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Abnormal Psychology (Concepts of normality and abnormality (Abnormal…

- - - - Limitations of clinical interviews
        The individual is automatically labelled as the patient. This means the psychiatrist is look for evidence of abnormal behaviours. This assumption that if a person is seeking assistance, they must have a mental disorder is called sick role bias
        The fact the person is being observed or asked personal questions may increase anxiety and therefore change/intensify behaviour. This is called reactivity. This could be seen as further evidence of dysfunctional symptoms.
        A clinician's unique style, degree of experience and theoretical orientation will definitely affect the interview.
      - Affective symptoms: emotional elements, including fear, sadness, anger.
        Behavioural symptoms: observational behaviours, eg, crying, physical withdrawal, pacing
        Cognitive symptoms : ways of thinking, pessimism, personalisation, self image
        Somatic symptoms : physical symptoms, including facial twitching, stomach cramping, and changes in weight.
  - - - Why is it so difficult to come up with a reliable diagnosis?
        Blood and urine testing cannot currently be used to diagnose psychological disorders
        Disorders are 'clusters of symptoms'. These symptoms are assumed to be related to one another, even though this may not be the case.
        Many symptoms are difficult to measure. EG; hearing voices. Psychiatrists are heavily dependant on self reported data and this is known to result in some bias.
        Individuals may suffer from two or more psychological disorders. This is known as comorbidity.
      - Studies
        
        Lipton and Simon (1985)
        Randomly selected 131 patients in a hospital in New York. All patients had been diagnosed with a psychological disorder. 7 clinical experts at the Manhatten psychiatric Center reevalyated the selected patients and their diagnosis was compared with the original diagnosis. Of the original diagnosis of Schizophrenia, only 16 received the same diagnosis on re-evaluation; 50 were diagnosed with a mood disorder, even though only 15 had been diagnosed with such disorder initially. Such results indicate that the same symptoms may not lead to the same diagnosis by a different psychiatrist. Demonstrates importance of having more than one professional give a diagnosis.
        Limitations: patients were already undergoing treatment . This may have led to changes in symptoms. Due to studying reliability of diagnosis in naturalistic settings.
        
        Lobbestael, Leurgand and Arntz (2011)
        Investigated the reliability of diagnosis using the DSM IV with a sample of 151 participants, consisting of both patients and non-patients. The original clinical interviews often lasting up to 2 hours were audiotaped. The interviews were assessed by a second psychiatrist who did not know the diagnosis made by the first psychiatrist.
        The results showed that generally there was a higher reliability for personality disorders over other disorders. 71% reliability for MDD, 84% for personality disorders. High rate of consistency in diagnosis indicates that a diagnostic manual like the DSM IV in this case ensures clinicians are in agreement on a diagnosis. But does not mean it is valid.
        Strengths: Single blind procedure- second psychiatrists did not know the diagnosis made by the first. Using audio tapes ensured non verbal behaviour or appearance of patient did not effect diagnosis- also limitation.
  - - - When an individual come into a clinic and complains of certain symptoms, the clinician will assume there is something wrong with them and they want a treatment. The clinician will always have to interpret symptoms and the patients own account and this could lead to biases even though a modern classification system is part of the process. There is always a risk that clinician may fall victim to confirmation bias. Confirmation bias is a result fo schema that allow us to understand and predict a situation. In other words a psychiatrist sees what they expect to see. Confirmation bias is influenced by both stereotyping and social norms.
        
        Temerlin (1970)
        Clinical psychologists watched a video of an interview of a healthy individual. One group heard a respected psychologist say, 'a very interesting man because he looked neurotic , but was actually quite psychotic'.
        After watching the tape, participants selected their best guessed diagnosis from a list of 30 choices. 10 psychotic, 10 neurotic and 10 miscellaneous personality types including 'normal or healthy personality'. A majority of 60% said the patient was psychotic, in control group none made this diagnosis.
    - - Role of gender schema. For some disorders, women are diagnosed more frequently than men and vice versa. Is there actually a gender difference? Or due to gender stereotypes?
        Women are 2 to 3x more likely to become clinically depressed than men. It is a widely held belief that women are more emotional than men, therefore more vulnerable to emotional upsets because of hormonal fluctuations.
        
        Studies
        
        Brown and Harris
        Argued women are exposed to more stressors than men as a result of social hierarchies. This higher level of stress could be linked to depression, demonstrating the role of the interaction of biological and social factors in the disorder.
        
        Amenson and Lewinsohn (1981)
        Argued that prevalence rates may be different due to women being over diagnosed with depression. They compared the help seeking behaviour of men and women with similar levels of self reported depressive symptoms. They found that both genders were equally likely to seek psychiatric help or go to a general practitioner. The researchers also found that men and women with equal levels of self reported symptoms were equally likely to be diagnosed as depressed in a clinical interview.
        
        Swami (2012)
        Carried out a study on 1218 British adults. Participants were given a paper survey to fill out where there was a vignette of either male or female. The description met the diagnostic criteria for depression according to DSM IV and ICD-10. Asked if the individuals suffered from a mental disorder. Participants were more likely to indicate that a male vignette did not suffer from a mental health disorder compared to a female vignette. May indicate that gender stereotyping effects diagnosis
    - - Cochrane and Sashidharan (1996) point out that it is commonly assumed that the behaviours of the white population are normative and that any deviation from this by another ethnic group reveals some racial or cultural pathology. Conversely, Rack (1982) argues that if a member of a minority ethnic group exhibits a set of symptoms that is similar to that of a white british born patient they are assumed to be suffering from the same disorder which may not be the case.
        
        Li-Repac (1980) test the role of stereotyping in diagnosis. Wanted to compare the diagnoses of both white and Chinese-American therapists of both white and Chinese male subjects. She hypothesised that the therapists would generally agree on the concept of normality . Differences would exist in the actual diagnoses when diagnosing someone of a different cultural group. Found that European American clinicians saw the Chinese patients as more depressed and lower in self-esteem. European American clinicians saw Chinese patients as less socially competent and as having less capacity for interpersonal relationships. Chinese- American clinicians reported more severe pathology than did the European American clinicians when judging quiet clients.
        
        Real differences exist between cultures in the symptomology of the disorders. Marsella (2003) agues that depression takes a primarily affective form in individualistic cultures. In more collectivist cultures, somatic symptoms such as headaches are dominant. Depressive symptoms patterns may actually differ across cultures because of cultural variation in sources of stress as well as resources for coping with stress.
        Bolton (1999) used an emic approach in Rwanda to help distinguish between PTSD and normal grief in responce to genocide.
    - - Stressors of all kinds are likely to affect those living in poverty. Research shows that ones socioeconomic status may influence one's mental health but also the diagnosis. Midtown Manhatten study conducted a series of interviews with over 1000 interviews of individuals in the city. The study found that the highest levels of mental illness among the lower class.
      - Johnstone (1989) found that regardless of the symptons, more serious diagnoses were given to lower-class patients. they were more likely to spend longer periods in hospitals and were more likely to be prescribed drug therapy rather than psychotherapy. Health professionals argued that those in lower class were less likely to benefit from verbal techniques as they were less literate. Lower classes have less access to protective factors that help them maintain a positive mental health
- - - - Thompson et al (2004) suggests depression and anxiety account for about 1/3 of all psychiatric hospital admissions in the UK. Depression is two to three times more common in women than in men and occurs frequently to those in lower socioeconomic groups and among young adults.
      - SYMPTOMS\
        
        Affective symptoms: feelings of guilt and sadness; lack of enjoyment or pleasure in familiar activities or company
        Behavioural symptoms: Passivity; lack of initiative
        Cognitive symptoms: frequent negative thoughts; low self esteem; suicidal thoughts; irrational hopelessness; inability to concentrate.
        Somatic: Loss of energy, insomnia, or hypersomnia, weight loss/gain, diminished libido
  - - - Genetic research argues that genetic predisposition can partly explain depression. One of the many ways this is investigated is through twin studies. Kendler et al (2006) used 40,000 twins from the Swedish Twin Registry and found the concordance rate for MZ twins was lower than the concordance rate for DZ twins was much lower. Also suggested that the disorder may be more genetic in origin for women than for men.
        The fact the concordance rate for MZ twins is below 100% does not contradict the argument that depression is genetically inherited. It may mean that the gene is there, but both twins may not have experienced the same levels of stress and so they may not have expressed the same genes.
      - A meta analysis by Sullivan et al (2000) looked at twin and family studies of major depressive disorder. The research showed that genes may account for 1/3 of all cases of depression. Shared environmental factors provided only a negligible role in adults, but played a more significant role in the onset of depression in children. The researchers concluded that there is not a single gene that leads to depression, but rather that depression is a result of several genes that work together to produce a vulnerability to depression when other risk factors are present.
      - Modern research in genetics now focuses on genetic mapping. Recent research has used DNA markers to try and identify the gene or genes that are involved in depression.
        The Human Genome Project allowed us to see that there are up to 11 genetic markers that seem to correlate with MDD. One of the difficulties in linking genes to the disorder is the nature of the diagnosis- symptoms vary between individuals in both type and extent.
      - Caspi et al (2003) examined the role of the 5-HTT gene in depression. The gene plays a role in the serotonin pathways. Two short version mean that you are more likely to develop major depressive disorder. The study was prospective, longitudinal study.
      - Cai et al (2015)may move us to finding specific genes. The researchers analysed DNA sequences from 5,303 Chinese women with depression and another 5.337 controls.
      - Evaluation of Genetic Arguments
        +Twin studies have been highly reliable in their results
        +Modern research has allowed us to actually locate genetic variations using very large sample sizes.
        +Modern research recognises the interaction of environmental and biological factors and does not use a solely reductionist approach
        --Correlational studies do not establish a cause and effect relationship
        -Twin studies have the problem of population validity- twin samples do not necessarily represent the general population
        -It is impossible to isolate variables and separate out social factors in twin studies.
        -Genetic arguments do not account for the variations in symptomology in different cultures .
        -It is not yet clear how genetic markers interact
    - - The serotonin hypothesis of depression argues that a reduction in serotonin leads to an increased predisposition to depression. Low levels of serotonin appear to result in OCD like symptoms including obsessive thoughts and compulsive behaviours. It also may result in impulsivity, suicidal thoughts and aggressive behaviours. Lower levels are also linked to mood swings, worrying, insomnia and sadness. All the genes in Caspi's study were responsible for serotonin transmission. Drugs like Prozac increases serotonin levels and were created to restore chemical balance. This leaves the serotonin hypothesis with very little support. Plenty of evidence SSRIs increase communication from neurons that release serotonin.
        
        Rausch et al
        To study the serotonin hypothesis using a placebo and a serotonin antagonist.
        Carried out a double blind study. 18 participants were given either a placebo or serotonin hypothesis. The results were measured by self and observer rated depression scores.
        In comparison to the placebo the drug caused a significant depression in mood.
        Lack of serotonin plays a part in depression.
        
        evaluation
        placebo is a form of deception. stress and harm to participant.
      - Neurogenesis theory of depression. This theory argues that depression is the result of the cessation of neuron birth in the hippocampus as well as in other neural networks related to serotonin, dopamine and norepinephrine. Cortisol appears to be the the reason for this lack of neurogenesis. Patients with MDD displays a symptom called HPA-axis hyperactivity that results in ver secretion of cortisol. Over secretion of cortisol leads to reduced serotonin and other neurotransmitters in the brain including dopamine which has been linked to depression.
        
        What is the evidence for the neurogenesis theory
        
        Depressed patients seem to have smaller hippocampi than the general population. Hippocampi are also smaller during periods of depression than periods of good mental health.
        
        Glucocorticoids (stress hormones) are elevated in depression and appear to inhibit neurogenesis in the hippocampus in rodents and non-human primates.
        
        Chronic administration of anti-depressants increases neurogenesis in the hippocampus in rodents.
        
        Malberg et al (2000) first suggested the possibility that neurogenesis supports the effect of antidepressants in a rat model for depression. They first injected antidepressants into the rats including a monamine oxidase inhibitor and an SSRI. In addition some rats received electroconvulsive shock. All of these methods have been successful in the treatment of some depressed patients. All treatments increased neurogenesis in the hippocampus and proposed that this increase is the mechanism to fight depression. In spite of the strong evidence in rodents, we still dont have a lot of evidence to suggest this is the case in humans.
        
        Videbech and Ravnkilde (2004) performed a meta analysis of 12 studies using brain scans to compare the hippocampal volume in patients with a diagnosis of depression with healthy controls. The sample consisted of 351 patients and 279 controls. The analysis found up to 10% reduction of the hippocampus was significantly correlated to the number of depressive episodes. A hippocampal reduction could explain the common symptom of memory problems in patients with depression. However, this study was cross-sectional and the data correlational. We cannot assume that a small hippocampus is the result of a lack of neurogenesis and the reason for depression. Bidirectional ambiguity in results, does depression cause shrinkage? or people with small hippocampi more vulnerable to depression?
      - Evaluation of Biochemical arguments for depression
        +there are several longitudinal case studies and animal research that support the theories.
        +Practical application of the theories has led to successful drug treatments that have improved some peoples lives.
        
        Correlational research mean that causation cannot be established and bidirectional ambiguity not resolved.
        
        The treatment aetiology fallacy- that is, the mistaken notion that the success of a given treatment reveals the cause of the disorder.
        
        Biological explanations cannot explain the range of symptoms associated with depression. There may be cultural and cognitive factors as well
  - - - People who feel depressed tend to think depressed thoughts. It is commonly assumed that a depressed mood somehow leads to cognitive symptoms. Cognitive theories of depression aim to explain why some people are more vulnerable to depression when confronted with negative events, whereas others only suffer mild short-term distress. The interpretation people give to their life experiences influences their vulnerability to depression, meaning that depressed cognition, cognitive distortions and irrational beliefs produce the disturbances of mood characteristic depression.
        
        Aaron Beck is seen as the founder of cognitive therapy. He argues that depression is rooted in what he called a patient's 'automatic thoughts' that is, negative self schemas organised around themes of failure inadequacy, loss, and worthlessness. All these personalised thoughts are triggers by particular stimuli that lead to emotional responses and they are seen as potential vulnerabilities for the onset of depression.
        
        Becks theory of depression has three components.
        
        The negative cognitive triad: depressed patients have negative views of the self, the world and the future.
        
        They have negative schemas triggered by negative life events (dysfunctional beleifs)
        
        They engage in cognitive biases- 'irrational thinking'
        
        Beck argues that negative schemas can develop because of family problems, social rejection by peers, poor school experiences, or by having depressed members of the family or close social circle. These schema are activated in depressed people whenever they are in a situation which in any way resembles the situations in which the schema were created. Beck describes three typical schema that are a characteristic of depressed people; an ineptness schema, self blame schema, and negative self evaluation schema.
        
        Beck also argues that there are several patterns of faulty thinking or cognitive biases that are typical in depressed patients.
        Arbitrary inference: drawing conclusions based on little or no evidence.
        Dichotomous thinking: An all or nothing approach to viewing the world. Love me or hate me
        Exaggeration: Overestimating the significance of negative events.
        Overgeneralisation: Applying a single incident to all similar incidents.
        Personalisation:Assuming that others' behaviour is done with the intention to hurt or humiliate you.
        Selective abstraction: Drawing conclusions by focusing on a single part of a whole.
        
        Studies
        Several studies support the theory that cognitive biases are linked to depression.
        
        Alloy et al (1999) Wanted to see if one's thinking patterns could be used to predict the onset of depression. They carried out a longitudinal study in which they followed a randomly selected sample of young Americans four six years. As this was a prospective study, their thinking style was tested as the beginning of the study. They were places in either the 'positive cognitive group' (low risk) or the 'negative cognitive group' (high risk) based on a number of tests such as the Cognitive Style Questionnaire. After 6 years, they found that only 1% of those in positive group had developed depression compared to 17% in the negative thinking group. Negative cognitive style could lead to development of depression
        
        Joiner et al (1996)gave a questionnaire to university students before mid-term exams. Those who ad negative cognitive thoughts before the exam and who ended up doing poorly showed an increase in depressive symptoms. Those who did well, did not. This shows that patterns of cognition alone are not enough to lead to depression, but must be in response to environmental stimuli.
    - - Nolen-Hoeksema has found that women are more likely to amplify depression by ruminating about their feelings and their possible causes- that is, they think a lot about how they feel and try to understand the reasons they feel the way they do. Nolen-Hoeksema(2000) found that both men and women who ruminate more following the loss of loved ones are more likely to become depressed and to suffer longer and more severe depression than those who ruminate less. According to the researcher, rumination appears to be more consistently predict the onset of depression rather than duration but in combination with negative cognitive styles can predict the duration of depressive symptoms
      - Brain research supports this theory. Farb et al (2011) showed 16 formerly depressed patients sad and neutral movie clips and tracked their brain activity using fMRI. They compared this to 16 healthy controls. All participants filled out a questionnaire measuring their adaptive and maladaptive cognitive models in the face of emotional challenges. They also measured the severity of depression in patients. The researchers calculated correlations between emotional reactivity in patients after the scanning and subsequent relapse status over 18 month period follow up period. Prediction was that activity in the medial frontal cortex predicted relapse. Results supported the hypothesis. 10 out of 16 had relapsed. Faced with sadness, the relapsing patients showed more activity in the frontal region of the brain, known as the medial prefrontal gyrus. These responses were also linked to higher rumination. Healthy participants showed activity in the visual cortex.
        
        This study suggests there are important differences in how formerly depressed people respond to emotional challenges that predict future well-being. Ruminating in order to analyse and interpret sadness may actually be an unhealthy reaction that can perpetuate the chronic cycle or depression. Researchers argue that the study itself is limited in its ability to conclusively determine the neural predictors of depressive relapse due to small sample size and limited scans.
  - - - On this research, Brown suggested a vulnerability model of depression based on a number of factors that could increase the likelihood of depression. These vulnerability factors are grouped into three types:
        
        Protective factors: these factors decrease the risk of depression in combination with particularly stressful life events; eg strong sense of community.
        
        Vulnerability factors: these factors increase the risk of depression in combination with stressful life events. 1) Loss of one's mother before age of 11, 2) Lack of confiding relationship, 3) more than three children under the age of 14 at home and 4) unemployment
        
        3.Provoking agents are acute and ongoing stress
      - There is also evidence that shows that smaller more consistent stressors may play a more significant role in one's overall mental health. This could be because larger life events can been interpreted as having significance and meaning, whereas hassles are seen as irritations without purpose.
        Vulnerability models are unable to explain why some people develop depression when exposed to environmental stressors, but they do help us to prevent the disorder by providing more protective factors for individuals who may be at risk of the disorder .Vulnerability models are also usually case studies so are difficult to generalise.
    - - One of the limitations of many of the theories of the aetiology of disorders is what. Early research argues that disorders like depression were absent from some cultures .They were using Western designed tests and looking for a Western set of symptoms. This is due to them using an etic approach to research. Collectivist cultures are less likely to want to express themselves.
      - Parker, Cheah and Roy (2001)
        Two sets of depressed out patients, Chinese and Australian. Asked the primary symptom. Results showed that 60% of Chinese and only 13% Australian identified a somatic symptom as reason for seeking help. Australians more likely to identify mood or cognitive difficulties
      - Kirmayer (2001)
        His theory is that cultures create socially acceptable sets of symptoms for mental disorders. These are known as explanatory models and are continually changing in globalisation. May account for a rise in a disorder. Western symptoms in Japan have become more common.
      - Evaluation
        
        Modern biological research on the role of stress in depression appears to support vulnerability models
        +Vulnerability models acknowledge the interaction of biological and environmental factors.
        
        Sociocultural approaches explain gender and cultural differences in the prevalence and symptomology of depression
        
        -Vulnerability models are based on measuring stressful life events. Questionable whether its a valid measure.
        
        Cultural theories are descriptive in nature, do not explain the origin.
        
        Cross cultural research is a problem.
        
        Correlational in nature.
- - - - Psychoactive drugs account for a large proportion of prescriptions. Pratt at al (2011) reported that between 2005-2008 more than 1 in 10 Americans ages 12 and older report taking an antidepressant drug. In 2010 antidepressants were the second most commonly prescribed medications.
      - The goal for treatment for MDD with antidepressant medication is generally to provide symptom relief. A positive response to a drug treatment is defined as a clear improvement and remission is defined by the near absence of symptoms. However even when remission is achieved, an individual may have a risk of relapse.
        
        Drugs typically work by affecting neurotransmitters such as dopamine, serotonin and noradrenaline. Antidepressants aim to increase or decrease the levels of available neurotransmitters in the synaptic gap. Neurotransmission is affected by reuptake pumps. After the neurotransmitter is released and binds to the post synaptic membrane, the neurotransmitter is reabsorbed into the terminal buttons. SSRIs (selective serotonin reuptake inhibitors) block the process of reuptake and allow higher levels of serotonin in the synapse.
        
        Evaluation of drug therapy
        
        Key strength of drug therapy is that for many people who suffer with depression, it alleviates the symptoms that make day-to-day living difficult. Many psychiatrists agree that antidepressants are more effective than placebos for severe mood disorders, and may help to prevent suicide.
        
        Geddes et al (2003) carried out a systematic review of 31 randomized trials with 4410 patients and concluded that antidepressant drugs are an effective way to treat depression and prevent prolapse. Drugs have been effective in reducing the number of hospital in patients who are being treated for psychological disorders.
        
        In spite of strengths, there are some serious limitations. One is the issue of side effects- negative effects of using the drugs themselves. Antidepressants are known to cause, nausea, increased weight gain, loss of sexual desire, dizziness, insomnia, blurred vision, constipation and anxiety. Some of these side effects actually contribute to lowering ones self esteem.
        
        Another limitation is that clinicians are still not sure how these drugs alleviate symptoms of depression and why symptoms and why the treatment is not effective for all patients. Usually takes several weeks of treatment before therapeutic benefit results. Not all patients respond to them.
        
        Relying too heavily on drug treatment may lead to the neglect of important psychological or social factors. Using a drug treatment can be argued to be a reductionist approach. Only provides temporary relief.
        
        Antidepressants may leas to the issue of dependence on the drug. Discontinuation syndrome (withdrawal). Hollen et al (2005)compared the discontinuation of antidepressants after 16 weeks of treatment with discontinuation of cognitive behavioural therapy and found that 76% of drug patients had relapsed compared to 31% of CBT patients
  - - - Cognitive Behavioural Therapy
        Blend of cognitive therapy and behavioural therapy. Therapist helps client to change negative thought patterns. Beck suggested that psychological problems are associated with maladaptive thinking patterns and unhealthy behaviours that can be changed by a working relationship between he client and a therapist. Not specific events that cause the problem but its the way the individual interprets them. Therapy focuses on current issues and symptoms. The client is an active participant in the therapy session; learns to identify unhealthy thoughts and behaviours so they can gradually be replaced by positive ones. Typically around 12-20 weekly sessions combined with daily practise exercises to help the client use the new skills. based on cognitive therapy and includes behaviour modification.
        
        Aims
        Identify and correct faulty cognitions and unhealthy behaviours. Beck argues that people with emotional difficulties tend to commit logical errors that lead to self depreciation. Client is encouraged to find out which thoughts are associated with depressed feelings and correct them- cognitive restructuring. Aim is to teach client how to monitor thought processes and then to test them against reality, so that they can eventually change their behaviour. Validity testing is used. This is when a therapist asks the client to defend his or her beliefs. If the patient cannot produce evidence supporting the assumptions, the faulty nature of that belief is challenged.
        
        Second aim is to help clients develop effective coping strategies and problem solving skills. Two key ways he did this: first was cognitive rehearsal where a client is asked to imagine a difficult situation from the past then together they can practise how to cope with the problem. The hope is that by developing new schema for coping with problems, they will be better handled when real problems occur.
        Second they were given homework. This was to encourage self discovery and reinforce what is happening in therapy sessions. This could be to read about specific issues, keep a diary, try out a new strategy learnt in therapy. Also taught communication skills in regard to ones feelings and encourage the increase of activities that could be rewarding. Teach how to cope with stress.
        
        Evaluation of CBT
        
        Strengths
        Patients do not experience any side effects and studies indicate it is as effective as antidepressants in treating depression. Reduces risk of relapse after therapy has stopped.
        CBT clients have lower relapse rates than those treated solely by drug therapy. Rush et al (1977) suggest that the higher relapse of those treated with drugs is because CBT patients learn how to cope with depression with coping strategies.
        It is persona; and requires client patient relationship.
        
        Limitations
        CBT may not be the most appropriate therapy for all clients. For a patient who is suicidal, may take too long to take effect and individual may not be in a state that would allow for discussions about their cognitive processes.
        Focuses on symptoms rather than causes. Does not look at history or biological factors.
        Concern about potential gender and cultural biases playing a role in the therapy. It is a directive therapy
    - - Mindfulness encourages adopting an attitude of openness and acceptance towards present experiences and thoughts. Mindfulness-based stress reduction meditation may help patients to reduce psychological stress which is often a factor in psychological disorders. Also includes methods to change dysfunctional thoughts that could lead to problematic emotions and behaviours.
      - Aim of this therapy is to help clients let go of negative thinking patterns instead of being obsessed by them. The focus on current perspective instead of ruminating about the past or fearing the future is seen as a valuable strategy to keep the client's mind out of a depressive or anxious loop. MBCT is based on integration of elements of CBT
      - Segal et al (2010) studies 84 people in remission for Major depressive disorder to determine the long term effect of MBCT. The patients were randomly assigned to one of 3 conditions: patients discontinued antidepressants and attended 8 weekly group sessions of MBCT; patients continued taking therapeutic dose of antidepressants without MBCT; patients discontinued active medication and were switched to placebos. Relapse was defined as a return, for at least 2 weeks of symptoms sufficient to meet the criteria for major depression. MBCT could help prevent recurring depressive episodes as well as medications and better than placebo.
  - - - Indigenous psychotherapy
        These therapies are embedded within the culture and do not include anyone from the outside culture. They are carries out by someone who is sanctioned within the community to be a therapist. Indigenous healing encompasses therapeutic beliefs and practices that are rooted within a given culture- for example, heavy reliance on family and community networks as well as spiritual and religious beliefs. These practises are difficult to transfer to a different cultural setting.
        
        The study of indigenous psychotherapy is difficult for several reasons. Indigenous therapies require no formal training. It is often practised within families or communities and is not open to people outside the community. There is a lack of standardised procedures that could be evaluated for effectiveness. As a result there is a lack of reliable quantitative results of these practises that could be studies through meta-analysis.
        
        There are exceptions to the difficulty in their study. For example, Morita therapy is a therapy that is rooted in fundamental beliefs and values in Japanese culture. These include:
        
        Feelings and natural responses to our life circumstances and we need to try not 'fix' or 'change' them.
        
        Dogmatic thinking; that is perfectionism and high demands on oneself that hinder recovery. Liberation from self-centeredness leads to healing.
        
        Isolation and rest, rather than verbal interaction is essential to recovery.
        The therapy usually begins with a period of rest before counselling begins. Counselling focuses on changing one's perspective toward the larger community and away from oneself. It also asks the patient to practise mindfulness through meditation. Focus in recovery.
        
        Ando et al (2009) wanted to determine the effect of mindfulness based meditation on anxiety and depression in Japanese patients undergoing anti cancer treatment. 28 patients participates in two sessions of meditation therapy. They were instructed to practise at home between sessions. The study used a pre-test/ post-test design. Patients completed questionnaires before and after the treatment. The results showed that anxiety and depression levels decreased significantly. The researchers argue that a sense of spiritual wellbeing is what resulted in lower levels of both anxiety and depression.
        
        Spiritually or religious practises are often a integral part of indigenous therapies. In Malaysia, time for prayer and focusing on verses of the Koran that address 'worry' are some techniques that have made psychotherapy culturally relevant. Sometimes with chinese clients, verses from Taoist writings that highlight main principles such as restricting selfish desires, learning how to be content and learning to let go are read and reflected on by the client. Known as Chinese Taoist cognitive psychotherapy (CTCP)
        
        Zhang et al (2002)
        Carried out a study to test the efficacy of CTCP. In their study, 143 Chinese patients with generalised anxiety disorder were randomly assigned to one of three treatment groups; CTCP only, anti anxiety drugs only, or combination of the two. Patients were evaluated before the study and after one month and again after 6 months. They found that antidepressants had most reduction of symptoms after 1 month but after 6 months CTCP had greater reduction of symptoms, with low chances of relapse.
      - Cross-cultural psychotherapy
        Also know as 'intercultural counselling'. This is when the therapist is from a different culture from the patient. The therapists adapts therapeutic methods that have been shown to be effective to meet the cultural needs of the patient.
- - - - Kleinman (2004) argues that any depressed Chinese people do not report feeling sad, but rather express boredom, discomfort, feelings of inner pressure, and symptoms of pain, dizziness, and fatigue. When attempting to diagnose these patients, Western psychiatrists may fail to attribute these symptoms to depression.
        Prevalence rates are not universal and they change overtime.
    - - Twenge (2014) found that teens in the US are significantly more likely to show signs of depression than their 1980's counterparts. And research on schizophrenia shows a drop in the number of schizophrenic cases in hospitals. It is clear that prevalence rates are not constant .
        
        Twenge (2015) argues that one of the reasons for an increase in prevalence rates of depression among young people is a change in social norms that make a diagnosis in depression less of a stigma. The media play a role in promoting the need to seek help or to take medication. Prevalence rates are based on reported cases- if more people are coming forward for help, there will be a higher prevalence rate.
      - It is important to consider the environmental factors that may play a role in triggering disorders. Some environmental factors that may play a role in triggering disorders. An example of an obvious trigger is the Rwandan genocide which had a significant impact on the mental health of the average Rwandan. We cannot assume that negative environmental conditions will always have a negative impact on mental illness. World Health Organization (2011) publishes a report that showed there was no clear link between the economic crises and the change in prevalence for disorders. Family support and state programs helped to maintain this stability.
      - Prevalence in schizophrenia may be going down due to an optimistic approach that argues that we are now better at identifying and addressing risk factors. The more pessimistic approach argues that it has to do with the statistics gathered. Healy et al (2012) found that the rate of hospital admissions for schizophrenia has dropped. This may mean that doctors are less likely to admit patients and that this does not reflect an actual decrease in the prevalence of the disorder- but more about the accessibility of mental health care.
    - - Today we live in a globalised society. One of the key arguments for why we see a change in prevalence rates is that cultural groups around the world may change their expression of psychological distress as a result of exposure to the media from other cultures.
        
        In hong kong prior to the 1990's there were almost no women diagnosed with anorexia nervosa. There was a similar disorder on which patients wasted away. Patients often complained that their stomachs felt distended and they were not hungry. Also complained of the lack of meaning to their existence and experienced relentless guilt and shame. Key difference between this disorder and anorexia nervosa is that the patients did not have a false perception of their body weight.
        
        Watters argues that it was the death of a popular singer that began the increase in the prevalence of the disorder in Hong Kong. Found she was only skin and bones. Argued that women are attracted to the cultural template of behaviour which shows dysfunction or distress. When an individual feels psychological distress, the symptoms that one adopts come out of a symptom pool appropriate for one's culture, age and gender. As the society becomes more globalized we see a ride in illnesses seen outside of the culture. Difficult to test this theory
      - Final concern about globalisation is the marketing of pharmaceuticals. As individuals are exposed to the marketing of drugs that are alleged to improve one's mental health, this may lead to more people seeking out mental advice.
        
        An example of this is major depressive disorder in Japan. Traditionally, depression was seen as a need for spiritual guidance and time with family. The japanese did not see depression as a disorder but rather as a sign that one had to get back to their moral compass.
        Transnational pharmaceutical companies eventually came to Japan and became advertising SSRIs. Prozac came up with a slogan that had cultural resonance, 'depression is like a cold of the soul'. This avoided having a social stigma attached to the disorder and indicated it was a common thing. Also advertised there was a huge cost to untreated depression. Drug seen as a way to make people more competitive in the job market.