workbook - depression - routledge

A2 Level Psychology Workbook. Copyright © 2009 Psychology Press PSYCHOPATHOLOGY: DEPRESSION 1

Learning ObjectivesIssues to ConsiderKraepelin (1856–1926) and Bleuler (1857–1939) shaped the direction of the modern approachto mental illness, where different types of mental illness are diagnosed and classified accordingto specific symptoms. This is where we will begin the study of depression; we will look at theclinical characteristics or symptoms of the disorder. Diagnosis and classification raise issues suchas is the diagnosis of depression consistent (reliable) and accurate (valid)? You will be familiarwith the models of abnormality from this topic at AS level, so try to recall what factors are likelyto be implicated by the different models. We will also look at how the models of abnormalityexplain the causes of depression. Finally, we will consider the methods of treatment ofdepression.

On completion of this topic you should be familiar with the following.

Use this list of learning objectives as a revision checklist. Cross-reference the objectives with theSpecification.

Clinical characteristics and diagnosis of depression

Outline the clinical characteristics of the depression.

Discuss issues surrounding the classification and diagnosis of depression, including reliabilityand validity.

Biological explanations of depression

Critically consider biological explanations of depression.

Psychological explanations of depression

Outline and evaluate psychological explanations of depression.

Biological therapies for depression

Discuss biological therapies for depression.

Psychological therapies for depression

Outline and assess psychological therapies for depression.

PSYCHOPATHOLOGY: DEPRESSION

Clinical Characteristics and Diagnosis of Depression

For details, see Eysenck’s A2 Level Psychology (pages 425–431).


Fill in the blanks.

Mood disorders are characterised by disturbances of aff___t (mood), which can be in thedirection of depression or e__________n. This is distinguished from normal mood variationsby the duration and degree of disturbance. Depression is an emotional response that canhave physical, behavioural, cognitive, perceptual, motivational, emotional, and socialsymptoms.

Fill in the blanks.

Physical/behavioural symptoms

• Ap___________e is usually reduced, but can increase (comfort eating) and tends to beunhealthy.

• Sl______p disturbances occur, in_________ia tends to be most common with problems infalling asleep and early morning waking. But hypersomnia can also occur. This is excessivesleeping and may be an attempt to escape reality. Sleep disturbances result in tirednessand feelings of lethargy (loss of energy) or restlessness.

• Sex drive is usually reduced.

Perceptual symptoms

Auditory hallucinations may occur, which are extreme forms of self-cr_________lde__________s as the hallucinations often involve voices that are abusive and critical of thedepressive.

Cognitive symptoms

Depressives have slow, muddled th___________g and difficulty in making de____________s.Pessimistic, negative, and in severe cases s__________l thinking may occur. A negative self-co_________t can lead to fa______y thinking, when the individual is overly critical of him- orherself—this can develop into d_______________ns.

Motivational symptoms

Depressives show a lack of interest (ap________) in their appearance, work, home andothers. There is also reduced ac___________y due to their lack of interest and energy.

Clinical Characteristics of Depression


Social symptomsDepressives usually show so______l wit_____________l because they do not gain pleasurefrom social interaction, may feel they have nothing to contribute and do not want people tosee them in their depressed state.

Emotional/mood symptoms• Depressives show low m____d, unh___________ss, and anguish, and are often on the

verge of t______s.

• Anedonia refers to a loss of ple__________e in activities previously enjoyed.

• Diurnal mood variations may occur, in which the mood changes throughout the day,being particularly low on a morning and improving a little as the day progresses.

FIND OUT FOR YOURSELF: Make up a case study of depression involving all of the mainsymptoms and use as a revision aid.

Classification of depression

Fill in the blanks.

DSM-IV (Diagnostic and Statistical Manual, Volume 4, see A2 Level Psychology page 378),which is the American classification system, and the International Classification of Diseases,the tenth edition of which (ICD-10) was published by the World Health Organization in1992, are the two most common cla_________________n systems.

Diagnosis of depression

Ψ What are the DSM-IV diagnostic criteria for depression?

Ψ What are the ICD-10 diagnostic criteria for depression?

Issues in the classification and diagnosis of depression

Fill in the blanks

The categorical systemSeveral factors can reduce the reliability and validity of di_____________s of majorde______________e disorder (unipolar depression).

• First, classification systems such as DSM-IV-R (revised version of DSM-IV in 2000) and ICD-10 are categorical systems. This is an all-or-none approach in which patients areassumed to have the di_____________er or not. This seems straightforward but using the


Types of depression

Fill in the blanks.

Depression is the main symptom of a range of mood disorders, which include:

Ψ Major depression (uni___________)

Ψ Manic depression (bi________r)

Ψ Se__________al affective disorder (SAD)

Ψ Pre________________al sy___________e (PMS)

Ψ Po____________m depression (PPD).

Major depression can be divided into different types:

Ψ En____________s—caused by factors within the person.

Ψ R_____________e—caused by factors external to the person, such as stressful life events;this is the type that people are most likely to experience.

Although a useful distinction, this can be difficult to apply as the depression may be due tointernal and external factors. In clinical practice a distinction is often made between minor,ne________ic illness, and major, p________c illness.

Ψ What distinction is made between neurotic and psychotic illnesses?

Issues Surrounding Classification and Diagnosis

Fill in the blanks.

For any diagnostic system to work effectively, it must possess re___________y andv______________ty. Reliability means that there is good co________________cy over timeand between different people’s diagnosis of the same patient; known as inter-raterreliability. If diagnosis of depression is valid then patients who are diagnosed as sufferingfrom depression must have the di__________er. If a diagnostic system is to be valid, it mustalso have high reliability. Clearly if a disorder cannot be agreed upon (so lowre____________y) then all of the different views cannot be correct (so low v____________y).

In terms of classification, DSM-IV and ICD-10 take a categorical approach, which assumesthat all mental disorders are distinct from each other, and that patients can be categorisedwith a disorder based on them having particular sy_____________ms. However, diagnosingabnormality is not as straightforward as this approach suggests.


system in practice is not because a patient who has six symptoms every day for 13 dayswould not meet the criteria, yet clearly has experienced some de_____________n.

• Further evidence that the a____-or-n_______ system lacks validity is that those who don’tmeet the diagnosis of major depressive disorder or minor depressive disorder do still havesome form of depression, which may progress to major depression. For example, Horwathet al. (1992) found that over 50% of new cases of major depressive disorder (unipolardepression) had previously reported less s_____________e symptoms of depression.

Subjectivity of diagnosisJudging whether patients have any given symptom is su_______________e because theycannot be measured. For example, loss of pleasure in usual activities is a symptom of majordepressive disorder, but how much loss of pleasure is needed to qualify?

Comorbidity• Comorbidity means that a given individual has two or more mental di_________rs at the

same time.

• For example, many people suffer from both depression and anxiety. This means thediagnostic categories in DSM-IV and ICD-10 are not di________ct from each other yet theclassification systems assume that they are. Different forms of comorbidity mean it isdifficult to make comparisons between patients. It is also difficult for the therapist toknow which disorder to focus on first in tr_______________nt.

Diagnosis: semi-structured interviews• Patients are generally diagnosed on the basis of one or more in_____________s with a

therapist. Some interviews are very unstructured and informal. This can produce goodrapport between the patient and the therapist, but reliability and validity of diagnosistend to be low (Hopko et al., 2004).

• However, semi-structured interviews in which patients are asked a largely predeterminedseries of qu_____________s do have good reliability and validity. Two of the most usedsemi-structured interviews for depression are the Structured Clinical Interview for DSM-IV-Patient Version (SCID-I/P) and the Anxiety Disorder Interview Schedule for DSM-IV (ADIS-IV).

• SCID-I/P starts with an open-ended int___________w, which is followed by systematicquestions concerning sy___________s and current and lifetime disorders and lasts between60–90 minutes. Inter-rater reliability and di_____________c accuracy were both high withthe SCID-I/P (Ventura et al., 1998, see A2 Level Psychology page 430), and—surprisingly—were as good for relatively inexperienced interviewers as for experienced ones.

• ADIS-IV is mainly designed to diagnose anxiety disorders, but it also provides an assessmentof depression because many patients suffer with both. Symptoms are initially assessed byclosed y___/n___ questions, and then ratings are used to assess severity of the symptomsshown. Brown et al. (2001) found good inter-rater re____________ty when two therapistsused ADIS-IV to assess depression (i.e. the two therapists showed good ag_____________t).However, reliability was somewhat lower than for most of the anxiety disorders.

• This lack of reliability was mainly due to patients reporting different symptoms during thetwo interviews. However, there were also different diagnoses where one therapistdiagnosed d______________n and the other an_____________y. The “threshold issue”also reduces reliability because therapists sometimes disagreed as to whether thesymptoms exceeded the threshold; we considered this earlier in terms of how much lossof pleasure the patient must show.

Content validity• Content validity refers to the extent to which an assessment procedure obtains detailed

relevant information. Thus, the diagnostic interviews have co___________t validity if theyprovide detailed information regarding all of the sy_________________s of depression.

• SCID-I/P and ADIS-IV are clearly both high in content validity.

Criterion validity• Any form of assessment for depression possesses good cri_______________n validity if

those diagnosed as having depression differ in predictable ways from those notdi______________d with depression.

• There is evidence that patients diagnosed with major depressive disorder are less likely tobe in a long-lasting re_______________ip, to have a full-time j______, or to have manyfr______________s (Hammen, 1997).

• This provides some evidence for criterion validity, but note that poor social and workfunctioning are found in those suffering from most mental dis______________rs and sothis doesn’t distinguish patients with de_______________n from patients with othermental disorders.

Construct validity• Construct validity is the extent to which hypotheses about a given disorder are supported

by the ev_______________e.

• For example, it is often assumed that depression is associated with a lack of involvementin ple_______________e activities, and the evidence supports that assumption (Lewinsohnet al., 1992). Similarly, one hy______________is is that low levels of serotonin are linkedto depression and so the fact that individuals with depression have low levels of serotoninprovides some evidence for co__________________ct validity.


FIND OUT FOR YOURSELF: Research the DSM-IV and ICD-10 classifications for yourself.Identify similarities and differences in the two classifications systems.

CONCLUSIONS—SO WHAT DOES THIS MEAN?

Answer the following questions in your conclusions:

• Which types of validity are reasonably well supported?

• Which issues question the reliability and validity of diagnosis of depression?

Using this in the exam

Outline the clinical characteristics of depression. (5 marks)

Discuss the issues associated with the classification and diagnosis of depression. (20 marks)


Biological Explanations of DepressionFor details, see Eysenck’s A2 Level Psychology (pages 432–440).

Three biological explanations of depression are: genetic factors, biochemical imbalance, andevolutionary factors. These three factors are likely to be related, for example, evolutionarypressures have shaped the genes that we have inherited and our biochemical systems.

Evolutionary Explanations

Social competition hypothesis

Fill in the blanks.

According to the social competition hypothesis (e.g. Price et al., 1994), human social groupsare hierarchical and so c__________ts arise over position and au____________ty. Depressionis adaptive when the individual has lost in a social competition because accepting l______sand the consequent withdrawal ends the conflict. The loser retreats and so is protectedfrom further in__________y and so represents “damage limitation”. The individual suffers inthe short-term but this is better than risking further lo_____________s and so isad____________________e in the long-term.

EVALUATION OF THE SOCIAL COMPETITION HYPOTHESIS

Summarise the evaluation points below.

Ψ Doesn’t account for prolonged depression. Why not?

Ψ Reductionism. Why is the theory too simplistic?

Ψ Maladaptive rather than adaptive. How does the maladaptive nature of depressionchallenge the evolutionary explanation?

Social Navigation Hypothesis


Fill in the blanks.

According to the social nav__________________n hypothesis (Watson & Andrews, 2002),depression provides a social ru________________n function because it involves theindividual thinking at length about their problems and what to do about them. Also, thedistress of the depressed person may elicit help from others, the socialmo_______________n function.

RESEARCH EVIDENCE FOR THE SOCIAL NAVIGATION HYPOTHESIS

Summarise the research evidence below.

Ψ Strong social support. How does this support the hypothesis?

Ψ Realistic thinking of people with depression. How does this support the hypothesis?

EVALUATION OF THE SOCIAL NAVIGATION HYPOTHESIS


Ψ How effective is social rumination? Why does this explanation lack face validity?

Ψ Too optimistic. Why is the explanation too optimistic?


Ψ More maladaptive than adaptive. Why does the maladaptive nature of depressionquestion the explanation?

Ψ Social explanations may be stronger. What are these social explanations?

Bipolar Disorder and Increased Fitness

Fill in the blanks.

The manic phase of bi_______________r depression (when the individual alternatesbetween depressive and manic, i.e. euphoric, states) has been related tocre______________ty, lack of inhibition, and charismatic le_________________ip. WinstonCh_______________l, Abraham Li_____________n, Vincent Van G______h, and Ludwig vanBe_________________n are only a few of the many great leaders and artists who are said tohave suffered with bipolar disorder, which offers support for the evolutionary explanation.

Another adaptive explanation is linked to se____________________al affective disorder(SAD). Nearly all individuals with SAD suffer from severe depression during thewi___________r months. Patients with bipolar disorder are more likely to have manic phasesin the warmer months, (Carroll, 1991) and so there may be adaptive value in being mostac________e during the lighter time of the year.

EVALUATION OF INCREASED FITNESS

Summarise the evaluation point below.

Ψ Adaptive or maladaptive? Do the severe disadvantages of such a debilitating disorderoutweigh any possible adaptive value it might have?

OVERALL EVALUATION OF EVOLUTIONARY EXPLANATIONS


Ψ Post hoc. What does this mean and why does it question the scientific validity of evolu-tionary explanations?

Ψ Speculation rather than fact. Why are the explanations not fact?

Ψ Adaptive or maladaptive? Why are the explanations adaptive or maladaptive?

Ψ Alternative explanations. What are the alternatives?


Genetic Factors

Fill in the blanks.

Fa____________y, tw_____, and ad___________n studies suggest the involvement ofgenetic factors. The prevalence of depression in the random population (about 7% formajor depressive disorder and 1% for bipolar disorder) is the baseline against which thecon__________________e rates can be compared.


RESEARCH EVIDENCE FOR GENETIC FACTORS


Ψ Twin studies of major depression (Allen, 1976; McGuffin et al., 1996). How do theconcordance rates for MZ and DZ differ for major depression?

Ψ Twin studies of bipolar disorder (e.g. Craddock & Jones, 1999). How do the concordance rates for MZ and DZ differ for bipolar disorder?

Ψ Berrettini’s (2000) chromosome research. Which chromosomes was bipolar disorderlinked to?

Ψ Family studies review of major depression (Gershon, 1990). What evidence is therethat major depression runs in families?

Ψ Egeland et al.’s (1987) family study of bipolar disorder in the Amish community.Why did this community offer insight into bipolar disorder?

Ψ Adoption studies (Wender et al., 1986). How much more likely are the biological parents of adopted children with major depression to have experienced this disorder thanthe adopted parents?


RESEARCH EVIDENCE AGAINST GENETIC FACTORS


Ψ Nurture. How does this provide an alternative explanation for the difference in the concordance rates between MZ and DZ twins?

Ψ Hodgkinson’s (1987) research. How does this challenge Egeland et al.’s (1987) research?

Ψ Cultural transmission. Which counter-perspective accounts for cultural transmission, i.e. learning from others?

Ψ The research evidence on psychological factors can be used as evidence againstgenetics. Identify the psychological explanations. How can these be used as counter-perspectives?


Ψ Sullivan, Neale, and Kendler (2000). How does this study show a lack of reliability inthe findings on adoption?

EVALUATION OF GENETIC FACTORS


Ψ Stronger evidence for bipolar disorder. Which studies provide stronger evidence for agenetic basis to bipolar disorder than depression?

Ψ Nature vs. nurture. What conclusion can be made with reference to this debate?

Ψ Sample size. Assess the population validity of family, twin, and adoption studies.

Ψ Reliability. Which studies into genetics have reliability and which ones lack it?

Ψ Diathesis–stress model. Use this model to explain the interaction of nature and nurture.


Biochemical Explanations

Fill in the blanks.

The monoamine hypothesis suggests that depression is due to abnormal levels ofneu________________________rs in the monoamine group (nor______________ne,se_________________in, and do_______________ne). Neurotransmitters act at the synapsesor junctions between neurons in the brain. They facilitate or block nervous transmission.Noradrenaline and serotonin are related to ar___________al and sleep—high levels ofno________________ne are linked to high levels of arousal and increases in serotoningenerally reduce arousal. This was expanded upon with the permissive amine theory (Kety,1975, see A2 Level Psychology pages 436–437), which proposes that the level ofnoradrenaline and dopamine is controlled by se_____________n, and that low levels ofserotonin are in____________d. When serotonin is low the levels of noradrenaline fluctuatewildly; low levels are associated with depression, and high levels with mania. Thebiochemical system depends in part on g______________ic factors and so the genetics andbiochemical explanations are inter-linked.

RESEARCH EVIDENCE FOR BIOCHEMISTRY


Ψ The three monoamine group. How does the function of the neurotransmitters that belong to this group support a biochemical explanation?

Ψ The urine of depressives (Teuting, Rosen, & Hirschfeld, 1981). How does this provide evidence?


Ψ Antidepressant drugs, MAOIs and SSRIs, which treat major depression. Explainhow they affect the neurotransmitters.

Ψ Post-mortem studies. What do these reveal about serotonin?

Ψ Rampello, Nicoletti, and Nicoletti (2000). How does this study both support and expand upon Kety’s theory?

RESEARCH EVIDENCE AGAINST BIOCHEMISTRY


Ψ Thase et al. (2002, see A2 Level Psychology page 437). How does this research contradict Kety’s theory?

Ψ The drugs don’t work for all patients. Consider the varying effectiveness of drugs andthe time taken before they work.

Ψ The research evidence on psychological factors can be used as evidence againstbiochemistry. Identify the psychological explanations. How can these be used ascounter-perspectives?


Hormonal factors

Fill in the blanks.

Various conditions that are linked to ho_____________e changes can also result indepression, for example, pre________________al syndrome (PMS), po______________mdepression (PPD, after a woman has had a child), and se______________alaf______________e disorder. The female menstrual cycle involves changes in the levels ofo_______________n and pro___________________ne. Even greater hormonal changesoccur during pregnancy and post-birth and these hormonal fluctuations are linked todepression. Cor_______________l produced during the body’s response to st_________s hasbeen linked to depression, as levels of cortisol tend to be elevated in depressed patients.

RESEARCH EVIDENCE FOR HORMONAL FACTORS


Ψ Female admissions to psychiatric hospital. How do these support the theory?

Ψ Gender differences. How might these be explained by hormones?

Ψ Post-partum depression. What percentage of women suffer with this?


Ψ Blood plasma levels of cortisol. How do these support the role of hormonal factors?

Ψ The dexamethasone suppression test. How does this support the role of cortisol?

RESEARCH EVIDENCE AGAINST HORMONAL FACTORS


Ψ Child abuse. How does this offer an alternative explanation to hormonal factors?

Ψ History of emotional problems. How does this offer an alternative explanation to hormonal factors?

EVALUATION OF THE RESEARCH INTO BIOCHEMICAL AND HORMONAL


Ψ Cause, effect, or correlate. Why can we not establish whether biochemical imbalancesare a cause, effect, or correlate with depression?

Ψ Treatment aetiology fallacy. What is this and how does it question the explanation?

Ψ Reductionist and deterministic. Explain these criticisms.

Ψ Explanatory power. Why does the research on biochemicals and hormones lack explanatory power?




• How strongly is the genetics hypothesis supported?

• How does the diathesis–stress model best account for individual differences?

• Why can we not be sure that biochemicals and hormones cause depression?

• Why do the evolutionary explanations lack scientific validity?


Outline and evaluate one or more biological explanation(s) of depression. (25 marks)


Psychological Explanations of Depression

For details, see Eysenck’s A2 Level Psychology (pages 441–451).

Psychodynamic Approach

Fill in the blanks.

According to Freud we are victims of our feelings, as re____________n anddis_____________nt are defence mechanisms in response to a______l (death of a loved one)and sym________c (loss of status) loss, which enable us to cope with the emotional turmoilbut can result in depression. Individuals with excessive de___________ce on others for self-esteem as a consequence of oral fix___________n are particularly vulnerable and unable tocope with loss. Repressed anger at the loss is dis_________d onto the self, and this inner-directed anger affects self-esteem and causes the individual to re-experience loss thatoccurred in childhood. Freud believed the superego is dominant in the depressed person andthis explains the excessive g______ experienced by many depressives. In contrast, the manicphase occurs when the individual’s ego, or ra____________al mind, asserts itself and he/shefeels in control. This approach has face validity because even if a psychodynamic approach isnot favoured, it is widely accepted that ch____________d experience can predispose theindividual to mental illness in adulthood. For example, Kendler et al. (1996) found adultfemale twins who had experienced pa___________l loss through separation in childhoodhad an above-average tendency to suffer from ______________n in adult life. However, earlyl_____ does not consistently predict depression given that fewer than 10% of individualswho experience major losses go on to develop clinical depression. Freud predicts thatindividuals’ anger is turned inwards on themselves yet often it is turned ou___________dson those who are closest instead. Also, as usual, the key weakness is that Freud’s theorylacks empirical support and so is neither ve___________e nor fa___________le. Furthermore,any link between loss in childhood and depression is just an as______________n notca________________n and so we cannot conclude cause and effect.

Behavioural Approach

Fill in the blanks.

According to this approach, depression is due to maladaptive le____________g. Theprinciples of op__________t co__________g have been applied to explain depression usingrei__________nt and p_________________t. Depression could be due to a lack of positivere_________________nt or too much p______________________t.

RESEARCH EVIDENCE FOR THE BEHAVIOURAL APPROACH


Ψ Loss of reinforcement (Lewinsohn, 1974). How is loss linked to depression?

Ψ Learned helplessness (Seligman, 1975). When does this occur and how does it explaindepression?

Ψ Learned helplessness in humans (Hiroto, 1974). How has Hiroto demonstratedlearned helplessness in humans?


RESEARCH EVIDENCE AGAINST THE BEHAVIOURAL APPROACH


Ψ Loss without depression. Explain how this contradicts behavioural explanations.

Ψ Reduced reinforcement. How do Lewinsohn, Hoberman, and Rosenbaum (1988) challenge the effect of reduced reinforcement?

Ψ The role of cognitive factors (Abramson, Seligman, & Teasdale, 1978). Why maythese have more explanatory power?


EVALUATION OF THE BEHAVIOURAL APPROACH

Below are some evaluative points. However, these are limited because they do not fullyexplain the weaknesses. In the next section ‘So what does this mean?’ the evaluation iselaborated upon.

Write the number of the elaboration next to the correct evaluative point below.

Reductionist. The behavioural explanations are greatly oversimplified as they focus ononly one factor, the environment.

Environmentally deterministic. The behavioural explanations are deterministic as theysuggest that behaviour is controlled by the environment.

Ignores nature. The behavioural explanations overemphasise nurture and so fail to account for nature.

Extrapolation. The generalisability of Seligman’s research is an issue.

Face validity. The symptoms of depression do relate to learned helplessness.

Ecological validity. Seligman’s research lacks mundane realism.

Population validity. Learned helplessness as an explanation of the development of depression may lack population validity.

Cause or effect? Causation cannot be inferred as associations only have been identified.

ELABORATION—SO WHAT DOES THIS MEAN?

1. Learned helplessness as an explanation may lack generalisability as it may be morerelevant to certain types of people, e.g. those who lack social skills and so have limitedemotional support.

2. The symptoms of depression do appear similar to the responses shown by Seligman’s dogs, e.g. passive behaviour, and so the explanation does have intuitiveappeal.

3. This ignores the individual’s ability to control his or her own behaviour.4. This focus on the external means internal factors such as biological and cognitive are

ignored, which may be more influential.5. The lack of reinforcement experienced in social interactions or the tendency to feel

helpless may be a consequence of being depressed rather than a cause. Consequently,the behavioural explanations may be more relevant to the maintenance than the onsetof depression.

6. There are qualitative differences between humans and animals. Cultural transmissionplays a greater role in human than animal behaviour and is the reason whygeneralisations should be made cautiously.

7. Consequently, the research may not be generalisable to real-life settings and so may lackecological validity.

8. Biological factors are neither observable nor measurable and so are ignored by thebehavioural perspective.


Cognitive Factors

Fill in the blanks.

Cognitive dysfunction in att____________l style (Abramson et al.’s attribution model, 1978)and view of s___f and the w______d (Becks’s cognitive triad) have been linked to thedevelopment of depression. Negative sc_____as (organised information stored in long-termmemory) develop during childhood as a consequence of critical interpersonal experiences,and are activated when the individual experiences similar situations in later life.

RESEARCH EVIDENCE FOR COGNITIVE FACTORS


Ψ Abramson et al.’s (1978) attribution model. Explain internal, stable, and global attributions.

Ψ Abramson, Metalsky, and Alloy (1989). How have they developed the original theory?

Ψ Beck and Clark’s (1988) cognitive triad. Identify the three corners of the triad andother cognitive biases suggested by Beck.

Ψ A prospective study of attributional style (Lewinsohn, Joiner, & Rohde, 2001).Why does this provide strong evidence that negative thinking is a cause of depression?

Ψ Negative self-beliefs during pregnancy (Evans et al., 2005). How does this supportfaulty cognition as a cause of depression?


RESEARCH EVIDENCE AGAINST COGNITIVE FACTORS


Ψ Research suggests faulty cognition is an effect rather than a cause. Why is the direction of effect an issue?

EVALUATION OF COGNITIVE FACTORS


Ψ Face validity. Why does the cognitive explanation have intuitive appeal?

Ψ Success of cognitive treatments. Which treatment has CBT been found to be as effective as?

Ψ Self-report criticisms. What are the weaknesses?

Ψ Lack of reliability. Which prospective study challenges the evidence for faulty cognitionas a cause?

Social Factors

Ψ Cause or effect? Why may the relationship be curvilinear rather than causal?

Ψ Descriptive not explanatory. Why does the cognitive explanation lack explanatorypower?

Ψ Multi-dimensional approach. Explain why this offers more insight into depression thanthe cognitive approach.


Fill in the blanks.

Depression is often preceded by a high number of stressful life events. Interviews of depressedwomen showed that ______% had experienced at least one very stressful life event comparedto only _____% of the non-depressed women. S______ s__________t was identified as avariable that protected against depression as only 10% of women with a close friend becamedepressed compared to 37% of those without an intimate friend (Brown & Harris, 1978).However, as you may remember from studying stress at AS level, we are only as stressed as wethink ourselves to be. Thus, the critical mediating factor may be self-p__________on, whichsuggests that c_________ve factors predispose the individual as it is the way we think aboutthem that is crucial. This partly accounts for why people can experience very similarstr______________l situations and some become depressed whereas others don’t. However, tofully account for such variation the interaction of biological pr______________g factors (innatephysiological reactivity) and environmental factors (stress) needs to be considered. Furtherlimitations of the life events research include the fact that the information is obtainedre_________________ly several months afterwards, and so there might be problemsremembering clearly what happened. C__________e and e__________t is an issue because itis unclear whether life events have caused depression or depression caused the life events. Forexample, marital separation might cause depression, but depression can play an important rolein causing marital separation.


Socio-cultural Factors

Fill in the blanks.

According to socio-cultural theorists (e.g. Nolen-Hoeksema, 1990), the incidence of majordepressive disorder is influenced strongly by s__________l and c____________l factors. Anexample of a social factor is the presence of an intimate fr___________d because this hasbeen found to reduce incidence of depression (Brown & Harris, 1978).

Marital st__________s is another important social factor because Blazer et al. (1994, see A2Level Psychology page 448) found that di____________d individuals were more depressed thanindividuals who were married or who had never been married. However, we cannot be sure ofthe di___________n of effect, i.e. if divorce triggered depression or if depression led to divorce.

Culture has an effect on the nature of the symptoms reported because individuals in non-Western countries report mostly ph___________l symptoms (e.g. fatigue, sleepdisturbances), whereas g_________t and self-blame are more common sy___________s inWestern countries.

A sub-cultural factor is evident in the fact that major depression is twice as common inwo__________n in most countries of the world (Hammen, 1997). Note you could consider thisas an issue of bias in terms of di______________is as it may be women are just more likelythan men to be diagnosed with depression. However, the arguments against this are many asmaybe women are more likely than men to report their e__________l problems. Or maybewomen have more reasons than men to be depressed, given that they are exposed to morest_____________rs, e.g. gender bias in the workplace, the triple burden of w____k, h_______eand ch_____d care, and the fact they are often poorer than men. Kendler et al. (1993) foundthat women reported significantly more negative life e__________s than did men in the pastyear. It is also possible that women rely on a more emotion-fo___________d approach and sospend a lot of time thinking about their problems and focus excessively on their emotions,whereas men are more problem-focused or, if they do take an emotion-focused approach,they seek dis____________n from their problems (e.g. drinking al______________l) (Nolen-Hoeksma, 1991).

FIND OUT FOR YOURSELF: Design a survey to find out what gives people the “blues”. Youmust ensure this is ethical, so only proceed if participants are willing and inform them oftheir right to withdraw. Also consider bias and leading questions. To avoid these, take anopen-ended approach. Use qualitative analysis to identify themes and patterns.



• Why do the psychological factors provide only a partial explanation?

• Why is a multi-dimensional approach needed?

• Why is the idiographic approach preferable to a nomothetic approach?



Outline and evaluate one or more psychological explanation(s) of depression. (25 marks)


Biological Therapies for DepressionFor details, see Eysenck’s A2 Level Psychology (pages 451–459).

Drug Therapy: Major Depressive Disorder

Fill in the blanks.

Individuals with major depressive disorder often have low levels of the neurotransmittersser_____________n and nor_________________ne, according to the monoamine theory.Accordingly, drugs to treat this disorder are designed to rectify these low levels.

Monoamine oxidase inhibitors (MAOIs)

Fill in the blanks.

The MAOIs block monoamine oxidase and by so doing help to prevent the destruction ofno___________________ne. As a result, depressed patients taking MAOIs have increasednoradrenaline activity leading to a reduction in de_______________e symptoms. The MAOIsare reasonably effective in reducing depression, but they do produce various side effects.They block the production of mo_______________ne oxidase in the liver, leading to theaccumulation of tyramine. This is dangerous because high levels of tyramine cause highblood pr_____________re. Accordingly, depressed patients taking MAOIs have to follow acareful diet, making sure to avoid foods (e.g. cheese, bananas) containingty_________________e.

Tricyclics

Fill in the blanks.

Tricyclics slow down the reabsorption of s________________in and noradrenaline by thepresynaptic vesicles. Consequently, more of the neurotransmitters are left in the synapse,and so serotonin and noradrenaline activity increase at the postsynapticre_________________rs, which is linked to arousal and improved mood. The tricyclics areless dangerous than the MAOIs, but they can impair driving to a dangerous extent, andother side effects include dry mouth and constipation.

Selective serotonin re-uptake inhibitors (SSRIs)

Fill in the blanks

The most common drugs used to treat depression are the serotonin re-uptake inhibitors(SSRIs), of which Pr_______c is the best known. These drugs are more selective in theirfunctioning than the tricylics, in that they increase se_______________in activity by blockingthe re-uptake of serotonin, so leaving the serotonin to have an enhanced effect on thepostsynaptic neuron, without influencing other ne_____________________rs such as

noradrenaline. The SSRIs are as effective as the tricylics, but they possess some advantages.Depressed patients taking SSRIs are less likely to suffer from dry mouth and constipationthan those taking tricyclics, and it is harder to ov____________e on SSRIs. However, SSRIsconflict with some other forms of medication, and Prozac, a well-known SSRI, is reported tohave severe effects in some people, including suicidal thoughts, where none wereexperienced previously.


OVERALL EVALUATION OF ANTI-DEPRESSANT DRUGS


Effectiveness

Ψ Empirical support for effectiveness. How well is effectiveness supported by research?

Ψ Do not work for all patients. Why is this an issue?

Ψ Compliance. Why is this an issue?

Ψ Treat symptoms not causes. How do we know this is the case?


Ψ Relapse rates. How do Hollon et al. (2005) evidence high relapse rates?

Ψ Drugs work less well with those who have already been treated with drug treatment. Why?

Ψ Placebo effect. What is this?

Appropriateness

Ψ Individual differences. How many patients fail to respond?

Ψ Lack understanding of their effect. Why is this an issue?

Ψ Palliative not curative. What does this mean?

Ψ Compare unfavourably to cognitive treatment. Why?


Electroconvulsive Therapy: Major Depressive Disorder

Fill in the blanks.

Electroconvulsive therapy (ECT) was based on the observation that epileptics do not havesc________________________ia and so it was concluded that the two disorders areantaganostic (cannot have both). This led to the deduction that inducing se_____________scould help treat schizophrenia and this was done initially using drugs such as camphor andthen cardiazol. It was then discovered that electric sh_______ks could produce seizures andthat ECT had better outcomes than cardiazol. ECT was then used for other mental disorderssuch as d_______________on.

ECT involves passing an electric current through the head to produce br_____n seizures. Itused to result in patient terror and broken b_______s (because the whole body would be inseizure and traditionally no anti-anxiety drugs were used) and it was certainly ada___________s process. The modern use of ECT has a number of improvements includingmuscle re___________ts to minimise the convulsions and the use of an_____________cs sothat the patient is asleep during the treatment and so does not experience the same anxiety.In addition, bilateral ECT (administering ECT to both brain he______________es) has beenmainly replaced by unilateral ECT (applying it only to the non-dominant hemisphere) toreduce any memory l_______s.

Studies designed to assess the effe________________s of ECT often compare it againstsimulated ECT, in which patients are exposed to the equipment and believe falsely that theyhave received ECT. This is done to ensure that the beneficial effects of ECT are genuine andnot simply a pl__________o effect—seeing the equipment and believing that you arereceiving shocks might be enough to reduce symptoms in the absence of any actual shocks.


RESEARCH EVIDENCE FOR ECT


Ψ Janicak et al. (1985). How did they find ECT compared to drug therapy?

Ψ Severe depression. Why is ECT often the treatment of choice?

Ψ Petrides et al. (2001). How effective did they find ECT to be?

Ψ Pagnin et al. (2004). What did their meta-analysis find?

EVALUATION OF ECT


Effectiveness

Ψ ECT is highly effective. What evidence is there for this?

Ψ ECT is used when drug treatment fails. Why?

Ψ Treats symptoms not causes. Why is ECT palliative?

Appropriateness

Ψ ECT is consistent with the biological basis of depression. Why does this make ECTappropriate?

Ψ Side effects. What are the side effects of ECT?

Ψ Memory loss is not permanent. Who made this judgement?



Ψ We do not understand how it works. Why is this an issue?

Ψ Ethical issues. What are these issues?

Ψ Reductionism. Why is the treatment too simplistic?

Ψ Dosage. Why is this an issue?

Ψ Individual differences. How does this affect appropriateness?



• Which type of drug seems to be more effective?

• Why do biological treatments raise issues of appropriateness?


Using this in the exam(a) Outline one or more biological therapies for depression. (9 marks)(b) Evaluate the therapy(ies) described in (a). (16 marks)


Psychological Therapies for Depression

For details, see Eysenck’s A2 Level Psychology (pages 459–469)

Psychodynamic Therapy

Fill in the blanks.

The original form of psychodynamic therapy was psy________________is, which wasdeveloped by Sigmund Freud 100 years ago. Remember Freud linked depression to low self-esteem and excessive de_________________ce due to over- or under-gratification in the oralstage, which meant the individual was unable to cope with lo_____. Consequently, Freudargued that it is crucial in therapy to uncover depressed patients’ re_____________dmemories and allow them to gain insight into the factors causing their depression. Freudused free as________________on to gain access to the un_______________us, whichinvolves the client saying whatever comes into his or her mind. This method often doesn’twork very well because the client might be reluctant to say what he or she is really thinking.However, according to Freud, long pauses in what the client says indicate that he or she ismoving close to an important re_______________d idea. Skilled therapists regard thepresence of long pauses as an indication that additional questioning and discussion arerequired.

A second method Freud used to access the unconscious was dream an____________is. Heclaimed we are much more likely to gain access to repressed material while dreaming thanwhen we are awake because the censor in our minds that keeps the repressed material inthe un________________s does not work as well during sleep. The repressed material isincluded in our dreams in a disguised or symbolic form because of its unacceptable nature.Freud called the dream as we remember it the ma______________st content and the true orunderlying meaning the l_______________nt content. Dream analysis involves interpretationof the symbols in the manifest content and questioning clients about their dreams to workout the latent content.

Progress in therapy depends partly on transference. This involves the client transferring ontothe therapist the powerful em_______________al reactions previously directed at his/herown parents or other highly significant others. These intense feelings can be negative orpositive and the client is usually unaware of what is happening. Tr_________________ceoften provides a direct link back to the client’s childhood by providing a re-creation ofdramatic conflicts that were experienced at that time. As a result, transference can facilitatethe uncovering of re__________________ed memories.

Psychodynamic therapy today has moved away from Freud’s original approach becausepatients’ social rel_________________ips are considered and current psychotherapy doesnot place the same emphasis on childhood ex_________________es that Freud did. Theyrecognise that patients’ current problems are of central interest.

EVALUATION OF PSYCHODYNAMIC THERAPY


Effectiveness

Ψ Major depressive vs. bipolar disorder. Which one is psychodynamic therapy more effective for?

Ψ Strong empirical support. What evidence is there for the effectiveness of psycho-dynamic therapy?

Ψ Limited effectiveness for bipolar disorder. Why is there mixed evidence for effectiveness?

Appropriateness

Ψ The cognitive nature of the treatment. Why does this make psychodynamic therapyappropriate?

Ψ The focus on current problems. Why is this appropriate?



Ψ Ignores motivational factors. Why does this limit appropriateness?

Ψ Ignores behavioural problems. Why does this limit appropriateness?

Ψ Requires patient to be active and articulate. Why does this limit appropriateness?

Ψ Slow acting. Why does this limit appropriateness?

Ψ Drop-out rate. What leads patients to drop out?

Ψ Less appropriate for bipolar disorder. Why is this?

Behaviour Therapy


Fill in the blanks.

Behavioural therapy focuses on re______________ng non-depressive behaviours and notrewarding depressive behaviours. Particular focus is given to using reinforcement to improvedepressed patients’ so_________l skills.

Therapists use the Pleasant Events Schedule and an Activity Schedule to help clients to setup a weekly schedule for engaging in ple____________le activities. Behavioural activationrecommended by Beck et al. (1979) encourages the patient to become engaged in activitiesand situations that provide rei____________nt or reward and that fit in with the individual’slong-term goals. The client schedules daily activities, rates how much pl__________e andsense of achievement are associated with each activity, and explores different forms ofbehaviour designed to achieve his or her goals.

EVALUATION OF BEHAVIOUR THERAPY


Effectiveness

Ψ Moderate effectiveness. How effective is the treatment?

Ψ Compares unfavourably with other treatments. Why?

Ψ May not work for severe depression. Why not?

Ψ Empirical support. How does this suggest evidence that behavioural therapy may be effective for severe depression?


Ψ Low effectiveness for bipolar disorder. Why?

Appropriateness

Ψ The motivational nature of the therapy. Why is this appropriate?

Ψ Low drop-out rate. Why is this low?

Ψ Ignores cognition. Why is this a weakness?

Ψ Treats symptoms not causes. Why is the treatment palliative?

Ψ Reductionism. Why is the treatment too simplistic?

Cognitive and Cognitive-behavioural Therapy


Fill in the blanks.

Aaron Beck has contributed the most towards the development of co______________etherapy for depression. According to Beck, the negative and un__________tic beliefs ofdepressed clients need to be ch______________ed. This is accomplished through a stagedprocess: the first stage of cognitive therapy involves the therapist and the client agreeing onthe nature of the pr___________m and the goals for therapy. In the next stage the client’snegative thoughts are challenged. This involves ho__________rk assignments andhypothesis te___________g. Clients typically predict that carrying out their homeworkassignments will make them feel anxious or depressed, and so they are told to test theirpredictions. The clients’ hypotheses are generally shown to be too pe___________ic anddiscovering that many of their fears are groundless speeds recovery (Beck et al., 1979).

Cognitive therapists have expanded upon their original approach to include thebe______________al element, thus recognising the interconnectedness of c__________n,e__________n, and b______________r. Cognitive-behavioural therapy (CBT) involves acognitive element challenging negative thinking and a behavioural element, learningadaptive be_____________s. Thus, CBT recognises that it is important to focus on changingdepressed individuals’ behaviour as well as their ways of thinking about themselves and theworld around them. Kendall and Hammen (1998) have identified four basic assumptionsunderlying cognitive-behavioural therapy:1. Patients’ int___________________ns of themselves and the world around them often

differ from what is actually the case.2. Thoughts, behaviour, and feelings are all int__________________ed and so it is wrong to

identify one of these factors (e.g. behaviour) as being more important than the others.3. Therapy needs to change the ways people think about th______________es and the

w___________ld around them.4. Therapy needs to change the client’s cognitive processes and his or her behaviour,

because the benefits will be gr_______________r than if only one element was changed.

EVALUATION OF COGNITIVE AND COGNITIVE-BEHAVIOURAL THERAPY


Effectiveness

Ψ Strong empirical support. What support does Elkin (1994) provide?

Ψ Curative not just palliative. Why is the therapy curative?


Ψ Long-lasting effects. How do these affect relapse rates?

Ψ Moderately effective for bipolar disorder. How do Lam et al. (2000) provide evidenceof moderate effectiveness?

Ψ Reliability. Why is the evidence for moderate effectiveness for bipolar disorder reliable?

AppropriatenessΨ The cognitive nature of depressive symptoms. Why do these make the treatment

appropriate?

Ψ Dual focus of CBT. Why is this appropriate?

Ψ The behavioural aspect. Why is this appropriate?

Ψ Cognitions may be realistic rather than faulty. Why might patients’ cognitions berealistic?

Ψ The effects of changing faulty cognitions may be exaggerated. Why?

Ψ Insufficient consideration of personal relationships. How does this limit appropriateness?

Ψ Relapse rates. What does this suggest about the effect of therapy?


FIND OUT FOR YOURSELF: Try explaining the different therapies to a friend and then askthem to decide which treatment they think would be best for depression. Teaching somebodyelse is an excellent way to learn the information. Make sure you present a balanced account ofthe treatments otherwise your friend’s answer might be extremely biased!



• Why is it difficult to compare the effectiveness of treatments?

• Why is informed consent an issue?

• Why is the optimal approach to treatment multi-dimensional?

Using this in the exam(a) Outline one or more psychological therapies for depression. (9 marks)(b) Evaluate the therapy(ies) described in (a). (16 marks)


Example Essay Plan

(a) Outline one or more psychological therapies for depression. (9 marks)

(b) Evaluate the therapy(ies) described in (a). (16 marks)

The marking is broken down into three sets of criteria, AO1, AO2, and AO3, but this is not howyou should write your essay. The essay should include all these criteria in a holistic way, e.g. asyou write about each therapy you should then write about the research studies supporting orchallenging the effectiveness of the therapy. Then discuss the effectiveness and appropriatenessof the therapy. This could include methodological (e.g. participant sample size), ethical, andreductionist issues, etc.

AO1 (9 marks)A general but accurate description of the psychological therapies is needed. Use two therapiesto give breadth but be selective; it is wise not to give more than this so as to achieve depth.

AO2 (12 marks)Commentary and evaluation of the therapies are needed. These can include research studies onthe effectiveness of the therapies. A good focus is to base your commentary around theeffectiveness and appropriateness of the therapies.

AO3 (4 marks)Evaluation and/or interpretation of the research could include the weaknesses of the researchevidence that supports the therapies. Use reductionism to add to your evaluation.

So the essay could be structured in the following way.

Note the question is divided into AO1 in part (a) and AO2 in part (b).

(a) Outline one or more psychological therapies for depression. (9 marks)

Introduce psychoanalysis and outline Freud’s methods, including free association and dreamanalysis. Decide if you have time to explain the role of transference. Describe how modernpsychodynamic therapy has moved away from Freud’s original approach in terms of more focuson social relationships and less on childhood experiences.

Outline cognitive therapy as introduced by Aaron Beck and how cognitive therapists haveexpanded upon their original approach to include the behavioural element, thus recognising theinterconnectedness of cognition, emotion, and behaviour.

(b) Evaluate the therapy(ies) described in (a). (16 marks)

Consider the effectiveness of psychodynamic therapy, for example in treating major depressivedisorder. Use empirical evidence such as Leichsenring (2001).

Consider the limited effectiveness for bipolar disorder using studies such as Colom et al. (1998).But balance this with the fact that psychodynamic therapy has been found to improvecompliance with drugs, as found by Sajatovic et al. (2007).

Discuss the appropriateness of psychodynamic therapy, such as the cognitive nature of thetreatment and the fact the modern form focuses on current problems. However, discuss thelimitations to appropriateness, such as the fact that it ignores motivational factors and

behavioural problems. Psychodynamic therapy requires the patient to be active and articulateand so may be more relevant to some than others. Discuss other factors, such as the fact thetherapy is slow-acting and consequently the drop-out rate can be high because it takes time andeffort.

Introduce the strong empirical support for cognitive therapy, such as Elkin (1994). Assess thetherapy as curative not just palliative, which means the effects are long-lasting and patients areless likely to relapse back into depression. Consider how, in terms of treating the causes, CBTcompares well to other therapies.

Discuss the evidence that CBT is moderately effective for bipolar disorder, such as Lam et al.(2000) and that the evidence has reliability because Jones (2004) also found CBT to havemoderate effectiveness.

Discuss the appropriateness of CBT, including evidence for, such as the cognitive nature ofdepressive symptoms and the advantage of combining features of cognitive therapy andbehavioural therapy. However, consider issues against effectiveness, such as the fact thatcognitions may be realistic rather than faulty and the effects of changing faulty cognitions maybe exaggerated.

Include an overall evaluation of the psychological therapies. Discuss the fact that thepsychological therapies show that depression can be treated with more than just drugs andincreasingly CBT is being used. But discuss how comparisons of the effectiveness of differenttreatments should be treated with caution due to issues such as individual differences of thepatient or therapist. Consider the ethical issues of therapy, such as informed consent andconfidentiality. Conclude that the optimal approach to treatment is a multi-dimensional one, inwhich drugs are combined with one or more other treatments.


workbook - depression - routledge

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