Psychopathology
A-level Revision
Notes AQA(A)
WHAT YOU NEED TO KNOW
Definitions of Abnormality:
Statistical Infrequency, Deviation from Social Norms, Failure to Function
Adequately, Deviation from Ideal Mental Health.Biological Approach to OCD:
Characteristics, Genetic Theory, Neural theory, Drugs.Cognitive Approach to
Depression: Characteristics, Beck’s Negative Triad, Ellis’s ABC Model, CBT.Behavioural Approach to
Phobias: Characteristics, Two-Process Model, Systematic Desensitisation,
Flooding.
Statistical Infrequency
AO1
Under
this definition of abnormality, a person's trait, thinking or behavior is
classified as abnormal if it is rare or statistically unusual. With this
definition it is necessary to be clear about how rare a trait or behavior needs
to be before we class it as abnormal
For
instance one may say that an individual who has an IQ below or above the
average level of IQ in society is abnormal.
However
this definition obviously has limitations, it fails to recognize the
desirability of the particular behavior.
Going
back to the example, someone who has an IQ level above the normal average
wouldn't necessarily be seen as abnormal, rather on the contrary they would be
highly regarded for their intelligence.
This
definition also implies that the presence of abnormal behavior in people should
be rare or statistically unusual, which is not the case. Instead, any
specific abnormal behavior may be unusual, but it is not unusual for people to
exhibit some form of prolonged abnormal behavior at some point in their lives.
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Strengths
This
definition can provide an objective way, based on data, to define abnormality
if an agreed cut-off point can be identified.
Limitations
However,
this definition fails to distinguish between desirable and undesirable
behavior. Statistically speaking, many very gifted individuals could be
classified as ‘abnormal’ using this definition. The use of the term ‘abnormal’
in this context would not be appropriate.
Many rare
behaviors or characteristics (e.g. left handedness) have no bearing on
normality or abnormality. Some characteristics are regarded as abnormal
even though they are quite frequent. Depression may affect 27% of elderly
people (NIMH, 2001). This would make it common but that does not mean it
isn’t a problem
Deviation from Social Norms
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A
person's thinking or behavior is classified as abnormal if it violates the
(unwritten) rules about what is expected or acceptable behavior in a particular
social group. Their behavior may be incomprehensible to others or make others
feel threatened or uncomfortable. Social behavior varies markedly when
different cultures are compared.
For
example, it is common in Southern Europe to stand much closer to strangers than
in the UK. Voice pitch and volume, touching, direction of gaze and acceptable
subjects for discussion have all been found to vary between cultures.
With this
definition, it is necessary to consider: (i) The degree to which a norm is
violated, the importance of that norm and the value attached by the social
group to different sorts of violation. (ii) E.g. is the violation rude,
eccentric, abnormal or criminal?
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Strength
This
defintion gives a social dimension to the idea of abnormality, which offers an
alternative to the 'sick in the head' individual.
Limitations
Social
norms can vary from culture to culture. This means that what is considered
normal in one culture may be considered abnormal in another. This definition of
abnormality is an example of cultural relativism.
One
limitation of the deviation of social norms definition is that norms can vary
over time. This means that behavior that would have been defined as abnormal in
one era is no longer defined as abnormal in another. For example drink driving
was once considered acceptable but is now seen as socially unacceptable whereas
homosexuality has gone the other way. Until 1980 homosexuality was considered a
psychological disorder by the World Health Organization (WHO) but today is
considered acceptable.
Failure to Function Adequately
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Failure
to function adequately (FFA) refers to abnormality that prevent the person from
carrying out the range of behaviors that society would expect from them, such
as getting out of bed each day, holding down a job, and conducting successful
relationships etc.
Rosenhan
& Seligman suggested seven criteria that are typical of FFA. These include
personal distress (e.g. anxiety or depression), unpredictably (displaying
unexpected behaviors and loss of control) and irrationality among others. The
more features of personal dysfunction a person has the more they are considered
abnormal.
To assess
how well individuals cope with everyday life, clinician use the Global
Assessment of Functioning Scale (GAF), which rates their level of social,
occupational and psychological functioning.
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Strengths
The
definition provides a practical checklist of seven criteria individuals can use
to check their level of abnormality.
It
matches the sufferers' perceptions. As most people seeking clinical help
believe that they are suffering from psychological problems that interfere with
the ability to function properly, it supports the definition.
Limitations
FFA might
not be linked to abnormality but to other factors. Failure to keep a job may be
due to the economic situation not to psychopathology.
Cultural
relativism is one limitation; what may be seen as functioning adequately in one
culture may not be adequate in another. This is likely to result in different
diagnoses in different cultures.
FFA is
context dependent; not eating can be seen as failing to function adequately but
prisoners on hunger strikes making a protest can be seen in a different light.
Deviation from Ideal Mental Health
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Jahoda
suggested six criteria necessary for ideal mental health. An absence of any of
these characteristics indicate individuals as being abnormal, in other words
displaying deviation from ideal mental health.
- Resistance
to stress: Having effective coping strategies and being able to cope with
everyday anxiety provoking situations.
- Growth,
development or self-actualisation: Experiencing personal growth and
becoming everything one is capable of becoming.
- High
self-esteem and a strong sense of identity: Having self-respect and a
positive self-concept.
- Autonomy:
Being independent, self-reliant and being able to make personal decisions.
- Accurate
perception of reality: Having an objective and realistic view of the
world.
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Limitations
Difficulty
of meeting all criteria, very few people would be able to do so and this
suggests that very few people are psychologically healthy.
Cultural
relativism: hese ideas are culture-bound, based on a Western idea of ideal
mental health, and should not be used to judge other cultures.
AO2 Exam Style Question
'The following article appeared in a magazine: Hoarding disorder –
A ‘new’ mental illness Most of us are able to throw away the things we don’t
need on a daily basis. Approximately 1 in 1000 people, however, suffer from
hoarding disorder, defined as ‘a difficulty parting with items and possessions,
which leads to severe anxiety and extreme clutter that affects living or work
spaces’.
Apart
from ‘deviation from ideal mental health’, outline three definitions of
abnormality. Refer to the article above in your answer. (6 marks)
Characteristics of OCD
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Obsessive
Compulsive Disorder (OCD) is an anxiety disorder characterised by intrusive and
uncontrollable thoughts (i.e. obsessions), coupled with a need to perform
specific acts repeatedly (i.e. compulsions).
Common
clinical obsessions are fear of contamination (esp. being infected by germs),
repetitive thoughts of violence (killing or harming someone), sexual obsessions
and obsessive doubt. Compulsions are the behavioral responses intended to
neutralize these obsessions.
The most
common compulsions are cleaning, washing, checking, counting and touching. To
the compulsive these behaviors often seem to have magical qualities. If they
are not performed exactly “something bad” will happen.
Some
O.C.D. sufferers will meticulously perform their rituals hundreds of times and
experience extreme anxiety if prevented from carrying them out.
Cleaning/washing rituals are more common in women; checking rituals are more
common in men.
Cognitive (What do you THINK?):
Obsessions dominate ones thinking and are persistent and recurrent thoughts
images or beliefs entering the mind uninvited and which cannot be removed. At
some point during the course of the disorder the person has recognized that the
obsessions or compulsions are excessive or unreasonable.
Emotional (How do you FEEL?):
Obsessive thoughts often lead to anxiety, worry and distress.
Behavioral (How do you BEHAVE?): Compulsions are the
repetitive behavioral responses intended to neutralize these obsessions, often
involving rigidly applied rules. Most OCD sufferers recognise their compulsions
as unreasonable, but believe something bad will happen if they don’t perform
that behavior.
A02 Exam Style Question
Steven describes how he feels when he is in a public place. I
always have to look out for people who might be ill. If I come into contact
with people who look ill, I think I might catch it and die. If someone starts
to cough or sneeze then I have to get away and clean myself quickly.
Outline
one cognitive characteristic of OCD and one behavioral characteristic of OCD
that can be identified from the description provided by Steven. (2 marks)
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The
approach can also be criticised for ignoring environmental influences. For
example, people are not born with OCD they might learn it from their
environment through the process of classical and operant conditioning.
Strengths
of this approach include its testability via neuroscience research, evidence
for genetic and neurotransmitter involvement in conditions such as
schizophrenia. For example, the dopamine hypothesis argues that elevated levels
of dopamine are related to symptoms of schizophrenia.
Biological
explanations are reductionist as they focus on only one factor and at present
our understanding of biochemistry is oversimplified. This means other
psychological factors, such as cognitions are ignored.
The
biological explanations are also deterministic because they ignore the
individual’s ability to control their own behavior, which in turn may affect
their biochemistry levels.
Genetic Explanations
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Genetics
is the study of genes and inheritance. OCD seems to be a polygenic condition,
where a number of genes are involved in its development. Family and twin
studies suggest the involvement of genetic factors. The prevalence of OCD in
the random population (about 2–3%) is the baseline against which the concordance
rates can be compared.
The SERT
gene (Serotonin Transporter) appears to be mutated in individuals with OCD. The
mutation causes an increase in transporter proteins at a neuron’s membrane.
This leads to an increase in the reuptake of serotonin into the neuron which
decreases the level of serotonin in the synapse.
The COMT
gene is a gene that regulates the function of dopamine. It appears that this
gene is also mutated in individuals with OCD. However this mutation causes the
opposite effect as the SERT mutation discussed above. The mutated variation of
the COMT gene found in OCD individuals causes a decrease in the COMT activity
and therefore a higher level of dopamine.
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Carey and
Gottesman (1981) found that identical twins showed a concordance rate of 87%
for obsessive symptoms and features compared to 47% in fraternal twins. This
difference suggests that genetic factors are moderately important.
The
higher concordance rate found for identical twins twins may be due to nurture
as identical twins twins are likely to experience a more similar environment
than fraternal twins twins since they tend to be treated the same.
Genes
alone do not determine who will develop OCD—they only create vulnerability.
Thus, they are not a direct cause as other factors must trigger the disorder.
Evidence for this is that the concordance rates are not 100%, which shows that
OCD is due to an interaction of genetic and other factors.
The OCD
may be culturally rather than genetically transmitted as the family members may
observe and imitate each other’s behavior, as predicted by social learning
theory. Alternatively, family members might be more vulnerable to OCD because
of the stressful environment rather than because of genetic factors.
Neural Explanations
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Neural
mechanisms refer to regions of the brain, structures such as neurons and the
neurotransmitters involved in sending messages through the nervous system.
One
region of the brain; the prefrontal cortex (PFC), is involved in decision
making and the regulation of primitive aspects of our behavior. An over active
PFC, causing an exaggerated control of primal impulses
For
example, after a visit to the bathroom, your primal instinct to survive by
avoiding germs is brought to your attention. You may make the decision to wash
your hands to remove any harmful germs you may have encountered.
Once you
have performed the appropriate behavior, the PFC reduces in activation and you
stop washing your hands and go about your day. It has been suggested that if
you have OCD, your PFC is over activated. This means the obsessions and
compulsions continue, leading you to wash your hands again and again.
Abnormalities,
or an imbalance in the neurotransmitter serotonin, could also be related to OCD.
Reduced serotonin and excessive dopamine may cause OCD.
Serotonin
is the chemical thought to be involved in regulating mood. OCD patients have
low levels of serotonin.
Additionally
Dopamine is abnormally high in individuals with OCD. High levels of dopamine
have been thought to influence concentration. This may explain why OCD
individuals experience an inability to stop focussing on obsessive thoughts and
repetitive behaviors.
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The
brains of OCD patients are structured and function differently from those of
other people. Brain scans of OCD patients reliably show increased activity in
the PFC (Salloway & Duffy, 2002).
Whether
low serotonin causes OCD is unknown. All that's known is that low serotonin and
OCD are related. It is difficult to establish whether the low levels of
neurotransmitters cause OCD, are an effect of having the disorder, or are
merely associated. Causation cannot be inferred as only associations(i.e.
correlations) have been identified.
We do not
know whether high levels of dopamine cause OCD or whether OCD is caused by
something else and the effect is high levels of dopamine.
The
biochemistry hypothesis does not account for individual differences because the
research does not explain why one individual develops OCD and another develops
a different mental disorder, because low serotonin levels are also found in
other mental disorders. Thus, these biochemical abnormalities are not specific
to OCD, and may be true of any form of mental distress.
Psychological
therapy (CBT) can be very successful treatment and this is difficult to account
for in the serotonin hypothesis.
Biological Treatment - Drugs
Two
classes of drug have proved effective in the treatment of obsessive compulsive
disorder: serotonin reuptake inhibitors (SRIs) and selective serotonin reuptake
inhibitors (SSRIs). Both classes of drug increase serotonin levels, and so
support the neural explanation / biochemical hypothesis.
Drugs
that mainly affect neurotransmitters other than serotonin are of little or no
value in treating obsessive compulsive disorder.
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Studies
using drugs have shown a reduction in dopamine levels is positively correlated
with a reduction in OCD symptoms.
Experiments
which inject animals with drugs that increased levels of dopamine have caused
the animals to demonstrate OCD type behaviors.
Drugs
that increase serotonin (anti depressants such as SSRIs) have been shown to
reduce OCD symptoms. Soomro et al found that SSRIs were significantly better
than placebos in reducing symptoms in 17 different clinical trials
But
research results relating to serotonin are varied – sometimes symptoms have
been made worse. There is a great deal of contradictory research. - Drugs seem
to show only partial alleviation of the symptoms so the process is not fully
understood. The exact function of neurotransmitters in the development of OCD
is far from understood.
Most
SSRIs have side effects which can be unpleasant, e.g. dry mouth, a slight
tremor, fast heartbeat, constipation, sleepiness, and weight gain.
The
success of antidepressant drugs as a treatment does not necessarily mean the
biochemicals are the cause of OCD in the first place. This is known as the
treatment aetiology fallacy and, using headaches as an example, aspirin works
well as a treatment but this doesn’t mean the headache was due to an absence of
aspirin.
Characteristics of Depression
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Depression
is a mood, or affective disorder. This mental Illness is a collection of
physical, emotional, mental and behavioral experiences that are severe,
prolonged and damaging to everyday functioning.
The
criteria for depression to be diagnosed using the DSM-IV-TR is that at least 5
or more symptoms of depression should be apparent. The possible symptoms
include:
Behavioral (How do you BEHAVE
when you're depressed?): Neglect of personal appearance, loss of appetite,
disturbed sleep patterns (insomnia), loss of energy (tiredness), withdrawal
from others.
Emotional (How do you FEEL when
you're depressed?): Intense sadness, irritability, apathy (loss of interest of
enjoyment), feelings of worthlessness, anger.
Cognitive (How do you THINK when you're depressed?):
Negative thoughts, lack of concentration, low self-esteem, poor memory,
recurrent thoughts of death, low confidence.
The
cognitive approach believes that depression stems from faulty cognitions about
others, our world and us. This faulty thinking may be through cognitive
deficiencies (lack of planning) or cognitive distortions (processing
information inaccurately). These cognitions cause distortions in the way we see
things and caused behavior such as depression.
Ellis
suggested depression occurs through irrational thinking, while Beck proposed
the cognitive triad.
AO2 Exam Style Question
Ben recently moved away from home to go to university. He was
loving his new life of going out, meeting new friends, his new university
course. However, after a while he struggled getting out of bed and started to
become very tired.
His eating patterns changed and he lost a lot of weight. He
noticed that he got angry at little things and snapped at his friends. When he
was sat in lectures, he found it hard to concentrate for long periods of time.
Identify
the behavioral, emotional and cognitive aspects of Ben’s state. (3 marks)
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The
cognitive triad are three forms of negative (i.e. helpless and critical) thinking
that are typical of individuals with depression: namely negative thoughts about
the self, the world and the future. These thoughts tended to be automatic in
depressed people as they occurred spontaneously.
For
example, depressed individuals tend to view themselves as helpless, worthless,
and inadequate. They interpret events in the world in a unrealistically
negative and defeatist way, and they see the world as posing obstacles that
can’t be handled. Finally, they see the future as totally hopeless because
their worthlessness will prevent their situation improving.
The negative
triad interacts with negative schemas and cognitive biases to produce
depressive thinking.
Cognitive
biases are distortions of thought processes. Individuals with depression are
prone to making logical errors in their thinking and they tend to focus
selectively on certain negative aspects of a situation while ignoring equally
relevant positive information.
In
addition to cognitive biases, the negative triad is also influenced by schemas.
In essence, schemas can be seen as deeply held beliefs that have their origins
primarily in childhood. Beck believed that depression prone individuals develop
a negative self-schema. They possess a set of beliefs and expectations about
themselves that are essentially negative and pessimistic.
Beck
claimed that negative schemas may be acquired in childhood as a result of a
traumatic event (e.g. parental or peer rejection). Schemas influence how a
person interprets events and experiences in their life. Beck predicted that in
depression ‘latent’ (i.e. dormant) negative schemas that have been formed in
childhood become activated by a life events or ongoing stressors.
Negative
schemas and cognitive biases maintain the negative triad, a pessimistic view of
the self, the world (not being able to cope with the demands of the environment)
and the future.
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It may be
that negative thinking generally is also an effect rather than a cause of
depression. Perhaps individuals only start experiencing negative thoughts after
having developed depression. However, evidence that negative thinking can be
involved in the development of depression was obtained by Lewinsohn et al.
(2001).
They
measured negative thinking in non-depressed adolescents. One year later, the
life events of participants over the previous 12 months were assessed, and also
whether they were suffering from depression.
The
results showed those who had experienced many negative life events had an
increased likelihood of developing depression only if they were initially high
in negative attitudes. This study supports the theory that negative beliefs are
a risk factor for developing depression when exposed to stressful life events.
The
cognitive approach to depression is limited in that genetic factors are
ignored.
Little
attention is paid to the role of social factors relating to life events and
gender in the cognitive explanation of depression.
Ellis’s ABC Model
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Albert
Ellis (1957, 1962) proposes that each of us hold a unique set of assumptions /
beliefs about ourselves and our world that serve to guide us through life and
determine our reactions to the various situations we encounter.
Unfortunately,
some people’s assumptions are largely irrational, guiding them to act and react
in ways that are inappropriate and that prejudice their chances of happiness
and success. Albert Ellis calls these basic irrational assumptions.
According
to Ellis, depression does not occur as a direct result of a negative event but
rather is produced by the irrational thoughts (i.e. beliefs) triggered by
negative events.
Ellis
believes that it is not the activating event (A) that causes depression (C),
but rather that a person interpret these events unrealistically and therefore
has an irrational belief system (B) that helps cause the consequences (C) of
depressive behavior.
For
example, some people irrationally assume that they are failures if they are not
loved by everyone they know (B) - they constantly seek approval and repeatedly
feel rejected (C). All their social interactions (A) are affected by this
assumption, so that a great party can leave them dissatisfied because they
don’t get enough compliments.
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The
precise role of cognitive processes is yet to be determined. It is not clear
whether faulty cognitions are a cause of the psychopathology or a consequence
of it.
Sometimes
these negative cognitions are in fact a more accurate view of the world:
depressive realism.
Cognitive
theories lend themselves to testing. When experimental subjects are manipulated
into adopting unpleasant assumptions or thought they became more anxious and
depressed (Rimm & Litvak, 1969).
Treatment - CBT
How would you use the
therapy
Cognitive behavioral therapy aims
to change the way a client thinks, by challenging irrational and maladaptive
thought processes and this will lead to a change in behavior as a responses to
new thinking patterns. Specifically, our thoughts determine our feelings and
our behavior.
Therefore,
negative - and unrealistic - thoughts can cause us distress and result in
problems. When a person suffers with psychological distress, the way in which
they interpret situations becomes skewed, which in turn has a negative impact
on the actions they take.
Cognitive
therapists help clients to recognize the negative thoughts and errors in logic
that cause them to be depressed. The therapist also guide clients to question
and challenge their dysfunctional thoughts, try out new interpretations, and ultimately
apply alternative ways of thinking in their daily lives.
The
clients learn to discriminate between their own thoughts and reality. They
learn the influence that cognition has on their feelings, and they are taught
to recognize observe and monitor their own thoughts.
The
behavior part of the therapy involves setting homework for the client to do
(e.g. keeping a diary of thoughts). The therapist gives the client tasks that
will help them challenge their own irrational beliefs.
The idea
is that the client identifies their own unhelpful beliefs and them proves them
wrong. As a result, their beliefs begin to change. For example, someone who is
anxious in social situations may be set a homework assignment to meet a friend
at the pub for a drink.
CBT would
be used when a person's faulty thinking was effecting their life in a negative
way.
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A
strength of this therapy is that it has shown to be very effective in treating
depression, in fact, it has shown to produce longer lasting recovery than
antidepressants.
The
precise role of cognitive processes is yet to be determined. It is not clear
whether faulty cognitions are a cause of the psychopathology or a consequence
of it.
Sometimes
these negative cognitions are in fact a more accurate view of the world: depressive
realism.
Cognitive
theories lend themselves to testing. When experimental subjects are manipulated
into adopting unpleasant assumptions or thought they became more anxious and
depressed (Rimm & Litvak, 1969).
An
important advantage of CBT is that it tends to be short (compared to
psychoanalysis), taking three to six months for most emotional problems.
Patients attend a session a week, each session lasting either 50 minutes or an
hour.
Another
strength is that it can reduce ethical issues – the way this therapy works is
that the client is actively involved and in control. They feel empowered as
they are helping themselves.
AO2 Exam Style Question
Jack suffers from depression. His symptoms include loss of
concentration, lack of sleep and struggles to sleep at night. He finds himself
having absolutist thinking thinking that everything is negative and bad all the
time.
How might
a cognitive behavior therapist tackle Jack’s depression? (4 marks)
Characteristics of Phobias
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Phobias
are a type of anxiety disorder. Phobias are characterized by a marked and
persistent fear that is excessive or unreasonable, cued by the presence or
anticipation of a specific object or situation (e.g. flying, heights, seeing
blood).
The
symptoms of phobias can be place into one of three categories
Behavioural (How do you BEHAVE
when you see your feared object?): The phobic stimulus is either avoided or
responded to with great anxiety. For example, someone with a phobia of dogs may
cross the road every time they see a dog, therefore receiving negative reinforcement
which will maintain the phobia. This avoidance could interfere with the
individual’s normal daily routine.
Emotional (How do you FEEL when
you see your feared object?): Exposure to the phobic stimulus nearly always
produces a rapid anxiety response.
Cognitive (What do you THINK about your feared
object?): A person would recognise that the fear is excessive or unreasonable.
The person is consciously aware that the anxiety levels they experience in
relation to their feared object or situation are overstated.
The DSM
defines three categories of phobias: agoraphobia, social phobia and specific
phobias. Agoraphobia is fear of open spaces, but is better characterized as a
fear of being away from home.
Social
phobias involve an intense fear of social situation or having to interact with
other people. Specific phobias relate to a fear of a specific object, such as a
spider, or a situation, such as an enclosed space (claustrophobia).
The Two-Process Model
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The behavioural approach explains
the development and maintenance of phobia mainly using the theories of
classical conditioning and operant conditioning. These were first combined as a
single explanation for phobia by Mowrer, in the two-process model of phobia.
According
to the behaviorists, phobias are the result of a classically conditioned association
between an anxiety provoking unconditioned stimulus (UCS) and a previously
neutral stimulus. For example, a child with no previous fear of dogs gets
bitten by a dog and from this moment onwards associates the dog with fear and
pain. Due to the process of generalisation the child is not just afraid of the
dog who bit them, but shows a fear of all dogs.
Operant conditioning can
help to explain how the phobia is maintained. The conditioned (i.e. learned)
stimulus evokes fears, and avoidance of the feared object or situation lessens
this feeling, which is rewarding. The reward (negative reinforcement) strengths
the avoidance behaviour, and the phobia is maintained.
A02 Questions
Kirsty is
in her twenties and has had a phobia of balloons since one burst near her face
when she was a little girl. Loud noises such as ‘banging’ and ‘popping’ cause
Kirsty extreme anxiety, and she avoids situations such as birthday parties and
weddings, where there might be balloons.
Suggest how the behavioural approach might be used to explain
Kirsty’s phobia of balloons. (4 marks)
AO3
There is
empirical support to show how classical conditioning leads to the development
of phobias. Watson and Rayner (1920) used classical conditioning to create a
phobia in an infant called Little Albert.
Albert developed a phobia of a white rat when he learned to associate the rat
with a loud noise.
The
behaviourist approach adopts a limited in the origins of a phobia, as it
overlooks the role of cognition. Ignoring the role of cognition is problematic,
as irrational thinking appears to be a key feature of phobias. Tomarken et al.
(1989) presented a series of slides of snake and neutral images (e.g. trees) to
phobic and non-phobic participants. The phobics tended to overestimate the
number of snake images presented.
In theory
anyone could develop a phobia to a potentially harmful object, although this
does not always happen. Despite the fact the most adults have either
experienced, witnessed or heard about car accidents were another person is
injured, phobia of cars is virtually non-existent.
Seligman
(1970) suggests that humans have a biological preparedness to develop certain
phobias rather than others, because they were adaptive (i.e. helpful) in our
evolutionary past. For example, individuals that avoided snakes and high places
would be more likely to survive long enough and pass on their genes than those
who did not.
The idea
of biological preparedness is further supported by Ost and Hugdahl (1981) who
claim that nearly half of all people with phobias have never had an anxious
experience with the object of their fear, and some have had no experience at
all. For example, some snake phobics have never encountered a snake.
The
cognitive approach criticise the behavioral model as it does not take mental
processes into account. They argue that the thinking processes that occur
between a stimulus and a response are responsible for the feeling component of
the response.
Treatment - Systematic Desensitisation
AO1
Systematic desensitization is
a type of behavioural therapy based on the principle of classical conditioning.
This therapy aims to remove the fear response of a phobia, and substitute a
relaxation response to the conditional stimulus gradually using counter
conditioning. This will lead to extinction of the fear response. There are
three phases to the treatment:
First, the patient is taught a
deep muscle relaxation technique and breathing exercises. E.g. control over
breathing, muscle detensioning or meditation. This step is very important
because of reciprocal inhibition, where once response is inhibited because it
is incompatible with another. In the case of phobias, fears involves tension
and tension is incompatible with relaxation.
Second, the patient creates a
fear hierarchy starting at stimuli that create the least anxiety (fear) and
building up in stages to the most fear provoking images. The list is crucial as
it provides a structure for the therapy.
Third, the patient works their way up the fear hierarchy, starting at
the least unpleasant stimuli and practising their relaxation technique as they
go. When they feel comfortable with this (they are no longer afraid) they move
on to the next stage in the hierarchy. If the client becomes upset they can
return to an earlier stage and regain their relaxed state.
The
number of sessions required depends on the severity of the phobia. Usually 4-6
sessions, up to 12 for a severe phobia. The therapy is complete once the agreed
therapeutic goals are met (not necessarily when the person’s fears have been
completely removed).
Exposure
can be done in two ways:
· In vitro – the client
imagines exposure to the phobic stimulus.
· In vivo – the client is
actually exposed to the phobic stimulus.
Research
has found that in vivo techniques are more successful than in vitro (Menzies
and Clarke 1993). However, there may be practical reasons why in vitro may be
used.
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Practical Issues
One
weakness of in vitro systematic desensitization is that it relies on the
client’s ability to be able to imagine the fearful situation. Some people
cannot create a vivid image and thus systematic desensitization is not always
effective (there are individual differences).
Systematic
desensitization is a slow process, taking on average 6-8 sessions. Although,
research suggests that the longer the technique takes the more effective it is.
Theoretical Issues
Systematic
desensitization is highly effective where the problem is a learned anxiety of
specific objects/situations (e.g. phobias). However, SD is not effective in
treating serious mental disorders like depression and schizophrenia.
Studies
have shown that neither relaxation nor hierarchies are necessary, and that the
important factor is just exposure to the feared object or situation. Therefore,
therapies like flooding may be more effective.
Social
phobias and agoraphobia do not seem to show as much improvement. Could it be
that there are other causes for phobias than classical conditioning? For
example, if a fear of public speaking originates with poor social skills then
phobic reduction is more likely to occur in a treatment which includes learning
effective social skills than systematic desensitization alone.
Empirical Evidence
Rothbaum
used SD with participants who were afraid of flying. Following treatment 93%
agreed to take a trial flight. It was found that anxiety levels were lower than
those of a control group who had not received SD and this improvement was
maintained when they were followed up 6 months later.
Ethical Issues
SD
creates high levels of anxiety when patients are initially exposed, which
raises ethical issues and so questions appropriateness. It should be noted that
the virtual reality therapy does help resolve these issues.
Treatment - Flooding
AO1
Flooding (also known as
implosion therapy) works by exposing the patient directly to their worst fears.
(S)he is thrown in at the deep end. For example a claustrophobic will be locked
in a closet for 4 hours or an individual with a fear of flying will be sent up
in a light aircraft.
What
flooding aims to do is expose the sufferer to the phobic object or situation
for an extended period of time in a safe and controlled environment. Unlike
systematic desensitisation which might use in vitro or virtual exposure,
flooding generally involves vivo exposure.
Fear is a
time limited response. At first the person is in a state of extreme anxiety, perhaps
even panic, but eventually exhaustion sets in and the anxiety level begins to
go down. Of course normally the person would do everything they can to avoid
such a situation. Now they have no choice but confront their fears and when the
panic subsides and they find they have come to no harm. The fear (which to a
large degree was anticipatory) is extinguished.
Prolonged
intense exposure eventually creates a new association between the feared object
and something positive (e.g. a sense of calm and lack of anxiety). It also
prevents reinforcement of phobia through escape or avoidance behaviors.
AO3
Flooding
is rarely used and if you are not careful it can be dangerous. It is not an
appropriate treatment for every phobia. It should be used with caution as some
people can actually increase their fear after therapy, and it is not possible
to predict when this will occur. Wolpe (1969) reported the case of a client
whose anxiety intensified to such as degree that flooding therapy resulted in
her being hospitalized.
Also,
some people will not be able to tolerate the high levels of anxiety induced by
the therapy, and are therefore at risk of exiting the therapy before they are
calm and relaxed. This is a problem, as existing treatment before completion is
likely to strengthen rather than weaken the phobia.
However one application is with people who have a fear of
water (they are forced to swim out of their depth). It is also sometimes used
with agoraphobia. In general flooding produces results as effective (sometimes
even more so) as systematic desensitisation. The success of the method confirms
the hypothesis that phobias are so persistent because the object is avoided in
real life and is therefore not extinguished by the discovery that it is
harmless.
For
example, Wolpe (1960) forced an adolescent girl with a fear of cars into the
back of a car and drove her around continuously for four hours: her fear
reached hysterical heights but then receded and, by the end of the journey, had
completely disappeared.
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