3.4 Unit 4 Psychopathology, Psychology in Action and Research
Candidates will be expected to:
• develop knowledge and understanding of theories and studies relevant to the content for each area of
psychology in this unit
• analyse and evaluate theories, explanations and studies relevant to the content for each area of
psychologyin this unit
• undertake practical research activities involving collection, analysis and interpretation of qualitative
This unit is divided into three sections.
Section A: Psychopathology
Candidates will be expected to:
• develop knowledge and understanding of one of the following disorders:
o phobic disorders
o obsessive compulsive disorder
• apply knowledge and understanding of models, classification and diagnosis to their chosen
GUIDE TO CHANGES (from 2008)
i.e. very little has changed
except marksChanges to the mark allocations – on PSYA3
and PSYA4 (Sections A and B), each topic will now be worth 8 AO1 marks and 16 AO2/3
marks, making the total for PSYA3 72 marks and the total for PSYA4 83 marks
Student checklist for Phobias PSYA4
s and issues
Types of phobias
Reliability of diagnosis
Validity of diagnosis
Drugs and psychosurgery
Including evaluation in terms of
appropriateness and effectiveness.
A. Classification and Diagnosis of Phobias
General Introduction to anxiety disorders
DSM IV breaks down anxiety disorders into 5 subdivisions:
phobias, general anxiety, panic disorder, post-traumatic stress disorder, obsessive-compulsive
disorder (ICD 10 is very similar)
All of these share one thing in common: anxiety
(Anxiety is at the heart of what used to be called “neurosis” – extensively studied by Freud)
Fear and anxiety are complex reactions to a threat or danger.
Anxiety is an important adaptive response to ensure survival. In certain circumstances it is
important for an animal to experience anxiety because it places it in a state of heightened
arousal ready to respond to danger.
We experience anxiety on several levels:
Emotionally – a sense/feeling of panic
Cognitively – worry about what will happen, dire consequences
Physiologically – dry mouth, palpitations, tensed muscles, perspiration etc
Behaviourally – freeze or flight
Whilst anxiety and fear responses are normal reactions to a threat or danger, anxiety can
become a chronic and disabling response.
A person with an anxiety disorder experiences anxiety that is quite disproportionate to any
threat or danger that is posed.
Phobias are the most common of anxiety disorders (and among the most common of all mental
6 – 7 % of the population suffer from phobias(13% in one US survey, Stern, 1995)
Females outnumber males by 2 to 1
An aversion or fear of something is only classified as a phobia when the aversion becomes
excessive or unreasonable, and when there is no other possible physiological cause (e.g.
substance abuse), or if the symptoms can‟t be accounted for by another disorder. Even
then most people can adapt their life to avoid the feared stimulus. It is only when the
phobia interferes with a functional life (“failure to function”) that it is classified as a
mental disorder. The phobia is often accompanied by depression and panic attacks.
3 Types – the most disabling are social phobia and agoraphobia
1. Specific Phobias (there are 100‟s) 4 major sub-types:
Animal types: spiders, dogs (usually begins in childhood)
Situational types: flying, enclosed spaces (claustrophobia)
Natural environment types: heights, water
Blood-injection types: blood, injections, needles
(Other type: anything else that does not fit into the 4 major sub-types)
Use the Internet to research weird and wonderful phobias. What is yours called?
See Tb p 190 for DSM diagnostic criteria.
This is an excessive fear of social situations, based on a fear of exposure/humiliation.
Some sufferers fear eating in restaurants or using public toilets, others fear meeting
strangers or public speaking. They are afraid that someone will see them expressing
their fear – by blushing, a trembling hand or a quavering voice and think badly of them.
As a result they try to avoid certain social activities and situations. The feared social
situation induces extreme anxiety and may be accompanied by anxiety attacks
Onset: around 15 years of age- most prevalent in 18 -19 yr olds
70% of cases are female
3.Agoraphobia – with panic attack
The most common of phobias. This is a great fear of open or public places, but it is rare
in its own. It is usually accompanied by panic disorder which often precedes the
condition. Generally there is a fear of public places – of shopping malls, crowded streets
or travelling on public transport, but it manifests itself as a fear of leaving the home. At
first sight agoraphobia appears to be another social phobia. However, in most cases it
begins with a series of panic attacks. The sufferer has a feeling of impending doom and
often fears dying, going mad or losing control. As a result they are afraid of having a
panic attack in a place where they don‟t feel safe and where there may be nobody around
to help the. Where social phobics are afraid of others watching them, agoraphobics are
fearful for themselves. Safety, rather than embarrassment is their main concern.
Onset: early adulthood
75% are female
Diagnostic criteria: DSM IV “Panic disorder with Agoraphobia”
Recurrent, unexpected panic attacks
At least one panic attack has been followed by at least one month of worry about the
attack, concern about having attacks or changes in behaviour resulting from the attack.
Agoraphobia – anxiety about being in situations from which escape might be hard or
embarrassing in the event of a panic attack.
The panic attacks are not due to the use of some substance
Definition of a panic attack: DSM IV
Intense fear or discomfort with 4 or more bodily symptoms suddenly appearing, including:
palpitations, shortness of breath, accelerated heart rate, feeling of choking, nausea,
chest pain, feeling dizzy and fear of dying.
Exercise: task 1case studies of phobias.
Summary – Diagnostic criteria
DSM-IVr criteria include:
Marked and persistent fear that is excessive, cued by the presence or anticipation
of a specific object or situation.
The phobic object/situation is avoided or endured with intense anxiety or distress
The avoidance interferes significantly with the person‟s normal routine
Diagnosis of phobic disorder is only made if no other physiological cause or
disorder could account for the fear e.g. drug abuse.
Types of Phobia
SPECIFIC PHOBIAS, of animals, events (flying), bodily (blood), and situations (enclosed
SOCIAL PHOBIAS, of social situations, public speaking, parties, meeting new people.
AGORAPHOBIA, of public crowded places (not open spaces), of leaving safety of home
All phobias are more common in women than men, in particular Agoraphobia.
Social Phobia is most prevalent in adolescence and agoraphobia in middle age.
Issues of reliability and validity in the diagnosis of phobiasp191
What is reliability?
Test re-test reliability
Skyre et al (1991) Inter-rater R
Hiller et al (1990) test re-test R
Kendler (1999) test re-test R
Reasons for low reliability
Kendler et al (1999)
Demonstrating validity of methods of diagnosis
1. Concurrent validity
2. Construct validity
IMPLICATIONS OF LOW RELIABILITY AND/OR VALIDTY
Diagnosis by computer
Cultural differences in Diagnosis
4.Outline clinical characteristics of one anxiety disorder (5 marks)
5.Explain issues associated with classification and diagnosis of anxiety disorders.
4.Outline clinical characteristics of one anxiety disorder. (4 marks)
5.Outline clinical characteristics of either phobic disorders or obsessive compulsive
disorder. (5 marks)
6.Explain issues associated with the classification and/or diagnosis of either phobic
disorders or obsessive compulsive disorder. (10 marks)
B. EXPLANATIONS OF PHOBIC DISORDERS(old TB p 192)
1. GENETIC INHERITANCE
What is inherited?
-Few studies, conflicting evidence and no adoption studies
Family and twin studies –
provide modest support
The diathesis stress model
The Diathesis-Stress Model
It is likely that genetic factors predispose an individual to develop phobias, but
experience plays a role in triggering the response.
What is inherited?
But there is an uneven distribution of phobias – some are more common than others
and this needs explaining – this is done by the evolutionary approach
2. EVOLUTIONARY APPROACH
– there are 3 elements to this:
A) Ancient fears and modern minds
There is evidence to support the prepotencyand preparedness element of the
Ohman and Soars (1994)
Ohman et al (1976) conditioned fear into a group of Ps using various prepared (spiders, snakes) and
unprepared stimuli (flowers, pictures) being paired with an electric shock. Fear conditioning occurred rapidly
in the prepared stimuli group (many after one trail) whereas it took at least 5 trials in the unprepared stimuli
group. In extinction trials, the unprepared stimuli were extinguished immediately, but the prepared stimuli
took much longer.
However,McNally (1987) states that although there is firm evidence to show that
extinction to prepared stimuli is difficult, the evidence for rapid learning was at best
equivocal. This led Davey (1995) to propose expectancy biases:
Clinical Phobias: do the concepts of prepotency and preparedness explain clinically
Make notes on Behavioural Inhibition (green box) and Cultural Differences (yellow box)
on p 193.
PSYCHOLOGICAL EXPLANATIONS OF PHOBIC DISORDERS
Freud explained phobias using his idea of Ego Defence mechanisms.Anxiety provoking
thoughts or desires coming from the ID are REPRESSED into the unconscious where the
anxiety is DISPLACED(by the ego) onto another neutral object which becomes the
subject of the phobia.
In the case of Little Hans the ID‟s desire was to kill his father (Oedipus Complex) and
the fear of castration was displaced onto horses - the link was big “widdlers”!
Hans phobia was only resolved when he had overcome his Oedipus complex.
The case study of little Hans is regarded as poor evidence because it – expand..
Cannot be generalised
Classical conditioning explains Hans phobia better
However, research has also supported the psychodynamic explanation
Bowlby (1973): agoraphobia and separation anxiety
Whiting et al (1966): cross cultural studies
Therapies that target symptoms only are not 100% effective: e.g. SD
Phobias can be seen as learnt behaviour, either through classical conditioning, operant
conditioning or social learning theory. It is suggested that phobias are learnt in 2 stages:
first by Classical Conditioning andthen “stamped in”, or maintained by Operant C.
CLASSICAL CONDITIONING – Watson & Raynor (1920)
conditioned a baby boy known as Little Albert to fear white rats.
For several weeks, Albert played happily with a white rat
showing no fear. One day, while he was playing with the rat, the
experimenters struck a steel bar with a hammer close to Albert‟s
head. Albert was very frightened by the noise. This was repeated
each time he reached for the rat. Albert then developed an
intense fear of white rats (and Dr. Watson!).
UCS (Noise) + CS (Rat)
This refers to learning to behave in certain ways because the behaviour is reinforced, by
some sort of positive outcome or removal or avoidance of something negative. In terms
of phobias, avoidance of the phobic object or situation is reinforced by the reduction of
anxiety. (Mowrer, 1974)
Avoidance maintains the fear and preserves the phobia (an example of negative
reinforcement). Frequent contact with a phobicobjectmay reveal that it is harmless,
which will lead to the extinction of the phobia. However, people with phobias go to great
lengths to avoid the object of their fears, often planning ahead and putting up with all
manner of inconvenience, thus making the phobia resilient to extinction.
SOCIAL LEARNING THEORY.
Bandura (1986) developed social learning theory by showing the importance of
observational learning and imitation as a form of learning – especially from parents. If,
from an early age, we observe others being frightened or avoiding certain
objects/situations we are likely to observe and imitate, because the behaviour is
rewarding – it gets attention. We call this vicarious learning. This behaviour may then
be reinforced directly through OC.
Evidence to support behaviourism
1. Watson and Raynor (– don‟t just describe – say how)
2. Barlow and Durand (1995) report that 50% of those with a specific phobia remember
a specific past traumatic experience – e.g. those with a driving phobia remember a car
accident, and those with a choking phobia had an unpleasant choking incident in the past.
In ADDITION ADD NOTES ON Sue et al (1994) and Ost (1987)
Evidence contradicting behaviourism.
1.Not all phobics have had a specific frightening experience with the phobic object.
Menzies and Clarke (1993) carried out a study on child phobics with a water phobia and
found that only 2% had had a direct conditioning experience with water!
2. DiNardo et al (1988) found that 50% of dog phobics and 50% of normal controls had
had an anxious encounter with a dog – this suggests that dog phobias do not depend on
previous encounters with dogs, supporting the diathesis stress model – only those with a
genetic vulnerability go onto develop a phobia
In defence of behaviourists, children often have poor recall for events in childhood
under 3 years of age. Also the memory may have been repressed in Freudian terms, or
the traumatic event may have been associated with a neutral object (later phobic)
without the P knowing it (e.g. a traumatic event near a stream with running water which
the P was unaware of at the time).
Make further notes p 195
A phobic person develops irrational, distorted and negative thinking about an
object or situation
This causes them to exaggerate the threat posed
Phobic people realise their fear is irrational
When they are at a distance from their feared object they can cope, but as it
comes closer, they show symptoms such as raised heartbeat, panic etc.
For example, a social phobic fears social situations. They believe they will make a
fool of themselves when in meetings etc. and that other people will see them as
stupid. They will therefore stay in, and avoid meeting new people
Cognitive Bias(Beck 1985)
The Emotions we feel are the result of our interpretations of our experiences according
to our existing SCHEMAS.
Phobics are likely to
over exaggerate the negative consequences
Under estimate their ability to cope.
show “Catastrophic Misinterpretation”
It’s poisonous !
I can’t escape !
I’m going to die!
EVALUATION see p 195
COGNITIVE BEHAVIOUR THERAPY IS SUCCESSFUL
Additional notes p 195
Reductionism and determinism
6.Outline and evaluate one or more explanations of the anxiety disorder outlined in your
answer to Question 0 4 . Refer to research evidence in your answer. (4 marks + 6 marks)
3(a) Outline one psychological explanation and one biological explanation for either phobic disorders
or obsessive compulsive disorder. (9 marks)
(b) Evaluate explanations for either phobic disorders or obsessive compulsive disorder. (16 marks)
4. Outline and evaluate one psychological explanation for either phobic disorders orobsessive
compulsive disorder. (4 marks + 6 marks)
3. Outline and evaluate one or more biological explanations for either phobic disorders
or obsessive compulsive disorder. (4 marks + 8 marks)
4. Discuss one or more psychological explanations for either phobic disorders or
obsessive compulsive disorder. (5 marks + 8 marks)
3 Discuss explanations for phobic disorders. (8 marks + 16 marks)
6 Outline and evaluate one psychological explanation for phobic disorders. (4 marks + 8 marks)
BIOLOGICAL TREATMENTS FOR PHOBIC DISORDERS
If mental illness is seen as having biological, neurochemical, genetic factors, disease or
injury as a cause then it follows that treatment should also be based on biological or
medical practices. There are three types of medical intervention for dealing with
disturbed thinking or behaviour: - Psychosurgery, electroconvulsive therapy (ECT) and
chemotherapy (drugs). Chemotherapy is largely used (sometimes psychosurgery).
MINOR TRANQUILLISERS or ANXIOLYTIC DRUGS
Benzodiazepines (BZs) such as Valium and Librium
reduce anxiety by inhibiting neural activity in parts
of the brain by enhancing the activity of GABA
(gamma-amino-butyric-acid), a neurotransmitter
that has a quieting effect on neurons in the brain.
They can be useful in treating phobias, problems with sleeping and other somatoform
(body) disorders, and stress. Valium is thought to be the most widely prescribed drug in
Beta-blockers (BBs): reduce sympathetic nervous system arousal, rather than affect
the brain, and reduce the effects of adrenaline and noradrenaline (part of the SAM
system response to stress).Details…
As SNS arousal is a central feature of stress, beta-blockers can be very effective
against symptoms such as raised heart rate and blood pressure, and increased levels of
cortisol. (Beta blockers are often used by sports people to reduce arousal because ANS
arousal can have a negative effect upon performance).(SeeBlue box p 197 on BBs and
These are used to treat anxiety disorders as well as other disorders (moderate to severe
depressive illnesses, panic attacks and obsessional problems; they may also be used to
treat eating disorders).
Selective Serotonin Reuptake Inhibitors (SSRIs) include Seroxat and Prozac and are
the most commonly prescribed types of anti-depressants. SSRIswork by blocking the
reuptake of serotonin(and norepinephrine), increasing the quantity of serotonin available
to excite neighbouring cells. The neurotransmitter serotonin regulates mood and anxiety,
and thus helps with anxiety disorders.
Monoamine OxidaseInhibitors(MAOIs)inhibit the destruction of norepinephrine,
serotonin and dopamine but this can have serious side-effects and although not widely
used now, these can still be effective for some patients. Details…
EVALUATION make further notes p 197
EFFECTIVENESS OF CHEMOTHERAPY
Kahn (1986) found BZ‟s more effective than placebo.
Hildalgo (2001) found that BZ‟s were more effective than antidepressants.
Liebowitz (1985) found BZ‟s good for anxiety control.
X BUT Turner (1994) found no difference between a BB and a placebo in reducing
heart rate etc.
Liebowitz (1992)found MAOIs to be more effective than placebos + BBs
SSRI’s found effective against placebo for anxiety reduction & social phobias.
SSRI’ssimilar effectiveness to BZs, but preferred to BZ‟s as fewer side effects
What happened to Barbara Streisand?
APPROPRIATENESS OF CHEMOTHERAPY
NOT A CURE
Real life application – Fearful memories – green box p 197
Psychosurgery is surgical intervention to treat an area of the brain which is believed to
be malfunctioning, by severing connections to that part of the brain.
These days stereotactic psychosurgery is used: surgeons use computer based
stereotactic imaging to locate the precise point. They may then either burn the area
using the tip of a hot electrode or use a non-invasive tool like a gamma knife to focus
beams of radiation on the targeted site. The operations used to treat anxiety disorders
are capsulotomy and cingulotomy. See p 196
Deep brain stimulation: safer as it involves
no destruction of tissue – wires are
inserted permanently in target areas of the
brain and are connected to a battery in the
patient’s chest. When the current is on this
interrupts the target circuits in the brain.
Ruck et al (2003) study of capsulotomy for 26 patients with non-OCD anxiety disorders
13 generalised anxiety, 8 panic disorder and 5 with social phobia. There was a significant
reduction in anxiety scores a year later for 25 of them.
However, adverse side effects were extreme, including suicide attempts and epileptic
Psychosurgery is more often used with OCD sufferers and rarely with phobias, and then
only in very extreme cases. Treatment needs to be weighed against possible adverse side
Ethics – yellow box Make notes on the bits relevant to psychosurgery also p 211
BEHAVIOURAL THERAPIES BASED ON CLASSICAL CONDITIONING
Behaviour therapy – Classical Conditioning.
Behaviour therapy is often used to treat Phobias. It assumes that: 1. Phobias are learnt by classical conditioning and
2. They can be unlearnt by a similar process.
Phobias can be removed by counter-conditioning: learning a new association that runs
counter to the original association.
This is the principle behind Systematic Desensitisation.
(Behaviour therapies based on classical conditioning work best on behaviours that are not
undervoluntary control (an inappropriate association has been made between an
instinctual fear response and a previously neutral stimulus, such as fear of supermarkets,
snakes or clocks). Typically these are phobias and anxiety disorders as well as
SYSTEMATIC DESENSITISATION(see hand-out for other types)
This approach was developed by Joseph Wolpe (1958).
MODE OF ACTION:
Many individuals who are (non-rationally) afraid of a stimulus could learn that the
stimulus is not so fearful if they could re-experience the feared stimulus; in other words
“reality test”. But the anxiety it creates blocks this from happening. SD enables
individuals to overcome their anxieties by introducing them to the feared stimulus
gradually and by teaching relaxation techniques, so that a relaxed state is paired with
the fearful stimulus in a progressive manner. These are the steps:
Step 1 – Clients are taught relaxation techniques
Step 2 – With the help of a therapist, clients construct a fear hierarchy – a list of
feared objects or situations ranked from the least to the most feared. E.g. a person with
arachnophobia might imagine a spider in various situations from a picture in a book (least
feared) to crawling over their hand (most feared).
Step 3– In the presence of the therapist, the client then confronts each item in the
hierarchy while they are in a state of deep relaxation. They start with the least
feared item and move on once they feel relaxed and unafraid in its presence. This
confrontation may be real or imagined. The process continues until they reach the top of
the hierarchy and feel relaxed in the presence of all the items. If the systematic
desensitisation works, clients have been counter-conditioned – they have learnt a new
response to a stimulus. They no longer associate the object or situation with fear.
Task: Imagine you are a therapist helping a client overcome a fear of flying.
Construct a fear hierarchy for flying, with at least 6 items. Explain how
you would help a client through their fear using this hierarchy.
What is your fear? Design a fear hierarchy for your own phobia.
Behavioural treatment for Phobias Dr Jeffrey Wood from San Francisco (no relation!) talks about phobias, avoidance, flooding,
graduated exposure (systematic desensitisation).
Aversion Therapy and Homosexuallity
The sissy boy experiments?????
+ Research has found that that SD is successful for a range of anxiety disorders.
McGrath et al (1990) reported 75% of patients with phobias responding to SD.
Capafons et al (1998) successfully treated 20 patients for fear of flying. After a
programme of SD, Ps displayed less fear in a flight simulator and were more likely to fly
than a control group of patients awaiting therapy. (See green box p 199)
- However, spontaneous recovery from phobias has been found to be as high as 50-60%
after 1 year (McMorran et al, 2001).
Ohman et al (1975) suggests that SD may not be effective for treating phobias which
have an underlying evolutionary component (snakes, heights etc.) in comparison to phobias
which are acquired through personal experience.
Assessing success is problematic because often a variety of techniques are used – in
vivo, covert and even modelling. Menzies and Clarke, (1993)state that the actual key to
success is contact with the feared stimulus, therefore in vivo techniques are more
successful than covert ones.
Strengths: p 199
1. Behavioural therapies are relatively quick and require little effort on behalf of the
patient in comparison to other psychotherapies such as REBT. Details…
2. Behaviour therapies may be the only treatment possible for certain types of people,
e.g. those with learning difficulties and/or brain damage.
1. Inspiration for SD came from animal research. See orange box p 199. To what
extent can we generalise from animals to humans? How are human different?
2. Because behaviour therapies target symptoms only, symptom substitution may occur.
This is where new symptoms replace those that have been unlearned because the
underlying problem has not been treated. However, Langevin (1983), claims there is no
support for this objection
3. New behaviours may be learned in the therapist‟s office but these may not be
generalised to the real world, (context-dependent learning).
4. Is relaxation necessary?
COGNITIVE (BEHAVIOUR) THERAPY
Cognitive Behavioural Therapy CBT uses the cognitive approach to restructuring
cognitions, but it also has aspects of behaviourism.
Ellis developed REBT (Rational-Emotive Behaviour Therapy) in the 1950s.
The aim of REBT is to help the client identify their negative, irrational thoughts and to
replace these with more rational and positive ways of thinking. In the case of Phobias, it
is not the stimulus which is the problem, but the irrational beliefs that it is based on. If
the belief is tackled and replaced with rational thinking then the behaviour and emotion
will also change for the better. A therapy session includes both cognitive and behavioural
elements with homework in-between.
1. Irrational thoughts are identified using the ABC model: p 198 for e.g. s
2. Challenging the irrational beliefs, through effective disputing, and replacing them
with rational beliefs
These do what……
3. Behavioural Element:
The therapist and client decide together how the client‟s belief can be reality tested
through experimentation, either as role play or as homework assignments. The aim is
that by actively testing out possibilities, clients will themselves come to recognise the
consequences of their faulty cognitions. The therapist and client then work together to
set new goals for the client in order that more realistic and rational beliefs are
incorporated into ways of thinking. These are usually graded stages of difficulty so that
clients can build upon their own success (becomes reinforcing).
EVALUATION p 199
CBT is a very popular form of psychological therapy. It is straightforward, practical and
has proved successful in treating a wide range of problems.
EFFECTIVENESS: REBT has done well in outcome studies
Not suitable for all
Questioning of the theoretical basis of the therapy
4 Outline clinical characteristics of one anxiety disorder. (4 marks)
5.Briefly describe one psychological therapy for the anxiety disorder that you
outlined inyour answer to 4 . (5 marks)
6.Evaluate psychological therapies for this anxiety disorder. (16 marks)
0 4 „Biological therapies are useful for the short-term treatment of phobic disorders,
butpsychological therapies are more effective in the long-term.‟
Outline one biological and one psychological therapy for phobic disorders. Evaluate
these therapies in terms of their effectiveness. (8 marks + 16 marks)