Health & Clinical
Psychology
Healthy Living
Stress
Dysfunctional
Behaviour
Disorders
Module: G543
Contents
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Objectives for the Health and Clinical Psychology module
What is Health Psychology? Careers in Health Psychology
Unit G543: Health and Clinical Psychology
Exemplar exam paper
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PART A – INFORMATION TO HELP EVALUATE STUDIES
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Evaluation sheet for the theories/studies of Health Psychology
Guide for answering part A & part B exam questions
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PART B – HEALTHY LIVING

Introduction to Healthy Living
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Theories of Health Belief
 Compliance with a Medical Regime for Asthma (Becker 1978)
 Internal versus External Locus of Control (Rotter 1966)
 Analysis of Self-Efficacy Theory of Behavioural Change (Bandura and Adams 1977)
 Summary of the health belief theories
 Comprehension questions for theories of health belief
 Part A exam question
 Part B exam question
 Evaluation sheet of health belief theories/studies
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Introduction to Health Promotion
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 Theories of Health Promotion
 Chip pan fire prevention (Cowpe 1983)
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 Legislation-Bicycle helmet laws and educational campaigns (Dannenberg et al. 1993) 34
 Effects of Fear arousal (Janis & Feshbeck 1953)
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 Summary of the health promotion studies
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 Comprehension questions for health promotion
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 Part A exam question
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 Part B exam question
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 Evaluation sheet of health promotion theories/studies
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Introduction to Theories of Adherence
 Theories of Adherence
 Reasons for Non- Adherence (Bulpitt et al. 1988)
 Measures of Non –Adherence ( Lustman et al. 2000)
 Improving Adherence using Behavioural Methods (Watt et al. 2003)
 Summary of the theories/studies of adherence
 Comprehension questions for theories of adherence
 Part A exam question
 Part B exam question
 Evaluation sheet of theories of adherence theories/studies
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PART C – STRESS
Introduction
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Theories of Causes of Stress
 Measurement of Stress Response (Johansson 1978)
 Comparison of Two Methods of Stress Measurement (Kanner 1981)
 The Effect of Control on Reducing Stress (Geer and Meisel 1972)
 Comprehension questions for causes of stress
 Summary of the theories/studies of causes of stress
 Part A exam question
 Part B exam question
 Evaluation sheet of causes of stress theories/studies
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Introduction to Theories of Measuring Stress
 Theories of Measuring Stress
 Physiological Measures (Geer & Maisel 1973)
 Self-Report (Holmes & Rahe 1967)
 Combined Approach (Johannson 1978)
 Summary of the theories/studies of measuring stress
 Comprehension questions for methods of measuring stress
 Part A exam question
 Part B exam question
 Evaluation sheet of methods of measuring stress theories/studies
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Introduction to Theories of Managing Stress
 Theories of Managing Stress
 Stress Inoculation Therapy (Michenbaum 1975)
 Biofeedback and Reduction of Tension Headaches (Budzynski 1973)
 Social Relationships and Cancer Survival (Waxler-Morrison 2006)
 Summary of the theories/studies of managing stress
 Comprehension questions for managing stress
 Part A exam question
 Part B exam question
 Evaluation sheet of managing stress theories/studies
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PART D – DYSFUNCTIONAL BEHAVIOUR

Introduction
Introduction to theories diagnosing dysfunctional behaviour
 Diagnosis of Dysfunctional Behaviour
 Categories of Dysfunctional Behaviour (DSMI/ICD )
 Definitions of Dysfunctional Behaviour (Rosenhan and Seligman 1995)
 Sex Biases in Diagnosis of Disorders (Ford and Wediger 1989)
 Summary of the theories/studies of dysfunctional behaviour
 Comprehension questions for diagnosis of dysfunctional behaviour
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Part A exam question
Part B exam question
Evaluation sheet of diagnosis of dysfunctional behaviour theories/studies
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Introduction to theories explaining dysfunctional behaviour
 Theories Explaining Dysfunctional Behaviour
 Behavioural : Study of Classical conditioning(Watson and Raynor 1920)
 Biological : Twin studies (Gottesman and Shields 1991)
 Cognitive : Interviews with people with depression (Beck et al. 1974)
 Summary of the theories/studies explaining dysfunctional behaviour
 Comprehension questions for explaining dysfunctional behaviour
 Part A exam question
 Part B exam question
 Evaluation sheet of the explanations of dysfunctional behaviour theories/studies
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Introduction to treatments of dysfunctional behaviour
 Theories of Treatments of Dysfunctional Behaviour
 Successful Treatment of a Noise Phobia (McGrath 1990)
 Treatment of Social Phobia with Phenelenzine (Leibowitz 1988)
 Treatments for panic attacks (Ost & Westling 1995)
 Summary of the theories/studies of dysfunctional behaviour
 Comprehension questions for treatment of dysfunctional behaviour
 Part A exam question
 Part B exam question
 Evaluation sheet of treatment of dysfunctional behaviour theories/studies
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PART E – DISORDERS
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Introduction
150

Characteristics of Disorders
 Anxiety Disorders– e.g. phobias.
 Affective Disorders– e.g. depression.
 Psychotic Disorders– e.g. schizophrenia.
 Summary of the characteristics of disorders
 Comprehension questions for characteristics of disorders
 Part A exam question
 Part B exam question
 Evaluation sheet of characteristics of disorders theories
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Introduction to explanations of an Anxiety disorder
 Explanations of an Anxiety Disorder
 Behavioural Explanation: Study of Classical conditioning (Watson and Raynor 1920)
 Biological Explanation :Types of Phobia and biological predisposition to them
(Ohman et al 1975)
 Cognitive Explanation : Generalised Anxiety Disorder (Di Nardo 1998)
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Summary of the theories/studies of an Anxiety disorder
Comprehension questions for explanations of an anxiety disorder
Part A exam question
Part B exam question
Evaluation sheet of Explanations of an anxiety disorder theories/studies
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Introduction to treatments of an Anxiety disorder
 Treatments of an Anxiety Disorder
 Successful Treatment of a Noise Phobia (McGrath 1990)
 Treatment of Social Phobia with Phenelenzine (Leibowitz 1988)
 Treatments for panic attacks (Ost & Westling 1995)
 Summary of the theories/studies of treatments of an Anxiety disorder
 Comprehension questions for treatments for an anxiety disorder
 Part A exam question
 Part B exam question
 Evaluation sheet of treatments for an anxiety disorder theories/studies
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5
Health and Clinical Psychology
Objectives for this part of the module
Candidates should:  Be able to describe and evaluate the areas in the light of psychological theories,
studies and evidence;
 Always seek to apply psychological methods, perspectives and issues;
 Actively seek to apply theory and evidence to the improvements of real-life events and
situations;
 Explore social, moral cultural and spiritual issues where applicable;
 Consider ways in which the core areas of psychology (cognitive psychology,
developmental psychology, physiological psychology, social psychology and the
psychology of individual differences), studied in the AS course, can inform our
understanding of Psychology and Health
6
What is Health Psychology?
Health psychology is a relatively new area of psychology encompassing not only
dysfunctional behaviour, but also the whole area of human health. Health can be
considered to be a lack of illness, both physical and mental and can relate to many aspects
of the mind and body. On the physical side health psychology is not only to do with aspects
of health such as physical trauma or reduction in disease but also health behaviours such
as eating well, not drinking to excess and unhealthy behaviours such as smoking or
becoming stressed.
Being psychology it relies on empirical research to support theories
and models of health interventions and promotions. Once health has
been researched then the applications can be fully explored, such as
legislation and health promotion. All this should make for a healthier
society which means less public spending on health and people living
longer.
In studying the mind, health psychology looks at mental health, hence clinical psychology
and this examines the diagnoses, causes and treatments of a wide range of dysfunctional
behaviours and requires an individual differences approach to each therapy which accounts
for our human uniqueness and ensures the therapies meet our needs.
Careers in Health & Clinical Psychology
Health psychology is a relatively new pathway within psychology and as such is still
continuing to develop in terms of career options.
As health psychologist you would work in:
1. Hospitals and Health authorities – may deal with specific problems identified by
health care agencies or professional. They may also work in government health dept. or
any health-care charities or organisations
2. Clinical setting – Usually within the Health service. They may see patients with
depression, relationship problems, learning disabilities and serious mental illnesses.
They would assess a patient using methods such as interviews observations and
psychometric tests which may lead to a therapy regime such as counselling or Cognitive
Behavioural Therapy
3. Research – Within this sector, a health psychologist would remain as an academic and
drive progress in the field, and apply psychological research to; the promotion and
maintenance of health, the prevention and management of illness, the identification of
psychological illness, the improvement of the health-care system and the formulation
of health policy
7
Unit G543: Health and Clinical Psychology
There are many areas of health psychology that cannot be covered in this course for
example: disability and it’s affect on the family; management of illness and pain and
improving communication between patient and health practitioner the areas therefore
that are covered are
1. Healthy Living – this area considers theories that might explain health behaviours such
as health belief model and then looks at health promotion campaigns. It also looks at
adherence: understanding why people adhere to medical advice and why it is important
adhere to ensure the long-term health of society.
2. Stress – this area examines what will reduce stress and teach stress-management
techniques. Problems associated with measuring stress are also examined as this
affects validity.
3. Dysfunctional behaviour – this area examines how society defines dysfunctional
behaviour as this seems to predict how it is treated. This section looks at different
approaches explanations and treatments for dysfunctional behaviour.
4. Disorders – This section looks at three types of disorder in more detail examining the
characteristics of psychotic affective and anxiety disorders. Then identifies one
disorder and looks at it in greater depth from the Cognitive, Biological and behavioural
point of view, along with research supporting these explanations.
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9
Evaluation
Think!
about the study/approach/ method/issues/debates you have
just covered.
Ψ Approach/Perspective
-Physiological, Social, Cognitive,
Ind diffs, Developmental, Behaviourist,
Psychodynamic
 Methods –Design- Independent/ Repeated measures
(adv/disadv)
Type of study (eg experiment, self-report,
observation, case study – adv/disadv)
Ψ Issues -
Participants (representative?) setting, controls
Ecological Validity (how realistic is it; can the findings be applied to everyday life?)
Longitudinal and snapshot (is the study conducted over a long period or one point in time?)
Qualitative and Quantitative data (is the data descriptive or numerical?)
Usefulness (how is the research/theory/model useful in terms of how it explains human
behaviour?)
Application (how can the results of the research/theory/model be applied in everyday life
settings?)
Ethics (consent/informed consent, deception, withdrawal, debriefing, confidentiality, protection
of participants, observation without consent)
Generalisability (can these findings be applied to all individuals/situations?)
Reliability (is the method used within the research/theory/model consistent?)
Validity (is the method used within the research/theory/model measuring what it is supposed to?)
Ψ Debates –
Determinism and Free will (does this study/perspective suggest we have
freewill or that our behaviour/experience is determined?)
Reductionism and Holism (do the results of the study focus on one single level of
explanation, ignoring others or do they consider many explanations?)
Nature and Nurture (is this characteristic/behaviour due to genetics or
learning?)
Individual and situational explanations (can this behaviour be explained
by the situation/environment or is it due to personal characteristics?)
Ethnocentrism (can this behaviour be considered to be biased towards one ethnic group or
society?)
Approach bias (does the study support the beliefs of a specific approach?)
Psychology as a Science (is the method used within the study rigorous, ie. objective, reliable,
falsifiable?)
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GUIDANCE NOTES FOR ANSWERING 10 & 15 MARK
FORENSIC/HEALTH & CLINICAL PSYCHOLOGY
EXAM QUESTIONS
** There will be 4 questions for each topic on the exam paper. You are to chose and
answer 2 questions per topic **
How to answer a part (a) 10 mark Forensic/Health & Clinical psychology exam question

Once you choose your 2 X questions per topic, you are to answer the 10 mark questions
using PEC format. Each question will usually ask you to either “Outline”, “Describe” or
“Identify”.
 P (point, ie. describe/outline the main research/technique)
 E (example, ie. give examples of the features of the research/technique being
asked about)
 C (conclusion, ie. summarise the research/technique)

For each question you are to spend 12 mins and write approximately ½ side A4

The mark scheme for Part (a)
0 marks
1-2 marks
3-5 marks
6-8 marks
9-10 marks

No or irrelevant answer
There are very few psychological terms. The
description of the study is limited, mainly inaccurate
or lacks detail. The study has not been linked to the
question, or the model. The answer doesn’t have a
structure and contains many spelling errors.
There is basic use of psychological terms. The
description of the study is generally accurate, and
makes sense, is usually made relevant to the question,
but it lacks detail. There is some elaboration (using
examples), but the study isn’t linked to the question
very clearly. The answer has some structure and
organisation. It is mostly grammatically correct, but
there are some spelling errors.
The use of psychological terms is mainly accurate. The
description of the evidence is mainly accurate,
relevant and reasonably detailed. The elaboration
(explanations, use of examples) is good. It has been
made clear how the study is relevant to the question.
The answer has good structure and organisation. The
answer is mostly grammatically correct and there are
very few spelling errors.
There are lots of psychological terms and they are
used accurately. The description of the study is
accurate, relevant, makes sense and is very detailed.
There are a lot of elaborations (explanations, using
examples) and the study is clearly related to the
question. The answer is well structured and organised.
The answer is grammatically correct and has very few
spelling errors.
Checklist
  
There are a lot of psychological terms used
accurately
The description of the cause/study is
accurate
There are lots of examples from a
study/studies
There are explanations of key points to
show you understand what you have written
The answer is clearly related to the
question (use the words in the question in
your answer to help you)
There are no spelling errors and it is
grammatically correct
The answer is well structured and easy to
read
NB. This question assesses your A01 skills (knowledge & understanding). There are NO
marks rewarded for A02 skills (evaluation).
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How to answer a part (b) 15 mark Forensic/Health & Clinical psychology exam question

For this part of the question, you will be required to demonstrate your evaluative skills
(A02 & A03) by outlining a number of evaluative points covering a range of issues in
CREEC or CREECC format.
 Example CREEC format
Claim
Reason
Evidence
Evaluative
comment
Conclusion
The sample used by the researchers in the
fear arousal study lacked generalisibility
This is because the researchers used
opportunity samples of students to carry out
the research
Janis and Fleshbeck used psychological
students to carry out their research into fear
arousal and oral hygiene
The problem with this is that psychology
students who are getting credit for their
degrees are more likely to show
uncharacteristic behaviour by perhaps being
more willing to comply and give the
researchers what they want, being familiar
with fear arousal from their own reading and
this may unconsciously affect their answers.
This is called demand characteristics.
Therefore, we should be cautious when
applying the findings from students to actual
fear arousal
Example CREECC format
Claim
The sample used by the researchers in the fear
arousal study lacked generalisibility
Reason
This is because the researchers used opportunity
samples of students to carry out the research
Janis and Fleshbeck used psychological students to
carry out their research into fear arousal and oral
hygiene
The problem with this is that psychology students who
are getting credit for their degrees are more likely to
show uncharacteristic behaviour by perhaps being
more willing to comply and give the researchers what
they want, being familiar with fear arousal from their
own reading and this may unconsciously affect their
answers. This is called demand characteristics.
Evidence
Evaluative
comment
Countercomment
On the other hand Janis and Feshbeck need the
convenience of the opportunity sample to complete
their work in limited time and budget. Also it gives
results that can then be replicated using other
participants in the future.
Conclusion
Therefore, we should be cautious when applying the
findings from students to actual fear arousal

For each question you are to spend 18 mins and write approximately 1 side A4

The mark scheme for Part (b)
0 marks
1-3 marks
4-7 marks
8-11 marks
12-15
marks
No or irrelevant answer
Few evaluative points. There is no evidence of an
argument. There is no structure- it looks
disorganised. There are very few examples from
studies. There are very few conclusions, and very
little summary of the issues or arguments. Very
little of the answer is related to the question.
The argument and organisation are limited. Some
points are related to the question. There is
evidence of an argument, and this shows
understanding. There are some evaluation points.
Valid conclusions summarise the argument.
There are some evaluation points, and these cover
a range of issues. The argument is well organised,
but may lack balance or development. The answer is
related to the specific question. Good use of
examples. The argument is competent and
understanding is good. Valid conclusions summarise
the arguments effectively.
There are many evaluative points covering a range
of issues. The argument is well organised, balanced,
and developed. The answer is clearly related to the
question, and the examples are relevant and
effective. Valid conclusions summarise the issues
effectively, and shows thorough understanding.
Checklist



Use technical terms
Cover a range of evaluation points (at least 4)
Include strengths and weaknesses (2 of each)
Organise your work so it is easy to read- use
connectives
Form an argument- do you agree or disagree?
Use lots examples from relevant studies
Relate the answer to the question (use the
words in the question)
Write a conclusion that summarises what you
have said clearly.
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Topic 1 -Healthy Living
1. Theories of health belief
 The health belief model
 Locus of control
 Self-efficacy
2. Methods of Health promotion
 Media campaigns
 Legislation
 Fear Appeals
3. Features of adherence to medical regimes
 Reasons for non-adherence
 Measures of non adherence
 Improving adherence using behavioural methods
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Topic 1 – Healthy Living
Healthy living refers to the way people live
their lives. A health behaviour is
something you do to improve your health.
A lifestyle is a pattern of health
behaviours. Psychologists are interested in
the reasons behind why some people
choose to be healthy and others choose
not to. Some people eat their five portions
of fruit and vegetables a day and go to the
gym 3 times a week. Some go to the gym
but don’t eat their five a day. Some do
neither!! Why is this?
Theories of health belief help explain individual reasoning behind these decisions. This
involves considering the benefits and barriers) of adopting a health behaviour(The health
belief model) , considering how you feel personally in terms of controlling your health
behaviours (Locus of control) and whether or not you are confident that you can carry out
certain health behaviours (Self-efficacy).
Psychologists are also interested in what makes health communication persuasive. In
today’s society, people are encouraged from a very young age to eat a healthy diet and live
an active life and this is done by using different Methods of health promotion.
This was not always the case. Smoking for example was once
looked upon as a glamorous habit and film actors were used to
promote smoking. The beautiful Betty Grable, America's
favourite pin-up girl up to 1972, appeared in 84 films and her
"million dollar legs," were insured. Her picture appeared on the
packets of cigarettes she smoked. She died of lung cancer aged
56.
The media are used today to encourage people to give up
smoking or to not start in the first place.
Fear arousal, such as images of cancerous mouths are now used
on cigarette packets to warn individuals of the dangers of smoking. Legislation has also
been introduced to ban smoking in all public and work places.
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Finally, maintaining good health often involves adhering (sticking to/following) a healthy
lifestyle or to medical advice from a doctor or health worker. Medical regimes may involve
eating a healthy diet, exercising regularly or taking medication to treat an illness.
Research shows that individuals struggle to Adhere to medical regimes.
Psychologists are thus interested in reasons for non adherence. Some people do not
follow medical advice because they believe that they have good reason not to. Side
effects of medication are often a reason cited for non adherence.
Psychologists also need to be
confident that they can measure
adherence in individuals. These
methods vary from self- reports
to bio-chemical analysis which
involves a physiological approach
such as analysing the level of
medication in blood or urine.
When individuals do not adhere to medical advice,
health workers and psychologists try to come up
with ways to improve adherence.
Simple measures such as pill boxes help with
adherence, especially amongst the elderly.
.
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WHAT DO WE KNOW FROM AS?
Several studies or theories from AS Psychology explain why individuals might choose a
healthy lifestyle or not and believe that they have the ability change things:

GRIFFITHS (1994) studied cognitive styles - the way regular gamblers have of
thinking about gambling, weighing the odds and explaining away losses, that is quite
different from non-gamblers. This highlights how cognitive processes affect
behaviour. Thus with the health belief models a person’s thoughts affect whether
they change their lifestyles for the better, have self-belief so they feel they can
change their lifestyles and shows us that these cognitive thoughts can be altered so
a person can have more self-efficacy.

BANDURA (1961) was more interested in SITUATIONAL explanations, particularly
the idea that we might learn to behave in certain ways. His "Bashing Bobo"
experiment looked at how we learn to be aggressive, but his Social Learning Theory
(SLT) might help explain lots of other behaviours such as how in copying role models
we will eat the right or wrong foods or exercise or not? If it worked for them it may
work for us?

MILGRAM (1963) looked at behavioural study of obedience and that people act a
certain way depending on a given situation and this can be related to health with the
Health belief model: the social situation has an effect on whether people will adopt a
behaviour which will benefit them.
HOW CAN WE APPLY THE APPROACHES AND PERSPECTIVES TO HEALTHY
LIVING?

BEHAVIOURIST psychologists will try to look at the behaviour of people and their
environments and work out what sort of backgrounds or circumstances make someone
make healthy choices as opposed to those who do not.

COGNITIVE psychologists will try to study the thought processes of people. Their
beliefs - how they weigh up the odds, what are the pros and cons of making changes
to their lifestyle – who has strong internal belief and faith in themselves. There are
compelling and logical arguments for adopting a healthy lifestyle, however many of us
choose to ignore them. Why?

BIOPSYCHOLOGISTS will be more interested in the brain structure and genetics of
individuals and whether this links with them having certain personalities,
temperaments or abilities which makes them more prone to being overweight, or have
the type of personality which enables them to make life changes and believe they can
carry them through.
Theories of Health Belief
The Theories/Studies
1. Becker (1978) - Compliance with a Medical Regime for Asthma
2. Rotter (1966) - Internal versus External Locus of Control
3. Bandura and Adams (1977) - Analysis of Self-Efficacy Theory of
Behavioural Change
The main approach in this area is Cognitive psychology. It is interested in how people
think about health behaviours. There are many compelling and logical arguments for
adopting a healthy lifestyle, however many of us choose to ignore them.
17
1. Becker (1978) - Health Belief Model: Compliance with a medical
regime
Background- The Health Belief Model (HBM) is a tool that scientists use to try and predict
health behaviours. Originally developed in the 1950s, it is based on the theory that a person's
willingness to change their health behaviours is primarily due to the following factors:
Perceived Susceptibility - an individual's assessment of their risk of getting the condition.
People will not change their health behaviours unless they believe that they are at risk.
Perceived Severity - an individual's assessment of the seriousness of the condition, and its
potential consequences. The probability that a person will change his/her health behaviours to
avoid a consequence depends on how serious he or she considers the consequence to be.
Perceived Benefits - an individual's assessment of the positive consequences of adopting a
behaviour. It's difficult to convince people to change a behaviour if there isn't something in it
for them.
Perceived Barriers - an individual's assessment of the influences that facilitate or discourage
adoption of the promoted behavior) One of the major reasons people don't change their health
behaviours is that they think that doing so is going to be hard. Sometimes it's not just a matter
of physical difficulty, but social difficulty as well. Changing your health behaviours can cost
effort, money, and time.
The health belief model incorporates two more elements into its estimations about what it
actually takes to get an individual to make the leap. These two elements are cues to action and
self efficacy.
Cues to action are external events that prompt a desire to make a health change. They can be
anything from a blood pressure van being present at a health fair, to seeing a condom poster on a
train, to having a relative die of cancer. A cue to action is something that helps move someone
from wanting to make a health change to actually making the change.
Other constructs or mediating factors to consider, which were added later were; Demographic
variables (such as age, gender, ethnicity, occupation) Socio-psychological variables (such as
social economic status, personality, coping strategies) Health motivation (whether an individual is
driven to stick to a given health goal) Self-efficacy to be discussed separately.
18
Aim:
To use the health belief model to explain mothers’ adherence for their asthmatic children
Approach/Perspective (if any): Cognitive but includes social factors with demographic variables,
such as family size, education, occupation etc..
Type of Data: Quantitative
Method: A correlation between beliefs reported during interviews and the compliance with selfreported administration of asthma medication
Details: 117 mothers originally asked, 111 eventually agreed to take part. Respondents ranged in
age from 17 to 54 years and all but 7 were black. The children's ages ranged between 9 months
and 17 years.
The interview schedule, which required about 45 minutes to complete, dealt with the mother's
general health motivations and attitudes and her views about various aspects of asthma and its
consequences. Most questions were designed to provide measures of the HBM's dimensions.
They were asked questions regarding their perception of their child’s susceptibility to illness and
asthma, beliefs about its seriousness it’s interference with education and its interference with
their activities, whether it caused embarrassment or interfered with mothers activities. They
were also questioned about their faith in doctors and the effectiveness of the medication.
A covert evaluation of compliance was also made by drawing blood by finger stick and testing it
for the presence of theophylline, a substance basic to all of the drugs prescribed for asthma by
the cooperating physicians. Such objective verification of compliance was ultimately available for
80 (72 percent) of the 111 mothers. Their reports of medication administration were compared
with laboratory findings for the 80 children; a correlation of 0.913 was obtained, arguing for the
validity of the mother's statement as an additional indicator of compliance
Results;
A positive correlation between a mother’s belief about her child’s susceptibility to asthma
attacks and compliance to medical regimen was found.
There was also a positive correlation was also between the mother’s perception of the child’s
having a serious asthma condition and her administering the medication as prescribed.
Mothers who reported that their child’s asthma interfered with the mothers activities also
complied with the medication.
Costs negatively correlated with compliance (e.g. disruption of daily activities, inaccessibility of
chemists, the child complaining, and the prescribed schedule).
The demographic variable of marital status and education level correlated with compliance as
follows:
Married mothers were more likely to comply.
The greater the mother’s education the more likely she would be to adhere.
Conclusions:The HBM is a useful model to predict and explain different levels of compliance with
medical regimens
19
Evaluation: Issues
Evaluation: Debates
20
2. Rotter (1966) - Internal versus External Locus of Control
Background: Locus of Control is considered to be an important aspect of personality.
The concept was developed originally Julian Rotter in the 1950s
Locus of Control is a simple reductionist theory and refers to an individual's
perception about the underlying main causes of events in his/her life. Or, more
simply:
Do you believe that your destiny is controlled by yourself or by external forces (such
as fate, god, or powerful others)?
Rotter's view was that behaviour was largely guided by "reinforcements" (rewards
and punishments) and that through these; individuals come to hold beliefs about what
causes their actions. A locus of control orientation is a belief about whether the
outcomes of our actions are contingent on what we do (internal control orientation) or
on events outside our personal control (external control orientation)."
Thus, locus of control is conceptualised as referring to a unidimensional continuum,
ranging from external to internal:
External Locus of Control
Individual believes that
his/her behaviour is guided by
fate, luck, or other external
circumstances
Internal Locus of Control
Individual believes that
his/her behaviour is guided by
his/her personal decisions and
efforts.
People with a strong internal locus of control believe that the responsibility for
whether or not they get rewards/punishments ultimately lies with themselves.
Internals believe that success or failure is due to their own efforts. In contrast,
externals believe that things in life are controlled by luck, chance, or powerful
others. Therefore, they see little impact of their own efforts to change things.
Translated for health this means a person with high LOC will try to eat five portions
of fruit and veg a day and follow health advice but low LOC will they believe their
health is in someone else hands (doctors, parents fate religion) and fate will decide
whether they lice or die.
Therefore: Is Locus of Control a stable, underlying personality construct, (Nature)
or
Is Locus of control largely learned? (Nurture) There is evidence that, at least to some
extent, LOC is a response to circumstances. Some psychological and educational
interventions have been found to produce shifts towards internal locus of control (e.g.,
outdoor education programs.
21
Aim
Examines the degree by which individuals believe their health is controlled by
internal or external factors
Approach/Perspective
Cognitive Method
Review of six pieces of research into individuals perceptions of ability to control
outcomes based on reinforcement
Results
In the review P’s with internal LOC were more able to show behaviours that would
enable them to cope with a threat than those with an external LOC
Conclusions
Rotter concluede that LOC would effect many of out behaviours, not just health.
Also included summary by James et al. (1965) which found that smokers who give up
and did not relapse had a higher level of internal LOC than those who did not.
However, for women, where there was no significant difference between internal and
external LOC in those giving up instead other factors such as weight gain were
influential in giving up smoking. (Therefore indicating that LOC a factor in health
behaviours but other factors play a part).
Examples are: In health if a person gets ill do they believe they can control it, beat it.
Survive it. Many studies have shown that people who beat cancer have internal LOC
Wallston- Kaplon (1970) Internal LOC live longer after lung transplant.
Evaluation: Issues
Evaluation: Debates
22
3. Bandura and Adams (1977)- Analysis of Self-Efficacy Theory of
Behavioural change
Background: Self efficacy looks at a person's belief in his/her ability to make a health related
change. It may seem trivial, but faith in your ability to do something has an enormous impact on
your actual ability to do it. Thinking that you will fail will almost make certain that you do. In
fact, in recent years, self efficacy has been found to be one of the most important factors in
an individual's ability to successfully negotiate health changes.
Self-efficacy beliefs are cognitions that determine whether health behaviour change will
be initiated, how much effort will be expended, and how long it will be sustained in the
face of obstacles and failures. Self-efficacy influences the effort a person puts into
changing risk behaviour and the persistence to continue striving despite barriers and setbacks
that may undermine motivation.
Bandura points to four sources affecting self-efficacy;
Experience - "Mastery experience" is the most important factor deciding a person's selfefficacy. Simply put, success raises self-efficacy, failure lowers it.
Modeling - a.k.a. "Vicarious Experience" -“If they can do it, I can do it as well.” This is a
process of comparison between oneself and someone else. When people see someone succeeding
at something, their self-efficacy will increase; and where they see people failing, their selfefficacy will decrease. Modeling is a powerful influence when a person is particularly unsure of
him- or herself.
Social Persuasions
Social persuasions relate to encouragements/discouragements. These can have a strong
influence – most people remember times where something said to them significantly altered
their confidence. While positive persuasions increase self-efficacy, negative persuasions
decrease it.
Physiological Factors
In unusual, stressful situations, people commonly exhibit signs of distress; shakes, aches and
pains, fatigue, fear, nausea, etc. A person's perceptions of these responses can markedly alter
a person's self-efficacy. If a person gets 'butterflies in the stomach' before public speaking,
those with low self-efficacy may take this as a sign of their own inability, thus decreasing their
self-efficacy further, while those with high self-efficacy are likely to interpret such
physiological signs as normal and unrelated to his or her actual ability. Thus, it is the person's
belief in the implications of their physiological response that alters their self-efficacy, rather
than the sheer power of the response.
23
Aim:
To assess the self-efficacy of patients undergoing systematic desensitisation.
Approach: Cognitive
Type of Data: Quantitative and Qualitative
Method: A controlled quasi-experiment with patients with snake phobias.
A key concept Bandura identified as affecting behaviour is the efficacy expectation. This is
the belief that a person can successfully do whatever is required to achieve a desired
outcome. The key factors which affect a person’s efficacy expectation are:
Previous Experiences – how successful were you in the past e.g. quitting smoking
Vicarious experiences – The success of others
Verbal persuasion – Others telling you, you can do it
Emotional arousal – Too much anxiety (pressure) can reduce a person’s self-efficacy
In addition, cognitive appraisal of a situation might also effect expectations of personal
efficacy. Factors such as social, situational and temporal circumstances are contextual
factors that could influence such an appraisal. This means a person’s self-efficacy can alter
depending on the situation. Bandura cites the example of public speaking, and how the time,
audience, subject matter and type of presentation might all influence perceived coping
capabilities that represent self-efficacy. It is not simply down to personality traits.
Details: 10 snake phobic patients who replied to an advertisement in a paper (self-selected). 9
females and one male aged 19–57 years.
Pre-test assessment each patient was assessed for:



avoidance behaviour towards a boa constrictor.
fear arousal with an oral rating of 1–10.(self-report)
efficacy expectations (how much they thought they would be able perform different
behaviours with snakes-again self-report).
Systematic desensitisation – a standard desensitisation programme was followed where
patients were introduced to a series of events involving snakes and at each stage were taught
relaxation.
Post-test assessment. Each patient was again measured on behaviours and belief of selfefficacy in coping
Results: Higher levels of post-test self-efficacy were found to correlate with higher levels
of behaviour with snakes.
Conclusions: Desensitisation enhanced self-efficacy levels, which in turn lead to a belief that
the participant was able to cope with the phobic stimulus of a snake
24
Evaluation: Issues
Evaluation: Debates
25
Summary: Health Belief theories

A person’s lifestyle choices may be healthy or not healthy. They may choose to give
up smoking, eat healthily or exercise regularly.

There are many theories that would explain such choices, and the ones we have
looked at concentrate on the logical cognitive approach to such behaviour.

All the theories are linked, in that they are individual perceptions based on previous
information which might affect a person’s Locus of Control, their self-efficacy, and
how susceptible they think they are to ill-health.

These cognitive theories successfully explain how individuals might adopt one or more
behaviour, but not necessarily all of them.
26
Comprehension questions for theories of health belief
1.Becker (1978) - Compliance with a Medical Regime for Asthma

What is costs/benefits analysis?

What are demographic variables?

Why is the health belief model not reductionist?

What did Becker find in his research on parents of children with asthma

How did Becker improve the validity of the experiment?
2.Rotter (1966) Internal versus External Locus of Control

What are the two loci of control according to Rotter?

What did Rotter find out about people who felt they had control over the situation?

What did the research from James et al. find out?

Is Locus of control nature or nurture?

Describe an example of how LOC can explain a health behaviour?
3.Bandura and Adams(1977) Analysis of Self-Efficacy Theory of
Behavioural Change

What does self-efficacy mean?

What are the three factors that influence self-efficacy?

What factors might influence cognitive appraisal of a situation and affect
expectations of personal efficacy?

Who were the participants in Bandura’s study on self-efficacy?

What are the conclusions in Bandura’s study?
27
Part A exam question for theories of health belief

Describe self efficacy as a theory of health belief (10 marks)
Introduction
Linking sentence _____________________________________________________
Main body
Linking sentence _____________________________________________________
Conclusion
28
Part B exam question for theories of health belief

Discuss theoretical approaches to beliefs about health (15 marks)
Introduction
Linking sentence _____________________________________________________
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Linking sentence _____________________________________________________
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Linking sentence _____________________________________________________
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Linking sentence _____________________________________________________
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Linking sentence _____________________________________________________
Conclusion
29
Evaluation sheet for the Theories of Health Belief
Overview of topic:
__________________
__________________
__________________
__________________
Issue:
Issue:
Issue:
Debate:
Study 1
Researcher/s:
______________________
Study 2
Researcher/s:
______________________
Study 3
Researcher/s:
______________________
Key assumption:
______________________
Key assumption:
______________________
Key assumption:
______________________
Health Promotion
The Theories/Studies
1. Cowpe (1983) - Chip pan fire prevention
2. Dannenberg et al, (1993) - Legislation-Bicycle helmet laws and educational
campaigns
3. Janis & Feshbeck, (1953) - Effects of Fear arousal.
The main approach in this area is Cognitive psychology as it explores how communication
can be made persuasive enough for people to think differently about their health. The
Behavioural approach is also important as the reason behind change could be argued to be
due to imitation and social learning theory via media campaigns and fear arousal.
31
1.Cowpe (1989) - Media Campaigns: Chip-Pan Fire Prevention
Background: Television, adverts, posters and leaflets are all common means of getting
health messages across to the public.
Scottish media campaign on drink-driving showed that the numbers of people drinking at
home between Aug 2006 and Dec 2006 did not change significantly. There was, however,
a gradual decline amongst those who claimed to drink at home at least once a week
from73% to 71% not a great change but a move in right direction. Some campaigns do
not work as they result in change of attitude which does not result in a behavioural
change.
Occasionally campaigns in areas of health and safety can show effectiveness, e.g Cowpe
chip pan research.
Aim:
To test the effectiveness of an advertising campaign that demonstrated a procedure,
provided information, challenged perceptions about lack of ability to cope and
encouraged preventative actions.
Approach/Perspective :
Cognitive
Behavioural
Type of Data: Quantitative data (stats from fire brigade of actual fires)
Method: A quasi-field experiment (longitudinal) where a media campaign (12 week)
was shown in 10 regional television areas from 1976 to 1984. An analysis of the
number of chip pan fires reported between 1976 and 1982 plus two quantitative
consumer surveys in 1976 and 1983 were used to gather the data. (Repeated measures
design and P’s were interviewed after each campaign (condition)
Details: The campaigns were shown on television. Providing both information and fear
arousal.




There were two 60-second commercials, one called ‘in-attendance’ and one called
‘overfilling’.
These showed the initial cause of the fire and the actions required to put it out.
Slow motion and real time for effect
Three areas were shown reminders one year later. The number of reported chip
pan fires was analysed for each area
32
Results;
The net decline in each area over the twelve-month period of the campaign was
between 7% and 25%.
The largest reduction was during the campaign.
Overlap’ areas (areas that received two of the television stations) showed less impact.
The questionnaires showed an increase in the awareness of chip pan fire advertising
from 62% to 90%
People mentioning chip pan fires as a danger in the kitchen also increased in the
questionnaires from 12% to 28%
Conclusions:
• The advertising proved effective as shown by reduction in chip pan fires.
• The behaviour change is seen most during the campaign and reduces as time
passes after the end of the campaign. Thus there is a need to repeat periodically.
• The viewer is less likely to be influenced by the campaign if overexposed to it, as
in the overlap areas.
Evaluation: Issues
Evaluation: Debates
33
2. Dannenberg et al (1993)-Bicycle Helmet Laws and Educational
Campaigns
Background: Legislation is a law, or a set of laws that have been enacted by a legislative
body, which in our case is the Parliament at Westminster.
New laws are debated and passed by the British Parliament for a number of reasons,
including being part of the Government of the day’s manifesto promises, or as a
reaction to unfolding situations, for example terrorism or a natural disaster.
Health can be promoted through this manner for example, on the 1st July 2007
legislation was passed to ban smoking in all enclosed public places and workplaces in the
UK. On the 1st October 2007 the legal age for buying cigarettes increased to 18.
Legislation varies from country to country or state to state in the US in 2007 the max
blood alcohol level in the UK was 80mg per 100ml of blood. But the royal society for
prevention of accidents think it should be lowered particularly in young drivers as an
increase of just 20mg per 100ml has been shown to substantially increased the risk of
accidents in young drivers and legislation could reduce this risk.
The problem with any legislation is that it needs to be effective, would the laws be
obeyed if there was no chance of being caught? The police in 2007 needed evidence not
just a suspicion that they had been drinking to do a breathalyser.
How effective has the bam on smoking in public places been? What were its aims? Has
they been achieved?
A study by Dannenburg looked at legislation in Maryland USA to see how legislation
would compel young cyclists to wear helmets.
Aim: To review the impact of the passing of a law promoting cycle helmet wearing in
children
Approach/Perspective:
Cognitive
Behavioural
Type of Data:
Quantitative ( self-report questionnaires)
34
Method: Natural (quasi) field experiment as a law was passed in Howard County,
requiring children under 16 to wear helmets (Maryland, USA.) Children from 47 schools
in Howard County, and two control groups from Montgomery County and Baltimore
County, all in Maryland USA, They were aged 9–10 years, 12–13 years and 14–15 years.
In Montgomery County there was already a campaign to promote helmet use.
Independent design with each child naturally falling into one of the three counties.
(7332 children questioned)
Details: A questionnaire was sent using a four point Likert scale that asked about:
•
•
•
•
•
bicycle use.
helmet ownership.
awareness of law.
sources of information about helmets.
peer pressure.
Parents were asked to help the children complete to gain consent.
Results;
Responses to questionnaires were about 50% across the three counties.
Helmet ownership was higher amongst cycle owners and highest in younger age
groups.
In Howard County (the one with the law), reported usage had increased.
Howard County – 11.4% to 37.5%.
Montgomery County – 8.4% to 12.6%.
Baltimore County – 6.7% to 11.1%.
Conclusions:
Legislation has more effect than educational campaigns alone. Although a slight
rise in that county it was not significant from area where there was no campaign.
• This study was correlated with an observational study by Cote et al. in 1992,
which found similar rates of cycle helmet usage.
While not everyone adheres to the law (some people still drink and drive) adherence
cuts deaths and injuries significantly. In Maryland it is claimed that wearing helmets
will prevent 100 deaths and 56,000 hospitalisations each year.
•
35
Evaluation: Issues
Evaluation: Debates
36
3. Janis & Feshbeck (1953) - Effects of Fear Arousal
Both the risks of smoking and drink driving have addressed by fear arousal tactics.
Putting graphic images on packets of cigarettes and media campaigns that focus on the
severe health implications have been tried. On the whole they have little impact.
Why?
Psychologists suggest we become desensitised, we feel that it will happen to others, not
us.
Activity Consider the following images
They are all examples of different levels of fear appeals in relation to oral hygiene.
37
Using the following grid - decide what pictures fit into these categories.
You can only place a picture in one category
Minimal Fear
Appeal
Moderate Fear
Appeal
Strong Fear
Appeal
Which of these levels of fear arousal would be most effective in getting you to
improve your oral hygiene?
Give reasons for your answer:
38
3. Janis & Feshbeck (1953) - Effects of Fear Arousal
Aim: To investigate the consequences on emotions and behaviour of fear appeals in
communications
Approach/Perspective: Cognitive and behavioural
Type of Data: quantitative and qualitative
Method: lab experiment-independent design, with three experimental groups and one
control group.
Details:
•
•
•
•
•
•
•
Participants were 9th Grade students aged 14.0 to 15.11 years, mean age 15
years
A questionnaire was given one week before the lecture on health to ascertain
dental practices.
A fifteen minute illustrated lecture was presented to each group.
3 groups had a lecture on dental hygiene and the control group had a lecture on
the human eye.
Gp1. lecture had strong fear appeal, emphasising painful consequences of poor
dental hygiene, such as tooth decay and gum disease and statements such as ‘This
could happen to you!’. Gp2. moderate fear with little info on consequences factual
statements. Gp3 minimal fear appeal, neutral info on tooth decay and function
rather than consequences. Gp4. functioning of human eye.
Immediately after the lecture a questionnaire was given asking for emotional
reactions to the lecture.
One week later a follow-up questionnaire asked about longer term effects of the
lecture.
Results: The amount of knowledge on dental hygiene didn’t differ between the three
experimental groups.
The strong fear-appeal lecture was generally seen in a more positive light.
The strong fear-appeal group showed a net increase in conformity to dental hygiene
of 8% (measured by comparing the no. of recommended dental practises shown
before and after lecture -such as brushing for 3 mins)
The net increase in the moderate fear group was 22%.
The net increase in the minimal fear group was 36%.
The control group showed 0% change
Conclusions:
Fear appeals can be helpful in changing behaviours, but it is important that the level of
fear appeal is right for each audience. Note the minimal fear group was most effective.
There is several studies which used fear arousal. Leventhal et al. (1967) on smokers
who found that high fear arousal was more effective than middle or lower
contradictory to Fleshbeck.
39
Evaluation: Issues
Evaluation: Debates
40
Summary: Methods of Health Promotion

There may be ethical considerations in dictating or compelling behaviours for an
individual’s own benefit and perhaps individuals should make their own choices when
it comes to health.

It seems that a variety of health promotion methods can be effective in ensuring
healthy lifestyles, and one could argue that governments have a duty of care to
ensure that their citizens are as healthy as possible.
41
Comprehension questions for Health Promotion
1.Cowpe (1983)- Chip pan fire prevention

What was the aim of Cowpe’s research on chip pan fire prevention?

How long were the adverts shown for and what were they called?

How did they measure the success of the adverts?

What happened in ‘overlap’ areas?

Was the experiment thought to be effective, explain your answer?
2.Dannenberg et al, (1993)- Legislation-Bicycle helmet laws and
educational campaigns

What type of experiment was Dannenberg’s study?

Who were the sample and from where?

How did Dannenberg collect his data?

What did Dannenberg find?

What other study showed concurrent-validity with these results?
3.Janis & Feshbeck, (1953) -Effects of Fear Arousal

What type of research did Janis and Feshbech carry out?

What did the strong fear-arousal lecture contain?

Which group showed most increase in dental hygiene practices?

What did the control group experience?

When was the durability of the change in behaviour assessed?
42
Part A exam question for methods of health promotion

Describe one piece of research into media campaigning as a method of health
promotion (10 marks)
Introduction
Linking sentence _____________________________________________________
Main body
Linking sentence _____________________________________________________
Conclusion
43
Part B exam question for methods of health promotion

Discuss the ecological validity of research into methods of health promotion
(15marks)
Introduction
Linking sentence _____________________________________________________
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Linking sentence _____________________________________________________
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Linking sentence _____________________________________________________
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Linking sentence _____________________________________________________
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Linking sentence _____________________________________________________
Conclusion
44
Evaluation sheet for Methods of Health Promotion
Overview of topic:
__________________
__________________
__________________
__________________
Study 1
Researcher/s:
______________________
Study 2
Researcher/s:
______________________
Study 3
Researcher/s:
______________________
Key assumption:
______________________
Key assumption:
______________________
Key assumption:
______________________
Issue:
Issue:
Issue:
Debate:
45
Features of Adherence to Medical Regimes
The Theories/Studies
1. Bulpitt et al. (1988) - Reasons for non- adherence
2. Lustman et al. (2000) - Measures of non –adherence
3. Watt et al. (2003)- Improving adherence using behavioural methods
This area highlights that there are many factors which contribute to a person’s adherence
to a medical regime which range from social (the factors in a person’s life) to cognitive,
irrational thought processes about the drugs or therapies. Similarly when measuring
adherence this section looks at the social, and physiological methods employed and
examines which is more valid and reliable. Lastly, this section examines ways to improve
adherence which is important to improve health and save the NHS costs. Here it examines
a behavioural approach to encouraging adherence.
46
1.Bulpitt et al. (1988) - Reasons for Non-Adherence
Background: People do not arrive at medical appoints, do not follow treatment
programmes and frequently do not take medication WHY? Variety of reasons
People simply believe not in best interest- so stop, when begin to feel better stop
prescribed course, feel logical explanation for not continuing, althou’ docs would not
prescribe surplus medicine.
We need to consider why people do not adhere to medical advice, and this looks at
patients who have made a rational decision not to adhere. This means there is a logical
decision not to listen to medical advice. It may be linked to the HBM whereby the costs
outweigh the benefits, and the rational decision is not to continue with the medicine.
There are cases in the media where patients have refused potentially life-saving
treatments as the costs to their quality of life outweigh the less-than certain odds, of
prolonging life. Who is to say that is irrational?
Bulpitt’s study examined how males with hypertension (high blood pressure) weighed up
the costs of the medication and it’s side effects to the benefits of taking the
medication for their health.
Aim: To review the research on adherence in hypertensive (high blood pressure) patients
(adhere- means to stick to, remain, hold fast)
Approach/Perspective : Cognitive and Social
Type of Data: Qualitative approach
Method: Review Articles
Procedure: Research was analysed to identify the physical and physiological effects of
new drug treatments on a person’s life. These included work, hobbies and physical wellbeing.
Results; Drug did reduce headaches and depression compared to old drug but -side –
effects were: reduced circulation of blood leading to erectile dysfunction, sleepiness,
dizziness and also affected cognitive functioning, which affected work and hobbies.
Curb ( 1985) 85 males discontinued because of sexual problems
General medical council found 15% males withdrew due to side effects
Conclusions:
When costs side effects outweigh benefits less likely to adhere to treatments
Study in using qualitative approach gives insight into patients’ beliefs about medication
and how they weigh up the outcomes, confirming the cost-benefit analysis that patients
undertake before deciding to adhere to medical advice.
47
Evaluation: Issues
Evaluation: Debates
48
2. Lustman et al.(2000) - Measures of Non-Adherence
Background: Diff ways of measuring adherence and as in all psychological research no perfect
method.
1. Self –report- can lead to social desirability bias (not admit to not taking
medicine.(SUBJECTIVE)
2. Therapeutic outcomes- doc assess effect of medicine on p health (rough and ready
measurement of adherence) (SUBJECTIVE)
3. Pill and bottle counts and less reliable (SUBJECTIVE)
4. Mechanical methods- device for measuring how much medicine dispensed from container
(SUBJECTIVE) just because pill left bottle doesn’t mean been taken.
5. Record no. of repeat prescriptions
6. Biochemical methods- blood or urine tests (OBJECTIVE- reliable) but unlikely happen
every day in everyday life.
Study by Chung and Naya (2000) (Track cap)found that mechanical method was effective
however, need to consider whether being told compliance was being assessed may have
influenced patients.
Lustman showed how physical measurements such as blood sugar levels can indicate adherence to
regime necessary to control diabetes.
Glycohaemoglobin ( haemoglobin with glucose attached to it, GHb)levels will show the amount of
glucose in the blood. The regime a diabetic has to adopt changing diet and administering insulin
by injection should keep GHb levels normal. Therefore adherence can be measured by measuring
GHb levels.
Aim: To assess the efficacy of the anti-depressant fluoxetine in treating depression, by
measuring glycemic control
Approach/Perspective: Physiological and social
Type of Data: quantitative data (psychometric test and blood tests)
Method: A randomised controlled double-blind study (neither patients nor
experimenters know which is experimental group and which is control gp)
Details: 60 patients with type 1 or type 2 diabetes and diagnosed with depression
.Patients were randomly assigned to either fluoxetine or placebo groups. Patients were
assessed for depression using psychometric tests. Their adherence to their medical
regimen was assessed by measuring their GHb levels, which indicated their glycemic
control
Results;
Patients given the fluoxetine reported lower levels of depression. Patients given the
fluoxetine had lower levels of GHb, which indicated their improved adherence
Conclusions: Measuring GHb in patients with diabetes indicates their level of adherence
to prescribed medical regimes. Greater adherence was shown by patients who were less
depressed, and previous research has suggested that reducing depression may improve
adherence in diabetic patients.
49
Evaluation: Issues
Evaluation: Debates
50
3. Watt et al. (2003) - Improving Adherence using behavioural methods
Background: Many ways to improve adherence:







Reduce the costs so don’t outweigh the benefits.
Study demographic variables of HBM (e.g.
differences in males and females.)
How do perceptions of seriousness and
susceptibility influence adherence
Locus of control may influence (externals feel life
mapped out and medicines have no influence)
Emphasizing key info, and repeating instructions
and not using medical jargon (Ley 1973) worked
for elderly.
(Lewin 1992) give patients info and instructions
Behavioural strategies- use of reinforcement for
correct adherence.
Watt et al study used behaviourism and
reinforcement for correct adherence
thus a funhaler with a whistle and
spinner were used to reward children
for using inhaler correctly
Aim: Funhaler spacer – improving adherence without compromising delivery. To see if
using funhaler would improve children’s adherence to taking medication for asthma.
Approach/Perspective: Behavioural perspective.
Type of Data: Quantitative data through self-report
Method: Field and quasi (children with asthma) The experiment set up two conditions,
and then used self-report to measure the adherence rates.
Research: 32 Australian children (10 males and 22 females) aged from 1.5 to 6 years,
mean age 3.2 years. They had all been diagnosed with asthma and prescribed drugs
delivered by pressurised metered dose inhaler (pMDI). The parents gave informed
consent.
Each child was given the Breath-a-Tech to use for one week, and a questionnaire given for
the parents to complete. In the second week, the children used the Funhaler, and the
parents were given a matched questions questionnaire after the second week.
Results;
38% more parents were found to have medicated their children the previous day when
using the Funhaler compared to the existing
Conclusions:
Previous research had given reasons for non-adherence in children with asthma as
boredom, forgetfulness and apathy. The Funhaler set out to remedy this by reinforcing
correct usage of the inhaler with a toy that spins and a whistle that blows. This did
improve the adherence to the medication. So by making the medical regime fun, the
adherence, certainly in children, can be improved
51
Evaluation: Issues
Evaluation: Debates
52
Summary: Features of Adherence to Medical Regimes

Why do we adhere or not? There are many reasons.

There are also many ways to improve adherence?

It would be possible to use the HBM to explain why people do not adhere and also to
improve adherence.

This section has only touched on the plethora of idea, models and research into
adherence. Given the high cost of medication that is prescribed and NOT taken, in
addition the health costs of people not adhering to their regimes, the importance of
this area of health psychology can be seen not only in healthier patients, but less
wastage of resources.
53
Comprehension questions for Adherence
1.Bulpitt et al. (1988) - Reasons for non- adherence

What method did Bulpitt use for his research?

What were his findings?

What did they find that supported the health belief Model?

What were the general medical council’s findings?

Is this a situational explanation or individual?
2.Lustman et al. (2000) - Measures of non –adherence

What is GHb?

Lustman used a double blind study what does this mean?

What two methods were used to test for depression?

What were the findings?

What assumption is made about depression and adherence in this study?
3.Watt et al. (2003)-Improving adherence using behavioural methods

Who was the sample used in this study?

What technique did Watt et al. use to improve adherence?

What approach is this based on?

What are the strengths and weaknesses of using self-report to measure health
behaviour?

What were the conclusions of the study?
54
Part A exam question for Adherence to Medical Regimes
 Describe one way to measure non-adherence to medical advice (10 marks)
Introduction
Linking sentence _____________________________________________________
Main body
Linking sentence _____________________________________________________
Conclusion
55
Part B exam question for Adherence to Medical Regimes

Assess the reliability of research into non-adherence to medical advice (15 marks)
Introduction
Linking sentence _____________________________________________________
C
R
E
E
C/
C
Linking sentence _____________________________________________________
C
R
E
E
C/
C
Linking sentence _____________________________________________________
C
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C/
C
Linking sentence _____________________________________________________
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Linking sentence _____________________________________________________
Conclusion
56
Evaluation sheet for Features of Adherence to Medical Regimes
Overview of topic:
__________________
__________________
__________________
__________________
Study 1
Researcher/s:
______________________
Study 2
Researcher/s:
______________________
Study 3
Researcher/s:
______________________
Key assumption:
______________________
Key assumption:
______________________
Key assumption:
______________________
Issue:
Issue:
Issue:
Debate:
57
Topic 2 – Stress
1. Causes of stress and supporting evidence
 Work
 Hassles and life events
 Lack of control
2. Methods of measuring stress
 Physiological measures
 Self report
 Combined approach
3. Techniques for managing stress
 Cognitive
 Behavioural
 Social
58
Topic 2 – Stress
The first big question is what is
stress anyway? It is a term we
read about in the papers almost
daily. As a society we are
supposedly suffering from this
thing, it costs the country millions
of pounds a year in days off work
and stress related illness not to
mention broken marriages,
arguments and neglected children.
We tend to think of stress as something `out there`. Subjectively it feels as if there is
just too much to do, or too much being expected of us. We feel unable to cope and if it
goes on for too long we may even become ill.
50 years ago the term was not really used. People would get tired, they might have been
unhappy, but they probably would not have said they were stressed. Nowadays, however,
psychologists are interested in: What causes stress? Does the situations we are in cause
us to feel stressed or the people we are? How can we measure stress? By filling in
questionnaires or doing interviews can we get an objective measure or are only scientific
measurements a true and valid measure, and finally in order to safeguard people’s health
we need to investigate, How can we reduce or manage stress? If we make different
choices in life, can we reduce stress? And what techniques do psychologists favour when
helping people overcome stress. We might also ask whether stress is always a bad thing.
Is a lack of stress stressful?!
The stress experience is made up of stressors and the stress response.
Stressors = Stimuli that require a person to make some form of adaption or adjustment.
These may be external such as life threatening events such as an earthquake, life events
such as work, divorce or the minor hassles of day to day life such as being stuck in a
traffic jam or not finding a parking space, or internal, such as our feelings and thoughts
and our ability to cope with them, whether we feel in control of the situation. Stress is
therefore, the result of a mismatch between the demands of the situation and our ability
to cope with them.
59
Lazarus and Folkman (1984) defined stress as:“A pattern of negative physiological states and psychological responses
occurring in situations where people perceive threats to their well being which
they may be unable to meet.”
Stress consequently brings about a stereotyped set of biological and psychological
responses, this is the stress response. We are programmed to respond physically to
stress by producing adrenaline, which results in symptoms such as increased heart rate
and respiration and the closing down of functions not immediately vital such a digestion
(hence we often lose our appetite when stressed).
The Body’s Stress Response
The problem with this is, in today’s society when stressors happen on a daily basis, such as
financial worries or work worries that the constant production of adrenaline can attack
our immune system and reduce our ability to fight of disease. The UK and Health and
Safety Executive suggest that approx 1.4 million working days per year are lost due to
work-related stress! Therefore this topic introduces some of the influences that
psychologists have used to explain stress. In particular the causes of stress, methods for
measuring stress and how to manage it, in the hope that if we can understand health
behaviours and their antecedents, we can help people lead healthier lives, enhancing their
quality of life and also save society the cost of health care lost productivity
60
WHAT DO WE KNOW FROM AS?
Several studies or theories from AS Psychology may explain why individuals suffer stress:
 BANDURA (1961) was more interested in SITUATIONAL explanations, particularly
the idea that we might learn to behave in certain ways. This can be applied to feeling
stressed as here it is shown that situations; life events and hassles bring about stress
and our lack of control as an individual over the situation causes us to feel stressed.

GRIFFITHS (1994) studied cognitive styles – the way people perceive an event may
affect whether they get stressed from it.
HOW CAN WE APPLY THE APPROACHES AND PERSPECTIVES TO CRIME?

BEHAVIOURIST psychologists will try to look at the behaviour of people who suffer
from stress and discover what actions trigger stress, and then use various techniques
to overcome the stressful situation such as desensitization or flooding.

COGNITIVE psychologists will try to study the thought processes of people who
suffer from stress - how they weigh up the odds, cope with stress or how it affects
their everyday life.

BIOPSYCHOLOGISTS will be more interested in the genes and biological make up; are
some people more prone to stress and how then does the stress affect them
physiologically.

A theme that comes out of this unit is INDIVIDUAL vs SITUATIONAL Are some
people born with the propensity to get more stressed about life’s events and thus their
health suffers or is the situation people find themselves in no matter who they are,
that will cause stress.
61
Causes of Stress and supporting evidence
The Theories/Studies
1. Johansson (1978) - Stress in the Workplace
2. Kanner (1981) - Hassles and life events
3. Geer and Meisel (1972) - Lack of control
The first two studies examine the social influences in explaining what causes stress which
obviously stem from the social approach to psychology. However, only taking this view
would be reductionist, as the last study demonstrates, how we as individuals view the
stressors and feel about our ability to cope with them is explained in terms of the
cognitive and individual approaches. Therefore, when determining causes it is not only the
stressors in our lives, but the situation we are in and the person we are, which can affect
out stress levels.
62
1. Johansson (1978) - Stress and the Work place
Background: Stress is a biological response
to an external stressor/s
Biological response to the fight or flight
mechanism. The bodies stress response
causes an increase in blood pressure,
reduction in blood flow to the peripheral
blood vessels (hand and feet) and an increase
in adrenaline, noradrenalin and
corticosteroids to be released into the blood
stream. Over a long period of time this
stress response causes the body’s immune
systems to eventually break down.
Why is understanding stress useful:
Causes psychological problems like anxiety and depression.
Causes everyday physical illness like cough and colds by lowering the effectiveness of
the immune system.
Can cause heart disease and stroke by increasing build up of cholesterol.
May lead to illnesses like cancer
Causes millions of lost sick days from work
Causes accidents and injuries at work due to loss of concentration
Aim:
To measure the psychological and physiological stress response in two categories of
employees.
Approach/Perspective:
Cognitive
Physiological
Individual differences
Type of Data:
Quantitative –
Qualitative Method:
A quasi-experiment where workers were defined as being at high risk (of stress) or in a
control group.
An independent design with participants already working in one of the two categories, so
no manipulation of the independent variable.
63
Details:
24 workers at a Swedish sawmill. The researchers identified a high-risk group of 14
“finishers” in a Swedish sawmill. Their job was to finish off the wood at the last stage of
processing timber. The work was machine-paced, isolated, very repetitive yet highly
skilled, and the finishers’ productivity determined the wage rates for the entire factory
The 14 “finishers” were compared with a low-risk group of 10 cleaners, whose work was
more varied, largely self-paced, and allowed more socialising with other workers
Levels of stress-related hormones (adrenaline and noradrenaline) in the urine were
measured on work days and rest days They also gave self-reports of mood and alertness
plus caffeine and nicotine consumption. Body temperature was measured at the time of
urine collection. Self-rating scales of words such as ‘sleepiness’, ‘wellbeing’, ‘irritation’
and ‘efficiency’ were made on scales from none to maximal (the highest level the person
had ever experienced). Records were kept of stress-related illness and absenteeism
Results;
The high-risk group of 14 finishers secreted more stress hormones (adrenaline and
noradrenaline) on work days than on rest days, and higher levels than the control
group. The high-risk group of finishers also showed significantly higher levels of
stress-related illness such as headaches and higher levels of absenteeism than the
low-risk group of cleaners
In the self-report, the high risk group felt more rushed and irritated than the control
group. They also rated their well-being as lower than the control group.
% of adrenaline
compared to
baseline
Graph to show levels of adrenaline
in urine throughout the four
sample times
250
200
150
100
50
0
High Risk
Control
1
2
3
4
Urine Sample Time
Conclusions:
A combination of work stressors- especially repetitiveness, machine-pacing of work and
high levels of responsibility – lead to chronic (long-term) physiological arousal. This in
turn leads to stress-related illness and absenteeism.
If employers want to reduce illness and absenteeism in their workforce, they need to
find ways of reducing these work stressors, for example by introducing variety into
employees’ work and by allowing them to experience some sense of control over the pace
of their work.
64
Evaluation: Issues
Evaluation: Debates
65
2.Kanner et al.(1981) Daily Hassles & Uplifts- Comparisons of two
methods of stress measurement.
Background: Life event scales (SRRS) were devised to demonstrate how major life events such
as death, divorce, unemployment and severe illness can be used to calculate levels of stress and
consequently to predict illness (Holmes and Rahe 1967 -see measurements of stress for more
details). However even when we do not have extreme stressors like these we still end up feeling
stressed!
Some researchers have suggested that daily hassles lead to more stress, that is, minor hassles
can combine to become one large stress, and that these are a better predictor of health
problems than life events. Daily hassles are ‘irritating, frustrating, distressing demands that
to some degree characterise everyday transactions with the environment’ (Kanner 1981) – i.e.
the straw that broke the camel’s back!
Aim: To compare the Hassles and Uplift Scale and the Berkman Life Events Scale as
predictors of psychological symptoms of stress
Approach/Perspective : Cognitive and Social
Type of Data: Quantitative
Method: Longitudinal study using self-report and psychometric tests. 100 middle-aged
adults in California (mostly white, with adequate or above income, protestant and with at
least 9th grade education). Repeated design as participants completed both self-reports.
Procedure: All tests were sent out by post one month before the study began. The
participants were asked to complete:
•
•
•
The Hassles rating every month for nine months.
The Life Events rating after ten months.
The Hopkins Symptom Checklist (HSCL) and the Bradburn Morale Scale every
month for nine months. To assess their psychological symptoms of stress (Nine
subjects dropped out)
Results: It was found that the Hassles Scale was a better predictor of psychological
and physiological symptoms than were the life events scores. Hassles also seemed to
be consistent month on month. Life events for men correlated positively with hassles
and negatively with uplifts. For women, the more life events they reported, the more
hassles and uplifts reported. Hassle frequency correlated positively with psychological
symptoms on the HSCL The more hassles the participant reported the more symptoms
they reported.
Conclusions:
It was concluded that the assessment of daily hassles and uplifts may be a better
approach to the prediction of stress and ill health than the life events approach. Hassles
contribute to psychological symptoms whatever life events have happened.
66
Evaluation: Issues
Evaluation: Debates
67
3.Geer and Maisel (1972)- The Effect of control in reducing stress
reactions
Background:
Numerous studies show that job stress is far and away the major source of stress for
American adults and that it has escalated progressively over the past few decades.
Increased levels of job stress as assessed by the perception of having little control but
lots of demands have been demonstrated to be associated with increased rates of heart
attack, hypertension and other disorders. In New York, Los Angeles and other
municipalities, the relationship between job stress and heart attacks is so well
acknowledged, that any police officer who suffers a coronary event on or off the job is
assumed to have a work related injury and is compensated accordingly (including a heart
attack sustained while fishing on vacation or gambling in Las Vegas). Geer and Maisel
wanted to investigate the idea that one of the most stressful things we can experience is
that feeling of having absolutely no control over our situation.
Aim: To see if perceived control or actual control can reduce stress reactions to averse
stimuli - photos of crash victims.
Approach/Perspective: Physiological
Type of Data: Quantitative
Method:
Laboratory experiment 60 psychology undergraduates from New York University.
Independent design as participants were randomly assigned to one of three conditions.
Their stress levels were measured using galvanic skin response and heart- rate electrodes
Details:
Group 1: were given control over how long they looked at the images for. They could press
a button to terminate the image and were told a tone would precede each new image.
Group 2: Were warned the photos would be 60 seconds apart they would see the picture
for 35 seconds and a 10 second warning tone would precede each photo. The group had no
control but did know what was happening.
Group 3: were told that from time to time they would see photos and hear tones but were
not given timings or any control.
Procedure: each participant was seated in a sound proofed room and wired up to the GSR
and ECG machines. The machine was calibrated for 5 minutes while the participant
relaxed and a baseline measurement was then taken. Instructions were read over an
intercom. Each photo was preceded with a 10 second tone and then flashed up for 35
seconds (only the one group could terminate the photo and move on).
68
The GSR was taken at the onset of the tone and during the second half of the tone and in
response to the picture.
Results;
ECG recordings were discarded as they appeared inaccurate.
Group 2 showed most stress.
Group 1 showed least stress.
Conclusions:
That having control over your environment can reduce stress responses.
Evaluation: Issues
Evaluation: Debates
69
Summary: Causes of Stress

Each of us would probably realise that a cause of Stress for one person may not be a
cause of stress for another.

Some people in high-powered jobs seem to thrive on the pressure, while others would
seem to burn out and show signs of physical and /or mental illnesses.

Individual differences are a major problem for any researcher looking at stress.

Cultural norms and expectations can influence how stressful events might be: this
means that ethnocentrism is also an issue psychologists need to consider.
70
Comprehension questions for Causes of Stress
1.Johansson (1978) - Stress in the Workplace

What are stressors?

What does adrenaline attack?

Where did Johansson carry out his research?

What type of experiment did Johansson carry out?

What happened to the adrenaline levels of the high-risk group throughout the day?
2.Kanner (1981) – Daily hassles and life events

What are daily hassles?

Who were the sample and what limitations does this impose on the result

What issues might arise with it being self-report?

What were the three variables correlated?

What are the strengths and weaknesses of the longitudinal method?
3.Geer and Meisel (1972) - Lack of control

What was the aim of Geer and Meisel’s research?

Group 2 was yoked to Group 1. What does this mean?

Who was the sample in this study and what limitations could they impose on study?

How the stress measured and what was good and bad about this method?

Why was each recording performed in a sound and electrically-shielded room?
71
Part A exam question for Causes of Stress

Describe one piece of research which considers work as a source of stress (10 marks)
Introduction
Linking sentence _______________________________________________
Main body
Linking sentence ______________________________________________
Conclusion
72
Part B exam question for Causes of Stress
Discuss problems of conducting research into the causes of stress (15 marks)

Introduction
Linking sentence_______________________________________________
C
R
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C/
C
Linking sentence__________________________________________________
C
R
E
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C/
C
Linking sentence_______________________________________________
C
R
E
E
C/
C
Linking sentence______________________________________________
C
R
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C/
C
Linking sentence _______________________________________________
Conclusion
73
Evaluation sheet for the Causes of Stress
Overview of topic:
__________________
__________________
__________________
__________________
Study 1
Researcher/s:
______________________
Study 2
Researcher/s:
______________________
Study 3
Researcher/s:
______________________
Key assumption:
______________________
Key assumption:
______________________
Key assumption:
______________________
Issue:
Issue:
Issue:
Debate:
74
Methods of Measuring and Stress
The Theories/Studies
1. Geer & Maisel (1973) Physiological Measures
2. Holmes & Rahe (1967) Self-report
3. Johannson (1978) Combined approach
There are various ways in which psychologists measure stress which we have
touched on in the last section: using physiological measures to assess the
biological reaction; asking people to assess their own stress levels or stressors
is also used. Of course there are methodological problems with both of these.
Here we are going to look at them in more detail, examining the physiological
approach against the social approach, investigate their methodological issues
and then ask whether a better way may be to combine them to create a more
holistic approach.
75
1.Geer and Maisel (1972)-Physiological Measurements of Stress.
Background: Physiological measures of stress can overcome the subjectivity of the selfreport by relying on scientific measurements of hormones, chemicals, heart rate and
blood pressure etc. the main problem with these is the validity. How can we be sure that
we are truly measuring stress levels. Think about other factors which can cause
physiological changes which can mimic stress reactions, caffine, recreational drugs or
alcohol.
Stress can be measured physiologically by any device that measures levels of arousal.
Adrenaline causes increased blood pressure which can be measured. Goldstein (1992)
found that paramedics had higher blood pressure during ambulance runs compared to at
home.
Galvanic Skin Response (GSR) measures the electrical resistance of the skin which is an
indicator of the level of arousal in the nervous system. Good for labs but not normal life.
Sample tests of Blood or Urine which can test the hormone level on the body secreted
through these. Lundenberg (1976) commuters on train higher levels of hormone secreted
on crowded short journey than long less crowded ride.
Aim: To see if perceived control or actual control can reduce stress reactions to aversive
stimuli (photos of crash victims).
Approach: Physiological
Type of Data: Quantitative
Method: Laboratory experiment 60 psychology undergraduates from New York University.
Independent design as participants were randomly assigned to one of three conditions.
Details: Each participant was seated in a sound-shielded room and wired up to galvanic
skin response (GSR) and heart-rate monitors. The machine was calibrated for 5 minutes
while the participant relaxed and a baseline measurement was then taken. Instructions
were read over an intercom. Each photo was preceded with a 10 second tone and then
flashed up for 35 seconds (only the one group could terminate the photo and move on).
The GSR was taken at the onset of the tone and during the second half of the tone and in
response to the picture.
Group 1: were given control over how long they looked at the images for. They could press
a button to terminate the image and were told a tone would precede each new image.
Group 2: Were warned the photos would be 60 seconds apart they would see the picture
for 35 seconds and a 10 second warning tone would precede each photo. The group had no
control but did know what was happening.
Group 3: were told that from time to time they would see photos and hear tones but were
not given timings or any control.
76
•
•
•
•
A Beckman Model RB polygraph was used to collect psycho-physiological data.
The data was converted from a voltmeter to a printout.
Each recording was performed in a sound and electrically-shielded room to ensure
no audio or visual input from the projector would interfere with the data collection.
The heart monitors were attached in standard positions, and the GSR electrodes
were placed between the palm and forearm of the participants’ non-preferred arm
e.g. left arm for right-handed people.
Results; The predictability group (Group 2) were most stressed by the tone as they
knew what was coming, but did not have control over the photograph.
The control group (Group 1) were less stressed by the photograph than the
predictability group and no-control group (Groups 1 and 2) as they had control.
Conclusions: Participants showed less GSR reaction, indicating less stress, when they
had control over the length of time they could look at the disturbing photographs. It
is likely that being able to terminate aversive stimuli reduces the stressful impact of
those stimuli.
Evaluation: Issues
Evaluation: Debates
77
2. Holmes and Rahe (1967) Self–Report Measures: Life Events as
Stressors.
Background: Self-report methods include questionnaires, interviews and diary keeping.
Holmes and Rahe used self-report measure with their Social Readjustment Rating Scale (SRRS).
This looked at life events that have occurred in a person’s life and rates their importance. The
readjustments need to cope with these life events causes stress, so the more life events you
have to cope with the more stressed you are.
Aim: Creating a method that estimates the extent to which life events are stressors
Approach: Social
Type of Data: Quantitative
Method: In the correlation there was an independent design. A questionnaire designed
to ascertain how much each life event was considered a stressor with 394
participants’ 179 males and 215 females, from a range of educational abilities, races
and religions.
Details:
 Holmes and Rahe examined the medical records of 5,000 patients (all American
service men). From these, they put together a list of 43 life events which seemed
to precede (come before) illness.
 394 subjects (179 males and 215 females) from range of educational abilities and
ethnic groups and religions took part.
 Each participant was asked to rate the series of 43 life events. Rating should be
based on personal experience and perceptions of other people’s experience. The
amount of readjustment and the time it would take people to readjust were to be
considered
 They were told that ‘marriage’ had been given an arbitrary value of 50. The
participants then had to give a number to each of the other life events, indicating
how much readjustment they’d involve relative to marriage.
 Death of a spouse was judged (on average) to require twice as much readjustment
as marriage.
 The resulting values became the weighting (numerical value) of each life event.
 The amount of life stress a person has experienced in a given period (e.g. 12
months) is measured by the total number of life change units (LCUs).
 These units are calculated by adding the mean values (in the right hand column of
the table on the next page) associated with the events the person has
experienced during that time. The ranks (left hand column) simply denote the
order in which the life events appear in the SRRS.
78
Most life events were
judged to be less
stressful than getting
married.
But 6, including death
of a spouse, divorce and
personal
injury
or
illness were rated as
more stressful.
Holmes
and
Rahe
found that people with
high LCU scores for
the preceding year
were
likely
to
experience some sort
of physical illness the
following year.
For example, someone
scoring over 300 LCU s
had about an 80%
chance of becoming ill.
Results: Correlations between groups were tested and found to be high
in all but one group.
Males and females agreed. Participants of different ages, religions,
educational level agreed.
There was less correlation between white and black participants.
Conclusions: The events chosen are mostly ordinary (although some are
extraordinary. E.g. going to jail, but they do pertain to the western way
of life). There is also some socially desirable events which reflect
western values of materialism, success and conformism. The degree of
similarity between groups is impressive and shows agreement in general
at what constitutes a life event and how much they cause stress.
Holmes and Rahe concluded that stress could be measured objectively as
an LCU score. This, in turn, predicts the person’s chances of becoming
ill (physically and / or mentally) following the period of stress. Stress
and illness are not just correlated. Stress actually makes us ill.
79
Evaluation: Issues
Evaluation: Debates
80
3.Johansson et al.(1978) Combined Approach: Measurement of Stress
Response.
Background: The combined approach used both physiological and self-report can give us the
objectivity of scientific measurements and rich qualitative data that helps understand
behaviours such as stress.
Aim: To measure the psychological and physiological stress response in two categories of
employees.
Approach: Physiological and Cognitive (psychological)
Type of Data: Quantitative and Qualitative
Method: A quasi-experiment where workers were defined as being at high risk (of
stress) or in a control group. An independent design with participants (24) already
working in one of the two categories, so no manipulation of the independent variable. The
high-risk group (14 ) were classified as having jobs which were repetitive and
constrained, little control of pace or work routine, more isolated and having more
responsibility
Details: Each participant was asked to give a daily urine sample when they arrived at
work and at four other times during the day so that their adrenaline levels could be
measured This is a physiological measure. Body temperature was also measured at the
same time. These measures gave an indication of how alert the participants were
These measures were combined with a self-report where each participant had to say
how much caffeine and nicotine they had had since the last urine sample. They also had
to rate a list of emotions and feelings such as sleepiness, wellbeing, calmness, irritation
and efficiency. These were on a continuum from minimum to maximum and on a mm
scale. The score was how many mm from the minimum base point they had marked
themselves to be feeling. The baseline measurements were taken at the same time on a
day when the workers were at home.
This combined method of physiological measures and self-reports gave some good
qualitative and quantitative data, which enabled Johansson et al. to compare the two
groups, but have some understanding of the impact of higher stress levels on the
participants
Results; The high-risk group had adrenaline levels twice as high as their baseline and
these continued to increase throughout the day.
The control group had a peak level of 1 ½ times baseline level in the morning and this
then declined during the rest of their shift.
In the self-report, the high-risk group felt more rushed and irritated than the
control group. They also rated their wellbeing lower than the control group.
Conclusions: The repetitive, machine-paced work, which was demanding in attention to
detail and was highly mechanised, contributed to the higher stress levels in the high-risk
group.
81
Evaluation: Issues
Evaluation: Debates
82
Activity
Fill in the following table: Explanation
Strengths
Limitations
Self-Report
Physiological
Combined
83
Summary: Measurements of Stress

As with measuring any behaviour, each method has its strengths and
weaknesses, yet if psychology aspires to be accepted as a science we must
acknowledge the objectivity of scientific methods.

Just measuring chemicals or physiological responses will yield less
information than the more qualitative data that self-report techniques can
give us.

Rich qualitative data can help us understand behaviours such as stress.

Perhaps the combined approach is the most useful, though it may be most
costly in terms of resources and time.
84
Comprehension questions for Measurements of Stress
1.Geer & Maisel (1973) - Physiological Measures

What is a galvanic skin response?

What is the link between stress and galvanic skin response?

Why were the heart rate monitors placed in a standard position?

What are the strengths of obtaining Objective data?

What variables could affect the validity of the results?
2.Holmes & Rahe (1967) - Self-report

What are the strengths and limitations of using self-report?

Consider why these may be particularly relevant to asking people about their
stress?

Consider how valid these results will be?

How will individual /situational debate link with this method?
3.Johannson (1978) - Combined approach

What is the combined approach when measuring stress?

Which two measures did Johansson use?

How valid were these results?

How does this methods link to the reductionism/holism approach?
85
Part A exam question for Measurements of Stress

Outline one piece of evidence which suggests that stress can be caused
by hassles and/or life events (10 marks)
Introduction
Linking sentence_______________________________________________
Main body
Linking sentence _______________________________________________
Conclusion
86
Part B exam question for Measurements of Stress

Evaluate the reliability of methods of measuring stress (15marks)
Introduction
Linking sentence
_____________________________________________________
C
R
E
E
C/
C
Linking sentence ______________________________________________
C
R
E
E
C/
C
Linking sentence _______________________________________________
C
R
E
E
C/
C
Linking sentence _______________________________________________
C
R
E
E
C/
C
Linking sentence ______________________________________________
Conclusion
87
Evaluation sheet for Measurements of Stress
Overview of topic:
__________________
__________________
__________________
__________________
Study 1
Researcher/s:
______________________
Study 2
Researcher/s:
______________________
Study 3
Researcher/s:
______________________
Key assumption:
______________________
Key assumption:
______________________
Key assumption:
______________________
Issue:
Issue:
Issue:
Debate:
88
Techniques for Managing Stress and Supporting Evidence
The Theories/Studies
1. Cognitive: SIT (Michenbaum 1975)
2. Behavioural: Biofeedback. (Budzynski 1973)
3. Social: social support (Waxler-Morrison 2006)
The social, behavioural and cognitive approaches all view the physiological
symptoms of stress as emerging because of different stressors. Therefore, we
will examine three techniques for managing stress, each based on one of the
above approaches. All have credence and all have been validated by empirical
research although there are others which are just as reputable.
89
1. Meichenbaum (1975) - Cognitive: Stress Inoculation Therapy
Background: Meichenbaum’s assumption is that stress is caused by faulty processing of
information. Therefore, stress inoculation therapy assumes that people sometimes find
situations stressful because they think about them in catastrophising ways and the aim of the
therapy is thus to train people to cope more effectively with potentially stressful situations.
SIT is a psychotherapy method intended to help patients prepare themselves in advance to
handle stressful events successfully and with a minimum of upset. The use of the term
"inoculation" in SIT is based on the idea that a therapist is inoculating or preparing patients to
become resistant to the effects of stressors in a manner similar to how a vaccination works to
make patients resistant to the effects of particular diseases.
It is similar to hardiness and has three stages.
1. Cognitive preparation (or conceptualisation) involves the therapist and patient exploring
the ways in which stressful situations are thought about. Typically, people react to
stress by offering negative self-statements like 'I can't handle this'. This makes the
situation worse. A key part of what needs to be communicated in the SIT
conceptualization stage is the idea that stressors are creative opportunities and puzzles
to be solved, rather than mere obstacles. Patients are helped to differentiate between
aspects of their stressors and their stress-induced reactions that are changeable and
aspects that cannot change, so that coping efforts can be adjusted accordingly.
2. Skill acquisition and rehearsal, attempts to replace negative self-statements with
incompatible positive coping statements. These are then learned and practised. A variety
of emotion regulation, relaxation, cognitive appraisal, problem-solving, communication and
socialization skills may be selected and taught on the basis of the patient's unique needs.
3. Application and follow through involves the therapist guiding the person through
progressively more threatening situations that have been rehearsed in actual stressproducing situations. The patient may be encouraged to use a variety of simulation
methods to help increase the realism of coping practice, including visualization exercises,
modeling and vicarious learning, role playing of feared or stressful situations, and simple
repetitious behavioural practice of coping routines until they become over-learned and
easy to act out. Initially the person is placed in a situation that is moderate to cope with.
Once this has been mastered, a more difficult situation is presented.
90
Technique
•
•
•
Cognitive Behavioural
Technique
Gets people to analyse
and evaluate the
effectiveness of their
coping strategies
Teaches new coping
strategies e.g. positive
visualisation /relaxation
Strengths
•
•
•
•
•
Effects can be long
lasting
Good if stressor is
specific e.g. exams
Can be generalised to
new situations
Improves perceived
control and self efficacy
Non -invasive
Limitations
•
•
•
•
Time consuming
Needs high levels of
commitment
Therapists are
expensive
Not effective with very
high levels of stress or
more generalised stress
Aim: Standard behavioural measures have tried to help people become desensitised to
stress. Meichenbaum compared these standard behavioural methods with cognitive ones.
Cognitive therapy sessions aimed at enabling people to identify their stressors and
change their mental processes when under stress rather than just their behaviours.
Approach/Perspective: Cognitive
Type of Data: Qualitative
Method: It was a field experiment with participants put into three groups, SIT,
standard desensitisation and a control group. Each participant was tested using a test
anxiety questionnaire and grade averages before and after treatment. It was a blind
situation in that the people assessing them did not know which condition they had
been in. Matched pairs design with random allocation to groups and gender controlled
in each group.
Details: 21 students ages 17 – 25 responded to an advert about treatment of test
anxiety.
The SIT group received 8 therapy sessions giving them insight into their thoughts
before tests. They were then given some positive statements to say and relaxation
techniques to use in test situations. The systematic desensitisation groups were also
given 8 therapy sessions with only progressive relaxation training whilst imaging
stressful situations. The control group were told they were on a waiting list for
treatment.
Results; Findings: performance in tests in the SIT group improved the most although
both therapy groups showed improvement over the control groups
The significant difference was between the two therapy groups and the control
group.
Participants in the SIT group showed more reported improvement in their anxiety
levels, although both therapy groups showed overall improvement compared to the
control group.
Conclusions: Conclusions: that SIT is an effective way of reducing anxiety in students
who are prone to anxiety in test situations and more effective than simply behavioural
techniques when cognitive component is added in.
91
Evaluation: Issues
Evaluation: Debates
92
2.Budzynski et al (1970)-Behavioural: Biofeedback
Background: A different approach to stress reduction is seen in biofeedback, which has a
behavioural perspective. One aspect of the behavioural approach is the idea that
consequences of behaviour can lead to it being repeated or not (reinforcement). If
something is pleasurable or rewarding we are more likely to repeat it.
Simply put, biofeedback is a means for gaining
control of our body processes to increase relaxation,
relieve pain, and develop healthier, more
comfortable life patterns.
Biofeedback gives us information about ourselves by
means of external instruments. Using a thermometer
to take our temperature is a common kind of
biofeedback. Clinical biofeedback follows the same
principle, using specialized instruments to monitor
various physiological processes as they occur.
Moving graphs on a computer screen and audio tones that go up and down "reflect" changes
as they occur in the body system being measured. Biofeedback training familiarizes us with
the activity in our various body systems so we may learn to control this activity to relieve
stress and improve health. Trying to change physiological activity without biofeedback is
like playing darts while blindfolded - we can't see whether we are hitting the mark or not.
Biofeedback lets us know precisely when we are changing our physiologies in the desired
direction.
Biofeedback is not a treatment. Rather, biofeedback training is an educational process for
learning specialized mind/body skills. Learning to recognize physiological responses and
alter them is not unlike learning how to play the piano or tennis - it requires practice.
Through practice, we become familiar with our own unique psychophysiological patterns and
responses to stress, and learn to control them rather than having them control us.
By giving visible or audible feedback on the state of the body it is assumed that we would
be more likely to repeat the method of reducing stress. This is the method used by
Budzynski et al.’s (1970) research on patients with tension headaches. These headaches are
thought to be caused by sustained contraction of the scalp and neck muscles. Which is
associated with stress, therefore by relaxing the muscles (reducing the stress response),
the headaches should be reduced.
93
Technique
Biofeedback
Become aware of
physiological response
(e.g. heart rate) –
machines can be used to
provide feedback
 Learn to control this
response (e.g. deep
breathing)
 Apply this control in
everyday situations

Strengths
•
•
•
•
Non-invasive
No side effects
(compared to drugs)
Gives individual control
over stress response
Reduction in blood
pressure etc can be
long term
Limitations
•
•
•
May need expensive equipment
and trained staff
Requires effort and
commitment from patient – not
easy to learn
Behavioural techniques are
based on studies with animals
e.g. rats and may not
generalise to human learning
Aim: to see if biofeedback techniques work and help reduce tension headaches or whether
the effect is due to the placebo effect. The placebo effect is a positive psychological
effect that can occur even when there is no actual treatment.
Approach/Perspective : Behavioural
Type of Data: Quantitative
Method: Experimental method with patients trained in the laboratory. Data was collected
using muscle tension measurements (EMG) with an electromyography, a machine which
gives feedback by a graph by applying electrodes to the muscles. Patients were also given
a psychometric test for depression (MMPI) and asked to complete questionnaires on their
headaches. It was an independent measures design with participants randomly assigned to
one of three groups.
Details: Participants: 18 replied to a newspaper advert in the USA. They were screened
by telephone and then had psychiatric and medical examinations to ensure there were no
other reasons for their headaches. There were 2 males and 16 females aged 22-44 with a
mean age of 36.
 Group A had real biofeedback training with relaxation using the EMG
 Group B had biofeedback training but with false (pseudo) feedback
 Group C were used as a control group
Procedure: all groups kept a diary of their headaches for two weeks, rating them from 0
mild to 5 severe. Groups A and B were told to practice relaxation after the training for
15 – 20 mins each day.
Results: After 3 months group A’s muscle tension was significantly lower than the other
two groups. Reporting of headaches in group A also fell significantly compared to their
base line which it did not in the other two groups.
Follow up: after 18 months where 4 were contacted, 3 reported very low headache
activity and the fourth reported some reduction.
Conclusions: Biofeedback is an effective way to reduce stress levels by reducing tension
therefore effective method of stress management.
Relaxation techniques are more effective than just being monitored but better with
biofeedback.
94
Evaluation: Issues
Evaluation: Debates
95
3.Waxler-Morrison et al (1993) - Social: Relationships and Cancer survival
Background :The last technique is less of an intervention than a social situation. Having
close friends and family on whom you can count has far-reaching benefits for your health.
It doesn't take a scientific study to show that surrounding yourself with supportive
family, friends and co-workers can have a positive effect on your mental well-being, but
there's plenty of research to confirm it. A strong social support network can be critical
to help you through the stress of tough times, whether you've had a bad day at work or a
year filled with loss or chronic illness.
Support networks are used for a variety of problems: slimming clubs, Alcoholics
Anonymous, cancer clubs are all ways in which people with problems can increase their
social support.
Waxler-Morrison et al’s (1993) research into women with breast cancer and their survival
rates showed that support networks can increase the positive outcome of survival after
breast cancer. Sklar and Amisman (1981) reviewed a large body of literature which
concluded that cancer growth is amplified by stress and therefore it could be determined
that by reducing this stress with social support this must have positive outcomes for
those suffering from cancer.
However, as we have seen there are always many factors involved in human behaviour and
taking the reductionist approach of only giving one explanation or assuming one technique
is responsible is too simplistic and doesn’t encompass the complexities of humans and our
activities.
Cancer Support Networks
96
Technique


Strengths
People with strong
support networks
suffer less stress and
have better health


Specific support
networks can be set up
e.g. cancer clubs, selfhelp groups



Limitations
Effects can be long lasting 
Good if stressor is specific
e.g. cancer/bereavement

Improves perceived control
and self efficacy
Non –invasive

Inexpensive often relies on
volunteers
People may resist being
helped in this way
Dependent on quality and
availability of support
network
Can’t necessarily be
generalised to new
situations
Aim: To look at how a woman’s social relationships influence her response to breast cancer and
survival.
Approach: Social
Type of Data: Quantitative and Qualitative
Method: A quasi-experiment with women who were diagnosed with breast cancer. Using
questionnaires and some (18) interviews, plus examination of medical records. The women
naturally fitted into categories based on their existing social support networks
Details: 133 women under 55 years who were referred to a clinic in Vancouver with breast
cancer
Patients were mailed a self-administered questionnaire to gather information on their
demography and existing social networks. Questions included their educational level, who they
were responsible for (e.g. children), contact with friends and family, perception of support from
others, and a psychometric test of social networks that combined martial status, contact with
friends and family and church membership.
Details of their diagnosis were taken from their medical records between June 1980 and May
1981, survival and recurrence rates were checked in their medical records in January 1985.
Results: Six aspects of social network were significantly linked with survival. These were:
marital status, support from friends, contact with friends, total support, social network and
employment.
The qualitative data from the interviews showed that practical help such as childcare, cooking
and transport to hospital were the concrete aspects of support.
Married women who survived tended to report supportive spouses. Jobs were seen as
important, even if they were not financially important, as they were a source of support and
information.
Conclusions: The prospective aspect of the study: choosing a sample, assessing social
networks and then waiting to see outcomes for patients, removed the biases of retrospective
studies.
Several characteristics of the women’s social networks, including marriage and employment
status are significantly related to survival, so the conclusion is that the more social networks
and support, the higher the survival rate of women with breast cancer. Although it is
acknowledged that the main factor influencing survival is still the state of cancer at the time
of diagnosis, with nodal status and clinical stage of cancer being significantly linked with
survival
97
Evaluation: Issues
Evaluation: Debates
98
Summary: Managing Stress

Remember stress is not necessarily a bad thing! Stress is blamed for a
whole range of physical illnesses and psychological disorders. It is said to be
costing industry vast sums of money in absence from work and poor
performance at work. Stress is now pictured almost exclusively in
negative terms. But, it is important to remember that the stress response
is a valuable survival mechanism which motivates people. It warns of a
threat in the environment and galvanises the individual to take action and
deal with the situation. But, many of the techniques of stress management
are designed to calm people down and subdue the stress response.

Stress is also motivational, without a bit of stress in our lives many of us
would not perform at our best. E.g. Stage fright and performance anxiety
often bring out the best in people.

It appears that there is no one cause of stress and no uniform reaction to
stress; it is difficult to measure it accurately, and there are many stress
reduction techniques, all of which can claim some success, as least on the
participants in the supporting research.

It is perhaps one of the joys of being human, that no one can explain our
behaviour; we are complex animals and we need to have a variety of tools at
our disposal to explain, measure and treat atypical behaviour. However, we
would have to ask: is being stressed atypical?
99
Comprehension questions for Managing of Stress
1.Michenbaum (1975) Cognitive :SIT.

What was the design in Michenbaum’s study?

What is the assumption of the cognitive approach adopted by Michenbaum?

What are the three stages of the stress inoculation therapy?

Explain what the happened to the group who underwent systematic
desensitisation?

What were the findings and how did they know SIT was effective?
2.Budzynski (1973) Behavioural : Biofeedback.

Which two approaches are combined in biofeedback?

What was the aim of Budzynski et al.’s research?

What does the term ‘placebo’ mean?

What is pseudo-biofeedback?

How did Budzynski overcome the ethical problem of treating only one group?
3.Waxler-Morrison (2006) Social: social support.

How was the information gathered and how might this affect the validity of
the study?

What is an advantage and disadvantage of the kind of data collected?

This was a prospective study what does this mean and why does this remove
bias?

What were the results?

How would it be suggested that someone manage stress on a daily basis?
100
Part A exam question for Managing of Stress

Describe one cognitive technique for managing stress (10 marks)
Introduction
Linking sentence _____________________________________________
Main body
Linking sentence ______________________________________________
Conclusion
101
Part B exam question for Managing of Stress

Discuss whether stress should be managed by treating the individual or their
situation (15 marks)
Introduction
Linking sentence ______________________________________________
C
R
E
E
C/
C
C
R
E
E
C/
C
Linking sentence ______________________________________________
Linking sentence______________________________________________
102
C
R
E
E
C/
C
C
R
E
E
C/
C
Linking sentence _______________________________________________
Linking sentence _____________________________________________
Conclusion
103
Evaluation sheet for Managing of Stress
Overview of topic:
__________________
__________________
__________________
__________________
Study 1
Researcher/s:
______________________
Study 2
Researcher/s:
______________________
Study 3
Researcher/s:
______________________
Key assumption:
______________________
Key assumption:
______________________
Key assumption:
______________________
Issue:
Issue:
Issue:
Debate:
104
Topic 3 – Dysfunctional Behaviour
1. Diagnosis of dysfunctional behaviour
 Categorising
 Definitions
 Biases in diagnosis
2. Explanations of dysfunctional behaviour
 Biological
 Behavioural
 Cognitive
3. Treatments of dysfunctional behaviour
 Biological
 Behavioural
 Cognitive
105
Topic 3 – Dysfunctional Behaviour
It is important to note firstly that psychology is a
science that looks at trends, not certainties, so for
every piece of evidence that appears to explain human
behaviour, there is probably another that refutes it.
This is the case when studying dysfunctional
behaviour, which is a more up to date term for what
was called mental illness. Thus, if someone is not able
to function as a human being and given the label
dysfunctional and it carries fewer stigmas than the
label abnormal. However, as we have previously seen
labelling someone has ethical issues because of the
stickiness of the label which can lead to discrimination,
therefore the diagnosis needs to valid and safe.
No psychologist can say for certain what causes dysfunctional behaviour; the evidence may
point to factors that may cause a disposition or tendency towards a disorder but all humans
are unique, complex individuals and therefore, not everyone behaves in the same way.
The first section of the course consequently examines dysfunctional behaviour, how to
categorise dysfunctional behaviour so it can be diagnosed, what the definitions of
dysfunctional behaviour are then examining the biases in diagnosis that exist, which
further confound the issue and reflect society’s views on dysfunctional behaviour.
Psychologists from various approaches will have their own explanations for dysfunctional
behaviour, for example behaviourists would consider the causes to be learned behaviour and
the second section will look at three explanations: the biological, which is the genetic
explanation, the behavioural explanation as in classical conditioning and the cognitive
explanation such as maladaptive thoughts.
It follows therefore, that the treatments recommended by each approach will be based on
the assumptions of that approach, if the cause is biological it follows that the treatment
should be biological, thus the third section will examine a biological treatment, where drug
therapy was used, a behavioural treatment which involved desensitisation and cognitive
therapy which is a cognitive treatment.
106
WHAT DO WE KNOW FROM AS?
Several studies or theories from AS Psychology explain why individuals might suffer because
of dysfunctional behaviour:




FREUD (1909) introduced the idea of people having unconscious motivations. In
particular, he suggested people can behave in a dysfunctional way because of underlying
unconscious emotional issues that were not dealt with as a child. Thus leading to phobias
as seen by Little Hans.
MAGUIRE (2000) looked at how the brain changes structure depending on what we use it
for. If taxi drivers develop unusual hippocampi after spending years memorising routes
and distances, maybe individuals' brains will change after years of being depressed or
phobic.
GRIFFITHS (1994) studied cognitive styles - the way regular gamblers have of thinking
about gambling, weighing the odds and explaining away losses, that is quite different from
non-gamblers. Maybe this different way of thinking has caused individuals to behave in a
dysfunctional manner.
ROSENHAN (1954) studied the reliability of diagnosing dysfunctional behaviour and
highlighted a disadvantage of being diagnosed that is the stickiness of labelling.
HOW CAN WE APPLY THE APPROACHES AND PERSPECTIVES TO DYSFUNCTIONAL
BEHAVIOUR?




BEHAVIOURIST psychologists will try to look at the behaviour of individuals and their
environments and work out what sort of backgrounds or circumstances may cause
dysfunctional behaviour;
COGNITIVE psychologists will try to study the thought processes of people with
dysfunctional behaviour – are they different from a normal person? What is there
thinking? how do they weigh up actions to be taken and cope with stressors - that makes
them different from everybody else;
PSYCHODYNAMIC psychologists argue that the dysfunctional behaviour stems from
unconscious, unresolved emotional;
BIOPSYCHOLOGISTS will be more interested in the brain structure of patients, and ask
questions like: do people suffer from depression because of a biological predisposition and
what drugs can help make their lives more normal.
One of the themes that comes from this unit is NATURE vs NURTURE. Are some people
born with the predisposition to suffer from dysfunctional behaviours or are the situations
people experience causes them to suffer from for example, depression, or anxieties.
107
Diagnosis of Dysfunctional Behaviour
The Theories/Studies
1. DSMI/ICD – Categories of Dysfunctional Behaviour
2. Rosenhan and Seligman (1995) – Definitions of dysfunctional Behaviour
3. Ford and Wediger (1989) – Sex Biases in Diagnosis of Disorders
This section examines how dysfunctional behaviour is categorised and defined in order to
help practitioners identify behaviours and consequently enable patients to get the help that
is necessary. However, it highlights the reductionist nature of categorizing, and illustrates
how taking holistic approach which takes into consideration individual differences and
cultural diversity needs to be considered. The study then draws attention to how culture is
affected when diagnosing by demonstrating that biases occur because of preconceived ideas
about the nature of men and women, which ultimately affects the reliability of the methods
used.
108
1.DSM / ICD - Categories of Dysfunctional Behaviour.
Background: The definition of a mental disorder is important for investigation to enable a
practitioner to identify and treat a particular disorder but it also helps for health care as well as
for health care and the insurance industry (especially health insurance and pension insurance).
The following elements are of particular importance for the definition of a mental disorder:
 Personal harm and suffering

Abnormality (statistical, social, individual)

Limitations or disabilities in what a person can perform

Danger for others or the individual him/herself
In most instances more than one of these elements has to occur at the same time and over a
prolonged period of time. In order therefore, to standardize the description and interpretation
of mental disorders, diagnosis and classification systems were set up.
At present there are two established classification systems for mental disorders: The
International Classification of Diseases (ICD-10) published by the World Health Organization
(WHO) and the classification system of the American Psychiatric Association (APA), the
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
Aim:
To compare the two ways of categorising dysfunctional behaviour
Approach/Perspective:
Type of Data:
Qualitative
The Diagnostic and Statistical Manual of Mental disorders (DSM-IV)
This was compiled by over 1000 mental health professionals who collaborated to
produce a practical guide to clinical diagnosis and help improve reliability of mental
health diagnosis not just in US but around world This resulted in a simpler
classification using criteria sets. The DSM is a diagnostic tool designed to enable
practitioners to identify a particular disorder and therefore treat the disorder. It is
updated regularly, with the current version being DSM-IV.
It is complex with a range of Axis (variables to consider, alongside features of mental
health there is social, physical and environmental issues also. This classification system
of the American Psychiatric Association (APA), the Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV), consists of five axes of disorders. The five axes of
DSM-IV are:
Axis I - Clinical Disorders (all mental disorders except Personality Disorders and Mental
Retardation)
Axis II - Personality Disorders and Mental Retardation
Axis III – Etc..
109
The are 16 main categories of clinical disorders (Axis I) according to DSM-IV the ones
we are concerned with are:
5.Schizophrenia and Other Psychotic Disorders
6.Mood Disorders
7.Anxiety Disorders
Here there is some acknowledgement of individual differences as no individual is the
same and thus, the features of their illness may not be the same. Also this manual
attempts to highlight ethnic diversity and how a clinician from one culture may find it
more difficult diagnosing someone from another culture.
The classification of disorders can change with time; for example, until 1973
homosexuality was perceived as a mental disorder. As society became more enlightened it
was removed from the DSM-II and replaced by the category ‘sexual orientation
disturbance’. Again this changed to ‘ego-dystonic homosexuality’ in the DSM-III in 1980.
In the DSM-III-Revised in 1987 a category of ‘sexual disorder not otherwise specified’
was introduced, and this has continued in the DSM-IV.
The criteria here include ‘persistent and marked distress about one’s sexual orientation’.
So it would appear now that society is not labelling homosexuality as a disorder, but that
distress about one’s sexuality may lead to a disorder or to a diagnosis of a disorder.
Newer disorders such as eating disorders are included as they become more identifiable
in society. Bulimia was introduced as a disorder in DSM-III in 1980. Binge-eating
disorder (BED) was introduced in 1994 into the 4th edition of DSM. The criteria for
disorders such as anorexia can change over time; denial of having the disorder is now a
criterion included in DSM-IV, and the body mass index (BMI) for anorexia was changed
to allow for cross-cultural consistency.
International Classification of Diseases and Related Health Problems (ICD-10)
This manual is published by the World Health Organisation (WHO) and is used in many
countries throughout the world in diagnosing both physical and mental conditions.
It was set up to track and diagnose diseases and mental health issues world-wide and
consists of 10 main groups, the most notable for us are:
F2 Schizophrenia, schizotypal and delusional disorders
F3 Mood [affective] disorders
F6 Disorders of personality and behaviour in adult persons.
In addition, there is a group of “unspecified mental disorders”.
110
The ICD-10 was used in 40 countries to see if it improved psychiatric diagnosis across
cultures, however, it is only a snap shot of dysfunctional behaviour and definitions and
criteria must continue to be revised.
Version 10 of the ICD was first published in 1992, and was a revision of previous
versions. The ICD-8 was used as the basis for much cross-cultural collaboration in the
1980s, with the aim of refining the definitions for disorders in the 10th version. This
allowed for inconsistencies and ambiguities to be removed and resulted in the clear set
of criteria now found in ICD-10.
The draft in 1987 was used in 40 countries to see if this improved psychiatric diagnoses
across cultures. Of course ICD-10 is only a snapshot of the field of dysfunctional
behaviour, and as cultures change so revision of definitions and criteria must continue to
take place.
ICD-11 should be drafted by 2008
Thus the major difference between ICD-10 and DSM-IV is that DSM a multi-axial tool.
Clinicians have to consider if a disorder is from Axis 1 (clinical disorders) and/or Axis 2
(personality disorders). Then the general medical condition of the patient is considered,
plus any social and environmental problems. This makes DSM more holistic in relation to
diagnosing than the reductionist approach of the criteria based ICD. Many clinicians
would use the two diagnostic tools side by side.
111
Evaluation: Issues
Evaluation: Debates
112
2. Rosenhan and Seligman (1995) Definitions of Dysfunctional Behaviour.
Background:
Culture refers to all ways of thinking, feeling and acting that people learn from other
members of society. Different cultures will shown cross-cultural differences in beliefs,
traditions, norms etc. and may have different views on defining and classifying abnormality.
For example, in the West Indies it is perfectly acceptable to admit to hearing voices, it is
considered a religious experience, people pray and God answers them. In Britain, hearing
voices is considered a symptom of schizophrenia.
Subculture: - This refers to a social group within a society e.g. gender, social class, age and
ethnic groups. The dominant culture within a society is likely to be seen as the norm and
subcultures as abnormal. The frequency of mental disorders can vary in relation to
subcultures. For example, schizophrenia is between twice and eight times more prevalent in
lower socio-economic groups in society. Rack (1984) found that African Caribbean’s in
Britain are sometimes diagnosed as mentally ill, on the basis of behaviour which is perfectly
normal within their subculture (hearing voices and smoking marijuana (cannabis psychosis)).
Women are also more likely than men to be diagnosed with clinical depression. Some mental
disorders have been found to be specific to certain cultures. The term given to these
disorders is Culture Bound Syndromes (CBS), for example PMT and Anorexia Nervosa are
particularly Western disorders.
Abnormality is difficult to define. Views of abnormality change across cultures vary within
cultures over time and vary from group to group (e.g. Chavs and Goths) within the same
society (cultural relativism). It is essential to examine views of abnormality as they form
the basis for defining and identifying psychological disorders.
How do we decide what is ‘normal’ or ‘abnormal’, and whether the behaviour constitutes a
psychological disorder (e.g. depression, schizophrenia, phobias, post traumatic stress
disorders, eating disorders etc.) Rosenhan and Seligman (1995)
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Frequency
Aim: How can we define abnormality or normality?
Approach/Perspective:
Type of Data:
Way 1: Statistical Infrequency
A norm is a standard or rule that regulates behaviour in a social setting e.g. it is the norm in
our society to be polite and say please and thank you. Norms are socially acceptable or
‘normal’ standards of behaviour. Abnormality is defined as moving away from the norm, noncompliance with society’s norms and values. In statistical terms human behaviour is
abnormal if it falls outside the range that is typical for most people, in other words the
average is ‘normal’. Things such as height, weight and intelligence fall within fairly broad
areas. People outside these areas might be considered
Normal Distribution of IQ
abnormally tall or short, fat or thin, clever or
120
unintelligent etc. In statistical terms they are
100
abnormal because their behaviour has moved away
80
from the norm.
60
Example: - The Normal Distribution Curve for IQ 40
This is calculated using psychometric intelligence
20
tests. The norm for IQ is 100. Anything between 70
0
0
50
100
150
200
and 130 is considered normal for IQ, an IQ of less
IQ Score
than 70 or more than 130 is statistically infrequent
and therefore considered abnormal
Mark on the graph the norm or average IQ score and the cut off points for abnormality (e.g. 100, 70 and 130).
Limitations: The cut off points are rather arbitrary. How can someone with an IQ of 70 be
considered normal, whilst a person with an IQ of 1 point difference (69) be considered
abnormal?
It ignores desirability of behaviour, in terms of IQ we might accept that someone has an
abnormally low IQ, but we would probably all wish to have a high IQ and wouldn’t label that
as abnormal.
Some disorders, for example depression, are statistically very frequent, but still classified
as abnormal.
Way 2: Deviation from Social Norms
Every society or culture has standards of acceptable behaviour/norms. Behaviour that
deviates, (moves away) from these norms is considered abnormal. Social norms are approved
and expected ways of behaving in a particular society or social situation. For example, in all
societies there are social norms governing dress for different ages, gender and occasion
Cultural and historical relativism: - what is statistically frequent and acceptable in one
culture and time period is not necessarily the norm in another. For example, arranged
marriages are statistically frequent in India, Marijuana smoking is statistically frequent in
Jamaica.
However, it is difficult to use on its own, as this might encompass behaviours such as
exceptionally high IQ, or stamp collecting. So it is quite limited. Other behaviours might be
quite common, such as depression diagnoses but it could be argued that this illness is
dysfunctional. There has to be more to it than just numbers.
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Way 3: Failure to Function Adequately
Perhaps a more useful definition is that if a person is not functioning in a way that enables
them to live independently in society then they are “dysfunctional”. There are several ways a
person might not be functioning well. These might be dysfunctional behaviours such as
obsessions in obsessive compulsive disorder, where a person cannot leave the house due to
the rituals they need to undertake before they can leave. If a person is distressed by their
behaviour, not being able to go out of the house is distressing for agoraphobics. If the
person observing the patient is uncomfortable this could be dysfunctional behaviour, such as
when a person is talking to themselves whilst sitting next to you on the bus. Unpredictable
behaviour, where a person might have dramatic mood swings or sudden impulses can also be
seen as dysfunctional. Irrational behaviour, where a person might think they are being
followed, or people are talking about them could also lead to a failure to function adequately.
This failure to function adequately might be the most useful definition of the four.
However, there are problems with this, in that the context of the behaviour might influence
our view on it. We probably all talk to ourselves at times. Maybe a person who has been
involved in a fire will obsessively check appliances before leaving the house. It can be quite a
subjective view as to whether a person is not functioning adequately.
Way 4: Deviation from Ideal Mental Health
So far we have outlined definitions of abnormality. This definition instead attempts to
define normality, and assumes that absence of normality indicates abnormality. However,
normality is as difficult to define as abnormality. Jahoda (1958) approached this problem
by identifying various factors that were necessary for ‘optimal living’ (maximising enjoyment
for life). The presence of these factors indicates psychological health and well-being.
Jahoda’s 6 elements of Optimal Living
1.Positive view of self: Well adjusted individuals have high self-esteem and self
acceptance.
2.Personal Growth and Development: This refers to developing talents and abilities to the
full.
3.Autonomy: The ability to act independently and make your own decisions.
4.Accurate view of reality: Seeing the world as it really is without distortions (lack of
paranoia).
5.Positive Relationships: Normal people can form close, satisfying relationships with other
people, both giving and receiving affection. They do not make excessive demands to satisfy
their own needs. Mentally ill people may be self-centred and look for affection, but are
never able to find it.
6.Master of your own environment: Normal people can meet demands within different
situations and are able to adapt to changing circumstances.
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Evaluation: Issues
Evaluation: Debates
116
3. Ford and Widiger (1989) Biases in Diagnosis-Sex bias in the diagnosis of
disorders
Background: Boverman (1970)found that mental health professionals used different adjectives
to describe normal male and female (submissive and concerned with appearance) which makes any
female not fitting with this to be abnormal! This stereotypical view of genders is one way in
which diagnosis can be biased.
Aim: To find out if clinicians were stereotyping genders when diagnosing disorders
Approach/Perspective (if any): Individual differences
Type of Data: Quantitative
Method: Self-Report where health practitioners were given scenarios and asked to make
diagnoses based on the information. The independent variable was the gender of the patient in
the case study and the dependent variable the diagnosis made by the clinician
Details: 354 clinical psychologists from 1127 randomly selected from the National Register, with
a mean 15.6 years clinical experience. 266 psychologists responded to the case histories.
An independent design as each participant was given either a male, female or sex-unspecified
case study. Participants were randomly provided with one of nine case histories. Case studies of
patients with anti-social personality disorder (ASPD) or histrionic personality disorder (HPD) or
an equal balance of symptoms from both disorders were given to each therapist. Each case study
was male, female or sex-unspecified. Therapists were asked to diagnose the illness in each case
study by rating on a 7-point scale the extent to which the patient appeared to have each of nine
disorders
1.
2.
3.
4.
5.
6.
7.
8.
9.
Dystheymic (form of mild depression)
Adjustment (stress-related disorder due to social/emotional issues)
Alcohol abuse
Cycothymic disorder (type of depression resulting in frequent mood disorders)
Narcissistic (a personality disorder in which people have inflated sense of self and
little regard for other’s feeling’s. Underpins lack of self-esteem)
Histrionic (personality disorder whereby suffer shows excessive emotionality and
attention seeking. Can include inappropriate seductive bahvaiour)
Passive-aggressive (personality trait manifested negatively, eg. learned helplessness)
Antisocial (behavioural pattern of disregard for, and violation of, the rights of
others that begins in childhood or early adolescence and continues into adulthood)
Borderline personality disorder (a condition in which a person makes impulsive actions,
and has an unstable mood and chaotic relationships)
Results; Sex-unspecified case histories were diagnosed most often with borderline
personality disorder.
ASPD was correctly diagnosed 42% of the time in males and 15% of the time in females.
Females with ASPD were misdiagnosed with HPD 46% of the time, whereas males were only
misdiagnosed with HPD 15% of the time.
HPD was correctly diagnosed in 76% of females and 44% of males.
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Conclusions: Practitioners are biased by stereotypical views of genders as there was a clear
tendency to diagnose females with HPD (histrionic personality disorder) even when their case
histories were of ASPD (antisocial personality disorder).
There was also a tendency not to diagnose males with HPD, although this was not as great as the
misdiagnosis of women
Evaluation: Issues
Evaluation: Debates
118
Summary: Diagnosis of Dysfunctional Behaviour

It is clear that diagnosing and categorising dysfunctional behaviour is not an exact
science.

Diagnosing often depends on how society views any particular disorder at any one time,
and the biases inherent in that society.

There are dysfunctional behaviours that cause distress to patients and their families,
and which can be treated to facilitate a better quality of life.
119
Comprehension questions Diagnosis of Dysfunctional Behaviour
1.DSMI/ICD – Categories of Dysfunctional Behaviour

What are the current diagnostic manuals used in the USA and the UK?

Who published the ICD?

What is the major difference between ICD-10 and DSM-IV?

Name and advantage and disadvantage to giving an individual diagnosis?

When using these is the diagnosis reliable?
2.Rosenhan and Seligman (1995) – Definitions of dysfunctional Behaviour

What are the four definitions of abnormality according to Rosenhan and Seligman?

What does Jahoda suggest you should have for ideal mental health?

How might a person be considered to function inadequately?

Which culture is more likely to be diagnosed with dysfunctional behaviour according to
The Mental Health Act Commission’s ‘Count Me In Census’ (2005)?

What factors affect the reliability and validity of defining dysfunctional behaviour?
3.Ford and Widiger (1989) – Sex Biases in Diagnosis of Disorders

Who were the sample and how ere they selected?

Ford and Widiger believed that histrionic personality disorder was seen as more likely in
women. How can this be explained?

What were the three research conditions?

What did Ford and Widiger find out about bias in diagnosis?

What was Ford and Widiger’s conclusion?
120
Part A exam question for Diagnosis of Dysfunctional Behaviour

Describe how gender biases diagnoses of dysfunctional behaviour (10 marks)
Introduction
Linking sentence __________________________________________________
Main body
Linking sentence __________________________________________________
Conclusion
121
Part B exam question for Diagnosis of Dysfunctional Behaviour
Evaluate the effectiveness of diagnosing dysfunctional behaviour (15 marks)

Introduction
Linking sentence __________________________________________________
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Linking sentence __________________________________________________
Conclusion
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Evaluation sheet for Diagnosis of Dysfunctional Behaviour
Overview of topic:
__________________
__________________
__________________
__________________
Study 1
Researcher/s:
______________________
Study 2
Researcher/s:
______________________
Study 3
Researcher/s:
______________________
Key assumption:
______________________
Key assumption:
______________________
Key assumption:
______________________
Issue:
Issue:
Issue:
Debate:
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Explanations of Dysfunctional Behaviour
The Theories/Studies
1. Watson and Raynor (1920) – Behavioural - Little Albert (Classical
conditioning)
2. Gottesman and Shields (1991) - Biological – Twin studies (Genetic)
3. Beck et al. (1974) - Cognitive – Interviews with people with depression
(Maladaptive thoughts)
There are different explanations for human behaviour, and as you will know from AS
these are based on approaches such as the cognitive, biological, psychodynamic
approach and perspectives such as the behaviourist perspective. Basic assumptions
about behaviour should be transferable to any behaviour, including therefore
dysfunctional behaviour (remember little Hans and psychodynamic behaviour). This
section looks at the cognitive, biological and behaviourist approach to explaining
dysfunctional behaviour and what evidence there is for supporting these
assumptions.
‘Little Albert’ and ‘Classical Conditioning.’
125
1. Watson and Raynor (1920) - Classical conditioning
Background: Behaviourism is a school of thought in psychology that assumes that learning occurs
through interactions with the environment. (The nurturist argument that believes behaviour has
little to do with the individual but more to do with the situation they are in) One of the bestknown aspects of behavioural learning theory is classical conditioning. Discovered by Russian
physiologist Ivan Pavlov, classical conditioning is: ‘a learning process that occurs through
associations between an environmental stimulus and a naturally occurring stimulus’
- The unconditioned stimulus is one that unconditionally, naturally, and automatically triggers a
response. E.g. when you smell one of your favourite foods, you may immediately feel very hungry,
the smell of the food is the unconditioned stimulus.
- The unconditioned response is the unlearned response that occurs naturally in response to the
unconditioned stimulus. In our example, the feeling of hunger in response to the smell of food is
the unconditioned response.
- The conditioned stimulus is previously neutral stimulus that, after becoming associated with
the unconditioned stimulus, eventually comes to trigger a conditioned response. In our earlier
example, suppose that when you smelled your favourite food, you also heard the sound of a
whistle. While the whistle is unrelated to the smell of the food, if the sound of the whistle was
paired multiple times with the smell, the sound would eventually trigger the conditioned response.
In this case, the sound of the whistle is the conditioned stimulus.
- The conditioned response is the learned response to the previously neutral stimulus. In our
example, the conditioned response would be feeling hungry when you heard the sound of the
whistle.
Behaviourists believe we are born as blank slates and all behaviour is learnt. Any dysfunctional
behaviour is learnt by operant conditioning, classical conditioning (rewards and punishments) and
social learning (Bandura and the Bobo doll). Therefore, this places the responsibility on us not to
teach dysfunctional behaviour. Obviously this is a simplistic explanation for complex behaviours
and this section is will only examine and concentrate on the classical conditioning explanation of
phobia acquisition.
Aim: To see if it is possible to induce a fear of a previously unfeared object through
classical conditioning.
To see if the fear will be transferred to other similar objects. To see what effect time
has on the fear response. To see how possible it is to remove the fear response in the
laboratory.
Approach/Perspective:
Behavioural
Type of Data:
Quantitative
Method: A case study undertaken on one boy: ‘Little Albert who was 8 months old and
lived in the hospital with his mother, a nurse. He was ‘stolid and unemotional’. A single
subject design.
126
Details: Albert’s baseline reactions to the stimuli were noted. He showed no fear when
presented with a rat, a rabbit, a dog, a monkey, a mask with hair. When Albert was 11
months old the experiments started.
Session One: Albert was presented with a rat. Just as he reached for it, a steel bar
behind him was hit. This procedure was repeated. Findings: The first time the steel bar
was struck when Albert touched the rat, he jumped and fell forward. The second time he
began to whimper. A fear response had been conditioned
Session Two: The following week the rat alone was presented. Then three presentations
were made with the rat and the loud noise. This was followed with one presentation of
just the rat. Then two more presentations with the rat and the noise were made. Finally
the rat alone was presented. Findings: Albert reacted to the rat alone by immediately
crying, turning to the left and crawling quickly away from the rat. The conditioning of a
fear response was evident and so it is possible to condition fear through classical
conditioning.
Session Three: Albert was brought back five days later and given toy blocks (a neutral
stimulus) to play with. Presentations were then made of: the rat, a rabbit, a dog, a Santa
Claus mask etc. Findings: After each presentation of the blocks, Albert played with them
happily. The other stimuli produced negative responses of crying, moving away from the
stimulus and crawling away. Transference of the fear had been made to other similar
objects
Session Four: Albert was then taken to a well-lit lecture theatre to see if the response
was the same as it was in the small room used up till now. In the different room the fear
reaction was slight, until the bar was hit. Then the fear reaction increased.
Session Five: One month later Albert was tested with various stimuli. Albert continued
to show fear reactions. Findings: Time had not removed the fear response
Conclusions:
Session 2 – After five paired presentations the conditioning of a fear response was
evident and so it is possible to condition fear through classical conditioning.
Session 3 and 4 – Transference of the fear had been made to other similar objects,
although it appeared the less like the original stimulus the objects were (e.g. the
cotton wool), the less negativity was shown.
Session 5 – Time had not removed the fear response.
Unfortunately Albert was taken out of the hospital on the day of Session 5, so Watson
and Rayner were never able to carry out their aim of trying to find ways of removing a
phobia in the laboratory. We don’t know if Albert had a fear of furry animals for the
rest of his life!
Research by Mary Cover Jones on Little Peter, (Jones, 1924) did show how a fear of
rabbits could be overcome using a treatment of systematic desensitisation.
127
Evaluation: Issues
Evaluation: Debates
128
2. Gottesman and Shields (1991) – A review of recent adoption twin
and family studies of schizophrenia
Background: The biological approach would favour the nature side of the of the
nature-nurture debate thus the focus is on the individual not the situation in
explaining behaviour. Consequently the explanation of dysfunctional behaviour would be
that something in our biology is the fundamental cause of our behaviour. This could be a
genetic cause or a malformation of brain structures
Aim: To review research into genetic transmission of schizophrenia
Approach/Perspective: Biological
Type of Data:
Method:
A review of adoption and twin studies into schizophrenia between 1967 and 1976.
• 3 adoption studies by Kety, Wender and Rosenthal
• 5 twin studies by Kringlen et al. and Gottesman and Shields.
In total there were 711 participants in the adoption studies. In the twin studies a total
of 210 monozygotic (identical) twin pairs and 319 dizygotic (non-identical) twin pairs
were studied.
Details: The incidence of schizophrenia in adopted children and monozygotic twins was
extrapolated from the research.
Results;
All adoption studies found an increased incidence of schizophrenia in adopted
children with a schizophrenic biological parent.
Kety found that biological siblings of children with schizophrenia showed a much
higher percentage of schizophrenia.
All twin studies found a higher concordance rate for schizophrenia in monozygotic
(MZ) than dizygotic (DZ) twins.
In Gottesman and Shield’s own study the rate was 58% for identical twins, and 12%
for non-identical twins.
Conclusions:
There is obviously a heavy genetic input into the onset of schizophrenia.
Concordance rates less than 100% show there must be some interaction with the
environment.
129
Evaluation: Issues
Evaluation: Debates
130
3. Beck et al (1974) Cognitive - Interviews with Patients Undergoing
Therapy for Depression
Background: The cognitive approach sees behaviour as being the consequence of some
internal processing of information. Much like a computer, we take in the information,
process it and respond in some way. If however, there is a problem with the circuit
boards in a computer the response may not be what we would expect and this is the same
for humans. If something goes wrong with information that we attend, how we perceive it
or store it, then the response may not be what everyone expects which leads to the label
of dysfunctional behaviour. Beck (1967) is one of the founders of the cognitive approach
and had much to say about how faulty thinking can influence our behaviours.
Aim: To understand cognitive distortions in patients with depression.
Approach: Cognitive
Type of Data: Qualitative
Method:
Clinical interviews with patients who were undergoing therapy for depression.
Independent design as the patients were compared with a group of 31 non-depressed
patients undergoing psychotherapy, matched for age, sex, and social position.
 50 patients diagnosed with depression
 16 men and 34 women.
 age range from 18–48 with median age of 34.
Face-to-face interviews with retrospect reports of patients’ thoughts. Some patients
kept diaries of their thoughts and brought these to the therapy sessions. Records of the
verbalisations of the non-depressed patients were kept to compare with the depressed
patients.
Results;
Certain themes appeared in the depressed patients, e.g. low self-esteem, self-blame,
overwhelming responsibilities and desire to escape, anxiety caused by thoughts of
personal danger, and paranoia and accusations against other people.
Depressed patients had stereotypical responses to situations.
Depressed patients regarded themselves as inferior to others
Some patients felt themselves unlovable and alone.
Self-blame was shown even when blame couldn’t be apportioned to the person.
These distortions tended to be automatic, involuntary, plausible and persistent
Conclusions:
In depression, and even mild depression, patients have cognitive distortions that deviate
from realistic and logical thinking
131
Evaluation: Issues
Evaluation: Debates
132
Summary: Explanations of Dysfunctional Behaviour

The different approaches’ assumptions influence their explanations of the causes
of dysfunctional behaviour.

The biological explanation is the most commonly used in our society; as this
reflects the emphasis on mental health being a medical problem

The prescription of anti-depressants, tranquilisers and antipsychotic drugs
reflects this view; these are now more often seen as short-term fixes that need
to be combined with other talking therapies such as CBT to address the
underlying problems.
133
Comprehension questions for Explanations of Dysfunctional
Behaviour
1.Watson and Raynor (1920) - Little Albert

What theory did Watson and Rayner support?

What were the four aims of Watson and Rayner’s research on Little Albert?

Identify the conditioned and unconditioned stimulus and the conditioned and
unconditioned response?

What is meant by the term generalization in this study?

Why were Watson and Rayner unable to test the last question?
2. Gottesman and Shields (1991) – Twin studies

What method did Gottesman and Shields use?

How did they use concordance rates in the study?

What are retrospective reports and how do they affect the validity of the
study?

What were the findings from the twin studies Gottesman and Shields reviewed?

What were the conclusions?
3. Beck et al. (1974) – Interviews with people with depression

Who were the patients in Beck’s study on cognitions in dysfunctional behaviour?

What was the aim of the study?

How did the patients report their cognitions?

What did Beck find out about the cognitions of patients with depression?
134
Part A exam question for Explanations of Dysfunctional
Behaviour

Outline a biological explanation of dysfunctional behaviour (10 marks)
Introduction
Linking sentence _________________________________________________
Main body
Linking sentence_________________________________________________
Conclusion
135
Part B exam question for Explanations of Dysfunctional
Behaviour

To what extent are explanations of dysfunctional behaviour reductionist? (15 marks)
Introduction
Linking sentence ________________________________________________
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Linking sentence _______________________________________________
Conclusion
136
Evaluation sheet for the Explanations of Dysfunctional Behaviour
Overview of topic:
__________________
__________________
__________________
__________________
Study 1
Researcher/s:
______________________
Study 2
Researcher/s:
______________________
Study 3
Researcher/s:
______________________
Key assumption:
______________________
Key assumption:
______________________
Key assumption:
______________________
Issue:
Issue:
Issue:
Debate:
137
Treatments of Dysfunctional Behaviour
The Theories/Studies
1. McGrath (1990) – Successful Treatment of a Noise Phobia
2. Leibowitz (1988) -Treatment of Social Phobia with Phenelenzine
3. Ost & Westling (1995) -Treatments for panic attacks
There many treatments for dysfunctional behaviour from all of the approaches
however, the three treatments covered in this section reflect the three approaches
examined in the explanation of dysfunctional behaviour section. This section
therefore, looks at the cognitive, biological and approaches and the behaviourist
perspective to treating dysfunctional behaviour.
138
1. McGrath (1990) – Successful Treatment of a Noise Phobia: Behavioural
Background: Behaviour is learnt and has little to do with the individual but instead the
situation they are in. Classical conditioning theory, look at previous notes.
Aim: To treat a girl with specific noise phobias using systematic desensitisation.
Approach/Perspective : Behavioural
Type of Data:
Method: A case study that details the treatment of a noise phobia in one girl. A single
participant design.
Details: A nine-year-old girl called Lucy, who had a fear of sudden loud noises,
including: balloons, party poppers, guns, cars backfiring and fireworks. . She had lower
than average IQ, and was not depressed, anxious or fearful (tested with
psychometric tests), so only had one specific phobia.





Lucy was brought to the therapy session and told what would happen. Her parents gave consent for
further sessions.
At the first session, Lucy constructed a hierarchy of feared noises.
Lucy was taught breathing and imagery to relax, and was told to imagine herself at home on her
bed with her toys. She also had a hypothetical ‘fear thermometer’ to rate her level of fear from 110. As she was given the stimulus of the loud noise, she had paired her feared object (the loud
noise) with relaxation, deep breathing and imagining herself at home with her toys. This would
naturally lead her to feel calm.
She then associated the noise with feeling calm. So after four sessions she had learned to feel
calm when they noise was presented.
She did not need to imagine herself at home with her toys any more.
Results; At the end of the first session, Lucy was reluctant to let balloons be burst.
At the end of the first session, Lucy was reluctant to let balloons be burst even at
the far end of the corridor. When the therapist burst the balloon anyway Lucy cried
and had to be taken away. She was encouraged to breathe deeply and relax.
By the end of the fourth session, Lucy was able to signal a balloon to be burst 10
metres away. , with only mild anxiety.
On the fifth session, Lucy was able to pop the balloons herself.
Over the next three sessions, Lucy was able to pull a party popper if the therapist
held it.
By the tenth and final session, Lucy’s fear thermometer scores had gone from 7/10 to
3/10 for balloon popping, from 9/10 to 3/10 for party poppers and from 8/10 to 5/10
for the cap gun.
Conclusions: It appears that noise phobias in children are amenable to systematic
desensitisation The important factors appear to have been giving Lucy control to say
when and where the noises were made, and the use of inhibitors of the fear response,
which included relaxation, conservation and a playful environment
139
Evaluation: Issues
Evaluation: Debates
140
2.Leibowitz (1988) - Treatment of Social Phobia with Phenelenzine:
Biological
Background: Biological treatments are often the first treatments offered for
dysfunctional behaviour, often because diagnosis is made by medical practitioner and the
medical approach supports the use of drug therapy. One of the benefits of
psychopharmocotherapy is the speed of the effects, some drugs almost instantaneous
results. However, other therapies are now used to supplement the biological therapy
such as cognitive which can bring about longer lasting change and without the side
effects that drug therapy may incur.
Aim: To see if the drug phenelzine can help treat patients with social phobia.
Approach/Perspective : Biological
Method: A controlled experiment where patients were allocated to one of three
conditions, and treated over eight weeks. They were assessed for social phobia on
several tests such as Hamilton Rating Scale for Anxiety and the Liebowitz Social Phobia
Scale. This had common manifestations of social phobia and patents rated 1–4 for the
fear produced and 1–4 for the steps taken to avoid the phobic situation.
Details: An independent design with patients being allocated randomly to one of four
groups.
One group was treated with phenelzine, and one given a matching placebo. A second
treatment group was given atenolol and another placebo group was given a matching
placebo.
80 patients meeting DSM criteria for social phobia aged 18–50 years. They were
medically healthy and had not received phenelzine for at least two weeks before the
trial. Each was assessed to see that there were no other disorders and each signed a
consent form before the research.
Patients were assessed at the beginning, and then given their drug or placebo, with
gradual increases in dosage of phenelzine or atenolol in the treatment groups.
Each patient was then reassessed on the Hamilton Rating Scale for Anxiety and the
Liebowitz Social Phobia Scale.
Independent evaluators were used to carry out clinical assessments in a double blind
situation.
Results;
After eight weeks significant differences were noted for the phenelzine groups, with
better scores on the tests for anxiety compared to the placebo groups. There was no
significant difference between the patients taking atenolol and those taking a placebo
Conclusions:
Phenelzine but not atenolol is effective in treating social phobia after eight weeks of
treatment.
141
Evaluation: Issues
Evaluation: Debates
142
3.Ost & Westling (1995) - Treatments for Panic Attacks: Cognitive
Background: Cognitive Behavioural uses cognitive approach to restructure thoughts as well as
behaviourism (relaxation) the way the person behaves. Does not look at the Cause but focuses
on the present symptoms. How the person thinks about an event and its effect on what they did.
If negative thought can be reinterpreted then the person will feel better and the behaviour will
change.
Aim: To compare cognitive behaviour therapy (CBT) with applied relaxation as therapies for
panic disorder.
Approach/Perspective Cognitive
Method: A longitudinal study with patients undergoing therapy for panic disorder.
Independent design experiment with participants randomly allocated to one of two conditions,
cognitive or drug therapy. The patients with DSM diagnosis of panic disorder, with or without
agoraphobia. Recruited through referrals from psychiatrists and newspaper advertisements.
26 females and 12 males, mean age 32.6 years (range 23–45 years). From a variety of
occupations and some married, some single and some divorced
38 patients were diagnosed with moderate to severe depression were assessed using Beck’s
Depression Inventory and two other rating scales.
Details: Pre-treatment: baseline assessments of panic attack, using a variety of
questionnaires (e.g. the Panic Attack Scale, Agoraphobic Cognitions Questionnaire, etc.)
Patients recorded details of every panic attack in a diary.
Each patient was then given 12 weeks of treatment (50–60 minutes per week), with homework
to carry out between appointments.
Applied relaxation was used to identify what caused panic attacks, and then relaxation
training started with tension-release of muscles. This was gradually increased so that by
session 8 rapid relaxation was used and patients were able to practise their techniques in
stressful situations.
CBT was used to first identify the misinterpretation of physical symptoms and then to
generate an alternative cognition in response. For example, not to feel panic when something
stressful happened, but to come up with an alternative explanation (e.g. my heart racing is not
a heart attack but a normal physical reaction to stress and it will slow down in a minute). This
was then tested in situations where participants had panic situations induced, but were not
allowed to avoid them, so that eventually they had to accept that their restructured thoughts
were right. Patients were then reassessed on the questionnaires.
After one year a follow up assessment using the questionnaires was carried out. The therapy
session were prescribed and controlled and observed to ensure reliability.
Results;
Applied relaxation showed 65% panic-free patients after the treatment, 82% panic-free
after one year.
CBT showed 74% panic-free patients after the treatment and 89% panic-free after a year.
These differences were not significant.
Complications such as generalised anxiety and depression were also reduced to within the
normal range after one year.
Conclusions: Both CBT and applied relaxation worked at reducing panic attacks, but it is
difficult to rule out some cognitive changes in the applied relaxation group even though this is
not focused on in this research.
143
Evaluation: Issues
Evaluation: Debates
144
Summary: Treatments of Dysfunctional Behaviour

The treatments of dysfunctional behaviour are not limited to those in this
booklet; there are other approaches beyond the specification, such as humanistic
client-centred therapy and psychodynamic therapies. Who can forget the case of
Little Hans and Freud in the AS course?

Within the approaches that have been covered, there are many more
treatments, for example there are biological treatments such as
electroconvulsive therapy.

Similarly there are many therapeutic techniques based on the assumptions of
operant conditioning, such as token economies, and on classical conditioning such
as flooding, in addition to Mc Grath’s systematic desensitization described here.
145
Comprehension questions for Treatments for Dysfunctional
Behaviour
1. McGrath (1990) – Successful Treatment of a Noise Phobia

Which Behaviourist theory is this technique based upon?

Who was the participant in McGrath’s study on systematic desensitization?

What is systematic desensitization?

How many sessions did Lucy have to have before she became less fearful?

What was Lucy able to do by the end of her treatment?
2. Leibowitz (1988) Treatment of Social Phobia with Phenelenzine

Which approach did Leibowitz use to treat social phobias?

How were the participants assessed for social phobia?

Why did Leibowitz use a placebo group?

What design did Leibowitz use?

Which approach has treatments that remove the basis of the fear rather than
treating the symptoms?
3. Ost & Westling (1995) Treatments for panic attacks

What does the cognitive approach suggest as a way to treat anxiety disorders?

How were the patients assessed before treatment?

Which two therapies did Ost and Westling compare?

What did Ost and Westling find?

How did Ost and Westling explain the similarity in findings between the two
therapy groups?
146
Part A exam question Treatments for dysfunctional
Behaviour

How could dysfunctional behaviour (either affective or anxiety or psychotic)
be treated cognitively? (10 marks)
Introduction
Linking sentence _____________________________________________
Main body
Linking sentence ______________________________________________
Conclusion
147
Part B exam question for Treatments of Dysfunctional Behaviour

Assess the effectiveness of treatments of dysfunctional behaviour (15 marks)
Introduction
Linking sentence_______________________________________________
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Conclusion
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Evaluation sheet for Treatments of Dysfunctional Behaviour
Overview of topic:
__________________
__________________
__________________
__________________
Study 1
Researcher/s:
______________________
Study 2
Researcher/s:
______________________
Study 3
Researcher/s:
______________________
Key assumption:
______________________
Key assumption:
______________________
Key assumption:
______________________
Issue:
Issue:
Issue:
Debate:
149
Causes and Treatments of Dysfunctional Behaviour
Activity
The following table has a list of psychiatric disorders or dysfunctional behaviour. Can
you identify:
 What may be the cause of the behaviour?
 How could it be treated?

Which psychological approach each one could be based on?
Dysfunctional
behaviour
Causes
Ways to treat it
Approach/
Perspective
Depression
Schizophrenia
Obsessive
compulsive
disorder
Anxiety disorder
Agoraphobia
Panic disorders
Bipolar disorder
ADHD
Compulsive eating
Kleptomania
Aspergers
syndrome
150
Activity
1. Make a list of the strengths and weaknesses of each of the treatments
Strengths
Weaknesses
Behavioural
therapy
Drug treatments
Cognitive therapy
2. Now highlight the similarities between the treatments.
3. What is the responsibility on the part of the patient?
4. Consider how the approach each treatment adopts might limit the effectiveness of
the treatment.
151
Topic 4 - Disorders
Disorders refers to mental health problems that can affect an individual at some point,
or on a continuous basis through their life
Psychologists and Psychiatrists are interested in what types of mental health issues
affect individuals and the impact these disorders can have on their lives. To be clear on
what mental health issue a person is showing symptoms of a psychologist will look at the
type of disorder and The Characteristics of Disorders.
These characteristics help diagnose the disorder and also allow the
psychologist/psychiatrist to decide on a course of action to help the individual overcome
or alleviate their problem. Very generally speaking, there are three types of disorders:
1. Anxiety Disorders such as phobias, panic disorder, post-traumatic stress disorder
and generalised anxiety disorders are typified by a continuous feeling of fear and
anxiety. This can have a huge impact on everyday life and make daily functioning
difficult.
2. Affective Disorders refer to the disabling moods that individual’s experience which
causes disruption to their social, family and work lives. Examples are depression,
bipolar disorder and dysthymia.
3. A Psychotic Disorder relates to the concept of psychosis which is the general term
for disorders that are characterised by a loss of contact with reality. This can be
very confusing and frustrating for the individual and can lead to a withdrawal from
society. Schizophrenia is the most frequently reported psychotic disorder in
psychological literature.
The second section of Disorders will focus on Explanations of a disorder. We can
choose from either an anxiety or an affective or a psychotic disorder. We are focusing
on an anxiety disorder (phobias and generalised anxiety disorders).
152
To fully understand an anxiety disorder, psychologists try to explain them from various
perspectives:
A Behavioural Explanation for a phobia would suggest that an individual has been
conditioned (classical conditioning) to fear that object or they are imitating the
behaviour of a role model (social learning theory) who has demonstrated that phobia.
A Biological Explanation of a phobia suggests that people are biologically prepared to
fear some objects more than others. For example more people are scared of snakes
than grass. This suggests a process of evolution that has resulted in fear of objects
that can harm you. This allows for the survival of our species.
A Cognitive Explanation for generalised anxiety disorder focuses on thinking patterns
and excessive worrying patterns. Worrying too much about something may result in
anxiety, even when in reality there is no reason to worry. Worrying about dangerous or
threatening phenomenon makes sense but worrying about things that do not pose a
threat creates unnecessary anxiety.
After diagnosing a disorder, the Psychologist or Psychiatrist then needs to decide on
the best treatment for the patient – hence the Treatments for Disorders section (we
will focus again on phobias and generalised anxiety disorder). Treatments for disorders
often leads to disagreements between clinical staff as there are various treatments
based on psychological theory to choose from, such as:
 Behavioural Treatments focus on unlearning a phobia and to do this classical
conditioning or systematic desensitisation is often used.
 Biological Treatments might be used to treat a phobia. This usually involves the use
of psychopharmocotherapy or drug therapy. Other therapies may be used to enhance
the drug treatment such as cognitive therapy.
 Cognitive Treatments often involve cognitive behavioural therapy (CBT) which
involves getting individuals to restructure how they think about whatever it is they
have a phobia for.
153
WHAT DO WE KNOW FROM AS?
Several studies or theories from AS Psychology explain why individuals might suffer
from a disorder. Find studies from AS that can link with this topic.
HOW CAN WE APPLY THE APPROACHES AND PERSPECTIVES TO DISORDERS?
BEHAVIOURIST
COGNITIVE
PSYCHODYNAMIC
BIOPSYCHOLOGISTS
154
Characteristics of Disorders
Three categories of disorder
1. Anxiety – e.g. phobias, post traumatic stress disorder, obsessivecompulsive disorder
2. Affective – e.g. depression, bipolar, cyclothymic disorder
3. Psychotic – e.g. schizophrenia, delusional disorder, substance induced psychotic disorder
The main approaches in this area are behaviourism, biological psychology and cognitive
psychology. Disorders can be described in terms of classical conditioning and social
learning (behaviourism) or in terms of instinct (biological) or by studying thinking
patterns (cognitive).
155
1. Characteristics of Disorders: Anxiety Disorders
These are when someone has a continuous feeling of fear and anxiety which is
disabling – it stops the sufferer leading a normal life. They can be triggered by
something that seems trivial to others; or even be triggered by a non existent
threat that seems real to the person concerned. There are many different types of
anxiety disorder including panic disorder,
generalised anxiety, post traumatic
DSM-IV Classification for specific
stress, and phobia.
phobia
Anxiety disorders give a continuous

Marked and persistent fear that is
feeling of fear and anxiety which is
excessive or unreasonable
disabling and can impose on daily

Exposure to phobic stimulus
functioning. They can be triggered by
provokes immediate anxiety
something that may seem trivial to
response
others; they may even be triggered by

The person recognises the fear as
non-existent threats that nevertheless
excessive
seem very real to the person. In the UK in

The phobic situation is avoided
2000 the Office of National Statistics

The phobia disrupts the person’s
reported that 1 adult in 6 in the UK had a
normal life
neurotic disorder anxiety or depression.

The phobia has lasted more than 6
Anxiety disorders encompass many
months in people under 18 years of
different disorders including panic
age.
disorders, OCD, Phobias, Post Traumatic
ICD-10 Classification for a specific
Stress Disorder and other generalised
phobia
anxiety disorders.

The psychological or autonomic
symptoms must be primary
manifestations of anxiety, and not
secondary to other symptoms such
as delusions.

The anxiety must be restricted to
the presence of the particular
phobic object or situation.

The phobic situation is avoided
wherever possible
156
PHOBIAS
Phobias essentially have a definite, persistent fear of a particular object or
situation. A stimulus such as a snake, dog, and a man’s beard will provoke an
immediate response, which may be similar to a panic attack. The individual may
experience physical symptoms such as shortness of breath or palpitations, and may
feel intense terror and may begin to lose control. Even though the individual knows
that the fear is irrational they can still not control the immense terror the stimulus
produces. This response alone is not enough to be actually diagnosed with a phobic
disorder, if the fear disrupts the individuals day to day life, the disorder may be
diagnosed.
There are many different types of anxiety disorder including panic disorder,
generalised anxiety, post traumatic stress, and phobia.
157
2. Characteristics of Disorders: Affective Disorders
Affective means to do with moods. It is normal for moods to change. The problem
for affective disorders is that the changes are extreme, and damaging to the
person who suffers from them. Depression is when someone feels very down. Mania
is when that person feels elated. Sometimes the two alternate – this is called
bipolar, where the sufferer swings from one to the other, sometimes with quiet
periods of normality in between,
DSM-IV Classification of single-episode
sometimes in rapid succession, and
depression
sometimes having combinations of

Five or more of the following symptoms

Insomnia most nights
the two together. Although bipolar

Fidgeting or lethargy
disorder is extreme there are

Tiredness
milder, but problematic affective

Feeling of worthlessness or guilt
disorders such as dysthymia – a

Less ability to concentrate
persistent depression which can

Recurrent thoughts of death

These symptoms are not caused by medication,
cause poor appetite, or overeating,
or situations such as bereavement, and they are
insomnia, or low energy, low self
enough to hinder the person from important dayesteem, poor concentration or
to-day.
struggling to make decisions, and
ICD-10 Classification of depression
feelings of hopelessness.

Depressed mood

Loss of interest and enjoyment
Cyclothymia is a milder former of

Reduced energy
bipolar disorder where the sufferer

Other common symptoms are:
fluctuates between irritable or

Marked tiredness after only slight effort
elated (hypomania) or dysthymic.

Reduced concentration and attention

Reduced self-esteem and self-confidence
Ideas of guilt and unworthiness

To recap we all have different

Bleak and pessimistic views of the future
moods; sometimes we are happy and

Ideas or acts of self harm or suicide
sometimes we are sad, and these are

Disturbed sleep
natural responses to events in our

Reduced appetite.
lives. However, you will see that the
characteristics of mood or affective
disorders are disabling moods. This means that the disorder prevents the individual
from leading a normal life, at work socially or within their family, which would cause
them to be diagnosed with depression or bipolar disorder.
158
An example of affective disorder is Depression.
Depression is more than just feeling ‘cheesed off’.
There is reduced concentration, disturbed
sleeping, low self esteem, pessimism, disturbed
eating, sometimes ideas of self harm – in children
there is sometimes irritability rather than sad
moods
Symptoms of Depression
Emotional




Sadness
Depressed Mood
Anhedonia – (loss of
pleasure in usual activities)
Irritability
Physiological/behavioural
•
•
•
•
•
Sleep disturbance
Appetitive Disturbance
Psychomotor retardation or
agitation
Catatononia –
Fatigue and loss of energy.
Cognitive Symptoms
•
•
•
•
Poor concentration,
Indecisiveness
Sense of worthlessness or guilt,
Poor Self esteem
Hopelessness, Suicidal Thoughts
Delusions and hallucinations with
depressing themes.
Different types of depression

Bipolar – mood fluctuates between manic episodes and depressive episodes, these
periods are often separated with periods of ‘normality’. Some individuals experience
symptoms very rapidly or very slowly and can the cycle between mania, normality and
depression can be sometime days, weeks to month and sometimes years.

Dysthymia- mood disorder, not considered to be as severe as major depression, but can
be thought of a chronic depression. Diagnosed if have 3 or more symptoms, including
depressed mood. Duration – 2 YEARS! Must never have been without the symptoms

Melancholic – no pleasure, depressed mood, worse in morning, weight loss.

Psychotic – Delusions and hallucinations'

Catatonic – Catelepsy- trance like, disturbance in speech.

Atypical – Weight gain, hypersommia,

Postpartum – Major depression within 4 week of delivery of child.
159
3. Characteristics of Disorders: Psychotic Disorders
Psychosis is the general term for disorders that involve a loss of contact with
reality. It covers many disorders, which may involve delusions (hallucinations that
cause a person to lose their sense of what is really happening in their life). It can
therefore lead to withdrawal from the outside world as the person becomes more
confused and disorientated. Psychotic disorders tend to be characterised by
delusions and disorganised speech or behaviour, they include all types of
schizophrenia; schizoaffective disorders and brief psychotic disorders. Symptoms
can be positive with distorted thinking and can be negative where normal behaviour
such as showing emotion and speaking fluently are absent.
Schizophrenia
Positive Symptoms – present
symptoms
Delusions
Auditory hallucinations
Disorganised speech
DSM-IV Classification of
Schizophrenia -Two or more of the
following

Delusions

Hallucinations

Disorganise speech and Disorganised
behaviour

Negative symptoms
Plus

Social occupational dysfunction, at least 6
months duration – no other explanation
can be found- such as medication, or
developmental disorders.
,
Negative Symptoms – considered to be
the loss or absence of normal
characteristics.
Losing emotional responses
Inability to feel pleasure
Lack of motivation
Disorganised aspect
ICD-10 Classification of
Schizophrenia

Thought echo, thought insertion or
withdrawal broadcasting.

Delusions of control

Hallucinatory voices

Persistent delusions

Persistent hallucinations

Incoherence or irrelevant speech

Catatonic behaviour

Negative symptoms such as marked
apathy

A significant and consistent in the
overall quality of some aspects of
personal behaviour.
160
Summary: Characteristics of a Disorder

The DSM and the ICD have shown how the characteristics of disorders are
identifies and categorised, so it fairly easy to see the characteristics of each
type of disorder. Some people in high-powered jobs seem to thrive on the
pressure, while others would seem to burn out and show signs of physical and
/or mental illnesses.

What is also clear is that there is room for misdiagnosis, as some people may
show all the characteristics, or may show some to a greater or lesser degree.

Diagnosis is not simply a checklist of disorders to be ticked against a
patient’s symptom.

There is room for disagreement; biases by cultures or practitioners may
unwittingly lead to misdiagnosis or even diagnosis where there should not be
one.
161
Comprehension questions for Characteristics of Disorders
1. Anxiety Disorders – eg. phobias, post traumatic stress disorder.



What are the general characteristics of a phobia?
Which of the following is NOT a DSM-IV characteristic of a phobia?
 Marked and persistent fear that is excessive or unreasonable.
 Exposure to phobic stimulus provokes immediate feelings of guilt and worthlessness.
 The person recognizes the fear as excessive.
 The phobia has lasted more than 6 months in people under 18 years of age .
Which of the following is NOT an ICD-10 characteristic of a phobia?
 The psychological and physical response must be primarily anxiety.
 The anxiety is restricted to the phobic situation or object.
 The person with the phobia sleeps whenever possible.
2. Affective Disorders – eg. depression, bipolar, cyclothymic disorder



What are some of the general characteristics of depression?
Which of the following are DSM-IV characteristics of depression?
 insomnia most nights
 fidgeting or lethargy
 delusion of control
 marked and persistent fear that is excessive or unreasonable
 disorganised speech
 recurrent thoughts of death.
Which of the following are ICD-10 characteristics of depression?
 loss of interest and enjoyment
 The psychological and physical response must be primarily anxiety.
 thought echo or broadcasting
 persistent hallucinations
 reduced concentration
 ideas of guilt and unworthiness.
3. Psychotic Disorders – eg. schizophrenia, delusional disorder.



What are the general characteristics of schizophrenia?
Which of the following are ICD-10 symptoms of schizophrenia?
 Delusion of control.
 Increased tiredness.
 Reduced self esteem and self confidence.
 Ideas of guilt and unworthiness.
 Thought echo or broadcasting.
 Bleak and pessimistic views of the future.
 Trance-like behaviour.
 Reduced appetite.
Can you give some examples of positive and negative symptoms of schizophrenia?
162
Part A exam question for Characteristics of Disorders

Describe the characteristics of a psychotic disorder (10 marks)
Introduction
Linking sentence __________________________________________________
Main body
Linking sentence __________________________________________________
Conclusion
163
Part B exam question for Characteristics of Disorders

Evaluate difficulties when identifying characteristics of psychological
disorders(15 marks)
Introduction
Linking sentence_______________________________________________
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Linking sentence__________________________________________________
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Linking sentence_______________________________________________
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Linking sentence______________________________________________
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Linking sentence _________________________________________________
Conclusion
164
Evaluation sheet for Characteristics of Disorders
Overview of topic:
__________________
__________________
__________________
__________________
Study 1
Researcher/s:
______________________
Study 2
Researcher/s:
______________________
Study 3
Researcher/s:
______________________
Key assumption:
______________________
Key assumption:
______________________
Key assumption:
______________________
Issue:
Issue:
Issue:
Debate:
165
Explanations of Anxiety Disorders - Phobias
Three Explanations of an Anxiety Disorder
1. Watson & Raynor (1920) – Behavioural: Conditioned Emotional reaction
2. Ohman et al (1975) – Biological: Types of Phobia and biological
predisposition to them
3. Di Nardo (1998) – Cognitive: Generalised Anxiety Disorder
The main approaches in this area are behaviourism, biological psychology and cognitive
psychology and psychodynamic theory. Disorders can be explained in terms of classical
conditioning and social learning (behaviourism) or in terms of instinct (biological) or by
studying thinking patterns (cognitive).
In your exam, there will be questions on explanations of anxiety
or affective or psychotic disorders. You only need to focus on one
type- as such we will focus on anxiety
(phobias and generalised anxiety disorder).
So, in the exam you need to answer the question in relation to
anxiety disorders.
166
1. Behavioural Explanations
Phobias are seen as learnt behaviour, either through classical conditioning, operant
conditioning or social learning theory.
Classical Conditioning – Watson & Rayner (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 = Unconditioned stimulus
UCR = Unconditioned response (Natural)
CS = Conditioned stimulus
CR = Conditioned response (Manipulated)
UCS (Noise)
UCS (Noise) + CS (Rat)
CS (Rat)
UCR (Fear)
UCR (Fear)
CR (Fear)
This explanation sees the origin of phobias as through linking two things together
even though there is no logical, nor causal connection between them.
167
1. Watson & Raynor (1920) – Behavioural: Conditioned Emotional
reaction
Aim: To see if it is possible to induce a fear of a previously unfeared object through
classical conditioning.
To see if the fear will be transferred to other similar objects. To see what effect time
has on the fear response. To see how possible it is to remove the fear response in the
laboratory.
Approach/Perspective : Behavioural
Method:
A case study undertaken on one boy: ‘Little Albert who was 8 months old and lived in
the hospital with his mother, a nurse. He was ‘stolid and unemotional’. A single subject
design.
Details:
See notes on previous study on Little Albert in Dysfunctional
Conclusions:
Session 2 – After five paired presentations the conditioning of a fear response was
evident and so it is possible to condition fear through classical conditioning.
Session 3 and 4 – Transference of the fear had been made to other similar objects,
although it appeared the less like the original stimulus the objects were (e.g. the
cotton wool), the less negativity was shown.
Session 5 – Time had not removed the fear response.
Unfortunately Albert was taken out of the hospital on the day of Session 5, so
Watson and Rayner were never able to carry out their aim of trying to find ways of
removing a phobia in the laboratory. We don’t know if Albert had a fear of furry
animals for the rest of his life!
Research by Mary Cover Jones on Little Peter, (Jones, 1924) did show how a fear of
rabbits could be overcome using a treatment of systematic desensitisation.
Notes: Operant conditioning also provides am explanation for acquiring and reinforcing
a phobic behaviour. i.e Child in bed hears thunder runs to parents room, safe and
comforting. Next time thunder comes what are they going to do? Stay lonely in bed or
go to parents for comfort. Realise get cuddles if frightened of thunder so continue to
show fear. Behaviour becomes entrenched and fear reaction becomes an automatic
response.
SLT- Bandura discovered p’s would develop fear of buzzer if saw someone else in pain
when it sounded.
168
Evaluation: Issues
Evaluation: Debates
169
2.Ohman et al (1975) – Biological: Types of Phobia and biological
predisposition to them
Background: based on assumption that a disorder has a biological cause. Mental
disorders are same as physical disorders just located in diff place in the body. Mental
disorders can be treated in same way as physical illness, mainly with drugs.
This explanation sees phobias as serving an evolutionary purpose – so for example a fear
of snakes helps people to save their lives. This even introduces a genetic element.
Ost (1992) found 64% of people with blood and injection phobia had a first degree
relative who shared the same disorder. Seligman’s research on preparedness suggests
many phobias may have originally been based on instinctive responses to danger, to things
that could threaten human survival. This is because we have evolved with a fear of things
that could harm us,(simplified evolutionary theory).
Ohman set out to show how easier to induce phobias of snakes rather than nonthreatening items such as faces or houses and Ohman 1975 was more able to use classical
conditioning to cure people with fears of houses and flowers than of spiders or snakes, this could be taken as supporting Seligman’s preparedness theory.
Aim: To see if phobias of snakes could be more easily conditioned than phobias of faces
or houses, indicating a biological preparedness to develop phobias of certain objects
Approach: Behaviourist
Method: Laboratory experiment, with participants linked to a machine that would
present pictures and then deliver shocks after some of them.
Their fear reaction was measured by skin conductance.
Independent design with participants being in one of three conditions. Electric shocks
were given after presentation of snakes, houses or faces.64 paid volunteers aged 20–
30 years.
There were 38 females and 26 males and they were all psychology students from the
University of Uppsala in Sweden
Details:




Each participant was wired up to a machine that would measure their skin
conductance.
They were given a shock at a level that they as an individual rated as definitely
uncomfortable but not painful.
Pictures were presented on coloured slides for 8 seconds and, if they were going
to be given a shock, it occurred immediately as the picture was shown.
Participants were seated comfortably and told that they would experience a
number of shocks and that they would see three different types of pictures:
snakes, human faces and houses.
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

The order of the pictures was randomised.
32 participants received shocks after the snakes and of the other 32, 16 received
shocks after pictures of houses, and 16 received shocks after pictures of human
faces
Results;
All participants had a similar measure of skin conductance prior to the conditioned
stimulus (shock) being presented.
After the presentation of the shocks with the pictures the responses were as follows:
Participants shown snakes had on average .062 conductance to the snakes and .048
conductance to the houses and faces.
The higher the conductance the more they were sweating, which is a physiological
response to fear.
The control groups who were shocked after faces or houses showed only .037
conductance to their conditioned stimuli (houses or faces) and .030 to the neutral
stimuli that didn’t appear with shocks.
N.B. the unit of measurement was micro mhos, which is a measure of conductance of
electricity.
Conclusions:
Participants were more likely to show fear reactions to snakes than houses or faces.
This shows a biological preparedness to develop phobias to objects that may cause us
danger, such as snakes.
For genetic explanation it is important to realise that people do not inherit a specific
gene for an illness, such as depression, rather, people inherit the vulnerability to it.
Activity
Fred Flintstone has a phobia of dinosaurs - explain in your own words how this phobia
could be explained in terms of biology
Explanation
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Evaluation: Issues
Evaluation: Debates
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3.Di Nardo (1998) – Cognitive: Generalised Anxiety Disorder
Background: Cognitive explanations see the origin of phobias in faulty thinking –
concern about some issues that are threatening is perfectly rational, but excessive and
disproportionate anxiety is not. So a bad experience may lead to negative thoughts
which lead to fear, so the negativity and the fear feed on themselves leading to poor
thinking and an inability to cope properly when parallel situations crop up subsequently.
DiNardo (1988) studied people who had a traumatic experience with dogs; some
developed a phobia of dogs, others did not. Those who developed phobias were more
likely to believe that they would have a similar negative experience in the future.
Phobias can be maintained or made worse by the way people think about their situation.
A high level of anxiety may lead to catastrophising – imagining the worst possible
outcome of every situation whilst ignoring the possibility of positive outcomes.
Di Nardo found only half people who had had a traumatic experience with dog
develop a phobia therefore, they must interpret the event differently from those
with phobias. (Faulty thinking pattern.)
Aim: To assess whether ‘excessive worry’ is a symptom of General Anxiety Disorder
(GAD)
Approach/Perspective: Cognitive
Method: Quasi-experiment covering three clinics in the USA. Independent design.
Patients with and without diagnoses of GAD.
Procedure
Patients were interviewed twice to assess the reliability of using two different
structured interviews. The frequency of the symptom ‘excessive worry’ was analysed
along with the percentage of day for which the patient said they displayed the
symptom.
Results;
Significantly more patients with GAD reported excessive worry than non-patients.
More patients without GAD reported no-excessive worry.
Patients with GAD reported excessive worry for 59.1% of the day compared with
41.7% of non-GAD patients.
Conclusions:
Excessive worry, which indicates faulty thinking, is found in more GAD patients. Its
absence can be used to rule out a diagnosis of General Anxiety Disorder. Patients
with GAD spend more time each day worrying.
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Evaluation: Issues
Evaluation: Debates
174
Summary: Explanations of Disorders

As you can see there are many different approaches to explaining anxiety
disorders

Each approach has some relevance to our understanding

It might be useful to adopt an eclectic approach and use parts of each of these to
fully understand phobias.

Psychodynamic and social may have different explanations

All the explanations have their strengths and weaknesses, some are better at
explaining some disorders than others.

It is important to remember that human behaviour, including dysfunctional
behaviour has MANY causes, some of which we still have to identify.
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Comprehension questions Explanations of Disorders
1. Watson & Raynor (1920) – Conditioned Emotional reaction

How would the behavioural approach explain how phobias develop?

What was Albert’s first response to the rat?

Explain whether this fits in with the situational or individual debate?

This approach is thought of as highly scientific. Why?

Think of a negative issue for this study and explain it?
2. Ohman et al (1975) – Types of Phobia and biological predisposition
to them

What is biological preparedness?

What were the phobic objects to be conditioned in Ohman et al’s study on phobias
and preparedness?

What were the three conditions of the study?

How did the researchers measure the fear reaction?

Explain whether this fits in with the situational or individual debate?
3. Di Nardo (1998) – Generalised Anxiety Disorder (Cognitive
Explanation)

How does this explanation explain a phobia?

What is GAD?

What was Di Nardo’s aim?

What did he conclude?

Think of a debate which links to this study?
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Part A exam question for Explanations of Disorders

Outline a behavioural explanation of one Disorder (either affective or anxiety or
psychotic) (10 marks)
Introduction
Linking sentence __________________________________________________
Main body
Linking sentence __________________________________________________
Conclusion
177
Part B exam question for Explanations of Disorders

Compare explanations of the disorder you referred to in part (a) (15 marks)
Introduction
Linking sentence_______________________________________________
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R
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C/
C
Linking sentence__________________________________________________
C
R
E
E
C/
C
Linking sentence_______________________________________________
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R
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Linking sentence______________________________________________
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Linking sentence _________________________________________________
Conclusion
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Evaluation sheet for Explanations of an Anxiety Disorder
Overview of topic:
__________________
__________________
__________________
__________________
Study 1
Researcher/s:
______________________
Study 2
Researcher/s:
______________________
Study 3
Researcher/s:
______________________
Key assumption:
______________________
Key assumption:
______________________
Key assumption:
______________________
Issue:
Issue:
Issue:
Debate:
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Treatments for an Anxiety Disorder - Phobias
Three treatments for an Anxiety Disorder
1. McGrath (1990) – Successful Treatment of a Noise Phobia
2. Ost & Westling (1995) -Treatments for panic attacks
3. Leibowitz (1988) -Treatment of Social Phobia with Phenelenzine
The main approaches in this area are behaviourism, biological psychology and cognitive
psychology and psychodynamic theory. Disorders can be treated in terms of unlearning
behaviours or systematic desensitisation (behaviourism) or through drug treatments
(biological) or cognitive behavioural therapy (cognitive).
Treatments of disorders can be a very
contentious issue in that different
psychologists define treatment
differently. There is also the issue of
whether or not treatments are a cure for
mental illness or whether they are just a
means of helping individuals to cope with
their day to day lives.
Depending on the explanation for a
phobia, the treatment will vary.
Issues to look out for here are ethics
and reductionism, ie. ethically is the
chosen treatment the correct one for
the individual and does it fully treat the
condition or does it focus on one
explanation for a phobia (reductionism)
In your exam, there will be questions on explanations of
anxiety or affective or psychotic disorders. You only need to focus
on one type- as such we will focus on anxiety (phobias).
So, in the exam you need to answer the question in relation to
anxiety disorders.
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1. Behavioural Treatments
Behavioural treatment would consist of trying to ‘unlearn’ behaviours – so that if two
stimuli are seen as linked together but are not connected causally, then the impression
of a connection should be broken.
The following techniques are just for interest- you only need to be familiar with
systematic desensitisation
Sometimes ‘flooding’ is used. This means directly exposing the patients to the object, or
situation they fear. E.g. if you fear heights, then you would be taken to the top of a tall
building , and encouraged to stay there – the idea being that as you stayed there you
would realise there was no basis to your fear and therefore the fear would disappear.
Another therapy is Implosion Therapy. This is where the patient imagines the fear
situation – it is the same idea as flooding, only it is in the mind, not physical exposure.
Aversion therapy tries to get rid of ‘maladaptive’ behaviours by linking them to painful
experiences. E.g. putting a chemical into cigarettes to make you sick when you smoke so
that you associate smoking with being sick and therefore stop smoking. Another example
is of homosexuals being shown pictures of naked men and then blasted with electric
shocks so that instead of being aroused by the stimulus they would associate it with pain
and be ‘cured’. The problem with aversion therapy is that it causes a great deal of pain,
but generally speaking does not change the behaviour.
181
Token Economies are exactly what they claim to be – when a patient behaves in an
approved way, s/he is given a token, such as a plastic disc that can then be exchanged
for a privilege, and this reinforces ‘appropriate’ behaviour. The problem is that patients
may act to get the token, thence the privilege, rather than genuinely have changed their
behaviour.
Sometimes patients are ‘desensitised’. They are taught relaxation techniques then they
construct a fear hierarchy, - what are they just afraid of, and what they are most
terrified of, then with the help of the therapist the patient confronts each item in the
hierarchy whilst in the state of deep relaxation. This way the association between the
object, or situation, and fear, is broken, and the patient has been counter-conditioned.
Systematic desensitisation is the behavioural treatment that we will focus on
182
1.McGrath (1990) – Successful Treatment of a Noise Phobia Behaviourist
Background Behaviourists suggest that treatment consist of un-learning behaviours
in this case CC where pairing two stimuli together would result in a ‘no-fear’
response. And there is generally a lot of evidence to suggest that systematic
desensitisation works.
Aim: To treat a girl with specific noise phobias using systematic desensitisation.
Approach/Perspective (if any): Behavioural
Method: A case study that details the treatment of a noise phobia in one girl. A
single participant design.
Details:
See details of study In Treatments of Dysfunctional Behaviour
Results; At the end of the first session, Lucy was reluctant to let balloons be
burst. At the end of the first session, Lucy was reluctant to let balloons be burst
even at the far end of the corridor. When the therapist burst the balloon anyway
Lucy cried and had to be taken away. She was encouraged to breathe deeply and
relax.
By the end of the fourth session, Lucy was able to signal a balloon to be burst 10
metres away. , with only mild anxiety.
On the fifth session, Lucy was able to pop the balloons herself.
Over the next three sessions, Lucy was able to pull a party popper if the therapist
held it.
By the tenth and final session, Lucy’s fear thermometer scores had gone from
7/10 to 3/10 for balloon popping, from 9/10 to 3/10 for party poppers and from
8/10 to 5/10 for the cap gun.
Conclusions:
It appears that noise phobias in children are amenable to systematic desensitisation
The important factors appear to have been giving Lucy control to say when and
where the noises were made, and the use of inhibitors of the fear response, which
included relaxation, conservation and a playful environment
183
Evaluation: Issues
Evaluation: Debates
184
2. Leibowitz (1988) -Treatment of Social Phobia with Phenelenzine –
Biological Treatments
Background: Biological treatments are often the first treatments offered for
dysfunctional behaviour, often because diagnosis is made by medical practitioner
and the medical approach supports the use of drug therapy. One of the benefits
of psychopharmocotherapy is the speed of the effects, some drugs almost
instantaneous results. However, other therapies are now used to supplement the
biological therapy such as cognitive which can bring about longer lasting change
and without the side effects that drug therapy may incur.
Aim: To see if the drug phenelzine can help treat patients with social phobia.
Approach/Perspective : Biological
Method: A controlled experiment where patients were allocated to one of three
conditions, and treated over eight weeks. They were assessed for social phobia on
several tests such as Hamilton Rating Scale for Anxiety and the Liebowitz Social
Phobia Scale. This had common manifestations of social phobia and patents rated
1–4 for the fear produced and 1–4 for the steps taken to avoid the phobic
situation.
Details:
See details of study In Treatments of Dysfunctional Behaviour
Results;
After eight weeks significant differences were noted for the phenelzine
groups, with better scores on the tests for anxiety compared to the placebo
groups. There was no significant difference between the patients taking
atenolol and those taking a placebo
Conclusions:
Phenelzine but not atenolol is effective in treating social phobia after eight
weeks of treatment.
185
Evaluation: Issues
Evaluation: Debates
186
3. Cognitive Treatments
Cognitive treatment looks at the way a person is thinking, and tries to get the patient to
see the errors in thinking that will help bring about a cure to the disorder itself. It also
extensively uses relaxation techniques for some disorders. Cognitive Behavioural
Therapy gets the patients to identify problem feelings, thoughts, and behaviours then
progress to identifying the distortions involved and to generate alternative thoughts
and responses, while identifying the dysfunctional beliefs and schemas that give rise to
the distortions. CBT is usually a highly successful therapy.
CBT has been used to treat panic attacks. Panic attacks are sudden surges of
overwhelming anxiety and fear. The first symptoms of a panic attack are likely to be
feeling flushed or hot, sweaty palms, a feeling that you can’t catch your breath or you
are breathing too fast. When you are breathing in this way what you are doing is
reducing the amount of carbon dioxide that is in your lungs which creates these
symptoms which can be terrifying.
These may include:
A thumping heartbeat
Trembling
Tingling in hands, arms and face
Dizziness
A feeling you are about to die
Chest pain
Breathlessness
Feeling unable to swallow
Blurred vision
Intense fear
Cold hands and feet
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3. Ost & Westling (1995) -Treatments for panic attacks
Background: Cognitive Behavioural uses cognitive approach to restructure thoughts
as well as behaviourism (relaxation) the way the person behaves. Does not look at
the Cause but focuses on the present symptoms. How the person thinks about an
event and its effect on what they did. If negative thought can be reinterpreted then
the person will feel better and the behaviour will change.
Aim: To compare cognitive behaviour therapy (CBT) with applied relaxation as
therapies for panic disorder.
Approach/Perspective:Cognitive
Method: A longitudinal study with patients undergoing therapy for panic disorder.
Independent design experiment with participants randomly allocated to one of two
conditions, cognitive or drug therapy. The patients with DSM diagnosis of panic
disorder, with or without agoraphobia. Recruited through referrals from
psychiatrists and newspaper advertisements.
26 females and 12 males, mean age 32.6 years (range 23–45 years). From a variety of
occupations and some married, some single and some divorced
38 patients were diagnosed with moderate to severe depression were assessed
using Beck’s Depression Inventory and two other rating scales.
Details:
See details of study In Treatments of Dysfunctional Behaviour
Results;Applied relaxation showed 65% panic-free patients after the treatment,
82% panic-free after one year.
CBT showed 74% panic-free patients after the treatment and 89% panic-free
after a year.
These differences were not significant.
Complications such as generalised anxiety and depression were also reduced to
within the normal range after one year.
Conclusions: Both CBT and applied relaxation worked at reducing panic attacks, but
it is difficult to rule out some cognitive changes in the applied relaxation group
even though this is not focused on in this research.
188
Evaluation: Issues
Evaluation: Debates
189
Summary: Treatments for Disorders

Treatment of Disorders is a contentious issue in that different psychologist
define treatment differently. Is the treatment a cure for the mental illness or
management of the symptoms’ to enable the person to live a relatively normal life!

Different approaches take different views:
1. Biologists try to manage the symptoms through physical measures
2. Behaviourists suggest re-learning behaviour thereby curing the symptoms with
no concern for the cause.
3. Cognitive behavioural therapists try to cure by restructuring patients thinking.

The way the approach explains the disorder will lead to a treatment and each
treatment has strengths and weaknesses in terms of appropriateness and
effectiveness.

You must consider the ethical implications of the treatments and the reductionist
nature of them.

Each of these approaches is reductionist, except perhaps CBT which is in keeping
with their assumptions about behaviour, reducing their explanation down to one
factor, and treating one factor.

Again it may be useful to adopt an eclectic approach and use parts of these
theories to fully understand phobias and as before it is important to realise that
human behaviour including disorders has many causes. Some of which we still have
to identify.

It is clear that there is still someway to go to ensure that effective treatment is
available to everyone with a disorder.

None of the researchers’ are claiming 100% success rate, and so the final decision
must be left to the practitioner to decide the best way to help patients with a
mental disorder.
190
Comprehension questions Treatments for Disorders
1. McGrath (1990) – Successful Treatment of a Noise Phobia

Think of 2 strengths and 2 limitations to using behavioural treatments?

Link a debate with this study and explain it?
2. Ost & Westling (1995) -Treatments for panic attacks

Think of 2 strengths and 2 limitations to using cognitive treatments?

Link a debate with this study and explain it?
3. Leibowitz (1988) -Treatment of Social Phobia with Phenelenzine

Think of 2 strengths and 2 limitations to using biological treatments?

Link a debate with this study and explain it?
191
Part A exam question for Treatments for Disorders

How could a psychological disorder (either affective or anxiety or psychotic) be
treated biologically? (10 marks)
Introduction
Linking sentence __________________________________________________
Main body
Linking sentence __________________________________________________
Conclusion
192
Part B exam question for Treatments for Disorders

Compare approaches to treating the disorder you referred to in part (a) (15 marks)
Introduction
Linking sentence_______________________________________________
C
R
E
E
C/
C
Linking sentence__________________________________________________
C
R
E
E
C/
C
Linking sentence_______________________________________________
C
R
E
E
C/
C
Linking sentence______________________________________________
C
R
E
E
C/
C
Linking sentence _________________________________________________
Conclusion
193
Evaluation sheet for Treatments of an Anxiety Disorders
Overview of topic:
__________________
__________________
__________________
__________________
Study 1
Researcher/s:
______________________
Study 2
Researcher/s:
______________________
Study 3
Researcher/s:
______________________
Key assumption:
______________________
Key assumption:
______________________
Key assumption:
______________________
Issue:
Issue:
Issue:
Debate:
194
195