask YourselfDo you think psychological disorders are harder to diagnose compared to a medical disorder? Why? Why not?
1.1 Normality versus Abnormality
Abnormal behaviour involves disordering of emotions, thoughts and behaviour. Diagnosing such a disorder is a much more challenging process than diagnosing a physical disorder. One difficulty facing mental health professionals is that there is no agreed definition of normality and abnormality. As a consequence, a diagnosis may not be reliable or valid. Cultural issues with diagnosing an individual with a mental disorder add to the complexity. Being diagnosed with a mental disorder has profound consequences which raise important ethical considerations. The following section will explore attempts to define abnormality and examine various classification systems used to provide a valid and reliable diagnosis.
‘Abnormal’ means ‘deviating from what is normal or usual’. But this then raises the question of what is ‘normal’. Each cannot be defined without defining the other. And the problem with normal behaviour is that it relies on specific social and cultural norms that are socially constructed and mutually agreed but vary from place to place. When we are born and raised in a particular culture, we internalise the norms and accept them (with the occasional protest), but understanding the norms of another culture can present problems. For example, as Wakefield (2007) points out, inability to learn to read due to a dysfunction in the corpus callosum (assuming that this theory of some forms of dyslexia is correct) is harmful in literate societies, but not harmful in preliterate societies, where reading is not a skill that is taught or valued, and thus not a disorder in those societies.
What is normal also varies with time as well as place. In the 19th century Europe and the USA, psychiatrists believed that both physical and mental activity could be harmful to women. A common diagnosis for women was ‘hysteria,’ a general term that could be applied to almost any woman. A common ‘cure’ for hysteria was bed rest to prevent both physical and mental activity.
Though clearly defining abnormality remains a challenge, this does not mean that deviant behaviour does not exist. As Rosenhan explains (1973, p. 250):
‘To raise questions regarding normality and abnormality is in no way to question the fact that some behaviours are deviant or odd. Murder is deviant. So, too, are hallucinations. Nor does raising such questions deny the existence of the personal anguish that is often associated with mental illness. Anxiety and depression exist. Psychological suffering exists. But normality and abnormality, sanity and insanity, and the diagnoses that flow from them may be less substantive than many believe them to be.’
Faced with these challenges mental health professionals use several different ways of defining abnormality.
Statistical infrequency
One means of defining abnormal is to refer to statistical infrequency. Statistically, rare behaviour becomes defined as ‘abnormal’. One example might be autism, which only occurs in between 1% and 2% of children in Asia, Europe and North America (Center for Disease Control and Prevention, 2013). One problem here is that behaviour may be rare, such as the ability to speak over five or six languages, without being a sign of a mental disorder. How rare does a behaviour need to be before it is defined as abnormal? The statistical infrequency measure does not apply to disorders like depression and phobias which are very common. Other approaches are needed.
Deviation from social norms
Deviation from social norms is a definition based on social attitudes to behaviour. If someone breaks the unwritten rules of society, by invading personal space or dressing and acting inappropriately, for example, then they might be labelled ‘abnormal’. The danger here is that people who do not conform to society’s expectations are too easily labelled deviant and seen as a threat to society. For example, throughout the mid to late 20th century, many Eastern European governments labelled political activists as mentally ill and confined them to mental institutions.
Another example is homosexuality and transsexuality. While some societies have become much more tolerant of these social and sexual identities, such behaviour is illegal and punishable by public caning and imprisonment in others. It was only in 1973 that homosexuality was removed as a mental disorder from the DSM-II classification. (DSM = Diagnostic and Statistical Manual of Mental Disorders, used by mental health professionals to classify abnormal behaviour). ‘Sexual Orientation Disturbance’ replaced the category of homosexuality. This represented a compromise between the view that choosing to be a homosexual was a mental disorder and the view that it is merely a normal sexual variation. If you were homosexual and disturbed by this, then you had a mental disorder. If you accepted your sexuality you did not have a mental disorder.
The newly published DSM-5 adopts a similar approach to transgender people by using the classification of Gender Identity Disorder. A new term is ‘gender dysphoria’, which identifies distress over ‘a marked incongruence between one’s experienced/expressed gender and assigned gender.’ So, again, it is distress created by the difference between your expressed and your birth gender that is the problem.
Though the DSM-5 is published by the American Psychiatric Association and used widely, it is not accepted by all mental health professionals. Just because a disorder is removed from the manual, it does not mean that the behaviour is now seen as normal in many cultures.
Focus on Research
Szasz (1960) first argued that mental illness was a myth in an article and later in his controversial text The Myth of Mental Illness. His basic premise is that many psychological disorders should not be categorised as diseases like physical disorders as they are really ‘problems in living’. All of us face dilemmas and struggles but this does not mean that we are mentally ill. He was highly critical of these problems being treated as if they were medical problems and he argued against using diagnostic systems like the DSM because they imply that there is an actual disease.
Szasz’s views remain highly controversial and his central idea that mental illness is a myth has been dismissed as going too far (Poulsen, 2012). However, his ideas still spark debate about how to define normality and abnormality and ensure that the ethical consequences of diagnosis are not overlooked.
Failure to function adequately
Everyone has difficulties in coping with the world sometimes, but if an individual’s behaviour, mood or thinking affects their well-being then that behaviour can be judged abnormal. In other words, if a behaviour makes life unbearable then it is abnormal. But judging when a person’s behaviour is making life dysfunctional remains a challenge. For example, a heavy smoker or drinker is not necessarily seen as engaging in the abnormal behaviour, even though they are self-harming and may alienate their friends and bring difficulties at work. The person who is not functioning adequately may feel that they are absolutely fine. The issue becomes how much the person’s abnormal behaviour is adversely affecting or threatening others, and how judgemental they are.
Wakefield (2007) proposes a model for using the idea of failure to function to categorise behaviours as normal or abnormal. He introduced the term ‘harmful dysfunction’ for the diagnosis of mental disorder – a behaviour should be negatively valued both by the community and the individual (harmful) and also due to the malfunction of some internal mechanism (dysfunction). While the first of these might be easy to determine, the malfunction of an internal mechanism (such as a neurotransmitter problem) has not been found to be related to many instances of abnormal behaviour, which would then mean they were not diagnosed as a mental disorder. The implications of this for treatment are not clear.
Deviation from ideal mental health
Judging a behaviour as dysfunctional has not been widely adopted as a way of defining normality and abnormality. Jahoda (1958) took a different approach and described some characteristics that mentally healthy people should possess. She outlined the following:
Individuals should have a positive attitude about themselves.
Individuals should have a sense of self-actualisation. They should be working towards being the best they can be.
Individuals should be independent and self-reliant.
Individuals should be able to cope with stress.
Individuals should be able to adapt to new situations.
Individuals should have an accurate perception of reality.
Though the list is focused on positive goals it has been criticised as being subjective. People from different cultures might feel that the ideals of autonomy and independence are far from ideal and represent instead isolation. Recently, a group of psychologists including Martin Seligman (who came up with the 7 features of abnormality in 1989 with David Rosenhan) have developed a discipline within psychology called ‘positive psychology’, looking at how, why and under what conditions positive emotions and character traits flourish and prevent mental health problems. (See Seligman and Csikszentmihalyi, 2000, and Peterson and Seligman, 2004). They asked, ‘Can psychologists take what they have learned about the science and practice of treating mental illness and use it to create a practice of making people lastingly happier?’ (Seligman et al., 2005).
Petersen and Seligman (2004) argue that their classification of character strengths and virtues is a positive complement to the various editions of the Diagnostic and Statistical Manual of Mental Disorders. See their table below:
Peterson and Seligman’s Character Strengths and Virtues is extensive and has empirical cross-cultural support (see Seligman et al., 2005) but nonetheless could be open to debate. For example, some might argue that many of the character strengths are dependent on good physical health and a certain amount of control over one’s own life.
Ask YourselfDo you think psychological disorders are harder to diagnose compared to a medical disorder? Why? Why not?
1.2 Classification Systems
As mentioned above, manuals of diagnostic criteria have been developed to try and help mental health professionals distinguish between normality and abnormality. The four that you will need to know something about are:
Name
Date of most recent edition
Published by
Comments
May 2013, 5th edition (DSM 5)
American Psychiatric Association
Used in the USA, South America and parts of Africa and Asia. A recent update has caused controversies, which will be discussed as we come to them.
2010, 10th edition (ICD-10)
World Health Organization
Used in Europe. The 11th edition is now being developed.
Chinese Classification of Mental Disorders
2001, 3rd edition (CCMD 3)
Chinese Society of Psychiatry
Used in China. Written in Chinese and English and has about 40 culturally-related diagnoses.
Continually updated
Great Ormond St Children’s Hospital in London, UK
Developed especially for children.
The development and use of these manuals will be examined in the next sections.
1.3 The Role of Clinical Biases in Diagnosis
Clinical biases - culture
Different cultures have different criteria for judging what is normal and abnormal and different ways of explaining abnormal behaviour. For example, the main problems with the cross-cultural diagnosis are culture-bound syndromes that do not exist outside of their own society; mental health professionals’ culture blindness and cultural stereotypes; reporting bias; and symptoms that vary cross-culturally.
Culture-bound syndromes
If a particular abnormal behaviour or mental disorder does not exist outside the culture of a patient, and they come to a psychiatrist or psychologist who is not from their culture, then the clinician will not have the tools with which to diagnose and will be as puzzled as anyone else, unless they have taken care to inform themselves about mental disorders from different cultures. This may well result in a misdiagnosis and mistreatment.
Different cultures have different criteria for judging what is normal and abnormal, and different ways of explaining abnormal behaviour.
Two examples of culture-bound syndromes are:
amok or mata elap: (Malaysia) which is characterised by a period of brooding followed by an outburst of violent, aggressive, or homicidal behaviour directed at people and objects. The episode tends to be precipitated by a perceived insult and seems to be prevalent only among males. It is sometimes the first symptom of a serious mental disorder.
shenjian shuairuo: (Chinese) equivalent to a diagnosis of ‘neurasthenia’. Symptoms include physical and mental fatigue, dizziness, headaches and other pains, difficulty concentrating, sleep disturbance and memory loss. Other symptoms include gastrointestinal problems, sexual dysfunction, irritability, excitability, and various signs suggesting disturbances of the autonomic nervous system. Very similar to the Western diagnosis of the major depressive disorder, but often without the lowered mood.
The American Psychiatric Association has not included a comprehensive list of culture-bound syndromes in the DSM-5, though some cultural syndromes are detailed in the Appendix of the manual. Instead, the criteria for each disorder have been updated where relevant to reflect cross-cultural variations in presentations, and to give more detailed and structured information about cultural concepts of distress. They explain with two examples:
Uncontrollable crying and headaches are symptoms of panic attacks in some cultures, while difficulty breathing may be the primary symptom in other cultures.
The criteria for social anxiety disorder now include the fear of ‘offending others’ to reflect the Japanese concept in which avoiding harm to others is emphasised rather than harm to oneself (APA, 2013a).
While this widens the criteria and makes them more sensitive, it does not solve the problem of totally different disorders being present in some cultures. An important thing to note is that all disorders are culture-bound, including all Western disorders, as they arise in a cultural context. No psychological disorder can escape a cultural influence.
Focus on Research
A study illustrating how cultural stereotypes can lead to a clinical bias in diagnosis was conducted by Burr (2002) in the UK. She investigated how cultural stereotypes of women from South Asian communities affected mental health care professionals’ explanations for patterns of suicide and depression. Burr noted that low rates of treated depression and high rates of suicide in women from some South Asian communities are evident in data from the UK. Burr argued that explanations for these apparent differences are likely to be located in stereotypes of ‘repressive’ South Asian cultures. She conducted qualitative research using focus groups and individual interviews to determine if there were cultural stereotypes about South Asian communities. Participants were mental health carers from a UK inner city area of relatively high social deprivation. Focus group interviews were conducted with a range of mental health care professionals who worked in both inpatient and outpatient mental health care services. In addition, individual interviews were conducted with consultant psychiatrists and general medical doctors.
Analysis of data from the interviews suggests that health carers held cultural stereotypes. The South Asian culture was perceived as repressive, patriarchal (patriarchal = dominated by males) and inferior to a western cultural ideal. Burr contended that these stereotypes have the potential to misdirect diagnosis.
Culture blindness and cultural stereotypes
As was outlined earlier, there are cross-cultural differences in what is perceived as abnormal behaviour. It is not uncommon for example, in some cultures, to see or hear deceased relatives. So, this should not always be considered as a symptom of a psychological disorder. Studies in New Zealand show that the Maori and Pacific Islanders have different definitions from the New Zealanders from a European background for what is and is not a mental health issue. Using the DSM-IV (APA, 1994), affective disorders account for only 16% of diagnoses given to Maori mental health patients (compared with 30% for Europeans), whereas 60% of diagnoses of Maoris were for schizophrenia, compared with 40% for Europeans (Tapsell and Mellsop, 2007, cited in Law et al., 2010). The symptoms presented by Maoris are normal in their culture – seeing or hearing the deceased, mental withdrawal when feeling at a disadvantage – but can be interpreted as symptoms of schizophrenia by psychiatrists with a lack of cultural understanding.
Focus on Research
Tapsell and Mellsop (2007) conducted a meta-study of research investigating the diagnosis and treatment of Mâori, an indigenous people of New Zealand. Studies were reviewed in terms of methodology, findings and implications.
In some psychiatric settings, the authors noted that Maoris were more likely to present with hallucinations and aggression rather than depression and episodes of self-harm. Studies of prisons and community-based samples reported that Mâori were less likely to access care and, when given a diagnosis of depression, less likely to be prescribed antidepressant medication. The rates of depression were significantly higher in Mâori (women), and Mâori were also overly represented in those experiencing anxiety and substance misuse disorders.
The researchers concluded that these differences between Mâori and non- Mâori in New Zealand might reflect actual differences between certain ethnic and cultural groups, or they may reflect inadequacies on the parts of non- Mâori healthcare workers, their diagnostic tools and the services in which they operate, in catering for Mâori patients.
Reporting bias
Reporting bias occurs when data is gathered about a particular disorder based on hospital admissions. Actual cases of the disorder may not be properly diagnosed or particular cultural groups may avoid seeking the help of mental health care professionals. For example, Chinese patients may present with physical symptoms (Yeung and Kam, 2006). Some ethnic groups may not have full access to mental health care because of their socio-economic status (Tracy, 2017).
Cross-cultural variations in symptoms
The symptoms of the mental disorders in the two main manuals (DSM-5 and ICD-10) are not necessarily the symptoms that will be present in patients from ethnic minority groups. For example, people from East Asia (especially China) will exhibit more somatic (physical) symptoms when depressed than their western counterparts and another example is that black patients in the UK with bipolar disorder (called manic depression in the UK) report fewer suicidal thoughts and more manic episodes, which leads them to sometimes be diagnosed with schizophrenia instead (Kirov and Murray, 1999). See this link to an article by Ethan Watters in the New York Times, on both cross-cultural and historical variations in symptoms and what is classified as a mental disorder.
Haroz et al. (2017) investigated cultural bias in the DSM-5 by conducting a review of qualitative studies into cultural differences in depression worldwide. They argued that the criteria and standard measuring scales and questionnaires based on DSM-5 are not culturally sensitive enough to diagnose depression cross-culturally.
Confirmation bias
You will recall from Chapter 5 that confirmation bias is a tendency to search for or interpret information in a way that confirms one's preconceptions. In the area of abnormal psychology, confirmation bias occurs when psychologists and psychiatrists interpret behaviour as fitting in with their original diagnosis of the disorder and ignore any behaviour that does not.
More recent research supports the theory. Parmley (2006) found confirmation bias to be powerful and ubiquitous (ubiquitous = universal and pervasive).
Focus on Research
Mendel et al. (2011) investigated the process of diagnosis to determine how prone mental health professionals are to confirmation bias. They observed that errors can have tremendous consequences with one wrong decision leading to others. A decision task was given to 75 psychiatrists and 75 medical students. They found that 13% of psychiatrists and 25% of medical students showed confirmation bias when searching for new information after having made a preliminary diagnosis. A significant number of participants were less likely to change their original diagnosis after searching for conformity information than those who searched for information that challenged the original diagnosis.
Psychiatrists conducting a confirmatory search for information that supported their diagnosis made a wrong diagnosis in 70% of the cases compared to 27% or 47% for a contradictory information or balanced information search. Participants choosing the wrong diagnosis also prescribed different treatment options compared with participants choosing the correct diagnosis.
The researchers’ conclusion was that confirmatory information search carries with it the risk of wrong diagnostic decisions. Psychiatrists should be aware of confirmation bias and instructed in techniques to reduce bias.
1.4 Validity and Reliability of Diagnosis
Validity and reliability of diagnosis are closely related to having an understanding of what is normal or abnormal behaviour and to the use of the classificatory systems. A diagnosis is usually required before anyone can be treated, and therefore it is important to get it right.
Validity
A valid diagnosis is when a diagnosed person really has a particular disorder as defined by the diagnostic classification systems. The problem is that it is difficult to establish this without using a system, and systems all vary to a lesser or greater extent. A term like major depressive disorder refers to a collection of symptoms that vary between the three main manuals. The issue of validity is especially important when there are no biological diagnostic tests for the disorder.
One controversial issue is how to distinguish between a normal response to a life event and the presence of a psychological disorder. For example, depression is a normal response to bereavement (bereavement = mourning for the death of a loved one) and trauma. In the DSM IV-text revised edition (APA, 2000), depression after the loss of a loved one was only diagnosed as a major depressive disorder if the depression had continued for longer than two months. In the new DSM-5, the reference to bereavement has been withdrawn, with the result, according to critics, that grief and anxiety will be classified as mental illnesses. (See, for example, http://www.bbc.co.uk/news/health-20986796 ). Revision of the classifications implies a revision of the symptoms and changing the validity of past diagnoses.
Focus on Research
Rosenhan’s famous 1973 study aimed to determine whether the sane can be distinguished from the insane and if the salient characteristics that lead to diagnosis reside within the patients themselves or within the environments and contexts in which observers find them. His study was a covert participant observation. The participants were the staff and the patients of twelve psychiatric hospitals in a variety of US states.
Procedures: Eight pseudopatients (pseudopatients = not real), including Rosenhan, attempted to gain admittance to 12 psychiatric hospitals in a variety of states by calling the hospital for an appointment and then complaining they had been hearing voices saying ‘thud’, ‘empty’ and ‘hollow’. Apart from changing their names and disguising their professions in some cases, all other details of their history presented by the patients were accurate and truthful. Once admitted to a hospital, the pseudopatients behaved normally and cooperated with all procedures and directions. They took detailed notes in an open and transparent manner.
In four of the hospitals, the pseudopatients carried out an observation of the behaviour of staff towards patients that illustrated the experience of being hospitalised on a psychiatric ward. The pseudopatients approached a staff member with a request, which took the following form: ‘Pardon me, Mr/Mrs/Dr X, could you tell me when I will be presented at the staff meeting?’ or ‘Can you tell me when I am likely to be discharged?’
To compare the results, Rosenhan carried out a similar study at Stanford University Hospital with students asking university staff a simple question about admissions, directions, etc. All the pseudopatients except one were admitted with a diagnosis of schizophrenia. The other was admitted with ‘manic-depressive psychosis’. It took between 7 and 52 days for them to be released, with an average hospital stay of 19 days. When released they were not judged as ‘cured’, instead, the schizophrenia was seen as being in remission (remission = a decrease in the severity of symptoms). The patients on the wards often recognised that the pseudopatients were sane when the staff did not. Despite their public show of sanity, the pseudopatients were never detected by the staff. Fellow patients, however, frequently noted the sanity of the pseudopatients and commented on it openly.
The pseudopatients noted that the staff did not mix with the patients, avoided spending time with them, did not make eye contact or respond to their questions. This was in direct contrast to the behaviour of staff at Stanford University when stopped by strangers and asked for directions, advice etc.
Follow-up study: In the light of these findings it was also important to determine if the insane could be judged sane. A follow-up study was therefore conducted at a research hospital where the staff doubted that such an error could be made at their hospital. The staff was told that over the next three months one or more pseudopatients would attempt to gain admission to the hospital. Members of staff were asked to rate each patient who presented themselves for admission on a 1–10 scale, with 1 or 2 indicating a strong confidence that the patient was a pseudopatient. Of the 193 patients admitted, 41 were alleged with high confidence to be pseudopatients, 23 were considered suspect by at least one psychiatrist and 19 were considered suspect by one psychiatrist and another staff member. There were in fact no pseudopatients.
Conclusions: This study revealed that the diagnostic process is prone to errors. The diagnosis appears not to depend on the sanity or insanity of the patients themselves but on where they find themselves. Once labelled with schizophrenia, it was impossible for the pseudopatients to rid themselves of this label. The label profoundly affects the way others regarded them and treated them. Rosenhan concluded that once a person is designated as abnormal, that diagnosis colours all other perceptions of that person and his/her behaviour. The pseudopatients’ normal behaviour was overlooked or misinterpreted. A psychiatric label has a life and influence of its own. The behaviour of the patients was attributed to their own pathology, not to the routines and restrictions of hospital life or the way they were treated by staff. Even note taking was seen as a symptom of a psychiatric disorder.
Rosenhan's conclusions show how confirmation bias influenced diagnosis. Once people are diagnosed, then behaviour that seems to confirm that diagnosis is attended to and anything that doesn’t is ignored. Staff ignored the fact that once admitted, the pseudo-patients all said they no longer heard voices. Instead, they paid excessive attention to other behaviours that were then misinterpreted as confirming their diagnosis.
Rosenhan notes that there is an enormous overlap in the behaviours of the sane and the insane. We all feel depressed sometimes, have moods, become angry and so forth, but in a psychiatric hospital, these everyday human experiences and behaviours were interpreted as pathological. He also observed that psychiatric labels even when they are invalid are ‘sticky’ as a diagnosis would cling to a person for life, influencing every aspect of their existence.
Rosenhan's study was groundbreaking because it provided evidence that the situation affected the diagnosis of mental illness rather than symptoms of the illness itself. This study also revealed that the diagnosis of a mental illness acted as a self-fulfilling prophecy, affecting the family and friends of the patient and the patient themselves. The patient could never be cured of schizophrenia but would be discharged with schizophrenia in remission. The study also revealed that the stigma of mental illness was active amongst the hospital staff responsible for the diagnosis, treatment and care of the mentally ill. These attitudes are all the more harmful because they are unconscious. Later Rosenhan in this interview observed that mental health nurses were doing the best they could, but they needed to be reminded that patients are not just a ‘collection of symptoms’ but are real people with spouses, mortgages, families and friends. This study also highlights the problem of the validity of diagnosis, which in this case was non-existent. The symptoms the pseudopatients described (hearing voices saying ‘thud’, ‘empty’ and ‘hollow’) are not part of the criteria for schizophrenia in any of the manuals, and those admitted as suffering from this disorder were not suffering from anything except a misdiagnosis.
Face validity
Face validity is when criteria appear to measure what they say they do. ADHD as an abnormal behaviour has good face validity, in that the criteria describe the behaviour involved in what is accepted cross-culturally by clinicians as ADHD (Canino and Alegria, 2008). However, the problem with criteria with clear face validity is that they are more vulnerable to a social desirability bias. Individuals may manipulate their response to deny or hide problems, or exaggerate behaviours in order to fall within the criteria.
Construct validity
Construct validity is to do with whether the diagnostic test administered can be used to support the diagnosis. Can psychologists be sure that the questions asked are valid for the disorder being tested? The only way to do this is to test the questionnaires with patients who have already been diagnosed using other measures, and look for consistency. The psychologist Aaron Beck did this with his Beck’s Depression Inventory, version 2, using 210 psychiatric outpatients, and found a high level of agreement with other scales. The criteria he used were a mixture of those found in the OCD and DSM manuals, plus agitation, concentration difficulty, worthlessness and loss of energy (Beck, 1967). He found that the questions used had high construct validity, in that those already diagnosed through other measures as having depression, also fit the criteria with their answers to his inventory.
Psychological literature exposes a number of biases that can influence one’s judgment (e.g., pathology bias, confirmatory bias, hindsight bias, misestimation of covariance, decision heuristics, false consensus effect and over-confidence in clinical judgment). Clinical judgment, the subjective method of arranging client data to establish a diagnosis and a treatment plan, can also be biased and may lead to inaccurate assessment and inefficient treatment. Taking repeated measures of symptoms, similar to the single subjects research design used in the behavioural sciences, may lead to better therapy because it reduces judgment bias.
Reliability
Reliability is basically accuracy. The two most important forms of reliability when it comes to diagnosis are inter-rater reliability and test-retest reliability.
Inter-rater reliability
Inter-rater reliability is when another mental health professional, preferably without knowing the original diagnosis and using the same classification system, comes to the same conclusion about a patient. Inter-rater reliability from one psychologist to the next can be low because disorders overlap. For example, depression and anxiety disorders have many of the same symptoms.
Test-retest reliability
This is the reliability of diagnosis over time. Disregarding those re-diagnoses that are due to changing classifications, a patient who is diagnosed by a psychiatrist with a certain disorder should, if they have not recovered, be diagnosed with the same disorder by the same clinician at any future date. The diagnosis should not change. Think of the Rosenhan study: if the mental health staff had reinterviewed the participants immediately after their admission, they should have discharged all of them. If they were admitted because they heard voices, then hearing no voices would logically be sufficient for discharge.
However, as Rosenhan points out, diagnostic labels are ‘sticky’ and all subsequent behaviour becomes interpreted in the light of the original diagnosis (1973, p. 257).
Ethical considerations
As can be seen in the previous examples and discussion, there is a large overlap between cultural and ethical considerations in diagnosis. Those not diagnosed, misdiagnosed or mistreated because of their culture are already being treated unethically. Central issues in the ethics of diagnosis are stigmatisation, self-fulfilling prophecy and confirmation bias.
Stigmatisation
The word stigma refers to shame or disgrace associated with something most people in society see as socially unacceptable. Therefore, stigmatisation of those with a mental disorder is treating them as if they should be ashamed, as if they are in disgrace, because to have a mental disorder is socially unacceptable. Before we say to ourselves that we would never do that, think about if your teacher revealed that they had previously been hospitalised for depression, or your sports coach said that they function much better when on their medication for their bipolar disorder. The very fact that this information is much less likely to be revealed than that concerning a physical problem already shows that there is a stigma attached to it. After all, your reaction if your teacher mentions, ‘Oh, yes, I broke my collar bone last year,’ is likely to be much less strong than your reaction to their previous depression.
Goffman (1961) wrote about the stigmatising consequences for the individual of labelling a particular action or pathological state as deviant, and Rosenhan’s (1973) study shows how once labelled, a person’s actions are all framed within that label.
More recently, researchers have described the experience of stigmatisation at the level of the individual, and differentiated between: self-imposed stigma due to shame, guilt and low self-esteem; socially imposed stigma due to social stereotyping and prejudice; and structurally imposed stigma, caused by policies, practices and laws that discriminate against the mentally ill.
Focus on Research
Schwenk et al. (2010) investigated the concerning prevalence of depression and suicidal thoughts among medical students, a group that may experience poor mental health care due to stigmatisation. The study was conducted in 2009, covering all students enrolled at the University of Michigan Medical School. A little more than 65% participated in the survey—505 students out of 769 enrolled. Their aim was to examine the perceptions of depressed and non-depressed medical students regarding the stigma associated with depression.
Outcomes of the study revealed that 14.3% of the students were identified as having moderate to severe depression, higher than the 10–12% range found in the population at large. The results also revealed that 53.3% of medical students who reported high levels of depressive symptoms were worried that revealing their illness would be risky. Almost 62% of the same students said asking for help would mean their coping skills were inadequate.
The researchers suggested that new approaches may be needed to reduce the stigma of depression and to enhance its prevention, detection and treatment. ‘The effective care of mental illness, the maintenance of mental health and effective emotional function, and the care of professional colleagues with mental illness could be taught as part of the ethical and professional responsibilities of the outstanding physician and become a critical component of the teaching, role modelling, and professional guidance that medical students receive as part of their curriculum in professionalism’ (Schwenk et al., 2010, p. 1189).
Self-fulfilling prophecy
A self-fulfilling prophecy is a process by which expectations of other people or groups lead those persons or groups to behave in ways that confirm those expectations. When we are labelled as something, the self-fulfilling prophecy theory would argue that we internalise this label and our belief that we are really ‘depressed’, ‘manic’, or even just ‘different’ means that we act in a way that makes this label, and the attached prediction about our behaviour, come true. In other words, the belief makes reality conform to the belief. While we may not become depressed merely by being labelled depressed, knowing that we are depressed may make us isolate ourselves and feel powerless to change our situation.
Ask YourselfAre there stereotypes about abnormal behaviour in your community?
1.5 Assessment Advice
The essay titles for Paper 2 will only use command terms that correspond to assessment objective 3. These are:
Contrast
Give an account of the differences between two (or more) items or situations, referring to both (all) of them throughout.
Discuss
Offer a considered and balanced review that includes a range of arguments, factors or hypotheses. Opinions or conclusions should be presented clearly and supported by appropriate evidence.
Evaluate
Make an appraisal by weighing up the strengths and limitations.
To what extent?
Consider the merits or limitations of an argument or concept. Opinions and conclusions should be presented clearly and supported with appropriate evidence and sound argument.
QUESTION
STUDY
QUESTIONS (ERQs)
Discuss/evaluate/contrast/to what extent?
Research methods (approaches to research) used when investigating factors influencing diagnosis
Any two studies listed below are suitable for these ERQs
Ethical considerations of research into factors influencing diagnosis
Any two studies listed below are suitable for these ERQs
Factors influencing diagnosis
There could be a question here on the role of biological factors or cognitive or sociocultural factors influencing diagnosis. Cognitive factors are addressed in the topic of clinical biases. Biological and sociocultural factors are addressed in the section on the etiology of disorders.
Normality versus abnormality
Szasz (1960)
Wakefield (2007)
Jahoda (1958)
Petersen and Seligman (2004)
Classification Systems
DSM and the ICD
The role of clinical biases in diagnosis
Burr (2002)
Tapsell and Mellsop (2007)
Mendel et al. (2011)
Validity and reliability of diagnosis
Rosenhan (1973)
Schwenk et al. (2010)
Pies (2007)
2. Etiology of Abnormal Psychology
2.1 Etiology of Major Depressive Disorder
MDD is an example of an affective disorder which are disorders related to mood. See the DSM-5 criteria below:
DSM-5 criteria for major depressive disorder (MDD)
Depressed mood or a loss of interest or pleasure in daily activities for more than two weeks.
Mood represents a change from the person's baseline.
Impaired function: social, occupational, educational.
Specific symptoms, at least five of these nine, present nearly every day:
Depressed mood or irritable most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
Decreased interest or pleasure in most activities, most of each day.
Significant weight change (5%) or change in appetite.
Change in sleep: insomnia or hypersomnia.
Change in activity: psychomotor agitation or retardation.
Fatigue or loss of energy.
Guilt/worthlessness: feelings of worthlessness or excessive or inappropriate guilt.
Concentration: diminished ability to think or concentrate, or more indecisiveness.
Suicidality: thoughts of death or suicide, or has a suicide plan. (APA, 2013b)
For the purposes of the IB Diploma, we will be examining major depressive disorder (MDD). We will start by describing the major symptoms of this disorder and then examine theories about its biological, cognitive and sociocultural causes. (Etiology refers to the study of the causes of a disorder.)
Ask YourselfDo you find any of these symptoms surprising?
The biological approach
Areas of interest to psychologists taking a biological approach to MDD have been genetic influences and biochemical imbalances.
Genetic influences and MDD
The risk of MDD rises if you have a parent or sibling with the disorder (Sullivan et al., 2000). If one identical twin has MDD, then there is an approximately 50% chance that at some time the other twin will also be diagnosed with it. Kendler et al. (2006) conducted a huge study in Sweden, with personal interviews of 42,161 twins, including 15,493 complete pairs, from the national Swedish Twin Registry. The researchers estimated the heritability of MDD at 35-40%, with heritability being significantly higher in women than men (42% to 29%).
They found that twin pair resemblance for lifetime MDD was not predicted by the number of years the twins had lived together in the home of origin or by the frequency of current contact. This tends to support the idea of a biological, rather than a sociocultural etiology.
This leads to the question as to why women should be so much more likely than men to inherit a predisposition (predisposition = tendency) to MDD, which is something that is not answered in the biological research. This gender imbalance in the incidence of MDD is something we will address when we look at sociocultural factors in etiology.
Focus on Research
Kendler et al. (2006) conducted an extensive Swedish twin study with 15,493 complete twin pairs listed in the national twin registry. You first read about this study in Chapter 4.
The researchers used telephone interviews over 4 years to diagnose major depressive disorder (MDD) based on (a) the presence of most of the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) symptoms, or (b) having had a prescription for antidepressants.
The researchers found an average concordance rate for MDD across all twins was 38%, in line with previous research. They also found no correlation between the number of years that the twins had lived together and lifetime major depression, suggesting this was a true heritability rate. The rate among female monozygotic twins was 44% and amongst males, 31%, compared with 16% and 11% for female and male dizygotic twins respectively.
If the disorder was purely genetic, we might expect the monozygotic concordance rates to be much higher. But the difference between monozygotic and dizygotic concordance rates is enough to indicate a strong genetic component.
The findings suggest that the heritability of MDD is higher in women than in men and that some genetic risk factors for MDD are sex-specific.
Biopsychologists often use correlational studies (twin and family/kinship) like this to investigate the heritability of MDD.
In an effort to try to determine the genes that put people at risk of developing MDD, some researchers have turned to linkage analysis. This involves finding families in which MDD has appeared across several generations and then examining the DNA from affected and unaffected family members, looking for differences (Plomin and McGuffin, 2003).
The study by Risch et al. (2003) shows how far psychologists and biologists have to go in trying to identify a role for any particular gene in MDD.
Focus on Research
Risch et al. (2009) investigated the genetic background to MDD and found that a certain gene variation long thought to increase risk in conjunction with stressful life events actually may have no effect. This serotonin transporter gene (5HTTLPR) was argued in a 2003 study by Caspi et al. to increase the risk of major depression in people who had a number of stressful life events over a five-year period. However, attempts to replicate these findings have had inconsistent results.
To examine whether the 2003 study's finding could be confirmed, Risch et al. reviewed relevant replication studies. The researchers did a meta-analysis, re-analysing data on 14,250 participants in 14 studies published from 2003 to 2009. Of these, the researchers also re-analysed original data, including unpublished information, on 10,943 participants from ten studies published before 2008. The data was re-analysed to see whether there were associations between the serotonin transporter gene, stressful life events and depression.
By applying the same methods used in the 2003 study, the researchers found a strong association between the number of stressful life events and risk of depression across the studies. However, the serotonin transporter gene did not show a relationship to increased risk for major depression, either alone or in interaction with stressful life events, in the analysis of the 14 studies. Recent research is still focusing on the 5HTTLPR gene, but looking at the diversity of its functions, rather than just its role with regard to serotonin.
Neurotransmission and MDD
Although there is no real clear picture concerning how depression might develop biologically, many theories have centred on the hypothesis that the transmission and reuptake of neurotransmitters, especially serotonin, dopamine and noradrenaline, underlie depression. These neurotransmitters are known collectively as the catecholamine neurotransmitters, or sometimes as monoamine oxidase (MAO) transmitters. This theory was proposed in the mid-1950s, after researchers found that drugs that affected the release and breakdown of these transmitters had varying effects on mood (Gross, 2010, p. 708). This was a huge turning point as previous treatments for depression had often involved long periods in mental institutions, undergoing such treatments as insulin comas, ECT or ‘sleep cures’. (See López-Muñoz and Alamo, 2009, for a fascinating history of the treatment for depression.)
In 1965, Schildkraut put forth the hypothesis that depression was associated with low levels of noradrenaline, and later researchers theorised that serotonin was the neurotransmitter of interest (Coppen et al., 1967). The (rather reductionist) theory that depression was caused by a lack of certain neurotransmitters, led to the development of antidepressant drugs, hailed as a major breakthrough in the treatment of MDD. A large amount of research demonstrated the effectiveness of a new drug, fluoxetine (marketed initially as Prozac), that was developed in 1988 as a replacement for the older antidepressants (tricyclics and monoamine oxidase inhibitors [MAOIs]) that targeted the enzyme monoamine oxidase, preventing it from breaking down the neurotransmitters, and so allowing them to remain active in the synaptic gap for longer.
Fluoxetine and similar drugs are selective/specific serotonin reuptake inhibitors. Because they have been successful in treating MDD, a stronger link has been established between low levels of serotonin and depression (Davison and Neale, 2001).
However, although the ‘neurochemical’ theory of depression is the longest-standing of the biological theories and the main antidepressants have an effect on levels of serotonin and noradrenaline, by the time the drugs’ effects are felt (which can be about four weeks) the levels have returned to their previous level, even though the patient is feeling better. So the lack of serotonin and noradrenaline cannot be as directly implicated in the mood disorder as claimed (Gross, 2010, p. 708).
Moreover, Lacasse and Leo argue that there is no baseline ‘normal’ level of serotonin against which to measure a depressed person’s levels, and just because aspirin cures a headache, this does not mean that the headache was caused by a lack of aspirin (2005, p. 1212). Levinson (2006) notes that the short allele on the 5-HTT gene acts the same way as Prozac – it prevents the reuptake of serotonin, but people with the short allele on this gene are more likely to suffer from depression. This means that a possible cause of depression and a possible cure for depression actually act the same way.
Therefore, it would be correct to assume that a lot more investigation needs to be undertaken into this area.
Cognitive approach
According to the cognitive model of the etiology of MDD, it is our thoughts and beliefs that shape our behaviour and emotions. The role of cognitive processing in emotion and behaviour is the main factor in determining how we perceive, interpret and assign meaning to an event (‘It is not what happens to you, it is how you feel about it.’). According to the cognitive approach, psychological distress is dependent on your personality as shaped by schemas, cognitive structure and your assumptions, acquired through your life experience and your interpretation of that experience.
The most prominent psychologist associated with this theory is Beck, who proposed that depression results when people's attributions for external events are based on maladaptive beliefs and attitudes. Beck (1967) argued that deviation from logical and realistic thinking was found at every level of depression. Some typical themes are found in the ideas of depressed patients that differ significantly from that of non-depressed individuals. Themes of low self-evaluation, ideas of deprivation, exaggeration of problems and difficulties, self-criticism, self-command and wishes to escape or die are commonly found among people with MDD. This cognitive vulnerability is a high-risk factor for depression.
The cognitive model of depression assumes three specific concepts that result in cognitive vulnerability:
the cognitive triad—a negative view of oneself, the world and the future;
schemas—patterns of maladaptive thoughts and beliefs;
cognitive errors—faulty thinking accompanied by negative and unrealistic representations of reality (Beck, 1967 and 1979).
Cognitive Triad—a pattern of reportable depressive thoughts that consist of:
A negative view of the self which is perceived as deficient, inadequate, or unworthy. Depressed people see themselves as inadequate, incapable of success and always as a victim of circumstances.
A negative view of the world, as interactions with others and life, in general, are perceived as difficult or hopeless. Depressed people consider all past and present experiences through a lens of negativity, constantly emphasising defeats and failures, and showing a victim mentality.
A negative view of the future in that current difficulties or suffering are seen as continuing indefinitely. When depressed people view the future, they see only despair and hopelessness.
Schemas—maladaptive beliefs and attitudes that become active when we are under stress, especially during bad circumstances. In other words, it is how we interpret the world around us and how we assign positive and negative meaning to whatever happens to us.
Cognitive Errors—these are also known as cognitive distortions. They are inaccurate thoughts that are usually used to reinforce negative thinking or emotions — telling ourselves things that sound rational and accurate, but really only serve to keep us feeling bad about ourselves. For instance, a person might tell themselves, ‘I always fail when I try to do something new; I, therefore, fail at everything I try.’ This is an example of ‘black or white’ (or polarised) thinking. The person is only seeing things in absolutes — that if they fail at one thing, they must fail at all things. If they added, ‘I must be a complete loser and failure’ to their thinking, that would also be an example of overgeneralisation — taking a failure at one specific task and generalising it to their very self and identity. Grohol (2009) lists 15 common cognitive distortions, of which polarised thinking and overgeneralisation are just two.
Focus on Research
A recent study by Haeffel and Hames (2013) investigated if changes in cognitive vulnerability would occur during major life transitions, such as starting college. They tested the hypothesis that cognitive vulnerability could change via a contagion effect. In other words, the negative cognitive thought patterns associated with vulnerability to depression could be ‘caught’ from one’s roommate. They tested this hypothesis with a sample of randomly assigned college roommate pairs (103 pairs of students new at college) and found that participants who were randomly assigned to a roommate with high levels of cognitive vulnerability were likely to ‘catch’ their roommate’s cognitive style and develop higher levels of cognitive vulnerability. Moreover, those who experienced an increase in cognitive vulnerability had significantly greater levels of depressive symptoms over the time of the study than those who did not.
Beshai et al. (2012) conducted a cross-cultural study of depressed individuals in Canada (186 participants) and Egypt (150 participants) to test Beck's (1979) cognitive triad theory, which states that depressed individuals hold negative, automatic thoughts about the self, the world and the future. Despite the central role in Beck’s theory of the cognitive triad, it has rarely been tested cross-culturally.
This study examined the relationship between feeling unhappy over a long period and a number of inventories designed to assess negative cognitions. Unhappy and anxious individuals in both countries harboured significantly more negative thoughts towards self, world and future than a control group. Additionally, Egyptian participants showed significantly more negative thoughts toward self and the world than their Canadian counterparts even after controlling for feelings of unhappiness. This research supports the cross-cultural validity of the cognitive theory for MDD.
To summarise, cognitive theories assume that people's attributions for events, their perceptions of control and self-efficacy, and their beliefs about themselves and the world influence their behaviours and emotions when reacting to a situation. In general, an individual with various maladaptive beliefs and attitudes becomes more vulnerable to depression because of his or her generalised negative belief pattern.
Sociocultural factors
Psychologists taking a sociocultural approach focus on the role played by social and cultural factors in the development of MDD. According to the statistics, after the age of 15, girls and women are twice as likely as boys and men to be diagnosed with the major depressive disorder (see Nolen- Hoeksema and Girgus, 1994). While biologists have pointed at hormone differences related to the menstrual cycle as likely triggers for depression, sociocultural psychologists have argued that adolescence for girls is a time of restrictions on their choices and devaluation based on their gender. Coupled with the social pressure on females to internalise feelings of anger and be unassertive in the face of challenges, depression seems a likely outcome (Nolen-Hoeksema and Girgus, 1994).
Poverty and isolation have also been argued to be factors in the development of MDD. Nicholson et al. (2008) found that men in the most economically and socially disadvantaged groups in Poland, Russia and the Czech Republic were five times more likely to report depressive symptoms than were richer citizens. Given that poor men and richer men share the same biology, sociocultural factors could be assumed to play a relevant role here.
Focus on Research
Nicholson et al. (2008) investigated the extent of social inequalities in depression in Eastern Europe, the relative importance of social position at different points in the life-course and whether social patterns differs between men and women.
The study was a cross-section survey of 12,053 men and 13,582 women in Russia, Poland and the Czech Republic. Participants were surveyed about three points in their lives: childhood (their access to household amenities like hot water, refrigeration etc. and the education level of their father), their education (primary, secondary, vocational and tertiary) and their current social-economic circumstances (ownership of household items, e.g. mobile phones and tv and lack of finances to buy goods and pay bills,).
Results included the following:
The prevalence of depression was higher in women than all men in all countries.
Men in the most disadvantaged groups were five times more likely to report high depressive symptoms.
Men and women in all counties with few amenities and more financial difficulties were more likely to report depressive symptoms.
Lower education was associated with depression in all counties and both sexes.
Conclusions
These results indicate that the determinants of depression may differ between stable, affluent countries in the western world and countries where economic and social conditions are more challenging.
Social circumstances are the primary influence on increased depressive symptoms of countries recently experiencing social changes.
Diathesis-stress model of etiology
A diathesis-stress model of the etiology of mental disorder sees an interaction of biological, cognitive and sociocultural factors as responsible for the disorder. For example, what we inherit from our parents is a genetic predisposition for MDD (biological). This would explain the high correlation for MDD seen in identical twins. However, it is not a perfect correlation. As the studies examined earlier showed, it is around 30% or 40%. Environmental triggers account for whether or not the inherited predisposition results in mental disorder (sociocultural).
As well as biological predispositions which are triggered environmentally, Haeffel and Hames’ (2013) study of the new college students mentioned earlier shows that a stressful life event (sociocultural) and a roommate who is cognitively vulnerable (sociocultural) can trigger cognitive vulnerability (cognitive) in those predisposed to it.
Ask YourselfWhich explanation of the causes of abnormal behaviour makes the most sense to you?
2.2 Prevalence Rates of Depression
It is very difficult to place a figure on the percentage of the world’s population that are suffering at any one time from MDD. The Global Burden of Disease (2010) study tried to do this with many physical and mental disorders. Ferrari et al. (2013) explain how data was gathered to determine prevalence rates of MDD (See Focus on Research).
Gender
To summarise, the figures in the Global Burden of Disease (Spencer et al.,2017) study gave the prevalence of MDD worldwide in 2015 as 4.4%. Depression was more common among females (5.1%) than males (3.6%). Prevalence rates varied by age, peaking in older adulthood (above 7.5% among females aged 55-74 years, and above 5.5% among males).The total estimated number of people living with depression increased by 18.4% between 2005 and 2015.
Biological factors include differences in hormones and genes.
Cognitive factors account for why women may be more prone to lowered mood and guilt.
Sociocultural factors include:
women are more likely to go to the doctor when they feel depressed;
male doctors, having stereotypical beliefs about women, are more likely to diagnose them as depressed;
women are more isolated than men, often being at home with children.
Culture
All of the cultural considerations that have already been discussed must be taken into account when evaluating prevalence data on MDD (culture blindness, reporting bias, cross-cultural variation in symptoms, etc.). The National Institute for Mental Health puts the prevalence of MDD in the United States at 6.7% and any internet search will come up with varying statistics for different regions of the world.
Focus on Research
Ferrari et al. (2013) conducted a study of the literature in order to present a global summary of the prevalence and incidence of MDD, accounting for sources of bias and dealing with heterogeneity.
They undertook a systematic review of prevalence and incidence of MDD by searching electronic databases like Medline, PsycINFO and EMBASE.
The results suggested that there were over 298 million cases of MDD globally at any point in time in 2010, with the highest proportion of cases occurring between 25 and 34 years of age. Prevalence was very similar across time (4.4% in 1990, 4.4% in 2005 and 2010), but higher in females (5.5%) compared to males (3.2%) in 2010.
Regions in conflict had a higher prevalence than those with no conflict. The annual incidence of an episode of MDD followed a similar age and regional pattern to prevalence but was about one and a half times higher, consistent with an average duration of 37.7 weeks.
There is a direct link between the beliefs regarding the etiology of disorders and the therapeutic approach taken to treat them.
2.3 Assessment Advice
QUESTION
STUDY
QUESTIONS (ERQs)
Discuss/evaluate/contrast/to what extent?
Research methods (approaches to research) used when investigating the etiology of MDD
Any two studies listed below are suitable for these ERQs
Ethical considerations of research into the etiology of MDD (etiology of disorders)
Any two studies listed below are suitable for these ERQs
The etiology of MDD. You may be asked to discuss/evaluate/contrast two explanations of MDD.
Depends on your choice of explanations.
Biological explanations for MDD.
Kendler (2006)
Risch et al. (2009)
Cognitive explanations for MDD.
Beck (1967)
Haeffel & Hames (2013)
Sociocultural explanations for MDD.
Tapsell & Mellsop (2007)
Nicholson et al. (2008)
Prevalence rates of MDD.
Ferrari et al. (2013)
Global Burden of Disease (2017)
3. Treatment of Disorders
3.1 Biological Approach to Treatment
Biological (also referred to as biomedical) approaches to treatment assume that MDD is caused by malfunction of the brain, especially mechanisms involving neurotransmission. Therefore, drugs or therapy that aim to redress this insufficiency are the preferred biomedical approach.
There are three main categories of drugs for MDD: two older groups—tricyclics and MAO-inhibitors are effective, but have troublesome side effects and can be lethal if misused. One of the most popular of the SSRIs is fluoxetine (Prozac). The main criticism of any drug therapy is that it treats the symptoms, but does not cure the disorder, and the medication needs to be continued for the effect to be maintained. Moreover, many drugs have significant side effects that can outweigh the benefits felt from them. On the other hand, patients do not attempt suicide as they did with earlier drugs.
It is difficult to assess the effectiveness of anti-depression medication, as we cannot know what the course of the MDD would have been if the patient had not taken the medication. One way to address this is by using trials comparing a group of patients who have taken medication for MDD and a control group who have taken a placebo. Kirsch et al. conducted a meta-analysis that suggested that there is only a small difference in efficacy between taking a placebo and taking medication (2008, cited in Law et al., 2010).
However, many new drugs are being investigated. One surprising candidate is ketamine, an anaesthetic that is also sold on the street illegally under names such as Special K. In a recent trial, it snapped people out of depression almost instantly, unlike available medications that often take weeks to work (Berman et al., 2000) and it has been used in a maintenance programme to produce long-term recovery (Messer and Haller, 2010). Ketamine acts on different neurotransmitter receptors (glutamate, rather than serotonin) than current antidepressants do. The problem is that it affects parts of the brain not related to depression, and the drug can also cause hallucinations, so may not be suitable for all patients.
Electroconvulsive therapy (ECT)
This is a kind of psychiatric therapy that involves giving a short electrical stimulus to the brain through tiny electrodes in the temples. The charge lasts from 1 to 4 seconds and it causes epileptic-like seizures to the patient. The patient is, however, anaesthetised and is given a muscle relaxant to depress breathing. Oxygen is given until the patient is able to breathe normally again. The majority of patients would receive six to twelve ECT sessions for a whole treatment, given one electrical charge per day, two or three times in a week.
Electroconvulsive therapy is sometimes used for people with MDD for whom drug treatment fails. Lapidus et al. (2013) note that a low-dose ECT treatment to the right side of the brain only has an immediate antidepressant effect, and higher repeat doses are not needed. Both drugs and ECT are often more effective when combined with psychotherapy.
Focus on Research
Duman and Aghajanian (2012) conducted research into the changes in the neurons and in the synaptic gap during MDD. They conducted a meta-analysis of clinical studies that demonstrate that depression is associated with reduced size in brain regions that regulate mood and cognition, including the prefrontal cortex and the hippocampus, and decreased neuronal synapses in these areas. Antidepressants can block or reverse these neuronal deficits, but typical antidepressants have limited efficacy and delayed response times of weeks to months. They comment that a notable recent discovery shows that ketamine produces rapid (within hours) antidepressant responses in patients who are resistant to typical antidepressants. Basic studies show that ketamine rapidly induces synaptic gap action and reverses the synaptic deficits caused by chronic stress.
3.2 Psychological Treatments of Depression
Cognitive-behavioural therapy
Beck laid major emphasis on understanding and changing core psychological beliefs as an approach to treating depression. By restructuring negative thinking, he believed that positive changes could be made in the depressed client. He considered the role of a therapist as crucial in the treatment. The therapist involves the client in setting realistic goals and taking responsibilities for action and thought. By changing thought and perception, a change can be brought in behaviour and emotional responses. A course is outlined to educate the client on the concept of faulty thinking. New ideas and ways of thinking are generated to develop a positive outlook on oneself, one’s experiences and the environment around. Sometimes, home assignments are also given to help the depressed person review and understand the impact of faulty thinking on behaviour and emotional well-being.
Cognitive-behavioural therapy (CBT) emerged from Beck’s theory as to the causes of depression. It is the most common psychological treatment for MDD. Cognitive-behavioural therapy (CBT) is a term that encompasses numerous specific treatment approaches. As the name suggests, cognitive-behavioural treatments incorporate both cognitive and behavioural strategies. With regard to depression, CBT refers to the use of both cognitive restructuring and the behavioural strategy of activity scheduling or behavioural activation. In other words, it addresses the underlying negative thoughts that lead to the depression and helps the person see that these thoughts are faulty and are responsible for their emotional state.
Beck and Weishaar (1989) believe that in order to treat MDD, clients need to treat their faulty interpretations and conclusions as testable hypotheses. The role of the therapist in a cognitive-behavioural intervention is to help the clients examine alternative interpretations and to produce contradictory evidence in order to move to cognitive restructuring, whereby the client revises and replaces his/her faulty thoughts and beliefs. It is the thought that counts.
Cognitive-behaviour group therapy
Cognitive-behaviour group therapy (CBGT) may be defined as therapy that uses the dynamics of the group format, in addition to the common cognitive behavioural therapy techniques to change distorted, maladaptive and dysfunctional beliefs, interpretations, behaviours and attitudes (Bieling et al., 2006).
CBGT has been shown to be effective in residential settings, as well as in outpatient clinics. Hunter et al. (2012) found that CBGT was an effective treatment for major depression for clients in residential substance abuse treatment programmes, resulting in a decrease in symptoms of depression and a decrease in substance abuse after discharge. The theory behind group therapy for MDD is that people may feel more compelled to engage in group discussion than they are when alone with a therapist. They may also learn from hearing about the experiences of others in similar circumstances. If through the group they meet others who have recovered or improved, they may also feel more hopeful about their own chances of doing the same.
Eclectic approaches
An eclectic approach is an approach that combines two or more techniques for treatment. The treatment is adapted to suit the needs of the individual or group. Sometimes patients receive drug therapy in combination with psychological treatment, and half of all therapists describe themselves as taking an eclectic approach (Myers, 2010). Many combinations are possible, but the most common is drug therapy and CBT combined.
There are different types of eclectic approach. The most common is simultaneous use, which is using certain therapies at the same time. Sequential use is when one therapy follows another, and stage-oriented use is when one therapy is used at the critical stage and other(s) are introduced at the maintenance stage. Stage-oriented therapy often involves drug use to stabilise behaviour and emotions so that the person may benefit from CBT at the maintenance stage.
Lebow (2002) gives a list of advantages of the eclectic approach:
An eclectic approach has a broader theoretical base and therefore may be more sophisticated than an approach using only one theory.
There is greater flexibility offered to the client, and individual therapy needs may be met.
There is more chance of finding an effective treatment if two approaches are used in tandem.
This approach is suitable for a wider range of clients than a single approach.
A therapist using an eclectic approach is not biased towards one treatment theory and method, and therefore may be more objective.
A therapist using an eclectic approach can revise and rebalance treatment according to which approach appears to be most effective.
However, he warns that the eclectic approach should not be the same as having any clear idea of what would work and nor should it be applied inconsistently. Sometimes the approach is too complex for one therapist to undertake, and finally, all treatment, eclectic or not, should only be used if backed up by evidence from previous studies that it works.
Petersen et al. (2007) write that drug/psychotherapy combinations are useful, so long as the two are combined in specific ways. Recent research (Fava et al., 2005) has suggested that sequential administration of antidepressant and psychotherapeutic treatments, with the therapy coming after the acute-phase drug response, may be more protective against relapse and recurrence than simultaneous treatment.
Focus on Research
A study by Elkin et al. (1989) is valuable as it compares different approaches to treatment. This was a double-blind design study with 250 randomized participants. This study aimed to investigate the efficacy of three different treatments [efficacy = the power to produce an effect]. The study compared CBT, SSRIs, and interpersonal therapy (a psychological therapy similar to CBT). There was also a placebo group in this study. The study found the quickest improvement from those on antidepressants but, with time (a few weeks), there was also an improvement from those in both types of therapy. Over 50% of the participants were considered recovered after months of treatment in each treatment group. 29% recovered in the placebo group, which was statistically significantly lower. There was no statistically significant difference across the treatment groups in terms of efficacy. The study had a large sample and was carefully controlled. It was also a double-blind study. It demonstrated strong reliability, validity, and low researcher bias. Nearly 50% of the participants in the treatment groups did not recover. That may be worth evaluating. What other factors may impact treatment and recovery? As well, medical researchers continue to improve on SSRIs. Therefore, the results could change over time.
3.3 The Role of Culture in Treating Depression
There are two aspects of the role of culture in treatment: the mental health professional should be competent in providing therapy to a person of various cultures, and the therapy itself should be sensitive to the culture of the client. For example, Yeung and Kam (2006) argue that Chinese clients may present depression in a different way to Americans and Europeans. They reported that only a small proportion (14%) of Asian American patients spontaneously described symptoms such as depressed mood, irritability, rumination and poor memory but a much higher proportion (76%) of patients with depression presented with physical symptoms as their chief complaint. In this and other cross-cultural contexts, a therapist should show cultural competence by understanding how a patient’s beliefs will affect the presentation of symptoms and acceptance of a diagnosis like depression. A culturally-sensitive psychological evaluation is essential.
Once a valid diagnosis has been determined, a mental health professional should understand that therapy may need to be modified. Gross (2010) gives a number of examples:
A therapist should understand that social roles within Asian families are often clearly defined and structured by age and sex, such that a father’s authority is rarely challenged within the family. Growing up in such a culture may play an important part in shaping the values a patient brings to therapy.
Similarly, a therapy that emphasises individual autonomy over family loyalties might inadvertently violate the patient’s cultural traditions and so be counterproductive.
A therapist who expects their patients to take responsibility for making changes in their lives may be ineffective with patients whose cultural worldview stipulates that important events are caused by factors such as fate, chance, or powerful others.
Practitioners who consider psychotherapy a secular (secular = non-religious) endeavour would do well to remember that in many cultures, any kind of healing must acknowledge the patient’s spirituality.
Focus on Research
Qiu et al. (2013) designed a study to investigate the effectiveness of GCBT in treating major depression in Chinese women with breast cancer. Group Cognitive-Behaviour Therapy or (GCBT), is similar in approach to Cognitive-Behavioural Group Therapy, (CBGT) discussed above. Sixty-two breast cancer patients diagnosed with major depression were randomly assigned to the GCBT group (N = 31) or a waiting list control group provided with an educational booklet (N = 31). Data was gathered from self-reports of depression and it was found the GCBT group had a significant reduction in depression compared to the control group. The results of this trial suggest that GCBT is effective for treating major depression, as well as for improving quality of life and self-esteem in breast cancer patients.
The Asian American Mental Health Services organisation has developed an awareness of cultural issues in treatment since it was set up to serve Asian Americans in New York City. The staff are Asian, and they possess specialised knowledge and skills about delivering mental health services to Asians. They know, for instance, that when a client comes in complaining of an inability to move a part of the body, it's important to conduct a culturally-sensitive psychological evaluation, rather than automatically sending the client away for a physical check-up. The program operates a Chinese unit, which has a continuing treatment program for patients who are chronically mentally ill. There is also a Japanese unit, a Korean unit and a Southeast Asian unit, all with outpatient clinics. For Asian Americans, the key factors to consider are the educational background of clients who come to the clinic for help and the degree of acculturation that has taken place. Some clients interpret mental illness as punishment for some wrongdoing carried out by themselves, by their family members, or by their ancestors. In this interview in 2016, (Gluck, 2017) observed that many Chinese Americans feel ashamed to seek or participate in treatment. For most Asian Americans, the individual is commonly viewed as a reflection of the entire family and Lee, a Chinese practitioner, recommends that the whole family should be included in treatment.
Lee provides a case study of how culture should be considered in treatment. She describes how the husband of a Cambodian woman suffering from depression was against her receiving treatment from the Asian American Mental Health Services clinic. He believed that she was being haunted by evil spirits. A treatment programme was designed that combined a standard treatment for depression with cultural practices designed to ward off bad spirits. Lee argues that by including and respecting the cultural practices, successful outcomes were more likely.
Focus on Research
Ward and Brown (2015) aimed to determine the efficacy of a culturally adapted treatment for African Americans experiencing MDD. This treatment, Oh Happy Day Class (OHDC), involved a 2.5-hr weekly, culturally specific CBGT for 12 weeks. The course involved learning skills to cope with depression. The course content included African-American cultural beliefs and humanistic principles originating in Africa. African American clinicians delivered the course, and topics included anger management, forgiveness and constructive thinking.
Two pilots using a one-group pretest-posttest design were conducted with a sample of male and female participants from a suburban city in the Midwest of the USA. Local clinics and other community groups recommended participants. Pilot I consisted of 18 women with a mean age of 75. Pilot II consisted of 18 women and 17 men with a mean age of 51years.
The participants completed several psychological tests and surveys to measure their level of depression, cognitive functioning, quality of life, physical health and attitudes towards seeking mental health services. The measures of depression were administered before the course and then after 6 and 12 weeks. They were tested again 12 weeks after the end of the course.
Pilot I showed a statistically significant decline in depression symptoms from pre- to post-intervention of the 73% of participants who completed the entire course. 66% of participants completed the full OHDC in Pilot II. Results showed that there was a significant decrease in depression symptoms for both men and women. Participants reported being satisfied with the OHDC. However, there was no change in attitudes toward seeking mental health services.
The investigators concluded that these were promising findings for a culturally adapted treatment for depression. They saw the need for further research on the efficacy of the OHDC in a large-scale, randomised, control trial.
Ask YourselfDo you think this approach is effective or should traditional cultural beliefs like evil spirits be ignored or even challenged?
3.4 Assessing the Effectiveness of Treatments for Depression
Biological treatments
There is a long history of treating MDD with different types of drug. While some are undoubtedly effective in reducing symptoms, there are also problems of addiction and side effects, and the criticism that they treat symptoms rather than the disorder itself are valid.
Strengths of biological treatments for mental disorders
If drug therapy or ECT succeeds in reducing the symptoms of psychologically crippling mental disorders, then this in itself has to be seen as a huge advantage. Research suggests that in many cases symptoms lessen in severity, especially when used in tandem with psychotherapy (Cuijpers et al., 2010). For some people, just having a label to attach to their feelings, and being told that medication might help, may be enough to make them feel somewhat better. In the case of MDD, if providing medication is continued for at least nine months after the symptoms have gone, then the chance of relapse is greatly reduced.
Limitations of biomedical treatment for MDD
The antidepressants prescribed can be physically and psychologically addictive. There are many documented side effects, and most antidepressant medication takes at least four weeks to start working. They treat the symptoms, but unless the cause of the disorder is addressed, it is likely that it will recur.
While ECT has been shown by many studies to reduce the symptoms of MDD there is still no clear picture of exactly how it works, which makes its use controversial. It also has, usually temporary, effects on a person’s memory, which can be distressing. See Read and Bentall’s research below:
Focus on Research
Read and Bentall (2010) conducted a meta-analysis of studies on the efficacy of electroconvulsive therapy (ECT) for the treatment of depression. Using databases of studies and previously conducted meta-analyses, they identified all studies that compared ECT with simulated-ECT (SECT). (Simulated ECT acted as a placebo.) They found that there was minimal support for the effectiveness of ECT compared to simulated ECT. They argued that the cost-benefit analysis for ECT is so poor that its use cannot be scientifically justified. They noted that there was strong evidence of persistent, and for some, permanent retrograde and anterograde amnesia.
In general, the biomedical approach is reductionist and fails to take a holistic approach, instead focusing on particular neurotransmitters. MDD can be a symptom of something very wrong in a person’s life that will not be immediately apparent and may take long sessions of therapy to uncover. According to Halligan (2007), it is crucial to take a biopsychosocial rather than a biomedical perspective and reject the belief that illness is the result of discrete biological processes. Instead, illnesses and mental disorders can be meaningfully explained in terms of cognitive and sociocultural factors, and consideration of these has to form part of the treatment.
Psychological treatments
Strengths of individual CBT for MDD
The CBT model has great appeal, because, unlike biomedical treatments, it puts control in the hands of the client, rather than the psychologist or psychiatrist. Cognitive theories lend themselves to testing as many people with psychological disorders, particularly depressive, anxiety, and sexual disorders, have been found to display maladaptive assumptions and thoughts. Cognitive therapy has therefore been found to be very effective for treating these types of mental disorder (Beck et al.,1989).
Studies confirming the efficacy of CBT have been criticised for a lack of rigour (Kramer, 2008). One of the most enduring criticisms of CBT is that it does not put enough emphasis on a person’s emotional life. CBT theory contends that what you feel is somehow not very important to why you do what you do and think what you think. It has been described by Rowe (2008) as a ‘quick fix’ that simplifies the assault to the sense of self that lies at the heart of mental distress.
Limitations of individual CBT for MDD
The maladaptive cognitions seen in psychologically-disturbed people could be a consequence of their mental disorder, rather than a cause. The cognitive model is narrow in scope—thinking is just one part of human functioning, and maybe broader (biological and/or sociocultural) issues need to be addressed. For people who have difficulty expressing themselves verbally, CBT may prove impossible.
Focus on Research
Clarke et al. (1999) examined the effectiveness of cognitive-behavioural therapy (CBT) for depressed adolescents. Adolescents with major depression (N = 123) were randomly assigned to one of three eight-week conditions: adolescent group CBT (16 two-hour sessions); adolescent group CBT with a separate parent group; or control on a waiting list. Subsequently, participants completing the CBT groups were randomly reassigned to one of three conditions for the 24-month follow-up period: assessments every four months with extra (‘booster’) CBT sessions; assessments only every four months; or assessments only every 12 months. The CBT groups yielded higher major depression recovery rates (66.7%) than the control (48.1%), and greater reduction in self-reported depression. Outcomes for the adolescent-only and adolescent + parent conditions were not significantly different. Rates of recurrence during the two-year follow-up were lower than those found with treated adult depression. The booster sessions did not reduce the rate of recurrence in the follow-up period but appeared to accelerate recovery among participants who were still depressed at the end of the acute phase.
QUESTION
STUDY
QUESTIONS (ERQs)
Discuss/evaluate/contrast/to what extent?
Research methods (approaches to research) used when investigating the treatment of MDD.
Any two studies listed below are suitable for these ERQs.
Ethical considerations of research into the treatment of MDD.
Any two studies listed below are suitable for these ERQs.
Biological treatments of MDD.
Duman & Aghajanian
Read and Bentall (2010)
Psychological treatments of MDD.
Beck & Weishaar (1989)
Lebow (2002)
The role of culture in the treatment of MDD.
Qiu et al. (2013)
Ward & Brown (2015)
The effectiveness of treatment of MDD.
Read & Bentall (2010)
Clarke et al. (1999)
Elkins et al. (1989)
Further Reading
The Pamoja Teachers Articles Collection has a range of articles relevant to your study of the sociocultural approach to understanding behaviour.
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