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Flashcards in Abnormal Psychology Deck (117):


conformity to standard/regular behavioural patterns



behaviour that doesn't conform to regular patterns


using statistics to identify abnormality

interpretation of abnormal behaviour as behaviour that is statistically infrequent/uncommon


weaknesses of the interpretation of abnormality as statistically infrequent behaviour

- harder to be sure of the average when numbers aren't involved (e.g. how much hunger is normal/abnormal?)
- we need to know more about a person before labelling their behaviour as normal/abnormal
- abnormality is often attributed to mental illness
- however, not all abnormalities is considered a sign of madness/disorder
- people with very low IQ are labeled with disorders, but people with very high IQ are respected and not stigmatised (although both are statistical abnormalities)


social norms vs statistics in identifying abnormal behavior

- social norms dictate proper behavioural responses to specific situations (e.g. it's acceptable to talk loudly in a noisy cafe but not in a cinema)
- when social rules are violated, even if the violations are not statistically infrequent, it is considered abnormal
- people who deviate from social norms tend to be considered abnormal and will be attributed to mental illness


problems with defining abnormalities using social norms

- social norms vary across cultures
- Read et al. (2004) found a historical variation in abnormal behaviour: things that were considered mental illness symptoms are now acceptable in many cultures & situations
- social norms are largely determined by groups with social power (e.g. in many cultures it is considered abnormal for a woman to drink too much alcohol but it's not abnormal for men)


using observations of maladaptiveness to identify abnormality

- assumption: all humans behave in a way beneficial to themselves (i.e. doesn't interfere or enhances functioning)
- people are expected to develop understanding and conformity to social norms (regardless of agreement)
- maladaptive behaviour: behaviour that interferes with one's ability to function within that social context, e.g. Internet addiction (people may be so hooked on the internet that their real relationships decay)


problem with associating maladaptiveness with abnormality

- sometimes people will engage in behavior detrimental to functioning
- this is not always because of a serious disorder
e.g. Guillermo Farinas, a political protestor, went on a hunger strike to protest against Internet censorship


using observations of suffering/distress to identify abnormality

- maybe one should inquire over another person's health if they see maladaptive behavior
- however, this assumes the other person has the self-awareness to know they're in distress
e.g. Irritability is a depression symptom that men often overlook as they don't think it's important
- note that distress is a normal reaction to challenging life events (e.g. death of a loved one)


Jahoda's positive mental health theory

- Marie Jahoda (1958) tried to define normality instead of abnormality
- she thought it would be easier to identify abnormal behavior as behavior that deviates from the definition of normality


the six components of Jahoda's positive mental health theory

- positive self-schema
- growth and development
- fitting in well in society
- self-government/independence
- accurate perception of reality
- feeling in control of events in one's life

This approach suggests that ideal mental health means an individual has:
- realistic and positive acceptance of self
- consistent resistance to stress
- the ability to take voluntary action to accentuate growth in their environment


problems with Jahoda's positive mental health theory

- very few people actually fit in the six criteria
- Taylor and Brown (1988): depressed people have a more accurate perception of reality, and functioning adequately requires some extent of self-delusion


Diagnostic and Statistical Manual of Mental Disorders

- describes disorders in clear terms to minimise differing interpretations (so different clinicians will likely reach the same diagnosis)
- groups disorders into categories and lists symptoms required for diagnosis of a particular disorder
- the disorders listed are not set in stone
- enforces multiaxial approach: a clinician should consider a potential patient's symptoms, medical conditions, and social and environmental problems they may face
- this supports the idea that the origin of each person's problem should be analysed via a bio-psycho-social framework


International Classification of Diseases (ICD)

- originally a means of standardising records of causes of death
- for classification rather than diagnosis
- contains wide range of diseases and conditions
- mental disorders section looks similar to DSM as the authoring teams consult each other


Chinese Classification of Mental Disorders (CCMD)

- culture-specific: it focuses on issues related to Chinese culture
- disorders in ICD and DSM that aren't common in China are left out
- some disorders in CCMD aren't in ICD or DSM (as some are culture-bound)
e.g. Koro, an anxiety/depression disorder caused by a meditative exercise (Qigong)


ethical considerations of using diagnostic systems

- may not be reliable
- not valid to take a medical approach to psychological problems
- interpretations of symptoms may vary
e.g. in the Soviet Union, schizophrenia diagnoses were given far more liberally than in USA
- ethnic minorities or women might not be treated equally like others in their diagnoses (psychologists may not make an effort to understand cultural differences, etc)


types of reliability tests

- inter-rater reliability
- test-retest reliability


inter-rater reliability

assessed by asking multiple practitioners to diagnose the same person with the same diagnostic system


test-retest reliability

asking a practitioner to diagnose a person more than once (e.g. on two different days)


Nicholls et al. (2000) AIM

to test the reliability of DSM, ICD, and the Great Ormond Street hospital's diagnostic system using inter-rater reliability


Nicholls et al. (2000) PROCEDURE

1. Two practitioners were asked to use ICD/DSM/GOS to diagnose 81 children
2. The 81 children had complained of eating problems


Nicholls et al. (2000) RESULTS

Inter-rater reliability (rates of agreement between the two practitioners) of:
- DSM: 0.636
- ICD: 0.357
- GOS: 0.879


Nicholls et al. (2000) CONCLUSION

- GOS is most reliable
- possibly because GOS was specifically designed for children
- expected that with more children, more diagnoses would occur and agreement rates would increase


Nicholls et al. (2000) EVALUATION

- less than half of the children diagnosed using DSM could be diagnosed with a classified eating disorder, so rates of agreement for DSM could not be fully established


Seeman (2007) study

- literature review examining evidence related to diagnosis reliability
- found that initial schizophrenia diagnoses (especially concerning women) may change as clinicians found out more about their patients
- common for clinicians to discover that other conditions caused the symptoms leading to schizophrenia diagnoses
- indicates problem of test-retest reliability with schizophrenia diagnoses


key concern for diagnostic systems

whether they correctly diagnose people with disorders, and not give a diagnosis to healthy people


criticism of validity issues with the biomedical diagnostic process

- R.D. Laing: diagnosis is closer to being a social fact than a medical one, and is is full of financial, political, and legal implications
- diagnosis is not important to treatment
- Cosgrove et al. (2006): many advisors serving on DSM panels have financial ties to the pharmaceutical industry

- Thomas Szasz: it's wrong to label non-conforming behaviour as indicative of a mental disorder
- disorders are essentially labels given to a set of behaviours, emotions, and/or thoughts
- Wakefield et al. (2007): a wide range of other life events can account for depression symptoms and there is a lack of clarity about when depression symptoms really indicate a disorder

- Caetano (1973) study on Labelling Theory
- Rosenhan et al. (1973) study on the varying interpretations of normality


studies concerning reliability issues

- Nicholls et al. (2000) on inter-rater reliability of DSM, ICD, and GOS
- Seeman (2007) on how schizophrenia diagnoses can change as clinicians get to know their patients


Caetano (1973) aim

to demonstrate labelling theory during a diagnosis


labelling theory

- the theory that the behavior of the person being diagnosed isn't the most important component of diagnosis
- once a diagnosis is made, it tends to stick
- any suggestion that the subject is mentally ill will be a powerful influence on any decision

supporting studies:
- Caetano (1973)
- Rosenhan et al. (1973)


Caetano (1973) procedure

1. A male psychiatrist is videoed carrying out separate, standardised interviews with a university student and a mental patient
2. 2 groups were shown the videos
- 77 psychology students
- 36 psychiatrists
3. The 2 groups were split into 2 subgroups that were given differing info:
- one was told that both were volunteers that were paid to participate
- the other was told both were mental patients
4. They were asked to diagnose the interviewees


Caetano (1973) findings

psychiatrists with clinical experience were more likely to be persuaded by the info given


Caetano (1973) conclusion

the study demonstrates labelling theory


Caetano (1973) evaluation

- the student could've had an undiagnosed psychiatric disorder
- the patient could've been close to normal (he had the appearance and attitude of a hippie on drugs)


Rosenhan et al. (1973) aim

to test the ability of diagnoses to tell the difference between normal people and people with disorders


Rosenhan et al. (1973) procedure

1. Rosenhan and a group of colleagues and acquaintances went to 12 different hospitals complaining of hearing voices, but presenting their history and current state as normal
2. They were admitted with a schizophrenia diagnosis
3. On admission, they ceased complaining of any symptoms
4. They eventually got out with a diagnosis of schizophrenia in remission


Rosenhan et al. (1973) findings

- their normality was never detected although descriptions from staff showed no evidence of abnormal behavior
- however, staff took all their normal behaviour in a negative light
- when taking notes about what happened in the hospital, hospital staff noted their writing was excessive and abnormal
- when walking along the corridors because they were bored, they were accused of obsessive pacing
- 35 of the 118 other patients expressed doubt to the pseudo-patients' presences, suspecting they were checking on the hospital


Rosenhan et al. (1973) additional study

- found that abnormal people can be mistaken for normal

1. Staff at another's hospital claimed they wouldn't have been fooled by the pseudo patients
2. In response to Rosenhan's invitation to estimate how many pseudopatients were sent by him to that hospital, staff estimated with confidence that 41 of 193 people admitted during that period were pseudopatients
3. Rosenhan had sent none - all were genuine patients


criterion-related validity issues in diagnoses

- Gavin Andrews noted only moderate agreement in the diagnosis of anxiety disorders between DSM and ICD
- when a person can diagnosed according to one system but not in another by the same person, this indicates poor validity
- Peters et al. (1999) found only moderate agreement between DSM and ICD due to DSM listing distress/impairment to functioning as an anxiety symptom


implications of labelling theory

- if a patient's condition improves, we won't be convinced by the diagnosis of improvement
- the knowledge of a disorder diagnosis has negative effects on how society treats the person subsequently


social implications associated with a diagnosis

- although discrimination due to medical condition is illegal, ex-patients can still feel discouraged due to fear of discrimination
- Read (2007) found that people have bad attitudes to mental disorders because they associate disorders with dangerousness and unpredictability
- Sato (2006) notes that schizophrenia was renamed in Japan because the stigma was so bad that less than 40% of patients diagnosed with it were informed of the diagnosis


career implications associated with a diagnosis

- 92% of UK citizens would be afraid of admitting to a disorder diagnosis because they think it could damage their career
- more than half of the respondents to a survey stated they'd rather not hire someone with a mental disorder


implications of treatment for a disorder

- treatment after diagnosis may worsen/create symptoms
- iatrogenesis may occur
- conditions in the institutions may be cruel and dehumanising, in a way that makes returning to society hard

e.g. a depression diagnosis may cause the person to take time off work -> finds it hard to reintegrate upon returning -> loses their job -> spiral into further depression



- phenomenon in which treatment for a condition causes other complications
- adaptation to life in an institution may cause development of new behaviours
- Rosenhan et al. (1973) observed during their stay at institutions that social interactions were lacking in care and concern


cultural bias in treatment

- Read et al. (2004): migrants and ethnic minorities in Western countries are over-represented in mental institutions
- diagnostic biases occur and psychiatry uses diagnosis and institutionalisation instead of trying to understand differences
- Morgan et al. (2006): in the UK, incidence of schizophrenia is 9x higher for Afro-Caribbeans and 6x higher for Africans than for Caucasians


gender bias in diagnosis

- diagnostic criteria for depression is a description of normal female responses to social pressure
- so women are more likely to be diagnosed with depression


why diagnoses, despite their implications, are essential

- potential denial of treatment to those who need it
- severely depressed people who fail to be diagnosed will not get treatment and may carry out a suicide attempt
- the safety of the interviewee is more important than potential long-term effects of stigma
- maybe a diagnosis isn't the best way to achieve this, but there is a lack of alternatives


possible role of differing culture in diagnoses and manifestation of disorders

- perhaps there's an underlying issue that appears differently depending on cultural tradition and expectations
- or some groups may be more likely than others to seek help for depression
- or there might be genuine biological and/or sociocultural differences
- Levav et al (1997) noted that upon comparison of rates of alcoholism and depression across religious groups, Jewish men were more likely to be diagnosed with depression and less likely with alcoholism

- another possibility is that the clinician's cultural mindset influences their judgment (e.g. in their interpretation of a symptom)
- Read et al. (2004): Maori people are over-represented in mental institutions in NZ. Clinicians think it's acceptable to use European diagnostic systems on non-Europeans, which may lead to misunderstandings and misdiagnosis


implications of differing cultures on diagnoses in NZ

- Tapsell & Mellsop (2007): affective disorder diagnoses are given to only 16% of Maori vs 30% of Europeans, while schizophrenia diagnoses are given to 60% of Maori diagnoses vs 40% of Europeans. Maori also have more complaints of hallucinations, aggression, and problems with living.
- Arroll et al. (2002): Maori are less likely to be medicated for depression than Europeans in NZ
- Maori culture: Mate Maori (abnormal behavior breaking cultural norms, especially sacred ones) is treated by going to a tohunga (priest)
- it isn't uncommon for Maori to report seeing dead relatives
- so it's not always appropriate to consider cultural manifestations as symptoms of disorders


implications of differing cultures on diagnoses in UK

- Palmer & Ward (2006): people who experienced trauma in a previous environment will be affected by both difficulties in the present environment and memories of the old
- stigma to disorders and language barriers can limit access to psychologists, who may not understand their language or culture
- Kirov & Murray (1999) studied a group of patients taking lithium prophylaxis (drug for depression & bipolar disorder). They found a difference in symptoms and diagnoses resulting in the medication. Black patients were less likely than white to have suicidal ideas, and more likely to have manic symptoms, resulting in bipolar diagnoses.
- Riordan et al. (2004) found that compulsory institutionalisation was more likely to occur to blacks than whites


depression symptoms

5 or more of the following symptoms must be observed during the 2-week period:
- frequently depressed/irritable (through self-appraisal or observation)
- significantly diminished interest/pleasure in almost all activities (through self-appraisal or observation)
- significant weight loss/gain (change of 5+%) when not dieting, or increase/decrease in appetite
- frequent insomnia/hypersomnia
- psychomotor agitation/retardation (self-appraisal AND observation)
- frequent fatigue
- diminished concentration and/or indecisiveness (self-appraisal or observation)
- recurrent thoughts of death and suicidal ideation, or a suicide attempt


conditions where depression symptoms will not apply

- when they can be accounted for by a recent damaging event (only counts up to 2 months after event, or if subject doesn't feel a majority of severe depression symptoms)
- when symptoms don't significantly impair the subject's social/working/etc life
- when symptoms can be attributed to effects of medication or a medical condition (e.g. hypothyroidism)


prevalence rate of depression in USA

- Kessler and Merikangas (2004): according to the US National Institute of Mental Health (USNIMH), depression has a lifetime prevalence rate of 16.6% in the US
- it affects women more than men, with the difference starting at 13
- women are 3 times more likely to get a depression diagnosis


prevalence rate of depression in Poland and Russia

Polish men: 20.4%
Polish women: 32.9%
Russian women: 33.7%

Nicholson et al. (2008)


criticism of Nicholson et al. (2008)

- used self-report data
- may reflect a reporting bias rather than genuinely higher rates of depression


biological etiology of depression - evolutionary theory

- Hagen et al. (2004): depression could be a psychological adaptation to signal need and get help from others
- but that's impossible to test experimentally, and genetic basis needs to be found


biological etiology of depression - possible effects of neurotransmitter release/reuptake on depression

- research found that reserpine and iproniazid, drugs related to the release and breakdown of catecholamine neurotransmitters, affected mood
- led to theory that depression is caused by deficiencies of catecholamine neurotransmitters
- supported by research indicating effectiveness of fluoxetine (Prozac)
- Lacasse & Leo (2005) noted a lack of evidence that depressed people have low levels of serotonin
- Sarek (2006): tianeptine, a drug that does the opposite of Prozac, is commonly used in South America and Europe to treat depression


biological etiology of depression - genetic component

- Kendler et al. (2006): out of 42000 participants, monozygotic twins had concordance rates of 0.44% for female and 0.31% for male while dizygotic twins had 0.16% for female and 0.11% for male. The results indicate a strong genetic component for depression.
- research suggests that short alleles of the gene 5-HTT increases chances of depression
- Levinson (2005): despite 5-HTT's effect being to hinder serotonin reuptake, depression medication (e.g. Prozac) also prevent serotonin reuptake but improve depression symptoms (opposite effect). She/he also notes that the gene makes people more sensitive to stressful events, and doesn't directly cause depression.


biological etiology of depression - stress hormone

- Burke et al. (2005): non-depressed people's cortisol levels rise and fall rapidly under stress, but depressed people remain under stress for longer
- Cutuli et al. (2010) found a high correlation between high cortisol levels and a history of negative life events
- Fernald and Gunnar (2009): in Mexico, higher levels of cortisol were found in children whose families couldn't participate in poverty help programs, while depressed mothers who participated had lower stress levels in children


cognitive etiology of depression - Beck's theory

- Aaron Beck (1976) suggested that depressed people have a cognitive triad of negative thoughts: about self, the world, and the future
- they maintain these beliefs through cognitive biases: over-generalisation (e.g. I always fail tests), selective abstraction, and polar reasoning (attempting to remove ambiguity)
- this gives the person a negative self-schema that makes it difficult for a person to think positively
- criticism: while it's descriptively powerful, it's still not clear whether info-processing causes depression


cognitive etiology of depression - Hankin and Abramson

- Hankin and Abramson (2001) extended the Beck (1976) model
- they added that the occurrence of a negative event creates a negative effect before the cognitive triad comes into effect
- this explains how trauma contributes to a negative self-schema


cognitive etiology of depression - Ellis' theory

- Albert Ellis (1962) offers a similar theory
- irrational and self-defeating beliefs affects a person's interpretation of events, which lead to negative emotional consequences


cognitive etiology of depression - feedback on the Ellis model and the Beck model

- Robins and Block (1989): depressed people have negative thinking styles
- however, Taylor and Brown (1988) notes that depressed people are more realistic in their interpretation of reality


sociocultural etiology of depression - vulnerability model

Brown and Harris (1978) proposed a vulnerability model based on the interaction of vulnerability factors and stimulating events


sociocultural etiology of depression - vulnerability factors

- losing one's mother at an early age
- unemployment
- >3 young children at home
- lack of a confiding relationship


sociocultural etiology of depression - criticism of vulnerability model

- while unemployment and poverty are associated with depression, they aren't likely to be responsible for feelings of extreme sadness

- however, critics assert that factors are culture-dependent as work and material wealth provide different levels of meaning, status, and identity in different cultures
- some cultures place different roles of support on family members, and different values on the existence of intimate relationships


sociocultural etiology of depression - effect of social support

- Wu and Anthony (2000): lower prevalence of depression in Hispanic communities as levels of social support are higher
- Gabilondo et al. (2010) found that depression occurs less frequently in Spain than in north European countries due to stronger traditional family roles and higher levels of religiousness


sociocultural etiology of depression - effect of social inequalities

- Cohen (2002): higher depression rates are observed in countries and historical periods where social inequalities are stronger
- possibly due to feelings of powerlessness and worthlessness
- also possibly due to perceptions of inequality, unfairness, and inability to participate in the "ideal" society of higher socio-economic groups
- Nicholson et al. (2008): men in the most socio-economically-disadvantaged groups in Poland, Russia, and the Czech Republic were 5x more likely to report depression


sociocultural etiology of depression - effect of changes in diagnostic patterns

- critics suggest that depression doesn't exist in cultures outside the West, but occur now due to Westernisation
- this may not reflect social pressure but change in diagnostic patterns as western diagnostic methods are taken
- Okulate et al. (2004): depression is accompanied by somatic symptoms, but certain core symptoms are common across cultures
- Binitie et al. (1975): the affective component of depression is most often shared, with somatic symptoms secondary in Africa, while in Europe suicidal thoughts and guilt are more common secondary symptoms


sociocultural etiology of depression - effect of cultural dimensions

- Arrindell et al. (2003): high correlation between prevalence of depression and scores on masculinity-femininity index
- Chiao and Blizinsky (2010): depression is associated with individualism and has a negative correlation with the frequency of 5-HTT short alleles
- it's possible that cultural norms in collectivistic cultures have developed to protect more biologically-vulnerable groups


biomedical depression treatments - serotonin drugs

- due to serotonin theory, many meds aim to prevent the reuptake of serotonin
- this increases the efficiency of serotonin present
- such drugs are called SSRIs (selective serotonin reuptake inhibitors)


biomedical depression treatments - criticism of SSRIs

- they treat the symptoms but don't cure the disorders
- side effects include sexual problems, dry mouth, insomnia, and increase in suicidal thoughts
- SSRIs are more helpful in more serious cases because depressive episode have a recurring tendency
- however, medication must be used in conjunction with therapy


biomedical depression treatments - effectiveness of drugs

- Kirsch et al. (2008): there is only a small difference between placebo and medication
- very few studies are published that show medication is only a little more effective than placebos
- Broich (2009): argues that instead of measuring change in severity of symptoms, an absolute criterion should be set and the percentage of patients who reach it should form an additional measure of efficacy
- political and economical implications: if Kirsch et al. (2008) findings are accepted, a massive loss of income for the pharmaceutical industry would occur
- ethical problem with Kirsch et al. (2008): lying to patients about their treatment is deceptive and dangerous


depression treatments - comparison between treatments

Cuijpers et al. (2009):
- psychotherapy groups do significantly better than control groups (which include discussions as placebo)
- medication (especially SSRIs) are more effective than psychotherapy in alleviating symptoms
- psychotherapy is effective in improving symptoms and have good long-term effects for milder patients


biomedical depression treatments - electroconvulsive therapy (ECT)

- controversial, severely restricted in many countries
- only offered if other treatments have failed
- Read et al. (2004): almost half the people who receive ECT are over 65 and majority are female (76% in Finland)


depression treatment - individual therapy

- cognitive-behavioural therapy (CBT)
- identifies the automatic, negative thoughts perpetuating depression
- helps the person see and understand the connection between these thoughts and their condition
- by addressing the thoughts together and with assignments like keeping a mood diary, the patient can change their negative self-schema and find the positive side to things
- this therapy also aims to help individuals regain the interest in activities they lost during depression


depression treatment - interpersonal therapy

- a sympathetic person discusses past experiences with the patient, without theoretical guidance or backing
- concentrates on helping the patient develop and use positive social support networks
- also improves communication skills
- IPT helps adjust patients' expectations to be more realistic


depression treatment - IPT vs CBT

- Parker et al. (2006): IPT alone isn't as quick as medication in improving symptoms but improvement is noticed further down
- studies comparing IPT and CBT haven't found significant differences but Parker et al. (2006) suggests this is due to psychotherapies not having a purely theoretical basis


depression treatment - IPT/CBT vs medication

Parker et al. (2006):
- patients who do IPT primarily and add medication do better than the reverse case
- could be due to expectation of the patient to prefer medication to solve problems

Butler et al. (2006):
- CBT is extremely effective but not usually greater than effect of medication
- however, outcomes are usually better when the two are combined


depression treatment - IPT/CBT and collectivist cultures

Hodges and Oei (2007):
- because of the power distance between therapist and patient, CBT may be more effective in Chinese culture
- due to patients being more likely to accept therapist's advice without question
- however, successful CBT requires an element of argument and the therapist must be persuasive
- so although the therapist's words are accepted, the argument process being omitted would result in the true nature of the patient's thoughts in depression remaining unidentified


depression treatment - eclectic therapy

- usually medication + psychotherapy
- as medication is the fastest way to obtain results mild enough for psychotherapy
- it's considered irresponsible to take either one without the other (medication without therapy, or vice versa)
- in the former case it's because the person will become dependent on medication and may relapse if they stop taking it
- in the latter case it's because when a person's thinking is disordered, it becomes difficult to connect to them logically
- successful CBT teaches people skills required to function sans medication


depression treatment - group therapy

- people who may not hear/share when alone with a therapist might do so around others
- they might learn vicariously through others' experience
- and be more optimistic about their own recovery if they see others who've improved


depression treatment - effectiveness of group CBT

- Hyun et al. (2005): randomly assigned depressed youths at a runaway shelter to group CBT or control (no treatment), and group CBT was extremely effective

- McDermut et al. (2001) and Toseland and Siporin (1986) found that group therapy was at least as effective as individual therapy

- Truax (2001): group therapy is well validated empirically but meta-analyses tend to omit more severely-depressed patients
- so we don't know if CBT is effective for everyone
- if dissatisfaction with any member is present, someone might drop out
- it might be counterproductive to populate the group with severely depressed people


gender distribution of anorexia/bulimia

only 5-15% of anorexia/bulimia patients are male


anorexia death rates

van Kuyck et al. (2009):
- USNIMH suggests that female anorexia patients have a death rate 12x higher than the general female population
- anorexia is the disorder with the highest mortality rate


prevalence rate of anorexia

Zandian et al. (2007):
- anorexia generally affects households with above-average income
- affects 0.3% of the population
- begins at the ages of 14-19


effect of culture on prevalence of anorexia

- anorexia is far more common in western/individualist societies
- possibly due to exposure to thin models on the media
- also possibly due to social pressure to conform to a particular body type and weight
- eating problems are more uncommon in less developed countries or countries that impose stricter regulations on women, but this could be due to anorexia being concealed more
- Roland (1970): class and ethnicity are important - most anorexia patients are Caucasian (mostly of Italian or Jewish descent)
- rates of anorexia appear to increase during affluent periods and in cultures where food is in abundance


effect of gender on anorexia

- females have higher anorexia rates
- bc females may be pushed to conform more
- or maybe males with body-image issues perform different behaviours rather than self-starve


symptoms of anorexia

- refusal to maintain a minimally normal body weight for their age and height (maintaining a body weight of ~85% the recommended weight)
- intense fear of gaining fat despite being underweight
- denial of seriousness of being severely underweight, or delusions regarding self-appraisal of body weight
- amenorrhea occurs (missing 3 or more menstrual cycles)


biological etiology of anorexia - evolutionary theory

Surbey (1987)
- found that weight loss occurs after amenorrhea, and anorexia occurs mostly in girls maturing early
- starvation may be an adaptive response to stress, to delay the fertility status till a better time
- females who delay menstruation may enjoy greater reproductive success later
- furthermore, adaptive behaviour during a famine is to focus on getting food
- however, the reproductive adaption theory excludes males, which is a weakness even if males make up ~15% of patients


biological etiology of anorexia - anorexia may be caused by another disorder

Zandian et al. (2007):
- anorexia is an expression of an OCD
- OCD often precedes anorexia in patients
- while the OCD doesn't usually manifest in males as an eating disorder, it does in females due to their biology


biological etiology of anorexia - heritability and genetics

- Bulik et al. (2006) estimated heritability to be 56%, suggesting a strong genetic component
- Striegel-Moore and Bulik (2007): molecular genetic studies isolated genes (particularly related to serotonin receptors) that may cause mood issues in anorexia patients
- however, the relation between the genes and the disorder is unclear


biological etiology of anorexia - effect of serotonin

- Striegel-Moore and Bulik (2007): molecular genetic studies isolated genes (particularly related to serotonin receptors) that may cause mood issues in anorexia patients
- serotonin levels are low in many anorexia patients

Zandian et al. (2007):
- noted that studies measuring serotonin levels don't have a "before" measure, and if an "after" is included, resumption of regular eating habits and healthy weight occur along with a return to normal serotonin levels
- however, serotonin is known to inhibit eating, so it's likely that decreased serotonin levels aren't caused by anorexia but are a result of it (due to less food intake)


biological etiology of anorexia - effect of brain activity

van Kuyck et al. (2007):
- noted that brain-imaging studies with anorexia patients show that the parietal cortex is frequently inactive
- decreased activity could account for patients overestimating their own weight and shape
- could lead to anosognosia
- the size of the parietal cortex is sexually dimorphic, explaining the large difference in prevalence between genders
- however, it's possible that differences in neurological makeup are responsible for anorexia
- and poor diet may change the brain distribution in these areas



a patient's lack of knowledge/awareness about their disorder


sexually dimorphic

differing between genders


biological etiology of anorexia - anorexia development model

Zandian et al. (2007):
- the risk factors for anorexia development: reduced food intake & reduced physical activity
- these 2 factors encourage the release of corticotrophin-releasing factors and cortisol, which stimulate the release of dopamine
- this gives anorexia patients a reward for dieting and increases the chances of further anorexic behavior
- locks the patient in a cycle of addiction


cognitive etiology of anorexia - possible etiologies

- anorexia may be caused by disordered thinking or incorrect perceptions
- idea that dieting and control are related is a schema perpetuated in western culture
- sense of control over their eating patterns increases to the point where controlling their food intake becomes a measure of self-worth
- Fairburn et al. (1999) explores how low self esteem and an extreme need for control might cause anorexia
- Bruch (1962) explores how anorexics may have faulty perceptions of their body size


sociocultural etiology of anorexia - social perpetuation of fat-shaming

- Lee et al. (1996): a social fat phobia may be an underlying cause of anorexia
- anorexia develops most in areas where there's a lot of media influence
- anorexic females are more likely to accept beauty standards in media
- it's unclear whether this receptiveness is a cause or an effect of anorexia, or if there's another factor


sociocultural etiology of anorexia - implications of westernisation

- Lee et al. (1996): perhaps increase in anorexia diagnoses in other countries could be due to increased use of Western diagnostic systems
- body weight doesn't necessarily indicate psychological disorders: 16% of healthy but slim Chinese women would be classified as anorexic according to Western diagnostics
- Yasuhara et al. (2002): anorexia is 4x more prevalent in Japan in 1998 than 1993, likely due to changes in social support networks and moral values


sociocultural etiology of anorexia - implications of media

- Strahan et al. (2007): the influence of media causes people to think everyone accepts thin models as normal and attractive, instead of convincing them they're the wrong body shape
- anorexia represents conformity to the perceived expectations of others
- Norton et al. (1996): the probability of finding a woman with Barbie's shape is less than 1:100000
- Sypeck et al. (2006): models and beauty contests are becoming increasingly smaller as advertising for diet and exercise has increased


biomedical therapy for anorexia nervosa

- SSRIs are used but there's limited evidence it's effective on its own
- Holtkamp et al. (2005): SSRIs can help prevent relapse
- Kaye et al. (2001): patients given a placebo over a 1-year period were much more likely to drop out
- critics argue that SSRIs target anorexia symptoms that don't cause the disorder, and claim that negative moods don't cause anorexia even if they frequently occur together


General biomedical approach to anorexia treatment

1. weight gains are prioritised, and IV drips may be necessary
2. patient must be encouraged to eat normally again (likely through CBT)

NOTE: treatment for anorexia is almost always eclectic


individual therapy for anorexia - why CBT

Bowers (2002) claimed that neither a physician, psychotherapist, nor a dietician can deal with an anorexic patient alone


individual therapy for anorexia - aims of CBT in this context

- to help the patient understand that their mentality causes problems and to help patients change it
- to change negative self-statements
- to change their basic assumptions (typically high expectations for self) that are resistant to change
- to change cognitive schemas associated with weight, food, and control


individual therapy for anorexia - CBT process

1. Spend time talking to the patient to establish the content of the schemas related to food, weight, and control
2. Allow patients to practice identifying their own thoughts and emotions regarding those areas (as they may have trouble with identifying)
3. Challenge the patient to produce evidence for their ideas on these areas and come up with alternatives to their negative thoughts


individual therapy for anorexia - CBT criticism

- has generally good outcomes
- as CBT attempts to address the core of the problem (the negative schemata associated with weight/food/control)
- relapse is unusual


individual therapy for anorexia - behaviourist treatments

- operant conditioning approach is usually taken
- in which target behaviours are enforced by giving rewards personalised to the patient
- staff observe a patient and reward small improvements in their behaviour (e.g. finishing a meal) with rewards (e.g. watching TV)
- intended to form immediate feedback about success in learning new eating habits


individual therapy for anorexia - criticism on behaviourist treatments

- behaviourist treatments are often successful in helping patients reach normal weight parameters
- however, relapse is more likely than CBT
- as the core problem of the disorder hasn't been addressed
- the reward system must also have been internalised by the patient or supported by their surroundings when the patient leaves the hospital


individual therapy for anorexia - family therapy

- between individual and group therapy
- the family is trained to support the sufferer
- the whole family benefits as their communication styles change
- some models of causation allege that interactions (particularly mother-daughter) contribute to the development of anorexia
- so learning to communicate more effectively is beneficial for many family members, not just the patient
- Harris and Kuba (1997) note that there are more individuals with eating disorders than are diagnosed, and that treatment for minority groups require special attention (therapy should involve the family, community, and maybe people of cultural significance to them, like a shaman or other spiritual leaders)


group therapy for anorexia - effectiveness

Woodside and Kaplan (1994) put patients in group therapy to specifically target negative attitudes to eating, using a CBT-like approach. All patients showed improvement on the eating attitudes test


group therapy for anorexia - function for patients

- very common for patients
- for inpatients, to help them get better
- also for outpatients, to help prevent relapse


group therapy for anorexia - advantages

- cost-effective
- allows patients to interact with others who are at different stages of recovery
- provides hope for those in early stages
- provides confirmation of progress and increased self-esteem for patients farther along stages, as they get to help others


group therapy for anorexia - criticism

- Polivy (1981): being in a group with other anorexic patients prevents patients from developing an identity apart from that of group membership
- this makes it hard for patients to create their own identity, without resorting to individual therapy
- members of the group may also teach other (maybe unintentionally) strategies to hide weight loss or avoid weight gain


cognitive etiology of anorexia - faulty perception

Bruch (1962) suggested that anorexics overestimate body size


cognitive etiology of anorexia - low self esteem/need for control

Fairburn et al. (1999):
- low self-esteem and an extreme need for control might be the cause of anorexia
- the need for control might be met more easily in eating than other domains
- attention bias to negative info
- patients may stop looking at their body for improvements, so they continue even if they have lost adequate weight


cognitive etiology of anorexia - criticism of etiology theories

- extreme perceptions and low self-esteem may be common among women
- Fallon and Rozin (1988) found that when families compared their body shape to their ideal, only the sons reported their body shape was good while the women believed that they weren't thin enough
- psychologists suggest that Beck's model for depression could be applied to anorexia as well

Decks in IB Psychology HL Class (60):