Psychology CIE 9990 Health, Abnormality

alternative techniques (acupuncture, stimulation therapy/TENS)

Acupuncture is derived from ancient Chinese medicine where needles are inserted into various areas of the body and twirled to stimulate the release of certain pain-relieving substances such as endorphins. It is based on some scientific evidence that states that the treatment can stimulate certain nerves under the skin and in the muscles. Simulation Therapy/TENS also offers pain relief. Pads are positioned either side of the source of the pain to send electrical stimulation across the skin and along the nerve strands to prevent pain signals reaching the brain. Both techniques encourage the release of endorphins (the body's natural pain-killers) and serotonin (a brain chemical involved with mood).

2.1 biomedical (genetic, biochemical and neurological)

Genes (such as PTPRD and SLITRK3) have been found to have a possible role in OCD type symptoms. Mattheisen et al. (2015) did a large scale study of 1406 patients with OCD and other members of the general population to analyze and identify genes that may be linked to OCD symptoms. The gene PTPRD was implicated along with SLITRK3, both of which interact to regulate particular synapses in the brain. Taj et al (2013) researched another candidate gene called DRD4 (dopamine D4 receptor). 173 OCD participants compared to 201 healthy controls completed a range of questionnaires that measured OCD and mental health. All were genotyped for the DRD4 gene and variants. It was revealed that the 7R allele frequency was higher in the OCD group (especially in females) suggesting another potential genetic cause for OCD. (an Allele is a variant form of a gene). Biochemical - OCD, is an anxiety disorder and like many anxiety disorders, it is marked by low levels of serotonin. Serotonin has a variety of functions that make a deficiency a serious and anxiety- producing issue. Oxytocin and serotonin are interconnected in the brain. Oxytocin (the love hormone) is involved in trust and attachment. Leckman et al. (1994) measured levels by analyzing cerebral spinal fluid and patient accounts of behavior and found that some forms of OCD were related to oxytocin dysfunction. Neurological - The brain pathway involved in OCD is a loop involving three brain regions. The orbitofrontal cortex (OFC) notices when something is wrong and sends a 'worry' signal to the thalamus. The thalamus directs signals from many parts of the brain back to the OFC. This forms a loop in the brain. The caudate nucleus lies between the OFC and the thalamus and regulates signals sent between them. When the thalamus receives a 'worry' signal, it becomes excited and sends strong signals back to the OFC, which interprets them. Normally, the caudate nucleus acts like the brake on a car, suppressing the original 'worry' signals sent by the OFC to the thalamus, preventing the thalamus from becoming hyperactive. But in OCD, the caudate nucleus is thought to be damaged, so it cannot suppress signals from the OFC, allowing the thalamus to become over-excited. If this occurs, the thalamus sends strong signals back to the OFC, which responds by increasing compulsive behavior and anxiety. Evaluation: This is supported by PET scans of patients with OCD, taken while their symptoms are active (e.g. when a person with a germ obsession holds a dirty cloth). Such scans show heightened activity in the OFC. All biomedical explanations use objective, empirical data, high levels of control and standardized procedures. Lack of ecological validity in studies. Cause and effect issues. Eg. Does having OCD upset biochemical levels, or do abnormal biochemical levels cause OCD?

2.3 learned helplessness/attributional style (Seligman, 1988)

Learned helplessness occurs when the subject endures repeatedly painful or otherwise aversive stimuli which it is unable to escape from or avoid. After such experiences, the organism often fails to learn or accept "escape" or "avoidance" in new situations where such behavior is likely to be effective. In other words, the organism learned that it is helpless, has accepted that it has lost control and thus gives up trying even as changing circumstances offer a method of relief from said stimuli. Learned helplessness theory in depression is the view that clinical depression may result from a real or perceived absence of control over the outcome of a situation. Attribution Theory suggests that we can attribute the CAUSE of an event to External / Internal, stable / unstable, specific / global factors. Internal-external (the event is caused by the person versus the situation) Stable/unstable (the cause of the event will last a long time versus a short time) Global/specific (the cause of the event will influence many versus few situations). Seligman et al. (1988) extended the original theory of LH suggesting that attributional style determined why people responded differently to adverse events. 39 patients with unipolar depression and 12 with bipolar all from same outpatient clinic, a mix of genders and a mean age of 36 years. Compared with a control group 10 non-clinical participants. participants completed a short form of the BDI to assess the severity of symptoms. They then completed the Attributional Style Questionnaire consisting of 12 hypothetical good and bad events. The participants had to make causal attributions for each one and rate each cause on a seven-point scale for internality, stability and globality. Both unipolar and bipolar participants were found to have more pessimistic, negative attributional style compared to the non-clinical control group. The more severe the depression score on the BDI, the worse the pessimism on the Attributional Style Questionnaire. For those with unipolar depression undergoing cognitive therapy, an improvement in attributional style correlated with an improvement in BDI scores. This suggests that the way we make attributions is an important mechanism underlying the experience of depression. Evaluation Standardised questionnaires. The attributional style questionnaire and BDI are considered to be valid and reliable measurement tools. However, the link found was correlational (not able to determine cause and effect). Quantitative data is easy to analyze/ objective and lends itself to statistical analysis. Does not give researchers depth of knowledge - no why questions - need back up with interviews for more information when investigating the depression. Strengths and weaknesses with self-reports (honesty, SDB, understanding the questions, etc. Reductionism (biological) Determinism (biological) Nature-nurture Real life application (therapies developed)

2.4 repeat prescriptions (Sherman et al., 2000)

The use of repeat prescriptions as a measure of non-adherence was tested. This is a common way of noticing non-adherence. 116 asthmatic children were interviewed with parents/carers on a visit to the clinic and were asked where they obtained their medication. Repeat prescriptions can be used with long-term treatments. Instead of seeing the doctor every time they need more medication, they can just request a repeat prescription. The belief is that if patients are motivated enough to get a repeat prescription, then they must be adhering to the treatment.

psychological techniques: cognitive strategies (attention diversion, non-pain imagery and cognitive redefinition)

cognitive redefinition focuses on the relationships between cognitions, emotions, and behaviours. Patients question self-defeating beliefs in a bid to move from thinking 'I am in too much pain to exercise' to 'exercising may relieve my pain'. Redefining pain as 'warm' rather than 'piercing' also impacts the way the brain perceives pain. Morley, Shapiro and Biggs (2004) developed a training programme in which they taught patients how to use attention diversion strategies (where patients focus on something that is not linked to pain to take away the attention from it) Non-pain imagery is where patients create a mental scene away from the pain and the therapist's guide them through it and encourage the use of a variety of senses. This is very effective for mild or moderate pain.

specification points

1. characteristics of anxiety disorders 1.1 characteristics of generalized anxiety and examples/case studies of phobias 1.2 types: agoraphobia and specific phobias (blood phobia, animal phobia, button phobia) 1.3 measures: the blood injection phobia inventory (BIPI); Generalised Anxiety Disorder assessment (GAD-7) 2. explanations of phobias 2.1 behavioral (classical conditioning, Watson, 1920) 2.2 psychoanalytic (Freud, 1909) 2.3 biomedical/genetic (Ost, 1992) 2.4 cognitive (DiNardo et al., 1988) 3. treatment and management of anxiety disorders 3.1 systematic desensitization (Wolpe, 1958) 3.2 applied tension (Ost et al., 1989) 3.3 cognitive-behavioral therapy (Ost and Westling, 1995)

specification point

1. characteristics of bipolar and related disorders 1.1 definitions and characteristics of abnormal affect 1.2 types: depression (unipolar) and mania (bipolar) 1.3 measures: Beck depression inventory 2. explanations of depression 2.1 biological: genetic and neurochemical (Oruc et al., 1997) 2.2 cognitive (Beck, 1979) 2.3 learned helplessness/attributional style (Seligman, 1988) 3. treatment and management of depression 3.1 biological: chemical/drugs (MAO, SSRIs) 3.2 electroconvulsive therapy 3.3 cognitive restructuring (Beck, 1979) 3.4 rational emotive behavior therapy (Ellis, 1962)

specification point

1. characteristics of impulse control disorders and non-substance addictive disorder 1.1 definitions (Griffiths, 2005) 1.2 types: kleptomania, pyromania (Burton et al., 2012) and gambling disorder 1.3 measures: Kleptomania Symptom Assessment Scale (K-SAS) 2. causes of impulse control disorders and non-substance addictive disorder 2.1 biochemical: dopamine 2.2 behavioral: positive reinforcement 2.3 cognitive: feeling-state theory (Miller, 2010) 3. treating and managing impulse control disorders and non-substance addictive disorder 3.1 biochemical (Grant et al., 2008) 3.2 cognitive-behavioral: covert sensitization (Glover, 2011), imaginal desensitization (Blaszczynski and Nower, 2002), impulse control therapy (Miller, 2010)

specification points

1. characteristics of obsessive-compulsive and related disorders 1.1 types of and common obsessions, common compulsions, hoarding, and body dysmorphic disorder 1.2 examples and case studies ('Charles' by Rappaport,1989) 1.3 measures: Maudsley Obsessive-Compulsive Inventory (MOCI), Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) 2. explanations of obsessive-compulsive disorder 2.1 biomedical (genetic, biochemical and neurological) 2.2 cognitive and behavioral 2.3 psychodynamic 3. treatment and management of obsessive-compulsive and related disorders 3.1 biomedical (SSRIs) 3.2 psychological: cognitive (Lovell et al., 2006) and exposure and response prevention (Lehmkuhl et al., 2008)​

Specification points

1. characteristics of schizophrenia spectrum and psychotic disorders 1.1 definitions, types, examples and case studies of schizophrenia and psychotic disorders 1.2 schizophrenia and delusional disorder 1.3 symptom assessment using virtual reality (Freeman, 2008) 2. explanations of schizophrenia and delusional disorder 2.1 genetic (Gottesman and Shields, 1972) 2.2 biochemical (dopamine hypothesis) 2.3 cognitive (Frith, 1992) 3. treatment and management of schizophrenia and delusional disorder 3.1 biochemical (antipsychotics and atypical antipsychotics) 3.2 electroconvulsive therapy 3.3 token economy (Paul and Lentz, 1977) 3.4 cognitive-behavioral therapy (Sensky, 2000)

specification points

1. practitioner and patient interpersonal skills 1.1 non-verbal communications (McKinstry and Wang, 1991) 1.2 verbal communications (McKinlay, 1975; Ley, 1988) 2. patient and practitioner diagnosis and style 2.1 practitioner style: doctor and patient-centered (Byrne and Long, 1976, Savage and Armstrong, 1990) 2.2 practitioner diagnosis: type I and type II errors disclosure of information (Robinson and West, 1992) 3. misusing health services 3.1 delay in seeking treatment (Safer, 1979) 3.2 misuse: hypochondriasis (Barlow and Durand, 1995) 3.3 Munchausen syndrome (Aleem and Ajarim, 1995)

specification point

1. sources of stress 1.1 physiology of stress and effects on health: the GAS Model (Selye, 1936) 1.2 causes of stress: work (Chandola et al., 2008), life events (Holmes and Rahe, 1967), personality (Friedman and Rosenman, 1974) 2. measures of stress 2.1 physiological measures: recording devices and sample tests (Wang et al., 2005, Evans and Wener, 2007) 2.2 psychological measures: self-report questionnaires (Holmes and Rahe, 1967; Friedman and Rosenman, 1974) 3. management of stress 3.1 medical techniques (biochemical) 3.2 psychological techniques: biofeedback (Budzynski et al., 1969) and imagery (Bridge, 1988) 3.3 preventing stress (Meichenbaum, 1985)

specification points

1. strategies for promoting health 1.1 fear arousal (Janis and Feshbach, 1953; Cowpe, 1989) 1.2 Yale model of communication 1.3 providing information (Lewin, 1992) 2. health promotion in schools, worksites and communities 2.1 schools (Tapper et al., 2003) 2.2 worksites (Fox et al., 1987) 2.3 communities (five city project, Farquhar et al., 1985) 3. individual factors in changing health beliefs 3.1 unrealistic optimism (Weinstein, 1980) 3.2 transtheoretical model (Prochaska et al., 1997) 3.3 health change in adolescents (Lau, 1990)

specification points

1. types and theories of pain - definitions of pain: acute and chronic organic pain; psychogenic pain (phantom limb pain) - theories of pain: specificity theory (Descartes, 1664), gate control theory (Melzack, 1965) 2. measuring pain - self-report measures (clinical interview) - psychometric measures and visual rating scales (McGill pain questionnaire, visual analogue scale) - behavioral/observational measures (UAB pain behavior scale) - pain measures for children (paediatric pain questionnaire, Varni and Thompson, 1976; Wong-Baker scale, 1987) 3. managing and controlling pain - medical techniques (biochemical) - psychological techniques: cognitive strategies (attention diversion, non-pain imagery and cognitive redefinition) - alternative techniques (acupuncture, stimulation therapy/TENS)

specification points

1. types of non-adherence and reasons why patients don't adhere 1.1 types of non-adherence (failure to follow treatment; failure to attend appointment) and problems caused by non-adherence 1.2 why patients don't adhere: rational non-adherence (Bulpitt, 1994) 1.3 the health belief model (Becker and Rosenstock, 1974) 2. measuring non-adherence 2.1 subjective: self-reports (Riekart and Droter, 1999) 2.2 objective: pill counting (Chung and Naya, 2000) 2.3 biochemical tests (Roth and Caron, 1978) 2.4 repeat prescriptions (Sherman et al., 2000) 3. improving adherence 3.1 improve practitioner style (Ley, 1988) 3.1 behavioural techniques (Yokley and Glenwick, 1984; Watt et al., 2003)

1.3 measures: Beck depression inventory

21-item psychometric self-report for ages 13+ which assesses attitudes and symptoms of depression. Each item has four statements. The participant then rates the statement 0-3 in terms of how much it applies to them over the past week or last two weeks. Items are summed to create a total score, with higher scores indicating higher levels of depression. I do not feel sad (0) - I feel so sad I can't stand it (3). 17-20, borderline clinical depression, 31 - 40 severe depression. It is used for research purposes and also in clinical practice. Evaluation: A number of studies have examined the validity and reliability of BDI across different populations and countries, results have consistently shown good internal, and test-retest reliability Criterion validity has also shown to be high. (Criterion validity - the extent to which the tool agrees with other measures, and can predict outcomes). Quantitative data, objective, can compare the effectiveness of therapy. The BDI takes approximately 10 minutes to complete so it is quick Practical application to see the severity Easy to administer Issues of SDB as this is socially sensitive research. The patient might exaggerate or downplay their symptoms so validity is reduced

1.3 the health belief model (Becker and Rosenstock, 1974)

A model used to predict whether someone will adhere. Individual perceptions such as perceived susceptibility and seriousness of the disease is affected by: modifying factors and cues to action. modifying factors such as age, gender and ethnicity. Cues to action such as being sent a reminder. A cost-benefit analysis is then carried out (benefits V barriers), and this determines the action taken. Becker et.al. (1971). Random sample of 125 children being treated in a large teaching hospital. Aged 6 weeks to 10 years, all were placed on oral antibiotics with a follow-up visit. One hour interview with each patient immediately after the doctor's appointment. Adherence was operationalised by asking the name of the medication, number of times a day it was to be given, date of follow-up appointment, administering the medication and keeping the follow-up appointment. Results - mothers who adhered; Were more interested in their child's health Were more concerned about the illness Perceived the illness as a substantial threat to their child's health. Had confidence in the doctors and the medication. Conclusion - the model is useful in explaining and predicting compliance behaviour

3.2 electroconvulsive therapy

A person receives a brief amount of electricity to the brain to induce a seizure. The patient is anaesthetised and given a sedative to relax muscles. Electrical current is passed through the head for no longer than a second via electrodes attached to the skull. The seizure will last for up to one minute. Can be bilateral - across both brain hemispheres or unilateral - across the non-dominant hemisphere. Modern ECT involves passing an electrical current unilaterally through the non-dominant side of the brain (to reduce memory loss) to induce a seizure. The seizure is the 'treatment'. Six to 12 sessions, twice a week. summarised- biomedical therapy for severely depressed patients in which a brief electric current is sent through the brain Evaluation: Extremely rare side effects: lasting neurological damage or death Positive effects may be short-lived Procedure affects the Central Nervous System (CNS) and the Cardiovascular system, which can be dangerous for those with pre-existing medical conditions Doesn't have the same kind of side effects as medication so ppl who can't take medicine e.g. pregnant women can have ECT Can be useful for acute, severe symptoms and those with catatonia. Real Life Application: can be very effective for some individuals especially if antipsychotics don't work on them (treatment-resistant Schizophrenia). But it is normally considered to be far less effective than antipsychotics and is likely only to be used in urgent acute cases or for those with primarily catatonic symptoms Use of animals: Effects of electric shocks on cattle were observed in the first stages of developing this form of treatment, can be unethical as the electric shocks would've had severely harmful effects on the cattle (as shown very harmful to humans without anesthetic), however it is unlikely there were any ethics guidelines regarding the use of animals at the time this research was conducted Ethics: potentially harmful to patients physically and mentally as there are many side effects including memory loss, although measures have been taken to limit this by using unilateral application of electricity, bilateral is used if unilateral doesn't work Individual vs Situational: ECT is very effective on some people (success stories) but doesn't work at all on others suggesting different people respond to it differently

3.3 cognitive-behavioral therapy (Ost and Westling, 1995)

A phobia sufferer believes that the feared situation is inherently dangerous (negative schema). This belief leads to negative automatic thoughts (NATs) and catastrophic thinking that occurs as soon as the feared situation is encountered. These thoughts lead to a phobic reaction. CBT enables the patient to manage their fears by gradually helping them to restructure their negative schemas, so lessening NATs. Cognitive Restructuring: People with phobias underestimate their ability to cope with fear in difficult situations. Cognitive restructuring teaches people to identify these sorts of counterproductive thought patterns, and replace them with more realistic thoughts, that result in decreased anxiety and avoidance. Identify the misinterpretations of bodily sensations. Generate alternative, non- catastrophic interpretations. Therapist challenges the beliefs. Ost and Westling (1995) compared CBT with applied relaxation in the treatment of panic disorder. Volunteer sample (newspaper and psychiatric referrals). 38 patients were treated individually over 12 weekly sessions, those in the applied relaxation group received training in deep muscle relaxation only. The CBT group received training in restructuring their thoughts associated with the panic attacks. Assessed before, after and in a one-year follow-up. Rated using self-reports, and they also kept a diary of panic attacks and rated their severity. Results - No sig. dif. between groups for panic attacks. Both methods were successful short-medium term. Ethics - systematic desensitization - exposure to the phobia causes intense stress (possible psychological and physical harm). Applied tension? CBT? Cost-benefit analysis Usefulness - Can applied tension be used for anything else? Can systematic desensitization be used to treat everything? Is the research useful? How useful are case studies? Does the treatment have to be done by a therapist or can the patient learn the 'tools'? Competing explanations - there are different models here, all of which have different assumptions. Comparing and contrasting is a high-level skill and is worth doing. Nature-nurture (SD is nurture, so The patient for those phobias that have been learned)

1.1 types of non-adherence (failure to follow treatment; failure to attend appointment) and problems caused by non-adherence

Adherence can be defined as; 'The extent to which a patient's behavior and following of treatment programs coincide with the advice and guidance provided by doctors and other health care professionals'. Non-adherence takes many forms; Do not keep appointments; Do not follow advice. Fail to collect their prescriptions Discontinue medication early Fail to change their daily routine Miss follow-up appointments Rates of adherence may be affected by what practitioners are asking patients to do; Short term compliance (a course of antibiotics) Change of lifestyle (eat more veg, do more exercise) Stop doing something (smoking, drinking alcohol) Long term programmes (diabetic regime) Non-adherence leads to increased morbidity (incidence of disease in a population), mortality (death) and financial costs. Problems caused by non-adherence to medical advice; Increased medical intervention More frequent visits to the doctor More medical tests and treatments Emergency admissions Increased seriousness of the illness or even death Delay in improvement

1.2 examples and case studies ('Charles' by Rappaport,1989)

Age 14 - started to wash compulsively, same ritual everyday - 3 hours showering, 2 hours getting dressed. This had been going on for two years. His mother contacted Rappaport. Treated with drug Anafranil and linked this with a behavioral management programme such as washing only in the evening. For a while, symptoms disappeared. Over time, Charles went on to cope with his disorder.

1.2 types: agoraphobia and specific phobias (blood phobia, animal phobia, button phobia)

Agoraphobia is known as the fear of public places. Characterized by a fear of two or more of the following: Standing in line or being in a crowd. Being in open spaces. Using public transport. Being outside the home by oneself. Being in enclosed spaces. These situations cause fear and anxiety to the individual meaning that they will actively avoid agoraphobic situations or experience real distress while enduring them. Approximately 2-3% of the population suffer agoraphobia and the majority are women. Research shows that agoraphobia develops as a result of severe panic attacks that the person does not expect to happen (Barlow, 2002). Blood phobia (Haemophobia) is an irrational fear of blood and can be extended to needles, injections or other invasive medical procedures. Hemophiliacs may actively avoid receiving injections or situations/occupations which involve exposure to blood. They experience an increase in heart rate when they see blood combined with a drop in blood pressure which can often lead to fainting. Animal phobias commonly include dogs, insects, and snakes. Individuals avoid contact with them. To be diagnosed with a specific phobia, the fear must be triggered immediately on exposure to the object or situation. They are quite common - affecting 10% of the population and are more prevalent in women than men.

3.3 cognitive restructuring (Beck, 1979)

Aims to change NATs, negative views about the self, world, and future which cause depression, into realistic ones. Using a six-stage process, the person is taught to identify unpleasant emotions such as sadness, the situation that causes them and the associated negative thoughts (I am worthless). They are taught to challenge negative thoughts and replace them with positive ones. Evaluation: Hans & Hiller (2013) meta-analysis (34studies) on adults with unipolar depression. Outpatient CBT was effective in reducing depressive symptoms, maintained at least six months after the CBT ended. Average dropout rate was 25% (quite high). Wiles et al. (2013) 469 people with depression randomly allocated to either continue usual care (including ongoing drug therapy) or care with CBT. Those who received the therapy were three times more likely to respond to treatment and experience a reduction in symptoms. Therapy only as good as the therapist With severe depression, it may be hard to engage in the therapy.

1.1 characteristics of generalized anxiety and examples/case studies of phobias

Anxiety is a fear that is disproportionate to the situation. It is accompanied by various physiological reactions such as increased heart rate, sweating, muscle tension, and rapid and shallow breathing. The actual threat is minor but is perceived as major. Panic attacks may be experienced and can last for a few minutes to several hours. Some people suffer from generalized anxiety disorder which is when the anxiety can happen in response to many situations or phobias which are specific to unique stimuli. A phobia is an extreme and irrational fear of an object or situation, which is disproportionate to the actual danger involved, and leads to avoidance of that object or situation. A fear becomes a phobia when it interferes with everyday life. Phobias may have a gradual onset or may happen very quickly as a result of a particular experience. The person may engage in extreme and complicated behaviors in order to avoid the object or situation that causes panic attacks. Kimya (female, 39 years) has a bird phobia where she is even scared of photos of birds. She has no idea where the anxiety came from. Saavedra and Silverman, button phobia (year 12 core study).

3.1 systematic desensitization (Wolpe, 1958)

Based on classical conditioning, this was developed by Wolpe in 1958, specifically for the counterconditioning of fears, phobias, and anxieties. The aim is to replace the conditioned fear, which is maladaptive, with relaxation, which is adaptive and desirable. This is based on the principle of 'reciprocal inhibition' where we cannot be relaxed and experience fear at the same time. Three phases of treatment: An anxiety hierarchy is constructed - a range of situations or events with which the fear is associated. These are arranged in order from the least fearful (e.g. imagining exposure) to the most fearful (e.g in vivo). Eg. go from a picture of a spider right up to holding a spider. The person is trained in deep muscle relaxation and deep breathing techniques. This counteracts the effects of anxiety-related hormones such as adrenaline. The person then thinks about, or is brought into contact with, the least fearful item and applies relaxation techniques. When relaxed the next item in the hierarchy is presented. This continues up the hierarchy until the person is desensitized. So the fear response is relearned to become relaxation. Evaluation: Lots of evidence to support its effectiveness eg. Willis treated women with a mouse phobia and they still showed improvement eight weeks later. The patient has some control over the speed of the progression (they can go back down the hierarchy) It works better for simple phobias (eg. fear of dogs), so is not as effective for eg. social phobias. Can be stressful Based on classical conditioning, this was developed by Wolpe in 1958, specifically for the counterconditioning of fears, phobias, and anxieties. The aim is to replace the conditioned fear, which is maladaptive, with relaxation, which is adaptive and desirable. This is based on the principle of 'reciprocal inhibition' where we cannot be relaxed and experience fear at the same time. Three phases of treatment: An anxiety hierarchy is constructed - a range of situations or events with which the fear is associated. These are arranged in order from the least fearful (e.g. imagining exposure) to the most fearful (e.g in vivo). Eg. go from a picture of a spider right up to holding a spider. The person is trained in deep muscle relaxation and deep breathing techniques. This counteracts the effects of anxiety-related hormones such as adrenaline. The person then thinks about, or is brought into contact with, the least fearful item and applies relaxation techniques. When relaxed the next item in the hierarchy is presented. This continues up the hierarchy until the person is desensitized. So the fear response is relearned to become relaxation. Lots of evidence to support its effectiveness eg. Willis treated women with a mouse phobia and they still showed improvement eight weeks later. The patient has some control over the speed of the progression (they can go back down the hierarchy) It works better for simple phobias (eg. fear of dogs), so is not as effective for eg. social phobias. Can be stressful

2.1 behavioral (classical conditioning, Watson, 1920)

Behaviourism states that phobias are caused by conditioning. In classical conditioning, a neutral stimulus is paired with an unpleasant experience and results in a conditioned stimulus (phobia) eliciting a conditioned response (fear) e.g. Little Albert was scared of white rats due to a loud noise being associated with the animal. After conditioning, Little Albert was scared by the animal alone. Maintenance of phobias can be explained through operant conditioning where avoidance of the phobia is obviously rewarding (negative reinforcement) Evaluation: Use of case studies (strengths and weaknesses). Some phobias have no obvious bad experience eg. many people have phobias of snakes, yet few have had a bad experience with one. The preparedness theory (Seligman) can better explain these phobias. Many people with phobias have had a bad experience showing the role of learning.

2.2 psychoanalytic (Freud, 1909)

Believed that phobias are the result of defense mechanisms employed by the ego to deal with unresolved conflicts between the id and the superego. The conflict originates in childhood and is either repressed or displaced onto an object symbolically connected to the feared impulse. The object of the phobia is not the, of the anxiety. Eg. Little Hans had a fear of horses, displaced from a fear of his father. Evaluation: There is no scientific evidence that the id, ego or superego exist A phobia may be a direct result of an incident (e.g. phobia of a dog after being bitten by a dog) rather than displaced anxiety. Very little/no supporting evidence. The only evidence is one case study. It does have some face validity - it seems to make sense.

2.3 biochemical tests (Roth and Caron, 1978)

Biochemical tests that can be used to monitor blood plasma concentrations of drugs used on the cardiovascular system. Taking a blood or urine sample can indicate whether or not the medication has been taken. Dosage can also be monitored. He concluded that blood and urine samples were the most accurate measurement of adherence. Patients said their intake of antacid averaged 89%, however, their actual intake averaged only 47%. Estimates of intake made by the 3 physicians were more accurate than patients, but averaged 50% higher than actual intakes.

3.1 medical techniques (biochemical)

Biochemicals such as beta blocker (BB's) reduce anxiety and blood pressure which is linked to stress. BB's reduce the activity of the adrenaline released during a stress response by binding to the receptors on the cells of the heart and other parts of the body stimulated during arousal. This makes it harder to stimulate these cells forcing the heart to beat more slowly and with less force. Eventually, the person feels calmer and less anxious. Other chemicals (e.g Benzodiazepines) work more directly by making specific neurons in the brain resistant to arousal; thus, inducing a feeling of calm.

managing and controlling pain medical techniques (biochemical)

Biological techniques that have been highlighted by Sarafino (2006) help to reduce/eliminate pain. For example, peripherally acting analgesics (aspirin) reduce the number of impulses from the pain receptors in the skin so they don't reach the pain centers in the brain. Centrally acting analgesics work directly on the central nervous system. Local anesthetics (e.g. novocaine) block nerve cells directly at the site of the pain, other drugs work indirectly (e.g. antidepressants) which relieve pain.

2.1 practitioner style: doctor and patient-centered (Byrne and Long, 1976, Savage and Armstrong, 1990)

Byrne and Long, 1976, identify different styles of patient-practitioner interactions 2,500 recorded tapes of medical consultations in several countries Most tapes were doctor-centered, where the doctor asked closed questions that required brief replies. In only 23% of the cases, the patient was stopped at 18 seconds. The tapes that were patient-centered included open-ended questions, where medical jargon was avoided and the doctors allowed patients to be part of the decision-making process on the cure. Savage and Armstrong, 1990 compare the effect of directing and sharing styles of consultation- patients satisfaction 359 randomly selected patients consulting with 1 general practitioner from an inner London general practice Patients- randomised to receive a directing or sharing style Patients who had the directing style of consultation reported significantly higher levels of satisfaction on almost all outcome measures.

3.4 cognitive-behavioral therapy (Sensky, 2000)

CBT recognizes the importance of cognitive processes in Sz as well as the behavioural symptoms. CBT aims to help people change by recognizing and making sense of their psychotic thoughts that affect their behavior. They are also given help to recognize that these are not facts. Sensky (2000) compared CBT specifically developed for Sz with befriending. Randomized controlled design. 90 patients who had not responded to medication, 19 sessions over 9 months. Delivered by experienced nurses. Patients assessed by blind raters using recognized assessments. Both groups showed significant reductions in positive and negative symptoms and depression. At a nine-month follow-up, those in the CBT group continued to show improvements in positive symptoms, whereas those in the befriending group did not. High validity as randomized control trial (random allocation) Therapists were carefully trained so standardized approach. No side effects with CBT Effectiveness of CBT may depend on the effectiveness of the therapist. Reductionism v Holism: treats both positive and negative symptoms of Sz so is a more holistic approach especially when used alongside biochemical therapies. Individual vs Situational: Individuals have different symptoms each so will undergo different therapy but the backbone of the therapy remains the same for them all and is effective. Real Life Application: CBT has good real-life application as it can be used to treat patients with treatment-resistant Sz improving their quality of life

1.1 definitions and characteristics of abnormal affect

Concerns disorders of mood and emotion, most typically depression and manic depression (bipolar disorder). Affect = emotion. They are classed as 'mood disorders' in the DSM-5.

1.2 schizophrenia and delusional disorder

Delusional disorder is characterized in DSM-5 as the presence of one or more delusions for a month or longer in a person who, except for the delusions and their behavioral ramifications, does not appear odd and is not functionally impaired. Prominent hallucinations and other psychotic or marked mood symptoms are absent. Non-prominent hallucinations and odd behaviors related to the delusional theme may be present. Examples of types of delusional disorder are: Erotomanic- belief that another person is in love with them Grandiose- convinced they have a great unrecognised skill or status Jealous- belief that partner is being unfaithful Persecutory- belief that a person is being conspired against or pursued by others who intend to harm them

2.2 cognitive (Beck, 1979)

Depression is a result of faulty information processing (cognitive distortion). People react differently to negative situations because of thought patterns that they have built up throughout their lives. Schemas (core beliefs) are formed in early life and these may be negative. For example, a self-blame schema makes the person feel responsible for everything that goes wrong, while an ineptness schema causes them to expect failure every time. These predispose the person to have negative automatic thoughts (NATs). Depression results from the negative cognitive triad, comprising unrealistically negative views about the self, the world, and the future. Beck used a cognitive triad to understand depression. For example, negative views about the world lead to negative views about the future which lead to negative views about oneself which lead to negative views about the world and e.c.t.

2.1 biological: genetic and neurochemical (Oruc et al., 1997)

Depression may be genetic. First degree relatives share 50% of their genes. Depression may also be caused by neurochemicals. Schildkraut (1965) suggested that too much noradrenaline causes MANIA and too little causes depression. However, serotonin was found to exist in low levels for both depression and mania, so both serotonin and noradrenaline imbalances are involved in affective disorders. Oruc et.al. (1997) (Polymorphism - a variation in a gene / genes. Rather than the term mutation (which suggests a unique change) polymorphism refers to the different expressions that may be present in a normal population, even if that expression occurs infrequently. Sexually dimorphic - any differences between males and females of any species which are not just differences in organs. Differences are caused by inheriting either male / female patterns of genetic material). 42 participants (25 F, 17 M) 31-70 years of age with bipolar disorder. Drawn from two psychiatric hospitals in Croatia. A control group of 40 participants with no personal or family history of mental health disorders matched for age and sex. 16 of bipolar group also had at least one first degree relative who had been diagnosed with a major affective disorder such as bipolar. Information was collected from participants, family members with diagnosis confirmed with medical records. DNA testing was carried out to test for polymorphism (variation) in serotonin receptor 2c and the serotonin transporter (5-HTT) genes. These genes were chosen since alterations in them can lead to disturbances in specific biochemical pathways with known links to depressive disorders. Serotonin as a neurotransmitter is understood to be sexually dimorphic - so when results were analyzed separately by gender, associations were observed in females. Polymorphisms in these genes could be responsible for an increased risk of developing bipolar disorder in females only. Evaluation: The sample size was small Was the control group really a control group? Why is age an extraneous variable? Objective, empirical data was collected, supporting psychology as a science.

2.4 cognitive (DiNardo et al., 1988)

Di Nardo et al. believe that people who have any traumatic experience e.g. with dogs but do not develop a phobia must interpret the event differently to phobics. So, it is the way that people think about their experience that makes the difference. It is an exaggerated expectation of harm in some people who leads to the development of a phobia. They think they are less able to cope than others. DiNardo et.al. 1988 - Sample - 14 dog-fearful and 21 non-fearful female college students (aged 18-21) were interviewed to investigate frightening and painful experiences (conditioning events) with dogs, and their expectations about the consequences of contact with dogs. They found that conditioning events were common in both groups, but only half of those who had a traumatic experience with a dog, even when they were physically harmed, developed a phobia. Experiences were similar, expectations of future events were different. So, factors other than conditioning events must affect whether or not painful experiences develop into a dog phobia. Evaluation: They accept the acquisition of fear through learning, for example, conditioning, but also emphasize the person's own interpretation of events. They, therefore, present a more holistic explanation than some others. Practical therapeutic applications. The treatments have proved highly effective for anxiety disorders such as phobias. The success of the treatments supports the explanation. Psychologists can conduct experiments to identify the different thought processes of those who have a phobia and those who do not. This makes the explanation scientific and objective. Issues of cause and effect - do the cognitions determine the behavior, or does the behavior determine the cognitions? Nature / nurture - genetics v conditioning and cognitive processing. Children as participants - ethical issues Determinism v free will; biological and behavioral approaches are both deterministic, cognitive is more free-will. Reductionism v holism - biological and behaviorist is more reductionist. Use of longitudinal research (Freud) v snapshot research (eg. experiments).

1.1 non-verbal communications (McKinstry and Wang, 1991)

Doctor's clothing as NVC. 475 patients seeing 30 doctors from 5 GP in Lothian, Scotland. Interviewed about opinions on 8 photos (1 male and 1 female used in a similar pose), 5 male, 3 female. Doctor A- White coat over a formal suit. B-Formal suit, white shirt and tie. C-Tweed jacket, informal shirt, and tie. D-Cardigan, sports shirt, and slacks. E-Jeans, open-necked short sleeved shirt. F- White coat over the skirt and jumper. G-Skirt, blouse and woolen jumper. H-Pink trousers, jumper and gold earrings Which doctor would they feel the happiest seeing for the first time? 0-5 rating on Likert scale Closed questions asked too. A male doctor wearing formal suit preferred most, 238 voted 5, Female doctor in white coat preferred, 263 voted 5 Preference for traditional dress seen most in older patients. 64% said the way their doctor dressed was important.

2.1 biochemical: dopamine

Dopamine is a 'happy' chemical. When it is released, it gives feelings of pleasure and satisfaction. These feelings of satisfaction become desired, and to satisfy that desire the person will repeat behaviors that cause the release of dopamine. Eg. When someone with kleptomania steals something, their reward centers are stimulated and dopamine is released. When these behaviors become compulsive, however, levels of dopamine in the striatum are reduced. More stealing/gambling/setting fires is required to achieve the same levels of euphoria. This deficiency in dopamine can lead to the continuing of compulsions and addictions. This mechanism is called 'reward deficiency syndrome'. Evaluation: There is some evidence that symptoms of gambling disorder and compulsive shopping emerge alongside the use of these drugs which again suggests a link between dopamine and impulse control disorders. Issues of inferring cause and effect - do abnormal DA levels cause the disorder, or does having the disorder alter levels of DA?

2.3 cognitive: feeling-state theory (Miller, 2010)

Experiences become fixated memories. Eg. if you win when gambling, the feeling is so intense, that it becomes fixated in your memory. Miller refers to this as a feeling-state. So, whenever you want that feeling again, you gamble to achieve it. So, the real desire is for the feeling, not the behavior. Intense Desire + Intense Positive Experience = Feeling-state Addictions are created when positive feelings linked with specific behaviors form a state-dependent memory. If a person's feeling-state about starting a fire is, 'I am a powerful human being' combined with the positive emotions, physiological arousal and memory of setting the fire, then this could create a compulsion for fire-setting behavior. Underlying negative thoughts or experiences are most likely to create the feeling-states that lead to impulse control disorder. For example, the pyromaniac who has the feeling-state, I am powerful when setting a fire may have underlying negative beliefs about themselves such as they are weak or unimportant. Individual V situational - brain differences lead to individual explanations, but the situation we are in may cause the behavior, so the situation can explain the behaviors as well.

1.1 fear arousal (Janis and Feshbach, 1953; Cowpe, 1989)

Fear appeals are 'persuasive messages which emphasize the harmful, physical and social consequences of failing to comply eht the rreomdentaions of the message.' using a lab experiment Janis and Feshbach asked 200 students in the US about their oral health before allocating them to one of four conditions: high, moderate or minimal fear arousal or a control. One week later, those in the minimal fear group (lecture about tooth decay with X rays not graphic images) reported higher levels of agreement with the advice (50%) compared to the high fear group (grapho images of diseased mouths with grave consequences) who showed just 28% agreement. No behavioural change was noted in the control group. TV advertising is also used to promote health in the home. Cowpe (1989) investigated the net decline in fires in 10 UK regional TV areas over a 12 month period. Results showed a 7% decline to the central and 25% for the granada television areas. Surveys also highlighted an increase in knowledge about the fire

3.1 delay in seeking treatment (Safer, 1979)

Find out why patients delay treatments 93 patients of mixed age, race, and gender seeking treatment for the first time for a particular symptom at four clinics in major inner-city hospitals, USA. Patients were asked when they first noticed the symptoms when they decided they were ill and when they decided to seek medical attention - as well as other health-related questions that might indicate the motivations behind their decisions. Appraisal delay is the length of time taken to decide you are ill, the delay is increased by reading the symptoms. The delay is decreased by not reading your symptoms. Illness delay is the time when you call the doctor. Utilisation delay is when you get help

personality (Friedman and Rosenman, 1974)

Friedman and Rosenman found personality to contribute to stress. Their longitudinal study on 3154 healthy men, aged 39-59 from USA, revealed twice as many Type A participants had died of cardiovascular problems after 8.5 years. Over 12% of Type A's had experienced a heart attack, compared to just 6% of Type B's. Type A's also had higher blood pressure and higher cholesterol and were more likely to smoke and have a family history of CHD, both of which increased their risk.

3.1 behavioural techniques (Yokley and Glenwick, 1984; Watt et al., 2003)

General prompt, Specific prompt, Specific prompt plus increased opening hours, Specific prompt plus monetary incentive Entire population of non-immunised pre school children from a medium-sized US town Each parent was sent a reminder to immunise their child dependent on the condition they had been randomly allocated to. Watt et al., 2003 The "Funhaler", incorporates incentive toys which are isolated from the main inspiratory circuit by a valve. Here we show that its use does not compromise drug delivery. Improved adherence combined with satisfactory delivery characteristics suggest that the Funhaler may be useful for management of young asthmatics.

2.2 worksites (Fox et al., 1987)

Health promotions have also been used to reduce accident in the workplace, Fox et al (1987) conducted a 12 year longit study into opencast pits in the USA. Using a token economy, employing earn stamps for working without lost time due to injuries for being in work groups in which all other workers had no lost time due to injuries, but not being involved in equipment damaging, accidents, for making adopted safety suggestions, and for unusual behaviour which prevented an injury of accident. They lost stamp awards if they or other workers were injured, pauses equipment damaged or failed to report accident or injuries. The stamps could be exchanged for a selection of thousand of items at redemption stores. The reduction in costs at both mines was approx. 90% far exceeding the cost of operating the token economy.

imaginal desensitization (Blaszczynski and Nower, 2002)

Imaginal desensitization involves teaching a brief progressive muscle relaxation procedure. Clients are then instructed to visualize themselves being exposed to a situation that triggers the drive to carry out their impulsive behavior, contemplating acting on their urge but then leaving the situation in a state of continued relaxation without having acted upon their urge. Sessions can be recorded for home-practice and can help to reduce the desires if practiced outside of the therapy sessions. Blaszczynski and Nower, 2003 The main aim is to reduce the urge, the tension and the excitement felt. Learn to relax and apply to situations of high arousal. The therapist helps the client identify the cues that trigger the feelings. They visualize the setting where the cues are present, then use PMR to relax (to counter the tension that is felt). Eg a cue may be that it's 5 pm and you are about to finish work. That immediately reminds you about gambling and so the urge starts. In therapy, you imagine that scene and apply PMR. You then imagine the next scene eg. driving to the casino after work then do PMR. next, you imagine yourself in the casino, and the colors, noise, smells, etc., then do PMR. Then imagine the excitement as you approach your favorite machine, then PMR. The final scene involves imagining the negative feelings associated with the behavior, then PMR. Sessions last about 20 mins but should be conducted 3 - 4 times a day. At home clients also complete monitoring tables, so they tick when they have done a session (Session monitoring table) and identify triggers and the thoughts and feelings that accompany them (trigger monitoring tables). Evaluation: Evidence of success (greatly reducing gambling) at 12 month and five-year follow-ups. It empowers the client by providing the necessary skills to resist such urges It can be used anywhere once the individual has learned the technique It can be applied to a range of similar problems Need to have a good imagination Clients may forget to complete the forms or may fill them in even though they have not completed a session; May forget what has happened when completing the tables

1.1 definitions (Griffiths, 2005)

Impulse control disorder is a failure to resist temptation, urge or impulse Griffiths (2005) believed that there are six components that help define any addiction; Salience - when an activity becomes the most important activity in life Euphoria - the experience such as a 'rush', a 'buzz' or 'high'. Tolerance - an increasing amount of activity is required to achieve the same effect Withdrawal - unpleasant feelings and physical effects that occur when the addictive behavior is suddenly discontinued or reduced. Conflict - with those around them (interpersonal) with other activities (job, schoolwork, social life, hobbies, interests) or from within the individual themselves (intrapsychic conflict). Relapse - chances of relapse are very high, even after a long time. Impulse control disorder has three defining features; growing tension before, pleasure and relief during, then after, the person may or may not feel guilt, regret or blame.

1.3 providing information (Lewin, 1992)

In a medical setting Lewin found that psychological adjustment is better when patients are provided with information. 176 patients with a first myocardial infarction (heart attack) were randomly allocated to wither a self help program based on a heart manual or given a standard care plus a placebo package information and informal counseling. Results showed that psychological adjustment as assessed by the Hospital Anxiety and Depression Scale, was better in the rehabilitation group at the 1 year. They had significantly less contact with the Gp and fewer were readmitted to hospitals in the first 6 months compared to the control group (10% v 25%)

1.3 symptom assessment using virtual reality (Freeman, 2008)

Investigate whether people without severe mental illnesses may experience unfounded paranoid thoughts. A non-clinical sample of 200 students, they completed a questionnaire to measure stress and anxiety (paranoid thinking, emotional stress, and other social and cognitive traits) before entering a virtual reality library/train situation (for 5 minutes where they interacted with neutral characters). Findings were those who scored highly on questionnaires showed high levels of persecutory ideation (the process of forming an idea that one is at risk of being ill-treated and harmed by others) in VR. One-third of the population shows some signs of paranoia

2.1 genetic (Gottesman and Shields, 1972)

Investigated 57 twins. Twins were identified as MZ or DZ using blood group and fingerprint analysis. Researchers interviewed both the patients and their twins. Participants also undertook a personality test and cognitive tests. They found a concordance (the presence of a particular observable trait or disorder in both individuals within a set of twins) rate of approx. 50% for MZ and 9% for DZ. In MZ twins, the co-twin was more likely to be schizophrenic if the illness of the other twin was severe. There was then a higher likelihood their co-twin also showed some schizophrenic symptoms, whereas in mild cases co-twin concordance was far lower. Evaluation: Small sample sizes in twin studies Concordance rates not 100% for MZ so must be other factors. Scientific studies, well-controlled, objective data.

1.2 types: kleptomania, pyromania (Burton et al., 2012) and gambling disorder

Kleptomania is not being able to resist the urge to steal, collect or hoard things. Kleptomaniacs may steal things (even though they have no money to pay), even things of little or no value. Sometimes the harder the challenge of stealing, the more the thrill, relief, and guilt. They may feel tension before the act, then pleasure after. 0.3 - 0.6% of the population, mainly women. Pyromania (Burton et.al. 2012), is when the individual sets fires (and often watch the fire or emergency services) to reduce tension or to obtain and then reduce affective (emotional) arousal. It can cause distress and shame. Before setting the fire, the person must feel tension or arousal, must show attraction to fire, must feel a sense of relief or satisfaction from setting the fire and witnessing it, and must not have other motives for setting the fire. Diagnosis - individuals who have deliberately and intentionally set fires on more than one occasion. Gambling disorder is when a person has to gamble to gain euphoria or relieve tension. This typically includes feelings of gratification or relief afterward. It is the only non-substance addictive disorder in the DSM-5. Evaluate: Understanding these disorders means that we can design better treatments for them, so there are real-life applications. Socially sensitive research, so ethical considerations.

3.3 health change in adolescents (Lau, 1990)

Lau (1990) wanted to investigate health change in adolescents. A longitudinal study was used to explore the sources of stability and change in young adults' health beliefs. During the first three years of college peers will have a strong impact on the magnitude of that change in health behaviors. However, parents are much more important than peers as sources of influence over these beliefs and behaviors. A self report method was used over a three year period. 947 parent and child pairs were used.

3.1 improve practitioner style (Ley, 1988)

Ley (1988) found that 28% in the UK had low satisfaction ratings of their treatment. Dissatisfaction of hospital patients was 41%. Ley - patients want to know about their problem and their treatment, rather than not being told. Ley stated that dissatisfaction came from; Poor emotional support and understanding from the doctor. Lack of information about the illness or the treatment. Atreja-Simplify the routine. Imparting knowledge effectively. Modify patient beliefs. Patient and family communication. Leaving the bias. Evaluating adherence

1.3 measures: Maudsley Obsessive-Compulsive Inventory (MOCI), Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)

MOCI is a psychometric test originally designed by Hodgson and Rachman (1977) to assess OCD. It is a self-report questionnaire using a forced-choice 'yes' or 'no'/true or false format. It has 30 questions/items with four subscales. It assesses symptoms related to checking, washing, slowness, and doubting. Checking (9 items) - frequently has to check things (gas, water taps, doors) several times Cleaning/washing (11 items) - I am not unduly concerned about germs and diseases (reverse scored). Slowness (7 items) - I am often late because I cannot seem to get through everything on time Doubting (7 items) - I have a very strict conscience. Total score out of 30 - measures the nature, extent, and severity of the OCD. Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) measures the nature and the severity of OCD. It is a semi-structured interview, 30 minutes, check list of different obsessions and compulsions with a ten-item severity scale. The scale allows individuals to rate the time they spend on obsessions, how hard they are to resist and how much distress they cause. A checklist is used to check whether treatment is working (measures progress) or to inform a treatment plan. Scores range from 0 (no symptoms) to 40 (severe symptoms). Those above 16 considered in the clinical range. Evaluation: MOCI and Y-BOCS both have high concurrent validity - individuals will score similarly on different tests for OCD. Also offer good test-retest reliability (r = 0.8). This is important for researchers wanting to use the tools in trialing interventions. Self-reports rely on accurate and honest answers. Subjective, those resistant to treatment may lie, or downplay symptoms, etc. However, tools are objective, avoid researcher bias, quantitative and qualitative data gathered. Quantitative data so can track progress easily. However, no qualitative data so we do not know why people behave the way they do.

1.2 verbal communications (McKinlay, 1975; Ley, 1988)

McKinlay, 1975 Investigated whether women in a maternity ward understood 13 medical terms. Participants (pregnant lower class women) were read each word then heard it in context in an interview. They were told 'This is not a test of you' Responses were accurately recorded then scored by two doctors working blind. 2/3 understood 'breech' and 'navel', almost none understood 'protein' or 'umbilicus'. On average, each word was understood by less than 40% of women Ley, 1988 Suggested that doctor communication plays an important role in adherence as it influences patient understanding, recall and satisfaction, which all influence adherence. He made suggestions for how doctors could improve adherence, such as using less medical terminology. He investigated the effectiveness of these suggestions as well - e.g. he found that patient recall of a consultation improved from 55% to 70% after doctors read through a manual of suggestions for improvement.

1.3 measures: Kleptomania Symptom Assessment Scale (K-SAS)

Measure the thoughts, urges, and behaviors associated with compulsive stealing. It is an 11-item rating scale used during treatment which measures impulses, thoughts, feelings behavior and behaviors related to stealing. The individual is asked to consider this in relation to the past 7 days. Each item is rated on a point-based scale, typically 0-4 or 0-5. The higher the rating, the more likely they are to have the disorder. An example of a question is ''During the past week, how often did thoughts about stealing come up?" None......constantly. Evaluation: Has scored well on test-retest reliability Found to have good concurrent validity with the Global Assessment of Functioning Scale. Quantitative data - easy to analyse / compare / conclude / easy to assess outcomes of interventions. However, it relies on self-report, which means there could be response bias, as individuals may feel shame, etc. and under-report symptoms.

3.1 biological: chemical/drugs (MAO, SSRIs)

Monoamine oxidase inhibitors (MAOIs) were one of the first groups of antidepressants to be used widely. It's responsible for breaking down and removing the neurotransmitters norepinephrine, serotonin and dopamine. So, MAOIs prevent these neurotransmitters from being broken down and allow them to remain at higher levels in the brain. Selective serotonin reuptake inhibitors (SSRIs) act on the neurotransmitter serotonin to stop it being reabsorbed and broken down once it has crossed a synapse in the brain. SSRIs are the most commonly prescribed antidepressant drug in most countries. Evaluation: Effectiveness - Well controlled experimental research using large samples and control groups (increases internal and external validity) and standardized procedure and controls increases reliability. High control - high internal validity - cause and effect can be established. Use a study to show how effective the drugs are (percentages showing improvements). Drugs are a quick fix which means symptoms can be alleviated rapidly. Usefulness - does everyone respond well to the drugs? Some do, some don't. Both MAOIs and SSRIs are shown to be more effective than placebos. However, the impact of these drugs on patients is far more noticeable in patients with moderate to severe symptoms and less so in patients diagnosed with mild depression (Fournier et al. 2010) Drugs treat symptoms, not causes. Reductionist Ethics of drug therapy - physical and psychological harm? Both MAOI and SSRI can have mild, temporary side effects such as headaches or more severe consequences e.g. suicidal thoughts. If they are severely depressed, we have to questions whether they can give fully informed consent. MAOIs Side effects: headaches, drowsiness/insomnia, nausea, diarrhea, and constipation. Issues with withdrawal from this type of medication and may interact negatively with other medication. For these reasons, MAOIs are reserved only for atypical depression when other anti-depressants and treatments have failed. However, they are effective, sometimes more so than SSRIs and tricyclics. SSRIs They tend to have fewer and less severe side effects than MAOIs though different individuals may respond better to particular drugs.

3.3 Munchausen syndrome (Aleem and Ajarim, 1995)

Munchausen is a mental disorder in which a person repeatedly and deliberately acts as if they have a physical or mental illness when they are not really sick to draw attention, sympathy or reassurance. Munchausen syndrome by proxy is a condition where a person exaggerates, or induces mental or physical health problems in those who are in their care, with the primary motive of gaining attention or sympathy from others. A 22-year-old female was referred to hospital experiencing painful swelling over her right breast and a history of recurrent swellings over the abdomen. She reported having surgical drainage in other hospitals on about 20 occasions. After four days of hospitalization, she developed a similar abscess in the opposite breast; both were surgically drained. As she could not explain any cause for her abscesses, suspicion was raised. A psychiatric consultation was arranged. She was defensive and rationalizing her answers. She showed a superficial affect regarding her problem, but no clear features of depression. A factitious disorder was the most likely diagnosis. Eventually, a syringe full of faecal material and needles were found. When confronted, she became angry and hostile and left the hospital against medical advice.

1.1 types of and common obsessions, common compulsions, hoarding, and body dysmorphic disorder

Obsession - recurring and persistent thoughts that interfere with normal behaviour. E.g. fearing contamination from dirt, bacteria etc. when touching surfaces, or imagining a fire breaking out in every building you have entered. Compulsion - a recurring action a person is forced to enact. E.g. washing hands many times until thoroughly clean, checking fire exits or exit routes in every building entered. Obsessive-compulsive disorder (OCD) is an anxiety disorder in which people have unwanted and repeated thoughts and feelings (obsessions eg. Ithe germs on my hands may kill someone) that create anxiety. The only way to lower the anxiety is to carry out certain behaviours (compulsions eg. washing hands) in response to these. The person carries out the behaviours to reduce the impact or get rid of the obsessive thoughts, but this only brings temporary relief. The anxiety then starts to build as the obsessions begin again. A person's level of OCD can be anywhere from mild to severe, but if left untreated, it can limit his or her ability to function at work or school or even to lead a comfortable existence at home or around others. The DSM-V(5) describes the main symptoms of OCD as: Recurrent obsessions and/or compulsions. Recognition by the individual that the obsessions and compulsions are excessive and/or unreasonable. That the person is distressed or impaired, and daily life is disrupted by the obsessions and compulsions. People can have obsessions, compulsions or both, with OCD being one of the most common anxiety disorders. Some estimate 69% of those diagnosed have obsessions AND compulsions (with 25% just obsessions and 6% just compulsions). Generally there is some trigger event followed by obsessive thoughts which cause discomfort if not resolved. Then there might be the ritual of checking or washing. The compulsion involves repeating the action continually. Hoarding is an OCD in which individuals experience great difficulty getting rid of possessions. For many hoarders, this means they collect so many possessions, their homes may be unsafe, due to access or hygiene. Homes may be difficult to clean. Individuals experience distress associated with discarding possessions, which can then impact their ability to live with their families, have visitors. Hoarding can include any item, regardless of value. Body dysmorphic disorder - A psychological disorder in which a person becomes obsessed with imaginary defects or faults in their appearance and then spends an extensive period of time looking in the mirror. The person will develop a distorted view of their appearance. They may spend a lot of time worrying about these faults. These faults are likely to be slight or not at all obvious to others. These behaviours are intensely time-consuming - spending hours each day performing rituals to hide their defect.

1.2 causes of stress: work (Chandola et al., 2008)

One cause of stress is workplace. Chandola et al 2008 investigated biological and behavioral factors of stress, there were 10,308 london based civil servants (male and female all aged 35-55) Behavioural risk factors metabolic syndrome, heart rate variability, morning rise in cortisol and incidence of CHD. they found that chronic work stress was associated with CHD particularly among participants aged under 50. Similar association was found between work stress and behaviors including low physical activity and poor diet, metabolic syndrome and lower heart rate variability. Around 32% of the effect of work stress of CHD was attributional to its effect on health behaviours it as a important determinant of CHD among working age populations.

2.2 behavioral: positive reinforcement

Operant conditioning - the enjoyment of winning/seeing the fire/stealing is a positive reinforcer ( a reward that increases the likelihood of their repeating the behavior). Negative reinforcement - avoiding withdrawal symptoms or negative affect (anxiety, tension, etc.) by continuing to carry out the behavior. Schedules of reinforcement - Gambling machines are programmed to pay out once in every 500 plays. This means that a gambler is reinforced only sometimes. Research has shown that this type of partial reinforcement is very powerful and addictive, and explains why they continue to gamble even when they lose.

3.1 biochemical (Grant et al., 2008)

Opiates as a treatment for gambling. Opiates increase dopamine 284 participants, male and female split, double-blind experiment, a 16-week course of the opiate nalmefene or an 18-week course of the opiate naltrexone. Randomly assigned to the three conditions. Grant wanted to see if opiates would reduce gambling. Gambling severity was assessed using the PG Y-BOCS (pathological gambling boss). There was a significant reduction in symptoms in the opiate groups (at least 35% reduction). There were also individual differences as those with alcohol-related addictions showed even greater improvement. Evaluate: Gambling operationalized Only causes not root Experiment weakness and strengths Igd design weakness and strengths Double-blind, No researcher bias Random allocation high control

2.3 biomedical/genetic (Ost, 1992)

Ost (1992) Blood-phobic (n = 81) and injection-phobic (n = 59) patients fulfilling the DSM-III-R criteria for simple phobia were compared on a number of variables. Blood phobics were shown a 30 minute video of surgery being performed. The injection phobic group were given 20 steps from cleaning the fingertip to performing a fingertip prick. Both groups could withdraw when they wanted. Both groups had a high proportion who had a history of fainting (70% blood, 56% injections), much higher than in other phobias. 62% of people with a blood and injection phobia reported a 1st-degree relative who shares the same disorder. The prevalence rate for the general population is just 3%. Overall, the similarities were more marked than the differences, and it, that these two specific phobias should be regarded as one diagnostic entity. There is a strong genetic link for these phobias. Evaluation: Objective data, standardised procedures, controls etc. Did not consider individual experiences of participants that may have led to the phobia.

2.3 communities (five city project, Farquhar et al., 1985)

Other promotions, target whole communities. In a large (350,000 participants) experimental field study Farquhar et al, (1985) investigated the feasibility of community wide education to lower CVD risks, disease and mortality. Over a 6 year period four independent population surveys, four surveys of a cohort, and continues surveillance for CVD events were conducted. The population surveys which were designed to obtain information attitudes to obtain health on knowledge and behaviour were conducted on randomly collected samples of 12-74 year olds from Monterey, Salinas, Modesto and San Luis Obispo. Physiological measures such as blood pressure and non fasting blood samples were also taken from some participants. The treatment cities were Monterey and Salina with the other two acting as controls. Santa Maria was a third control where only morbidity and mortality were monitored (no info was collected)

types and theories of pain definitions of pain: acute and chronic organic pain; psychogenic pain (phantom limb pain)

Pain is defined as sensory and emotional discomfort associated with actual/threatened tissue damage acute organic pain is temporary (lasting approx. up to months) goes away after it is healed. E.g bee sting, hand burn. chronic organic pain occurs intermittently or continuously for more than 6 months. Pain persists after the injury has healed. E.g cancer, arthritis, headaches Psychogenic pain is a physical pain that has a psychological origin. Phantom limb pain is the sensation of pain from a limb that has been lost, it is experienced by amputees.

2.1 physiological measures: recording devices and sample tests (Wang et al., 2005, Evans and Wener, 2007)

Physiological measures of stress include recording devices such as fMRI scans. The neuro images produced highlight specific areas of the brain that change between stressful tasks and rest state allowing us to infer that these areas are activated by the stress. Wang et al (2005) used fMRI on 32 participants. 25 in a "stress" condition and seven acted as "controls." Participants performed arithmetic out loud, whilst being prompted to respond more quickly and to repeat themselves after error, inducing stress. Self reported stress and anxiety levels, and saliva, were collected immediately after. Results showed that stress induces negative emotions and that the right prefrontal cortex play a key role in how we response. Sample tests e.g saliva, measures levels of cortisol in the body. Higher levels indicate physiological arousal (e.g stress) focusing on personal space Evans and Wener (2007) recruited 139 adult commuters from Manhattan to collect saliva via chewable swabs to determine the effect of car and seat density on stress. Car density was inconsequential, but seat density affected both self reported stress and levels of cortisol in the participants saliva. This suggest that frequent intrusion of personal space can lead to stress.

3.2 psychological techniques: biofeedback (Budzynski et al., 1969) and imagery (Bridge, 1988)

Psychological techniques: biofeedback Budzynski et al., 1969 Biofeedback combines physiological and psychological techniques. You are wired up to an electromechanical device that provides immediate feedback on the body's physiology eg. heart rate monitor. Budzynski et.al. wanted to assess the effectiveness of biofeedback on tension headaches. Relaxing the frontalis lobes (from top of skull to forehead) should relieve suffering. Electrodes were attached across the forehead one inch above the eye. Random allocation of 15 Pps to three conditions;Experimental group told the pitch of the tone would vary with level of muscle tension. Told to relax as much as possible to keep pitch low. Control - constant low tone, told to relax deeply and told this tone would help them relax. Control - relax deeply in silence. Results were collected over five sessions and the DV was operationalised by calculating mean scores. Those in the biofeedback condition showed significant reduction in in muscle tension and this was greater than the two control groups. This shows that operant conditioning and 'shaping' of behaviours can be applied to physiological body responses. So this shows obvious real life applications. Imagery Bridge, 1988 Relaxation can lower blood pressure and reduce other stress-related problems. It can help manage pain and promote healing. Bridge (1998) Controlled randomised trial lasting six weeks, 139 outpatients were being treated with radiotherapy for early breast cancer. Patients completed the Leeds General Scales Measure (LGSM) which rates severity of depression and anxiety (for those not with a clinical diagnosis of this), before and after the six-week trial. They also completed a mood scale which rates 65 items such as anger, fatigue, confusion. Patients were fully informed and were randomly allocated to the three conditions; Relaxation. Relaxation plus imagery. CoNo significant difference on LGSM, but mood scores differed significantly in both experimental conditions. This difference was enhanced in the relaxation and imagery condition. The effectiveness was thought to be linked to the simplicity of using imagery; patients would smile when it was a difficult time to smile.

3.1 unrealistic optimism (Weinstein, 1980)

Psychologists have found that unrealistic optimism may be an individual factor in changing a person's health belief. Unrealistic optimism causes a person to believe that they are at a smaller risk of a negative event compared to others. They expect others to be victims of misfortune, not themselves. This happens because of various factors including desired end state, cognitive mechanisms and overall mood. Weinstein (1980) used 2 studies to test that people are unrealistically optimistic. For example, the first study included 258 college student who were asked to estimate how much their own chances of experiencing 42 life events differed from the chances of their classmates. Examples of positive events are winning the lottery and marriage. Examples of negative events are divorce, and death.Weinstein found that participants rated their own chances to be below average for negative events. dnd above average for positive events. Cognitive and motivational considerations led to predictions that degree of desirability, perceived probability, personal experience, perceived controllability, and stereotype salience would influence the amount of optimistic bias evoked by different events. Study 2 tested the idea that people typically focus on factors that improve their chances of achieving good outcomes. Students listed the factors that they thought influenced their own chances of experiencing eight future events, the amount of unrealistic optimism shown by this second group for the same eight events decreased significantly.

1.2 why patients don't adhere: rational non-adherence (Bulpitt, 1994)

Reasons for non-adherence can be intentional or unintentional. Bulpitt (1994) considers that one reason for non-adherence is because of a rational choice we have made. Rational choice theory is a way of looking at the number of potential courses of action and using 'logic' to decide which action to take. His 1994 paper was a review of several pieces of research. The research suggested that patients make a rational decision based on a cost-benefit analysis, as to whether or not they take the prescribed treatment. Bulpitt also considered the costs and benefits of drug treatment for the elderly for hypertension. Risks found were gout, chest pains and changes in bowel habits. Benefits were that there was a 44% reduction in coronary events with a mixture of drugs. He concluded that benefits far outweigh costs (although those patients who do not adhere to the treatment programme do not consider this to be the case).

1.1 definitions, types, examples and case studies of schizophrenia and psychotic disorders

Schizophrenia (Sz) - is a psychotic illness, which means a loss of reality. 1% of the population is diagnosed with Sz. The DSM-5 defines Sz and psychotic disorders as sharing one or more of the following: Delusions (beliefs that are clearly false) Hallucinations (sensory experiences that may involve hearing and seeing things that don't exist in reality) Disorganized thoughts (mixed up and racing thoughts may lead to jumbled speech) Catatonic behavior (rigid and unmoving in awkward places or constant repetitive movements) Negative symptoms Positive symptoms are additional to what would normally be expected, and negative symptoms are behaviors below what would normally be expected, for example, social withdrawal The Sz spectrum refers to a range of disorders that are similar, but also different in various ways eg. symptoms, duration, severity. Schizotypal personality disorder or schizotypal disorder is a mental disorder characterized by severe social anxiety, thought disorder, paranoid ideation, derealization, transient psychosis, and often unconventional beliefs. Flat affect ( lack of visible response) DSM-5 requires two episodes of psychosis to qualify for the schizoaffective disorder diagnosis. Conrad 23-year-old male had his first psychotic episode on holiday when 22. Diagnosed with schizoaffective disorder. Spent 8 months in a psychiatric ward on drug therapy. Struggles with weight gain as a side effect. Carol 26-year-old female. She began to experience auditory hallucinations and delusions and act in bizarre ways and withdrew from people. She was hospitalized at age 18 for 1 month and dropped out of college. In the past 7 years, she has been hospitalized 12 times. There was no history of psychiatric illness in the family. Diagnosed with schizophrenia.

2.3 cognitive (Frith, 1992)

Schizophrenia is a result of 'faulty information processing' due to specific 'cognitive deficits'. Sz sufferers have problems with meta-representation, which is the ability to reflect upon our thoughts, behaviors and feelings. Those with Sz may fail to recognize that their perceived hallucinations are in fact just inner speech (the kind of self-talk people normally experience). Evidence to support came from Frith who found that those with Sz performed worse when they had to decide whether items that had been read out loud were done by themselves, an experimenter or a computer. Frith suggests that delusional thinking may also arise from a misinterpretation of perception. Thoughts that are actually self-generated appear to be coming from an external source. These failures in monitoring can lead to delusions, auditory hallucinations and thought insertion. Also, those with Sz do not have the ability to monitor the intentions of others which can lead to delusions of paranoia. Evaluation: Cognitive theories don't explain the causes, only the symptoms of schizophrenia. Cognitive explanations can be easily combined with other models (such as biological models), to provide more complete explanations for conditions. There are psychological studies to support findings (eg. Frith study above) Reductionism vs Holism: More holistic than biological explanation (it does consider biology) but still ignores social and environmental factors. This means an individual explanation is better than a situational one.

1.1 physiology of stress and effects on health: the GAS Model (Selye, 1936)

Seyle (1936) explored links between stress and illness in rats. Finding consistent physiological responses (e.g. developing stomach ulcers) regardless of the type of stressor (e.g. trauma of being handled and injected) he proposed the GAS model to explain this response. First, alarm reaction (the autonomic nervous system stimulates increasing heart rate and the release of hormones e.g adrenaline to prepare the body to action), resistance stage (the body struggles with the stress, the parasympathetic branch of the SNS attempt to return to as state of relaxation) and exhaustion stage (if the stressor persists physical resources become depleted eventually leading to collapse)

3.2 applied tension (Ost et al., 1989)

Specifically for people with blood and injection phobias. At the sight of blood, blood pressure drops sharply (called vasovagal response), often leading the person to faint (passing out). Applied tension involves tensing the muscles in the arms, legs, and body for about 10-15 seconds, relaxing for 20-30 seconds and then repeating both these five times to raise blood pressure. Applied Tension/relaxation, or both (Ost et al., 1989) 30 patients with blood or wounds phobias. Self-report to assess the tendency to faint, used applied tension and/or applied relaxation. IG design, 5 - 10 sessions, 45 - 60 mins. Exposed to situations involving blood. Results; 73% of patients improved (i.e. no fainting) at the end of the treatment and 77% had still improved at follow-up six months later. This was in all groups, but the Applied Tension takes half the time, so, a better therapy. Evaluation: Patients from the same hospital, so low generalisability SDB may be an issue. Ethics

theories of pain: specificity theory (Descartes, 1664), gate control theory (Melzack, 1965)

Specificity theory states that the body has a separate sensory system for perceiving pain. Descartes (1664) was the first to describe pain as a perception of the brain rather than the heart. A specialized series of neurons transmit impulses from specific pain receptors in the skin to dedicated 'pain centers' in the brain (nociception), where they are then perceived as pain. Melzack (1965) stated that nerve impulses pass through a series of 'gates' in the dorsal horn in the spinal cord. 'Gates' can 'open', to allow pain to travel to the brain, or 'close', to stop this happening. Physical factors that open the gate: extent of injury, inappropriate activity level. Close the gate: medication, counter-stimulation eg. massage. Emotional, open: anxiety, worry, tension, depression. Close: Positive emotions, relaxation, rest. Mental open: focusing on pain, boredom. Close: concentration, distraction, doing other things in life

3.3 preventing stress (Meichenbaum, 1985)

Stress Inoculation Therapy, prevent stress altogether. SIT is a cognitive technique intended to help patients prepare themselves in advance to handle future stressful events by inoculating themselves against negative effects in the same way that we are inoculated against infection. Three distinct stages of SIT are highlighted: Conceptualisation (patients taught to think differently about stress e.g. see stressors as problems to overcome), Skills acquisition (Coping strategies are taught & rehearsed in real life) and Rehearsal, application and follow through (Learned coping skills are applied in increasingly stressful situations).

What is stress?

Stress is defined as 'emotional and physiological reactions to situations which we feel threatened beyond our capacity to cope'. Stress is caused by two things; Levels of anxiety you experience. Your body's reaction to your thought processes (fight or flight). Stress happens when we appraise a situation and feel that we cannot cope with the demands of that situation. It can be positive or negative. The cause of the stress is known as the stressor.

2.2 biochemical (dopamine hypothesis)

Suggests that Sz is caused by excessive amounts of dopamine (DA) or an oversensitivity of the brain to dopamine. Some Sz's have abnormally high numbers of D2 (Dopamine type 2) receptors. An excess of DA causes the neurons that to fire too often and therefore transmit too many messages, overloading the system and causing symptoms of Sz. The hypothesis was developed from observations of three types of drug; antipsychotics lower levels of DA, and reduce positive symptoms, amphetamines, and L-Dopa increase levels of DA and can cause hallucinations and delusions. Evaluation: Post mortems Neuroimaging/brain scans show raised DA receptors in some areas of the brain eg. limbic system. Too simplistic Not everyone reacts well to drug therapy Only really explains positive symptoms.

1.3 measures: the blood injection phobia inventory (BIPI); Generalised Anxiety Disorder assessment (GAD-7)

The Blood-Injury Phobia Inventory (BIPI) is a way of measuring this specific phobia. It comprises 18 situations involving blood and injections. The self-report measure lists possible situations and individuals evaluate different reactions that might occur to them in each. These include cognitive, physiological and behavioral responses. They are asked to rate on a scale of 0-3 the frequency of each symptom (0 = never, 1 = sometimes, 2 = almost always, 3 = always). Eg. When I see blood on my arm or finger after pricking myself with a needle; I don't think I will be able to bear the situation - I think I am going to faint - I think that something bad is going to happen to me Generalized anxiety disorder assessment (GAD-7) This questionnaire is a screening test often used to enable further referral to a psychiatrist or counselor. Seven items measure the severity of anxiety. These include, 'Feeling nervous, anxious or on edge', 'Being so restless that it is hard to sit still' and 'Feeling afraid as if something awful might happen'. Participants score between 0 - 3 for each item (0 = not at all, 3 = nearly every day). This tool is typically used by general practitioners and in primary care settings rather than specialists. Evaluation: Both the BIPI and the GAD-7 have shown to have high concurrent validity with other measures. Quick, cheap and easy to use. Can be used to assess the effectiveness of therapy. Self-report questionnaires so rely on the accuracy of reporting by the participant. Psychometrics reduce behavior down to quantitative measures - i.e reductionist and over-simplistic - we don't know WHY the behaviors occur. Cultural bias as different cultures have different levels of certain phobias. Eg. social phobia Psychometric tests Cultural bias

life events (Holmes and Rahe, 1967)

The SRRS (Holmes and Rahe) was based on 43 major-life events taken from their analysis of 5,000 patients' records. 400 people determined the readjustment necessary to deal with each event. Using 'Marriage' as a baseline of 50, this generated Life Change Units (LCU) - indicators of the level of stress experienced. Scores 150> indicated the risk of stress related illness, this rose by 50% if the score was 300>.

2.2 psychological measures: self-report questionnaires (Holmes and Rahe, 1967; Friedman and Rosenman, 1974)

The SRRS (Holmes and Rahe)was based on 43 major-life events taken from their analysis of 5,000 patients' records. 400 people determined the readjustment necessary to deal with each event. Using 'Marriage' as a baseline of 50, this generated Life Change Unit's (LCU) - indicators of the level of stress experienced. Scores 150> indicated the risk of stress related illness, this rose by 50% if the score was 300>. There was a high level of agreement r=0.9 between all those who took part. Friedman and Rosenman aimed to test the hypothesis that type A personality could predict incidents of heart disease. Their longitudinal study on 3154 healthy men, aged 39-59 from USA, revealed twice as many Type A participants had died of cardiovascular problems after 8.5 years. Over 12% of Type A's had experienced a heart attack, compared to just 6% of Type B's. Type A's also had higher blood pressure and higher cholesterol and were more likely to smoke and have a family history of CHD, both of which increased their risk.

behavioral/observational measures (UAB pain behavior scale)

The University of Alabama Pain Behaviour Scale is used to assess chronic pain over time through observing patients performing activities such as walking and tying shoelaces. The nurse rates each of the ten behaviours identified from 0-1 (none, occasional, frequent) to calculate how much the pain is affecting the patient's behaviour. With a maximum of ten, the higher the score - the more pain they are experiencing.

psychometric measures and visual rating scales (McGill pain questionnaire, visual analogue scale)

The VAS is typically a 100mm line with descriptors showing only alternative ends of the pain spectrum. The patient indicates their current pain on the scale. Pain is calculated by measuring the distance from the starting point, to the mark made. The McGill pain questionnaire is more informative. Patients indicate the location of pain (Internal or External) on a diagram of a body, then choose one word from 20 sub-classes to describe the intensity. Each word holds different values from which a pain-rating index is calculated. Then, they describe the pattern of pain and explain what relieves or increases it. Finally, they rate the intensity of the pain on a 6-point verbal rating scale.

pain measures for children pediatric pain questionnaire, Varni and Thompson, 1976 Wong-Baker scale, 1987

The Varni/Thompson Pediatric Pain Questionnaire (PPQ) assesses the intensity of pain, the sensory, affective, and evaluative qualities of pain and the location of pain in children. The tool can be used by children from four years old who have chronic pain. The PPQ includes a VAS, a color-coded body diagram, adjectives, and open-ended questions. Wong-Baker FACES Rating Scale (1987) This scale can be used by children as young as three. It is designed to assess how much pain the patient is feeling. There are a series of faces ranging from '0' - no hurt, to '10' hurts worst.

1.2 Yale model of communication

The Yale Model of Communication focuses on the situations under which people are most likely to change their attitudes in response to a persuasive message. According to this model it is vital that the source of this information is credible and trustworthy and present both sides of a argument. It is also important that the message is personal and that the recipient receives some level of threat by ignoring the advice. The yerkes dodson law states that individuals have their own optimum levels of arousal and health promotions must catch the attention of the recipient but not to the point where they disregard the message due to the anxiety it provokes. Finally messages must consider the demographics of the audience and be tailored accordingly so that the message is understood allowing them to make informed choices about behavioural change.

2.2 cognitive and behavioral

The cognitive explanation considers that obsessive thinking is based on faulty reasoning (Rachman, 1977). For example, the belief that hands are covered in harmful germs that could kill is due to errors in thinking. These mistaken cognitions can worsen under stressful conditions. Compulsive behaviors are the outcome of faulty thinking, attempts to alleviate the unwanted thoughts and the anxiety they create. The cognitive approach looks at why people misinterpret their thoughts associated with the 'obsession' and how these become obsessive.OCD thoughts increase with stress. In an everyday situation, most people can learn to control these, but people with OCD tend to have thoughts that are more vivid and elicit greater concern. This could be due to childhood experiences that have taught these people that some thoughts are dangerous and unacceptable and this has affected their information-processing networks. When new information is processed, it is affected by these networks and generates stress and anxiety that can only be alleviated with compulsive behaviors. Behavioral - Compulsive behavior can be explained through operant conditioning. Washing hands - the person is rewarded (positive reinforcement) as they have clean hands, and rewarded negatively (negative reinforcement) due to a reduction in anxiety. Evaluation: Much of the research relies on self-reports eg. Y-BOCS and MOCI Those with OCD do report higher levels of irrational thinking.

impulse control therapy (Miller, 2010)

The goal of this therapy is to establish normal behaviors, not eliminate the behavior completely. Eg. a compulsive shopper can still shop but without overspending. The therapy is linked to the feeling-state explanation and attempts to change distorted thoughts. The behavior that produces an intense feeling is identified. The positive feeling and physical sensations associated with it are also identified. They recreate this in their mind, and at the same time, perform 'eye movement desensitization and reprocessing' (EMDR) exercises. EMDR works by targeting a particular feeling-state and vividly imagining it. At the same time, the client's eyes follow the therapist's finger back and forth. It is thought that this action helps process the memory more normally and is linked to REM. A case study of an individual with pathological gambling illustrates the application of ICT. John is a compulsive gambler who has lost his first marriage, got debts and depression. With the therapist, he identified the feeling-state of a gambling memory of winning and visualized this scene whilst conducting EMDR. This led to a reduction in the urge to gamble over five sessions. Three months later, he was enjoying poker twice a week but could leave the table after a set time whether he was winning or losing. His relationships had also improved. Evaluation: Unclear exactly how the therapy works. Participants do not have to stop the behavior completely. Evidence of success in many studies, even after a few months Application to real life (studies show how effective therapies are). Reductionism (eg. use of opiates ignores what has happened in a person's life to cause the issue.

2.1 schools (Tapper et al., 2003)

The information psychologists have learned about health promotion is utilised to promote specific problems such as obesity in children. Tapper et al 2003 investigated the effective peer modeling and rewards based interventions on children consumptions of fruit and veg. 402 children (aged 4-11) from 3 primary schools in England and Wales were recruited. There liking of 16 diff fruit and veg were assessed .children were presented with 'snack packs' at snack time and at lunch time they received a whole fruit or, on alternate days fruits and vegetables. Children with packed lunches were presented with either a whole fruit or four vegetables/ mix salad. The procedure remained the same during the intervention except peer modeling videos of 'food dudes' were shown; superheroes who save the world by battle 'junk punks'. Children received rewards (e.g stickers and pen) and letters of praise for imitating the food dudes by imitating their behaviour (eating fruit and veg). This peer modeling and rewards intervention was effective in increasing children's consumption of, and express liking for fruit and veg which ultimately results in a reduction in the risk of obesity.

3.2 transtheoretical model (Prochaska et al., 1997)

The transtheoretical model (Prochaska et al., 1997) suggest that, as individuals start on the track of a health behaviour, they move through 6 staged change. For example, precontemplation stage (people don't take action- within the next 6 months), contemplation (people are aware of the pros and cons and it produces ambivalence to change in future- within the next 6 months), preparation (ready to take action by putting pans in place- within 30 days). Action stage (specific modifications in lifestyle that they intend to commit to -within the last 6 months), maintenance (sustained behaviour and prevention of relapse- more than 6 months) and termination (100% self efficacy in ability to prevent relapse, no desire to turn to unhealthy behaviours). The processes of change are activities, including self regulation and self liberation that help people move from stage to stages.

3.4 rational emotive behavior therapy (Ellis, 1962)

The way people feel is largely influenced by how they think. REBT helps create and maintain constructive, rational patterns of thinking. The main way of achieving this is through a process known as 'disputing'. The therapist forcefully questions irrational beliefs to reformulate them. Individuals begin to see that the consequences (C) (depression) are only partly a result of an activating event (A). They must accept that holding onto negative and self-defeating beliefs (B) is what leads to the depression. Disputing self-defeating beliefs (D) and replacing with healthier beliefs leads to healthier thoughts, feelings and behaviours (E). Evaluation 236 comparisons of REBT to baseline, control groups or other psychotherapies demonstrated significant improvement over baseline measures and control groups. Recent research comparing the effectiveness of REBT to antidepressants suggests that both methods of treatment are equally effective in relieving symptoms of depression (Iftene et al., 2015). Therapy only as good as the therapist With severe depression, it may be hard to engage in the therapy. Ethics (can they give fully informed consent if severely depressed? Individual situational (little focus on the situation) Nature-nurture

3.2 cognitive-behavioral: covert sensitization (Glover, 2011)

Therapy in which an undesirable behaviour is paired with an unpleasant image in order to eliminate that behaviour (classical conditioning). Therefore, the impulsive behaviour could be paired with an unpleasant image or experience. For example, if the person was addicted to gambling they could think about their gambling and then look at images of people who have gone bankrupt. They could eventually learn to do this while gambling or bring these images with them and look at them when they imagine gambling. Glover, 2011 involves a case study of a 56 year old woman seeking help with shoplifting. (14 years daily shoplifting) The aversive imagery was nausea and vomiting. 19 months after the therapy her stealing behaviour had greatly reduced and self esteem and socialization had improved.

3.2 misuse: hypochondriasis (Barlow and Durand, 1995)

They strongly believe they have a serious or life-threatening illness despite having no, or only mild, symptoms. The DSM-5 no longer includes hypochondriasis (hypochondria) as a diagnosis. Instead, people may be diagnosed as having illness anxiety disorder. Risk factors for illness anxiety disorder may include: A time of major life stress. Threat of a serious illness that turns out not to be serious. History of abuse as a child. A serious childhood illness or a parent with a serious illness. Personality traits, such as having a tendency toward being a worrier. Excessive health-related internet use Although classed as a somatoform disorder (experiencing physical symptoms that cannot be explained), it may be better classed as an anxiety disorder. This is important for the treatment of the disorder. Often there is an external trigger (eg. a serious illness or death of a loved one) which they perceive as a threat, leading to heightened anxiety. A disproportionate amount of disease in the family when they were young children They may have learned that an ill person gets a lot of attention when younger. Symptoms- Preoccupation with the idea you are seriously ill based on no real evidence. Finding little or no reassurance from doctor's visits or negative test results. Worrying excessively about a medical condition because it runs in your family. Repeatedly checking your body for signs of illness or disease. Frequently making medical appointments for reassurance — or avoiding medical care for fear of being diagnosed with a serious illness. Frequently searching the internet for causes of symptoms or possible illnesses

2.2 practitioner diagnosis: type I and type II errors

Type I error- false positive, for example doctor telling a man he is pregnant. Results due to chance, accept alternative hypothesis not the null. Type II error- false negative, for example telling a pregnant women that she isn't pregnant. Accept the null hypothesis (not the alternative/experimental hypothesis) but the results were due to manipulating the IV. Problems of communication- more of a likelihood of type I and II errors may occur.

3.1 biochemical (antipsychotics and atypical antipsychotics)

Typical (first generation) antipsychotics aims to reduce severity of positive in patients with Sz & related disorders. They (eg. Chlorpromazine) work by blocking the D2 receptors on the postsynaptic neuron. This means that the effects of DA on the postsynaptic neuron is reduced. Atypical (second generation) antipsychotics (eg. Clozapine) work by temporarily occupying the D2 receptors on the postsynaptic neuron, then they dissociate. This reduces the effects of DA on the postsynaptic neuron. Double-blind placebo-controlled studies are used to develop these drugs. They reduce agitation and hostility in the patient. After 2+ weeks reduces positive symptoms. Evaluation: Real-life Application: Primary treatment for Sz is drug therapies in the form of antipsychotics as its effective in reducing positive symptoms in the majority. Reduced hospitalization. The introduction of antipsychotic medications into clinical practice has enabled many individuals to lead meaningful lives in the community without the continual burden of psychotic symptoms. Ethics: Double Blind trial conducted so half of the patients were not given treatment in the form of antipsychotics, however, it can be argued that they consented knowing they may not be given treatment Individual vs Situational: Antipsychotics are ineffective on some people with treatment-resistant Sz showing Sz varies from person to person and thus the effectiveness of drug varies from person to person. Reductionism vs Holism: Can be argued that use of SGAs is a more holistic approach to treatment as they treat both positive and negative symptoms however must keep in mind that all drug therapy is purely biological → reductionist approach to treatment to only use drug therapy. Typical 50% show significant improvement in the first few weeks. 30-40% show partial improvement, but a significant minority show no improvement, so treatment resistant for Sz Many side effects due to high affinity for dopamine receptor including weight gain, drowsiness, extrapyramidal symptoms (dyskinesias, parkinsonism) Only treats positive symptoms Treat symptoms, not causes Atypical Treats both positive and negative symptoms (to some extent) of Sz → greatly improving quality of life Less likely to produce unwanted side effects such as EPS (extrapyramidal symptoms) Carry increased risk of side effects such as weight gain and obesity → heart disease & diabetes

1.2 types: depression (unipolar) and mania (bipolar)

Unipolar depression is one type of affective disorder. The central characteristics of this type of disorder are the sadness and hopelessness experienced by the individual for most of the day, on most days. (Bipolar disorder) a manic depression person will have intense feelings of happiness and 'over-activity'. The main difference between the two is that depression is unipolar, meaning that there is no "up" period, but bipolar disorder includes symptoms of mania. Symptoms of unipolar (depression) are: Changes in mood- long period of feeling sadness/despair. Loss of interests in enjoyable activities. Changes in behavior- fatigue or lethargic. Difficulty in concentrating. Difficulty in sleeping or too much sleep; loss or gain in appetite /weight. Avoiding others and activities. Finding it difficult to make decisions. considering/attempting suicide. Symptoms of manic (bipolar) are: Changes in mood-Feeling very excited; having lots of energy and enthusiasm. Feeling irritable/rage. Changes in behavior- easily distracted (having racing thoughts). Sudden interest in new projects and activities. Overconfidence, quickly speaking. Sleeping less or appearing not to need sleep. Engaging in risky behaviours.

3.2 electroconvulsive therapy

biomedical therapy for severely depressed patients in which a brief electric current is sent through the brain to induce a seizure. A person receives a brief amount of electricity to the brain to induce a seizure. The patient is anesthetized and given a sedative to relax muscles. Electrical current is passed through the head for no longer than a second via electrodes attached to the skull. The seizure will last for up to one minute. Can be bilateral - across both brain hemispheres or unilateral - across the non-dominant hemisphere. Modern ECT involves passing an electrical current unilaterally through the non-dominant side of the brain (to reduce memory loss) to induce a seizure. The seizure is the 'treatment'. Six to 12 sessions, twice a week. Evaluation: Extremely rare side effects: lasting neurological damage or death Positive effects may be short-lived Procedure affects the Central Nervous System (CNS) and the Cardiovascular system, which can be dangerous for those with pre-existing medical conditions Doesn't have the same kind of side effects as medication so ppl who can't take medicine e.g. pregnant women can have ECT Can be useful for acute, severe symptoms and those with catatonia. Used only with severe depression, when there are risks of suicide, but can be effective in this situation. Dierckx et.al. (2012) 1000 patients with uni- and bipolar disorder found 50% effectiveness, similar to drugs and CBT. Benefits are short term Real Life Application: can be very effective for some individuals especially if antipsychotics don't work on them (treatment resistant). But it is normally considered to be far less effective than antipsychotics Use of animals: Effects of electric shocks on cattle were observed in the first stages of developing this form of treatment, can be unethical as the electric shocks would've had severely harmful effects on the cattle (as shown very harmful to humans without anesthetic), however it is unlikely there were any ethics guidelines regarding the use of animals at the time this research was conducted Ethics: potentially harmful to patients physically and mentally as there are many side effects including memory loss, although measures have been taken to limit this by using unilateral application of electricity, bilateral is used if unilateral doesn't work Individual vs Situational: ECT is very effective on some people (success stories) but doesn't work at all on others suggesting different people respond to it differently

measuring pain self-report measures (clinical interviews)

clinical interviews assess the intensity, duration, location, and type of pain.

2.3 disclosure of information (Robinson and West, 1992)

compare the level of disclosure of genitourinary issues between a questionnaire and a computerized interview. Information on the medical history and symptomatology of patients was obtained either by a computerized interview or a paper questionnaire and the results compared. A comparison was also made between these methods and notes taken during a standard physician interview. 69 patients presenting at a Genito-urinary clinic. Significantly more symptoms were elicited by the computer. Both methods also elicited significantly more symptoms than were recorded by the physician.

2.1 subjective: self-reports (Riekart and Droter, 1999)

examine whether those who agreed to take part in research involving self-report measures differed in terms of adherence from those who refused to take part and those who did not complete the study. aged between 11 and 18 who had type 1, insulin dependent diabetes. 94 families were approached to participate, 80 agreed to be involved. They were given; an 'Adherence and IDDM Questionnaire-R which was a semi-structured interview to assess adherence to treatment. A Demographics Questionnaire including questions on age, gender, ethnicity, disease duration and family demographics. The adolescents completed 1 and the parents completed 2. Both parents and adolescents were also given another questionnaire to complete at home. If they had not returned it within 10 days, they were called once to remind them. IDDM - Insulin dependent diabetes mellitus. R = 'revised' There were significant differences in adherence levels between the participants and those who did not return their self-reports despite similar demographics. Those who returned the questionnaires had significantly higher treatment scores and tested their blood sugars more often than those who did not return the questionnaires.

2.2 objective: pill counting (Chung and Naya, 2000)

measure adherence rates in oral asthma medication using a Trackcap device (electronic check by seeing tracking how many times the cap opened). 57 patients with asthma Each patient was given 56 tablets (3 weeks plus a spare week) the lid of the medication had a chip so it could identify when it was opened. They were told to take the tablet approximately 12 hours apart. They came back to the clinic after 3 weeks (four times in total) Patients were told that compliance would be assessed in the study, but they were not told about the Trackcap device. Compliance was defined as: The number of TrackCap events per number of prescribed tablets; and the difference between number of tablets dispensed and number returned per number prescribed. mean compliance = 80% as measured by Trackcap events Adherence was defined as the number of days with two TrackCap events at least 8h apart per the total number of days' dosing. Mean adherence = 64%

3.3 token economy (Paul and Lentz, 1977)

to investigate the effectiveness of one operant conditioning (learning process through which the strength of a behavior is modified by reinforcement or punishment) strategy to reinforce appropriate behavior with schizophrenic patients. 84 patients with chronic admissions to psychiatric institutions independent measures design used to compare outcomes of 3 different forms of treatment Patients in the token economy group were given a 'token' as a reward for appropriate behaviors. Tokens could be exchanged for luxury items Time sampling was used to observe patient behavior as well as standardized questionnaire scales and individual interviews. Evaluation: Rigorous enforcement in other hospitals is unlikely thus study is low in ecological validity and mundane realism Ethical issues: denying privileges to patients who don't behave appropriately may make them demotivated and distressed by the therapy, resulting in psychological harm. Can be seen as an abuse of power Only works on negative symptoms Paul and Lentz (1977) Evidence to suggest it is effective (eg. 97% were able to live in the community in comparison to a milieu group (71%) and a hospital group (45%). Staff monitored and issued with the manual to ensure procedures were standardized Reductionism: It doesn't take into account physical factors and biochemical factors that may have caused the illness and its symptoms. Only focuses on improving behavior as a result of symptoms but not the actual symptoms e.g hallucinations and delusional thinking. Cultural Bias: the medical health center was in Illinois; thus, we cannot generalize the results to everyone else in the population. In a study by Paul & Lentz) Practical Application: the token economy is not sustainable in many medical wards because it costs money. Lowered practical application as only treats behavior, not symptoms.