Category: Diagnosis

Black thoughts, black boxes and black magic

23/4/2014

Are America's children over-medicated?

In the IB Psychology Abnormal option we examine the effect of various biomedical approaches to the treatment of various psychological disorders. We examine the biomedical approach to the treatment of major depression under the following two learning outcomes:

Examine biomedical, individual and group approaches to treatment.
Evaluate the use of biomedical, individual and group approaches to the treatment of one disorder.

There are different biomedical treatments for depression that could be considered here, for example lobotomies and electroshock (electroconvulsive) therapy, but by far the most widely used biomedical approach to the treatment of major depression is the use of antidepressants. You are probably familiar with the brand names Prozac and Zoloft even if you have never had a sad day in your life. The biological mechanisms behind our most common (and effective) antidepressants seem grounded in sound science.

Serotonin is our brain's 'feel good' neurotransmitter, and by boosting serotonin levels in the brain we should be able to make our depressive patients feel a whole lot better about themselves and life in general. SSRIs, or selective serotonin re-uptake inhibitors, do exactly this, they inhibit the neurotransmitter serotonin from being reabsorbed back into the synapses where it was initially released, thus allowing for a build up of serotonin in the synaptic gap and an increase in activity in serotonergic neurons. What you will find once you dig deep enough is that this is incredibly controversial.

This question of biomedical treatments is examined in-depth in two model answers to the IB Psychology ERQs

And, when we start prescribing these medications to our children in ever increasing numbers you can be sure that serious questions are going to be raised. Consider the list of side effects of one of our most commonly prescribed SSRIs:

The long, long side effects of Prozac list:

anxiety
decreased appetite
decreased sexual ability
decreased sexual drive
diarrhea
dizziness
drowsiness
dry mouth
headache
increased sweating
nausea
nervousness
symptoms of hypoglycemia (low blood sugar), including:
anxiety or nervousness
chills
cold sweats
cool pale skin
difficulty concentrating
drowsiness
excessive hunger
fast heartbeat
headache

shakiness or unsteady walk
unusual tiredness or weakness
tiredness
trouble sleeping
upset stomach
weakness
breast enlargement or pain
difficulty urinating
fast or irregular heartbeat
hallucinations
inability to sit still, or restlessness
missed menstrual periods
allergic reaction (e.g., skin rash, hives, or itching)
bleeding (e.g., unusual nosebleeds, bruising, blood in urine, coughing blood, bleeding gums, cuts that don't stop bleeding)
liver problems (e.g., nausea, vomiting, diarrhea, loss of appetite, weight loss, yellowing of the skin or whites of the eyes, dark urine, pale stools)
mania (e.g., decreased need for sleep, elevated or irritable mood, racing thoughts)
symptoms of increased pressure in the eyes (e.g., decreased or blurred vision, eye pain, red eye, swelling of the eye)
talking, feeling, and acting with excitement and activity you cannot control
unusual or incomplete body or facial movements
unusual secretion of milk (women)
convulsions (seizures)
serious allergic reaction (e.g., abdominal cramps, difficulty breathing, nausea and vomiting, or swelling of the face and throat)
bleeding in the stomach
hyponatremia (low blood sodium), including:
confusion
convulsions (seizures)
increased thirst
lack of energy
serotonin syndrome, including:
diarrhea
fever
increased sweating
mood or behaviour changes
overactive reflexes
racing heartbeat
restlessness
shivering or shaking

ARe America's Children Over-medicated?

The documentary above provides an informative and entertaining look into the world of psychotropic medications being prescribed to children in America.

Is the effectiveness of SSRIs due to the placebo effect? Reviewing the evidence we can conclude that using the most common antidepressant medications, the SSRIs such as Prozac and Zoloft are no more effective than taking a placebo. Moreover, reviewing the list of side effects, taking a placebo may be a whole lot safer!

The biomedical treatment of depression
The biomedical approach to treatment is based on the assumption that if a mental problem is caused by biological malfunctioning, the cure is to restore the biological system with drugs. For example, the serotonin hypothesis of depression suggests that depression is linked to low levels of the neurotransmitter serotonin (Coppen, 1967). Serotonin is a neurotransmitter produced by specific neurons in the brain that are called serotonergic neurons because they produce serotonin. Antidepressant treatment should therefore aim to regulate serotonin levels. Antidepressants are often used in the treatment of bulimia nervosa because many patients also suffer from other disorders such as depression (the problem of comorbidity).

Antidepressants are also used to treat minor depressive symptoms but the American Food and Drug Administration (FDA, 2004) warned that the use of antidepressants for children and adolescents could perhaps lead to an increased risk of suicide. In fact, the FDA adopted a "black box" label warning indicating that antidepressants may increase the risk of suicidal thinking and behaviour in some children and adolescents with major depression at about twice the rate of placebo. A black-box warning is the most serious type of warning in prescription drug labelling.

Selective serotonin reuptake inhibitors (SSRIs)

Figure 1: SSRIs increase serotonin levels in the synaptic gap

Antidepressants in the form of selective serotonin reuptake inhibitors (SSRI) block the reuptake process for serotonin This results in an increased amount of the serotonin in the synaptic gap (see figure 1). The theory is that this increases serotonergic nerve activity leading to an improvement in mood. Essentially, the only evidence that exists in favour of the serotonin hypothesis is the alleged efficacy of SSRIs – if they make your serotonin more potent and this improves your condition, the problem must have been in your serotonin levels to begin with, or so the logic goes. According to Lacoste & Leo (2005) this is an example of backward reasoning. Assumptions about the causes of depression are based on how people respond to a treatment and this is logically problematic. For example, the symptoms of headaches can be treated by aspirin, but this is definitely not to say that the cause of headaches is a deficiency of aspirin.

SSRI drugs such as Prozac, Zoloft and Paxil are now amongst the most commonly prescribed antidepressants and this has been taken as indirect support for the serotonin hypothesis. They do affect mood and emotional responses positively in most people (although much of this may be due to the placebo effect; Kirsch et al., 2008). SSRIS have been criticised because they treat the symptoms of depression but do not cure the mental disorder, and because depressive episodes usually recur, it is necessary for patients to continue taking the medication. Unless the medication is used with therapy, it is unlikely that the disorder will disappear permanently.

However, SSRIs are popular because they have fewer side effects than previous drugs such as tricyclic antidepressants. Not everyone can use SSRIs and the most common side effects are headache, nausea, sleeplessness, agitation and sexual problems.

Neale et al. (2011) conducted a meta-analysis of published studies on the outcome of antidepressants versus placebo. The study focussed on:
(i) patients who started with antidepressants and then changed to placebo,
(ii) patients who only received placebo, and
(iii) patients who only took antidepressants. The study found that patients who do not take antidepressants have a 25% risk of relapse, compared to 42% or higher for those who have been on medication and then stopped it.

According to the researchers, antidepressants may interfere with the brain’s self-regulation. They argue that drugs affecting serotonin or other neurotransmitters may increase the risk of relapse. The drugs reduce symptoms in the short-term but, when people stop taking the drug, depression may return because the brain’s natural self-regulation is disturbed.

Ingeniously, Henninger et al. (1996) performed experiments where they reduced serotonin levels in healthy individuals to see if they would develop depressive symptoms. The results did not support that levels of serotonin could influence depression; i.e., there was no evidence for a cause-effect relationship, and they argued that it was necessary to revise the serotonin hypothesis. This is strong evidence against the hypothesis because if low levels of serotonin do cause depression and they were successful in reducing serotonin levels in their participants (and the evidence presented suggests that this was the case), then this can be considered strong evidence against the serotonin-depression hypothesis. However, there has been debate around just how depression was monitored in this study.

Leauhter et al. (2002) examined changes in brain function during treatment with placebo. The study examined brain function in 51 patients with depression who either received placebo or an active antidepressant medication. An EEG was used to compare brain function in the two experimental groups. The design was double-blind and ran over none weeks. The study used two different SSRI, which were randomly allocated to participants.

Results showed a significant increase in activity in the prefrontal cortex nearly from in the beginning in the trial in the placebo group. The pattern was different from the patients who were treated with the SSRI but patients in both groups got better. This indicates that medication is effective, but placebo is just as effective. The findings from the study are intriguing. The difference in activity in the brain indicates that the brain is perhaps able to heal itself since there was a positive effect for both groups. Believing that they are being treated could be enough for many patients.

Kirsch et al. (2002) found that there was a publication bias in research into the effectiveness of SSRI in depression. In fact, if the results of all studies (including the ones that had not been published) were pooled together it would seem that the placebo effect accounted for 80% of the antidepressant response. A placebo is a substance that has no therapeutic effect, and is used as a control in testing new drugs. Of the studies funded by pharmaceutical companies, 57% failed to show a statistically significant difference between antidepressant and a neutral placebo. This and similar studies cast doubt on the serotonin hypothesis, not to mention the ethics of drug companies. However, it is still widely promoted by pharmaceutical companies and presumably believed by the 10% of Americans taking these SSRIs to treat depression.

In sum, when evaluating the evidence for the biomedical approach to the treatment of major depression we can conclude that SSRIs may reduce depressive symptoms but they have side effects and do not cure patients. It is likely that the placebo effect could account for the effectiveness of the medication. Further, because the mechanisms are not well understood not how antidepressants affect the brain in the long-term, it is possible that the heavy use of these could well be damaging. There is also increasing criticism of the role of pharmaceutical companies and their marketing of antidepressants, which has led to an increase in the prescription of SSRI.

So parents, your kid is acting a little bit moody, disinterested and disengaged from her surrounds, should you be pushing your GP for some Prozac?

Have a read of the side effects of antidepressants in children and adolescents in the journal article below.

Black Magic - The Placebo Effect

Antidepressants are placebos

Black box warnings

side effects of SSRIs on children

If your answer to the above question was a resounding "No way!", based on the evidence that that they aren't effective, then you may have added reason to pat yourself on the back ... the FDA has also issued a 'black box' warning on all SSRI antidepressants. They found and believed it was in the public interest that those taking SSRIs be warned that there is an increased risk of suicidal thoughts or behavior (suicidality) in children and adolescents treated with SSRI antidepressant medications.

The black box warning, a type of warning issued by the FDA that must appear on the packaging of certain prescription drugs. The U.S. Food and Drug Administration (FDA) has required all pharmaceutical companies to place a boxed warning on the labeling of prescription antidepressants, or in literature describing it. It is the strongest warning that the FDA requires, and signifies that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects.

In this instance, the FDA believes that already depressed children are more likely to commit suicide because taking these medications leads to the idea of suicide becoming more salient.

Consequently, prescriptions issued for antidepresants have fallen by over 20 per cent in the US.

Now, this may seem a good thing in light of all of the evidence presented here. But consider this: during this time, child and adolescent suicides in the US jumped by 11 per cent! So, I'll leave you with this final thought ... should we now be prescribing a nice, safe placebo instead for a mental illness that has very real consequences for the sufferer?

Author: Derek Burton – Passionate about IB Psychology

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Abnormality is in the eye of the beholder

14/4/2014

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Another ERQ model answer from IB Psychology

Abnormal psychology is based upon the assumption that we know what 'abnormal' is, which in turn, is based upon us knowing what 'normal' is. So, how exactly do we make these judgments?

You're hanging out a LOT in your dark, smelly and incredibly messy bedroom, not talking to family and only interacting with your friends online. Teachers are concerned about you, your family is worried sick. Do you have some sort of social anxiety disorder? Surely this is a manifestation of a mental illness? ... but hang on! Isn't this just 'normal' teenage behaviour?

Have you ever wondered just how easily you could be confined to a mental hospital if say, your parents, didn't like the way you were behaving? If their concepts of normality and abnormality differed from yours? The answer is, probably pretty easily, but not as easily as in the past, and more easily in some countries than in others. Thus, we need some some sort of objective definition or classification of what abnormal behaviour actually is, and how we can make a judgement as to whether someone has a mental illness or not.

The IB Psychology learning outcome: Examine concepts of normality and abnormality, takes a very good look at this thought-provoking issue.

Much of what we examine in the model ERQ answer focuses on Rosenhan's seminal research. Rosenhan (1973) performed some ground-breaking research with his quasi-experimental study. Here, he and his fellow researchers managed to gain admittance to a variety of psychiatric hospitals around the US after presenting themselves and claiming that a voice in their head was saying "empty", "hollow" and "thud". They found that getting committed was very easy, and getting out was very, very hard ...

short videos examining concepts of mental illness and abnormality

Just Give Me the Answers! provides you with the complete collection of model answers for all extended response questions in the Paper 1 and 2 IB Psychology exams. This will save you hundreds of hours of work!

Rosenhan's 1973 original article
This article, published in the very prestigious 'Science' journal caused a great deal of controversy and forced the Psychiatric industry to examine their understand of, and practices and procedures around the 'mentally ill'. It changed the way we diagnose and assess degrees of mental illness.

Examine concepts of normality and abnormality

Another exemplar model ERQ answer for the IB Psychology course. This one is from the Abnormal option and if the student manages to replicate in their IB Psychology exams they are guaranteed to be awarded the full possible 22/22 marks.

Examine concepts of normality and abnormality

The presence of a mental disorder may be considered a deviation from mental health norms and hence the study of mental disorders is often known as abnormal psychology. ‘Normal’ and ‘abnormal’, as applied to human behaviour, are relative terms. Many people use these classifications subjectively and carelessly, often in a judgmental manner, to suggest good or bad behaviour. As defined in the dictionary, their accurate use would seem easy enough: ‘normal’ – conforming to a typical pattern and ‘abnormal’ – deviating from a norm. The trouble lies in the word norm. Whose norm? For what age person? At what period of history? In which culture?

The definition of the word abnormal is simple enough but applying this to psychology poses a complex problem. The concept of abnormality is imprecise and difficult to define. Examples of abnormality can take many different forms and involve different features, so that, what at first sight seem quite reasonable definitions, turns out to be quite problematical. There are several different ways in which it is possible to define ‘abnormal’ as opposed to our ideas of what is ‘normal’

Defining normality

Mental health model of normality (Jahoda, 1958)

The model suggests criteria for what might constitute normal psychological health (in contrast to abnormal psychological health). Deviation from these criteria would mean that the health of an individual is ‘abnormal’:

The absence of mental illness
Realistic self-perception and contact with reality
A strong sense of identity and positive self-esteem
Autonomy and independence
Ability to maintain healthy interpersonal relationships (e.g., capacity to love)
Ability to cope with stressful situations
Capacity for personal growth and self-actualisation

Evaluation of the mental health model of normality

The majority of people would be categorised as ‘abnormal’ if the criteria were applied to them. It is relatively easy to establish criteria for what constitutes ‘physical health’ but it is impossible to establish and agree on what constitutes ‘psychological health’. According to Szasz (1962) psychological normality and abnormality are culturally defined concepts, which are not based on objective criteria.

Taylor & Brown (1988) argue that the view that a psychologically healthy person is one that maintains close contact with reality is not in line with research findings. People generally have positive ‘illusions’ about themselves and they rate themselves more positively than others (Lewinshohn et al., 1980). For example most people rate themselves as being above average in driving ability, and above average in physical appearance, both of which are a statistical nonsense when considering the essential nature of an average.

Further, the criteria in the model are culturally biased value judgements; i.e., they reflect an idealised perception of what it means to be human in a Western culture. For example, self-actualisation (Maslow, 1968) means the achievement of one's full potential through creativity, independence, spontaneity, and a grasp of the real world. The concept of self-actualisation to a South Sudanese in the middle of sectarian strife, war and famine would be nonsensical at that point in time.

Defining abnormality

The mental illness criterion (the medical model)

The mental illness criterion sees psychological disorders (abnormality) as psychopathology. Pathology means ‘illness’ so it literally means ‘illness in the psyche’. The criterion is linked to psychiatry, which is a branch of medicine, specifically, a branch of medicine that deals with the diagnosis, treatment, and prevention of mental and emotional disorders. Patients with psychological problems are seen as ‘ill’ in the same way as those who suffer from physiological illnesses.

Diagnosis of mental illness is based on the clinician’s (clinical psychologist, psychiatrist) observations, the patient’s self-reports and diagnostic manuals (classification systems) that classify symptoms of specific disorders to help doctors find a correct diagnosis. The most widely used classification system is the new DSM-5, which is the fifth edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders. In the United States the DSM serves as a universal authority for the diagnosis of psychiatric disorders. Treatment recommendations, as well as payment by health care providers, are often determined by DSM classifications.

Being diagnosed or labelled as being abnormal – mentally ill can have striking consequences in this model, as a controversial study designed to test the medical model and its conception of normality and abnormality.

Rosenhahn (1973) – on being sane in insane places

Aim: To test reliability and validity of diagnosis in a natural setting. Rosenhahn wanted to see if psychiatrists could distinguish between ‘abnormal’ and ‘normal’ behaviour.

Procedure: This was a covert participant observation with eight participants consisting of five men and three women (including Rosenhahn himself). Their task was to follow the same instructions and present themselves at 12 psychiatric hospitals in the US. These pseudo-patients telephoned the hospital for an appointment, and arrived at the admissions office complaining that they had been hearing voices. They said the voice, which was unfamiliar and the same sex as themselves, was often unclear but it said “empty”, “hollow”, “thud”.

After they had been admitted to the psychiatric ward, the pseudo patients stopped simulating any symptoms of abnormality. The pseudo patients took part in ward activities, speaking to patients and staff as they might ordinarily. When asked how they were feeling by staff they said they were fine and no longer experienced symptoms. Each pseudo patient had been told they would have to get out by their own devices by convincing staff they were sane.

Results and conclusion: All participants were admitted to various psychiatric wards and all but one were diagnosed with schizophrenia (the other diagnosis was for manic depression). All pseudo-patients behaved normally while they were hospitalised because they were told they would only get out if the staff perceived them to be well enough.

The pseudo-patients took notes when they were hospitalised but this was interpreted as a symptom of their illness by the staff. It took between 7 and 52 days before the participants were released. They came out with a diagnosis (schizophrenia in remission) so they were ‘labelled’.

A follow-up study was done later where the staff at a specific psychiatric hospital were told that imposters would present themselves at the hospital and that they should try to rate each patient whether he or she was an imposter. Of the 193 patients, 41 were clearly identified as impostors by at least one member of the staff, 23 were suspected to be impostors by one psychiatrist, and 19 were suspected by one psychiatrist and one staff member. There were no impostors.

Rosenhahn claims that the study demonstrates that psychiatrists cannot reliably tell the difference between people who are sane and those who are insane. The main experiment illustrated a failure to detect sanity, and the secondary study demonstrated a failure to detect insanity. Rosenhahn explains that psychiatric labels tend to stick in a way that medical labels do not and that everything a patient does is interpreted in accordance with the diagnostic label once it has been applied.

Evaluation: This controversial study was conducted nearly 40 years ago but it had an enormous impact on psychiatry. It sparked off a discussion and revision of diagnostic procedures as well as discussion of the consequences of diagnosis for patients. The development of diagnostic manuals (e.g., DSM-V) has increased the validity and reliability of diagnosis of what is abnormal or normal in terms of mental health, although diagnostic tools are not without flaws.

The method used raises ethical issues (the staff were not told about the research) but it was justified since the results provided evidence of problems in the diagnosis of mental illness (i.e., being non-beneficially abnormal) which could benefit others. There were serious ethical issues with the follow-up study since the staff thought that imposters would present, but they were real patients and may not have had the treatment they needed.

Evaluation of the mental illness criterion

Proponents of the mental illness criterion argue that it is an advantage to be diagnosed as ‘sick’ because it shows that people are not responsible for their acts. For example, an individual who does not get out of bed because they have been diagnosed for depression; i.e., labelled as being ‘depressed’ and not because they are fatigued (a symptom).

Although the origin of some mental disorders (e.g., Alzheimer’s disease) can be linked to physiological changes in the brain, most psychological disorders cannot. Also, critics of the mental illness criterion argue that there is a stigma (i.e., a mark of infamy or disgrace) associated with mental illness.

Abnormality as statistical deviation from the norm

Deviance in this criterion is related to the statistical average. The definition implies that statistically common behaviour can be classified as ‘normal’. Behaviour that is deviant from the norm is consequently ‘abnormal’. In the normal distribution curve most behaviour falls in the middle. A normal distribution curve is a theoretical frequency distribution for a set of variable data (e.g., scores on an IQ test), usually represented by a bell-shaped curve symmetrical about the mean.

An individual with an intelligence quotient (IQ) of 150 is a deviation from the norm of 100. It is statistically rare but it is considered desirable to have high intelligence. Mental retardation seen as an abnormality in the other direction (sometimes defined as having an IQ below 70) but this is considered undesirable. Obesity is becoming statistically ‘normal’ but obesity is considered undesirable.

Evaluation of the statistical criterion

The use of statistical frequency and deviation from the statistical norm is not a reliable criterion to define abnormal behaviour since what is ‘abnormal’ in a statistical sense may both be desirable and undesirable. What may be considered abnormal behaviour can differ from one culture to another so it is therefore impossible to establish universal standards for statistical abnormality. The model of statistical deviation from the norm always relates to a specific culture.

Abnormality as deviation from social norms

Social norms constitute informal or formal rules of how individuals are expected to behave. Deviant behaviour is behaviour that is considered undesirable or anti-social by the majority of people in a given society. Individuals who break rules of conduct or do not behave like the majority are defined as ‘abnormal’ according to this criterion.

Social, cultural and historical factors may play a role in what is seen as ‘normal’ or ‘abnormal’ within a certain society. For example, around the 1900s in the UK, homosexuality was seen as abnormal and people could be imprisoned or forcibly treated for this ‘mental illness’. Homosexuality was classified as an abnormal sexual deviation in the DSM-II (1968). In later revisions of the manual, homosexuality in itself was not seen as abnormal – only feeling distressed about it was.

Evaluation of the deviation from statistical norms criterion

This criterion is not objective or stable since it is related to socially based definitions that change across time and culture. Further, because the norm is based on morals and attitudes it is vulnerable to abuse. For example, political dissidents could be considered ‘abnormal’ and sent to hospitals for treatment, which was something that occurred in the former Soviet Union. Using this criterion could lead to discrimination against minorities, including people who suffer from psychological disorders.

Psychological disorders may be defined and diagnosed in different ways across cultures and what seems to be a psychological disorder in one culture may not be seen the same way in another culture. The DSM includes disorders called ‘culture-bound syndromes’; for example, penis panic (!) or Koro. This indicates that it is impossible to set universal standards for classifying a behaviour as abnormal.

General conclusion

None of the above definitions provide a complete definition of abnormality. Mental health (e.g., Jahoda) and mental illness (i.e., the medical model) are probably two-sides of the same coin, but do provide insights of their own. Examining these concepts through statistical deviations from norms does not tell us about the desirability of the deviation. 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.

Word count: 2 000

Author: Derek Burton – Passionate about IB Psychology

Model IB Psychology ERQ Answer

Comments

Black thoughts, black boxes and black magic

ARe America's Children Over-medicated?

Black Magic - The Placebo Effect

Antidepressants are placebos

Black box warnings

side effects of SSRIs on children

Abnormality is in the eye of the beholder

short videos examining concepts of mental illness and abnormality

Examine concepts of normality and abnormality

IB DipLOMA PsychologY:

Archives

Categories

Black thoughts, black boxes and black magic

ARe America's Children Over-medicated?

Black Magic - The Placebo Effect

Antidepressants are placebos

Black box warnings

side effects of SSRIs on children

Abnormality is in the eye of the beholder

short videos examining concepts of mental illness and abnormality

Examine concepts of normality and abnormality

IB DipLOMA Psycho﻿logY:

Archives

Categories

IB DipLOMA PsychologY: