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Chapter 2

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Konstantine Zakzanis

Current paradigms and the role of cultural factors Paradigm: is a set of basic assumptions, a general perspective that defines how to conceptualize and study a subject, for together and interpret relevant data, even how to think about a particular subject  A paradigm injects inevitable biases into the definition collection of data.  There are four major types of paradigms: biological, cognitive – behavioral, psychoanalytic, and humanistic – existential  The psychodynamic and humanistic-existential paradigms have become less influential over the years. The biological paradigm  Biological paradigm of abnormal behavior is a continuation of somatogenic hypothesis. This broad perspective holds that biological processes cause mental disorders. This paradigm has often been referred to as the medical model or disease model.  In all medical illnesses some biological processes is disrupted or not functioning normally.  Removal of ovarian cysts or the entire ovaries was employed as treatment for melancholia, mania, and delusions. Contemporary approaches to the biological paradigm  Psychopathology is caused by the disturbance of some biological process. Those working with the biological paradigm assume that answers the puzzles of psychopathology will be found within the body. Behavior genetics  Behavior genetics is the study of individual differences in behavior that are attributable in part to differences in genetic makeup.  The total genetic makeup of an individual, consisting of inherited genes, is referred to as the genotype.  An individual's genotype is his or her unobservable genetic constitution; in contrast, an individual's phenotype is the totality of his or her observable, behavioral characteristics, such as levels of anxiety.  The genotype is fixed at birth, but it should not be viewed as a static entity.  Genes controlling various features of developmental switch off and on at specific times to control aspects of physical development.  The phenotype changes over time and is viewed as the product of an interaction between the genotype and the environment.  Various clinical syndromes are disorders of the phenotype, not of the genotype. Whether these genotypes will eventually engendered to phenotypic behavior disorder will depend on environment and experience.  A predisposition, also known as the diathesis, may be inherited, but not the disorder itself.  The study of behavior genetics has relied on four basic methods to uncover whether predisposition for psychopathology is inherited: comparison of members of the family, comparison of pairs of twins, and investigation of adoptees, and linkage analysis.  The family method can be used to study genetic predisposition among family members because the average number of genes shared by 2 blood relatives is known. Siblings on average, as well as parents, are identical and 50% of their genetic background.  People who share 50% of their genes with a given individual are called first- degree relatives of that person.  Nephews and nieces shared 25% of the genetic makeup of an uncle and are called second-degree relatives.  Index cases/probands: the starting point in investigations is the collection of a sample of individuals that bear the diagnosis in question  if a genetic predisposition to the disorder being studied is present, first- degree relatives of the index cases should have the disorder at a rate higher than that found in the general population.  In the twin method, both monozygotic twins (identical) and dizygotic twins (fraternal) are compared.  When the twins are similar diagnostic, there said to be concordant. To the extent that a predisposition for a mental disorder can be inherited, concordance for the disorder should be greater in genetically identical monozygotic pairs than in dizygotic pairs. When the monozygotic concordance rate is higher than the dizygotic rate, the characteristic being studied is said to be heritable.  Just because children possess the mental illness of their parents, it does not mean that they are genetically inherited.  Equal environment assumption: environmental factors that are partial causes of concordance are equally influential for monozygotic pairs and dizygotic pairs.  The equal environment assumption would assert that monozygotic pairs and dizygotic pairs have equivalent numbers of stressful life experiences.  Other factors such as violation of the equal environments assumption, the sex of the participant, and his or her age when the assessment took place can complicate the results of twin research.  Genetic and environmental factors contribute to exposure to assault traumas, for example, sexual assault.  Only environmental factors contributed to exposure to events involving non- assaultive traumas, for example car accidents or natural disasters.  Genetic factors may determine, in part, the extent to which a person is likely to experience posttraumatic stress after an assaultive trauma.  Adoptees method: the use of children with abnormal disorders who were adopted and reared apart from their parents  If high frequency of panic disorder were found in children reared apart from parents who also had panic disorder, we would have to support for the theory that a genetic predisposition is in the works for this disorder. Molecular genetics  Molecular genetics is an approach to show whether a disorder has a genetic component; it tries to specify the particular gene or genes involved and the precise functions of these genes.  Allele: refers to any one of several DNA coding that occupied the same position or location on a chromosome  A person's genotype is his or her set of alleles.  Genetic polymorphism: refers to variability among members of the species. It involves differences in the DNA sequence that can manifest in very different forms among members in the same habitat. It entails mutations in a chromosome that can be induced or naturally occurring.  Genetic discoveries among human have primarily been the product of research initially with animals.  Linkage analysis: a method and molecular genetics that is used to study people. Researchers using this method typically study families in which a disorder is heavily concentrated. They use blood samples to study the inheritance pattern of characteristics whose genetics are fully understood, referred to as genetic markers (eye color).  If the occurrence of a form of psychopathology among relatives goes along with the occurrence of another characteristic whose genes are known (the genetic marker), it is concluded that the gene predisposing individuals to psychopathology is on the same chromosome and in a similar location on that chromosome (it is linked) as the gene controlling the other characteristic.  Linkage analysis is a method in molecular genetics that is used to study people. This method is usually used to study families in which a disorder is concentrated.  Researchers can collect diagnostic information in blood samples from affected individuals and their relatives and use it to study the inheritance pattern of characteristics whose genetics are fully understood. This is called a genetic marker. For example if the occurrence of a form of psychopathology among relatives goes along with occurrence of another characteristic whose genetics are known, it is concluded that the gene predisposing individuals to the psychopathology is on the same chromosome.  Linkage analysis found association between obsessive-compulsive disorder and the gamma-aminobutyric acid type B receptor one gene.  A great success in the use of this method can be seen with the identification of specific genes on several chromosomes that are extremely important in Alzheimer's disease. Chromosome 9 is associated with enhanced risk for externalizing psychopathology (aggression and anger).  Researchers in this area often hypothesized gene–environment interactions. This is the idea that the disorder is the joint product of a genetic vulnerability and specific environmental experiences.  An exclusive focus on genetic factors promotes the notion that illness and mental illness are predetermined. This belief that ‘biology is destiny’ could limit the extent to which people try to modify the lifestyle and environmental factors. Neuroscience and Biochemistry in the Nervous System  Neuroscience is the study of the brain and the nervous system.  The nervous system is composed of billions of neurons. Each neuron has four major parts: 1. The cell body 2. Several dendrites 3. One or more axons of varying lengths 4. Terminal buttons and the many end branches of the axon  When a neuron is stimulated at its cell body or through its dendrites, a nerve impulse, which is a change in the electrical potential of the cell, travels down the axon to the terminal endings.  A nerve impulse needs to pass from one neuron to another. The terminal buttons of each axon contains synaptic vesicles, small structures that are filled with neurotransmitters, chemical substances that allow a nerve impulse to cross the synapse. The nerve impulses cause the synaptic vesicles to release molecules of their transmitter substances. These molecules flood the synapse and diffuse toward the receiving or postsynaptic neuron.  The cell membrane of the postsynaptic cell contains receptor sites that are configured so that specific neurotransmitters can fit into them. When a neurotransmitter fits, a message can be sent.  To return to its normal state the released neurons that did not find its way to the postsynaptic receptor remain in the synapse needs to be broken down by enzymes. Some neurons in the synapse are pumped back into the presynaptic cell through a process called reuptake.  Norepinephrine, a neurotransmitter of the peripheral sympathetic nervous system, is involved in producing states of high arousal and this may be involved in anxiety disorders. Both serotonin and dopamine are neurotransmitters in the brain. Serotonin may be involved in depression and dopamine in schizophrenia.  Another brain transmitter is GABA, which inhibits some nerve impulses and may be involved in anxiety disorders.  The onset of puberty results in a decrease in serotonin and the decrease in dopamine activity in certain cortical areas. The changes of hormones as the brain continues to develop contribute to the increased risk of psychopathology during adolescence.  Some theories propose that a given disorder is caused by either too much or too little of a particular transmitter. For example mania results from too much norepinephrine, and anxiety disorders from too little GABA.  Neurotransmitters are synthesized in the neuron to a series of metabolic steps that begin with an amino acid. An enzyme catalyzes each reaction. Too much or too little of a particular transmitter could result from an error in these metabolic pathways.  Similar disturbances in the amounts specific transmitters could result from alteration in the usual processes by which transmitters are deactivated after being released into the synapse. A failure to pump leftover neurotransmitter molecules back into the presynaptic cell would leave excess transmitter molecules in the synapse. When a new nerve impulse cause further neurotransmitter substances to be released into the synapse, the postsynaptic neuron would get a double dose of neurotransmitter making more likely for new nerve impulse to be created.  The delusions and hallucinations of schizophrenia may result from an overabundance of dopamine receptors. Biological Approaches to Treatment  Implication of the biological paradigm is that prevention or treatment of a mental disorder should be possible by altering bodily functioning.  The use of psychoactive drugs has been increasing. In 1985, psychoactive drugs were prescribed in the US about 33 million physician visits and in 1994, almost 46,000,000.  Tranquilizers such as Valium can be effective in reducing the tension associated with some anxiety disorders possibly by stimulating GABA neurons to inhibit other neural system that create the physical symptoms of anxiety.  Antidepressants such as Prozac (now most widely prescribed psychoactive drugs) increase neural transmission in neurons that use serotonin as a neurotransmitter by inhibiting the reuptake of serotonin.  Antipsychotic drugs such as Clorazil used in the treatment of schizophrenia reduce the activity of neurons that use dopamine is a neurotransmitter by blocking the receptors.  Stimulants increase the level of several neurotransmitters that help kids pay attention.  Some disorders need medication such as schizophrenia and bipolar.  Drugs can take effect relatively quick in comparison to psychological interventions.  Treatment of depression with selective serotonin reuptake inhibitors rather than a placebo is associated with clinical improvement of symptoms by the end of first week of use. The improvement continues at a decreasing rate for at least six weeks.  Nonbiological intervention can have beneficial effects.  Effects of CBT on OCD showed decreased metabolism in the right caudate nucleus whereas CBT for phobia resulted in decreased activity in limbic and paralimbic areas.  Due to findings from brain imaging research, antipsychotic medication cannot be prescribed that the fraction of the dosages considered standard 10 years ago. These effects are similar to those observed after successful treatment with SSRIs.  Neural imaging research is beginning to show the involvement of prefrontal and limbic regions in the perception and modulation of psychological stress.  Functional imaging could ultimately prove useful to monitor treatment effects and facilitate choice of intervention Evaluating the Biological Paradigm  Reductionism refers to the view that whatever is being studied can and should be reduced to its most basic element or constituents. Reductionism asserts that psychology; psychopathology and psychiatry will ultimately be nothing but biology.  The whole is greater than the sum of its parts.  In philosophical circles, the reductionist perspective has been severely criticized. Problems such as delusional beliefs and dysfunctional attitudes may be impossible to explain biologically, even with a detailed understanding of the behavior of individual neurons. It can be a result of psychological or social factors. Psychological interventions can be as effective as drug treatment and produce changes in the functioning of our brains.  Psychiatric disorders cannot be reduced to abnormalities in oral or molecular activity and psychological problems need to be understood at multiple levels.  Behavioral/learning paradigms and cognitive approaches were eventually combined in the cognitive behavioral paradigm. This perspective emphasized the role of social factors, including socio-cultural considerations and internal psychological processes. The Cognitive-Behavioral Paradigm  Contemporary versions of cognitive – behavioral therapy are primarily cognitive in their emphasis, however the principles from behavioral or learning perspective have been incorporated. The Behavioral Perspective  This perspective view abnormal behavior is responses learned in the same way as other human behaviors. The Rise of Behaviorism  John B Watson was a key figure in behaviorism. Behaviorism was a response to the focus on introspection favored by human psychology.  Watson promoted a focus on behaviorism by extrapolating the work of psychologist investigating learning in animals. The dominant focus of psychology switch from thinking to learning.  Behaviorism: an approach that focuses on observable behavior rather than consciousness.  Classical conditioning: o (Pavlov), unconditioned stimulus; a stimulus elicits a response with no prior learning. o Unconditioned response: the response elicited by an unconditioned stimuli. o Conditioned stimuli: the conditioned stimulus is previously neutral stimulus that, after becoming associated with the unconditioned stimulus, eventually comes to trigger a conditioned response. o Conditioned response: the conditioned response is the learned response to the previously neutral stimulus. o Extinction: refers to the lowering of the probability of a response when a characteristic reinforcing stimulus is no longer presented.  Classical conditioning could instill pathological fear.  Operant Conditioning: o (Thorndike), law of effect: behaviour that is followed by satisfying consequences will be repeated and behaviour that is followed by unpleasant consequences will be discouraged (first called instrumental learning) o Skinner introduced operant conditioning, applied to behaviour that operates on the environment. He reformulated the law of effect by shifting the focus from the linking of stimuli and responses (S-R connections) to the relationships between responses and their consequences or contingencies. o Stimuli do not so much get connected to responses as they become the occasions for responses to occur, if in the past they have been reinforced. o Discriminative stimulus: external events that in effect tell an organism that if it performs a certain behaviour a certain consequence will follow. o Renaming the law of effect “principle of reinforcement”, skinner distinguished 2 types of reinforcement:  Positive reinforcement: refers to the strengthening of a tendency to respond by virtue of the presentation of a pleasant event, called a positive reinforcer.  Negative reinforcement: also strengthens a response, but it does so via the removal of an aversive agent, such as the cessation of electric shock, called negative reinforcers. o Shaping: rewarding a series of responses that are successive approximations of the desired response.  Modelling: o Learning by watching and imitating others. o Self efficacy: an individual’s perceived sense of being capable o 4 key processes in observational learning: attention, retention, reproduction and motivation o Modeling explained acquisition of abnormal behavior. Behavioral Therapy  Behaviour therapy/behaviour modification: is an attempt to change abnormal behaviour, thoughts and feelings by applying in a clinical context the methods used and the discoveries made by experimental psychologists in their study of both normal and abnormal behaviour.  Three theoretical approaches and behavior therapy includes: o Modeling o Counterconditioning and exposure: because learning paradigms assumed that behavior is the result of learning, treatment often involves relearning a new more adaptive response. Counter conditioning is relearning achieved by eliciting a new response in the presence of a particular stimulus. Eliciting a new response in the presence of those stimuli can eliminate a response to a given stimulus. The counter conditioning principle derives from a behavior therapy technique called systematic desensitization. It is hypothesized that counter conditioning underlies the efficacy of desensitization; a state or response antagonistic to anxiety is substituted for anxiety as the person is exposed gradually to stronger and stronger doses of what he or she fears. Another type of counter conditioning is aversive conditioning. In aversive conditioning, a stimulus is often paired with an unpleasant event. o The application of a operant conditioning o (Cognitive-behavior therapy is often considered a fourth aspect of behavior therapy)**  Systematic desensitization:  A person who suffers from anxiety works with the therapist to compile a list of feared situations, starting with those that arouse minimal anxiety and progressing to the most frightening.  The person is also taught to relax deeply  Step-by-step, while relaxed, the person imagines the graded series of anxiety- provoking situations  The relaxation tends to inhibit any anxiety that might otherwise be elicited by the imagined scenes.  The fearful person becomes able to tolerate increasingly more difficult imagined situations as he climbs the hierarchy over a number of therapy sessions.  Aversive conditioning: a stimulus attractive to the patient is paired with an unpleasant event, such as a drug that produces nausea, in the hope of endowing it with negative properties. Operant Conditioning as an intervention:  Problem behaviour is thought to have four possible consequences: 1. Attention seeking 2. Escape from tasks 3. The generation of sensory reinforcement 4. Accessing tangible items or other reinforcers.  Making positive reinforcers contingent on behavior is used to increase the frequency of desirable behavior.  Problems treated with this method include autism, learning disabilities, mental retardation, bedwetting, aggression, hyperactivity, tantrums and social withdrawal.  The main premise is that the same learning conditions and processes that created maladaptive behavior can also be used to change maladaptive behavior.  Treatment typically consists of altering the consequences of the problem behavior. For example, by time-out; where the person is banished for a period of time to a dreary location with no positive reinforcers. The Cognitive Perspective  Cognition: a term that groups together the mental processes of receiving, recognizing, conceiving, judging, and reasoning. This paradigm focuses on how people structure their experiences, how they make sense out of them, and how they relate their current experiences to past ones that have been stored in memory. The Basic of Cognitive Theory  Cognitive psychologists regard the learner as an active interpreter of the situation, with the learner's past knowledge and posting perceptual funnel and experience. The learner fits new information into an organized network of already accumulated knowledge, often referred to as a schema, or cognitive set. These psychologists believe that the learning process consist of a much more complex process than the passive formation of new stimulus – response associations.  New information may fit schema, but if it does not, the learner rearranges the schema to fit the information or construes the information in such a way that fit the schema.  A widely held view of depression places the blame on a particular cognitive set, namely, individuals overriding sense of hopelessness. Beck’s Cognitive Therapy  Psychiatrist Aaron Beck developed cognitive therapy for depression based on the idea that a depressed mood is caused by distortions in the way people perceive life experiences.  A depressed person may focus exclusively on negative happenings and ignore positive ones.  Beck’s therapy tries to persuade clients to change their opinions of themselves and the way in which they interpret their life. The general goal of this therapy is to provide clients with experiences, both inside and outside the consulting room that will alter their negative schemas and dysfunctional beliefs and attitudes.  The main emphasis of this therapy is to replace negative thoughts with more adaptive thoughts. Beck dismissed the old psychoanalytic theory, that depression is self – directed hostility. He replaced it with the motto of negative cognitive bias – an automatic misprocessing of information.  The brain imaging studies demonstrate an overreaction of the amygdala to negative stimuli. Rationale-Emotive Behavior Therapy  Albert Ellis also held the thesis that suggested that sustained emotional reactions are caused by the internal sentences that people repeat to themselves, and these self – statements reflect sometimes unspoken assumptions-irrational beliefs- about what is necessary to lead a meaningful life.  He developed a therapy called rational – emotive behavior therapy. This therapies aimed is to eliminate self – defeating beliefs through a rational examination of them.  Ellis suggested that many people actually believe that they must be thoroughly competent in everything they do. Therefore, if a person makes an error, it becomes a catastrophic. A person's unrealistic expectation is unproductive and creates severe emotional distress and behavioral dysfunction. Clinical Implementation of Rational-Emotive Behavior Therapy  In REBT, once a therapist becomes familiar with the client’s problem, the therapist presents the basic theory of rational – emotive behavior therapy so that the client can understand and accept it. The therapist persuade the client that his or her emotional problems will benefit from a rational examination, the therapist proceeds to teach the person to substitute for rational self – statements and internal dialogue meant to ease the emotional turmoil.  Once a client verbalizes a differently belief or self statement during a therapy session, it must be made part of everyday thinking. The client is given homework assignments designed to help them experiment with the new self talk and to experience the positive consequences of viewing life in a positive light. Cognitive Behavior Therapy  Classical behavior therapies emphasize the direct manipulation of overt behavior and occasionally covert behavior, with thoughts and feelings being construed as internal behaviors (a.k.a. meditational learning). It pays little attention to direct alternation of the thinking and reasoning processes of the client.  Bandura and other theorists were influential in promoting the notion that external events are also represented and reflected internally by conditions, and then focusing on a particular person, it is important to consider the interplay of behaviors and conditions.  Cognitive behavior therap
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