The clinical symptoms of depression are characterised by an all-encompassing sadness, composed of a remarkably broad range of feelings, thoughts, and physical manifestations. These include low self-esteem, suicidal thoughts, pessimism, and feelings of dejection and hopelessness. Most sufferers will experience sleep disturbance and a loss of appetite and libido. All of these symptoms are usually accompanied by overwhelming tiredness, a lack of interest or enjoyment, guilt feelings, crying spells and social withdrawal. Other common features are psychomotor retardation (general slowing down physically), loss or motivation, and feelings of inadequacy and helplessness. There is often a diurnal mood variation (sufferers may feel worse either in the mornings or in the evenings). See table below for a more detailed explanation of the behaviours associated with depression.
Affective
Physiological
Cognitive
Behavioural
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Anger
Abdominal pain
Ambivalence
Aggressiveness
Anxiety
Anorexia
Confusion
Agitation
Apathy
Backache
Inability to concentrate
Alcoholism
Bitterness
Chest pain
Indecisiveness
Altered activity level
Denial of feelings
Constipation
Loss of interest and motivation
Drug addiction
Dejection
Dizziness
Self blame
Intolerance
Guilt
Fatigue
Self- depreciation
Irritability
Helplessness
Headache
Self- destructive thoughts
Lack of spontaneity
Hopelessness
Impotence
Pessimism
Overdependence
Loneliness
Indigestion
uncertainty
Poor personal hygiene
Low self-esteem
Lassitude
Psychomotor retardation
Sadness
Menstrual changes
Tearfulness
Sense of personal worthlessness
Nausea
Underachievement
Sexual non responsiveness
Withdrawal
Sleep disturbances
Vomiting
Weight changes
Give two or more physiological causes of depression
The cognitive model
Of the causes of depression proposes that people experience symptoms of depression because their thinking is disturbed. Depression is a cognitive problem that is dominated by the person’s negative evaluation of themselves, their world and their future. In the course of their development certain experiences sensitize the individual and make them vulnerable to depression. They also acquire a tendency to make extreme, absolute judgments; loss is viewed as irrevocable and indifference as total rejection.
The depression prone person is likely to explain an adverse event as a personal shortcoming. `The deserted husband believes “she left me because I’m unlovable.” Instead of considering the other possible alternatives, such as personality incompatibility, the wife’s own problems, or her feelings towards him. As he focuses on his personal deficiencies, they expand to the point where they completely dominate his self concept. He can think of himself only in a negative way and is unable to acknowledge his other abilities, achievements, and attributes. This negative set is reinforced when he interprets ambiguous or neutral experiences as additional proof of his deficiencies. Comparisons with other people further lower his self-esteem. And thus every encounter with others becomes a negative experience. His self-criticisms increase as he views himself as deserving of blame’. (Beck)
In the cognitive model of depression, it is thought that many cases develop through early life experiences, where parents have been excessively critical, the child may internalise the impact rule that being valued only comes from perfect performance. This assumption may become latent or silent during parts of adult life, where any endeavours are met with a reasonable degree of success. Thus, prior to becoming depressed, the person had by unrelenting hard word, managed to live up to the excesses of their conditional belief however, any notable failures activate the latent assumption and the person becomes sensitised to any signs of falling short of their perfectionist standard.
A common factor that interferes with the application of the cognitive model apparently disparate presentations of persistent depression is avoidance. In persistent depression avoidance can serve to mask negative thinking patterns or inhibit the effect of negative thoughts on mood. On occasions, negative thinking may be overt or apparent due to such avoidance. Pinpointing such avoidance in persistent depression is often prerequisite to identifying negative thoughts.
The behavioural model
The behavioural explanation of the causes of depression is based on the view that abnormality is seen as the result of learning from the environment. In other words depression is a response to life experiences and stressors. Disturbances of mood are a specific response to stress. There are two major types of stress that a person may experience. The first is the stress of major life events that are evident to others. The second type of stress may not be obvious at all to others, but it is the minor stress or irritations of daily life. These are the small disappointments, frustrations, criticisms, and arguments that when accumulated over time and in the absence of compensating positive events produce a major and chronic negative impact. It is appropriate, therefore, to examine in more detail some of the sources of life stressors that may produce disturbances of mood. Four such, sources include major life events, roles, coping resources, and physiological changes. Major life events (Holmes and Rahe) did the pioneering work in this area with the development of social readjustment rating scale.
Rank
Life event
Mean value
1
Death of spouse
100
2
Divorce
73
3
Marital separation
65
4
Jail term
63
5
Death of close family member
63
6
Personal injury or illness
53
7
Marriage
50
8
Fired at work
47
9
Marital reconciliation
45
10
Retirement
45
11
Change in health of family member
44
12
Pregnancy
40
13
Sex difficulties
39
14
Gain of new family member
39
15
Business readjustment
39
16
Change in financial state
38
17
Death of close friend
37
18
Change to different line of work
36
19
Change in number of arguments with spouse
35
20
Mortgage over 10,000
31
21
Foreclosure of mortgage or loan
30
22
Changes in responsibilities at work
29
23
Son or daughter leaving home
29
24
Trouble with in-laws
29
25
Outstanding personal achievement
28
26
Wife begin or stop work
26
27
Begin or end school
26
28
Change in living conditions
25
29
Revision of personal habits
24
30
Trouble with boss
23
31
Change in work hours or conditions
20
32
Change in residence
20
33
Change in school
20
34
Change in recreation
19
35
Change in church activities
19
36
Change in social activities
18
37
Mortgage or loan less than 10,000
17
38
Change in sleeping habits
16
39
Change in number of family get- together’s
15
40
Change in eating habits
15
41
Vacation
12
42
Christmas
12
42
Minor violations of the law
11
The scale ranks important life events and assigns a specific value to each one on the basis of the amount of coping behaviour needed by the individual to deal with the event. As the score of the mean value increases, the likelihood of an illness increases.
The behavioural model overcomes the ethical issues raised by the medical model of labelling someone as `ill’ or abnormal, instead the model concentrates on behaviour and whether it is adaptive of maladaptive. Those who support the psychodynamic model, however, claim the behavioural model focuses only on symptoms and ignores the cause of abnormal behaviour they claim that the symptoms are merely the tip of the iceberg, the outward expression of deeper underlying emotional problems.
Coping resources Life stress may also take the form of inadequate coping resources. Personal resources available to individuals include their socioeconomic status (income, occupation, social position, and education), families (nuclear and extended), interpersonal networks, and the secondary organizations provided by the broader social environment. The far-ranging effects of poverty, discrimination, inadequate housing, and social isolation cannot be ignored or taken lightly.
Physiological changes Disturbances in mood may also occur as a response to physiological changes produced by drugs or a wide variety of physical illnesses. Drug- induced depressions have been noted to occur following treatments with various antihypertensive drugs and the abuse of addictive substances, such as amphetamines, and barbiturates. Depression may also occur, secondary to a wide variety of medical illnesses, for example viral infections, nutritional deficiencies, endocrine disorders, anaemia’s, and central nervous system disorders, such as multiple sclerosis, tumours, and cerebral vascular disease.
Evaluate psychodynamic therapy in treatment of depression in terms of its strengths and weakness
Psychodynamic therapy is a generic term that embraces all those therapies of an analytic nature. Probably the majority of psychodynamicists adhere to work and teaching of Freud. But also in this group you will find therapy based on ideas of various other psychologists including Jung and Adler.
In this type of therapy, the therapist keeps his own personality out of the picture. This vital aspect of psychodynamic psychotherapy and it enables the therapist to be like a blank canvas onto which patients can transfer and project deep feelings about themselves, their parents and other significant people in their life.
It is then up to the therapist to handle all the feelings and information that emerge, to gradually help patients to deal with all this `baggage’. In this way the therapists helps patients gain a better understanding of what their disturbances are and how their mind works. The term “psychodynamic” refers to a group of explanations that try to account for the dynamics of behaviour i.e. the forces that motivate behaviour. Freud’s revolutionary theory was that depression does not have a physical cause, but instead arises from unresolved, unconscious conflicts which form in early childhood. This model is based on Freud’s theory of psychosexual development. A child passes through a series of stages (oral, anal, phallic, latency, and genital) if there is a major conflict at any of these stages, the child can spend an unusually long time at that developmental stage (called fixation) if and adult experiences great personal problems, he or she will tend to show regression (going backwards through the stages of psychosexual development) to the stage at which he or she had previously been fixated. The prime goal of therapy is to enable patients to gain access to their repressed ideas and conflicts, and to encourage them to face up to whatever pops out from the unconscious mind. Freud initially used hypnosis as a means of accessing repressed memories but later turned to the analysis of dreams and technique of free association, where a client is encouraged to say the first thing that comes in to his or her mind. The strengths of psychodynamic therapy is that it identifies traumatic childhood experiences as a factor in the development of depression in later life.
A weakness of this type of therapy is that the therapist may appear disinterested in the client’s current problems. A depressed patient wants to talk about themselves now as opposed to then. Another weakness to the Freudian approach is that it tends to focus too much on sex, and does not emphasise the importance of interpersonal and social factors in causing and maintaining depression. A patient must have the right to approve or disapprove of any treatment programme and a depressed patient may well have fears and doubts about “laying their soul to bear” to a stranger. Another ethical implication of this type of therapy is that patients may not take any responsibility for their illness depends on unconscious processes over which they have no control. In addition, the idea that adult mental illness is based in childhood experiences implies that parents are at least partially to blame. Is it ethical to cause distress to parents by suggesting that they are responsible for their child’s mental illness?
Serious ethical issues are raised by numerous recent cases of false memory syndrome, where patients in therapy have made allegations about childhood physical or sexual abuse which may or may not be true. Freud believed that men and women have their own biologically determined sexual natures, and depression can develop when the natural course of their sexual development is thwarted. This notion is ethically dubious, as it ignores cultural differences in sexual attitudes and behaviour.
Outline the clinical characteristics of Schizophrenia
Although the popular concept of “split personality” is still common the reality of Schizophrenia is far more complex. The two most frequently found elements of the illness are delusions and hallucinations.
Bizarre delusions are common. The content of these delusions is patently absurd and has no possible basis in fact, such as delusions of being controlled, thought broadcasting or thought insertion. Suffers often report grandiose or religious delusions or beliefs about themselves having physical symptoms which do not in fact exist. They may feel persecuted or irrationally jealous. A particularly distressing symptom consists of auditory hallucinations in which either a voice keeps up a running commentary on the individual’s behaviour of thoughts, or two or more voices converse with each other.
To the outsider the sufferer may appear incoherent, blinded or even catatonic. There is a marked deterioration from their previous level of functioning in such areas as work, social relations and self care. Below is a list of symptoms from American Psychiatric Association: Diagnostic and statistical manual of mental disorders, third edition, Washington, D.C, APA, 1980.
Social isolation or withdrawal
Marked impairment in role functioning as wage earner, student, or homemaker
Marked peculiar behaviour (e.g., collecting garbage, talking to self in public, or hoarding food)
Marked impairment in personal hygiene and grooming
Blunted, flat, or inappropriate affect
Digressive, vague, over elaborate, circumstantial, or metaphorical speech
Odd or bizarre ideation, or magical thinking, e.g., superstitousness, clairvoyance, telepathy, “sixth sense”, “others can feel my feelings,” overvalued ideas, ideas of reference
Unusual perceptual experiences, e.g., recurrent illusions, sensing the presence of a force or person not actually present.
Give two or more psychological (psychodynamic/behavioural/cognitive) expiations of Schizophrenia
Psychodynamic
Psychoanalytical theory states that Schizophrenic behaviour results when the ego can no longer withstand the pressures emanating from the id and from external reality. The ego of the psychotic person struggles to cope with stress because of serious deficiencies in the relationship between the person as a child and his mother. When the person is anxious and stressed he employs ego defence mechanisms in an unhealthy way in an effort to control unacceptable impulses and thoughts. Take for example a man or woman with paranoid delusions. So much psychic energy is invested in holding down these terrible thoughts and impulses that there is little energy left to deal with normal daily living. The person withdraws from usual activities and has difficulty maintaining basic physiological needs such as nutrition and hygiene. If stress and anxiety gets even worse, ego functioning may deteriorate further, and the person will be flooded with frightening thoughts and impulses. As ego identity disintegrates communication is confused and garbled, and the person is alone in their own world.
According to Freud, schizophrenia is a form of regression, back to the oral stage of development; the oral stage is the first stage of psychosexual development. A baby is born a bundle of id, is self indulgent and concerned only with a satisfaction of their needs. There is a need gratify these impulses but their experiences in the real world result in conflict, people with schizophrenia are overwhelmed by anxiety because their egos are not strong enough to cope with id impulses in schizophrenia, this can lead to self indulgent symptoms such as delusions, such as hearing voices which may have an ultimate authority.
It has been suggested that schizophrenia has a psychosomatic cause the origin is solely in the mind. At best it could only be a partial explanation of some symptoms, e.g. delusions. In reality Freud is denying the experience of patients with schizophrenia, it is unscientific and extremely difficult to test. Concepts such as repression are difficult to observe and measure, although this difficulty does not invalidate the theory. The theory is based on unrepresentative samples, case studies, from which it is difficult to generalise. The theory fails to account for gender differences the onset for males is around 20 years, and for females 30 years. Nor does the theory explain why, prior to diagnosis, their behaviour has appeared normal. Furthermore, it also excludes considerations of the environment.
A concise explanation of Schizophrenia was given by O.A. Will in his 1961 study of
“Human relatedness and the schizophrenic reaction”. “The expression of complicated patterns of behaviour adopted by the organism in an effort to deal with a gross inadequacy in relating to other humans”.
The Behavioural explanation
Schizophrenia can evolve as the results of various experiences that influence the growth of the individual. In most instances a series of life events predisposes the individual to difficulty with interpersonal relationships. The family is the unit within which the first experiences with closeness to others take place. Lack of maternal stimulation or attention deprives the infant of a sense of security and there is failure to establish basic trust. This can lead to a suspicious attitude toward others that may continue throughout life. The quality of mothering attention is also important. A child may be adequately fed and receive impeccable physical care but without any communication of maternal caring. A child who is treated like an object may well become an adult who treats others like objects.
Family communication patterns may also be stressors leading to disruptions in relationships. Patients with a medical diagnosis of schizophrenia are frequently members of families with identifiably disturbed communication patterns.
Relationship problems frequently become manifest in the symptomatic behaviour of one family member. This deviant behaviour develops when the family is subjected to intolerable levels of stress. A family member who acts”crazy” may serve the function of keeping the family system intact.
For example, if there is a family rule that hostility is never expressed directly between family members, and the parents are involved in a conflict which they may not confront, tension will build up within the family system. One of the children may respond to this tension by “acting crazy” and performing destructive acts in the home.
Evaluate cognitive behavioural therapies in the treatment od schizophrenia in terms of its strengths and weakness
Cognitive behavioural therapy is a kind of psychotherapy which aims to change the way that people think about their problem and thus alters the effects of the problem itself. One specific example is stress inoculation training, which is a technique to reduce stress through the use of stress management techniques, and self statements that aim to restructure the way the person thinks. A second example is increasing hardiness, which is building up in the patient a cluster of traits possessed by those people best able to cope with stress.
The main strength of C.B.T in the treatment of schizophrenia is that it gives more power, choice, and responsibility for their treatment to a group of patients who have traditionally had things done to them, for example in the form of medication, social skills training and even ECT. There is no doubt that distorted and irrational beliefs and this treatment targets abnormal thinking. The purely cognitive approach grew out of dissatisfaction with the behavioural model and its emphasis on purely external factors. It emphasised internal mental influences and the power of the individual to shape their own thinking. Recently the two approaches have been integrated, so CBT treatment deals with maladaptive behaviours as well as distorted thoughts and beliefs.
The weakness of this therapy is that it can be seen as rather limited genetic factors are ignored, and not much attention is paid to the role of social and interpersonal factors or of individual’s life experiences in producing schizophrenia.
Discuss the ethics of cognitive behavioural therapy
Because the cognitive approach to therapy concentrates on the concept that mentally ill people have distorted thoughts and beliefs, it follows that sufferers of schizophrenia may feel that their illness is their own fault. This raises some ethical issues. Patients will be even more stressed if they have to take responsibility for their illness. It is unfair to blame patients for being ill, because their families may be mainly responsible, since it may be that maladaptive experiences in adulthood are based in childhood experiences, over which the sufferer has no control. It is even more striking to understand that the negative thoughts and beliefs of patients could be rational, and reflect the awful circumstances of the way they live in other words, if the patient feels blame they are unlikely to contemplate change.
Outline the characteristics of one eating disorder
(Bruch .H. The golden cage: the enigma of anorexia nervosa 1978) Perception is also an important aspect of the behaviour of young people with anorexia nervosa. These people perceive that they are fat and literally starve themselves to achieve their goal of being thin. However, because of the distortion in body image that they experience, the goal is unattainable. Even when emaciated to the point that their appearance is skeletal, they will maintain that they are fat and persist in their attempt to lose weight.
Bruch describes the typical anorexic process as `beginning with a diet. Initially, the dieter experiences a sense of deprivation and difficulty in maintain the restrictions. However, she then enters a stage of pride in her accomplishment and this perpetuates the behaviour. At the same time, biological effects of starvation cause distortions in perception of body sensations. There is a heightening of sensory experience and a feeling that has been compared to intoxication. As the condition progresses, the patient begins to feel special and different because of her superhuman effort and extraordinary accomplishment. These results in her alienation and isolation from others who fail to understand her behaviour and its meaning to her. She is then becomes increasingly absorbed in her own world and her behaviour assumes even greater importance to her.’
Anorexia nervosa is really a misnomer. Anorexia means lack of appetite. People with anorexia nervosa do experience hunger, and it is the victory over hunger that provides their reward. Anorexics are often fascinated with food and cooking, becoming students of nutrition. They may compulsively loiter in places where food is sold or served and watch other people eat. Their life becomes centred on food and the avoidance of eating. Anorexics go to extremes to avoid weight gain. They will induce vomiting, take diuretics and laxatives, and exercise strenuously. Many other physical changes are common in anorexic women, including amenorrhea (periods stopping), lanugo (extra body hair especially facial), and bradycardia (heart problems).
Another eating disorder that is similar in some respects to anorexia nervosa is bulimia. The bulimic person experiences episodes of binge eating, frequently followed by vomiting. Binge eating is compulsive intake of food that is stopped only when the person vomits, experiences pain runs out of food, or is interrupted. It is differentiated from anorexia nervosa by the fact that severe weight loss is not generally seen and the individual is well aware that their behaviour is abnormal. Bulimics are usually able to maintain a more normal weight by alternating binging and vomiting or by eating very little between binges.
Give two or more psychological explanations of eating disorders
Psychodynamic
Eating disorders usually begin in adolescent girls (90% of sufferers are female). This may suggest that this coincides with the onset of sexual development and sexual fears. Psychodynamic theorists have suggested that an adolescent girl may be terrified by their own feelings of sexual desire, or a fear of becoming pregnant, or even (and this may seem farfetched but is based on ignorance of the facts of life) of a fear of becoming pregnant by oral sex. If eating is mentally links in adolescent to getting pregnant, then starving herself will prevent pregnancy. It also stops menstruation so ovulation stops so no pregnancy.
Another psychodynamic explanation of eating disorders is that some adolescent girls are afraid of growing up and have an unconscious desire to remain pre-pubescent. If they lose a lot of weight their bodies will not develop normally and they can hang on to the belief that they are still children.
Finally, some patients who present with eating disorders were victims of sexual abuse as children. Consequently they hate their bodies and may even self-harm.
There is a theory, supported by Minuchin, Roseman, and Baker (1978) that eating disorders may be firmly rooted in family dynamics. The term “enmeshment” is used to describe a family where there is no space for the personal independence of the child family members all seem to do everything together. Adolescence should be a time when the child develops their independence. If they cannot do this the anorexic adolescent may rebel by refusing to eat. Families which are enmeshed like this find it difficult to sort out conflicts (Minuchin et al.1978). In the theory of psychodynamics such families create anxiety. This is where ego-defences come in; parents unable to cope with their anxiety put the blame (unconsciously) on the anorexic child herself. Parental conflicts are common in families of both anorexics and bulimics (Kalusy, Crisp, and Harding 1977). This research came to the conclusion that families with an anorexic child tend to be ambitious, to deny or ignore conflicts, and blames other people for their problems.
Behavioural
The psychological theory of classical conditioning teaches us a great deal about the development of anorexia. These sufferers associate eating with anxiety they associate losing weight with avoiding bad thoughts and feelings (Leitenberg, Agras, and Thompson (1968)). The other relevant psychological theory is operant conditioning. The anorexic gets pleasure from gaining attention. It is also rewarding or re-enforcing because slim people are considered more attractive than fat ones. Similarly, there is a behavioural explanation of bulimia. When a bulimic binges it causes them anxiety, so when they vomit they revise the situation and their anxiety is reduced. This reduction in anxiety makes the person feel better, so the cycle of bingeing followed by vomiting is maintained. (Rosen and Leitenberg 1985).
Discuss the ethics of behavioural therapies
The term is used when considering moral behaviour among professionals, such as behavioural therapists. Certain things may be less acceptable than others, but if the ultimate end is for the good of the patient, then we may feel than an undesirable behaviour is acceptable. A psychiatric ward full of patients with eating orders can be one of the most depressing places on earth. Behavioural therapy usually involves giving patients targets and rewards regarding their consumption of food and drink. Patients with eating disorders can be distressed, stubborn, and frightened; the behavioural programmes developed for their recovery are often unwelcome and in themselves cause anxiety.
There are major ethical issues occurring on a daily basis can staff force people to eat against their will? What of the rights of these individuals to be treated in a caring and respectful way? I doubt that loss of privileges constitute a caring and respectful way of helping a disturbed patient who refuses to eat. The issues of informed consent and the protection of patients from harm are huge points of conflict in the therapeutic treatment of people with eating disorders.
