Treatment: Depression

• Examine biomedical, individual and group approaches to treatment
• Evaluate the use of biomedical, individual and group approaches to the treatment of one disorder
• Discuss the use of eclectic approaches in treatment
• Discuss the relationship between etiology and therapeutic approach in relation to one disorder

1. Biological:
- Janowsky et al suggested that depression may stem from an imbalance in neurotransmitters. He gave participants a drug that decreased noradrenaline in their body, and found that participants became profoundly depressed within minutes of having taken the drug. The fact that depression can be artificially induced by certain drugs suggest that some cases of depression might stem from a disturbance in neurotransmission.
- Teutung et al analysed and compared urine samples from depressed and non-depressed patients. He found that depressed people's urine had lower levels of noradrenaline and serotonin compared to non-depressed patients, and concluded that depressed people have lower levels of certain neurotransmitters. 

Biomedical:

The biomedical approach is based on the assumption that if the problem is caused by biological malfunctioning, drugs can be used to restore the biological system. Since depression involves imbalances in neurotransmitters (typically low levels of serotonin/adrenaline), then drugs can be used to elevate a depressed mood. Most common groups of drugs are known as SSRIs - selective serotonin reuptake inhibitors - which increases the level of serotonin.

Studies For:
- Bernstein et al found that antidepressant drugs are an effective way to treat depression in the short run, significantly helping 60-80% of people.
- Kirsch and Sapirstein analysed the results from 19 studies, covering over 2318 patients who had been treated with SSRIs, and found that antidepressants were 25% more effective than a placebo.
- Cujipers et al found that medication was more effective in psychotherapy in improving symptoms, but that the best results were found in studies that used a combination of drugs and medication.

Studies Against:
- Blumenthal et al found that exercise was just as effective as SSRIs in treating depression in an elderly group of patients
- Leuchter and Witte found that depressive patients receiving drug treatments improved just as well as those receiving a placebo. Researchers argue that the brain does not respond to the same way to placebos and drugs, but people's mental health improved even when on a placebo, indicating that there are other ways to improve from depression other than antidepressants, which may have side effects.

Evaluation:
Generally, antidepressant drugs are an effective way to treat depression, but only in the short term. Just relying on drugs will not cure depression, as well as they have side effects, such as sexual problems, insomnia, and dry mouth. It is also argued that drugs do not target the problem, but just address the symptoms. It is therefore important for patients to use a combination of both drugs and therapy - drug itself is unlikely to make the disorder disappear permanently.

2. Cognitive:

- Beck et al suggested that cognitive distortion theory of depression, which are ways in which our mind convinces us of something that isn't true. He proposed that a person's cognitive vulnerability to depression is based on negative schemas, which are activated by stressful events. This gives the person a pessimistic attitude about themselves, the world and the future, making it very difficult for the person to see anything positive in life.

- Wessman and Beck assessed the thought processes of depressed people to establish if they were using negative schemas. Thought processes were assessed by using the dysfunctional attitude scale (DAS). Participants were asked to fill in a questionnaire by ticking whether they agreed or disagreed with a set of statements. They found that depressed people were more likely to make negative assessments than non-depressed people. 

- Alloy et al followed a sample of young Americans in their 20s for 6 years. Their thinking style was tested and they were placed in the "positive thinking group" and the "negative thinking group" according to their ways of thinking. After 6 years, they found that only 1% of those in the positive thinking group developed depression compared to 17% of those in the negative thinking group. The results indicate that there may be a link between negative cognitions and depression.

Individual Approach

The individual approach to depression is aimed to deal with distorted cognitions. Cognitive-Behaviourial therapy is an example of individual therapy, and it consists of identifying the negative thoughts assumed to underlie depression as well as helping the person to understand the connection between their negative thoughts and their emotional state.

Studies For:
- Rush et al found that CBT is an effective way of treating patients
- Dobson also found that cognitive therapy is more effective than drugs or a placebo
- Riggs et al studied effectiveness of CBT in combination with either a placebo or an SSRI. The researchers concluded that treatment with drugs and CBT is effective but that treatment with a placebo and CBT is almost as effective. This shows that CBT is effective.
- Nemereoff et al found that CBT in combination with drugs was the most effective in treating depression

Evaluation:

Cognitive therapies are cost-effective because they do not usually involve prolonged treatment. They are effective in treating the cause of the problem. No side effects have been found.

3. Group Approaches
Group approaches are for those that find it difficult to share with a therapist, and may be more encouraged to open up in discussions when they are surrounded with others that are going through a similar phase.

Studies For
- Hyun et al randomly assigned depressed adolescents to group CBT or a group receiving no treatment. They found group CBT to be extremely effective at relieving symptoms of depression, compared to the group receiving no treatment.
- Siporin reviewed 74 studies comparing individual and group treatment. Group treatment was found to be as effective as individual treatment in 75% in the studies, and more effective in the remaining 25%. In no case was individual therapy found to be more effective than group therapy.

Evaluation
Group approaches are effective, but dissatisfaction with the group or any of its members may lead to drop out and this will affect the effectiveness. Many factors need to be considered: confidentiality and privacy, must not be exclusion or group cohesion, conformity etc. Other people may not be comfortable in sharing. Studies have shown that group therapy is highly effective, and more effective than individual therapy.

Discuss cultural and gender variations in prevalence of disorders

This essay will focus on the cultural and gender variations in the prevalence of an affective disorder, depression, and an eating disorder, bulimia nervosa, and whether or not there is a cultural and gender difference in the onset of these disorders.

Individuals with bulimia are afraid of weight gain, and they will undertake binge eating and then use compensatory methods to lose weight, such as induced vomiting, excessive exercise and use of laxatives. Symptoms of bulimia include swollen salivary glands, due to vomiting, stomach and intestinal problems, feelings of guilt after binge eating and negative distorted image about their body weight.

According to statistical evidence, eating disorders are more common in females than in males. An estimated 35% of those with binge-eating disorders are males, with the rest of it being females. Eating disorders are also more common in teenagers, with 50% of girls between the ages 11-13 seeing themselves as overweight.

Fallon and Rozin wanted to see if there was a gender difference in body image. They showed US undergraduates figures of their own sex and asked them to indicate the figure that looked most like their shape and their ideal figure. Men selected very similar figures, whereas women tend to choose thinner attractive bodies that were much thinner than the shape they indicated as their own. They also asked men to choose a female figure that they thought was attractive to them, and found that the figure they found attractive was heavier than the ideal figure that women chose. Women believed that men prefer thinner women than they actually do. They concluded that there is a gender difference in the perception of body image, which explains why women are more susceptible to eating disorders than men.

There are also cultural differences in the susceptibility of bulimia. Lee, Hsu and Wing found that bulimia and anorexia was non-existent among the Chinese in Hong Kong. Chinese people are usually slim, and therefore they do not share the Western fear of being fat. The Chinese regard thinness as a sign of ill-health, unlike the Western view that it is a sign of self-discipline. Obesity is a sign as a sign of weak control in the West, whereas Chinese people see it as a sign of wealth and prosperity. Having grown up in Hong Kong myself, I have never met someone with an eating disorder, and the majority of people are either underweight or within the normal weight range.

Baguma et al also found cultural differences in the susceptibility of bulimia. It seems that the culture we live in really affects our eating behaviours. He asked British and Uganda students to examine a set of nude bodies ranging from very thin to very obese. When asked to rate which body they thought were ideal, the British people tend to chose very thin bodies, whereas Uganda students chose very obese bodies. In the Uganda society, fat is beautiful, and in the British society, slim is attractive. Thus this shows that cultural factors affect the way we think, which may explain why the Western society has such a high rate of people with eating disorders.

Similarly, there are also cultural and gender variations in the prevalence of depression. People with depression usually experience feelings of guilt and sadness, lack of enjoyment and pleasure in anything. They will have frequently negative thoughts, including low self-esteem and suicidal thoughts.

According to statistical evidence, women are two to three times more likely to be clinically depressed than men. Women are also more likely to experience several episodes of depression. This may be explained by gender norms or gender differences in society. Koss et al found that discrimination against women began early in their lives. Women are twice as likely to suffer sexual abuse in childhood and this pattern of victimization is maintained in adulthood, where women make up the majority of victims in physical assault.

Culture may also influence our onset of depression, as some cultures discourage depression more than others. For example, Chiao et al found that depression was higher in individualistic cultures than in collectivistic cultures. Similarly, Gabilondo et al found that depression occurs less frequently in Spain (collectivistic culture) and there there is a lower suicidal rate compared to Europe countries (individualistic). This is perhaps because collectivist groups discourage depression as they have more social support than individualistic cultures, who encourage independence.

In conclusion, there are cultural and gender variations in the onset of depression and bulimia. In both disorders, women are more vulnerable and susceptible in developing these disorders than men. Similarly, culture also plays an important role in the influence of these disorders. People are affected by their culture - if their culture rewards thinness, then they will strive to be thin.

Affective Disorder: Depression

Discuss to what extent biological, cognitive and sociocultural factors influence abnormal behaviour

Evaluate psychological research (that is, theories and/or studies) relevant to the study of abnormal 

To what extent do biological, cognitive and sociocultural factors influence abnormal behaviour

This essay will focus on the biological, cognitive and social factors that influence the affect disorder: depression. People who are depressed usually experience feelings of guilt and sadness, lack of enjoyment or pleasure in anything. They will have frequently negative thoughts about themselves, including low self-esteem and suicidal thoughts.

The biological factors that I will be focusing on is evolutionary origins, genetic predisposition and effects of neurotransmitters.

Hagen et al suggested that depression has evolutionary origins. It is a psychological adaption favoured by natural selection and serves two purposes: to signal need and elicit help from others. He suggested that depression is evolved towards loss and failure. The feelings of sadness triggered by loss or failure is adaptive because it would discourage the behaviour that led to it, thus preventing even greater loss. This may explain why females are more susceptible to depression because of the defeat in competition with males. However, evolutionary theories of depression remain speculative and there has not been much evidence to prove that this is true.

Genetic researchers argue that genetic predisposition may predispose some people to develop depression more easily than others. Nurnberger and Gershon reviewed the results of 7 twin studies with monozygotic and dizygotic twins in which one pair had been diagnosed with depression. He found that the concordance rate (which is the inheritance of two related individuals) to be higher for monozygotic twins (65%) compared to dizygotic twins (14%). This supports the hypothesis that genetic factors might predispose some people to depression. Long-term stress may result in depression in some individuals who have this genetic predisposition which makes them more vulnerable and susceptible in developing depression compared to those that do not have this genetic predisposition. However, because the concordance rate was not 100%, this means that genetics are not entirely to blame, but that other factors may have influenced depression as well. 

Another biological explanation is neurotransmitters. Janowsky et al suggested that depression may stem from an imbalance in neurotransmitters. He gave participants a drug that decreased noradrenaline in their body, and found that participants became profoundly depressed within minutes of having taken the drug. The fact that depression can be artificially induced by certain drugs suggest that some cases of depression might stem from a disturbance in neurotransmission. In a similar study, Teutung et al analysed and compared urine samples from depressed and non-depressed patients. He found that depressed people's urine had lower levels of noradrenaline and serotonin compared to non-depressed patients, and concluded that depressed people have lower levels of certain neurotransmitters. However, abnormal levels of neurotransmitters may not cause depression, but may be the case that depression causes imbalances in neurotransmission - the direction of cause and effect is uncertain. The human body is very complex, and so we cannot simply attribute our behaviour to neurotransmitters.

After identifying the biological factors that could influence depression, we are still left without a clear understanding of how depression may develop. The evolutionary theory seems vague without much supported evidence, genetic predisposition is not 100%, and the direction of cause in neurotransmitter is uncertain. 

Perhaps the cognitive level of analysis may suggest a more clear understanding, as it is more related to how we develop depression in the first place. Beck et al suggested that cognitive distortion theory of depression, which are ways in which our mind convinces us of something that isn't true. He proposed that a person's cognitive vulnerability to depression is based on negative schemas, which are activated by stressful events. This gives the person a pessimistic attitude about themselves, the world and the future, making it very difficult for the person to see anything positive in life.

Wessman and Beck assessed the thought processes of depressed people to establish if they were using negative schemas. Thought processes were assessed by using the dysfunctional attitude scale (DAS). Participants were asked to fill in a questionnaire by ticking whether they agreed or disagreed with a set of statements. They found that depressed people were more likely to make negative assessments than non-depressed people. This supports Beck's theory that depression is based on negative schemas. However, because the study was based on questionnaires, there is the question of whether it is valid because people may not take questionnaires seriously or their answers may just be guesses. 

In another study, Alloy et al followed a sample of young Americans in their 20s for 6 years. Their thinking style was tested and they were placed in the "positive thinking group" and the "negative thinking group" according to their ways of thinking. After 6 years, they found that only 1% of those in the positive thinking group developed depression compared to 17% of those in the negative thinking group. The results indicate that there may be a link between negative cognitions and depression. This, again, supports Beck's theory. 

However, Beck's theory is reductionist, meaning it doesn't take into consideration biological or sociocultural factors and how they interact. The participants in the study may have been influenced by other factors, such as genes or social/cultural factors, and not purely by the way they think. Also, not everyone in the negative thinking group developed depression, meaning that not everyone who has this pattern of thinking became depressed. 

To derive oneself to think negatively about themselves and their lives may mean that they must've been influenced in some way by social or cultural factors. No doubt bad lifestyle and intense stress will contribute to our mood.

Brown and Harris wanted to investigate the social factors that might contribute to depression in women of child-bearing age. They interviewed a total of 400 women and found that a total of 15% of women were depressed and 18% were on the borderline of being depressed. They identified the following contributory social factors that lead to depression:

- not having paid unemployment

- having 3 or more children under the age of 14 living at home

- not having a close and confiding relationship with a partner

- loss of their own mother in childhood

Brown and Harris also found that working-class women were five times more likely to be depressed than middle-class women, perhaps because of the stress that they experience in relation. Social factors, such as isolation, stress, poverty and lack of support with child care, all contribute to the onset of depression, according to Brown and Harris.

Culture may also influence our onset of depression, as some cultures discourage depression more than others. For example, Chiao et al found that depression was higher in individualistic cultures than in collectivistic cultures. Similarly, Gabilondo et al found that depression occurs less frequently in Spain (collectivistic culture) and there there is a lower suicidal rate compared to Europe countries (individualistic). This is perhaps because collectivist groups discourage depression as they have more social support than individualistic cultures, who encourage independence. 

The sociocultural approach seems much more clear as we tend to be depressed when we are under stress or when we are lonely and without friends. 

It may also be the interaction of biological, cognitive and sociocultural factors that causes depression. For example, depression may be the result of a genetic predisposition, with precipitating events in the environment (i.e. stress) combined with negative cognitive distortions.

Eating Disorder: Bulimia

Discuss to what extent biological, cognitive and sociocultural factors influence abnormal behaviour

Evaluate psychological research (that is, theories and/or studies) relevant to the study of abnormal 

To what extent do biological, cognitive and sociocultural factors influence abnormal behaviour

This essay will focus on the biological, cognitive and social factors that influence the eating disorder: bulimia nervosa. Individuals with bulimia are afraid of weight gain, and they will indulge in binge eating and then using compensatory methods to prevent weight gain, such as induced vomiting, excessive exercise and use of laxatives. Symptoms of bulimia include swollen salivary glands, due to repeated vomiting, stomach and intestinal problems, feelings of guilt after binge eating, as well as negative distorted image about their body weight.

The biological factors that I will be focusing on is evolutionary origins, genetic predisposition and effects of neurotransmitter.

Frisch et al suggested that eating disorders have evolutionary origins. During times of poor environment, where pregnancy would be difficult and offspring would have little chance of survival, it would have been adaptive for women to delay their pregnancy until a more appropriate time. Because low body fats results in termination of ovulation and menstruation, extreme dietary behaviours will eventually lead to the  loss of fertility and the suppression of reproduction. Thus, preferences for thinner bodies would have been ideal for women who wanted to delay their pregnancy. However, an obvious weakness of this theory is that it excludes males, and it does not explain the eating behaviours in women that are not living in poor economic environments.

Genetic researchers argue that genetic predisposition may have influenced some people to be more "bulimic" than others. Kendler et al studied 2000 female twins in which at least one pair had been diagnosed with bulimia nervosa. He found that the concordance rate (which is the inheritance of two related individuals) to be consistently higher in monozygotic twins than dizygotic twins. Concordance rate was 23% in MZ twins compared to 9% in DZ twins, which suggests that genetics may have predispose some to develop eating disorders than others. The sample size was also very large, so it can be generalizable. However, concordance rate is not 100%, which means that genetics are not entirely to blame, but that other factors may have influenced eating disorder as well.

Another biological explanation is the role of neurotransmitters. Scientists have found low levels of serotonin in the brain of patients with eating disorders. Evidence of this is the study of Smith et al, who wanted to investigate the role of serotonin in patients with bulimia nervosa. Patients who recovered from bulimia nervosa were given a drug that reduced their serotonin levels. Smith closely monitored changes in behaviour after that. He found that patients reported an increase in negative thoughts about their body when their serotonin levels dropped. He concluded that low levels of serotonin may cause bulimia. Support for this theory also comes from an effective treatment for bulimia. Antidepressant drugs that increase serotonin levels can lead to dramatic reductions in the frequency of binge eating, according to Sterling and Hellewell. However, abnormal levels of neurotransmitters may not cause eating disorders, but may be the case that eating disorders cause changes in neurotransmitter - the direction of cause and effect is uncertain. The human body is very complex, and so we cannot simply attribute our behaviour to neurotransmitters.

After identifying the biological factors that could influence bulimia, we are still left without a clear understanding of how eating disorders may develop. The evolutionary theory seems vague and inapplicable in our society now, genetic predisposition is not 100%, and the direction of cause in neurotransmitter is uncertain.

Perhaps the cognitive levels of analysis may suggest a more clear understanding, as it is more related to how we develop eating disorders in the first place. Bruch suggested the body image distortion hypothesis, where many eating disorder patients suffer from the illusion that they are fat even when they are within the normal BMI range, and they tend to over-estimate their body size.

Zellner et al investigated women's assessments of their own body size. Female participants were given a questionnaire to see if they have a distorted image of their body. Females with high scores have a distorted image about their body, and females with low scores do not have a distorted image about their body. High scorers and low scorers were then assessed on their own body size, using line drawings of figures that ranged from thin to obese. The researchers then told the participants to choose a body that best resembled their own. They found that female participants with high scores tend to over-estimate their own body size and chose a larger body compared to female participants with low scores. This supports the body image distortion hypothesis, and it may be the case that many of the patients who suffer from eating disorder have a distorted image of their own body, and thus turn to extreme dietary behaviours to improve this. A weakness of this study is that it did not prove that patients with eating disorders have distorted image of their body, as the participants in this study did not suffer from eating disorder. It also excluded males, and therefore this study lacked population validity. Questionnaires are also an unreliable source of information, as participants usually don't know what to think and their answers may be "guesses". Those who scored low in the questionnaire may be too embarrassed to admit that they think negatively of their body, and there is the question of socially desirability bias in the questionnaire.

The cognitive explanation that people with eating disorders suffer from cognitive distortions is more descriptive than explanatory, as it does not explain how these distortions arise in the first place. It could also be the case that patients with eating disorder have distorted cognitions, rather than vice versa, and so it is difficult to establish cause and effect.

However, to derive oneself to think that their bodies are not ideal would mean that they must've been influenced in some way by social or cultural factors. Over the past 50 years, the ideal body shape for woman has changed in Western society, with more progression towards increasing thinness. The social learning theory states that people learn through observation and imitation of role models. As models start becoming increasingly thinner, this puts pressure on the people in society, who wants to imitate this rewarded behaviour by striving to be slim.

Orgen looked for evidence that the ideal shape for woman has become slimmer. The physical features of female fashion models from 1967-1987 were analysed. They found that over the 20 year period, models became taller, with a decrease in hip and bust measurements relative to waist size. Orgen concluded that the ideal female shape had become more androgynous and more slim. 

Bemis suggest that eating disorders arise from attempts by young woman to conform to a stereotypical and unrealistic body shape shown in magazines, televisions and advertisements. Many young woman look to the media for information about what is desirable, and if thinness appears to be highly valued than they would want to be thin as well.

Baguma et al carried out an experiment to see whether different societies and cultures will influence our body shape. He asked British and Uganda students to examine a set of nude bodies, ranging from very thin to very obese, and asked them to choose the body that they would want. He found that whereas British students chose very thin bodies, Uganda students chose very obese bodies. This is because in Western cultures, being thin is beautiful, but in Uganda being fat is beautiful. This shows that social and cultural factors influence how we think, which might explain why the Western society has such a high rate of people with eating disorders.

Support for this theory also comes from Lee, Hsu and Wing, who noted that bulimia and anorexia was non-existent among the Chinese people in Hong Kong. This can be largely explained in terms of sociocultural differences. Chinese people are usually slim, and do not share the Western fear of fatness. The Chinese regard thinness as a sign of ill-health and misfortune rather than the Western view of self-discipline. Obesity is seen as a sign of weak control, whereas Chinese people see it as a sign of health and prosperity.

The sociocultural approach seems much more clear, and that it is the society that has affected many individuals to develop eating disorders in attempt to look like models in adverts and feel beautiful about themselves. This is seen most in the Western society, where eating disorders are much more common. In societies like Hong Kong and Uganda, there is less pressure to be thin and therefore eating disorders are rare and almost non-existent.

It may also be the interaction of biological, cognitive and sociocultural factors that causes eating disorders. For example, it could be that genetic predisposition drives someone to think negatively about their body, and additional exposure to the environment and society's wants may have influenced someone to undertake binge eating and extreme dietary behaviours in order to improve their self-esteem and confidence.

Discuss cultural and ethical considerations in diagnosis

Diagnosis is the identification of groups or patterns of mental symptoms that reliably occur together to form a type of disorder. Diagnosing mental disorders is a very delicate process. Psychologists and clinicians must take precautions when making a diagnosis, as once a diagnosis is made, the life of the individual may be changed forever.

Concepts of abnormality differ between cultures, and this can have a significant influence over the validity of diagnosis. Behaviour that seems abnormal in one culture may be seen as perfectly normal in another, and therefore clinicians must take into account cultural considerations when making a diagnosis. They must take an emic approach to diagnosis.

For example, Koro is a culturally-bound syndrome in China where men believed that the penis is shrinking and that it will withdraw to the abdomen and cause death. Symptoms of this include fear and anxiety, and attempts to put weights on their penis to prevent it from retracting. Since this disorder is only found in China, some diagnostic manuals will not have it. The existence of culturally bound syndromes means that it is important for clinicians to consider the disorders found in many diagnostic manuals in order to make a fair assessment of the individual.

Cultural bias is also found in diagnosis. Sabin found cultural bias when clinicians were exposed to non-English speaking patients such as Mexican-Americans. The patient's emotional problems and symptoms were often misunderstood, which may explain why there is a much higher incidence of diagnosis made on ethnic minorities in the US and UK. Jenkins-hall and Sacco took Western clinicians and asked them to watch interviews with possible patients. There were four different conditions. The first condition was a Western-American woman that was not depressed. The second condition was an African-American woman that was not depressed. The third condition was a Western-American woman that was depressed. The fourth condition was an African-American woman that was depressed. The researchers found that the clinicians rated the non-depressed woman as the same, but that they were more likely to diagnosis the African-American woman depressed and less socially competent than the Western-American depressed woman. This shows that cultural bias exists, and therefore clinicians must take this into account. For a more reliable diagnosis, perhaps more than one researcher from a different culture should assess a patient.

Apart from cultural issues, diagnosis of abnormality can also follow some serious ethical issues, and these should be considered before making a diagnosis, as after making one there may be no turning back.

The labelling of people with mental disorder is called stigmatization. Rosenhan (1973) conducted a study where 8 normal patients would try to gain admittance to psychiatric hospitals. These patients claimed to be hearing unfamiliar voices in their heads. All but one were admitted with schizophrenia. The patients were told to stop displaying the symptoms, and they were all discharged after 19 days. However, they were stigmatized with the label "schizophrenia in remission". Had these participants been real patients, this label would follow them everywhere and may affect their ability to find a job or qualify for medical insurance. However, there are criticisms of this study. Firstly, the staff at the hospital are not entirely to blame as the participants admitted themselves and told the staff about their symptoms. The staff was simply just doing their job at identifying the symptoms and making a diagnosis. In real life, doctors are not normally confronted with people wishing to be admitted to psychiatric hospitals. The sample was too small, so there is a problem of whether it can be generalized. Even if a patient no longer shows any symptoms, the label "disorder in remission" still remains and this can affect the individual's self esteem and confidence.

The self-fulfilling prophecy states that when a stereotype or label is placed on an individual, they will internalise the role and thus conforming to the stereotype and start believing that they are abnormal. For example, if a patient is diagnosed with a mental disorder, the patient may start to believe that they are abnormal and start to behave similarly to the illness. Doherty et al found that patients who do not internalise the role of a mentally ill stereotype recovered much faster than those who exhibited the self-fulfilling prophecy. This finding emphasizes on the importance of taking in the ethical considerations before diagnosing patients.

Another ethical issue in diagnosis is confirmation bias, where clinicians tend to attribute a patient's behaviours to a disorder and looking for behaviours that confirm this disorder. This may be due to the assumption that if the patient is there in the first place, there must be something to diagnose. This is demonstrated again in Rosenhan (1973)'s study. Once the participants stopped exhibiting behaviours, they took notes on their experience. This was interpreted as a symptom of schizophrenia. When the participants were walking down the hallway, this was seen as a sign of nervousness. This shows that once a person is deemed mentally ill, any actions will be interpreted as symptoms of the disorder.

In conclusion, it is extremely important for clinicians to take into account the cultural and ethical considerations in diagnosis, as once a diagnosis has been made it is with the patient for the rest of their lives.

Discuss validity and reliability of diagnosis

Classification of mental disorder involves the identification of a group or pattern of mental symptoms that reliably occur together to form a type of disorder. This allows psychiatrists, doctors and psychologists to easily identify groups of similar patients. A diagnosis can be made, and a suitable treatment can be developed and administered to all those showing similar symptoms.

The DSM (Diagnostic and Statistical Manual of Mental Disorders) defines abnormality as a clinically significant syndrome associated with distress, loss of functioning, and an increase in the risk of pain or death. The DSM is a manual with over 200 specific diagnostic categories for mental disorder and lists the specific diagnostic criteria that have to be met for a diagnosis to be given.

However, one of the largest problems of diagnosing patients is whether or not the diagnosis is valid or reliable. Reliability is whether the same consistent diagnosis would be made for the same group of symptoms, and validity is whether a correct diagnosis is made.

There are two types of reliability. Inter-rater reliability is assessed by asking more than one practitioner to make a diagnosis for the same person and to see whether this diagnosis is consistent. Beck et al found that assessment on diagnosis for 153 patients, where each patient was assessed by more than 2 psychiatrists, was only 54%. This shows the unreliability of diagnosis. Similarly, Cooper et al found that New York psychiatrists were twice as likely to diagnose schizophrenia than London psychiatrists, who were twice as likely to diagnose mania or depression, when shown the same video-taped clinical interviews. This suggests that psychiatrists may be influenced by their culture beliefs when making a diagnosis. Lipton and Simon randomly selected 131 patients from a psychiatric hospital and attempted to re-diagnose them. This diagnosis was compared with the original diagnosis and found that of the original 89 patients who were diagnosed with schizophrenia, only 16 received this on re-evaluation. This clearly shows the unreliability of diagnosing patients, and how different psychiatrists will come up with different diagnosis.

Test-retest reliability is concerned with whether the same patient will receive the same diagnosis if assessed more than once by the same psychiatrist. Mary Seeman completed a literature review examining evidence relating to the reliability of diagnosis over time. She found that initial diagnosis of schizophrenia, especially in women, are more susceptible to change as clinicians found out more and more about their patients.

This clearly shows the unreliability of diagnosing patients. Although the DSM is constantly improving to better improve reliability, psychiatrists are still human and they are bound to make mistakes when diagnosing patients. Many factors need to be considered when making a diagnosis, such as their own researcher bias (reflexivity) and cultural bias.

Validity can also be a problem in diagnosis. Rosenhan (1973) conducted a study where 8 normal patients would try to gain admittance to psychiatric hospitals. These patients claimed to be hearing unfamiliar voices in their heads. All but one were admitted with schizophrenia. The patients were told to stop displaying the symptoms, and they were all discharged after 19 days. However, they were stigmatized with the label "schizophrenia in remission". Rosenhan was not satisfied with the results that normal patients could be classified as abnormal. He told psychiatrists that pseudo-patients would try to gain admittance to the hospital. In fact, there were no pseudo-patients, but 41 real patients were judged with great confidence to be a pseudo-patient by at least one member of staff. Rosenhan concluded that it was not possible to distinguish between sane and insane in psychiatric hospitals. This study shows good reliability, but poor validity in that normal patients could be given a diagnosis. However, there are criticisms of this study. Firstly, the staff at the hospital are not entirely to blame as the participants admitted themselves and told the staff about their symptoms. The staff was simply just doing their job at identifying the symptoms and making a diagnosis. In real life, doctors are not normally confronted with people wishing to be admitted to psychiatric hospitals. The sample was too small, so there is a problem of whether it can be generalized.

In conclusion, there will always be issues of validity and reliability in diagnosis. Certain groups of people will be more likely to receive a diagnosis to a disorder compared to others, and it is very difficult to remove the subjectivity and bias of practitioners from the diagnostic process. Psychiatrists will need to be careful when diagnosing patients, as once diagnosed the life of the individual will be changed forever.

Examine the concepts of normality and abnormality

Abnormal behaviour presents psychologists with a difficult task: it is difficult to define and therefore it is difficult to diagnose as it is based on the symptoms that people report or exhibit. There are four definitions of abnormality: statistical infrequency, deviation from social norms, dysfunctional behaviour and deviation from ideal mental health.

Statistical infrequency defines abnormality as a deviation from the statistical norm, meaning infrequently occurring behaviour. This approach is useful when looking at human characteristics that can be reliably measured, such as height. Most people's scores will cluster around the average, with very few tall people and very few small people. This is known as normal distribution. Therefore, statistically frequent behaviour is defined as normal and statistically infrequent behaviour is defined as abnormal.

However, there is no agreed definition as to how much behaviour must deviate from the norm to be considered as abnormal. Statistical deviation from the norm does not describe the desirability of the deviation. For example, both musical talent and high IQ are statistically infrequent but it is highly desirable. To ensure that behaviour is statistically infrequent requires the collection and maintenance of data which is both difficult and time consuming. It could be the case that by the time data is collected from a population and then inputted into a bell-curve, that the data of the population has already changed. The accuracy of data is also questionable.

Deviation from social norms defines abnormality as behaviour which departs from what is considered acceptable in a society. Norms are expected ways to behave in a society and those who do not think or behave like everyone else breaks these norms, and are considered abnormal. Most members of the society are aware of these norms and adjust their behaviour accordingly. For example, student-teacher relationships, behaviour on public transport etc.

However, there is no universal agreement for social norms. Different societies will have different social norms, and they will change over time. For example, it was much less socially acceptable to smoke cigarettes today than it was 20 years ago. Another problem of this definition is that it defines anyone who goes against social norms as abnormal. This means that people could be defined abnormal by their sexual preferences or religious beliefs.

Dysfunctional behaviour defines abnormality as psychological distress, such as negative thoughts, feelings or emotions, that causes discomfort to the individual. This approach is much more clear in defining abnormality rather than it being statistically infrequent or a deviation from social norms, as many of those with a mental disorder usually suffer from psychological distress. For example, those with eating disorders are typically disturbed by the perception that they are fat, and this causes distress and discomfort towards the individual - hence they can be defined as abnormal. Rosenhan suggested that dysfunctional behaviour can be judged based on 7 criteria:

1. Personal distress (experience unpleasant emotions)

2. Maladaptiveness (behaviour that interferes with our responsibility)

3. Irrationality (behaviour that has no rational basis)

4. Unpredictability (impulse behaviour)

5. Statistical Infrequent (deviation from statistical norm)

6. Observer discomfort (behaviour that causes discomfort to others)

7. Violation of moral and ideal standards

However, many people experience distress at some point in their lives, but this does not mean that they are abnormal. For example, a lost of a loved one may cause someone to experience distress, behaving in ways that are irrational and unpredictable, but this does not mean that they are abnormal. In fact, it may even be an appropriate response to circumstances. Observer discomfort also depends on who the observer is - what may be discomforting to others may be seen as perfectly normal to another. Violation of moral and ideal standards also depends on which standards we are using.

Deviation from ideal mental health defines abnormality as behaviour which departs from what is considered mentally healthy. In this context, normal can be defined as mentally healthy, and abnormal can be defined as mentally unhealthy. Jahoda defined 6 criteria in which mental health can be measured:

1. Attitudes of an individual towards his/herself

2. Growth, development or self-actualization

3. Integration

4. Autonomy

5. Perception of reality 

6. Environmental mastery

According to this approach, the more of these criteria that are satisfied, the healthier the individual. However, very few people are likely to achieve all of Jahoda's objectives, and it is also hard to measure the extent to which an individual misses these criteria. Furthermore, different cultures will have different ideas on what is considered ideal. For example, autonomy is valued in individualistic cultures, but in collectivist cultures, working together is valued instead.

None of the above definitions provide a complete definition of abnormality. Attempting to define abnormality is in itself a culturally specific task. What seems abnormal in one culture may be seen as perfectly normal in another, and hence it is difficult to define abnormality.