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 Yourself

Do 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.

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 Yourself

Do 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:

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.

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.

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).

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.

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.

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 Yourself

Are 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:

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:

1. 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).

2. Decreased interest or pleasure in most activities, most of each day.

3. Significant weight change (5%) or change in appetite.

4. Change in sleep: insomnia or hypersomnia.

5. Change in activity: psychomotor agitation or retardation.

6. Fatigue or loss of energy.

7. Guilt/worthlessness: feelings of worthlessness or excessive or inappropriate guilt.

8. Concentration: diminished ability to think or concentrate, or more indecisiveness.

9. 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 Yourself

Do 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.

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.

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.

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.

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 Yourself

Which 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.

2.3 Assessment Advice

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.

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.

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.

Ask Yourself

Do 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:

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.

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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