Abnormal Psychology An Integrative Approach, 8th Edition By David Barlow, Mark Durand, Stefan Hofman

C H A P T E R 1: Orientation to Medications Learning Outcomes 1-1 Define terms to understanding administration of medications.

1-2 List the major sources and uses of drugs.

1-3 Define drug standards, indicating how they are determined and why they are necessary.

1-4 List names by which drugs are known.

1-5 List drug references, explain how to use at least one, and make a drug card.

1-6 List the major drug laws and their main features.

1-7 List the federal agencies that enforce the drug laws and the importance of enforcing them.

Chapter Outline Key Terms Introduction to Pharmacology Pharmacology Drug Sources Drug Uses Drug Standards Drug Names Drug References Preparing Your Own Drug Cards Drug Legislation You and the Law Chapter Summary Chapter 1 Review Teaching Strategies § Ask students to identify the key terms they are already familiar with. Discuss the definitions of all the terms and be certain that students are clear about the meanings.

Point out any similarities that may be confusing to them and tell them to memorize those words to avoid confusion later on. Ask volunteers to share their methods of learning medical key terms. § Ask students to list the major sources of drugs and give examples of each. § If possible, obtain a film from the library or a pharmaceutical company explaining the process of drug trials. Show the film to the class. § Take a field trip to a pharmaceutical company in your area to observe the step-by-step process of manufacturing drugs. Ask students to summarize why, as health care workers, they should understand the drug manufacturing process. Discuss how the company followed drug legislation. § Invite a pharmacist into class (or visit a pharmacy) to discuss the process of testing for generic drugs. Ask students why it is important they understand this process. § Ask a pharmaceutical representative to speak to the class about how he or she can make a difference in patient care. § Visit a local pharmacy or invite a pharmacist into class to discuss what pharmacists teach patients when they dispense a drug. Ask for print material that is sometimes given to patients. Discuss in class how this material could be beneficial or harmful to the patient. § When students begin work in a health facility, ask them to make a list of all the drug references that are available to them in their work environment. Are the materials up-todate? Why are up-to-date references important to the patient and the health care worker? § Ask students to complete the Chapter 1 Review. Discuss answers, clearing up any misconceptions students may have. Review any material students had difficulty with. § Administer and grade the Chapter 1 Test in this Instructor’s Manual. § Develop and administer a performance test for preparing a drug card.

Gauwitz, Administering Medications, 8e

IM-1 | 1

The Development of Biological Treatments Consequences of the Biological Tradition THE PSYCHOLOGICAL TRADITION Moral Therapy Asylum Reform and the Decline of Moral Therapy Psychoanalytic Theory Humanistic Theory The Behavioral Model THE PRESENT: THE SCIENTIFIC METHOD AND AN INTEGRATIVE APPROACH

DETAILED OUTLINE Understanding Psychopathology  A psychological disorder is (1) a psychological dysfunction within an individual that is (2) associated with distress or impairment in functioning and (3) a response that is not typical or culturally expected. All three basic criteria must be met; no one criterion alone has yet been identified that defines the essence of abnormality.

 DISCUSSION POINT: What are some behaviors that may be considered “abnormal” by the above definitions, but do not constitute a psychological disorder?  DISCUSSION POINT: Do the words “abnormal” and “pathological” necessary mean the same thing? Can you be one without being the other? Is abnormality an “either-or” construct or is it better thought of as a continuum?  The field of psychopathology is concerned with the scientific study of psychological disorders. Trained mental health professionals range from clinical and counseling psychologists to psychiatrists and psychiatric social workers and nurses. Each profession requires a specific type of training.  Using scientific methods, mental health professionals can function as scientist-practitioners.

They not only keep up with the latest findings but also use scientific data to evaluate their own work and often conduct research within their clinics or hospitals.  Research about psychological disorders falls into three basic categories: clinical description (prevalence, incidence, course prognosis), causation (etiology), and treatment and outcomes.  DISCUSSION POINT: What are some of the factors that may lead a person to have a psychological disorder, such as depression? Be sure to elicit answers involving biological, psychological, and social components.  DISCUSSION POINT: Why do you think that two people can be diagnosed with the exact same psychological disorder while appearing to share none of the causative factors of that condition?

The Supernatural, Biological, and Psychological Traditions  Historically, there have been three prominent approaches to abnormal behavior. In the supernatural tradition, abnormal behavior is attributed to agents outside our bodies or social environment, such as demons, spirits, or the influence of the moon and stars; although still alive, this tradition has been largely replaced by biological and psychological perspectives. In the biological tradition, disorders are attributed to disease or biochemical imbalances; in the psychological tradition, abnormal behavior is attributed to faulty psychological development and to social context. It was from the psychological perspective that a renewed interest in the moral treatment of the mentally ill emerged, beginning in the last 1700s with Philippe Pinel.  Each tradition has its own way of treating individuals who suffer from psychological disorders. Supernatural treatments include exorcism to rid the body of supernatural spirits.

Biological treatments typically emphasize physical care and the search for medical cures, especially drugs. Psychological approaches use psychosocial treatments, beginning with moral therapy and including modern psychotherapy.  Sigmund Freud, the founder of psychoanalytic therapy, offered an elaborate conception of the unconscious mind, much of which is still conjecture. In therapy, Freud focused on tapping into the mysteries of the unconscious through such techniques as catharsis, free association, and dream analysis. Although Freud’s followers steered from his path in many

ways, Freud’s influence can still be felt today.  DISCUSSION POINT: How might Freudian theorists use the psychosexual stages to explain obsessive-compulsive disorder?  DISCUSSION POINT: If you were to receive treatment for an episode of depression from a provider, from which perspective would you want him or her to operate? The psychoanalytic, humanistic, or behavioral perspective? Why? (If students fall into the trap of choosing just one, encourage them to consider an answer that introduces the concept of eclecticism.)  One outgrowth of Freudian therapy is humanistic psychology, which focuses more on human potential and self-actualizing than on psychological disorders. Therapy that has evolved from this approach is known as person-centered therapy; the therapist shows almost unconditional positive regard for the client’s feelings and thoughts.  The behavioral model moved psychology into the realm of science. Both research and therapy focus on things that are measurable, including such techniques as systematic desensitization, reinforcement, and shaping.

The Present: The Scientific Method and an Integrative Approach  With the increasing sophistication of our scientific tools, and new knowledge from cognitive science, behavioral science, and neuroscience, we now realize that no contribution to psychological disorders ever occurs in isolation. Our behavior, both normal and abnormal, is a product of a continual interaction of psychological, biological, and social influences.

KEY TERMS psychological disorder, 3 phobia, 4 abnormal behavior, 4 psychopathology, 6 scientist-practitioner, 7 presenting problem, 7 clinical description, 7 prevalence, 7 incidence, 7 course, 8 prognosis, 8 etiology, 8 exorcism, 10 psychosocial treatment, 16 moral therapy, 16 mental hygiene movement, 17 psychoanalysis, 18

psychosexual stages of development, 21 castration anxiety, 21 neurosis (plural neuroses), 22 ego psychology, 22 self-psychology, 22 object relations, 22 collective unconscious, 22 free association, 22 dream analysis, 22 psychoanalyst, 22 transference, 23 psychodynamic psychotherapy, 23 self-actualizing, 23 person-centered therapy, 24 unconditional positive regard, 24

behaviorism, 18 unconscious, 18 catharsis, 18 psychoanalytic model, 19 id, 19 ego, 20 superego, 20 intrapsychic conflicts, 20

behavioral model, 24 classical conditioning, 24 extinction, 25 introspection, 25 systematic desensitization, 25 behavior therapy, 26 reinforcement, 26 shaping, 26

IDEAS FOR INSTRUCTION 1.

Activity: Distinguishing Normal from Abnormal Behavior. An exercise that helps students recognize the difficulty of distinguishing normal from abnormal behavior is to begin by presenting a small amount of information about a case. If your class is large, break your students into groups of four or five. Instruct each group to list the top four questions they would want to know about a case to evaluate the behavior. For example, present the following information: Case #1: Tom is uncomfortable riding escalators. As a result, Tom avoids using them.

After your students have explored the case, encourage them to ask the following types of questions: a. How old is Tom? Is it more "normal" for Tom to fear escalators if he is a child versus an adult? Discuss developmental issues. b. From what culture does Tom most likely come? Has he ever had exposure to an escalator? Cultural contexts must always be considered when evaluating abnormal behavior. c. How does Tom manage his fear? What symptoms does he have? d. To what extent does Tom avoid using escalators? Does his fear significantly interfere with his life? Also ask if your students would consider the behavior more abnormal if he had a fear of flying in airplanes versus escalators. In other words, at what point would the behavior be considered an abnormal fear versus a normal one? What if Tom is afraid of snow because he once saw it on television, but he lives in a climate where it never snows?

Case #2: Rachel has been caught urinating in the corner of her bedroom. Is her behavior abnormal? What information will you need in order to make this assessment?

Encourage students to ask the following types of questions: a. How old is Rachel? The clinical picture is very different if Rachel is 1 year old than if she is 13 years old. Discuss the importance of understanding developmental psychology. b. How many times has she engaged in the behavior? A pattern of behavior may be viewed differently than if it is a rare occurrence.

c. Does Rachel have a medical condition? Is she on any medications? Rachel may have a medical or organic condition that accounts for her behavior. Ask your students if identifying an organic condition would change their perception of Rachel. Discuss the implication of assigning less social stigma to medical versus psychiatric patients. d. Has Rachel experienced a recent trauma or is she exposed to unusual stressors? e. Has Rachel achieved urinary control in a developmentally expected way and has now lost that control, or has she never achieved it at all? f. How does Rachel feel about her behavior? How does she explain it?

Examples such as these stimulate students to explore cases more fully before making snap judgments about people’s behavior and illustrate the complexity in teasing out normal from abnormal behavior.

2.

Activity: What is Normal vs. Abnormal? A similar exercise is to break students into groups and have them work with HANDOUT 1.1. Students should complete the handout on their own and then discuss their opinions.

3.

Activity: Examples of Conditioning in Everyday Life. To illustrate learning theory, ask your students to apply what they have learned about conditioning and behavior therapy to their own lives. Students may choose a behavior they would like to change or eliminate, or may identify a new behavior they would like to acquire. Ask them to keep a journal of the conditioning technique they are using and the exact procedure they are employing. For example, a student may want to stop texting on her cellphone when she is driving. She could keep a journal to describe if she is using a classical or operant procedure and monitor the progress (or success!) of the conditioning.

4.

Activity: The Blind Men and the Human Elephant. To illustrate the importance of taking an integrative, multidimensional approach and the dangers of scientific tunnel vision, read John G. Saxe’s (1963) poem “The Blind Men and the Elephant.” The poem is available from several websites (using the complete search phrase “Saxe’s Blind Men and the Elephant”), including http://www.wordinfo.info/words/index/info/view_unit/1/?letter=B&spage=3. Then have students discuss what behaving as one of the blind men would look like from a supernatural, biological, or psychological perspective (include psychoanalytic, behavioral, humanistic views). Use human behavior in place of the elephant illustrated in the poem. Try wearing a turban and a robe, or using other props while reading the poem as a means to elicit humor and to make the message stick. Be careful, however, not to do so if it risks offending any of your students.

4. Activity: The Designer’s Guide to Gestalt Psychology. Read Igor Ovsyannykov’s blog1 and think about how basic design principles are grounded in the contrast of “normal” and “abnormal.” For example, the principle of closure allows creativity in design by leaving something to the imagination. Ask students to use their mobile devices to look for examples of closure and other Gestalt Principles from the blog. Discuss how these 1

https://creativemarket.com/blog/the-designers-guide-to-gestalt-psychology

designs are appealing using a psychoanalytic, behavioral, or humanistic viewpoint). (If students need a hint to get started, show pictures of the World Wildlife Fund or NBC logos).

5.

Activity: Myths, Magic, & Placebos: What Do They Have to Do with Having Rocks in Your Head? When you discuss material dealing with treatment of the mentally ill during the Middle Ages, see whether students know where the phrase “rocks in your head” originated. It actually originated during the Middle Ages, when city street vendors would commonly perform pseudosurgery on street corners. Troubled people with symptoms associated with mental illness would often frequent these vendors for relief.

The vendors, in turn, would make a minor incision on the skull, while an accomplice would sneak the surgeon a few small stones. The surgeon would then pretend to have taken the stones from the patient’s head. The stones were claimed to be the cause of the person’s problems and that the person was now cured. A similar variant on this theme is quite popular with modern magicians and some faith healers who purport to painlessly remove diseased organs from the bodies of their subjects. The procedure involves an elaborate ritual, accompanied by chicken or beef blood and associated meat parts. The magic rests in the illusion of the magician’s arm twisting and turning into the bloodcovered exposed belly of the subject and the slow removal of what appears to look like a body part. Ask students to think about other examples of modern-day cures that they have heard about or maybe experienced themselves. This is a good place to tie in the concept of the placebo effect and perhaps open up a discussion about the role of beliefs and expectancies in producing and alleviating medical and psychological forms of distress and suffering.

6.

Activity: Course Journal. At the beginning of your class, ask students to keep a journal regarding their experiences in learning about abnormal psychology. One suggested format would be to have them answer, on a weekly basis, the following questions: o What is the most significant fact that I learned about abnormal psychology this week? o What did I learn this week about the field of abnormal psychology that changed my existing perceptions (e.g., what “myth” did I once believe that I now see differently)? o One idea I had for a research study in abnormal psychology this week is _______.

You can have the students turn in this journal at the end of the course or to reflect on their experiences completing the journal in a small paper. If you are going to assign and collect the journals, don’t forget to remind students that they should only disclose information that they are comfortable with you reading! You may also introduce the topic of “Psychology Student Syndrome” here and ask them to track how often they feel that the topics discussed in class remind them of themselves, and discuss the normalcy of such perceptions.

7.

Rosenhan’s “On Being Sane in Insane Places.” Open your lecture on what is abnormal with the article “On Being Sane in Insane Places.” You can mention that one of the pseudopatients was a professional artist, and the staff interpreted her work in terms of her illness and recovery. As the pseudopatients took notes about their experience, staff members referred to the note-taking as schizophrenic writing. Ask students for any other types of behavior that they can think of that would be misinterpreted in a mental hospital setting. Use http://facstaff.bloomu.edu/jleitzel/classes/introabnormal/Spitzer_1975.pdf or see “On Being Sane in Insane Places”, Science, 1973, 179, pp. 250-257 to develop your lecture. (Be aware that the hyperlink of this article may warn you that the link may have viruses or harm your computer. Be assured this is a safe link)

8.

Invite a guest speaker from campus mental health/counseling services to discuss the range of services offered. This should reduce the fear and stigma of seeking any type of personal counseling services on campus. Additionally, it will let students know where to seek help should any personal issues arise during the semester. With the stress of student life, many students can and should use these services. You may also consider inviting a colleague who is a clinician if your institution does not have a counseling center or if the staff there are not available. This may also be an opportunity for a psychology student group (e.g., Psychology club, Psi Chi, etc.) to have a social event that focuses on the topic.

Uh Oh! Plan B Although instructors are skilled professionals in creating classroom experiences, things don’t always go as planned. The chapter-related lecture and activity suggestions in this section are for instances when your planned lecture or activity idea do not go as planned. Implement these to recover student interest and enhance student reading.

1. Fall Back on Didactic Lecture. Unfortunately mental health continues to carry a stigma and students may feel uncomfortable discussing “abnormality,” even in the abstract. The lecture suggestions here rely heavily on discussion. If your first class is quieter than you would like, don’t hesitate to provide more information. This gives you an opportunity to model a high level of comfort with the material and the students a chance to feel more comfortable with the topic.

2. Get up and MOVE. There are many ways in which to stimulate a discussion. If your setting permits, you can post signs around the room, forcing students to answer the question with their bodily presence and their voice. For example, most discussion questions can be answered from a Supernatural, Biological, and Psychological Tradition.

Ask the students to move to one sign. Then, ask the groups to explain the phenomenon given their chosen perspective. For example, “depression” can be explained by the Supernatural group as being infected by evil spirits, whereas the Biological group can identify the phenomenon by chemical markers in the brain, etc.

YouTube Video Clips: Chapter 1 Introduction: Watch as the United States Centers for Disease Control redefines Attention Deficit/Hyperactivity Disorder (ADHD) and Tourette’s Syndrome as a “journey” rather than a mental health problem to be “fixed.”

The Centers for Disease Control (2014). Children’s Mental Health Disorders: A Journey for Parents and Children. May 5, 2014. https://www.youtube.com/watch?v=ewbD2Dw0NLo The Supernatural Tradition: The American Culture is riddled with conflations of supernatural explanations of mental health disorders. This Michael Jackson classic is particularly poignant when you consider the lyrics: “They’re out to get you/there’s demons closing in on every side.

They will possess you unless you change the number on your dial.”

Belle, B., Riley, T., Temperton, R. Jackson, M. (1982). Thriller https://www.youtube.com/watch?v=sOnqjkJTMaA The Biological Tradition: What new depression cures are on the frontier? This one-hour lecture

by National Institutes of Health scientist Carlos Zarate discusses the biological basis of depression and potential biologically-based ways to address it.

Zerate, C. (2015). Relief from Severe Depression and Suicidal Ideation within Hours: From Synapses to Symptoms. November 4, 2015. https://www.youtube.com/watch?v=PiUhbbIvENg The Present: The Scientific Method and an Integrative Approach: Need an (educated) class laugh that reviews the scientific method in a clear straightforward way? Check out this campy classic made by two science professors and their students.

Tunes2Teach (2012). December 20, 2012. https://www.youtube.com/watch?v=bUa-ilQqEv0 The Scientific Method Rap.

SUGGESTED VIDEOS Abnormal behavior: A mental hospital. (CRM/McGraw-Hill Films). Portrays life in a modern mental hospital, including views of schizophrenics and of a patient receiving ECT. (28 min) Adlerian therapy. (Insight Media). Dr. Jon Carlson examines and demonstrates Adlerian therapy (also known as individual psychology). (100 min) B. F. Skinner and behavior change: Research, practice, and promise. (Research Press).

Features a discussion with B. F. Skinner and addresses some controversial issues related to behavioral psychology. (45 min) Carl Rogers. (Insight Media). Carl Rogers discusses the humanistic model of personality as well as his views on encounter groups, education, and other issues facing psychologists. (Two programs, each 50 min) Freud: The hidden nature of man. (Insight Media). Explores the concepts of psychoanalysis through interviews with Sigmund Freud himself. (29 min) Is mental illness a myth? (NMAC-T 2031). Debates whether mental illness is a physical disease or a collection of socially learned behaviors. Panelists include Thomas Szasz, Nathan Kline, and F. C. Redlich. (29 min) Keltie’s beard: A woman’s story. About a woman with heavy facial hair that she chooses not to cut. Useful in discussing the criteria for abnormal behavior. (9 min) Man facing southeast. Fascinating Argentine film about a man with no identity who shows up at a psychiatric hospital claiming to be from another planet. Neither the hospital staff nor the film’s audience ever figure out exactly what is happening.

Out of sight. (PBS). Discusses the development of institutions for the mentally ill and traces custodial care practices of the mentally disturbed. (60 min) Pavlov: The conditioned reflex. (Films for the Humanities and Sciences). Documentary focusing on the classic work of Ivan Pavlov; includes rare footage of his investigations on the conditioned reflex. (25 min) The dark side of the moon. (Fanlight Productions). Chronicles the lives of three men with mental disorders, from living on the streets to becoming useful members of society. They now work to help other people in similar situations. (25 min) To define true madness. (PBS). Examines mental illness through history and considers the progress made to understand psychological disorders. (60 min)

ONLINE RESOURCES American Psychiatric Association http://www.psych.org/ APA’s website contains psychology-related links, information on legal cases that have affected psychiatry, continuing education for therapists, and much more.

Clinically Psyched http://www.clinicallypsyched.com/ Collection of articles relevant to abnormal psychology, many of which are in the form of press releases, so you may want to track down the original sources. The topics covered span the discipline of abnormal psychology.

Internet Mental Health http://www.mentalhealth.com/ This comprehensive site contains information related to the assessment, diagnosis, and treatment of mental illness.

National Alliance for the Mentally Ill http://www.nami.org/ Links, membership information, and searchable indexes of mental disorders are all included on this site.

Personality Theories http://www.ship.edu/~cgboeree/perscontents.html Electronic textbook (e-text) created for undergraduate and graduate courses in personality theory.

The History of Psychology Website http://academic.udayton.edu/gregelvers/hop/welcome.asp Links to many psychology-related webpages on the Internet.

The National Institute of Mental Health http://www.nimh.nih.gov The NIMH website offers information about diagnosis and treatment of several mental health disorders.

Today in the History of Psychology http://www.cwu.edu/~warren/today.html The American Psychological Association created this website, which allows the user to access information on the history of psychology by selecting a date on the calendar.

SUPPLEMENTARY READING MATERIAL Additional Readings: Bjork, D. W. (1993). B.F. Skinner: A life. New York: Basic.

Bolles, R. C. (1993). The story of psychology: A thematic history. Pacific Grove, CA: Brooks/Cole.

Grob, G. (1994). The mad among us: A history of the care of America’s mentally ill.

New York: MacMillan.

Hatfield, A. B., & Lefley, H. P. (1993). Surviving mental illness. New York: Guilford.

Hunt, M. M. (1993). The story of psychology. New York: Doubleday.

Rosen, G. (1975). Madness in society: Chapters in the historical sociology of mental illness. New York: Anchor Books.

Rosenhan, D. (1973). On being sane in insane places. Science, 179, p. 253.

Spanos, N. P. (1978). Witchcraft in the histories of psychiatry: A critical appraisal and an alternative conceptualization. Psychological Bulletin, 35, 417–439.

Szasz, T. S. (1960). The myth of mental illness. American Psychologist, 15, 113–118.

Watson, R. I. (1991). The great psychologists: A history of psychological thought. (5th ed.). Reading, MA: Addison Wesley Longman.

Weitz, R. D. (1992). A half century of psychological practice. Professional Psychology: Research and Practice, 23, 448-452.

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HANDOUT 1.1 WHAT IS ABNORMAL? Consider the following situations. Most people would consider at least some of the actions of the people involved to be abnormal. What do you think? Think about each one as you read through the list. Then, talk with your group about your judgments. When you are through talking about each, elect a group spokesperson who will take notes on the reasons that the group members come up with as to why you did or did not consider each situation to be abnormal. You will have to “dig” mentally to put some of these reasons into words.

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1.

Your uncle consumes a quart of whiskey per day; he has trouble remembering the names of those around him.

2.

Your grandmother believes that part of her body is missing and cries out about this missing part all day long. You show her that the part she thinks is missing actually is not, but she refuses to acknowledge this contradictory information.

3.

Your neighbor has vague physical complaints and sees two or three doctors weekly.

4.

Your neighbor sweeps, washes, and scrubs his driveway daily.

5.

Your cousin is pregnant, and is dieting (800 calories per day) so that she will not get “too fat” with the pregnancy. She has had this type of behavioral response since she was 13 years old.

6.

A woman’s husband died within the past year. The widow appears to talk to herself in the yard, doesn’t wash herself or dress in clean clothes, and appears to have lost a lot of weight.

7.

A 10-year-old wants to have his entire body tattooed.

8.

A 23-year-old female smokes marijuana every day, is a straight-A student in college, has a successful job, and is in a solid long-term relationship.

9.

A person experiences several unexpected panic attacks each week, but is otherwise happily married, functions well at work, and leads an active recreational lifestyle.

10.

A 35-year-old happily married man enjoys wearing women’s clothes and underwear on the weekends when he and his wife go out on the town.

WARNING SIGNS FOR PSYCHOLOGICAL DISORDERS IN ADULTS  Confused thinking  Prolonged depression (sadness or irritability)  Feelings of extreme highs and lows  Excessive fears, worries, and anxieties  Social withdrawal or isolation  Dramatic changes in eating or sleeping habits  Strong feelings of anger  Delusions or hallucinations  Growing inability to cope with daily problems and activities  Suicidal thoughts  Denial of obvious problems  Numerous unexplained physical ailments  Substance abuse

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WARNING SIGNS FOR PSYCHOLOGICAL DISORDERS IN YOUNGER CHILDREN  Changes in school performance  Poor grades despite strong efforts  Excessive worry or anxiety (i.e., refusing to go to bed or school)  Hyperactivity  Persistent nightmares  Persistent disobedience or aggression  Frequent temper tantrums  Unexplained physical injuries or wounds

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WARNING SIGNS FOR PSYCHOLOGICAL DISORDERS IN OLDER CHILDREN AND PRE-ADOLESCENTS  Substance abuse  Inability to cope with problems and daily activities  Change in sleeping and/or eating habits  Excessive complaints of physical ailments  Defiance of authority, truancy, theft, and/or vandalism  Intense fear of weight gain  Lack of or decrease in interest in engaging with peers or friends  Prolonged negative mood, accompanied by poor appetite or thoughts of death  Frequent outbursts of anger .

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CHAPTER 2 AN INTEGRATIVE APPROACH TO PSYCHOPATHOLOGY CHAPTER OVERVIEW This chapter outlines the primary components of a multidimensional model of psychopathology. The multidimensional model considers genetic contributions, the role of the nervous system, behavioral and cognitive processes, emotional influences, cultural, social and interpersonal influences, and developmental factors in explaining the causes of—and even the factors that maintain—psychological disorders. This chapter describes these areas of influence as well as their interaction in producing mental disorder.

CHAPTER OUTLINE ONE-DIMENSIONAL VERSUS MULTIDIMENSIONAL MODELS What Caused Judy’s Phobia?

Outcome and Comments GENETIC CONTRIBUTIONS TO PSYCHOPATHOLOGY The Nature of Genes New Developments in the Study of Genes and Behavior The Interaction of Genes and the Environment Epigenetics and the Nongenomic “Inheritance” of Behavior NEUROSCIENCE AND ITS CONTRIBUTIONS TO PSYCHOPATHOLOGY The Central Nervous System The Structure of the Brain The Peripheral Nervous System Neurotransmitters Implications for Psychopathology Psychosocial Influences on Brain Structure and Function

Interactions of Psychosocial Factors and Neurotransmitter Systems Psychosocial Effects on the Development of Brain Structure and Function Comments BEHAVIORAL AND COGNITIVE PSYCHOLOGY Conditioning and Cognitive Processes Learned Helplessness Social Learning Prepared Learning Cognitive Science and the Unconscious EMOTIONS The Physiology and Purpose of Fear Emotional Phenomena The Components of Emotion Anger and Your Heart Emotions and Psychopathology CULTURAL, SOCIAL, AND INTERPERSONAL FACTORS Voodoo, the Evil Eye, and Other Fears Gender Social Effects on Health and Behavior Global Incidence of Psychological Disorders

DETAILED OUTLINE One-Dimensional versus Multidimensional Models  The causes of abnormal behavior are complex and fascinating. You can say that psychological disorders are caused by nature (biology) and by nurture (psychosocial factors), and you would be right on both counts—but also wrong on both counts.  To identify the causes of various psychological disorders, we must consider the interaction of all relevant dimensions: genetic contributions, the role of the nervous system, behavioral and cognitive processes, emotional influences, social and interpersonal influences, and developmental factors. Thus, we have arrived at a multidimensional integrative approach to the causes of psychological disorders. .

 DISCUSSION POINT: Discuss the causes of Judy’s phobia, or another case example of your choosing, in the context of a multidimensional vs. unidimensional framework (behavioral, biological, emotional, social, and developmental causes).  DISCUSSION POINT: Can you think of any cases of psychopathology that would have a unidimensional explanation? (Instructor should be prepared to play counterpoint, and repeated uses of this question will help to build an arsenal of appropriate responses.)

Genetic Contributions to Psychopathology  The genetic influence on much of our development and most of our behavior, personality, and even IQ score is polygenic—that is, influenced by many genes. This is assumed to be the case in abnormal behavior as well, although research is beginning to identify specific small groups of genes that relate to some major psychological disorders.  In studying causal relationships in psychopathology, researchers look at the interactions of genetic and environmental effects. In the diathesis-stress model, individuals are assumed to inherit certain vulnerabilities that make them susceptible to a disorder when the right kind of stressor comes along. In the reciprocal gene-environment or gene-environment correlation model the individual’s genetic vulnerability toward a certain disorder may make it more likely that the person will experience the stressor that, in turn, triggers the genetic vulnerability and thus the disorder. In epigenetics, the immediate effects of the environment (such as early stressful experiences) impact cells that turn certain genes on or off. This effect may be passed down through several generations.

Neuroscience and Its Contributions to Psychopathology  The field of neuroscience promises much as we try to unravel the mysteries of psychopathology. Within the nervous system, levels of neurotransmitter and neuroendocrine activity interact in complex ways to modulate and regulate emotions and behavior and contribute to psychological disorders.  DISCUSSION POINT: What are some disorders that students believe to be primarily biological in their origins?

Discuss findings for disorders such as schizophrenia and bipolar disorder in which interactions between biology and environment determine outcome.  Critical to our understanding of psychopathology are the neurotransmitter currents called brain circuits. Of the neurotransmitters that may play a key role, we investigated five: serotonin, gamma-aminobutyric acid (GABA), glutamate, norepinephrine, and dopamine.  DISCUSSION POINT: What do recent findings about the interaction of psychosocial factors with brain structure and function indicate regarding future research directions in abnormal psychology?

Behavioral and Cognitive Psychology  The relatively new field of cognitive psychology provides a valuable perspective on how behavioral and cognitive influences affect the learning and adaptation each of us experience throughout life. Clearly, such influences not only contribute to psychological disorders but also may directly modify brain functioning, brain structure, and even genetic expression. We examined some research in this field by looking at learned helplessness, social learning, prepared learning, and implicit memory.  DISCUSSION POINT: What are some examples of a situation where a person may develop pathological thoughts or actions based on learned helplessness? Based on maladaptive modeling?

Emotions  Emotions have a direct and dramatic impact on our functioning and play a central role in many disorders. Mood, a persistent period of emotionality, is often evident in psychological disorders. Some moods, such as fear and anger, are often regarded as unhealthy; however, there are clearly adaptive functions of moods, even when they don’t make people feel particularly happy.  Research has clearly illuminated the fact that some emotions have the potential to be harmful not just mentally but also physically. A consistent finding is that chronically elevated levels of anger are negatively correlated with heart health.  DISCUSSION POINT: What are some ways in which suppression of an emotion might lead to a negative health outcome? Have students generate examples.

Cultural, Social, and Interpersonal Factors  Social and interpersonal influences profoundly affect both psychological disorders and biology.  The existence of cultural disorders shows us how one’s cultural setting is related to definitions of pathology, as well as the emergence of specific illness symptoms. Such factors are also related to the treatment of mental symptoms.

Lifespan Development  In considering a multidimensional integrative approach to psychopathology, it is important to remember the principle of equifinality, which reminds us that we must consider the various paths to a particular outcome, not just the result. .

KEY TERMS multidimensional integrative approach, 33 genes, 36 diathesis-stress model, 38 vulnerability, 38 gene-environment correlation model, 40 epigenetics, 42 neuroscience, 42 neuron, 43 synaptic cleft, 43 neurotransmitters, 43 hormone, 47 brain circuits, 49 agonist, 50 antagonist, 50 inverse agonist, 50 reuptake 50

glutamate, 50 gamma-aminobutyric acid (GABA), 50 serotonin, 51 norepinephrine (also noradrenaline), 52 dopamine, 53 cognitive science, 58 learned helplessness, 59 modeling (also observational learning), 60 prepared learning, 60 implicit memory, 61 fight or flight response, 62 emotion, 62 mood, 63 affect, 63 equifinality, 70

IDEAS FOR INSTRUCTION 1.

Activity: Brain Areas & Their Function. To teach your students neuroanatomy and the contributions of neuroscience to psychopathology, prepare two sets of index cards. On one set, write the brain structures discussed in the text. The second set of cards should list the functions of these structures. For example, your cards could include the following: STRUCTURE Central nervous system Medulla and pons Cerebellum Midbrain Reticular activating system Limbic system Caudate nucleus Cerebral cortex Left hemisphere Right hemisphere Temporal lobe Parietal lobe Occipital lobe Frontal lobe Peripheral nervous system Somatic nervous system Autonomic nervous system Endocrine system Sympathetic nervous system Parasympathetic nervous system Pituitary gland

FUNCTION Consists of the brain and spinal cord Breathing, pumping of heart, digestion Motor coordination Coordinates movement with sensory input Processes of arousal and tension Emotional experiences/basic drives of sex, aggression, hunger, and thirst Controls motor behavior Contains over 80% of neurons in the central nervous system Verbal and other cognitive processes Perceiving surrounding events and creating images Recognizing various sights and sounds Recognizing various sensations of touch Integrates various visual input Thinking and reasoning abilities Coordination with brain stem to ensure body is working properly Controls our muscles Regulates the cardiovascular system and endocrine system Releases hormones into the bloodstream Mobilizes body during times of stress Renormalizes body after arousal states Master or coordinator of endocrine system

The goal of this quick activity is to have students match various structures of the brain with their respective functions. Divide the class in half and distribute one set of index cards to each group of students. Each student should receive one card. Instruct students to find the match for their structure/function, and tell them to do the activity without talking.

The above terms and simple descriptions can also easily be converted into various “game” type activities. Students may enjoy a Jeopardy! format as a classroom activity or review session.

2.

Activity: The Ubiquity of Emotion & Conditioning. Conditioning is so ubiquitous in everyday experience that it is often hard to see. Have students come up with examples of classically conditioned emotional/evaluative responses and use such examples to illustrate that most conditioning is quite adaptive. If students have trouble coming up with examples, you may start with conditioned taste aversions, objects or events that students fear, or words/images that elicit an emotional response (e.g., fear, anger, disgust; seeing flashing blue lights in your rearview mirror and getting caught for speeding). Have students talk about the dimensions that are involved in the conditioned responses in keeping with the text description of emotion as involving cognition, behavior, and physiology. As a trick, you may ask students whether they have ever felt that an exam they had taken was unfair. Don’t ask for a show of hands. Most students will raise their hands. You can then ask, “Why did you all raise your hands?” Use this example to illustrate the role of experience and socialization in learning and behavior (in this case, automatically raising one’s hand in response to a question in the classroom without being asked to do so).

3.

Activity: Susan Mineka’s Work on Vicarious Learning of Fear in Primates. Susan Mineka and her colleagues have performed some interesting experiments demonstrating vicarious learning of fear in lab-reared monkeys. Her work to date represents the most compelling evidence for observational learning of fear. Many students find the description of her classic studies interesting in itself.

4.

The Effects of Alcohol on Students in Social Situations. Ask the students to form small groups and have them develop an explanation for alcohol abuse and dependence using behavioral and cognitive theory. Have the groups write a summary of the group discussion to be shared with the entire class. This is a serious subject in colleges and universities, where every year there are many alcohol-related deaths often due to binge drinking.

Uh Oh! Plan B Although instructors are skilled professionals in creating classroom experiences, things don’t always go as planned. The chapter-related lecture and activity suggestions in this section are for instances when your planned lecture or activity idea do not go as planned. Implement these to recover student interest and enhance student reading.

1.

Big picture/Small picture—The brain and its organization are extremely complicated and the detail can easily overwhelm students. The question of “why” is missing from many psychopathology lectures. Including “the big picture” of why a particular region or function of the brain is important (even providing examples as you see fit) will help the information “stick!”

2. Using Art as an In-Class Visual—Encourage your students to bring colored pencils to class and label/color the parts of the brain as you discuss them. Research1 has suggested that color and the act of color can lead to better memory of the material.

Dzulkifli, M. A., & Mustafar, M. F. (2013). The Influence of Colour on Memory Performance: A Review. The Malaysian Journal of Medical Sciences : MJMS, 20(2), 3–9.

1

YouTube Video Clips: Chapter 2 What does it mean to be multidimensional? The concept is interdisciplinary. Watch how Michio Kaku defines the 10 dimensions of our universe. Excerpted from Michio Kaku (2014) "The Future of the Mind" https://www.youtube.com/watch?v=p4Gotl9vRGs (10:59) How is mental health biological, cultural, social, and interpersonal? This lecture details specific examples of genetic research on behavior and mental illness. Crespi, B. (2012). "Where Darwin meets Freud: Molecular Genetics, Evolution, and Psychopathology of the Social Brain". Simon Fraser University. https://www.youtube.com/watch?v=pAoueFNsvVg (1:12: 01) Our emotions can both inhibit and enhance our health and well-being. Watch Oprah Winfrey interview Gavin de Becker, author of the classic book, The Gift of Fear: And Other Survival Signals that Protect us From Violence. Dell Publishing. 1998. https://www.youtube.com/watch?v=bBProrposzc (4:24)

SUGGESTED VIDEOS Discovering psychology: The responsive brain. (Annenburg/CPB Collection). Examines the interaction of the brain, behavior, and the environment. Also shows how brain structure and function are influenced by behavioral and environmental factors. (30 min) Episode One: Reality Check. (Showtime). The first episode of the This American Life series features the story of “Second Chance,” a cloned bull version of a beloved pet. It demonstrates that despite identical genetics to its predecessor, behavioral differences exist. (29 min) Inside information: The brain and how it works. (Films for the Humanities and Sciences:).

This videotape describes how the many areas of the brain function and includes interviews with researchers in the field of neuroscience. (58 min) The brain, mind, and behavior. (PBS). This series focuses on the nature and function of the human brain, consciousness, and the effects of the brain and hormones on behavior. (8 parts, 60 min each) The enchanted loom: Processing sensory information. (Films for the Humanities and Sciences). Discusses how the brain is capable of sorting through vast sensory information and interpreting it on the basis of past experience and expectations. (60 min) The human brain. (Insight Media). Investigators discuss how the brain’s abilities can be enhanced through the proper environment. Also presents the case of a man who improves his condition after a serious brain injury. (25 min) The mind. (PBS). This series focuses on mental development in the context of normal and abnormal development.

The nervous system. (Insight Media). Explores the function of neurons as well as the central, peripheral, and autonomic nervous systems. (25 min)

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ONLINE RESOURCES Intro to the Brain https://www.youtube.com/watch?v=iTrQwJyxU8U Shows different parts of the brain and introduces concept of disease-related dementia History of Neuroscience http://faculty.washington.edu/chudler/hist.html Lists some of the most important events that occurred in neuroscience and psychology in chronological order, dating back to 4000 B.C. Neuropsychology Central http://www.neuropsychologycentral.com/resources.html Links to online sources on neuropsychological assessment, treatments, software, and newsgroups, just to name a few.

The Whole Brain Atlas http://www.med.harvard.edu/AANLIB/home.html An excellent site reviewing the structure and function of the human brain. Many of the links are quite advanced, but students with a real interest in this topic may spend hours perusing the various resources.

APA http://www.apa.org The homepage for The American Psychological Association.

The Albert Ellis Institute http://www.rebt.org/ The site for rational-emotive therapy, where you can find additional information on Ellis’s technique.

American Psychoanalytic Association http://www.apsa.org The American Psychoanalytic Association’s webpage.

SUPPLEMENTARY READING MATERIAL Additional Readings: Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall.

Beck, A. T., & Clark, D. A. (1988). Anxiety and depression: An information processing perspective. Anxiety Research, 1, 23-36.

Blatt, S. J., & Lerner, H. (1991). Psychodynamic perspectives on personality theory. In M. Hersen, A. E. Kazdin, & A. S. Bellack (Eds.) The clinical psychology handbook (2nd ed.). New York: Pergamon, 147-169.

Damasio, A. R. (1995). Descartes’ error: Emotion, reason, and the human brain. New York: Avon Books.

Ellis, A., & Harper, R. A. (1976). A guide to rational living. North Hollywood, CA: Wilshire Book Company.

Gross, C. G. (1998). Brain, vision, memory: Tales in the history of neuroscience.

Cambridge: MIT Press.

Hundert, E. (1991). A synthetic approach to psychiatry’s nature-nurture debate.

Integrative Psychiatry, 7, 76-83.

Kihlstrom, J. F. (1987). The cognitive unconscious. Science, 237, 1445-1452.

Marshall, L. H., & Magoun, H. W. (Eds) (1998). Discoveries in the human brain: Neuroscience prehistory, brain structure, and function. Totowa, NJ: Humana Press.

Mineka, S., Davidson, M., Cook, M., & Keir, R. (1984). Observational conditioning of snake fear in rhesus monkeys. Journal of Abnormal Psychology, 93, 355-372.

Ramachandran, V. S., & Blakeslee, S. (1998). Phantoms in the brain: Probing the histories of the human mind. New York: William Morrow & Company.

Rosenhan, D. (1973). On being sane in insane places. Science, 179, p. 253

Sacks, O. (1985). The man who mistook his wife for a hat and other clinical tales. New York: Summit Books.

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Anatomic Features of the Human Spinal Cord

Anatomic Features: Spinal nerves and internal organization of the spinal cord (gray and white matter) Function: Relays information to and from the brain; responsible for simple reflexive behavior

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Anatomic Features of the Human Skull

Anatomic Features: A fused connection of bony plates covering the brain Function: Protection of the brain

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Anatomic Features Protective Meninges of the CNS

Anatomic Features: Dura mater, arachnoid membrane, and pia mater Function: Protective covering of the central nervous system (CNS), location of venous drainage, and cerebrospinal fluid absorption

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Anatomic Features of the Ventricular System

Anatomic Features: Lateral (1st and 2nd), 3rd, and 4th ventricles, choroids plexus, cerebral aqueduct, and arachnoid granulations Function: Balancing intracranial pressure, cerebrospinal fluid production, and circulation

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Anatomic Features of the Brain’s Vascular System

Anatomic Features: Arteries, veins, circle of Willis Function: Arteries provide nourishment, oxygen, and other nutrients to the brain; the veins carry away waste products

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Anatomic Features of the Lower Brain Stem

Anatomic Features: Hindbrain contains the medulla oblongata (myelencephalon), and pons (metencephalon); midbrain contains the tectum and tegmentum, cranial nerves, reticular activating system Function: Relays information to and from the brain; responsible for simple reflexive behavior

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Anatomic Features of the Cranial Nerves

Anatomic Features: Located within the brain stem Function: Conducts specific motor and sensory information

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Anatomic Features of the Reticular Formation

Anatomic Features: Neural network within the lower brain stem connecting the medulla and the midbrain Function: Nonspecific arousal and activation, sleep and wakefulness

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Anatomic Features of the Hypothalamus

Anatomic Features: Hypothalamic nuclei, major fiber systems, and third ventricle Function: Activates, controls, and integrates the peripheral autonomic mechanisms, endocrine activity, and somatic functions, including body temperature, food intake, and the development of secondary sexual characteristics

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Anatomic Features of the Basal Ganglia

Anatomic Features: Structures of the caudate nucleus, putamen, globus pallidus, substantia nigra, and subthalamic nuclei Function: Important relay stations in motor behavior (such as the striato-pallidothalamic loop); connections from part of the extrapyramidal motor system (including cerebral cortex, basal nuclei, thalamus, and midbrain); coordinates stereotyped postural and reflexive motor activity

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Anatomic Features of the Limbic System

Anatomic Features: Structures of the amygdala, hippocampus, parahippocampal gyrus, cingulate gyrus, fornix, septum, and olfactory bulbs Function: Closely involved in the expression of emotional behavior and the integration of olfactory information with visceral and somatic information

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Anatomic Features of the Cerebral Hemispheres

Anatomic Features: Structures of the frontal, parietal, occipital, and temporal lobes Function: Higher cognitive functioning, cerebral specialization, and cortical localization

CHAPTER 3 CLINICAL ASSESSMENT AND DIAGNOSIS CHAPTER OVERVIEW This chapter outlines the processes of clinical assessment and diagnosis. Both domains are central to the study of psychopathology. Clinical assessment refers to a systematic evaluation and measurement of psychological, biological, and social factors in people with psychiatric disorders to provide idiographic information that may be helpful in treatment planning. Diagnosis is the process of determining whether a particular problem that distresses a person meets criteria for a psychological disorder. This chapter covers assessment techniques (clinical interview, behavioral assessment, physical examination, psychological and neuropsychological testing, neuroimaging procedures, and psychophysiological assessment), psychometric issues related to assessment and diagnosis (reliability, validity, and standardization), the nature and history of the DSM system, and issues surrounding diagnosis and classification (e.g., categorical, dimensional, and prototypic approaches). Throughout the chapter, the issues are illustrated with the case of Frank (young, serious, and anxious).

CHAPTER OUTLINE ASSESSING PSYCHOLOGICAL DISORDERS Key Concepts in Assessment The Clinical Interview Physical Examination Behavioral Assessment Psychological Testing Neuropsychological Testing Neuroimaging: Pictures of the Brain Psychophysiological Assessment DIAGNOSING PSYCHOLOGICAL DISORDERS Classification Issues Diagnosis Before 1980 DSM-III and DSM-III-R DSM-IV and DSM-IV-TR DSM-5

Creating a Diagnosis Beyond DSM-5: Dimensions and Spectra

DETAILED OUTLINE Assessing Psychological Disorders  Clinical assessment is the systematic evaluation and measurement of psychological, biological, and social factors in an individual with a possible psychological disorder; diagnosis is the process of determining that those factors meet all criteria for a specific psychological disorder.  Reliability (consistency), validity (accuracy), and standardization (norming) are important components in determining the value of a psychological assessment.  To assess various aspects of psychological disorders, clinicians may first interview and take an informal mental status exam of the patient. More systematic observations of behavior are called behavioral assessment.  DISCUSSION POINT: What does a mental status exam tell you about pursuing particular questions in your assessment?  DISCUSSION POINT: What are the potential problems in using a behavioral assessment? Do you think that a person should be told what they are looking for or should they go into the assessment without that information? Why?  A variety of psychological tests can be used during assessment, including projective tests, in which the patient responds to ambiguous stimuli by projecting unconscious thoughts; personality inventories, in which the patient takes a self-report questionnaire designed to assess personal traits; and intelligence testing, which provides a score known as an intelligence quotient (IQ).  DISCUSSION POINT: How might using a combination of projective and objective tests provide a more comprehensive picture of a client’s functioning?  Biological aspects of psychological disorders may be assessed through neuropsychological testing designed to identify possible areas of brain dysfunction. Neuroimaging can be used more directly to identify brain structure and function. Finally, psychophysiological assessment refers to measurable changes in the nervous system, reflecting emotional or psychological events that might be relevant to a psychological disorder.  DISCUSSION POINT:

Every form of assessment has strengths and weaknesses. If you had to choose one and only one form to assess a new client, which would you use? Why? How would you overcome the weaknesses of that particular method?

Diagnosing Psychological Disorders  The term classification refers to any effort to construct groups or categories and to assign objects or people to the categories on the basis of their shared attributes or relations. Methods of classification include classical categorical, dimensional, and prototypical approaches. Our current system of classification, the Diagnostic and Statistical Manual, five edition (DSM-5) is based on a prototypical approach in which certain essential characteristics are identified but certain “nonessential” variations do not necessarily change the classification. The DSM-5 categories are based on empirical findings to identify the criteria for each diagnosis.

Although this system is the best to date in terms of scientific underpinnings, it is far from perfect, and research continues on the most useful way to classify psychological disorders.  DISCUSSION POINT: If the authors had adopted a truly dimensional system of classification for DSM-5, how might that affect the field?  One of the most notable changes in the DSM-5 was the removal of the multiaxial diagnostic system, which had been in place since DSM-III. The first three axes were combined into the descriptions of the disorders themselves, and clinicians can separately comment on psychosocial or contextual factors (formerly axis IV) and the extent of the impact of a given condition (formerly axis V).  A dimensional approach has advantages in being more comprehensive in its descriptions of client behavior. However, finding the essential dimensions of anorexia, for example, may elicit considerable debate among theorists. A dimensional system may affect insurance reimbursement if there is not a clear demarcation noting mental illness. Researchers and clinicians would both need to adapt to this new approach of classifying and describing behavior.

KEY TERMS clinical assessment, 75 electroencephalogram (EEG),90 diagnosis, 75 idiographic strategy, 92 reliability, 77 nomothetic strategy, 92 validity, 77 classification, 92 standardization, 77 taxonomy, 92 mental status exam,78 nosology, 92 behavioral assessment, 80 nomenclature, 92 self-monitoring, 83 classical categorical approach,93 projective tests, 84 dimensional approach, 93 personality inventories, 85 prototypical approach, 93 intelligence quotient (IQ), 88 familial aggregation, 95 neuropsychological test, 88 comorbidity, 98 false positive, 89 labeling, 99 false negative, 89 neuroimaging, 89 psychophysiological assessment, 90

IDEAS FOR INSTRUCTION 1.

Activity: An Introduction to Assessment Methods. To help familiarize students with the various clinical assessment tools, begin by introducing a partial case history of a client.

Your students may work in groups or individually, but ask them to evaluate what tests and methods they would use with each client to determine a diagnosis. Students may be encouraged to focus on the strengths and limitations of each to emphasize that no single assessment method is entirely comprehensive. For example, you may present the following cases: a. Jack was brought into the rehabilitation unit last week. Three weeks ago, he suffered a head injury in a car accident. He has been referred to your office to determine the extent of his cognitive damage. What tests and methods of assessment should you use in your evaluation? The answer: referral for medical exam/neuroimaging, mental status, behavioral observation, intelligence tests, neuropsychological tests, and perhaps interviews with other sources. b. Carla reports feeling very depressed. She has isolated herself from friends and family, and has been unable to work. Carla’s family is concerned that she might try to commit suicide. They have approached you for help and advice. What tests and methods of assessment should you use in your evaluation? The answer: clinical/structured interview, physical examination, checklist or rating scales (e.g., Beck Depression Inventory, projective and/or objective psychological tests). c. Norman performs poorly in school compared to his classmates. He is fidgety and aggressive, and has great difficulty completing his homework assignments. His teachers are considering holding him back a year and want your advice. What tests

and methods of assessment should you use in your evaluation? The answer: clinical interview, behavioral assessment and observation in therapy and in class, physical examination, teacher and parent checklists or rating scales, and intelligence and achievement tests. d. A man shows up at the emergency room at a hospital. You are called to consult on this case. The man does not know his own name. He is unable to identify what city he lives in, and is not sure how he got to the hospital. What tests and methods of assessment would you want to administer at this point? The answer: physical and mental status examinations.

Note. You may want to draw from additional cases from the abnormal psychology casebooks. This exercise helps students learn about the assessment tools and learn that the assessment process entails choosing assessment devices and methods that appropriately address individual clients’ needs.

2.

Activity: Reliability, Validity, and Perceptual Bias in Clinical Assessment. A neat and simple exercise that can readily illustrate the relation between reliability and validity and the problem of personal bias is to do the following. First, tell students that you are about to put something up on the screen and that you want them all to watch carefully. As soon as the image disappears, they are to write down exactly what they saw. After these opening remarks, select a transparency master with the text “Paris in the the spring” and flash it up on a projection screen briefly (i.e., no longer than 5 seconds). Then, take it away and ask students to write down what they saw. You can then poll the students and tally responses on the board. What usually happens is that the majority of the class will report seeing “Paris in the spring.” Indeed, you could go ahead and calculate the interobserver reliability for the class and you would likely find it to be quite high. You can then go on to point out that while most of the class was in agreement, most of the class was also wrong. You can then put up the overhead for a closer examination and point out that what was flashed on the screen were the words “Paris in the the spring.” This is also a good time to point out the relation between reliability and validity and the issue of how our own experiences and preconceptions can bias what we see and how we interpret and respond to sense data during clinical assessment.

3.

Activity: Self-Monitoring, Reactivity, and Behavior Change. To illustrate the demands of self-monitoring, including reactivity, you can have students select some specific behavior, thought, or emotion that they would like to change (either increase in frequency or decrease in frequency). Examples might include the number of times they say “um” during a conversation, the number of cigarettes they smoke, the amount of time they spend studying, number of pages of text they read each day, the amount of food or drink they consume daily, the number of steps walked each day, etc. Then have students record the occurrence of the behavior immediately after it occurs for a period of one week. Students can then be asked to plot their data by day (i.e., “y axis” = frequency of the behavior, “x axis” = day). Reactivity should produce changes in the behavior in the desired direction. Encourage students to select a behavior that they would like to change, but also one that they would be comfortable discussing in class. Use this exercise to talk about reactivity, the demands of self-monitoring more generally, and the importance of accurate (reliable and valid) self-monitoring in clinical assessment. Most students will find it hard to monitor the frequency of each occurrence of the selected behavior.

4.

The Rorschach Test. The theory behind the test, created by Hermann Rorschach, is that the test taker’s spontaneous or unrehearsed responses reveal deep secrets or significant information about the taker’s personality or innermost thoughts. See http://deltabravo.net/custody/rorschach.php for a more in-depth discussion and the actual ink blots. Use these ink blots to lead a discussion of the validity and reliability of this method of assessment.

UH OH! PLAN B Although instructors are skilled professionals in creating classroom experiences, things don’t always go as planned. The chapter-related lecture and activity suggestions in this section are for instances when your planned lecture or activity idea do not go as planned. Implement these to recover student interest and enhance student reading.

Invite a guest speaker—Students usually have great interest in this chapter’s topic. Invite one or more psychologists who regularly use testing in their practice. New in town? Don’t know many psychologists in your area? The American Psychological Association has a website (http://locator.apa.org/) that can help you locate a possible speaker near you.

Give your students a test—Students love to learn more about themselves. Try a site which offers psychological evaluation. One chapter-relevant resource is the online Rorschach Test (http://theinkblot.com/). After you have finished the activity, discuss ways in which students can differentiate between scientific tests with predictive value and those which are “just for fun.”

YouTube Clips: Chapter 3 Want to see what a clinical interview looks in real life? Dr. John and Rita Sommers-Flanagan model best practices in clinical interviewing during client intake. https://www.youtube.com/watch?v=ViQeF1Glz34 (04:29) How does clinical interviewing change when you suspect that your client is suicidal? Dr. Shawn Shea disucsses interviewing techniques for this sensitive population. https://www.youtube.com/watch?v=MCqlLCR5mEs (11:58) PBS News Hour’s Judy Woodruff hosts a segment on what DSM-V means for diagnosing mental health. http://www.pbs.org/video/2365014970/ (08:29) Ready for a lighter note? Psychologists can be fun. Check out this video highlighting changes to the DSM through music video. https://www.youtube.com/watch?v=0rm5p3DTyE8 (02:18)

SUGGESTED VIDEOS Abnormal behavior: Fact and fiction. (Insight Media). This video examines both historical and current misconceptions and stereotypes regarding mental illness. Showing clips of two survivors of mental illness discussing their experiences, the video addresses the difficulties faced by these individuals in such everyday tasks as finding jobs and maintaining families. The video concludes by offering different approaches to viewing mental illness and advocating a more compassionate and humane understanding. (60 min) Basic interviewing skills. (Insight Media). This video presents vignettes that focus on techniques for interviewing clients. The five basic skills—listening, reflecting, questioning, expressing, and interpreting—are taught in separate segments that progress from basic to complex situations. The video concludes with a session in which all of these skills are integrated. (51 min) Behavioral interviewing with couples. (Research Press). Shows the six basic stages of an initial marriage counseling interview. (14 min).

Comprehensive clinical assessment. (Insight Media). This video discusses the range of skills that exemplify the art of social work practice and that are critical for effective intervention.

(30 min) Emotional intelligence. (Insight Media). Emotional intelligence describes a person’s comfort level with emotions and fluency with such social skills as listening, sharing, and being kind. This video presents research showing that school-aged children who cope better with daily social stresses stay healthier and learn more effectively. (30 min) Intelligence. (Insight Media). This video explains what IQ tests are designed to measure, describing their origins, their uses, and some of their failures. It addresses the debates on whether IQ tests measure aptitude or achievement and whether intelligence is fixed or changeable. (30 min) Intelligence testing. (Insight Media). This three-volume set features noted experts discussing aspects of intelligence testing. Arthur Jensen defends his contention that intelligence is a genetic fact of nature that correlates with certain physical attributes, Jonathan Baron offers a more social definition of intelligence, and Richard Burian responds to each contention. (3 volumes, 114 min total) Multiple intelligences: Intelligence, understanding, and the mind. (Insight Media). The first part of this set presents Howard Gardner’s theory of multiple intelligences. It discusses naturalist intelligence, recent work on performance-based assessments, new ideas about education for understanding, myths and applications of multiple intelligence theory, and teaching for understanding. The second presents Gardner fielding questions from educators about his theory. (2 volumes, 90 min total)

Personality. (CRM/McGraw-Hill). Depicts a college student undergoing a thorough assessment by a clinical psychologist that includes self-report, report from collateral sources, and the use of intelligence and projective tests. (30 min) The assessment/therapy connection. (Research Press). Arnold Lazarus performs a multimodal assessment of a 45-year-old depressed woman. (29 min) The clinical psychologist. (Insight Media). Depicts an initial assessment using different methods of assessment. (24 min) Violence risk assessment. (Insight Media). While clinicians can never predict violence or incidences of repeat violence with certainty, there are social, psychological, and biological risk factors that can be examined as part of a thorough assessment. This video uses a case dramatization to present a model for violence risk assessment. (37 min)

ONLINE RESOURCES APA http://www.apa.org The American Psychological Association homepage.

Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) http://www.behavenet.com/capsules/disorders/dsm4classification.htm This site provides diagnostic criteria and information relevant to the DSM-IV-TR. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR) http://www.behavenet.com/capsules/disorders/dsm4tr.htm This site provides information about the text revision to DSM-IV-TR, including information about diagnostic criteria.

Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) http://behavenet.com/diagnostic-and-statistical-manual-mental-disorders-fifth-edition-dsm-5tm This site provides information about DSM-5, including information about diagnostic criteria.

Glossary of DSM-5 Technical Terms http://quizlet.com/25508080/dsm-5-glossary-of-technical-terms-flash-cards/ This website provides a glossary of terms and definitions of DSM-5 technical terms.

Neuroimaging Links http://www.neuropsychologycentral.com/interface/content/links/page_material/imaging/imaging _links.html#a This site contains a series of excellent links to resources related to neuroimaging, neuroanatomy, and their relation to psychopathology.

Neuropsychology Central http://www.neuropsychologycentral.com/index.html This site contains information and links about neuropsychology and neuropsychological assessment.

Psychological Testing http://www.apa.org/science/programs/testing/index.aspx This APA website contains information and useful links related to psychological testing, including the ethics of testing.

SUPPLEMENTARY READING MATERIAL Additional Readings: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC. Burke, M. J., & Normand, J. (1987). Computerized psychological testing: Overview and critique.

Professional Psychology: Research and Practice, 18, 42-51.

Danna, R. H. (1993). Multicultural assessment perspectives for professional psychology.

Boston: Allyn & Bacon.

Golden, C. J. (1990). Clinical interpretation of objective psychological tests. Boston: Allyn and Bacon.

Halleck, S. L. (1991). Evaluation of the psychiatric patient: A primer. New York: Plenum.

Kellerman, H. (1991). Handbook of psychodiagnostic testing: An analysis of personality in the psychological report. Boston: Allyn and Bacon.

Lukas, S. R. (1993). Where to start and what to ask: An assessment handbook. New York: Norton.

Mash, E. J., & Terdal, L. G. (Eds.) (1988). Behavioral assessment of childhood disorders (2nd ed.). New York: Guilford.

Matarazzo, J. D. (1992). Psychological testing and assessment in the 21st century.

American Psychologist, 47, 1007-1018.

Pope, B. (1979). The mental health interview: Research and application. New York: Pergamon Press.

Trzepacz, P. T. (1993). The psychiatric mental status examination. New York: Oxford University Press.

Widiger, T. A., & Trull, T. J. (1991). Diagnosis and clinical assessment. Annual Review of Psychology, 42, 109–133.

HANDOUT 3.1 Somatotypes In the space provided, rate the degree to which you think you possess each of the three body types using a scale from 1 (low) to 7 (high) with a mean of 4 (average).  Endomorphic Body Type: Soft body; underdeveloped muscles; round shaped; over-developed digestive system Associated personality traits: love of food; tolerant; evenness of emotions; love of comfort; sociable; good humored; relaxed; need for affection Your Rating: ______  Mesomorphic Body Type: Hard, muscular body; overly mature appearance; rectangular shaped; thick skin; upright posture Associated personality traits: adventurous; desire for power and dominance; courageous; indifference to what others think or want; assertive; bold; zest for physical activity; competitive; love of risk and chance Your Rating: ______  Ectomorphic Body Type: Thin; flat chest; delicate build; young appearance; tall; lightly muscled; stoopshouldered; large brain Associated personality traits: self-conscious; preference for privacy; introverted; inhibited; socially anxious; artistic; mentally intense; emotionally restrained Your Rating: ______ Questions to Consider: 1. Do the personality traits associated with your ratings seem accurate (i.e., valid)?

2. Do you think this somatotype theory is generally accurate for most people?

3. Do you know any people for whom this theory works or doesn’t work?

4. What might be some problems with this theory and test?

CHAPTER 4 RESEARCH METHODS CHAPTER OVERVIEW This chapter outlines components of the research process in abnormal psychology. These components include the establishment of testable hypotheses, protection of internal validity, types of research design (i.e., case study, correlational, group and single-case experimental design, genetic linkage and analysis, cross-sectional, and longitudinal designs), the role of cultural factors that impinge upon research, and research ethics. This chapter also examines methods developed to discover what behaviors constitute problems, why people engage in behavioral disorders (etiology), and what constitutes effective treatments and beneficial treatment outcome. New material on clinical trials is discussed.

CHAPTER OUTLINE EXAMINING ABNORMAL BEHAVIOR Important Concepts Basic Components of a Research Study Statistical versus Clinical Significance The “Average” Client TYPES OF RESEARCH METHODS Studying Individual Cases Research by Correlation Research by Experiment Single-Case Experimental Designs GENETICS AND BEHAVIOR ACROSS TIME AND CULTURES Studying Genetics Studying Behavior over Time Studying Behavior across Cultures Power of a Program of Research Replication

Research Ethics

DETAILED OUTLINE Examining Abnormal Behavior  Research involves establishing a hypothesis that is then tested. In abnormal psychology, research focuses on hypotheses meant to explain the nature, the causes, or the treatment of a disorder.  Important concepts include consideration of both internal validity (is change in a dependent variable caused by changes in an independent variable?) and external validity (do results of a study apply outside the context of that study?). Related to these are attempts to control confounding variables through randomization, as well as the use of analogue models and examination of the generalizability of research findings to situations and circumstances outside the context of the specific study in question.  DISCUSSION POINT: Have students generate examples of confounding variables in psychopathology research.

What is the best way to control for confounding variables?  DISCUSSION POINT: It would seem that observation of a given phenomenon in an artificial setting, like a laboratory, would always call into question whether those findings would apply in the “real world.” If this is the case, then what is the value of such nonrealistic research protocols?  DISCUSSION POINT: Clinical and statistical significance are both important factors for researchers to achieve, but neither guarantees the existence of the other. Which do you think is more important, and why? How does your answer depend on the topic being researched?

Types of Research Methods  The individual case study is used to study one or more individuals in depth. Although case studies have an important role in the theoretical development of psychology, they are not subject to experimental control and must necessarily be checked in terms of both internal and external validity.  Research by correlation can tell us whether a relationship exists between two variables, but it does not tell us if that relationship is a causal one. Epidemiological research is a type of correlational research that reveals the incidence, distribution, and consequences of a particular problem in one or more populations.  DISCUSSION POINT:

If an epidemiologist is studying a new disease, or one that is beginning to emerge, would incidence or prevalence data be more useful? Why?  Research by experiment can follow one of two designs: group or single case. In both designs, a variable (or variables) is manipulated and the effects are observed to determine the nature of a causal relationship. It is important to remember that experimentation is the only type of research that gives us information about cause-and-effect relationships.

Genetics and Research across Time and Cultures  DISCUSSION POINT: How might endophenotype research contribute to the understanding of other disorders, such as depression? Relate the concept of endophenotypes to a dimensional, rather than categorical, classification system of psychological disorders.  Genetic research focuses on the role of genetics in behavior. These research strategies include family studies, adoption studies, twin studies, genetic linkage analyses, and association studies.  DISCUSSION POINT: What are some examples of ways that psychologists could create prevention programs to target specific behaviors or conditions? What are the barriers involved in implementing a prevention program?  Research strategies that examine psychopathology across time include cross-sectional and longitudinal designs. Both focus on differences in behavior or attitudes at different ages, but the former does so by looking at different individuals at different ages and the latter looks at the same individuals at different ages.  Prevention research can be viewed in four broad categories: health promotion or positive development strategies, universal prevention strategies, selective prevention strategies, and indicated prevention strategies.  The clinical picture, causal factors, and treatment process and outcome can all be influenced by cultural factors.  The more the findings of a research program are replicated, the more they gain in credibility.  Ethics are important to the research process, and ethical guidelines are set by many professional organizations in an effort to ensure the well-being of research participants. Ethical concerns are being addressed through informed consent and through the inclusion of participants in research design, implementation, and interpretation.

KEY TERMS dependent variable, 106 external validity, 106 hypothesis, 106 independent variable, 106 internal validity, 106 research design, 106 testability, 106 analogue model, 107 confound, 107 confounding variable, 107 control group, 107 generalizability, 107 randomization, 107 case study method, 109 clinical significance, 108 effect size, 108 patient uniformity myth, 108 statistical significance, 108 correlation, 109 correlation coefficient, 110 positive correlation, 110 directionality, 110 epidemiology, 110 negative correlation, 110 experiment, 111 placebo control group, 112 placebo effect, 112 comparative treatment research, 113 double-blind control, 112

repeated measurement, 114 single-case experimental design, 113 baseline, 115 level, 115 trend, 115 variability, 115 withdrawal design, 115 genotype, 117 multiple baseline, 115 phenotype, 117 endophenotypes, 117 human genome project, 117 adoption studies, 118 family studies, 117 genetic linkage analysis, 119 proband, 117 twin studies, 118 association studies, 119 genetic marker, 119 cohort, 120 cohort effect, 120 cross-sectional design, 120 longitudinal design, 120 retrospective information, 120 cross-generational effect, 121 sequential design, 121 informed consent, 123

IDEAS FOR INSTRUCTION 1.

Activity: The Case Study Method. To demonstrate the advantages and disadvantages of case study methodology, encourage students to conduct a case study of their own. They may look for a person who is willing to discuss a disorder they have (e.g., alcoholism, insomnia, eating disorder, etc.) or they can conduct a case study on a person’s experience of a phenomenon (e.g., divorce, war, loss, etc.), including some aspect of their own life and experience. Discuss the advantages of using this methodology and the drawbacks.

2.

Activity: The Correlational Method. Have your students look through popular literature to find claims about new and newsworthy psychological findings (see below under the heading Internet Resources for an online resource to Abnormal Psychology in the News). Most of the time, the popular literature is utilizing correlational data. Assist students in learning how to critically evaluate data that is presented in the popular literature. You may want to illustrate how easy it is to make false assumptions about correlational data. For example, if you tell your class that obesity and the number of hours children watch television is positively correlated, many students will surmise that those results are due to the fact that watching television prohibits children from exercising. However, an alternative explanation is that obese children choose to watch television because it is more difficult for them to exercise. Caution students about directionality problems and the possibility of a third factor being responsible for correlations. Again, correlation does not imply causation. To truly emphasize this activity, you may consider finding examples of the correlation-causation error in peerreviewed journals so that students can see that even professional researchers are prone to forgetting this important rule of correlational research.

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3.

Activity: Establishing Empirically Supported Treatments. Ask students to go to one of the many

websites that contain lists of empirically validated research in a given area such as http://www.psychologicaltreatments.org or https://www.drugabuse.gov/publications/principlesdrug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drugaddiction-treatment to illustrate how research design and research criteria translate into the science of psychotherapy.

The criteria for empirically supported treatments contain a rich source of information about research design and the process of developing efficacious treatments. You may also use this topic as a spring board to discuss the current controversies surrounding empirically supported psychotherapies, highlight the distinction between efficacy vs. effectiveness research, and discuss whether psychologists should move toward having a model like the Food and Drug Administration (FDA) in sanctioning psychotherapies and what empirically supported treatments mean for consumers of psychological services.

4.

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Activity: Random Assignment and Expectations Regarding Psychotherapy. The following activity is designed to illustrate random selection and random assignment as well as the role of expectations and feelings regarding treatment. To illustrate random selection, tell students that you are going to perform a little experiment in class that may involve the possibility of earning extra credit. Also, explain that everyone should pretend that the class represents the population as a whole. Begin by stating that your study has two conditions: a treatment and a wait-list control, and that people in the treatment condition will receive extra credit (the others will not, but may at some point in the future). Using your roster, begin by randomly selecting 10 students from the class and asking them to come forward one at a time (do this slowly). Now, pull out a coin and flip it as each student comes forward (illustrates the process of random assignment). If the coin comes up heads for the first student, place him or her in the treatment group off to your right. If the coin comes up tails for the next student, place him or her off to your left in the wait-list control group. You will want to make this part dramatic, so again handle each student one at a time (i.e., randomly select one student, go through the process of random assignment, and then move on). Continue until all 10 students are separated into groups (you should end up with about four or five students in each group). This is a good time to discuss how students felt immediately after they learned that they were being assigned to either the wait-list control or extra credit treatment. Relate their feelings to what patients may experience (but on a much larger scale) when enrolling in treatment research. You may want to go ahead and offer extra credit to all students who participated or perhaps a small prize, cheers, applause, etc.

5.

Designing a Research Project. Have the students come up with two or three questions on how to design a research project in abnormal psychology. For example: What are the symptoms of schizophrenia, and how are they changing? Have students identify appropriate independent variable(s), the dependent variable(s), and any needed control groups and describe how they would be operationalized. In addition, there are several questions the students should be able to answer: What research method would be the most practical to study abnormal behavior? How would using a different research method change the meaning of the study?

Uh Oh! Plan B Although instructors are skilled professionals in creating classroom experiences, things don’t always go as planned. The chapter-related lecture and activity suggestions in this section are for instances when your planned lecture or activity idea do not go as planned. Implement these to recover student interest and enhance student reading.

Students as Knowledge-Generators—Often, students attach mythic value to “scientists” who create new knowledge. Help plant the seed idea that they, too, can not only consume psychological knowledge but also generate it. Now is the time for crucial conversations such as “How would you empirically study that?” and “What would you do differently if you were studying the same thing?”. Guide students to become critical thinkers and some might just be your colleagues one day!

YouTube Clips For a funny recap of many of this chapter’s themes and ideas, check out “Crash Course” https://www.youtube.com/watch?v=hFV71QPvX2I (10:50) Why is behavior considered normal in one culure and abnormal in another? Find out more about how culture determines our definition of psychopathology. https://www.youtube.com/watch?v=prUFZIcgZiQ (03:11)

SUGGESTED VIDEOS Ethics and scientific research. (Insight Media). This video addresses ethical issues faced by scientific researchers, focusing on scientific misconduct and its control. It features Robert L. Sprague, recipient of the AAAS Scientific Integrity and Freedom Award, who discusses a case of a scientist who faked research on psychotropic drugs. (30 min) Experimental design. (Insight Media). This program distinguishes between observational studies and experiments, teaching basic principles of experimental design. It covers comparison, randomization, and replication, and includes a program that examines the question of causation.

(30 min each) Experiments in human behavior. (Insight Media). This still-image video shows how psychological experiments are designed, using examples from research on prisoner/guard .

relationships, obedience to authority, cult behavior, and alcohol consumption. It also discusses experimenter bias and examines when to use field studies, observational studies, and questionnaires. (35 min) How numbers lie: Media truth or fiction. (Insight Media). Numbers are powerful persuasion tools that can be twisted to support a particular point of view. This program teaches viewers how to think critically and analyze statistics disguised as facts. “Provides excellent examples…thought-provoking.” (23 min) Nature and nurture interwoven. (Insight Media). Using research in behavior genetics, ideas of heritability, and data from twin studies, this video questions the extent to which parents can alter their children’s futures by changing the circumstances of their lives. It profiles the Oliveira children from urban São Paulo, showing their visit to the rural region where their parents grew up and their encounter with their country cousins. (30 min) The mystery of twins. (Insight Media). Presenting the findings of a range of current research projects on the links between identical twins, this video explores what twins may be able to reveal about the different impacts of nature and nurture. It questions the importance of genes to behavioral choices, considers the evolutionary significance of naturally occurring clones, and addresses the possibility of ESP between people with matching genetic material. (52 min) The scientific method. (Insight Media). Tracing the evolution of the scientific method, this program shows the three-step process of observing, developing a hypothesis, and testing it through experimentation. It presents examples of how the scientific method is applied in the classroom and in professional research. (23 min) .

ONLINE RESOURCES APA Ethical Principles and Code of Conduct http://www.apa.org/ethics/code/ This is the online version of the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct.

Internal and External Validity Tutorials A tutorial on internal validity http://psych.athabascau.ca/html/Validity/ and external validity https://www.sophia.org/tutorials/external-validity--3 helps you better understand the importance of considering both in your research design.

Library Research http://www.apa.org/education/undergrad/library-research.aspx This APA website is designed for students and explains how to find library resources about psychology by searching journals, books, newspapers, etc. .

Preparing Your Laboratory Report Writing up your experimental findings? Want to see an excellent sample? The Purdue Online Writing Lab shows you how to make your final report final. https://owl.english.purdue.edu/media/pdf/20120820092738_670.pdf

SUPPLEMENTARY READING MATERIAL Additional Readings: Bersoff, D. N. (1995). Ethical conflicts in psychology. Washington, DC: American Psychological Association.

Bromley, D. B. (1986). The case-study method in psychology and related disciplines.

New York: Wiley.

Critelli, J. W., & Neumann, K. F. (1984). The placebo: Conceptual analysis of a construct in transition. American Psychologist, 39, 32–39.

Estes, W. K. (1991). Statistical models in behavioral research. Hillsdale, NJ: Erlbaum.

Garber, J., & Hollon, S. D. (1991). What can specificity designs say about causality in psychopathology research? Psychological Bulletin, 110, 129-136.

Greenberg, L. S., & Pinsof, W. M. (1994). Reassessing psychotherapy research. New York: Guilford.

Hayes, S. C., Barlow, D. H., & Nelson-Gray, R. O. (1999). The scientist practitioner: Research and accountability in the age of managed care, Boston, MA: Allyn & Bacon.

Hayes, S. C., Follette, V. M., Dawes, R. M., & Grady, K. E. (1995). Scientific standards of psychological practice: Issues and recommendations. Reno, NV: Context Press.

Hock, R. R. (1992). Forty studies that changed psychology: Explorations into the history of psychological research. Englewood Cliffs, NJ: Prentice-Hall.

Kazdin, A. E. (Ed.) (1992). Methodological issues and strategies in clinical research.

Washington, DC: American Psychological Association.

Keith-Speigel, P., & Koocher, G. P. (1985). Ethics in psychology: Professional standards and cases. New York: Random House.

Kratochwill, T. R., & Levin, J. R. (Eds.) (1992). Single-case research design and analysis: New directions for psychology and education. Hillsdale, NJ: Erlbaum. .

Levine, G. (1994). Experimental methods in psychology. Hillsdale, NJ: Erlbaum.

McGuigan, F. J. (1993). Experimental psychology: Methods of research. Englewood Cliffs, NJ: Prentice-Hall.

Monroe, S. M., & Roberts, J. E. (1991). Psychopathology research. In M. Hersen, A. E. Kazdin, & A. S. Bellack (Eds.) The clinical psychology handbook (2nd ed.). New York: Pergamon.

Routh, D. K. (1993). Clinical psychology since 1917: Science, practice, and organization. New York: Plenum.

Spring, B. (2007). Evidence-based practice in clinical psychology: What it is, why it matters; what you need to know. Journal of Clinical Psychology, 63, 611-631.

Trierweiler, S. J., & Stricker, G. (1998). The scientific practice of professional psychology. New York: Plenum.

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CHAPTER 5 ANXIETY, TRAUMA-AND STRESSOR-RELATED, AND OBSESSIVE-COMPULSIVE AND RELATED DISORDERS CHAPTER OVERVIEW This chapter outlines the concept of anxiety, fear, and its related disorders. Anxiety is a futureoriented state characterized by negative affect in which a person focuses on the possibility of uncontrollable danger or misfortune. Fear is a present-oriented mood state characterized by strong urges to escape and a surge of the sympathetic branch of the autonomic nervous system.

This chapter provides detailed descriptions of the nature and phenomenology of anxiety and panic attacks, and each of the major anxiety disorders (generalized anxiety disorder, panic disorder and agoraphobia, specific phobias, and social anxiety disorder (social phobia)), the trauma-and stressor-related disorders (acute stress disorder and posttraumatic stress disorder), and obsessive-compulsive and related disorders (obsessive-compulsive disorder and body dysmorphic disorder). For each, case examples are provided as well as summaries of symptomatology, course, prevalence, and etiological factors. Psychological and drug treatments are also discussed, along with the diagnostic changes that have occurred in the DSM-5 revision and how it will affect our understanding of these disorders moving forward.

CHAPTER OUTLINE THE COMPLEXITY OF ANXIETY DISORDERS Anxiety, Fear, and Panic: Some Definitions Causes of Anxiety and Related Disorders Comorbidity of Anxiety and Related Disorders Comorbidity with Physical Disorders Suicide

ANXIETY DISORDERS GENERALIZED ANXIETY DISORDER Clinical Description Statistics Causes

Treatment PANIC DISORDER AND AGORAPHOBIA Clinical Description Statistics Causes Treatment SPECIFIC PHOBIA Clinical Description Statistics Causes Treatment SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA) Clinical Description Statistics Causes Treatment

TRAUMA- AND STRESSOR-RELATED DISORDERS POSTTRAUMATIC STRESS DISORDER Clinical Description Statistics Causes Treatment

OBSESSIVE-COMPULSIVE AND RELATED DISORDERS OBSESSIVE-COMPULSIVE DISORDER Clinical Description Statistics Causes Treatment

BODY DYSMORPHIC DISORDER Plastic Surgery and Other Medical Treatments OTHER OBSESSIVE-COMPULSIVE AND RELATED DISORDERS Hoarding Disorder Trichotillomania (Hair Pulling Disorder) and Excoriation (Skin Picking Disorder)

DETAILED OUTLINE The Complexity of Anxiety Disorders  Anxiety is a future-oriented state characterized by negative affect in which a person focuses on the possibility of uncontrollable danger or misfortune; in contrast, fear is a presentoriented state characterized by strong and immediate escapist tendencies and a surge in the sympathetic branch of the autonomic nervous system in response to current danger.  A panic attack represents the alarm response of real fear, but there is no actual danger.  Panic attacks may be (1) unexpected (uncued) or (2) expected (cued), the distinction between which is clearly whether or not the context of the attack can be predicted based on past panic experiences.  Panic and anxiety combine to create different anxiety disorders.  Research evidence exists to support multiple causes of anxiety, including biological models that identify brain circuit and neurotransmitter involvement as well as psychological and social contributions. An integrated model of these factors considers how they all contribute simultaneously to the presence of abnormal, potentially pathological levels of anxiety.  DISCUSSION POINT: How could the “triple vulnerability” theory be used to explain the development of panic disorder?

Be sure that students can generate examples of generalized psychological vulnerability versus specific psychological vulnerability.

ANXIETY DISORDERS Generalized Anxiety Disorder  In generalized anxiety disorder (GAD), anxiety focuses on minor everyday events, not one major worry or concern.  Both genetic and psychological vulnerabilities seem to contribute to the development of GAD. In particular is the fact that individuals with GAD seem to be more sensitive to threat in general, particularly when the threat has some personal relevance.  Although drug and psychological treatments may be effective in the short term, the most successful long-term treatment may help individuals with GAD focus on what is really threatening to them in their lives. While benzodiazepine medications are useful for an acute, crisis stage of a week or two, recent evidence suggests that antidepressant medications such as Paxil and Effexor provide superior symptoms relief past that initial stage.

Panic Disorder and Agoraphobia  Panic disorder is marked by repeated attacks of debilitating, overwhelming anxiety that is often accompanied by a myriad of physical symptoms. It is sometimes, but not always, accompanied by agoraphobia, (a fear and avoidance of situations considered to be “unsafe”).  DISCUSSION POINT: What is the relationship between agoraphobia and panic disorder? How might these conditions also lead to other comorbid conditions?

This discussion could include how having a panic attack in a situation may make a person feel more vulnerable in that location, which could generalize to other situations as well. Because of agoraphobia, people limit their experiences with the outside world, which prevents them from being able to find out what would happen if they were to confront the fear. Comorbid depression and alcohol and substance use disorders may develop if the person has limited skills for coping with anxiety and distress.  We all have some genetic vulnerability to stress, and many of us have had a neurobiological overreaction to some stressful event—that is, a panic attack. Individuals who develop panic disorder then develop anxiety over the possibility of having another panic attack.  Both drug and psychological treatments have proved successful in the treatment of panic disorder. One psychological method, panic control treatment (PCT), concentrates on exposing patients to clusters of sensations that remind them of their panic attacks. The symptoms of agoraphobia that can accompany panic disorder can be effectively treated with gradual exposure exercises, sometimes combined with anxiety-reducing coping mechanisms.

These approaches do not “cure” the issue, however, as the panic attacks may persist and cause ongoing related agoraphobic issues.

Specific Phobia  In phobic disorders, the individual avoids situations that produce severe anxiety, panic, or both. In specific phobia, the fear is focused on a particular object or situation.  DISCUSSION POINT: How might a parent seek to determine if a child’s fears are reasonable, ordinary responses to the world or the beginning of an anxiety disorder?  DISCUSSION POINT: Do you have any severe fears? What would you use as a way of assessing whether that fear is or is not a phobia?

Students should be able to refer back to the discussion of the distinction between normal, abnormal, and pathological and should integrate several of those criteria into their evaluation of what escalates a fear into a phobia. Encourage students to participate only to their own level of comfort and appropriate self-disclosure. The instructor may want to have several hypothetical examples ready in case students are reticent to participate.  Phobias can be acquired by experiencing some traumatic event; they can also be learned vicariously or even be taught.

 Treatment of phobias is rather straightforward, with a focus on structured and consistent exposure-based exercises.

Social Anxiety Disorder (Social Phobia)  Social anxiety disorder (SAD) is a fear of being around others, particularly in situations that call for some kind of “performance” in front of other people. The fear often centers around a worry of behaving in some embarrassing or humiliating way that may bring negative judgment from others.  One model for how people acquire SAD suggests that those with the condition may be predisposed to be highly sensitive to negative messages from others, including anger, rejection, and criticism. These signals may be perceived in subtle facial expressions, contributing to the symptoms of the disorder.  Although the causes of SAD are similar to those of specific phobias, treatment has a different focus that includes rehearsing or role-playing socially phobic situations. In addition, drug treatments have been effective.  Selective mutism is a condition now categorized as an anxiety disorder, and is closely related to social anxiety disorder. It involves a lack of speech in situations where speaking is expected, and has a high level of comorbidity with SAD, and the treatment is similar to that of SAD with a greater emphasis on speech.

TRAUMA- AND STRESSOR-RELATED DISORDERS

Posttraumatic Stress Disorder  Posttraumatic stress disorder (PTSD) focuses on avoiding thoughts or images of past traumatic experiences. It is diagnosed when the symptoms emerge more than one month after the traumatic event, or if the symptoms persist for longer than one month. If the symptoms occur within the first month, the diagnosis is acute stress disorder.  The precipitating cause of PTSD is obvious—a traumatic experience. But mere exposure to trauma is not enough. The intensity of the experience seems to be a factor in whether an individual develops PTSD; biological vulnerabilities, as well as social and cultural factors, appear to play a role as well.  Treatment involves reexposing the victim to the trauma and reestablishing a sense of safety to overcome the debilitating effects of PTSD.  DISCUSSION POINT: What are some other challenges a therapist might confront when treating a client for PTSD using imaginal exposure?

Possibilities include a tendency for the client to want to leave therapy, difficulty selecting one event for exposure if the client has had a history of multiple traumas, difficulty getting the client to engage emotionally with the memory, and an increase in anxiety symptoms in early stages of the therapy.  Other conditions that are included in trauma and stressor-related disorders are adjustment disorders, attachment disorders, reacting attachment disorder, and disinhibited social engagement disorder.

OBSESSIVE-COMPULSIVE AND RELATED DISORDERS Obsessive-Compulsive Disorder  Obsessive-compulsive disorder (OCD) focuses on avoiding frightening or repulsive intrusive thoughts (obsessions) or neutralizing these thoughts through the use of ritualistic behavior (compulsions).  As with all anxiety disorders, biological and psychological vulnerabilities seem to be involved in the development of OCD.  Drug treatment seems to be only modestly successful in treating OCD. The most effective treatment approach is a psychological treatment, exposure, and ritual prevention (ERP).

Medication has not been found to be superior to this intervention, either in terms of efficacy or relapse prevention. In very severe cases of OCD that have not responded to other interventions and are causing significant life interruption, psychosurgery may be considered as a last resort.

Body Dysmorphic Disorder  In body dysmorphic disorder (BDD), a person who looks normal is obsessively preoccupied with some imagined defect in appearance (imagined ugliness). It was previously considered a somatoform disorder because of the focus on a “body” issue, but more recently the emphasis on the anxiety caused by the exaggerated or imagined defect has caused it to be recategorized

as an anxiety disorder.  Patients suffering from BDD often turn to plastic surgery or other medical interventions, which more often than not increase their preoccupation and distress.  DISCUSSION POINT: How do cultural standards of beauty influence BDD? What other disorders share similarity with BDD, and why might the suicide rate in this disorder be so high?

Other Obsessive-Compulsive and Related Disorders  Hoarding disorder is marked by a compulsive tendency to collect objects – often of no sentimental or material value – and to have tremendous difficulty with discarding any possession, and living with excessive clutter and disorganization, often to dangerous extremes.  Hoarding disorder was previously thought of as an extreme variation of OCD, but has recently been separated into its own diagnosis. Treatments may involve encouraging people to assign numerical values to specific objects, followed by discarding those that fall below a specific value. This can help to reduce anxiety that something truly important will be thrown away.  Trichotillomania (hair pulling disorder) involves pulling out one’s own hair from anywhere on the body, including the head, eyebrows, arms, or other locations. It can lead to great embarrassment as a result of appearance-related issues, along with one going to great lengths to cover up the actions. Research suggests that there may be a genetic mutation that explains many cases of this disorder.  Excoriation (skin picking disorder) is repetitive and compulsive picking on or at one’s skin, which can lead to bruises, scabbing, scarring, and damage.  Both trichotillomania and excoriation were previously labeled as impulse-control disorders, but the anxiety that accompanies the behaviors have caused them to be recategorized in DSM-5. Psychological treatments seem to be the most useful for bringing about improvement in both disorders.

KEY TERMS anxiety, 127 fear, 128

separation anxiety disorder, 153 social phobia, 154

panic, 128 panic attack, 128 behavioral inhibition system (BIS),130 fight/flight system (FFS), 130 generalized anxiety disorder (GAD), 134 panic disorder (PD), 139 agoraphobia, 139 panic control treatment (PCT), 145 specific phobia, 147 blood-injection-injury phobia, 149 situational phobia, 149 natural environment phobia, 149 animal phobia, 149

posttraumatic stress disorder (PTSD), 160 acute stress disorder, 161 adjustment disorders, 167 attachment disorders, 167 reactive attachment disorder, 168 disinhibited social engagement disorder, 168 obsessive-compulsive disorder (OCD), 168 obsessions, 168 compulsions, 168 body dysmorphic disorder (BDD), 173 trichotillomania, 177 excoriation, 177

IDEAS FOR INSTRUCTION 1.

Activity: Preparedness and the Pathways to Phobic Fear Acquisition. Objects of phobic fear are nonrandomly distributed to objects or situations that were threatening to the survival of the species throughout the course of evolution. This evolutionary perspective is described under the concept of preparedness. That is, we are prepared to more readily associate fear with some objects or situations (e.g., snakes, heights) than others (e.g., pajamas, electrical outlets), even though both may be associated with panic or trauma. Moreover, we know that fears may be acquired via direct conditioning or indirectly through observational learning or information transmission. To illustrate both concepts, have students write down an object or situation that they are particularly afraid of, including what event(s) they think led to the development of this top fear. Then, collect the sheets and categorize and tally the lists (or a representative sample thereof, particularly for large classes) on the board or via overhead. What you should find is that most students report fearing objects or situations that have some prepared evolutionary basis. You should also be able to illustrate that few students can recall actual direct conditioning events to explain how their fears developed and that many may simply say “I can’t remember how my fear started.” This exercise is a good spring board to a discussion of the nature and etiology of phobias, including the relation between phobias and impairment in life functioning.

2.

Activity: Demonstrating What Panic Attacks Are Like. This exercise is designed to help students appreciate what it might be like to have breathing difficulties and other autonomic symptoms associated with a panic attack. You will need 4" coffee-stirring straws with a tiny lumen (obtained from restaurants, grocery stores, or your campus food court/cafeteria). Before beginning this exercise, inform students that this activity may lead

to shortness of breath and may not be appropriate for those with respiratory difficulties due to colds, asthma, or other problems. Also inform students that this exercise is entirely voluntary, though participation is encouraged. Distribute one straw to each student. While seated, students should practice breathing only through the straw. They should avoid breathing through their noses or around the straw. Have students stand and, while continuing to breathe only through the straw, run in place for five minutes. Discuss the students’ experiences after running. Many find they become so short of breath they cannot continue to exercise as designed. Many will also report feeling light-headed, dizzy, tingly, and some may experience increased perspiration. Explore what it might be like to experience shortness of breath and the related sensations, particularly out of the blue in the course of their daily routine (e.g., going to class, when out on a date, at the library, a party, a movie, driving in a car, to name a few). Could they imagine how a panic attack might follow or coincide with the experience of these kinds of physical symptoms? Finally, it is important to have students understand that panic attacks are often very sudden events and that their physical and psychological experience at the end of the straw exercise would happen much more abruptly during an actual panic attack. I often illustrate the concept of abruptness by asking students whether they have ever been pulled over for speeding.

Many students will report yes. I then ask them to imagine how they felt when they looked into their rear-view mirror and saw flashing blue lights and a police car riding their tail.

Most report feeling gripped by fear, including a sinking feeling in the stomach, nervousness, and the like. The immediacy of this reaction is analogous to a panic attack.

3.

Activity: Demonstration of Graduated Exposure for Phobias or Panic. Students often appreciate being able to see what treatment might look like. Devise a hypothetical hierarchy of exposure for a common specific phobia or for panic disorder. Then, ask for a student volunteer and demonstrate how you would proceed to conduct exposure therapy, including the therapist-client issues you would consider as you move up the rungs of the fear hierarchy.

4.

Activity: Narrative Therapy and Exposure for PTSD. Students often have a difficult time understanding why one would want to have a patient suffering from PTSD relive memories and emotions associated with their trauma in therapy. Ask students to think about something moderately upsetting that happened in the past month. Stress that you do not want them to select an actual trauma, but instead pick an event that they have thought about and that they feel is not completely resolved in their minds. Have the students write about this event for 10 minutes, describing it in detail, including their reactions, thoughts, and feelings. Do not have the students turn it in, but have them discuss if the experience of writing changed their perception of the event.

5.

Activity: Student Debate on the Efficacy of Medications vs. Psychological Interventions in the Treatment of Anxiety-Related Disorders. Have students select an anxiety disorder of interest. Then, for each anxiety disorder, have students divide into debate teams. One team is to take a pro-medication perspective for a particular anxiety disorder and the other a pro-psychotherapy perspective. Have the respective teams go to the library and research the evidence and arguments favoring their positions. During class,

follow discussion of each anxiety disorder with the corresponding debate. For example, after you cover panic disorder, have the debate teams present their cases for either drug treatment or psychotherapy. Use the debate as a springboard for class discussion about the current state of the art regarding treatment efficacy, including how taking a one-sided position can be problematic when devising treatment.

6. Systematic Desensitization. Systematic desensitization is a technique used to treat phobias and other extreme or erroneous fears based on principles of behavior modification. Develop a lecture on this topic using the information at http://www.minddisorders.com/Py-Z/Systematic-desensitization.html as a basis of your classroom discussion. Show this short video on virtual reality and systematic desensitization http://www.youtube.com/watch?v=CQgKEp_NhHk. 7. Anxiety Disorders and the DSM-5. Develop a lecture on the changes that have taken place in DSM-5 and how they affect our understanding and diagnoses of anxiety disorders.

Uh Oh! Plan B Although instructors are skilled professionals in creating classroom experiences, things don’t always go as planned. The chapter-related lecture and activity suggestions in this section are for instances when your planned lecture or activity idea do not go as planned. Implement these to recover student interest and enhance student reading.

Pulling Students out of their Own Pain—Anecdotally, psychology students tend to believe that they themselves have unresolved mental health issues and/or they are more sensitive to those issues within themselves and their friends and family. Although this zeal for the content can be a springboard toward engagement, it can also be distracting to a class, particularly a large class. If you haven’t already done so, develop a plan as to how to redirect students who may use a discussion question or class activity as an opportunity for self-disclosure. Setting some boundaries (such as the need for class confidentiality, limits on individual comments, etc) may help. It is also suggested that the instructor have a list of the campus mental health counselors on hand as well as a nearby community resource. Reach out to struggling students after class and let them know that you care. Although class might not be the appropriate place to get help, you do want them to connect with the services that they need.

YouTube Clips As it is very difficult to conceptualize disorders without having some idea of what it “feels like,” these videos will focus on first-person accounts of the disorders described in the text: Anxiety Disorder https://www.youtube.com/watch?v=nCgm1xQa06c (03:23) Panic Disorder https://www.youtube.com/watch?v=uPlhgtQqA6c (01:34)

Social Anxiety Disorder (Social Phobia) https://www.youtube.com/watch?v=sgo6kwaAXSc (05:40) PTSD https://www.youtube.com/watch?v=XfkmyKrQk-w (01:58) OCD https://www.youtube.com/watch?v=M8ME2khsmuU (01:39) Body Dysmorphic Disorder https://www.youtube.com/watch?v=sTJY2Q_yZyY (05:40)

SUGGESTED VIDEOS As Good As It Gets. Jack Nicholson portrays a homophobic, racist novelist with obsessive-compulsive disorder.

Born on the fourth of July. Tom Cruise depicts a paralyzed Vietnam veteran coping with re-integration into post-war life. The film has particularly compelling scenes of VA hospitals during that time.

Chattahoochee. Korean War veteran with posttraumatic stress disorder is hospitalized and treated. Dennis Hopper plays a major role as a fellow patient.

Cognitive therapy for panic disorder. (APA Psychotherapy Videotape Series II: Specific Treatments for Specific Problems, American Psychological Association). This video illustrates the process of cognitive therapy for panic disorder. (45 min) Copycat. Sigourney Weaver stars as criminal psychologist Helen Hudson who is involved in unlocking the psyches of her previous client (an incurable psychotic who almost murdered her). Now she’s an agoraphobic, living a terrified existence defined by the walls of her apartment, with her computer modem and her loyal and compassionate assistant, Andy, her only links to the outside world. This film provides an excellent depiction of extreme agoraphobia.

Cyrano de Bergerac. This film depicts Cyrano, a man obsessed with the size of his nose and who is convinced that he is forever unlovable because of this presumed defect.

Extending the boundaries of treatment for panic. (Insight Media). This video explains the clinical goals of treatment of panic disorder, including the alleviation of attacks and relief of such symptoms as agoraphobia, anticipatory anxiety, phobic avoidance, and effective treatment strategies. It assesses the relative benefits of pharmacotherapy, cognitive-behavioral therapy, and combined regimens. (90 min) Fear and anxiety. (Films for the Humanities and Sciences). In this program, expert panelists discuss symptoms of anxiety disorders, how anxiety impacts everyday life, the relationship between fear and emotional memory, and new developments in treatment. (56 min)

Fear itself: Agoraphobia. (Films for the Humanities and Sciences). Explores the organic causes of phobias as well as possible treatments, focusing on agoraphobia. (26 min) Obsessive-compulsive disorder: The boy who couldn’t stop washing. (Films for the Humanities and Sciences). Adapted Phil Donahue show with Dr. Judith Rapport, author of the book by the same title. Considers symptoms, diagnosis, and possible cures of OCD. (28 min) Panic attacks. (Films for the Humanities and Sciences, Princeton). Covers the diagnosis and treatment of panic attacks and related disorders. (15 min) Posttraumatic stress disorder (Films for the Humanities and Sciences).

Roxanne. This film is a modern adaptation of Cyrano de Bergerac starring Steve Martin and Darryl Hannah.

Things that go bump: Facing our fears. (Prime Post). This multi-part series that aired on the Discovery Health Channel covers the etiology and treatment of specific phobias, social phobia, and panic disorder.

Treatment and assessment of childhood depression and anxiety. (Insight Media). Focusing on the broadening pharmacological treatment options for childhood depression and anxiety disorders, this video examines diagnostic criteria, epidemiology, and known neurobiological factors. It also discusses separation anxiety disorder, selective mutism, posttraumatic stress disorder, and generalized anxiety disorder. (120 min)

ONLINE RESOURCES Agoraphobia http://psychcentral.com/disorders/agoraphobia-symptoms/ Provides a description of agoraphobia and a set of related links.

Anxiety and Depression Association of America (ADAA) http://www.adaa.org/ This is the official website of the Anxiety and Depression Association of America (ADAA). The ADAA promotes the prevention and cure of anxiety disorders and depression and works to improve the lives of all people who suffer from them.

Anxiety Disorders http://www.apa.org/helpcenter/anxiety-treatment.aspx This site by the American Psychological Association provides information specific to generalized anxiety disorders; it also describes best practices and current treatments.

Mental Help Net http://www.mentalhelp.net/

This site may be the largest mental health site on the Internet. Includes links to other mental health-related sites, an online magazine for self-help organizations, plus a directory for therapists.

International Obsessive-Compulsive Disorder Foundation (IOCDF) http://www.ocfoundation.org/ This web page, developed by the International Obsessive-Compulsive Disorder Foundation and the Mend Association, includes information on support groups, services, and publications on this disorder.

The Phobia List http://phobialist.com/ This site provides a comprehensive list of the names of all phobias, including additional links to other phobia sites.

The National Center for PTSD http://www.ptsd.va.gov/ This website provides a wealth of information about PTSD, including current research and available treatments.

NIMH http://www.nimh.nih.gov The National Institute of Mental Health homepage, which offers information about diagnosis, treatment, and research into anxiety disorders, obsessive-compulsive disorder, and phobias.

SUPPLEMENTARY READING MATERIAL Additional Readings: Barlow, D. H. (2000). Unraveling the mysteries of anxiety and its disorders from the perspective of emotion theory. American Psychologist, 55, 1247-1263.

Barlow, D. H. (2001). Anxiety and its disorders: The nature and treatment of anxiety and panic, 2nd ed. New York: Guilford.

Barlow, D. H., Brown, T. A., & Craske, M. G. (1994). Definitions of panic attacks and panic disorder in the DSM-IV: Implications for research. Journal of Abnormal Psychology, 103, 553-564.

Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory perspective on the etiology of panic disorder. Psychological Review, 108, 4-32.

Clark, D. M (1988). A cognitive model of panic attacks. In S. Rachman & J. D. Maser (Eds.), Panic: Psychological perspectives. Hillsdale, NJ: Lawrence Erlbaum, 71-89.

McNally, R. J. (1987). Preparedness and phobias: A review. Psychological Bulletin, 100, 283-303.

Clipson, C. & Steer, J. (1998). Case studies in abnormal psychology. Boston, MA: Houghton Mifflin Company. Chapter 2, Panic Disorder. Chapter 3, ObsessiveCompulsive Disorder. Chapter 4, Posttraumatic Stress Disorder.

Craske, M. G. (2003). The origins of phobias and anxiety disorders: Why more women than men? Amsterdam: Elsevier.

Craske, M. G., & Barlow, D. H. (2000). Mastery of your anxiety and panic, 3rd ed. New York: The Psychological Corporation.

Eisen, A. R., Kearney, C. A., & Schaefer, C. E. (Eds.) (1995). Clinical handbook of anxiety disorders in children and adolescents. Northvale, NJ: Jason Aronson.

McCann, I. L., & Pearlman, L. A. (1990). Psychological trauma and the adult survivor: Theory, therapy and transformation. New York: Brunner/Mazel.

Neal, A., & Turner, S. M. (1991). Anxiety disorder research with African-Americans: Current status. Psychological Bulletin, 109, 400-410.

Phillips, K. A. (1991). Body dysmorphic disorder: The distress of imagined ugliness.

American Journal of Psychiatry, 148, 1138-1149.

Pynoos, R. S., Frederick, C., Nader, K., Arroyo, W., Steinberg, A., Eth, S., Nunez, F., & Fairbanks, L. (1987). Life threat and posttraumatic stress in school age children. Archives of General Psychiatry, 44, 1057-1063.

Turner, S. M., Beidel, D. C., & Nathan, R. S. (1985). Biological factors in obsessive-compulsive disorders. Psychological Bulletin, 97, 430-450.

Sattler, D., Shabatay, V., & Kramer, G. (1998). Abnormal psychology in context: Voices and perspectives. Boston, MA: Houghton Mifflin Company. Chapter 1, Anxiety Disorder.

Steketee, G. S. (1996). Treatment of obsessive-compulsive disorder. New York: Guilford.

Tuma, A. H., & Maser, J. D. (Eds.) (1985). Anxiety and the anxiety disorders. Hillsdale, NJ: Erlbaum.

Walker, J. R., Norton, G. R., & Ross, C. A. (Eds.) (1991). Panic disorder and agoraphobia: A comprehensive guide for the practitioner. Pacific Grove, CA: Brooks/Cole.

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WARNING SIGNS FOR GENERALIZED ANXIETY DISORDER  Continuous worry about major and minor events without just cause  Headaches and other aches and pains for no apparent reason  Constant bodily tension, feelings of fatigue, and difficulty relaxing  Difficulty focusing on one thing or task at a time  Frequent irritability (i.e., getting crabby or grouchy)  Trouble falling asleep or staying asleep  Experience excessive sweatiness or hot flashes  Feeling of having a lump in throat or feeling the need to vomit when worried

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Handouts WARNING SIGNS FOR PANIC DISORDER  Repeated experience of sudden bursts of fear for no reason  Experience of chest pains or a racing heart  Feeling dizzy, difficulty breathing, or experiencing excessive sweating  Frequent stomach problems and the feeling to vomit  Shaking, trembling, or tingling sensations  Feeling out of control  Feeling that one’s reactions are unreal  Fear of dying or going crazy

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WARNING SIGNS FOR SPECIFIC PHOBIAS  Feelings of panic, dread, horror, or terror in response to thoughts, images, or exposure to a specific object or situation (e.g., snakes, heights, planes)  Recognition that the fear goes beyond normal boundaries and the actual threat of danger  Reactions that are automatic and uncontrollable, practically taking over the person’s thoughts  Rapid heartbeat, shortness of breath, trembling, and an overwhelming desire to flee the situation—all the physical reactions associated with extreme fear  Extreme measures taken to avoid the feared object or situation

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WARNING SIGNS FOR SEPARATION ANXIETY DISORDER  Child feels unsafe staying in a room by him/herself  Child displays clinging behavior  Child displays excessive worry and fear about parents or about harm to him/herself  Child shadows the mother or father around the house  Child has difficulty going to sleep  Child has frequent nightmares  Child has exaggerated, unrealistic fears of animals, monsters, burglars, fear of being alone in the dark, or severe tantrums when forced to go to school

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WARNING SIGNS FOR SOCIAL ANXIETY DISODER (SOCIAL PHOBIA)  Feeling afraid or uncomfortable around other people  Difficulty being in situations where other people are involved  Intense fear of embarrassment  Constant fear of making a mistake and being watched and judged by others  Fear of embarrassment results in avoidance of important social activities  Excessive worry about upcoming social situations  Frequent blushing, sweating, trembling, or nausea before or after a social event  Avoidance of social situations (e.g., school events, making speeches)  Consumption of alcohol as a means to reduce such social fears

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WARNING SIGNS FOR POSTTRAUMATIC STRESS DISORDER  Recurring thoughts or nightmares about the event  Having trouble sleeping or changes in appetite  Experiencing anxiety and fear, especially when exposed to events or situations reminiscent of the trauma  Being on edge, being easily startled, or becoming overly alert  Feeling depressed, sad, and having low energy  Experiencing memory problems including difficulty in remembering aspects of the trauma  Feeling “scattered” and unable to focus on work or daily activities  Having difficulty making decisions  Feeling irritable, easily agitated, or angry and resentful  Feeling emotionally numb, withdrawn, disconnected, or different from others  Spontaneously crying; feeling a sense of despair and hopelessness  Feeling extremely protective of, or fearful for, the safety of loved ones  Not being able to face certain aspects of the trauma, and avoiding activities, places, or even people that remind you of the event

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WARNING SIGNS FOR OBSESSIVE-COMPULSIVE DISORDER  Feeling of being trapped in a pattern of unwanted and upsetting thoughts  Feeling a need to repeat thoughts/behaviors over and over for no good reason  Upsetting thoughts or images repeatedly enter one’s mind  Feeling an inability to stop thoughts or images  Difficulty stopping oneself from doing things again and again (e.g., counting, checking on things, washing hands, re-arranging objects, doing things until it feels right, collecting useless objects)  Excessive worry that terrible things will happen if not careful  Fear that one will harm someone one cares about

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WARNING SIGNS FOR BODY DYSMORPHIC DISORDER  Constant and excessive use or avoidance of mirrors  Spending lots of time (i.e., 1+ hours) grooming every day  Attempts to hide parts of body that one does not like  Experience of distress over performing grooming rituals that one feels compelled to do  Constant seeking of reassurance about looks and subsequent discounting of the feedback  Anxiety or depression about one’s appearance

CHAPTER 6 SOMATIC SYMPTOM AND RELATED DISORDERS AND DISSOCIATIVE DISORDERS CHAPTER OVERVIEW This chapter outlines the primary features of somatic symptom and related disorders and dissociative disorders. With respect to the former, the symptoms, prevalence, etiology, and treatment of somatic symptom disorder, illness anxiety disorder, and conversion disorder (functional neurological symptom disorder) are discussed, as well as psychological factors affecting a medical condition. For dissociative disorders, depersonalization-derealization disorder and dissociative amnesia (including dissociative fugue states) are discussed. The chapter also describes the relation between malingering and factitious disorders in the context of conversion reactions and dissociative identity disorder. In addition, the major characteristics of dissociative trance and dissociative identity disorder are described, including available treatment approaches.

CHAPTER OUTLINE SOMATIC SYMPTOM AND RELATED DISORDERS Somatic Symptom Disorder Illness Anxiety Disorder Clinical description Statistics Causes Treatment Psychological Factors Affecting Medical Condition Conversion Disorder (Functional Neurological Symptom Disorder) Clinical Description Closely Related Disorders Unconscious Mental Processes Statistics Causes

Treatment DISSOCIATIVE DISORDERS Depersonalization-Derealization Disorder Dissociative Amnesia Dissociative Identity Disorder Clinical Description Characteristics Can DID Be Faked?

Statistics Causes Suggestibility Biological Contributions Real Memories and False Treatment

DETAILED OUTLINE Somatic Symptom and Related Disorders  Individuals with somatic symptom and related disorders are pathologically concerned with the appearance or functioning of their bodies and bring these concerns to the attention of health professionals, who usually find no identifiable medical basis for the physical complaints.  There are several types of somatic symptom disorders. Somatic symptom disorder is characterized by a focus on one or more physical symptoms accompanied by marked anxiety and distress focused on the symptom that is disproportionate to the nature or severity of the physical symptoms. This condition may dominate the individual’s life and interpersonal relationships. Illness anxiety disorder is a condition in which individuals believe they are seriously ill and become anxious over this possibility, even though they are not experiencing any notable physical symptoms at the time. In conversion disorder, there is physical malfunctioning, such as paralysis, without any apparent physical problems. Distinguishing among conversion reactions, real physical disorders, and outright malingering, or faking, is sometimes difficult. Even more puzzling can be factitious disorder, in which the person’s symptoms are feigned and under voluntary control, as with malingering, but for no apparent reason.  DISCUSSION POINT:

What are some examples of normal physical symptoms that someone with somatic symptom disorder might interpret catastrophically?  DISCUSSION POINT: How might a psychologist detect the difference between headaches due to physical factors and those that might be conversion symptoms?  The causes of somatic symptom disorders are not well understood, but seem closely related to anxiety disorders.  Treatment of somatic symptom disorders ranges from basic techniques of reassurance and social support to those meant to reduce stress and remove any secondary gain for the behavior. Recently, specifically tailored cognitive-behavioral therapy has proved successful with these conditions.

Dissociative Disorders  Dissociative disorders are characterized by alterations in perceptions: a sense of detachment from one’s own self, from the world, or from memories.  Dissociative disorders include depersonalization-derealization disorder, in which the individual’s sense of personal reality is temporarily lost (depersonalization), as is the reality of the external world (derealization). In dissociative amnesia, the individual may be unable to remember important personal information. In generalized amnesia, the individual is unable to remember anything; more commonly, the individual is unable to recall specific events that occur during a specific period (localized or selective amnesia). In dissociative fugue, a subtype of dissociative amnesia, memory loss is combined with an unexpected trip (or trips).

In the extreme, new identities, or alters, may be formed, as in dissociative identity disorder (DID). The causes of dissociative disorders are not well understood but often seem related to the tendency to escape psychologically from stress or memories of traumatic events.  DISCUSSION POINT: Why might an alter identity develop in an individual? Ask students to generate examples of ways that an alter identity may be adaptive to the person.  Treatment of dissociative disorders involves helping the patient re-experience the traumatic events in a controlled therapeutic manner to develop better coping skills. In the case of DID, therapy is often long term. Particularly essential with this disorder is a sense of trust between therapist and patient.

KEY TERMS somatic symptom disorder, 185 dissociative disorder, 185 illness anxiety disorder, 187 conversion disorder, 193 malingering, 193 factitious disorder, 194 derealization, 199 depersonalization- derealization disorder, 199

dissociative amnesia200 generalized amnesia, 200 localized or selective amnesia, 201 dissociative fugue, 201 dissociative identity disorder, 203 alters, 203 dissociative trance disorder, 203

IDEAS FOR INSTRUCTION 1.

Activity: When Have I Assumed the Sick Role? To expose students to characteristics endorsed by people diagnosed with a somatic symptom disorder, including features of malingering or factitious disorders, you could ask students if they have ever used or faked physical symptoms to get out of having to perform important life activities (e.g., exams, classes, work, social functions), including use of such tactics to gain attention and sympathy from others.

2.

Activity: Understanding Somatic Symptom Disorder. You could administer the Hypochondriasis Scale of the MMPI-2 to your students. After scoring the scale, you could discuss results and how the test items relate to the DSM-5 diagnosis. To depict the process of a person with somatic symptom disorder, ask your students to keep a log of their bodily sensations for a few days. Examples may include stomach rumblings, headaches, muscle soreness, frequent urination, stiffness, tingling sensations, skin color changes, perspiration, and fatigue, among others. Have the students bring in their record and ask them to consider how a person with somatic symptom disorder might interpret these normal sensations. What physical ailment could they represent? Also, discuss with them why anxiety is so prevalent among people with this disorder. (Be sure to remind students that the diagnosis of hypochondriasis has been renamed in DSM-5. This may stimulate a discussion of the stigma associated with certain labels)

3.

Activity: “Normal” Dissociations. Before exploring the dissociative disorders, ask your students to identify periods of dissociation that are normal. For example, most students have had the experience of wanting to drive to a friend's house, but ending up at their school or office because they are so used to driving that route. Others have had experiences of driving on the highway only to find that they have no recollection of the last 10 or so miles they have driven, including obvious landmarks they had passed along the way. Alternatively, many have had the experience of dialing a phone number intending to talk to one particular friend, only to have dialed the number of someone else without being consciously aware of doing so. These examples illustrate that one can fail to be conscious of what one is doing, and yet safely guide oneself through a task. Another example occurs when studying. Again, almost every student has had the experience of

reading pages of material (perhaps in their Abnormal text!), only to snap out of their “trance” and realize that, although their eyes were moving over the words, they were thinking about very different things besides their textbook material. That is, they get to the bottom of a page and have no idea how they got there. Finally, many students may have experienced some form of trauma in which they felt cut off from feelings or numb from shock. Highlighting these experiences helps illustrate that dissociative disorders are not as bizarre as they first appear. Emphasizing the continuum of behavior is important here to enhance student empathy for people with this class of disorders. We are all capable of forms of dissociation, and people with severe dissociative disorders may be simply using a natural process to protect themselves from the ongoing onslaught of trauma.

4.

Activity: Invited Hypnotist or Pain Specialist. A useful class activity can be to invite a guest lecturer with expertise in hypnotism or the treatment of pain-related disorders to come and speak to your class.

5.

Dissociative Identity Disorder (DID). Previously referred to as multiple personality disorder (MPD), this dissociative disorder involves a disturbance of identity in which two or more separate and distinct personality states (or identities) control the individual’s behavior at different times. Use https://www.nami.org/Learn-More/Mental-HealthConditions/Dissociative-Disorders to help develop a lecture and discussion of dissociative identity disorder. Show https://www.youtube.com/watch?v=n2atzoaA2NI as example of dissociative identity disorder.

Uh Oh! Plan B Although instructors are skilled professionals in creating classroom experiences, things don’t always go as planned. The chapter-related lecture and activity suggestions in this section are for instances when your planned lecture or activity idea do not go as planned. Implement these to recover student interest and enhance student reading.

Keep your Eyes Out—Engaging students with this material is usually easy. After all, disorders described in this chapter match most of what students wanted to learn when they signed up for the course. However, given the prevalence of serious mental health disorders, which appear in the 18 to 25 year old traditional college age, be sure that you keep mental health resource cards handy. Students may well ask you for advice “for a friend” before or after class.

YouTube Clips: Chapter 6 The Khan Academy reviews the Somatic Disorders. https://www.youtube.com/watch?v=8G5WFKUzvA8 (05:53) Australia opens its first clinic for Functional Neurological Disorders https://www.youtube.com/watch?v=SxiUA1QFeaY (02:02) What is it like living with Dissociative Amnesia? 20/20 reports. https://www.youtube.com/watch?v=n1is6S4sCK4 (08:56)

SUGGESTED VIDEOS A Case Study of Multiple Personality: The Three Faces of Eve. (Insight Media). This classic recording of a woman with three distinct personalities includes a case background, actual interview sessions in which the psychiatrist elicits each personality, and scenes with the patient after complete recovery. (30 min) Agnes of God. Jane Fonda plays a court-appointed psychiatrist who must make sense out of pregnancy and apparent infanticide in a local convent. The film illustrates stigmata as an example of a conversion reaction.

Freud. This film illustrates several clinical manifestations of somatoform disorders (e.g., paralysis, false blindness, and false pregnancy).

Hanna and her sisters. Woody Allen stars as a hopeless hypochondriac who spends his days worry about brain tumors, cancer, and cardiovascular disease.

The devils. This film, adapted from Aldous Huxley’s book, The Devils of Loundun, traces the lives of 17th century French nuns who experienced highly erotic dissociative states attributed to possession by the devil.

Primal fear. The film depicts a man who commits heinous crimes, purportedly as a result of a dissociative disorder. The film raises questions about the problem of malingering and differential diagnosis.

The three faces of Eve. This film portrays a woman with three personalities (i.e., Eve White, Eve Black, and Jane).

Twelve o’clock high. This film depicts a general who develops conversion disorder (i.e., paralysis) in response to his role in the death of several of his subordinates. This film is based on a true story.

ONLINE RESOURCES The American Psychiatric Association provides articles and ongoing education related to best practices in the field of dissociative disorders. https://www.psychiatry.org/patients-families/dissociative-disorders American Society of Clinical Hypnosis http://www.asch.net/ Take a deep dive into topics introduced in this chapter.

Child Abuse: Statistics, Research, and Resources http://www.jimhopper.com/abstats/ A good resource for current research and informational links related to child abuse.

Pediatric Conversion Disorder http://www.emedicine.com/ped/topic2780.htm This article presents material related to conversion disorder, including the history of the diagnosis and current data on prevalence.

Mental Help Net - Dissociative Disorders http://www.mentalhelp.net/poc/center_index.php?id=41 Offers information and connections to other websites related to dissociative disorders.

Recovered Memories of Sexual Abuse http://www.jimhopper.com/memory/ A useful scholarly source of information and links related to recovered memories of sexual abuse.

The Sidran Institute http://www.sidran.org/

The website for the Sidran Institute, which focuses on trauma and trauma-related disorders. It provides more information for survivors and students interested in dissociative disorders.

SUPPLEMENTARY READING MATERIAL Additional Readings: (Please note: many of these references use outdated terminology, but may nonetheless be instructive on the basic foundations of somatic symptom and related disorders and dissociative disorders)

Bliss, E. L. (1980). Multiple personalities?: A report of 14 cases with implications for schizophrenia and hysteria. Archives of General Psychiatry, 37, 1388-1397.

Chase, T. (1990). When rabbit howls. New York: Jove.

Ford, C. V. (1995). Dimensions of somatization and hypochondriasis. Special issue: Malingering and conversion reactions. Neurological Clinics, 13, 241-253.

Kellner, R. (1986). Somatization and hypochondriasis. New York: Praeger.

Kellner, R. (1991). Psychosomatic syndromes and somatic symptoms. Washington, DC: American Psychiatric Press.

Kluft, R. P. (1991). Multiple personality disorder. In A. Tasman & S. M. Goldfinger (Eds.), American Psychiatric Press Review of Psychiatry, vol. 10. Washington, DC: American Psychiatric Press.

Loewenstein, R. J. (1991). Psychogenic amnesia and psychogenic fugue: A comprehensive review. In A. Tasman & S.M. Goldfinger (Eds.), American Psychiatric Press Review of Psychiatry, vol. 10. Washington, DC: American Psychiatric Press.

Lynn, S. J., & Rhue, J. W. (1994). Dissociation: Clinical and theoretical perspectives.

New York: Guilford.

Miller, M., & Bowers, K. S. (1993). Hypnotic analgesia: Dissociated experience or dissociated control? Journal of Abnormal Psychology, 102, 29-38.

Putnam, Frank W., et al. (1986). The clinical phenomenology of multiple personality disorder: A review of 100 recent cases. Journal of Clinical Psychiatry, 47, 285-293.

Spanos, N. P. (1997). Multiple identities and false memories: A sociological perspective. Washington, DC: American Psychological Association.

Thigpen, C. H., & Cleckley, H. M. (1957). The three faces of Eve. New York: McGrawHill.

Waites, E. A. (1993). Trauma and survival: Post-traumatic and dissociative disorders in women. New York: Norton.

Weintraub, M. I. (1983). Hysterical conversion reactions: A clinical guide to diagnosis and treatment. New York: SP Medical and Scientific Books.

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Handouts WARNING SIGNS FOR SOMATIC SYMPTOM DISORDER  Frequent visits to the doctor  Fixation on a disease that no doctor has diagnosed  Rejection of a doctor’s reassurance that there is nothing seriously wrong  Continuous doctor-shopping  Checking your body many times a day/week for peculiarities  Preoccupation with an illness that you see on television or in the newspaper  Excessive concern about fear or pain  Frequent thoughts of death

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WARNING SIGNS FOR FACTITIOUS DISORDER IMPOSED ON ANOTHER  Illness that persists in spite of traditionally effective treatments  The child has been to many doctors without a clear diagnosis  The parent (usually the mother) seems eager for the child to undergo additional tests, treatments, or surgeries  The parent is very reluctant to have the child out of her sight  Another child in the same family has had an unexplained illness  Parent has a background in healthcare  Symptoms appear only when the parent is present (Recall that this diagnosis does not apply exclusively to the victimization of a child, but can involve any dependent individual)

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WARNING SIGNS FOR DISSOCIATIVE IDENTITY DISORDER  Two or more distinct personalities exist within one person  Each personality has its own way of thinking about things and relating to others  At least two of the identities take control of the person’s behavior  The person is unable to recall important personal information

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CHAPTER 7 MOOD DISORDERS AND SUICIDE CHAPTER OVERVIEW This chapter outlines the characteristic features of mood disorders (major depressive disorder, persistent depressive disorder, double depression, bipolar I disorder, bipolar II disorder, and cyclothymia). Specifically, the epidemiology, etiology, and treatment of these conditions are described. Symptom feature modifiers, or those additional factors that have implications for predicting course or response to treatment, are also covered. This chapter is also devoted to the phenomenon of suicide, including prevention and intervention of suicidal ideation and intent.

Various clinical examples are presented throughout the chapter. Extensive discussion of the changes in mood disorders seen in the DSM-5 revision are discussed, along with implications for how those changes will impact our understanding of these disorders.

CHAPTER OUTLINE UNDERSTANDING AND DEFINING MOOD DISORDERS An Overview of Depression and Mania The Structure of Mood Disorders Depressive Disorders Additional Defining Criteria for Depressive Disorders Other Depressive Disorders Bipolar Disorders Additional Defining Criteria for Bipolar Disorders PREVALENCE OF MOOD DISORDERS Prevalence in Children, Adolescents, and Older Adults Life Span Developmental Influences on Mood Disorders Across Cultures Among Creative Individuals CAUSES OF MOOD DISORDERS

Biological Dimensions Additional Studies of Brain Structure and Function Psychological Dimensions Social and Cultural Dimensions An Integrative Theory TREATMENT OF MOOD DISORDERS Medications Electroconvulsive Therapy and Transcranial Magnetic Stimulation Psychological Treatments for Depression Combined Treatments for Depression Preventing Relapse of Depression Psychological Treatments for Bipolar Disorder SUICIDE Statistics Causes Risk Factors Is Suicide Contagious?

Treatment

DETAILED OUTLINE Understanding and Defining Mood Disorders  Mood disorders are among the most common psychological disorders, and the risk of developing them is increasing worldwide, particularly in younger people.  Two fundamental experiences can contribute either singly or in combination to all specific mood disorders: a major depressive episode and a manic episode. A less severe episode of mania that does not cause impairment in social or occupational functioning is known as a hypomanic episode. An episode of mania coupled with anxiety or depression is known as a dysphoric manic or mixed episode.  DISCUSSION POINT: Many people with bipolar disorder demonstrate poor insight during manic episodes. How might the experience of a manic episode be reinforcing, and what are the implications for treatment?

 An individual who suffers from episodes of depression only is said to have a unipolar disorder. An individual who alternates between periods of depression and mania has a bipolar disorder.  DISCUSSION POINT: Why might bipolar disorder confer a higher risk for suicide than major depression?  Major depressive disorder may be a single episode or recurrent, but it is always time limited; in another form of depression, persistent depressive disorder, the symptoms are somewhat milder but remain relatively unchanged over long periods. In cases of double depression, an individual experiences symptoms of a major depressive episode that is overlaid onto the symptoms of persistent depressive disorder.  Approximately 7% of bereaved individuals may experience a pathological, complicated grief reaction in which the normal grief response develops into a full-blown mood disorder.  The key identifying feature of bipolar disorders is an alternation of manic episodes and major depressive episodes. Cyclothymic disorder is a milder but more chronic version of bipolar disorder.  Patterns of additional features that sometimes accompany mood disorders, called specifiers, may predict the course or patient response to treatment, as does the temporal patterning or course of mood disorders. One pattern, seasonal affective disorder, most often occurs in winter.  DISCUSSION POINT: What are some of the possible explanations for postpartum onset of depression, in both mothers and fathers?  Premenstrual dysphoric disorder (PMDD) and disruptive mood dysregulation disorder have both been added to DSM-5. PMDD is marked by severe and sometimes incapacitating moodrelated symptoms that precipitate a woman’s menstrual period. Disruptive mood dysregulation disorder is marked by frequent temper outbursts that involve extreme verbal and/or physical acts of aggression, an absence of indications of manic episodes that would indicate a bipolar-related illness, and presence of symptoms prior to the age of 6 years.

Prevalence of Mood Disorders  Though serious whey they do occur, mood disorders are less common in prepubertal children, but rise dramatically in adolescence. They are also seen equally in younger boys and girls, but are seen far more in females than males during adolescence. Among those over the age of 65, estimates suggest that half or more suffer from symptoms of depression.  Bipolar disorder is seen in about 1% of children, adolescents, and adults.  The experience of anxiety across cultures varies, and it can be difficult to make comparisons, especially, for example, when we attempt to compare subjective feelings of depression.

Causes of Mood Disorders  The causes of mood disorders lie in a complex interaction of biological, psychological, and social factors. From a biological perspective, researchers are particularly interested in the stress hypothesis and the role of neurohormones. Psychological theories of depression focus on learned helplessness and the depressive cognitive schemas, as well as interpersonal

disruptions.

Treatment of Mood Disorders  A variety of treatments, both biological and psychological, have proved effective for mood disorders, at least in the short term. For those individuals who do not respond to antidepressant drugs or psychosocial treatments, a more dramatic physical treatment, electroconvulsive therapy, is sometimes used. Transcranial magnetic stimulation, a less invasive form of biomedical treatment than ECT, has shown some recent promise; however, ECT still appears to be more effective but carries a greater risk of short-term memory loss and confusion and, in some patients, long-term memory interruption. Two psychosocial treatments—cognitive therapy and interpersonal therapy—seem effective in treating depressive disorders.  DISCUSSION POINT: Have students talk about their perceptions of ECT and where those perceptions originated.

Encourage them to discuss how the actual practice of ECT may be similar to, and different from, their preconceived notions.  Relapse and recurrence of mood disorders are common in the long term, and treatment efforts must focus on maintenance treatment, that is, on preventing relapse or recurrence.

Suicide  Suicide is often associated with mood disorders but can occur in their absence or in the presence of other disorders. It is the eleventh leading cause of death, but among adolescents, it is the third leading cause. Experts suggest that the actual rate of suicide may be drastically under-reported, leading to a concern that it is in fact a much bigger problem than has been realized.  In understanding suicidal behavior, three indices are important: suicidal ideation (serious thoughts about committing suicide), suicidal plans (a detailed method for killing oneself), and suicidal attempts (that are not successful). Important, too, in learning about risk factors for suicides is the psychological autopsy, in which the psychological profile of an individual who has committed suicide is reconstructed and examined for clues.

KEY TERMS mood disorders, 218 major depressive episode, 218 mania, 219 hypomanic episode, 219 mixed features, 219 major depressive disorder, 220 recurrent, 220 persistent depressive disorder (dysthymia), 221 double depression, 221 hallucinations, 222 delusion, 223 catalepsy, 223 seasonal affective disorder (SAD), 225 integrated grief, 228 complicated grief, 228 premenstrual dysphoric disorder, 229 disruptive mood dysregulation disorder, 229

bipolar II disorder, 231 bipolar I disorder, 231 cyclothymic disorder, 232 neurohormones, 241 learned helplessness theory of depression, 245 depressive cognitive triad, 245 mood-stabilizing drugs, 254 electroconvulsive therapy (ECT), 254 cognitive therapy, 255 interpersonal psychotherapy (IPT), 256 maintenance treatment, 259 suicidal ideation, 262 suicidal plans, 262 suicidal attempts, 262 psychological autopsy, 263

IDEAS FOR INSTRUCTION 1.

Activity: Suicide Questionnaire. Give students HANDOUT 7.1 to enable them to test their knowledge about suicide. After they have completed the handout, discuss the correct answers with them and address concerns voiced by class members. Correct answers: a. (F) Although there may be some people who talk about suicide but never follow through, those who talk about suicide are at high risk for suicide. Many who successfully kill themselves have made earlier threats to do so. b. (F) Many people are suicidal for a short period of time; some who make it through a suicidal crisis recover completely. c. (F) Many people offer clues they are considering suicide before they attempt to kill themselves. About 80% of suicide attempts are preceded by a warning of some kind. d. (F) Talking about suicide can be helpful in prevention and does not trigger the act.

In fact, you may show the person that you are not frightened and are willing to talk about it with them. e. (T) A depressed person who gives away valued possessions may be preparing for suicide. f. (F) A sudden recovery from depression is a clue the person is considering suicide and has attained peace of mind as a consequence of their plan.

2.

Activity: Suicide Prevention. You may want to give your students HANDOUT 7.2 on suicide prevention. Discuss students’ reactions to the suggestions and add any recommendations that class members may have regarding helping someone who is suicidal. You may also use the discussion as an opportunity to talk about assisted suicide.

3.

Activity: Screening for Disorders in Primary Care. Break students into groups and have them imagine that they are in charge of implementing a screening program to detect mood disorders and suicidality among patients in the clinic. Stress that, because of demands on physicians’ time, they must limit their screening questionnaire to five items.

Discuss how they selected the items they chose, as well as the difficulty of detecting serious mood symptoms in the general population.

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4.

Invite a guest speaker who is a psychologist or psychiatrist specializing in treatment of mood disorders. Have the students develop questions during the class period before the guest lecturer is scheduled.

Uh Oh! Plan B Although instructors are skilled professionals in creating classroom experiences, things don’t always go as planned. The chapter-related lecture and activity suggestions in this section are for instances when your planned lecture or activity idea do not go as planned. Implement these to recover student interest and enhance student reading.

Managing Tough Topics: This chapter contained information about mood disorders which are likely familiar to most students, either through personal experience or depictions in the media.

Yet, the topic of suicide might be the most poignant to them. Suicide is unfortunately common in the traditional college age group. As in Chapter 6, watch your students for signs that they may be triggered by the material and allow them the flexibility to leave the classroom if they need to do so. It may also be a good idea to pass out fliers for the suicide prevention hotline and/or the counseling center on your campus to every to avoid stigmatizing students who reach out for help.

YouTube Clips: Chapter 7 ASAP Science summarizes current findings on depression in this short animated video. https://www.youtube.com/watch?v=GOK1tKFFIQI (03:45) Are “madness” and creativity linked? Dr. Shelley Carson answers the age-old assumption that creativity is borne from depression and other mental illness. https://www.youtube.com/watch?v=KwTlbehPDbI Country Singer/Songwriter Rascall Flats sings tribute to victims of suicide. https://www.youtube.com/watch?v=dp3Jvz3e8HU (04:53).

And finally, for fun…do dogs get depressed? Find out here: https://www.youtube.com/watch?v=NhTpxhWMCUA&feature=youtu.be (03:19)

SUGGESTED VIDEOS Antidepressant agents. (Insight Media). This video examines the causes and manifestations of depression. It considers neurotransmitters and receptors in the brain; presents theories related to how medication provides relief from depression; and examines the three categories of antidepressant agents—tricyclic agents, selective serotonin reuptake inhibitors, and monoamine oxidase inhibitors. (23 min) Breaking the dark horse: A family copes with manic depression. (Fanlight Productions).

The video presents a story of a woman with manic depression and how it affects her family and friends. (32 min) CBT for depressed adolescents. (Insight Media). This three-part video presents cognitivebehavioral intervention for adolescents with depression. It reviews the theoretical basis for cognitive-behavioral treatment (CBT) and then provides illustrative vignettes. Finally, it discusses potential difficulties encountered when using CBT with adolescents and their families.

(130 min) Demonstration of the cognitive therapy of depression. (Insight Media). Aaron Beck, one of the major proponents of cognitive theory and developer of the Beck Depression Inventory, demonstrates his method of cognitive therapy of depression in this interview with a depressed and suicidal woman. The tape illustrates how to conceptualize a patient in a cognitive framework. (40 min) Depression and manic depression. (Insight Media). Explaining that many cases of clinical depression remain untreated due to issues of stigma and fear, this video explores the relationship between untreated depression and suicide, using as examples the depressions of such well-known public figures as Mike Wallace and Kay Redfield Jamison. (28 min) Four lives: A portrait of manic-depression. (Insight Media). This video explores the psychological effects of bipolar affective disorder by examining four patients. Psychiatrists discuss the history and treatment of each patient, describing the rapid mood swings from depression to mania and considering common manifestations of these moods. The program also examines the uses of ECT, lithium treatment, and psychotherapy. (60 min) Girl, interrupted. This film, set in the 1960s, illustrates a compelling true story of a woman who attempted suicide and was subsequently self-committed to a mental institution. The range of psychopathology of the characters, including the depiction of treatment and life in a mental institution during the 1960s, is outstanding. This film nicely illustrates depression, suicide, but may be useful for personality disorders, schizophrenia, and ethical and legal issues as well.

It’s a wonderful life. This film presents Jimmy Stewart as a down-on-his-luck family man who responds to the stress of life in Bedford Falls by attempting suicide.

Life upside down. French film about an ordinary young man who becomes increasingly detached from the world. He is eventually hospitalized and treated, but without much success.

Ordinary People. This film deals with depression, suicide, and family pathology and presents a sympathetic portrayal of a young man who probably meets DSM-5 criteria for both PTSD and depression. Also addresses the issue of completed and attempted suicide, as well as ongoing suicidal ideation.

Psychopharmacology for the 21st century: Antidepressants. (Insight Media). In this program, Joel Holiner provides an in-depth overview of antidepressants, reviewing their efficacies, dosages, and side effects. He discusses uses of tricyclics, heterocyclics, lithium, and MAOIs for treating depression, anxiety, social phobia, bulimia, and OCD. He also presents recommendations for antidepressant use during pregnancy and highlights the advantages of the newest SSRIs, including Luvox and Celexa, the latest SS -Norepinephrine reuptake inhibitor. (30 min) The choice of a lifetime. (Fanlight Productions). This disturbing, but ultimately inspiring, film is told from the point of view of six people, ages 21 to 73, who stepped back from the brink of suicide. In candid interviews, they examine the circumstances that led to their despair, the forces that stopped them, and the methods of healing they discovered, including therapy, support groups, spirituality, and artistic expression. (53 min) The depressed child. (Insight Media). Around 7% of children and 27% of adolescents meet the criteria for major depressive disorder. If left undiagnosed, depression can have negative long-term effects or lead to suicide. This video examines the problem of youth depression and discusses such treatment options as counseling and antidepressant medications. (25 min) The hospital. George C. Scott depicts a suicidal physician.

The mosquito coast. Harrison Ford plays an eccentric American inventor who flees the U.S. for Central America because of his paranoia. His behavior throughout the film is bipolar and certainly manic.

Treatment strategies for the management of chronic depression. (Insight Media). An estimated 5% of depression victims suffer from lifelong, chronic depression. This program explores how outcomes may be complicated by comorbid psychiatric and medical conditions as well as chronic stressors. It discusses the diagnosis of chronic depression and presents management strategies and challenges for the clinician. (90 min)

ONLINE RESOURCES Bipolar I Disorder https://www.psychiatry.org/patients-families/bipolar-disorders

The American Psychological Association hosts a blog of up-to-date articles for further reading Cyclothymia http://www.mayoclinic.org/diseases-conditions/cyclothymia/basics/definition/con-20028763 The Mayo Clinic defines and lists treatment options for this rare disorder.

Depression and Bipolar Support Alliance http://www.dbsalliance.org/ Provides a number of links and resources related to mood disorders.

Depression Central http://www.psycom.net/depression.central.html Dr. Ivan’s Depression Central offers links to several sites on mood disorders, including sites for books, videos, research, diagnosis, and treatment.

Depression.org http://www.depression.org/ A useful resource to information about the nature of mood disorders, including links to other related sites.

Genetics and Depressive Disorders http://www.psycom.net/depression.central.genetics.html Depression Central is an extremely thorough clearinghouse for information on all mood disorders.

Medline Plus – Premenstrual Dysphoric Disorder http://www.nlm.nih.gov/medlineplus/ency/article/007193.htm Information from the National Institute of Health about causes, symptoms, and treatment of PMDD. The American Association of Suicidology http://www.suicidology.org Website of AAS which provides a wealth of information about suicide research and prevention.

The American Foundation for Suicide Prevention http://www.afsp.org/ Website of AFSP, an organization dedicated to understanding and preventing suicide through research, education, and advocacy.

Suicide Prevention App http://www.suicidepreventionapp.com/?gclid=COrA6LC_odACFQ1MDQodMPsCww More information about an application for smartphones about how to recognize warning signs and help those in trouble.

SUPPLEMENTARY READING MATERIAL Barnett, P. A., & Gotlib, I. H. (1988). Psychosocial functioning and depression: Distinguishing among antecedents, concomitants, and consequences. Psychological Bulletin, 104, 97–126.

Beck, A. T. (1987). Cognitive therapy of depression. New York: Guilford.

Bernard, M. E., & DiGuiseppe, R. (Eds.) (1989). Inside rational-emotive therapy. New York: Academic Press.

Burns, D. D. (1989). The feeling good handbook. New York: Plume.

Clark, D. A., & Beck, A. T. (1999). Scientific foundations of cognitive theory and therapy of depression. Philadelphia: Wiley.

Clipson, C., & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA: Houghton Mifflin Company. Chapter 5, Major Depressive Disorder. Chapter 6, Bipolar Disorder.

Copeland, M. E. (1994). Living without depression and manic depression: A workbook for maintaining mood stability. New York: New Harbinger.

Coyne, J. C., & Gotlib, I. H. (1983). The role of cognition in depression: A critical appraisal. Psychological Bulletin, 94, 472–505.

Dobson, K. S . (1989). A meta-analysis of the efficacy of cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 57, 414–419.

Faedda, G., Tondo, L., & Ross, J. (1993). Seasonal mood disorders: Patterns of seasonal recurrence in mania and depression. Archives of General Psychiatry, 50, 17-23.

Fremouw, W. J., Perczel, W. J., & Ellis, T. E. (1990). Suicide risk: Assessment and response guidelines. New York: Pergamon.

Goodwin, F., & Jamison, K. (1990). Manic-depressive illness. New York: Oxford University.

Gotlib, I. H. (1987). Treatment of depression: An interpersonal systems approach. New York: Pergamon.

Kolata, G. (1986). Manic-depression: Is it inherited? Science, 232, 575–576.

Sattler, D., Shabatay, V., & Kramer, G. (1998). Abnormal psychology in context: Voices and perspectives. Boston, MA: Houghton Mifflin Company. Chapter 4 Mood Disorders.

Styron, W. (1990). Darkness visible: A memoir of madness. New York: Vintage.

Thayer, R. E. (1996). The origin of everyday moods. New York: Oxford University.

Wender, P. H. et al. (1984). Psychiatric disorders in the biological and adoptive families of adopted individuals with affective disorders. Archives of General Psychiatry, 43, 923– 929.

Young, J. E., & Klosko, J. S. (1993). Reinventing your life: How to break free of negative life patterns. New York: Dutton.

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Handouts HANDOUT 7.1 WHAT DO YOU KNOW ABOUT SUICIDE? Respond to each of the following questions by answering true or false: 1.

_____

People who talk about suicide rarely follow through and actually attempt or commit suicide.

2.

_____

People who are suicidal will remain suicidal their entire lives.

3.

_____

Almost all suicides take place with little or no warning.

4.

_____

Talking about suicide often precipitates a desire to follow through and do it.

5.

_____

Giving away valued possessions is a clue that a person may be considering suicide.

6.

_____

Someone who is recovering from severe depression and suddenly develops a positive outlook on life rarely commits suicide.

.

HANDOUT 7.2 SUICIDE PREVENTION Although there is no one best way to approach a situation where suicide may be a possibility, the guidelines that follow may be helpful: 1.

Treat the person as a normal human being.

2.

Don’t consider the person too vulnerable or fragile to talk about the possibility of suicide.

Raise the subject yourself by asking the person directly. For example, “It sounds like you are feeling depressed. Have you been thinking about harming or hurting yourself or committing suicide?”

3.

Show the person you care about them even if you don’t know them very well.

4.

Help the person talk about and clarify the problem. Those who are depressed may have difficulty pinpointing the problem and may feel frustrated and confused.

5.

Listen carefully. People who are considering suicide are in mental and/or physical pain, although you may not be able to guess the type of pain or the source of the problem. Be there to help the person talk about the issue. You don’t need to fix the problem.

6.

Suicide is often viewed as the final solution to an overwhelming problem. The person who is depressed may have difficulty sorting out alternative solutions to the problem(s) he/she faces.

7.

Encourage the person to seek professional assistance. Crisis hotlines are available in many communities. If an immediate danger of suicide exists, do not leave the person alone. If the crisis seems to be improved for the moment, be sure you have a plan of action regarding professional help before leaving the person. Have the person promise to call you before doing any harm to him/herself. Offer to accompany him/her to see a mental health professional.

8.

If a friend refuses help, you may need to contact someone close to him/her such as a family member to share your concerns.

9.

Maintain contact with your friend.

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HANDOUT 7.3 THE MOOD DISORDER QUESTIONNAIRE Items in this questionnaire are intended as a screening instrument. Please answer each question as best you can by circling either yes or no: 1. Has there ever been a period of time when you were not your usual self and Yes

No

Yes

No

Yes Yes Yes Yes Yes

No No No No No

Yes Yes Yes

No No No

Yes Yes

No No

Yes

No

...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble? ...you were so irritable that you shouted at people or started fights or arguments? ...you felt much more self-confident than usual? ...you got much less sleep than usual and found you didn’t really miss it? ...you were much more talkative or spoke much faster than usual? ...thoughts raced through your head or you couldn’t slow your mind down? ...you were so easily distracted by things around you that you had trouble concentrating or staying on track? ...you had much more energy than usual? ...you were much more active or did many more things than usual? ...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? ...you were much more interested in sex than usual? ...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? ...spending money got you or your family into trouble?

2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?

Yes No 3. How much of a problem did any of these cause you, such as being unable to work; having family, money or legal troubles; or getting into arguments or fights? Please select one response only.

No Problem

Minor Problem

Moderate Problem

Serious Problem

Source Information. This screening tool was developed by the National Depressive and Manic-Depressive Association and is available online at http://www.ndmda.org/screening.asp. .

WARNING SIGNS OF DEPRESSION The following signs and symptoms are considered indicators of depression if they persist for a period of more than two weeks:  Feeling sad or empty most of the day, nearly every day  Reduced interest and pleasure in activities  Significant unintentional weight loss or gain or a change in appetite  Over or under sleeping  Feeling worthless, hopeless, and/or inappropriately guilty  Recurrent thoughts of death or suicide

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WARNING SIGNS OF CHILDHOOD DEPRESSION The following signs and symptoms are considered indicators of depression if they persist for a period of more than two weeks:  Persistent sadness and hopelessness  Withdrawal from friends and activities once enjoyed  Increased irritability or agitation  Missed school or poor school performance  Changes in eating and sleeping habits  Indecision, lack of concentration, or forgetfulness  Poor self-esteem or guilt  Frequent physical complaints, such as headaches and stomachaches  Lack of enthusiasm, low energy, or lack of motivation  Drug and/or alcohol abuse  Recurring thoughts of death or suicide

..

WARNING SIGNS OF BIPOLAR DISORDER Increased energy  Decreased sleep, little fatigue  An increase in activities  Restlessness Speech disruptions  Rapid, pressured speech  Incoherent speech, clang associations Impaired judgment  Lack of insight  Inappropriate humor and behaviors  Impulsive behaviors  Financial extravagance  Grandiose thinking Increased or decreased sexuality Changes in thought patterns  Distractibility  Creative thinking  Flight of ideas  Disorientation  Disjointed thinking  Racing thoughts Changes in mood  Irritability  Excitability  Hostility  Feelings of exhilaration Changes in perceptions  Inflated self-esteem  Hallucinations  Paranoia  Increased religious activities

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WARNING SIGNS OF MANIA AND HYPOMANIA  Insomnia or difficulty sleeping  Writing pressure  Others seem slow  Irritability or surges of energy  Making lots of plans  Flight of ideas  Pressured speech  Poor judgment and/or inappropriate behavior  Increased alcohol consumption  Spending too much money  Very productive  Taking too many responsibilities  Feeling superior  Increased creativity  Dangerous driving  Unnecessary phone calls  More sensitive than usual  Increased appetite and sexual activity  Noises louder than usual  Doing several things at once  Inability to concentrate  Friends notice behavior change  Difficulty staying still  Sociable and thrill seeking  Anxious and wound-up

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WARNING SIGNS FOR SUICIDE (GENERAL)  Verbal suicide threats or statements  Previous suicide attempt  Risk-taking behavior, reckless behavior  Final arrangements: giving away prized possessions, making peace, tying up loose ends  Neglect of academic work and/or personal appearance  Separation from loved ones or significant others  Themes in writing or art about death, depression, or suicide  Talk of wanting to die  Chronic depression; prolonged grief after a loss  Unusual purchases: gun, rope, medications; gathering of pills or poisons  Unusual sadness, discouragement, and loneliness  Unexpected happiness (sudden happiness following prolonged depression)  Physical complaints, hyperactivity, substance abuse, aggressiveness

CHAPTER 8 EATING AND SLEEP-WAKE DISORDERS CHAPTER OVERVIEW This chapter outlines the major characteristics of eating disorders (bulimia nervosa, anorexia nervosa, and binge-eating disorder) as well as obesity. Etiological, developmental, and cultural factors that impact these problems are described. In addition, treatment procedures are discussed, including cognitive-behavioral approaches, family and interpersonal therapy, and pharmacotherapy. This chapter also provides an overview of the key features of sleep-wake disorders, with primary emphasis on the dyssomnias (insomnia disorder, hypersomnolence disorder, narcolepsy, circadian rhythm sleep-wake disorder, and breathing-related sleep disorders), and lesser emphasis on some of the parasomnias (nightmare disorder, sleep terrors, and sleep walking [somnambulism] and related situations). Assessment of these conditions is addressed, as well as discussion of available medical and psychological treatments. Biological, psychological, and cultural influences on sleep and sleep behavior are discussed.

CHAPTER OUTLINE MAJOR TYPES OF EATING DISORDERS Bulimia Nervosa Anorexia Nervosa Binge-Eating Disorder Statistics CAUSES OF EATING DISORDERS Social Dimensions Biological Dimensions Psychological Dimensions An Integrative Model TREATMENT OF EATING DISORDERS Drug Treatments Psychological Treatments Preventing Eating Disorders

OBESITY Statistics Disordered Eating Patterns in Cases of Obesity Causes Treatment SLEEP-WAKE DISORDERS: THE MAJOR DYSSOMNIAS An Overview of Sleep Disorders Insomnia Disorder Hypersomnolence Disorder Narcolepsy Breathing-Related Sleep Disorders Circadian Rhythm Sleep Disorders TREATMENT OF SLEEP DISORDERS Medical Treatments Environmental Treatments Psychological Treatments Preventing Sleep Disorders Parasomnias and Their Treatment

DETAILED OUTLINE  The prevalence of eating disorders has increased rapidly over the last half century. DSM-5 has seen changes in both what is included in the category, as well as some of the diagnostic qualifiers and requirements of these conditions.  DISCUSSION POINT: What are the possible explanations for the gender disparity in rates of eating disorders?

In addition to media, cultural expectations, biological variables, and other influences, raise points such as diagnostic differences (what do clinicians notice in women versus in men?) and sports (when could dieting to obtain a particular weight for wrestling cross the line into an eating disorder?).

Bulimia Nervosa and Anorexia Nervosa  There are two prevalent eating disorders. In bulimia nervosa, dieting results in out-of-control binge-eating episodes that are often followed by compensating for the intake, either through purging the food through vomiting or other means or through trying to “make up” for the intake by exercising and/or fasting. Anorexia nervosa, in which food intake is cut dramatically, results in substantial weight loss and sometimes dangerously low body weight.  Both bulimia nervosa and anorexia nervosa can lead to very serious medical consequences, sometimes with potentially fatal outcomes.

Binge-Eating Disorder  In binge-eating disorder, a pattern of chronic and repeated binge eating occurs, but what distinguishes it from bulimia nervosa is the absence of compensatory behaviors that follow the binge-eating episodes.

Statistics and Course for Eating Disorders  Bulimia nervosa and anorexia nervosa are largely confined to young, middle- to upper-class women in Western cultures who are pursuing a thin body shape that is culturally mandated and biologically inappropriate, making it extremely difficult to achieve. Despite these data, it is important that students are reminded not to be misled into thinking that men cannot or do not suffer from eating disorders, or that they are less serious in men than in women. One study shows 0.8% of a large group of males having at least some of the symptoms of bulimia with another 2.9% having at least some of the symptoms of BED (Field et al 2014).  Without treatment, eating disorders become chronic and can, on occasion, result in death.

Causes of Eating Disorders  In addition to sociocultural pressures, causal factors include possible biological and genetic vulnerabilities (the disorders tend to run in families), psychological factors (low self-esteem), social anxiety (fears of rejection), and distorted body image (relatively normal-weight individuals view themselves as fat and ugly).  DISCUSSION POINT: How realistic is the body shape of dolls that children play with, such as Barbie? Do you think that Mattel Toys has gone far enough making strides to diversify Barbie’s looks?

What other kinds of dolls do you see that might promote unhealthy body images?  DISCUSSION POINT: You are a parent and your child has asked you for a doll as a birthday present. There are only two choices left at the toy store – one doll that has a very unrealistic thin image, and another that is a doll depicting an overweight or obese individual. You have to buy one because you know your child will be crushed if no doll is received as a gift.

Which one would you buy, and why? What are the potential pros and cons of either choice? Would your choice be different if you have a daughter versus a son?

Treatment of Eating Disorders  Several psychosocial treatments are effective, including cognitive-behavioral approaches combined with family therapy and interpersonal psychotherapy. Drug treatments are less

effective at the current time, although some newer research with Selective Serotonin Reuptake Inhibitors (SSRIs) looks promising.  DISCUSSION POINT: Why might IPT take longer to show positive results than cognitive-behavioral therapy?

Why might IPT show better results than CBT in the long run?

Obesity  Obesity is not a disorder in DSM but is one of the more dangerous epidemics confronting the world today. Cultures that encourage eating high-fat foods combine with genetic and other factors to cause obesity, which is difficult to treat. Professionally directed behavior modification programs, possibly combined with drugs, are moderately successful, but prevention efforts in the form of changes in government policy on nutrition seem the most promising.  DISCUSSION POINT: Why is there a relationship between immigration to the U.S. and obesity?  DISCUSSION POINT: Many of the causes of obesity seem very obvious, and most people are probably aware of them. Why, then, do you think this continues to be a growing problem of epidemic proportions?

Sleep Disorders  Sleep disorders are highly prevalent in the general population and are of two types: dyssomnias (disturbances of sleep) and parasomnias (abnormal events such as nightmares and sleepwalking that occur during sleep).  DISCUSSION POINT: Why would practicing a didgeridoo (an Indigenous Australian wind instrument which is very long in shape) lead to an improvement in sleep for people with breathing-related sleep problems?  Of the dyssomnias, the most common disorder, insomnia disorder, involves the inability to initiate sleep, problems maintaining sleep, or failure to feel refreshed after a full night’s sleep. Other dyssomnias include primary hypersomnolence disorder, narcolepsy (sudden and irresistible sleep attacks), circadian rhythm sleep disorders (sleepiness or insomnia caused by the body’s inability to synchronize its sleep patterns with day and night), and breathingrelated sleep disorders (disruptions that have a physical origin, such as sleep apnea, that leads to excessive sleepiness or insomnia).  The formal assessment of sleep disorders, a polysomnographic evaluation, is typically done by monitoring the heart, muscles, respiration, brain waves, and other functions of a sleeping client in the lab. In addition to such monitoring, it is helpful to determine the individual’s sleep efficiency, a percentage based on the time the individual actually sleeps as opposed to time spent in bed trying to sleep.  Benzodiazepine medications have been helpful for short-term treatment of many of the

dyssomnias, but they must be used carefully or they might cause rebound insomnia, a withdrawal experience that can cause worse sleep problems after the medication is stopped.

Any long-term treatment of sleep problems should include psychological interventions such as stimulus control and sleep hygiene.  Parasomnias such as nightmares occur during rapid eye movement (or dream) sleep, and sleep terrors and sleepwalking occur during nonrapid eye movement sleep.

KEY TERMS bulimia nervosa, 273 binge, 273 anorexia nervosa, 273 binge-eating disorder (BED), 273 obesity, 274 purging techniques, 276 night eating syndrome, 296 bariatric surgery, 299 rapid eye movement (REM) sleep, 302 dyssomnias, 302 parasomnias, 302 polysomnographic (PSG) evaluation, 302 actigraph, 2302 sleep efficiency (SE), 302

microsleeps, 2303 insomnia disorder, 303 primary insomnia, 303 rebound insomnia,306 hypersomnolence disorder, 307 sleep apnea, 307 narcolepsy, 307 breathing-related sleep disorders, 309 circadian rhythm sleep disorders, 310 nightmares, 315 disorder of arousal, 315 sleep terrors, 315 sleepwalking, (somnambulism), 316

IDEAS FOR INSTRUCTION 1.

Body Image and Media Messages. One week before you start to lecture on eating disorders, ask your students to bring in non-pornographic magazines targeted toward women (Elle, Marie Claire) or men (Men’s Health) to class. In class, divide your students into groups of four to eight based on gender. Give groups comprised of male students the magazines targeted toward women, and vice versa. Ask students to pick several images from each magazine and to identify the messages, either implicit or explicit, that advertising images give about body image.

2.

Treatment Planning for Phoebe. Divide your class into small groups and have them devise a treatment plan for Phoebe, the case study described in the book. Assign each group a particular theoretical perspective to use (cognitive-behavioral, family systems, interpersonal therapy, psychodynamic, purely cognitive, etc.). Instruct each group to a) list the primary target behaviors they would address in treatment, b) explain why Phoebe

may have developed her difficulties from a particular theoretical perspective, and c) plan a treatment based on that theoretical perspective.

3.

Food Preferences Are Predominantly Socialized. Our preference for certain foods over others is heavily influenced by culture, socialization, and experience. Such factors often exert a control of what we eat and avoid eating more so than simple biological need for nutrition and sustenance. To illustrate this concept, choose two foods that would be appropriate to eat depending on the time of day of your class. One food should be something that students would eat if they could, while the other food should be a food that would satisfy the body’s need for calories and nutrition, but that students would not prefer. For example, for a class meeting around noon, I give students the option of a nice slice of pizza or a bowl of oatmeal with a few prunes. Bringing food samples to class can make the exercise more effective. Ask students what food they prefer and why. In the example above, most students will overwhelmingly select the slice of cheese pizza. Use this exercise as a springboard to talk about social and cultural factors, including the media, which influence eating behavior, including poor eating habits.

4.

Dream Diaries This activity promises to be quite interesting. Approximately 2 weeks before the chapter on sleep disorders is discussed, tell your class to start keeping a dream diary. Encourage students to keep a pad of paper and pencil near their bed so they can write down any memory of a dream upon waking up. Alternatively, students can record a voice memo on their cell phones. After 2 weeks of keeping the diary, tell students to break up into groups and discuss one or two of their dreams with the other group members. The other students in the group should be instructed to give an interpretation of the dream (Freudian, Jungian, or their own). Although some students may prefer discussing their dreams with friends or other students, prepare yourself to be asked by many what the “true” meaning or interpretation of a particular dream is. This exercise often leads to interesting discussions of learned fears, symbolic meanings of dreams, Freudian psychoanalysis, and how activities during daytime can influence the nature and content of sleep and dreaming.

Uh Oh! Plan B Although instructors are skilled professionals in creating classroom experiences, things don’t always go as planned. The chapter-related lecture and activity suggestions in this section are for instances when your planned lecture or activity idea do not go as planned. Implement these to recover student interest and enhance student reading.

Class Discussion: Have students write on a piece of paper any sleep problems they have had in the recent past. Be sure not to identify students by name. Collect the papers and shuffle them to assure that no one can be identified. Lead a discussion based on the types of problems each student has identified. At the end of lecture, give names and contact information of professionals at your school or in the community who specialize in sleep disorders.

YOUTUBE VIDEOS: CHAPTER 8 We live in a world where hunger and obesity co-mingle. Watch this interview with Dr. Fang Hai, professor at the China Center for health development studies at Peking University; Dr. David Rutstein, Vice President for Medical Affairs at United Family Healthcare; and Dr. Eric Ding, epidemiologist and health economist at Harvard School of Public Health. https://www.youtube.com/watch?v=GWEoX44ebvw (14:24) What is life like when you have an eating disorder? Buzzfeed Reports. https://www.youtube.com/watch?v=UcN9AJIE2Po (03:51) Would it help to review the sleep disorders described in this chapter? Khan Academy: https://www.youtube.com/watch?v=VBcEz8bVbL0 (05:25).

SUGGESTED VIDEOS Dying to be thin. (Insight Media). Presenting statistics on the prevalence of eating disorders in America, this video reveals that there are many more sufferers than the stereotypical adolescent girls who starve themselves in emulation of media images of hollow-cheeked fashion models. It explores the psychological aspects of the diseases, considers the damage malnourishment does to the body, and examines effective therapies. (60 min) Eating disorders. (Fanlight Productions). The eating disorders anorexia and bulimia have traditionally been thought to affect only young, white women; this program stresses their growing impact on men and minorities as well. The stories of several individuals who have dealt with severe eating disorders highlight the fact that this illness is not just about food but about struggling with the loss of emotional control. (28 min) Freud’s interpretation of dreams. (Insight Media). The publication of Interpretation of Dreams revolutionized the way people look at their hopes, fears, and fantasies. Using a unique series of dream-sequence reenactments, this video examines what Freud termed “the royal road of the unconscious,” probing the meaning of dreams and what they reflect. (23 min)

Mental health/illness. (Insight Media). Although the direct relationship between psychological health and physical health has long been recognized, there is still a great deal of misinformation and even social stigma surrounding mental illness. This video examines the epidemiology of mental disorders and the treatment approaches emerging from research into the biology of these diseases. It focuses on the diagnosis and treatment of depression, a leading illness worldwide, and bulimia, which affects primarily teenagers and young adults. (30 min) Narcolepsy. (Fanlight Productions). This film presents the experiences of three individuals whose lives and relationships have been disrupted by narcolepsy. Intertwined with their compelling stories, it also offers solid, comprehensive scientific information about this disorder. (25 min) Shadows and lies: The unseen battle of eating disorders. (Fanlight Productions). This powerful and honest documentary profiles four women who are working themselves free from the deadly grip of eating disorders and from the overwhelming physical and psychological complications associated with these disorders. (30 min) Sleep disorders: Their effects and treatments. (Insight Media). Lack of sleep is a serious health hazard, increasing susceptibility to colds and viral infections. This program explains such causes of sleeplessness as insomnia, sleep apnea, narcolepsy, restless legs, and sleep timing disturbances. Sleep experts provide tips on how to fall asleep, manage night shifts, travel across time zones, and help infants and young children sleep through the night. (28 min) Slim Hopes. (Media Education Foundation). Jean Kilbourne, who created the Killing Us Softly film series, depicts the relationship between media images and women’s health in this program. (30 min) Teaching about anorexia nervosa. (Insight Media). This three-volume set describes the condition of anorexia nervosa. It features interviews with three patients, one of whom has successfully recovered. It also includes commentary of a dietician and presents a dramatization of the development and treatment of anorexia in a college student named Lizzie. (116 min total) The biology of sleep. (Insight Media). Featuring the commentary of a noted sleep expert, this video addresses the biology of sleep, revealing why sleep patterns differ so dramatically among human beings and showing how sleep changes throughout the lifespan. (30 min) Thin. (HBO Films). A documentary following several women receiving treatment for eating disorders at the Renfrew Center in Florida. (102 minutes) When food is the enemy: Eating disorders. (Insight Media). Examining the symptoms and complications of such major eating disorders as anorexia, bulimia, and binge eating, this video reveals self-perception as the key underlying issue for sufferers. It explains the seriousness of these dysfunctions, addresses the complexities of recovery, and features the commentary of experts and patients regarding causes and current methods of treatment. (15 min)

ONLINE RESOURCES Academy for Eating Disorders https://www.aedweb.org/ The Academy for Eating Disorders is a multidisciplinary professional organization focused on anorexia nervosa, bulimia nervosa, binge-eating disorder, and related disorders. This site provides some useful links and information related to eating disorders and their treatment.

American Sleep Apnea Association http://www.sleepapnea.org/ Information on the phenomenology, assessment, and treatment of sleep apnea.

Children and Sleep Disorders http://www.stanford.edu/~dement/children.html Information on numerous sleep disorders that affect children, including infant apnea, sleepwalking, nightmares, and sleep terrors.

Eating Disorders Anonymous http://www.eatingdisordersanonymous.org This website outlines the 12-step model for treatment of eating disorders, provides a nationwide listing of meetings, and contains numerous links to other relevant sites.

MedlinePlus: Sleep Disorders http://www.nlm.nih.gov/medlineplus/sleepdisorders.html Excellent resource for current research and links related to sleep disorders.

National Association of Anorexia Nervosa and Associated Disorders (ANAD) http://www.anad.org/ ANAD is the oldest national non-profit organization helping eating disorder victims and their families. In addition to its free hotline counseling, ANAD operates an international network of support groups for sufferers and families, and offers referrals to healthcare professionals, who treat eating disorders across the U.S. and in 15 other countries. This site contains useful information and links.

National Eating Disorders Association (NEDA) http://www.nationaleatingdisorders.org/ The National Eating Disorders Association (NEDA) is the leading non-profit organization in the United States advocating on behalf of and supporting individuals and families affected by eating disorders.

The Something Fishy Website on Eating Disorders http://www.something-fishy.org/ This webpage is a potpourri of information devoted to eating disorders, including treatments, prevention, and issues for men with eating disorders.

National Sleep Foundation

http://www.sleepfoundation.org/ The National Sleep Foundation is a nonprofit organization devoted to raising funds and awareness about the importance of sleep for health and productivity. Answers to questions regarding sleep disorders and proper sleep hygiene can be found here.

SleepDisorders.Com http://www.sleepdisorders.com/ An excellent megasite containing information and links related to sleep disorders.

SUPPLEMENTARY READING MATERIAL Additional Readings: Anderson, G. H., & Kennedy, S. H. (Eds.) (1992). The biology of feast and famine: Relevance to eating disorders. New York: Academic.

Bruno, F. (1997) Get a good night’s sleep. New York: Macmillan.

Clipson, C., & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA: Houghton Mifflin Company. Chapter 15, Bulimia Nervosa: The Self-Destructive Diet.

Cooper, R. (Ed.) (1994). Sleep. New York: Chapman and Hall Medical.

Durand, V. M. (1998). Sleep better!: A guide to improving sleep for children with special needs. Baltimore, MD: Paul H. Brookes Publishing.

Fairburn, C. G., & Wilson, G. T. (Eds.) (1993). Binge eating: Nature, assessment, and treatment. New York: Guilford.

Fichter, M. M. (Ed.) (1993). Bulimia nervosa: Basic research, diagnosis and therapy.

Chichester, England: Wiley.

Garner, D. M., & Garfinkel, P. E. (Eds.) (1985). Handbook of psychotherapy for anorexia nervosa and bulimia. New York: Guilford.

Hall, L., & Ostroff, M. (1998). Anorexia nervosa: A guide to recovery. Gurze Designs & Books.

Kazdin, A. E. (1990). Psychotherapy for children and adolescents. Annual Review of Psychology, 41, 21–54.

Kryger, M. H., Roth, T., & Dement, W. C. (Eds.) (1989). Principles and practice of sleep medicine. Philadelphia: Saunders.

Maas, J. (1998). Power sleep. New York: Villard.

Meisels, S. J., & Shonkoff, J. P. (Eds.) (1990). Handbook of early childhood interventions. New York: Cambridge University Press.

Moorcroft, W. H. (1993). Sleep, dreaming, and sleep disorders: An introduction.

Landham, MD: University Press of America.

Perl, J. (1993). Sleep right in five nights: A clear and effective guide for conquering insomnia. New York: William Morrow and Company.

Porter, T. (2002). A dance of sisters. Joanna Cotler Books.

Sattler, D., Shabatay, V.,& Kramer, G. (1998). Abnormal psychology in context: Voices and perspectives. Boston, MA: Houghton Mifflin Company. Chapter 12, Disorders of Childhood and Adolescence, Mental Retardation, and Eating Disorders.

Williams, R. L., Karacan, I., & Moore, L. A. (Eds.) (1988). Sleep disorders: Diagnosis and treatment. New York: Wiley.

.

Handouts WARNING SIGNS OF SLEEP DISORDERS  Consistent failure to get enough sleep, or sleep is not restful  Consistently feeling tired upon waking and/or waking with a headache  Feelings of chronic tiredness and fatigue during the day  Struggling to stay awake while driving, or when doing something passive (e.g., watching TV)  Difficulties concentrating at work or school  Coworkers, friends, or family members commenting on sleepiness  Showing a slowed or unusually delayed response to stimuli or events  Difficulty remembering things or in controlling emotions  Feeling the need to nap several times a day  Others have pointed out that you snore often or cease breathing during sleep

142

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WARNING SIGNS OF ANOREXIA/BULIMIA  Dramatic weight loss in a relatively short period of time  Wearing big/baggy clothes or dressing in layers to hide body shape and size  Obsession with weight/complaints of weight problems  Obsession with calories, fat content of foods, and exercise  Frequent trips to the bathroom immediately following meals  Visible food restriction and self-starvation and/or bingeing or purging  Use of diet pills, laxatives, ipecac syrup, or enemas  Isolation and fear of eating around and with others  Unusual food rituals (e.g., shifting the food around on a plate to look eaten)  Hiding food in strange places  Flushing uneaten food down the toilet (can cause sewage problems)  Vague or secretive eating patterns  Preoccupation with thoughts of food, weight, and/or cooking  Self-defeating statements after food consumption  Hair loss and/or pale or “grey” skin appearance  Dizziness, headaches, low blood pressure, constipation, or incontinence  Frequent sore throats and/or swollen glands  Perfectionistic personality, low self-esteem, and/or feelings of worthlessness  Complaints of often feeling cold  Loss of menstrual cycle and/or loss of sexual desire or promiscuous sex  Bruised or callused knuckles; bloodshot or bleeding in the eyes; light bruising under the eyes and on the cheeks  Mood swings (e.g., depression, fatigue)  Insomnia and/or poor sleeping habits

143

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WARNING SIGNS OF BINGE-EATING DISORDER  Rapid weight gain or obesity  Constant weight fluctuations  Frequently eats an abnormal amount of food in a short period of time (usually less than two hours) but does not use methods to purge food  Fear of not being able to control eating, and while eating, not being able to stop  Isolation (i.e., fear of eating around and with others)  Chronic dieting on a variety of popular diet plans  Holding the belief that life will be better if you can lose weight  Hiding food in strange places (closets, cabinets, suitcases, under the bed) to eat at a later time  Hoarding food (especially high-calorie/junk food)  Vague or secretive eating patterns (e.g., eating late at night)  Self-defeating statements after food consumption  Blaming failure in social and professional community on weight  Holding the belief that food is one’s only friend  Frequently feeling out of breath after relatively light activities  Excessive sweating, high blood pressure, and/or cholesterol  Leg and joint pain, weight gain  Decreased mobility due to weight gain

144

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RISK FACTORS FOR EATING DISORDERS AMONG DIETERS  Eating in secret  Bingeing and purging before beginning dieting  Expressing a desire to have an empty stomach  Preoccupation with food  Fear of losing control over eating

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CHAPTER 9 PHYSICAL DISORDERS AND HEALTH PSYCHOLOGY CHAPTER OVERVIEW This chapter outlines the primary psychological and social factors that influence the development and maintenance of several physical disorders. Specifically, the psychological effects of stress on the immune system and related diseases are described. Emphasis is given to AIDS, cancer, cardiovascular disease, hypertension, coronary heart disease, chronic pain, and chronic fatigue syndrome. In addition, lifestyle practices that place one at risk for certain physical disorders are discussed. Finally, both limited and comprehensive psychosocial treatment and prevention efforts for these problems are delineated.

CHAPTER OUTLINE PSYCHOLOGICAL AND SOCIAL FACTORS THAT INFLUENCE HEALTH Health and Health-Related Behavior The Nature of Stress The Physiology of Stress Contributions to the Stress Response Stress, Anxiety, Depression, and Excitement Stress and the Immune Response PSYCHOSOCIAL EFFECTS ON PHYSICAL DISORDERS AIDS Cancer Cardiovascular Problems Hypertension Coronary Heart Disease Chronic Pain Chronic Fatigue Syndrome PSYCHOSOCIAL TREATMENT OF PHYSICAL DISORDERS

Biofeedback Relaxation and Meditation A Comprehensive Stress- and Pain-Reduction Program Drugs and Stress-Reduction Programs Denial as a Means of Coping Modifying Behaviors to Promote Health

DETAILED OUTLINE Psychological and Social Factors that Influence Health  Psychological and social factors play a major role in developing and maintaining a number of physical disorders.  Two fields of study have emerged as a result of a growing interest in psychological factors contributing to illness. Behavioral medicine involves the application of behavioral science techniques to prevent, diagnose, and treat medical problems. Health psychology is a subfield of behavioral medicine that focuses on psychological factors involved in the promotion of health and well-being.  Psychological and social factors may contribute directly to illness and disease through the psychological effects of stress on the immune system and other physical functioning. If the immune system is compromised, it may no longer be able to attack and eliminate antigens from the body effectively, or it may even begin to attack the body’s normal tissue instead, a process known as autoimmune disease.  DISCUSSION POINT: Do you notice a relationship between stress in your life and the functioning of your immune system? Do you think this may be why you and your classmates have a higher tendency to get ill during stressful times of the semester, such as midterms and final exams? How do you think you could counter those effects?

Stressors such as final exams, moving to college, or other life events are likely to have influenced your students’ physical health.  DISCUSSION POINT: How might the experience of stress affect psychological disorders? How can clinicians assess for the impact of stress and modify treatment to account for stressful factors in a client’s life?  Growing awareness of the many connections between the nervous system and the immune system has resulted in the new field of psychoneuroimmunology.  Diseases that may be partly related to the effects of stress on the immune system include AIDS, cardiovascular disease, and cancer.

Psychosocial Effects on Physical Disorders  Long-standing patterns of behavior or lifestyle may put people at risk for developing certain physical disorders. For example, unhealthy sexual practices can lead to AIDS and other sexually transmitted diseases, and unhealthy behavioral patterns, such as poor eating habits, lack of exercise, or Type A behavior patterns, may contribute to cardiovascular diseases such as stroke, hypertension, and coronary heart disease.  The roots of many of the leading causes of death, such as heart disease, cancer, and diabetes, can be traced to lifestyle factors, principally smoking, diet, and physical activity  Psychological and social factors also contribute to chronic pain. The brain inhibits pain through naturally occurring endogenous opioids, which may also be implicated in a variety of psychological disorders.  Chronic fatigue syndrome is a relatively new disorder that is attributed at least partly to stress but may also have a viral or immune system dysfunction component.  DISCUSSION POINT: How have psychological contributions to the treatment of physical disorders changed the role of the psychologist in interdisciplinary settings? What are the implications for the role of psychologists in the future?

Psychosocial Treatment of Physical Disorders  A variety of psychosocial treatments have been developed with the goal of either treating or preventing physical disorders. Among these are biofeedback and the relaxation response.  Comprehensive stress- and pain-reduction programs include not only relaxation and related techniques but also new methods to encourage effective coping, such as stress management, realistic appraisals, and improved attitudes through cognitive therapy.  Comprehensive programs are generally more effective than individual components delivered singly.  Other interventions aim to modify such behaviors as unsafe sexual practices, smoking, and unhealthy dietary habits. Such efforts have been made in a variety of areas, including injury control, AIDS prevention, smoking cessation campaigns, and programs to reduce risk factors for diseases such as CHD.

KEY TERMS behavioral medicine, 324 health psychology, 324 general adaptation syndrome (GAS), 325 stress, 325 self-efficacy, 328 immune system, 328 antigens, 329 autoimmune disease, 330 rheumatoid arthritis, 330 psychoneuroimmunology

cardiovascular disease, 336 stroke/cerebral vascular accident (CVA), 336 hypertension, 336 essential hypertension, 336 coronary heart disease (CHD), 339 type A behavior pattern, 340 type B behavior pattern, 340 acute pain, 342 chronic pain, 342

(PNI), 330 AIDS-related complex (ARC), 331 cancer, 334 psychoncology, 334

endogenous opioids, 344 chronic fatigue syndrome (CFS), 346 biofeedback, 348 relaxation response, 349

IDEAS FOR INSTRUCTION 1.

.

Activity: Stress Log. This exercise is designed to help students gain an awareness of the stress they experience in their life and how they react to it. Have students keep a record of their stress for one week using a “Stress Log.” The log should consist of a table with separate columns for date, time, a rating of their stress in the moment on a 0-8 scale (as in Figure 9.15), a brief description of the stressful event, and their bodily, cognitive, and overt behavioral reactions. Instruct your students to try and complete their records once or twice a day and include the event they perceived as stressful, regardless how small, and their reactions. Have them review and turn in their records at the end of the week. Ask them to respond verbally or in writing to the following: a. What did you notice about the sources of your stress and the patterns of stress that you experienced? b. Are there situations or people that seem to precipitate considerable stress for you? c. What patterns, if any, do you notice in the way you responded to the stressors you experienced? d. How did this activity impact you, particularly regarding your perceptions about, and reactions to, stress? e. What changes would you like to make in your coping methods?

2.

Activity: Assessing the Type A Personality. The text describes the differences between Type A and Type B personalities. Students can gain some insight into whether they are Type A or B by completing HANDOUT 9.2. After they have answered all of the questions, tell them the questionnaire was designed to explore Type A characteristics.

Remind them that Type A is characterized by time urgency, competitiveness, and being hurried and driven by deadlines. This questionnaire is not diagnostic of that problem, but if they answered yes to several items, they may want to consider the possibility of Type A behavior as a potential pattern that may present health problems. If they answered yes to item 19 and also have strong, recurrent feelings of hostility and anger, they may be especially prone to health problems.

Source Information. Knight, S., Vail-Smith, K., Jenkins, L., Phillips, J., Evans, L., and Brown, K. (1994). How Do You Adapt/Cope With Stress? Instructor’s resource manual for Williams and Knight’s healthy for life: Wellness and the art of living. Pacific Grove, CA: Brooks/Cole.

3.

Activity: Discussion of the Relation between Health, Stress, and Use of Alcohol and Other Drugs. Exam time is often a source of stress, and typically the incidence of viral and bacterial infection rises predictably on campuses during exam periods. Many students also drink alcohol, smoke cigarettes, or experiment with other drugs. Ask students whether they have noted any relation between school stress and the likelihood of getting sick, whether they remain sick longer under times of stress, and whether they use alcohol or other recreational drugs more often during times of stress. You may use this as an opportunity to talk about adaptive ways to reduce stress and boost immunity and how some drugs actually weaken our body’s ability to fight stress and illness.

4.

Type A Personality and Management. A good topic for a lecture is the tendency for some managers and professors to encourage time-pressured and highly competitive modes of behavior. You should point out to students that Type A personalities (Type As) do not usually rise to the top of corporations for any of several reasons: (1) Some hard-driving Type As may die prematurely; (2) Type As tend to irritate others, making it difficult for them to maintain friendships and win the support of the backers they need to achieve the highest levels of management; and (3) Type As tend to perform best at tasks that require little compromise and contemplation.

Uh Oh! Plan B Although instructors are skilled professionals in creating classroom experiences, things don’t always go as planned. The chapter-related lecture and activity suggestions in this section are for instances when your planned lecture or activity idea do not go as planned. Implement these to recover student interest and enhance student reading.

Sometimes just Talking about Stress Can Stress You Out: Are you mid-semester? Are your students looking a little worse for the wear? Emphasize coping skills to help students re-take their sense of control that causes stress to become anxiety and depression. To help students gain more specific insight into how they attempt to cope with stress, distribute HANDOUT 9.1 and ask them to complete it. After they have finished, you should remind them that no strategy assures a person of positive results, and every (reasonable) strategy has some potential for having a positive effect in certain situations. According to some researchers, however, strategies that involve active methods of planning and coping and that focus on the positive tend to be associated with reduced anxiety and higher self-esteem. Such strategies as giving up, trying to hurt others, blaming oneself, and overindulgence tend to be less constructive ways of coping.

Source Information. Knight, S., Vail-Smith, K., Jenkins, L., Phillips, J., Evans, L., & Brown, K. (1994). How Do You Adapt/Cope With Stress? Instructor’s resource manual for Williams and Knight’s healthy for life: Wellness and the art of living. Pacific Grove, CA: Brooks/Cole.

YOUTUBE CLIPS: CHAPTER 9 Dr. Mary Ann McLaughlin of the Mount Sinai Hospital in New York reviews the impact of stress on heart disease. https://www.youtube.com/watch?v=-3AsaA1yfH4 (01:32) What does it feel like to live with Chronic Fatigue Syndrome? Here, a series of signs tell the tale. https://www.youtube.com/watch?v=sBjlsNSBXAc (01:07) Finally, need a fun stress-release? Nothing gets cheap (clean) laughs more than “Peanut Butter Jelly Time,” a 1980s style video with silly and catchy lyrics. https://www.youtube.com/watch?v=eRBOgtp0Hac (02:10)

SUGGESTED VIDEOS Blue. British filmmaker Derek Jarman died from complications from AIDS shortly after completing this movie. In the film, Jarman reviews his life and analyzes the ways in which his life has been affected by his disease.

Finding your way. (Fanlight Productions). Behavioral techniques for coping with the discomfort or pain of cancer treatment. (22 min) Stress, health, and coping. (Insight Media). This program explores a range of stressors from everyday tension to posttraumatic stress disorder. Case studies illuminate the link between psychology and biology in understanding stress. Norman Cousins discusses the relationship between stress and physical illness, Hans Selye’s general adaptation syndrome (GAS), and strategies for coping with stress and illness. (30 min) Marvin’s room. A compelling look at the ways in which chronic illness affects caregivers and families.

My left foot. Life story of Christy Brown, an Irish writer, who overcomes cerebral palsy.

Pain management. (Fanlight Productions). From The Dr. Is In series, this video offers an overview of the causes of pain and how it can be effectively managed if it cannot be cured. (28 min) Stress, health, and you. (Time-Life Films/Video). Includes discussion by Hans Selye and Richard Rahe, including suggestions for handling stress. (18 min) Tell them you’re fine. (Fanlight Productions). Three young people with cancer confront the day-to-day realities of coping with the impact of the disease, therapy, and the attitudes of family, friends, and coworkers. (17 min) Whose life is it anyway? Richard Dreyfuss depicts a sculptor who was paralyzed below the neck from a car crash and argues for the right to die.

ONLINE RESOURCES American Academy of Pain Management http://www.aapainmanage.org/ This site provides information and links related to the management of acute and chronic pain.

Health Psychology & Rehabilitation http://www.healthpsych.com/

This website provides information on research and viewpoints on the practice of health psychology in medical and rehabilitation settings.

High Blood Pressure http://www.nhlbi.nih.gov/hbp/index.html A useful National Institute of Health site about the assessment, prevention, and treatment of high blood pressure.

MedlinePlus: Chronic Fatigue Syndrome http://www.nlm.nih.gov/medlineplus/chronicfatiguesyndrome.html Provides a useful source of scholarly information about chronic fatigue syndrome.

American Psychosocial Oncology Society http://www.apos-society.org/ This site provides information and links related to the psychological and medical care of cancer patients.

Pain.com http://www.pain.com/ This is a megasite containing information and links to information about pain and pain management.

Society of Behavioral Medicine http://www.sbm.org/ A scholarly organization devoted to the science and practice of behavioral medicine.

The American Heart Association http://www.heart.org/HEARTORG/ This is the American Heart Association’s official website, providing information on books, support groups, educational materials, diets, fact sheets, research, and more on heart disease, stroke, and related conditions.

SUPPLEMENTARY READING MATERIAL Additional Readings: Anderson, B., Anderson, B., & DeProsse, C. (1989). Controlled longitudinal study of women with cancer. Journal of Consulting and Clinical Psychology, 57, 692-697.

Blanchard, E. B. (1989). Non-drug treatments for essential hypertension. New York: Pergamon.

Blanchard, E. B., & Epstein, L. H. (1978). A biofeedback primer. Reading, MA: Addison-Wesley.

Booth-Kewley, S., & Friedman, H. S. (1987). Psychological predictors of heart disease: A quantitative review. Psychological Bulletin, 101, 342-362.

Clipson, C., & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA: Houghton Mifflin Company. Chapter 8, Stress-Related Disorders.

Cohen, S., & Williamson, G. M. (1991). Stress and infectious disease in humans.

Psychological Bulletin, 109, 5-24.

Duckro, P. N., Richardson, W. D., & Marshall, J. E. (1995). Taking control of your headaches. New York: Guilford.

Fried, R. (1993). The psychology and physiology of breathing: In behavioral medicine, clinical psychology, and psychiatry. New York: Plenum.

Friedman, H. S. (Ed.) (1991). Hostility, coping, and health. Washington, DC: American Psychological Association.

Goodheart, C. D., & Lansing, M. H. (1997). Treating people with chronic disease: A psychological guide. Washington, DC: American Psychological Association.

O’Leary, A. (1990). Stress, emotion, and human immune function. Psychological Bulletin, 108, 363-382.

Resnick, R. J., & Rosensky, R. H. (1996). Health psychology through the life span: Practice and research opportunities. Washington, DC: American Psychological Association.

Rodin, J., & Salovey, P. (1989). Health psychology. Annual Review of Psychology, 40, 533–579.

Sattler, D., Shabatay, V., and Kramer, G. (1998). Abnormal psychology in context: voices and perspectives. Boston, MA: Houghton Mifflin Company. Chapter 6, Psychological Factors and Medical Conditions.

Selye, H. (1976). Stress in health and disease. Woburn, MA: Butterworth.

Strube, M. J. (Ed.) (1991). Type A behavior. Newbury Park, CA: Sage.

Watson, M. (Ed.) (1991). Cancer patient care: Psychosocial treatment methods. New York: Cambridge University Press.

Handouts HANDOUT 9.1 How Do You Adapt/Cope with Stress?

People adapt to or cope with stress in a variety of ways. Individuals tend to use their personal adaptation/coping styles fairly consistently, across situations. Which of the following is consistent with your style? Circle the question numbers that are true of you.

In the face of stressful situations, I tend to.....

1. Take some kind of action to try to solve the problem 2. Try to strategize about possible actions to take 3. Take time to consider my options and do some planning 4. Make myself wait for an opportune time to do something about it 5. Find out what other people would do in a similar situation 6. Talk to and get emotional support from others about my problem 7. Try to focus on the positive aspects of what is happening 8. Accept what is happening and learn to live with it 9. Seek guidance from God or my higher power 10. Get upset and vent my emotions eny a problem exists and refuse to believe it is happening 11. Give up trying to get what I want 12. Try to take my mind off the problem by turning to work or other activities 13. Use alcohol or other drugs to avoid thinking about the problem 14. Indulge myself by means of food, drugs, spending money, etc.

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HANDOUT 9.2 What Are Your Usual Reactions?

Take a minute to respond yes or no to the following statements: ___1. When I stop at a red light while driving, I find it difficult to patiently wait for the light to turn green. ___2. When I talk to other people, I find myself finishing their sentences for them. ___3. I often find myself trying to do several things at once (like reading while I eat). ___4. I have difficulty relaxing. ___5. I cannot sit still long enough to watch one program on television. ___6. I am often involved in too many projects at once. ___7. I tend to overextend myself. ___8. People tell me that I am a fast talker, eater, and walker. ___9. I cannot stand waiting in lines. ___10. I am very competitive. ___11. I am frequently angry and frustrated. ___12. When I am driving, I usually race through yellow lights and often speed. ___13. In order to enjoy sports or playing games, I need to win. ___14. I never seem to have enough time. ___15. I often eat “on the run.” ___16. I am not a patient person. ___17. I get upset with people who drive, move, talk, or think slowly. ___18. People tell me that if I do not slow down, I’m going to get an ulcer, high blood pressure, or have a heart attack. ___19. I probably have Type A behavior.

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HANDOUT 9.3 WARNING SIGNS OF STRESS  Increased irritability  Difficulty sleeping, awakening early, or excessive sleeping  Loss of energy or zest for life  Becoming increasingly isolated  Feeling out of control, engaging in uncharacteristic actions or emotions (crying a lot, becoming shrill, focusing on petty things)  Drinking too many caffeinated beverages or relying too much on nicotine and alcohol, sleeping pills, and other medications  Changes in the body’s normal functioning (e.g., a pounding heart)  Denying physical or psychological symptoms (e.g., “There’s nothing wrong with taking sleeping pills every night,” or “Anybody would be depressed in my situation.”)  Handling family members less gently or considerately than is customary  Entertaining suicidal thoughts

CHAPTER 10 SEXUAL DYSFUNCTIONS, PARAPHILIC DISORDERS, AND GENDER DYSPHORIA CHAPTER OVERVIEW This chapter outlines the primary features of sexual and gender identity disorders, including information regarding normal and unusual sexual behavior and attitudes. Gender dysphoria, sexual dysfunctions, and paraphilias are described, with an emphasis on clinical description, information about known causes, and assessment and treatment approaches (i.e., medical and psychosocial). The chapter also includes extensive discussion of the changes in this category of disorders that occurred in the DSM-5 revision.

CHAPTER OUTLINE WHAT IS NORMAL SEXUALITY? Gender Differences Cultural Differences The Development of Sexual Orientation AN OVERVIEW OF SEXUAL DYSFUNCTIONS Sexual Desire Disorders Sexual Arousal Disorders Orgasm Disorders Sexual Pain Disorder ASSESSING SEXUAL BEHAVIOR Interviews Medical Examination Psychophysiological Assessment CAUSES AND TREATMENT OF SEXUAL DYSFUNCTION

Causes of Sexual Dysfunction Treatment of Sexual Dysfunction PARAPHILIC DISORDERS: CLINICAL DESCRIPTIONS Fetishistic Disorder Voyeuristic and Exhibitionistic Disorders Transvestic Disorder Sexual Sadism and Sexual Masochism Disorders Pedophilic Disorder and Incest Paraphilic Disorders in Women Causes of Paraphilic Disorders ASSESSING AND TREATING PARAPHILIC DISORDERS Psychological Treatment Drug Treatments Summary GENDER DYSPHORIA Defining Gender Dysphoria Causes Treatment

DETAILED OUTLINE What Is Normal Sexuality?  Patterns of sexual behavior, both heterosexual and homosexual, vary around the world in terms of both behavior and risks. Approximately 20% of male and 8% of females surveyed engage in sex with numerous partners, putting them at risk for sexually transmitted diseases such as AIDS. Studies have also shown that 10% of men and 9% of women report homosexual sex attraction or behavior.  DISCUSSION POINT: Do you think that people’s attitudes toward sexual behaviors are affected by whether they are male or female? Do you think this influences how they judge others’ sexual behaviors?

Why or why not?

 Two types of disorders are associated with sexual functioning—sexual dysfunctions and paraphilic disorders. Gender dysphoria is not specifically a sexual disorder, but rather a marked incongruence between one’s natal (biological) sex and the gender one experiences or identifies with.

An Overview of Sexual Dysfunctions  Sexual dysfunction includes a variety of disorders in which people find it difficult to function adequately during sexual relations.  DISCUSSION POINT: How might assigning a sexual dysfunction diagnosis to a non-distressed individual impact his or her well-being? Are there any benefits to assigning a diagnosis that is not associated with present distress?  Specific sexual dysfunctions include disorders of sexual desire (hypoactive sexual desire disorder in males and females and female sexual interest/arousal disorder) in which interest in sexual relations is extremely low or nonexistent; disorders of sexual arousal (erectile disorder and female sexual interest/arousal disorder) in which achieving or maintaining adequate penile erection or sexual excitement and vaginal lubrication is problematic; and orgasmic disorders (female orgasmic disorder and delayed or premature ejaculation in males) in which orgasm occurs too quickly or not at all. The most common disorder in this category is premature ejaculation, which occurs in males; inhibited orgasm is commonly seen in females.  Sexual pain disorders, specifically genito-pelvic pain/penetration disorder in women, in which unbearable pain is associated with sexual relations, including vaginismus, in which the pelvic muscles in the outer third of the vagina undergo involuntary spasms when intercourse is attempted.

Assessing Sexual Behavior  The three components of assessment are interviews, a complete medical evaluation, and psychophysiological assessment.  DISCUSSION POINT: How might contradictory information obtained during the assessment of sexual behavior, such as a man who reports inhibited sexual desire but who shows nocturnal erections, aid the clinician?

Causes and Treatment of Sexual Dysfunction  Sexual dysfunction is associated with socially transmitted negative attitudes about sex, current relationship difficulties, and anxiety focused on sexual activity.  Psychosocial treatment of sexual dysfunctions is generally successful if available. In recent years, various medical approaches have become available, including the drug Viagra, Levitra, and similar drugs. Treatments focus mostly on erectile dysfunction and are effective and satisfying for about one third of patients who try them.

Paraphilic Disorders: Clinical Descriptions

 Paraphilia is sexual attraction to inappropriate people, such as children, or to inappropriate objects, such as articles of clothing. Paraphilia becomes a paraphilic disorder when the sexual attraction causes significant distress or impairment for the individual or causes harm or risk of harm to others.  The paraphilic disorders include fetishistic disorder, in which sexual arousal occurs almost exclusively in the context of inappropriate objects or individuals; exhibitionistic disorder, in which sexual gratification is attained by exposing one’s genitals to unsuspecting strangers; voyeuristic disorder, in which sexual arousal is derived from observing unsuspecting individuals undressing or naked; transvestic disorder, in which individuals are sexually aroused by wearing clothing of the opposite sex; sexual sadism disorder, in which sexual arousal is associated with inflicting pain or humiliation; sexual masochism disorder, in which sexual arousal is associated with experiencing pain or humiliation; sadistic rape, where rapists tend to show sexual arousal to violent and non-sexual material; and pedophilic disorder, in which there is a strong sexual attraction toward children. Incest is a type of pedophilia in which the victim is related, often a son or daughter.  DISCUSSION POINT: What are the arguments for, and against, retaining sexual sadism disorder and sexual masochism disorder in the DSM diagnostic system? When might consensual sexual activity be given a DSM diagnosis?  The development of paraphilic disorders is associated with deficiencies in consensual adult sexual arousal, deficiencies in consensual adult social skills, deviant sexual fantasies that may develop before or during puberty, and attempts by the individual to suppress thoughts associated with these arousal patterns.

Assessing and Treating Paraphilia  Psychosocial treatments of paraphilia are only modestly effective at best among individuals who are incarcerated, but somewhat more successful in less severe outpatients.

Gender Dysphoria  Gender dysphoria is a dissatisfaction with one’s natal (biological) sex and the sense that one is really the opposite gender (for example, a woman trapped in a man’s body). A person develops a sense of gender or gender identity between 18 months and 3 years of age, and it seems that both congruent gender identity and incongruent gender identity have biological roots influenced by learning.  Treatment for adults with marked gender incongruence (transsexualism) may include sex reassignment surgery integrated with psychological approaches.

KEY TERMS heterosexual behavior, 362 homosexual behavior, 362 sexual dysfunction, 366 male hypoactive sexual desire disorder, 368 female sexual interest/arousal disorder, 368 erectile disorder, 369 delayed ejaculation, 370 female orgasmic disorder, 370 premature ejaculation, 371 genito-pelvic pain/penetration disorder, 372 vaginismus, 372 paraphilic disorders, 383

frotteuristic disorder, 383 fetishistic disorder, 383 voyeuristic disorder, 384 exhibitionistic disorder, 384 transvestic disorder, 384 sexual sadism, 386 sexual masochism, 386 pedophilia, 387 incest, 387 covert sensitization, 390 orgasmic reconditioning, 391 gender dysphoria, 393 gender nonconformity, 396 sex reassignment surgery, 397

IDEAS FOR INSTRUCTION 1.

Activity: “Normal” Sexual Behavior Case Studies. To explore definitions of normal sexual behavior, you can read or distribute case studies and ask your students to evaluate the behavior. The students may want to work in small discussion groups and then present their group’s ideas to the class. Some examples of cases could include the following: a. Mr. Jones is a 72-year-old man. He lost his first wife four years ago but recently began dating another woman. He is concerned because he is “only able to have sex twice a week” and is seeking an intervention that will enhance his sexual performance. b. Kenny is a 14-year-old boy. Recently, he and his best friend, Rob, have begun mutually masturbating together after school. c. Sarah is a 28-year-old female. She has been married for 5 years but has never had an orgasm with her husband. She reports that she is not concerned about not having an orgasm because she finds the sexual contact with her husband pleasurable in other ways. d. Pat and Jan have been in a monogamous relationship for 8 years. They usually have sex with each other once a week. During sex, Pat enjoys slapping Jan in the face and Jan enjoys being slapped.

2.

Activity: Quick Classroom Poll. Ask students for a show of hands in response to the following question: “How many of you ever had diarrhea when you were a teenager?”

Most of the class will usually raise their hands fairly quickly. Then ask, “How many of you ever masturbated when you were a teenager?” Note the usual reluctance of handraising. Discuss the class response to both questions in the context of why we would rather admit to having experienced a rather awful illness than to having experienced an almost universally healthy sexual experience.

3.

Activity: Student Reflections on Sexual Dysfunctions. In small groups, ask students to select the sexual difficulties they consider to be the three worst ones to experience. Have them include their reasons for their choices. Share group choices looking for similarities and differences. Can the groups or class agree on the top three worst sexual problems to have, or are there enough differences to make this task impossible? This exercise is useful as a way to show how sexual problems are often idiosyncratic.

4.

Activity: Invite a Sex Therapist as a Guest Speaker. Obviously, a sex therapist would be a great speaker for this topic. Students could be asked to write anonymous questions or problems they have experienced a week prior to this class. Such questions could then be given to the sex therapist, and the therapist could respond to some of them in a generic fashion. Note that students should be informed that the goal is to have the sex therapist respond to real issues, and that participation is voluntary (though all information will be completely anonymous). This is also a good activity for a psychology club (or Psi Chi, or Psi Beta) activity to get students interested in this topic some information outside of the classroom.

5.

Sexual Deviances. The sheer number of separate sexual deviances listed in this chapter may indicate that people in the United States are particularly concerned with what is normal sexual behavior. Develop a lecture on this topic. Use http://www.goaskalice.columbia.edu/. “Go Ask Alice,” a sexual health question and answer service by Columbia University, as a source for this lecture.

Uh Oh! Plan B Although instructors are skilled professionals in creating classroom experiences, things don’t always go as planned. The chapter-related lecture and activity suggestions in this section are for instances when your planned lecture or activity idea do not go as planned. Implement these to recover student interest and enhance student reading.

Why language is important. No doubt that some of your students will be confused by sexuality/orientation-related terms in this chapter which seem to blend and change in response to new information and advocacy. For example, the term “transvestitism” discussed in this chapter may confuse or even offend some students. It is important to make a distinction between terms defined in DSM-5 (which are slow to change) and terms preferred by marginalized groups. At the time of this textbook writing, LGBTQQI was a common term (representing lesbian, gay, bisexual, transgender, queer, questioning, and intersex). However, many advocates are beginning to use the term LGBT+ to recognize the potential continuum of that which has heretofore been unrecognized. Explicitly engage your students in a conversation about why language matters and encourage them to think about adopting more gender-neutral and LGBT+ friendly language in their own conversations.

YOUTUBE CLIPS: CHAPTER 10 Check out the GLAAD (formerly Gay & Lesbian Alliance Against Defamation) YouTube Channel which features LGBTQ+ responses to current issues. https://www.youtube.com/user/glaadmedia Fan of Orange is the New Black? Listen to Laverne Cox talk about what it is like to be a superstar and a trans-woman. https://www.youtube.com/watch?v=IbNEP8vMvmw (02:32) For a more in-depth look at new biological and brain imaging-research on pedophilia, take a look at Dr. Cantor’s Mysteries of the Mind Series Interview https://www.youtube.com/watch?v=JB6zwvBtDK8 (05:25) We have all heard about the “hookup culture” on college campuses. What does this mean for college students today? Lisa Bunnage explains in this TedX talk. https://www.youtube.com/watch?v=jKAehegqTvg (16:23)

SUGGESTED VIDEOS As time goes by. (Fanlight Productions). Humans are sexual until the very end. The seniors profiled in this video openly share their experiences with love, romance, and growing old. (23 min) Cabaret. This film is about sadomasochism, bisexuality, and the relationship between sex and power.

Claire’s knee. This film depicts a middle-aged man who becomes obsessed with a young girl’s knee.

Fetishes. Examines the clients of Pandora’s Box, an elite club in New York City that caters to sexual fetishes.

Gender and relationships. (Insight Media). Explaining why human emotional interactions and attachments are so complex, this video stresses that even the most respected authorities remain uncertain about which factors influence people’s feelings of love, affection, and sexual attraction. It examines some of the most beguiling mysteries of the ages: What is love? What makes sexual behavior normal or abnormal? Do men and women differ in their sexual motives and behavior? (30 min) Human sexuality (it’s personal). (Insight Media). Sexuality is an integral part of human identity and a primary factor in human behavior. This video explores the development of sexual behavior and considers the range of sexual experience and preference that exists within contemporary human society. It also examines whether fear of the AIDS virus and other sexually transmitted diseases has altered patterns of sexual behavior. (28 min) Love and death in America: Sexual revolution/AIDS. (Insight Media). This video tours three decades of shifting American attitudes toward sex. It explores the 1960s break with inhibitions traceable to the nation’s Puritan origins, examines the impact of the birth control pill, and discusses the chaos of behavioral codes that followed the advent of AIDS. (50 min) Pulp fiction. This film depicts an underworld sadomasochistic den run by two sexual sadists.

Sex, lies, and videotape. This film depicts an impotent young man who can achieve orgasm only by masturbating while watching videotapes of women whom he has persuaded to share their most intimate details.

Sexual abuse of children: Victims and abusers. (Insight Media). Featuring candid interviews with therapists, victims, and recovering offenders, this video explores the devastating long-term effects of physical, emotional, and/or sexual abuse on children. (28 min)

The adjuster. This Canadian film explores voyeurism and exhibitionism.

The crying game. . This film explores homosexuality, transsexualism, interracial sexuality, and the ability of human beings to love one another in the context of an asexual relationship.

The sex history. (Insight Media). Wardell Pomeroy, coauthor of the Kinsey Report, demonstrates his style of taking a sex history, which he developed through taking 35,000 sex histories. Working with two resistant adults, he explains how to gather data, elicit information about sensitive topics, and build a positive rapport. He emphasizes the importance of using clear language, avoiding euphemisms, and being supportive. (60 min) Transgender revolution. (Insight Media). This video explores the growing subculture of transsexuality. It contains interviews with both the founder of the transsexual political organization, GenderPAC, and a neurosurgeon who specializes in sex change operations, and follows the surgical transformation of a man into a woman. (50 min) Unusual sexual behavior. (Insight Media). This training video features simulated interviews with six different clients. The clients portrayed include a man who is sexually interested in young boys, a couple whose marriage is threatened because the husband, a transvestite, has decided to “come out,” and a man who has an unusual sexual fetish. (66 min)

ONLINE RESOURCES Go Ask Alice http://www.goaskalice.columbia.edu/ “Go Ask Alice” is a sexual health question and answer service by Columbia University.

His & Her Health http://www.hisandherhealth.com/ This highly-credentialed, HON-registered site provides medical information and articles on the causes and treatments of male and female sexual dysfunction, prostate, incontinence, fertility, and related issues. The site includes videos, moderated chat rooms, bulletin board, and scheduled chats with a doctor.

Kinsey Institute for Research in Sex, Gender, and Reproduction, Inc. http://www.indiana.edu/~kinsey/ This excellent research website includes links to current research publications.

Society for the Scientific Study of Sexuality http://www.ssc.wisc.edu/ssss/ An international organization dedicated to the advancement of knowledge about sexuality. It is the oldest organization of professionals interested in the study of sexuality in the

U.S. This site details the importance of both production of quality research and the clinical education and social applications of research related to all aspects of sexuality.

SUPPLEMENTARY READING MATERIAL Additional Readings: Anderson, B. L. (1983). Primary orgasmic dysfunction: Diagnostic considerations and review of treatment. Psychological Bulletin, 93, 105–136.

Arndt, W. B. (1991). Gender disorders and the paraphilias. Madison, CT: International Universities Press.

Barlow, D. H. (1986). Causes of sexual dysfunction: The role of anxiety and cognitive interference. Journal of Consulting and Clinical Psychology, 54, 140–148.

Briere, J. (1992). Methodological issues in the study of sexual abuse effects. Journal of Consulting and Clinical Psychology, 60, 196–203.

Clipson, C., & Steer, J. (1998). Case studies in abnormal psychology. Boston, MA: Houghton Mifflin Company. Chapter 10, Premature Ejaculation: Under Pressure to Perform. Chapter 11, Pedophilia: Predator of Youth.

Davis, C. M., Yarber, W. L., & Davis, S. L. (Eds.) (1988). Sexuality-related measures: A compendium. Lake Mills, IA: Graphic Publishing.

Heiman, J. R., & LoPiccolo, J. (1988). Becoming orgasmic: A sexual and personal growth program for women. New York: Prentice-Hall.

Maletzky, B. M. (1991). Treating the sexual offender. Newbury Park, CA: Sage.

McCarthy, B. W. (1988). Male sexual awareness. New York: Caroll and Graf.

Rosen, R. C., & Leiblum, S. (Eds.) (1991). Erectile failure: Diagnosis and treatment.

New York: Guilford.

Rosen, R. C., & Leiblum, S. R. (Eds.) (1992). Erectile disorders: Assessment and treatment. New York: Guilford.

Sattler, D., Shabatay, V., 7 Kramer, G. (1998). Abnormal psychology in context: Voices and perspectives. Boston, MA: Houghton Mifflin Company. Chapter 10, Sexual Dysfunctions and Disorders.

Wilson, G. D. (1987). Variant sexuality: Research and theory. Baltimore, MD: Johns Hopkins University Press.

Wincze, J. P., & Carey, M. P. (1991). Sexual dysfunction: A guide for assessment and treatment. New York: Guilford.

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Handouts WARNING SIGNS OF A SEXUAL DYSFUNCTION  Occur in women more often than in men  Often occurs after the age of 30 but may occur prior to that age  Painful intercourse is a sign of sexual dysfunction  Increasing age increases the chance of sexual dysfunction  May occur in conjunction with cardiovascular disease, depression, diabetes, and general poor health, especially in erectile failure  Alcohol abuse and medications serve as predictors of sexual dysfunction  Estrogen deprivation especially in postmenopausal women  Sexual abuse especially before puberty is a significant risk factor for sexual dysfunction  Emotional or stress-related problems  Decreased libido  Delay or absence of an orgasm is a sign of sexual dysfunction  Inability to attain or maintain vaginal lubrication and swelling response in women  Inability to attain or maintain an erection in males  Loss of interest in sexual activity

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WARNING SIGNS OF PEDOPHILIC DISORDER  Vast majority are males and heterosexual  Sexual urges geared toward prepubescent child  Recurrent, intense sexually arousing fantasies with prepubescent child  Record of prior sexual conviction  Lack of intimate partners  Never being married is a risk factor for pedophilia  Poor relationship with own mother  Overly touchy and affectionate with kids  Being alone with children a lot  Being a victim of child abuse at a younger age  Excessive use or abuse of alcohol  Often accompanied by low self-esteem  Repeated lying

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CHAPTER 11 SUBSTANCE-RELATED, ADDICTIVE, AND IMPULSE-CONTROL DISORDERS CHAPTER OVERVIEW This chapter outlines the major features of substance-related disorders, with discussions of substance use, intoxication, abuse, and dependence. including categories regarding depressants (alcohol, barbiturates, and benzodiazepines), stimulants (amphetamines, cocaine, tobacco, and caffeine), opioids (heroin, codeine, and morphine), cannabis-related drugs (marijuana), hallucinogens (LSD and other substances), and other drugs of abuse (inhalants and steroids). In addition, patterns of drug use, etiological factors, mechanisms of action, and treatments are discussed within an integrative bio-psycho-social framework. The chapter concludes with a review and discussion of gambling disorder and impulse control disorders (intermittent explosive disorder, kleptomania, and pyromania).

LECTURE OUTLINE PERSPECTIVES ON SUBSTANCE-RELATED AND ADDICTIVE DISORDERS Levels of Involvement Diagnostic Issues DEPRESSANTS Alcohol-Related Disorders Sedative-, Hypnotic-, or Anxiolytic-Related Disorders STIMULANTS Stimulant-Related Disorders Tobacco-Related Disorders Caffeine-Related Disorders OPIOIDS CANNABIS-RELATED DISORDERS HALLUCINOGEN-RELATED DISORDERS

OTHER DRUGS OF ABUSE CAUSES OF SUBSTANCE-RELATED DISORDERS Biological Dimensions Psychological Dimensions Cognitive Dimensions Social Dimensions Cultural Dimensions An Integrative Model TREATMENT OF SUBSTANCE-RELATED DISORDERS Biological Treatments Psychosocial Treatments Prevention GAMBLING DISORDER IMPULSE-CONTROL DISORDERS Intermittent Explosive Disorder Kleptomania Pyromania

LECTURE OUTLINE Perspectives on Substance-Related Disorders  In DSM-5, substance-related and addictive disorders include problems with the use of depressants (alcohol, barbiturates, and benzodiazepines), stimulants (amphetamine, cocaine, nicotine, and caffeine), opiates (heroin, codeine, and morphine), and hallucinogens (cannabis and LSD) as well as gambling.  Specific diagnoses are further categorized as substance intoxication and substance withdrawal.  DISCUSSION POINT: What do you perceive to be the most significant drug problem in your community?

This discussion will bring out students’ beliefs about the dangerousness of drugs, association with criminal activity, addictive potential, and other factors. Encourage your students to discuss what influenced their selection.

 Nonmedical drug use in the United States has declined in recent times, although it continues to cost billions of dollars and seriously impairs the lives of millions of people each year.

Illicit and improrper use of prescription drugs is on the rise.

Depressants, Stimulants, Opioids, and Hallucinogens  Depressants are a group of drugs that decrease central nervous system activity. The primary effect is to reduce our levels of physiological arousal and help us relax. Included in this group are alcohol and sedative, hypnotic, and anxiolytic drugs, such as those prescribed for insomnia.  Stimulants, the most commonly consumed psychoactive drugs, include caffeine (in coffee, chocolate, and many soft drinks), nicotine (in tobacco products such as cigarettes), amphetamines, and cocaine. In contrast to the depressant drugs, stimulants make us more alert and energetic.  DISCUSSION POINT: Many of the drugs discussed in this chapter have effects similar to the symptoms of psychological disorders, such as mood swings and paranoia. What does this tell you about underlying biological or other factors in drug use?  Opiates include opium, morphine, codeine, and heroin; they have a narcotic effect—relieving pain and inducing sleep. The broader term opioids is used to refer to the family of substances that includes these opiates and synthetic variations created by chemists (e.g., methadone) and the similarly acting substances that occur naturally in our brains (enkephalins, betaendorphins, and dynorphins).  Hallucinogens essentially change the way the user perceives the world. Sight, sound, feelings, and even smell are distorted, sometimes in dramatic ways, in a person under the influence of drugs such as marijuana and LSD.  DISCUSSION POINT: Why is marijuana the most frequently used illegal drug in the U.S.?  DISCUSSION POINT: Recently some states have moved to not only decriminalize but actually legalize the possession and use of small amounts of marijuana. Do you support this movement? Why or why not? Can you think of some unintended consequences of such policy changes?

Causes and Treatment of Substance-Related Disorders  Most psychotropic drugs seem to produce positive effects by acting directly or indirectly on the dopaminergic mesolimbic system (the pleasure pathway). In addition, psychosocial factors such as expectations, stress, and cultural practices interact with the biological factors to influence drug use.  Substance Use Disorders are treated successfully only in a minority of those affected, and the best results reflect the motivation of the drug user and a combination of biological and psychosocial treatments.  Programs aimed at preventing drug use may have the greatest chance of significantly affecting the drug problem. However, at least some of the most prominent programs (e.g.

DARE) have been shown to be ineffective.  DISCUSSION POINT: What are the strengths and limitations of using biological treatments for substance abuse and dependence?

Gambling Disorder  Problem gamblers display the same types of cravings and dependence as persons who have substance-related disorders.  Similar brain systems appear to be involved with those addicted to gambling as seen in persons with substance-related disorders.  DISCUSSION POINT: How is pathological gambling similar to, and different from, substance use disorders?

What have we learned from the treatment of substance-related disorders that may be applied to pathological gambling?

Impulse-Control Disorders  In DSM-5, impulse-control disorders include three separate disorders: intermittent explosive disorder, kleptomania, and pyromania.

KEY TERMS substance-related and addictive disorders, 405 impulse-control disorders, 405 polysubstance use, 405 psychoactive substance, 406 substance use, 407 substance intoxication, 407 substance abuse, 408 substance dependence, 408 tolerance, 407 withdrawal, 408 depressants, 409 stimulants, 409 opiates, 409 hallucinogens, 409 other drugs of abuse, 409 alcohol-related disorders, 409 alcohol, 409 withdrawal delirium (delirium tremens/DTs), 411 Wernicke-Korsakoff syndrome, 411 fetal alcohol syndrome (FAS), 411

barbiturates, 414 benzodiazepines, 414 amphetamines, 416 cocaine, 418 tobacco-related disorders, 420 caffeine-related disorders, 421 opioid-related disorders, 422 Cannabis (Cannabis sativa) (marijuana), 423 cannabis use disorders, 424 LSD (d-lysergic acid diethylamide), 425 hallucinogen use disorders, 426 agonist substitution, 436 antagonist drug, 4237 nicotine, 436 nicotine patch, 437 controlled drinking, 438 relapse prevention, 439 gambling disorder, 441 intermittent explosive disorder, 442 kleptomania, 443

alcohol dehydrogenase (ADH), 412

pyromania, 443

IDEAS FOR INSTRUCTION 1.

Activity: Survey on Drug Use/Abuse Patterns. Many students believe that drug use and abuse have declined dramatically over the years, regardless of the drug type or classification (e.g., licit vs. illicit, hallucinogens vs. stimulants, etc.). One way to foster discussion on this topic is to ask students to complete HANDOUT 11.1, a survey developed by Dr. George F. Koob of the University of California, San Diego’s Department of Psychology before discussing this chapter. Dr. Koob has compiled the survey results from his “Drugs, Addiction, and Mental Disorder” classes for more than a decade and shares indications of certain trends in drug use with his students each year. A good follow-up assignment would be to have students research articles addressing the prevalence of drug use among certain populations (e.g. 18- to 24-year-old male vs. female smoking rates, etc.). Do the survey results match what the scientific literature concludes regarding drug use in the U.S.?

2.

Activity: Demonstrate Cigarette Smoking Residue. This exercise can be used to demonstrate the residue that remains in the body when smoking a cigarette. You will need two cigarettes and a “smoking apparatus” in this exercise. The apparatus can be borrowed from a local chapter of the American Cancer Society or American Lung Association, or it can be built at home. To build the apparatus, you need the following items: a. A clean, empty, flexible plastic bottle such as a dishwashing soap container with a top (a transparent bottle would be ideal). b. Plastic tubing about the size of a cigarette; a cigarette must be able to fit snugly within the tubing. c. A small ball of clay, a cotton ball or loose cotton, a book of matches, and two index cards on which to place cigarette parts and transparent tape.

Make an opening in the bottle cap so the tubing fits snugly. Insert the tubing through the hole, leaving about an inch extending out of the top. Use the clay to form a seal where the tube meets the top. Insert loosely packed cotton into the opposite end of the tubing. Be sure to do this demonstration in a well-ventilated room. The procedure is as follows: a. Squeeze air out of the bottle and place cigarette firmly into the end of the tubing. b. Light the cigarette and begin to slowly compress and release the sides of the bottle.

Continue until the cigarette is almost completely “smoked.” c. Remove the cigarette, cut off the filter, tape it to the index card, and pass it around.

Discuss the residue that remains and the effectiveness of filters. d. Remove the cotton from the tubing, tape it to the index card, and pass it around.

This represents the residue that is introduced into a smoker’s lungs despite the presence of a filter.

Instructors should consider institutional regulations regarding a lit cigarette in the classroom, even for educational purposes, and perhaps get advance authorization for this activity.

3.

Activity: Should Mandatory Drug Testing Become Part of Campus Life? Mandatory random drug testing is becoming increasingly routine in large corporations. Yet, whether such drug testing curbs drug abuse is a matter over which there is still considerable debate. Mandatory drug testing raises a host of ethical and constitutional issues about right to privacy. Discuss the issues related to mandatory drug testing and ask students to consider whether colleges and universities should adopt a regular policy of random drug testing among their students. What would be the implications of this move for drug use on college campuses? Would such a policy work to deter drug use? This topic should result in some lively discussion and debate.

4.

Activity: Student Response to Signs of Addiction in Friends and Family. Ask students to break up in small groups for this exercise and have each group address how they would approach a situation where they strongly suspected that either a family member or close friend was on the road to addiction. Would they be comfortable saying anything to that person about his or her use of drugs? How would they broach the subject? What sorts of reactions might they expect in the other person after they confronted him or her? What steps would they take to help that person? Sample the responses from different groups, tally them on an overhead or blackboard, and open the discussion up to an analysis of the assets and liabilities of different proposals.

5.

Drug Use and Health. Develop a lecture on the National Survey on Drug Use and Health, sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), which showed that the second most popular category of drug use after marijuana is the non-medical use of prescription drugs. The growing problem of abuse and addiction to prescription medications can be described and illustrated. The following link is to a SAMHSA website with extensive information on prescription drug abuse and relevant links, including a multimedia video segment that you can show in the classroom (http://www.samhsa.gov/prevention).

Uh Oh! Plan B Although instructors are skilled professionals in creating classroom experiences, things don’t always go as planned. The chapter-related lecture and activity suggestions in this section are for instances when your planned lecture or activity idea do not go as planned. Implement these to recover student interest and enhance student reading.

Discussing Drug Use in Context: Given the statistics (and well-known stereotypes) regarding problematic alcoholic consumption and illicit drug use among people of typical college-age, it is worth “norming” the problem for your particular college/university. Oftentimes students actually overestimate the percentage of their peers engaged in alcohol and drug use. Check with your campus administrators and/or health center. Many universities have conducted surveys or have other research about the prevalence of alcohol and drugs on your campus. Using a “real life” example can really add usefulness and context to this chapter.

YOUTUBE CLIPS: CHAPTER 11 There are a number of popular songs about drug use. Check out this YouTube Channel https://www.youtube.com/playlist?list=PLUvt2ON9yC0vFxrMqLqUXb9m8bZ5eeJDg containing 36 songs and challenge your students to list even more. What are the themes of the songs? How are drug use (and drug users) portrayed?

What is our federal government (SAMHSA and NIDA) doing about drug abuse in the United States. Find out here in the “Ask SAMHSA” series: https://www.youtube.com/watch?v=wgxdPM3sD_Y (04:12) and “Blending Intiatives” https://www.youtube.com/watch?v=ts5kuMjYyUc (05:59).

What are universities doing to educate and prevent alcohol disorders on campus? Look at this interesting intervention at MSU: https://www.youtube.com/watch?v=Av95T5TyNes (01:51)

SUGGESTED VIDEOS Clean and sober. This film provides a nice portrayal of Alcoholics Anonymous, alcoholism, and cocaine addiction.

Introduction to Structured Relapse Prevention: An Integrative Approach to Working With Alcohol and Other Drug Problems (Insight Media). This program presents an overview of Structured Relapse Prevention, an integrated therapeutic methodology that includes aspects of motivational interviewing, cognitive-behavioral treatment, and coping skills. (90 min) Drugs of Abuse. (Insight Media). In this DVD, doctors and clinicians join individuals in recovery to discuss the symptoms and consequences of drug abuse, the neurobiology of addiction, substance abuse treatment, and life in recovery. The program examines the progression from drug abuse to recovery management, looking at such drugs as alcohol, nicotine, marijuana, heroin, cocaine, inhalants, and prescription drugs. (90 min) Leaving Las Vegas. This film depicts in graphic visual imagery the struggle of a man suffering from severe alcoholism as he gives up on life and spirals into controlled chaos toward his own death. Features Nicholas Cage and Elisabeth Shue, both of whom won Oscars for their leading roles.

Sweet nothing. This film depicts the nature of crack addiction and is based on a true story.

Trainspotting. This film depicts the heroin scene in Edinburgh and presents accurate depictions of cold turkey heroin withdrawal symptoms.

Walk the line. This film shows rock icon Johnny Cash’s struggle with alcohol and drugs, including his eventual recovery.

When a man loves a woman. This film shows the struggles of a woman and her family as she struggles to overcome alcohol addiction. Inpatient treatment as well as marital therapy, Alcoholics Anonymous, and Al-Anon are used as part of the recovery plan. Features Meg Ryan and Andy Garcia.

ONLINE RESOURCES Alcoholics Anonymous http://www.alcoholics-anonymous.org/ The official webpage for Alcoholics Anonymous; information includes the “Twelve Steps to Recovery.”

Brief Addiction Science Information Source (BASIS) http://basisonline.org This site provides brief overviews, in lay language, of recent studies in substance abuse and dependence. Students may sign up for a periodic newsletter on substance misuse, as well as one on problem gambling.

Center for Education and Drug Abuse Research (CEDAR) http://cedar.pharmacy.pitt.edu CEDAR serves to elucidate the factors contributing to the variation in the liability of drug abuse and determine the developmental pathways culminating in drug abuse outcome, normal outcome, and psychiatric/behavioral disorder outcome. CEDAR is based at the University of Pittsburgh.

Cocaine Anonymous Home Page http://www.ca.org/ This group uses the Twelve Steps program to help recovering cocaine addicts. It includes phone numbers for local chapters as well as links.

Montana Methamphetamine Project http://www.montanameth.org/ This is the site of a major prevention project for methamphetamine use in Montana. The site contains media images, commercials, and other depictions intended to prevent youth from trying the stimulant drug.

National Council on Problem Gambling http://www.ncpgambling.org/ This website is a great resource about issues related to problem gambling and its treatment.

National Institute on Drug Abuse (NIDA) http://www.nida.nih.gov/

This site provides a wealth of information about drug abuse, drug treatment, and current research, including informative fact sheets about most major drugs of abuse.

Substance Abuse & Mental Health Services Administration (SAMHSA) http://www.samhsa.gov At this site, which features information for professionals as well as consumers of services, substance abuse topics are arranged in terms of specific areas of impact (e.g., homelessness, children, and families). Statistics related to drug use and abuse are available as well.

Web of Addictions http://www.well.com/user/woa/ This website provides fact sheets on drugs and drug abuse, links to other Internet resources, and places to get help with addictions.

SUPPLEMENTARY READING MATERIAL Additional Readings: Clipson, C., & Steer, J. (1998). Case studies in abnormal psychology. Boston, MA: Houghton Mifflin Company. Chapter 9, Alcohol Dependence: The Web that Denial Weaves.

Donovan, D. M., & Marlatt, G. A. (Eds.) (1988). Assessment of addictive behaviors.

New York: Guilford.

Ellickson, P. L., & Bell, R. M. (1990). Drug prevention in junior high: A multi-site longitudinal test. Science, 247, 1299-1305.

Galanter, M. (1996). Recent developments in alcoholism, Volume 13: Alcohol and violence: Epidemiology, neurobiology, psychology, and family issues. New York: Plenum.

Galanter, M., & Kleber, H. D. (Eds). (1994). Textbook of substance abuse treatment.

Washington, DC: American Psychiatric Press.

Gallant, D. M. (1987). Alcoholism: A guide to diagnosis, intervention and treatment.

New York: W. W. Norton.

Glantz, M., & Pickens, R. (Eds.) (1991). Vulnerability to drug abuse. Washington, DC: American Psychological Association.

Goldstein, A. (1994). Addiction from biology to drug policy. New York: Freeman.

Gomberg, E., & Nirenberg, T. D. (Eds.) (1994). Women and substance abuse. Norwood, NJ: Ablex Press.

Gootenberg, P. (1999). Cocaine: Global histories. New York: Routledge.

Gorski, T., & Miller, M. (1986). Staying sober: A guide for relapse prevention.

Independence, MO: Independence Press.

Heather, N., Miller, W. R., & Greeley, J. (Eds.) (1994). Self-control and addictive behaviors. New York: Pergamon.

Hester, R., & Miller, W. R. (1989). Handbook of alcoholism treatment approaches. New York: Pergamon.

Marlatt, G. A., & Gordan, J. R. (1985). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford.

McCrady, B. S., & Miller, W. R. (Eds.) (1993). Research on Alcoholics Anonymous: Opportunities and alternatives. New Brunswick, NJ: Alcohol Research Documentation.

Meyers, R. J., & Smith, J. D. (1995). Clinical guide to alcohol treatment: The community reinforcement approach. New York: Guilford.

Miller, W. R., & Hester, R. K. (1986). Inpatient alcoholism treatment: Who benefits?

American Psychologist, 41, 794–805.

Nathan, P. E. (1993). Alcoholism: Psychopathology, etiology, and treatment. In P. B. Sutker & H. E. Adams (Eds.) Comprehensive handbook of psychopathology. New York: Plenum Press, pp. 451–476.

Rotgers, F., Keller, D. S., & Morgenstern, J. (Eds.) (1996). Treating substance abuse: Theory and technique. New York: Guilford.

Sattler, D., Shabatay, V., & Kramer, G. (1998). Abnormal psychology in context: Voices and perspectives. Boston, MA: Houghton Mifflin Company. Chapter 9, SubstanceRelated Disorders.

Stoil, M. J., & Hill, G. (1996). Preventing substance abuse: Interventions that work. New York: Plenum.

Streissguth, A. (1999). Fetal alcohol syndrome: A guide for families and communities.

New York: Brooks Cole.

Tucker, J. A., Donovan, D. M., & Marlatt, G. A. (Eds.) (2001). Changing addictive behavior: Bridging clinical and public health strategies. New York: Guilford.

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Handouts WARNING SIGNS OF AN ALCOHOL-RELATED DISORDER  Drinking heavily after a disappointment, a quarrel, or when a boss is difficult  Drinking more heavily when experiencing difficulties or feeling under pressure  Ability to “handle” more liquor than when you first started drinking  Failure to remember events occurring during a previous drinking episode  Drinking extra amounts of alcohol secretively during social gatherings  Feeling uncomfortable during occasions when alcohol is not available  Feeling guilty about drinking  Feeling irritated when family or friends discuss your drinking  An increase in the frequency of memory blackouts  Wishing to continue drinking after others say “enough is enough”  Having a reason for the occasions when you drink heavily  Feeling regret while sober for things said or done while drinking  Attempts to switch brands or to follow different plans to control drinking  Failure to keep promises about cutting down on drinking  Failed attempts to control drinking by making a change in jobs or moving  Avoidance of family or close friends while drinking  Having an increasing number of financial and work problems  Feeling as though more people are treating you unfairly without good reason  Eating very little or irregularly while drinking  Drinking in the morning to alleviate the shakes  Noticing that it is difficult to drink as much as previously  Staying drunk for several days at a time  Feeling depressed and wondering whether life is worth living  Hearing or seeing things that aren’t there following a period of drinking

 Experiencing extreme fear after heavy drinking

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WARNING SIGNS OF A SUBSTANCE-RELATED OR ADDICTIVE DISORDER  Losing time from work due to drinking/drugs  Drinking/using drugs makes home life unhappy  Drinking/using drugs because of shyness around other people  Drinking/using drugs negatively affects your reputation  Feeling remorse after drinking/using drugs  Experiencing financial difficulties as a result of drinking/drugs  Decreased ambition since drinking/using drugs  Craving a drink/drugs at a definite time daily  Wanting a drink/drugs the next morning  Experiencing sleeping problems related to drinking/using drugs  Decreased efficiency since drinking/using drugs  Drinking/using drugs is jeopardizing one’s job or business  Drinking/using drugs to escape from worries or troubles  Drinking/using drugs while alone  Experiencing a complete loss of memory as a result of drinking/using drugs  Drinking/using drugs to build up self-confidence  Hospitalization or medical care due to drinking/drug use

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WARNING SIGNS OF GAMBLING DISORDER  Preoccupation with gambling (e.g., thinking of ways to get money to gamble)  Lost time from work or family due to gambling  Neglect responsibilities to yourself or family in order to gamble  Pawned or sold personal possessions for gambling money  Borrowed money under false pretences to gamble  Need to gamble with increasing amounts of money to achieve excitement  Repeated unsuccessful efforts to control, cut back, or stop gambling  Restless or irritable when attempting to cut down or stop gambling  Gamble as a way of escaping from problems or to relieve negative feelings  After losing money gambling, returning another day to “get even”  Lying to conceal the extent of involvement with gambling  Committing illegal acts (e.g., forgery, fraud, theft) to finance gambling  Jeopardizing a significant relationship, job, or educational/career opportunity because of gambling  Relying on others to provide money to relieve a desperate financial situation caused by gambling  Feeling hopeless, depressed, or suicidal due to gambling .

CHAPTER 12 PERSONALITY DISORDERS CHAPTER OVERVIEW This chapter outlines the nature of personality and the clinical characteristics, epidemiology, etiology, and treatment for the DSM-5 personality disorders. Cluster A (paranoid, schizoid, and schizotypal personality disorders), B (antisocial, borderline, histrionic, and narcissistic personality disorders), and C (avoidant, dependent, and obsessive-compulsive personality disorders) are described. In addition, specific issues regarding the classification of personality disorders are covered; namely, the debate over categorical vs. dimensional models of taxonomy, the diagnostic validity of personality disorders, and gender bias with respect to diagnosis.

CHAPTER OUTLINE AN OVERVIEW OF PERSONALITY DISORDERS Aspects of Personality Disorders Categorical and Dimensional Models Personality Disorder Clusters Statistics and Development Gender Differences Comorbidity Personality Disorders under Study

CLUSTER A PERSONALITY DISORDERS Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder

CLUSTER B PERSONALITY DISORDERS Antisocial Personality Disorder Borderline Personality Disorder

Histrionic Personality Disorder Narcissistic Personality Disorder

CLUSTER C PERSONALITY DISORDERS Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder

DETAILED OUTLINE An Overview of Personality Disorders  The personality disorders represent long-standing and ingrained ways of thinking, feeling, and behaving that can cause significant distress. Because people may display two or more of these maladaptive ways of interacting with the world, considerable disagreement remains over how to categorize personality disorders.  DISCUSSION POINT: Personality disorders are some of the most stigmatizing psychological disorders. Why might this be the case? How does such a stigma impact those who receive an Axis II diagnosis?  DSM-5 includes 10 personality disorders that are divided into three clusters: Cluster A (odd or eccentric) includes paranoid, schizoid, and schizotypal personality disorders; Cluster B (dramatic, emotional, or erratic) includes antisocial, borderline, histrionic, and narcissistic personality disorders; and Cluster C (anxious or fearful) includes avoidant, dependent, and obsessive-compulsive personality disorders.  DISCUSSION POINT: How can clinicians guard against a gender bias in their own diagnostic practices?  DISCUSSION POINT: If everyone has a “different” personality (i.e., if no two are alike), then how can we say that someone has a “disordered” or “sick” personality? What truly makes a personality pathological?

Cluster A Personality Disorders  People with paranoid personality disorder are excessively mistrustful and suspicious of other people, without any justification. They tend not to confide in others and expect other people to do them harm.

 People with schizoid personality disorder show a pattern of detachment from social relationships and a limited range of emotions in interpersonal situations. They seem aloof, cold, and indifferent to other people.  People with schizotypal personality disorder are typically socially isolated and behave in ways that would seem unusual to most of us. In addition, they tend to be suspicious and have odd beliefs about the world.

Cluster B Personality Disorders  People with antisocial personality disorder have a history of failing to comply with social norms. They perform actions most of us would find unacceptable, such as stealing from friends and family. They also tend to be irresponsible, impulsive, and deceitful.  In contrast to the DSM-5 criteria for antisocial personality, which focuses almost entirely on observable behaviors (for example, impulsively and repeatedly changing employment, residence, or sexual partners), the related concept of psychopathy primarily reflects underlying personality traits (for example, self-centeredness or manipulativeness).  DISCUSSION POINT: How might a clinician attempt to distinguish between someone who meets DSM-5 criteria for antisocial personality disorder and an individual who fits Cleckley’s concept of psychopathy? How do the two overlap, and how are they distinct from each other?  People with borderline personality disorder lack stability in their moods and in their relationships with other people, and they usually have poor self-esteem. These individuals often feel empty and are at great risk of suicide.  Individuals with histrionic personality disorder tend to be overly dramatic and often appear almost to be acting.  People with narcissistic personality disorder think highly of themselves—beyond their real abilities. They consider themselves somehow different from others and deserving of special treatment.

Cluster C Personality Disorders  People with avoidant personality disorder are extremely sensitive to the opinions of others and therefore avoid social relationships. Their extremely low self-esteem, coupled with a fear of rejection, causes them to reject the attention of others.  Individuals with dependent personality disorder rely on others to the extent of letting them make everyday decisions, as well as major ones; this results in an unreasonable fear of being abandoned.  People who have obsessive-compulsive personality disorder are characterized by a fixation on things being done “the right way.” This preoccupation with details prevents them from completing much of anything.  Treating people with personality disorders is often difficult because they usually do not see that their difficulties are a result of the way they relate to others.  Personality disorders are important for the clinician to consider because they may interfere with efforts to treat more specific problems such as anxiety, depression, or substance abuse.

Unfortunately, the presence of one or more personality disorders is associated with a poor treatment outcome and a generally negative prognosis.

KEY TERMS personality disorder, 449 paranoid personality disorder, 455 schizoid personality disorder, 457 schizotypal personality disorder, 459 antisocial personality disorder, 461 psychopathy,462 borderline personality disorder, 469

dialectical behavior therapy (DBT), 472 histrionic personality disorder, 472 narcissistic personality disorder, 474 avoidant personality disorder, 476 dependent personality disorder, 477 obsessive-compulsive personality disorder, 478

IDEAS FOR INSTRUCTION 1.

Activity: Identifying Personality Disorders. It is often difficult to discriminate between normal and abnormal behavior, especially where personality disorders are concerned. In fact, many students will identify their own behavior in various personality disorders. To illustrate concretely the difficulty in drawing diagnostic lines, make a list of behaviors and have your students judge and justify whether the behavior is normal or abnormal. Some examples of these behaviors: a. A woman who is careful to lock her car and house immediately after entering them because she fears intruders. Would you consider this behavior paranoid? Why or why not? When would it become paranoid? b. A car salesman who lies to people to manipulate them into buying a car and feels no guilt about making an unethical sale. Would you consider this behavior antisocial? c. A woman who does not socialize with other people. She communicates with people at her job, but outside of work, she has no social contact with others. Would you consider this behavior schizoid? d. A man who becomes upset when his partner rearranges his shirt drawer, when dinner is not ready on schedule, or has any other life circumstance which interferes with his rigidly planned work schedule. Would you consider this behavior obsessive-compulsive?

2.

Activity: Gender Bias and Normal Behavior. With respect to the discussion on gender bias, it is useful to have students experience this bias themselves. Pass out the vignette depicted in HANDOUT 12.1 to half of your students. Give the remaining students in your class HANDOUT 12.2, which depicts identical vignettes but with the gender of the pronouns changed. Do not tell your students there are alternate versions of the vignettes.

Ask each student to write down their “clinical” opinion about the person’s behavior in the scenarios. Ask them to judge if the behavior is normal or not. Furthermore, ask them to assign adjectives to the person in the vignette that would portray an accurate description of personality. Collect and record the opinions on the blackboard. Ask your students if any noticeable differences exist between students based on the gender of the subject. This can lead to a discussion on the potential impact gender biases can have on the diagnostic process.

3.

Activity: Diagnose a Film Character with a Personality Disorder. Have students watch Fatal Attraction, Misery, and/or Girl, Interrupted, or show clips from these films in class.

Then, ask students to arrive at a diagnosis of the lead characters in each film. In Fatal Attraction, Glenn Close depicts what many believe is a classic case of borderline personality disorder, whereas Kathy Bates in the film Misery depicts features of either paranoid or schizoid personality disorder. In Girl, Interrupted, Angeline Jolie depicts antisocial personality disorder, while Winona Ryder portrays a woman with borderline personality disorder.

4.

Activity: Student Identification with Personality Disorder Features. Students will often report that they see portions of themselves in the chapter descriptions of the features of some of the personality disorders. An exercise that may be useful to spark discussion about the relationship between normal and disordered personality would be to have students identify one personality disorder that they feel shares much in common with aspects of their own personality. Obviously, you are not asking students to self-diagnose but to select the disorder that descriptively comes closest to their own personality features. Have students write down the name of the disorder that is closest to them, and then collect the responses. Tally up the class information and put it up on the board or overhead. Use this exercise to talk about personality in general and what makes personality a disorder. You should find some interesting differences in the labels students most identify with. As an aside, to add humor to this exercise, you can tell the students that the label that best fits you as an instructor is narcissistic.

Uh Oh! Plan B Although instructors are skilled professionals in creating classroom experiences, things don’t always go as planned. The chapter-related lecture and activity suggestions in this section are for instances when your planned lecture or activity idea do not go as planned. Implement these to recover student interest and enhance student reading.

No, You Do Not Have It. With these chapters, students can come down with “medical student syndrome” while reading about personality disorders. Learn more here: https://en.wikipedia.org/wiki/Medical_students'_disease. Consider engaging your students around this topic and discuss the power of suggestion.

YOUTUBE CLIPS: CHAPTER 12 Osmosis.com has an excellent set of videos outlining the clusters of personality disorders: Cluster A: https://www.youtube.com/watch?v=9BqaHfJI1Z4 (06:52) Cluster B: https://www.youtube.com/watch?v=2XZ9cLJd5Gc (06:06) Cluster C: https://www.youtube.com/watch?v=_n2YUhNg41M (05:27) For a visually-rich description on treating Borderline Personality Disorder, see the Centre for Addiction and Mental Health’s video: https://www.youtube.com/watch?v=5tvwhqfGezQ (04:54)

SUGGESTED VIDEOS A streetcar named desire. This film provides a good depiction of histrionic personality.

Fatal attraction. Glenn Close displays classic characteristics of borderline personality disorder.

Girl, interrupted. This film, set in the 1960s, illustrates a compelling true story of a woman who attempted suicide and subsequently self-committed to a mental institution. The range of psychopathology of the characters, including the depiction of treatment and life in a mental institution during the 1960s, is outstanding. This film illustrates depression and suicide, but it is particularly useful as an illustration of borderline personality disorder. It can also be used to demonstrate antisocial personality disorder in the character of Lisa.

La cage aux folles. This film provides a good example of histrionic personality disorder.

Silence of the lambs. Sir Anthony Hopkins depicts a serial killer named Hannibal Lector.

The film illustrates severe antisocial personality disorder.

Taxi driver. This film illustrates delusional, paranoid thinking, and particular features of schizotypal personality disorder.

The conversation. This film stars Gene Hackman who plays a surveillance expert with a paranoid personality.

The odd couple. This film depicts Jack Lemmon as demonstrating many of the symptoms of obsessive-compulsive personality disorder.

The psychopath: Mad or bad? (Insight Media). This program describes the psychopath as an individual suffering from a type of personality disorder characterized by a lack of such normal feelings as guilt, love, stress, and concern. It discusses such traits as being asocial, highly impulsive, and aggressive, and explains that the psychopath is unable to feel but can cleverly mimic human personalities, thus frequently coming off as rational and even charming. The video also explores possible causes of psychopathy, linking it with retarded maturation and discussing such factors as the lack of a role model or parental rejection. (60 min) Understanding Personality Disorders. (Insight Media). Explaining that personality disorders can be mild enough to seem inconsequential or severe enough to be devastating, this DVD advocates an understanding of personality disorders that brings them out from the shadows of ignorance and shows how this knowledge can improve treatment outcomes. (25 min)

ONLINE RESOURCES Antisocial Personality Disorder http://www.mentalhealth.com/dis/p20-pe04.html This website is devoted to information pertaining to the diagnosis, etiology, and treatment of antisocial personality disorder.

Avoidant Personality Disorder http://www.mentalhealth.com/dis/p20-pe08.html This website is devoted to information pertaining to the diagnosis, etiology, and treatment of avoidant personality disorder.

Borderline Personality Disorder http://www.mentalhealth.com/dis/p20-pe05.html This website is devoted to information pertaining to the diagnosis, etiology, and treatment of borderline personality disorder.

BPD Central http://www.BPDCentral.com/ A website devoted to furthering the understanding of borderline personality disorder, written by those who live with a patient with BPD. Histrionic Personality Disorder http://www.mentalhealth.com/dis/p20-pe06.html This website is devoted to information pertaining to the diagnosis, etiology, and treatment of histrionic personality disorder.

Narcissistic Personality Disorder http://www.mentalhealth.com/dis/p20-pe07.html This website is devoted to information pertaining to the diagnosis, etiology, and treatment of narcissistic personality disorder.

National Institute of Mental Health (NIMH): Borderline Personality Disorder http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml This is a useful article on the diagnosis of BPD and current perspectives.

Obsessive Compulsive Personality Disorder http://www.mentalhealth.com/dis/p20-pe10.html This website is devoted to information pertaining to the diagnosis, etiology, and treatment of obsessive-compulsive personality disorder.

Paranoid Personality Disorder http://www.mentalhealth.com/dis/p20-pe01.html This website is devoted to information pertaining to the diagnosis, etiology, and treatment of paranoid personality disorder.

Schizoid Personality Disorder http://www.mentalhealth.com/dis/p20-pe02.html This website is devoted to information pertaining to the diagnosis, etiology, and treatment of schizoid personality disorder.

Schizotypal Personality Disorder http://www.mentalhealth.com/dis/p20-pe03.html This website is devoted to information pertaining to the diagnosis, etiology, and treatment of schizotypal personality disorder.

SUPPLEMENTARY READING MATERIAL Additional Readings: Adler, G. (1981). The borderline-narcissistic personality disorder continuum. American Journal of Psychiatry, 138, 46–50.

Clarkin, J. F., & Lenzenweger, M. F. (1996). Major theories of personality disorder.

New York: Guilford.

Clarkin, J. F., Marziali, E., & Munroe-Blum, H. (1992). Borderline personality disorder: Clinical and empirical perspectives. New York: Guilford.

Clipson, C., & Steer, J. (1998). Case studies in abnormal psychology. Boston, MA: Houghton Mifflin Company. Chapter 12, Borderline Personality Disorder: One Side Wins, The Other Side Loses. Chapter 13, Antisocial Personality Disorder: Bad to the Bone.

Cooper, A. M., Frances, A. J., & Sacks, M. H. (1991). The personality disorders and neuroses. New York: Basic.

Cowdry, R. W., & Gardner, D. L. (1988). Pharmacotherapy of borderline personality disorder: Alprazolam, canbumazepine, trifluoperazine, and tranylcypromine. Archives of General Psychiatry, 45, 111–119.

Hare, R. D. (1985). Comparison of procedures for the assessment of psychopathy.

Journal of Consulting and Clinical Psychology, 53, 7–16.

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford.

Livesley, W. J. (1995). The DSM-IV-TR personality disorders. New York: Guilford.

Millon, T. (1990). Toward a new personology: An evolutionary model. New York: Wiley.

Millon, T., & Davis, R. D. (1995). Disorders of personality: DSM-IV-TR and beyond.

New York: Wiley.

Oldham, J. M. (Ed.). (1991). Personality disorders: New perspectives on diagnostic validity. Washington, DC: American Psychiatric Press.

Stone, M. H. (1993). Abnormalities of personality: Within and beyond the realm of treatment. New York: Norton.

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Handouts HANDOUT 12.1 The Case of Robert and Karen 1. Robert is 10 years old. He attends school but is often in trouble because he is inattentive or rebellious toward the teacher. He has friends in class but frequently gets into physical fights with them, and on one occasion, hurt a classmate. He teases his younger brother at home and prefers to be outside playing baseball with friends rather than completing homework or chores.

2. Karen is a 35-year-old single woman. She is depressed because she wants to have children but has not found a suitable partner. Karen has recently quit her job and spends most of her time talking with friends on the telephone. She has no immediate plans to return to work and will look to her family to provide for her during this difficult time.

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HANDOUT 12.2 The Case of Karen and Robert 1. Karen is 10 years old. She attends school but is often in trouble because she is inattentive or rebellious toward the teacher. She has friends in class but frequently gets into physical fights with them, and on one occasion, hurt a classmate. She teases her younger brother at home and prefers to be outside playing baseball with friends rather than completing homework or chores.

2. Robert is a 35-year-old single man. He is depressed because he wants to have children but has not found a suitable partner. Robert has recently quit his job and spends most of his time talking with friends on the telephone. He has no immediate plans to return to work and will look to his family to provide for him during this difficult time.

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WARNING SIGNS OF PARANOID PERSONALITY DISORDER  An unmistakable sign of paranoia is continual mistrust  Feel as though they need to be constantly on guard  Tendency to view the world as a threatening place  Expect trickery and doubt the loyalty of others  Remain hyperalert for signs of threat  Maintain vigilance for any slight against them  Show a tendency to be defensive and antagonistic  Inability to accept blame and mild criticism  Tendency to be highly critical of others  Often argumentative and uncompromising  Appear cold and aloof socially  Often avoid intimacy with other people

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WARNING SIGNS OF SCHIZOID PERSONALITY DISORDER  No desire for social relationships  Lack ability to form close social relationships  Often single and unmarried, with little interest in sex or intimacy  Preference for solitary activities  Limited range of emotions, particularly in social settings (e.g., coldness, detachment, or flatness)  Often appear indifferent to compliments and criticisms  Find little or no joy in activities or in life

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WARNING SIGNS OF SCHIZOTYPAL PERSONALITY DISORDER  Behavior or appearance that is odd, eccentric, or peculiar  Ideas of reference (excluding delusions of reference)  Few close relationships  Odd beliefs or magical thinking (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations)  Unusual perceptual experiences, including bodily illusions  Suspiciousness or paranoid ideation  Inappropriate or constricted affect  Lack of close friends or confidants other than immediate family members  Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self

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WARNING SIGNS OF ANTISOCIAL PERSONALITY DISORDER  Defiance and disregard for social norms or the rights of other people  Regularly performing illegal acts that are grounds for arrest  Show little empathy for others  Lack remorse for persons they have hurt  Tendency to be self-absorbed (i.e., concerned with themselves)  Often appear superficial  Show difficulties in fulfilling responsibilities and commitments (e.g., work or financial obligations)  Habitually lying or being manipulative  Use of aliases and conning people for personal profit or pleasure  Frequent physical aggression and conflict with other people  Having had serious behavioral problems in childhood and teenage years  Blaming others or offering rationalizations for antisocial behavior  Being impulsive  May be accompanied with unusually early age of drug and/or alcohol abuse  Problems with the legal system

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WARNING SIGNS OF BORDERLINE PERSONALITY DISORDER  Frantic efforts to avoid real or imagined abandonment  A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation  Identity disturbances (e.g., unstable self-image or sense of self)  Impulsivity in areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)  Affective (emotional) instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)  Chronic feelings of emptiness  Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)  Transient (brief) stress-related paranoid ideation or severe dissociative symptoms

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WARNING SIGNS OF HISTRIONIC PERSONALITY DISORDER  Acting more emotional than a situation warrants  Constantly seeking praise and approval from others  Consistently seeking to be the center of attention  Self-centered and demands to be the center of attention  Inappropriately seductive or sexual  Excessively concerned with appearance  Tendency to dramatize situations  Theatrical speech, dress, and mannerism  Overly trusting and gullible and overly adjustable  Verbal communication is expressive but lacks detail  Easily alter emotions  Trapped in the present and caring little for the future or future plans  Often accompanied with an underlying feeling of low self-esteem  Very social and extroverted, however self-absorbed  May be accompanied with impotence in men and inability to orgasm in women

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WARNING SIGNS OF NARCISSISTIC PERSONALITY DISORDER  Physical posture implying and exuding an air of superiority  Amused indifference  Lack of eye and bodily contact  Speaks from the standpoint of condescension  Assumes a social posture as an “observer” and is otherwise asocial  Demanding “special treatment” of some kind (e.g., not waiting for a turn)  Either idealizes or devalues others  Tendency to try and “belong” while maintaining a stance as an outsider  Seeking constant admiration  A preference for showing off but lacking substance  A tendency to be shallow (i.e., a pond pretending to be an ocean)  Inability to admit ignorance about something  Speech containing frequent usage of “I,” “my,” “myself,” and “mine”  Show a grandiose sense of self-importance (e.g., if a scientist, he or she is on the very brink of a discovery with cosmic and global consequences)  Tendency to be easily hurt and/or insulted

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WARNING SIGNS OF AVOIDANT PERSONALITY DISORDER  Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection  Unwilling to get involved with people unless certain of being liked  Shows restraint within intimate relationships because of the fear of being shamed or ridiculed  Preoccupied with being criticized or rejected in social situations  Inhibited in new interpersonal situations because of feelings of inadequacy  Views self as socially inept (not fitting in), personally unappealing, or inferior to others  Unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

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WARNING SIGNS OF DEPENDENT PERSONALITY DISORDER  Need for others to control their lives  Difficulty in making decisions or initiating new projects on their own  Lack self-confidence and trust in their own abilities  Often belittle themselves (e.g., saying “I’m dumb,” or “I’m stupid)  Tendency to be submissive and clingy in social relationships  Avoidance of conflict  Feel a strong need to be taken care of  Fear of separation and abandonment

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WARNING SIGNS OF OBSESSIVE-COMPULSIVE PERSONALITY DISORDER  A tendency toward perfectionism  Hold inflexible ethical and behavioral standards  Tendency to be highly organized and rigidly disciplined  Pay excessive attention to details, rules, lists, and schedules  Difficulties in expressing warm feelings or emotions  Premium is placed on mental and emotional control

CHAPTER 13 SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS CHAPTER OVERVIEW This chapter outlines the primary features of schizophrenia and related psychotic disorders. Positive, negative, and disorganized symptoms as well as the historic subtypes of schizophrenia are described. Related problems include schizophreniform, schizoaffective, delusional, and brief psychotic disorders. Etiological factors, relapse, and treatment are discussed, as are the significant changes in this category of diagnoses that has occurred in the switch to DSM-5.

CHAPTER OUTLINE PERSPECTIVES ON SCHIZOPHRENIA Early Figures in Diagnosing Schizophrenia Identifying Symptoms

CLINICAL DESCRIPTION, SYMPTOMS, AND SUBTYPES Positive Symptoms Negative Symptoms Disorganized Symptoms Historic Schizophrenia Subtypes Other Psychotic Disorders

PREVALENCE AND CAUSES OF SCHIZOPHRENIA Statistics Development Cultural Factors Genetic Influences Neurobiological Influences

Psychological and Social Influences

TREATMENT OF SCHIZOPHRENIA Biological Interventions Psychosocial Interventions Treatment across Cultures Prevention

DETAILED OUTLINE Perspectives on Schizophrenia  Schizophrenia is a complex syndrome that has been recognized for many years. Perhaps the earliest and best description of this disorder was published in 1809 by John Haslam in his book Observations on Madness and Melancholy.  A number of historic figures during the 19th and early 20th century contributed to the evolving definitions and possible causes of this spectrum of disorders.

Clinical Description, Symptoms, and Subtypes  Schizophrenia is characterized by a broad spectrum of cognitive and emotional dysfunctions that include delusions and hallucinations, disorganized speech and behavior, and inappropriate emotions.  The symptoms of schizophrenia can be divided into positive, negative, and disorganized.

Positive symptoms are active manifestations of abnormal behavior, or an excess or distortion of normal behavior, and include delusions and hallucinations. Negative symptoms involve deficits in normal behavior on such dimensions as affect, speech, and motivation.

Disorganized symptoms include rambling speech, erratic behavior, and inappropriate affect.  DISCUSSION POINT: From your perspective, which of the types of symptoms of schizophrenia would be most distressing or debilitating?  Psychotic behaviors, such as hallucinations and delusions, characterize several other disorders; these include schizophreniform disorder (which includes people who experience the symptoms of schizophrenia for less than 6 months); schizoaffective disorder (which includes people who have symptoms of schizophrenia and who exhibit the characteristics of mood disorders, such as depression and bipolar affective disorder); delusional disorder (which includes people with a persistent belief that is contrary to reality, in the absence of the other characteristics of schizophrenia); and brief psychotic disorder (which includes people with one or more positive symptoms, such as delusions, hallucinations, or disorganized speech or behavior over the course of less than a month).

 A proposed new disorder – attenuated psychosis syndrome – includes one or more of the symptoms of schizophrenia such as hallucinations or delusions, but the individual is aware that these are unusual experiences and not typical for healthy persons. This is included in the Appendix of DSM-5 as a disorder in need of further study.

Prevalence and Causes of Schizophrenia  A number of causative factors have been implicated for schizophrenia, including genetic influences, neurotransmitter imbalances, structural damage to the brain caused by a prenatal viral infection or birth injury, and psychological stressors.  DISCUSSION POINT: What are some possible explanations for gender differences in the onset of schizophrenia?

How might gender influence the prognosis of someone with this disorder?  Relapse appears to be triggered by hostile and critical family environments characterized by high expressed emotion.  DISCUSSION POINT: With the contribution of endophenotype research to the understanding of schizophrenia, how might the diagnosis and classification of this disorder change? How is treatment likely to be affected?

Treatment of Schizophrenia  Successful treatment for people with schizophrenia rarely includes complete recovery. The quality of life for these individuals can be meaningfully affected, however, by combining antipsychotic medications with psychosocial approaches, employment support, and community-based social skills and family interventions.  Treatment typically involves antipsychotic drugs that are usually administered with a variety of psychosocial treatments, with the goal of reducing relapse and improving skills in deficits and compliance in taking the medications. The effectiveness of treatment is limited, because schizophrenia is typically a chronic disorder.

KEY TERMS schizophrenia, 485 catatonia, 486 hebephrenia, 486 paranoia, 486 dementia praecox, 486 associative splitting, 486 psychotic behavior, 488 positive symptoms, 488 delusion, 488 hallucination, 490

delusional disorder, 4894 shared psychotic disorder (folie a deux), 495 substance-induced psychotic disorder, 496 psychotic disorder associated with another medical condition, 496 brief psychotic disorder, 496 attenuated psychosis

negative symptoms, 491 avolition, 491 alogia, 4891 anhedonia, 492 flat affect, 492 disorganized speech, 492 inappropriate affect, 493 catatonic immobility, 493 schizophreniform disorder, 494 shizoaffective disorder, 494

syndrome, 496 schizotypal personality disorder, 496 prodromal stage, 498 schizophrenogenic mother, 507 double bind communication, 507 expressed emotion (EE), 507 token economy, 511

IDEAS FOR INSTRUCTION 1.

Activity: Name that Symptom! To test students’ understanding of the different symptoms of schizophrenia, divide the class into several teams. Prepare clinical examples of the various symptom categories. Take turns reading an example to each team, which then has a chance to determine the symptom being described. If the first team does not get the answer correct, then the next team can try. Examples of the clinical symptoms include the following: a. Disorder of thought content or delusion. The flicker of candles communicates secret messages about me to aliens. b. Delusion of grandeur. I am Queen of Eastern Europe. c. Delusion of persecution. The CIA is tracking me and planning on assassinating me in my sleep. d. Auditory hallucination. Voices tell me to jump out of windows. e. Visual hallucination. I can see large spiders crawling up my walls. f. Olfactory hallucination. I smell my family’s pets around me. g. Tactile hallucination. I feel little bugs crawling under my skin. h. Tangentiality. Oh, you want to know where I was, well, my brother called me to come over and he works on cars at a shop in town that has money problems. i. Loose association. I went to the store, but the violin was fixed so I could return to church and pray. j. Waxy flexibility and catatonic immobility. (Demonstrate). k. Alogia. (Ask a student to question you and then respond in monosyllables).

These represent one example per symptom, but you can provide additional examples.

Keep score so you can determine the team that wins the most points.

You may want to reward the winning team with extra credit points to get students invested in learning the material.

2.

Schizophrenia. The word schizophrenia is so widely misused that you should spend some time differentiating schizophrenia from multiple personality disorder by developing a lecture on this topic. A short history of terminology, from Kraepelin’s dementia praecox to Bleuler’s schizophrenia, would be useful… A listing of Bleuler’s four A’s (what he considered to be the fundamental symptoms of the schizophrenic spectrum disorders) helps dispel the idea that schizophrenics are anything like the three faces of Eve. The four A’s are: association (thought disorder), affect (inappropriate or blunted), ambivalence (indecisive in carrying out daily activities), and autism (withdrawal into self).

Uh Oh! Plan B Although instructors are skilled professionals in creating classroom experiences, things don’t always go as planned. The chapter-related lecture and activity suggestions in this section are for instances when your planned lecture or activity idea do not go as planned. Implement these to recover student interest and enhance student reading.

Battling Fiction with Fact. Everyone thinks that they know something about schizophrenia.

Even the lax terminology of “I can’t make up my mind, I am so schizophrenic” can give students a false sense of knowledge. In fact, schizophrenia is not as well understood as we would like and we do not yet have a “cure.” Encourage your students to be active in correcting the misuse of schizophrenia as a term and other psychology-related terms.

YOUTUBE CLIPS: CHAPTER 13 Crash Course refresher about the terms and concepts in this chapter: https://www.youtube.com/watch?v=uxktavpRdzU (11:43) Practice compassion by watching this short clip about a young girl born with Schizophrenia: https://www.youtube.com/watch?v=_vYQ6pbJt2k (03:01) How does Schizophrenia impact the people who love them? IRI Training delves into this in detail: https://www.youtube.com/watch?v=AnoUKWXTcBU&t=12s (50:01)

SUGGESTED VIDEOS A beautiful mind. This film presents the life of John Nash, a Nobel Prize winning mathematician, and his experience with schizophrenia. (Instructors may wish to emphasize that the movie takes great license with the actual life story of Dr. Nash. The depiction of hallucinations, delusions, and the difficulty a person with schizophrenia may have distinguishing reality from fantasy is nonetheless very valuable as a teaching tool.)

Antipsychotic agents. (Insight Media). Examining the medications used to alleviate psychotic symptoms, this video features reenactments that illustrate positive and negative symptoms as well as such features of cognitive dysfunction and dysphonic mood. It presents commonly prescribed agents used in the treatment of acute psychotic symptoms; addresses precautions, side effects, and drug interactions; and includes interviews in which professionals and patients discuss the impact of antipsychotic agents on patients with psychotic symptoms. (23 min) Birdy. This film depicts a catatonic inpatient in a military hospital who is also a Vietnam veteran.

Dark side of the moon. (Fanlight Productions). This film documents the struggles and successes of three formerly homeless men with mental illnesses. (25 min) Deficits of mind and brain. (Available through your Cengage Learning representative).

The second module begins with an overview of schizophrenia. Also provided are diagnostic criteria and examples of patients in therapy (showing thought insertion, thought withdrawal, and paranoid delusions). In the second portion of this module, four patients suffering from schizophrenia are presented. The third portion of this module uses the Wisconsin Card Sorting Task to demonstrate how lesion location has different effects on task completion. The fourth portion introduces PET imaging techniques for isolating patterns in cerebral processing across brain structures; the fifth describes cognitive deficits, and the sixth covers cognitive neuroscience and schizophrenia. The last portion covers genetics and schizophrenia.

First break. (Fanlight Productions). This film documents the impact of the “first break” of mental illness in three young people in their teens and early twenties, as well as the effects on their families. (51 min) I never promised you a rose garden. The patient depicted in this film has command hallucinations that tell her to kill herself. The film provides a sympathetic portrayal of psychiatry and treatment.

One flew over the cuckoo’s nest. This classic film stars Jack Nicholson as a patient in a psychiatric hospital. The film depicts life on an inpatient ward, including controversial treatments such as ECT and frontal lobotomies.

Repulsion. This is an intense film about sexual repression and psychotic decompensation, providing good examples of hallucinations.

Rosenhan’s Experiment: Being Sane in Insane Places. (Insight Media). In 1973, psychologist David Rosenhan conducted a study in which eight mentally healthy pseudo-patients entered psychiatric institutions in order to test the validity of psychiatric diagnosis. The pseudopatients mimicked symptoms of either schizophrenia or bipolar disorder to get admitted and then quickly stopped these behaviors once inside the hospital. This DVD looks at the methodological strengths and weaknesses of this classic study, reviews its findings, and considers its relevance today. (19 min)

The snake pit. This is one of the first films to document the treatment of patients in mental hospitals.

To Define True Madness: Concepts of Schizophrenia. (Insight Media). Exploring historical ideas of mental illness in different cultures, this program shows how early theories of mental illness based on spirit or divine possession gave way to secular, scientific views. It considers the sense of self and the idea of losing one’s mind, questioning if this defines a society’s ideas of personhood. (59 min)

ONLINE RESOURCES Mental Health America Schizophrenia http://www.mentalhealthamerica.net/conditions/schizophrenia This page provides an outstanding starting point for up-to-date information about the diagnosis, etiology, and treatment of schizophrenia, including numerous links to patient and scholarly websites.

National Alliance of the Mentally Ill http://www.nami.org This site is a useful resource for information related to the treatment of severe mental illness, including legal issues and national health policy guidelines.

NIMH Schizophrenia: Questions and Answers http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml This is a site containing questions and answers regarding schizophrenia provided by the National Institute of Health.

Psych Central -- Schizophrenia http://psychcentral.com/disorders/sx31.htm Site with lots of information about schizophrenia and available treatment options.

Schizophrenia.Com Home Page http://www.schizophrenia.com/ Provides links to other webpages devoted to schizophrenia. This is a good starting place for finding information on schizophrenia on the Internet.

SUPPLEMENTARY READING MATERIAL Additional Readings:

Andreasen, N. C., & Flaum, M. (1991). Schizophrenia: The characteristic symptoms.

Schizophrenia Bulletin, 17, 27-48.

Birchwood, M. J. (1989). Schizophrenia: An integrated approach to research and treatment. New York: New York University Press.

Brown, M. J., & Roberts, D. P. (2000). Growing up with a schizophrenic mother.

Jefferson, NC: McFarland.

Chapman, L. J., & Chapman, J. P. (1980). Scales for rating psychotic and psychotic-like experiences as continua. Schizophrenia Bulletin, 6, 476-489.

Clipson, C., & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA: Houghton Mifflin Company. Chapter 7, Schizophrenia.

Cromwell, R. L., & Snyder, C. R. (Eds.) (1993). Schizophrenia: Origins, processes, treatment, and outcome. New York: Oxford University Press.

Farber, S. (Ed.) (1993). Madness, heresy, and the rumor of angels: The revolt against the mental health system. Chicago: Open Court.

Fowles, D. C. (1992). Schizophrenia: Diathesis-stress revisited. Annual Review of Psychology, 43, 303-336.

Gray, J. A., Feldon, J., Rawlins, J. N. P., Hemsley, D. R., & Smith, A. D. (1991). The neuropsychology of schizophrenia. Behavioral and Brain Sciences, 14, 1-84.

Green, M. F. (2001). Schizophrenia revealed: From neurons to social interactions. New York: W. W. Norton.

Hatfield, A. B., & Lefley, H. P. (1993). Surviving mental illness: Stress, coping and adaptation. New York: Guildford.

Heinrichs, R. W. (2001). In search of madness: Schizophrenia and neuroscience. New York: Oxford University Press.

Johnstone, E. C., Humphreys, M. S., Lang, F. H., Lawrie, S. M., & Sandler, R. (1999).

Schizophrenia: Concepts and clinical management. New York: Cambridge University Press.

Leudar, I., & Thomas, P. (2000). Voices of reason, voices of insanity: Studies of verbal hallucinations. Florence, KY: Taylor and Francis/Routledge.

Lidz, T. (1985). Schizophrenia and the family. New York: International Universities Press.

Malone, J. A. (1992). Schizophrenia: Handbook for clinical care. Thorofare, NJ: SLACK Inc.

Nicholson, I. R., & Neufeld, R. W. J. (1993). Classification of the schizophrenias according to symptomatology: A two-factor model. Journal of Abnormal Psychology, 102, 259-270.

Robbins, M. (1993). Experiences of schizophrenia: An integration of the personal, scientific, and therapeutic. New York: Guilford Press.

Sattler, D., Shabatay, V., & Kramer, G. (1998). Abnormal psychology in context: Voices and perspectives. Boston, MA: Houghton Mifflin Company. Chapter 7, Schizophrenia.

Schiller, L., & Bennett, A. (1996). The quiet room: A journey out of the torment of madness. New York: Harper.

Straube, E. R., & Hahlweg, K. (Eds.) (1990). Schizophrenia: Concepts, vulnerability, and intervention. New York: Springer-Verlag.

Torrey, E. F. (1995). Surviving schizophrenia: A manual for families, consumers, and providers. New York: Harper.

Warner, R. (2000). The environment of schizophrenia: Innovations in practice, policy and communications. Philadelphia, PA: Brunner-Routledge.

Weiden, P. J., Diamond, R. J., Scheifler, P. L., Flynn, L., Diamond, R. I., & Ross, R. (Eds.) (1999). Breakthroughs in antipsychotic medications: A guide for consumers, families, and clinicians. New York: W.W. Norton.

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Handout WARNING SIGNS OF SCHIZOPHRENIA  Hearing or seeing something that isn’t there  A constant feeling of being watched  Peculiar or nonsensical way of speaking or writing  Strange body positioning  Feeling indifferent to very important situations  Deterioration of academic or work performance  A change in personal hygiene and appearance  A change in personality  Increasing withdrawal from social situations  Irrational, angry, or fearful response to loved ones  Inability to sleep or concentrate  Inappropriate or bizarre behavior  Increased withdrawal from social situations  Extreme preoccupation with religion or the occult

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CHAPTER 14 NEURODEVELOPMENTAL DISORDERS CHAPTER OVERVIEW This chapter outlines the primary features of neurodevelopmental disorders, with a particular emphasis on attention deficit/hyperactivity disorder, specific learning disorders, autism spectrum disorders, and intellectual disability. Major features of each of these disorders are outlined within a developmental framework, including integrative coverage of biological, psychological, and sociocultural variables that cause and/or maintain them. Available biological and psychosocial treatments for the developmental disorders are described, including efforts underway to prevent such problems.

CHAPTER OUTLINE OVERVIEW OF NEURODEVELOPMENTAL DISORDERES What Is Normal? What Is Abnormal?

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER SPECIFIC LEARNING DISORDER AUTISM SPECTRUM DISORDER Treatment of Autism Spectrum Disorder INTELLECTUAL DISABILITY (Intellectual Development Disorder) Causes PREVENTION OF NEURODEVELOPMENTAL DISORDERS

DETAILED OUTLINE Overview of Neurodevelopmental Disorders  Developmental psychopathology is the study of how disorders arise and change with time.

These changes usually follow a pattern, with the child mastering one skill before acquiring the next. This aspect of development is important because it implies that any disruption in the acquisition of early skills will, by the very nature of the developmental process, also disrupt the development of later skills.

Attention-Deficit/Hyperactivity Disorder  The primary characteristics of people with attention deficit/hyperactivity disorder are a pattern of inattention (such as not paying attention to school- or work-related tasks), impulsivity, and/or hyperactivity. These deficits can significantly disrupt academic efforts and social relationships.  DISCUSSION POINT: What are the possible explanations for gender differences in the diagnosis of ADHD? Specific Learning Disorder  DSM-5 describes specific learning disorders as academic performance that is substantially below what would be expected given the person’s age, intelligence quotient (IQ) score, and education. These problems can be seen as difficulties with reading, mathematics, and/or written expression. All are defined by performance that falls short of expectations based on intelligence and school preparation.  Communication and motor disorders seem closely related to specific learning disorder. They include childhood speech fluency disorder (stuttering), a disturbance in speech fluency, language disorder, and limited speech in all situations but without the types of cognitive deficits that lead to language problems in people with intellectual disability or one of the pervasive developmental disorders. They also include Tourette’s Disorder, which includes involuntary motor movements such as head twitching and vocalizations such as grunts that occur suddenly, in rapid succession, and in idiosyncratic or stereotyped ways.  DISCUSSION POINT: What are the benefits of “mainstreaming” children with learning disorders versus delivering special education services? What are the drawbacks of this approach?

Autism Spectrum Disorder  People with ASD all experience trouble progressing in language, socialization, and cognition.

This is not a relatively minor problem (like specific learning disorder) but is a condition that significantly affects how individuals live and interact with others.  Autistic spectrum disorder is a childhood disorder characterized by significant impairment in social communication skills and restricted, repetitive patterns of behavior, interests, or

activities. This disorder does not have a single cause; instead, a number of biological conditions may contribute, and these, in combination with psychosocial influences, result in the unusual behaviors displayed by people with ASD.  Impressive advances have been made in improving outcomes for many young children with ASD using early intervention programs. Treatment for older children involves behavioral interventions focused on their social communication deficits and the restricted, repetitive patterns of behavior, interests, or activities.

Intellectual Disability  The definition of intellectual disability has three parts: significantly sub-average intellectual functioning, concurrent deficits or impairments in present adaptive functioning, and an onset before the age of 18.  DISCUSSION POINT: What are the possible causes of the Flynn effect?  Down Syndrome is a type of intellectual disability caused by the presence of an extra 21st chromosome. It is possible to detect the presence of Down Syndrome in a fetus through a process known as amniocentesis.  Two other types of intellectual disability are common: Fragile X syndrome, which is caused by a chromosomal abnormality of the tip of the X chromosome, and cultural–familial intellectual disability, a rare problem resulting from adverse environmental conditions.

KEY TERMS neurodevelopmental disorders, 521 attention-deficit/hyperactivity disorder (ADHD), 522 copy number variants, 527 specific learning disorder, 530 childhood-onset speech fluency disorder (stuttering), 532 language disorder, 532 Tourette’s disorder, 523 Rett’s disorder, 534 childhood disintegrative disorder, 534 pervasive developmental disorder, not otherwise specified, 534

autism spectrum disorder (ASD), 534 joint attention, 535 prosody, 535 naturalistic teaching strategies, 539 intellectual disability (ID), 540 phenylketonuria (PKU), 544 Lesch-Nyhan syndrome, 544 Down syndrome, 544 amniocentesis, 545 chorionic villus sampling (CVS), 545 fragile X syndrome, 545 cultural-familial intellectual disability, 546

IDEAS FOR INSTRUCTION 1.

Activity: Would You Want to Know? Genetic research raises several interesting ethical questions, particularly with regard to the disorders discussed in this chapter. Ask students to consider whether they would want to know as parents whether their unborn child would have Down Syndrome, or perhaps even autism (if such a test were available). Also ask students to consider the ethical implications involved if and when routine genetic testing for development disorders comes of age. Would such testing be advantageous or potentially harmful?

2.

Activity: Rainman. In the film Rainman, Dustin Hoffman plays the role of Raymond, a man with autism spectrum disorder. Many students will likely be familiar with the film, but what they may not know or appreciate is whether Hoffman’s character accurately depicts the condition. Most experts agree that Hoffman’s character does not accurately represent autism spectrum disorder, and the textbook similarly reinforces this point. After discussing the diagnosis, show the film and ask students to identify whether Raymond displays the three main features of autism spectrum disorder and whether the film fits the facts with regard to autistic behavior. You may also open the discussion to issues related to media depiction of persons with other neurodevelopmental developmental disabilities.

3.

Activity: Guest Lecture by a Special Education Instructor. Ask a special education instructor to visit the class to talk about the intervention methods he or she uses to assist people with neurodevelopmental disorders. You may also supplement this with a speaker from your college or university student disabilities services.

4.

Invite a guest speaker from the community to discuss the range of services offered to individuals with developmental disorders. Many of your students will have had mainstreamed students in either middle school or high school; ask them to discuss the benefits to the individuals mainstreamed, themselves, and society.

Uh Oh! Plan B Although instructors are skilled professionals in creating classroom experiences, things don’t always go as planned. The chapter-related lecture and activity suggestions in this section are for instances when your planned lecture or activity idea do not go as planned. Implement these to recover student interest and enhance student reading.

Diagnosis and Wealth. Figure 14.1 (page 532 of the text) makes a visually-compelling argument about the link between wealth/state resources and diagnoses. Take some time to discuss this with students. Identify your state and ask if students are from/have spent considerable time in other states. What are their impressions and experiences? Prompt them to discuss the testing/diagnosis/mental health resources of which they aware. Are they private/insurance pay or available through the state? What difference does this make?

YOUTUBE CLIPS: CHAPTER 14 What does Autism “feel” like? The National Autistic Society shows you a minute in the life. https://www.youtube.com/watch?v=Lr4_dOorquQ (01:24) How do we treat each other? The Special Olympics implores us to use sensitivity when interacting with people with Intellectual Disabilities. https://www.youtube.com/watch?v=nc9aAY6-ujQ (03:36) People with Down Syndrome Speak Out about their life. https://www.youtube.com/watch?v=ILgLmChlxNg (04:36)

SUGGESTED VIDEOS ADHD: Adolescence to Adulthood (Insight Media). In this program, a panel of key experts and opinion leaders outlines the characteristics of ADHD; examines diagnosis; and discusses appropriate treatment options for children, adolescents, and adults with the disorder. (53 min) Autism: A world apart. (Fanlight Productions). This film depicts the stories of three families and what it is like to love and care for children with autism. (29 min) Dyslexia. (Fanlight Productions). This film, part of the The Doctor Is In series, examines the experiences of people with learning disabilities as well as the potential value to society of their alternative ways of learning. (30 min) Forrest Gump. This film traces the life of a character named Forrest Gump, with an IQ of 75. The film is useful to examine stereotypes about intellectual disability. (142 min) One of us. (Fanlight Productions). This film depicts four stories about integrating people with developmental disabilities into mainstream society. (27 min) Rainman. This film depicts Dustin Hoffman as Raymond, a man with autism spectrum disorder and savant syndrome. On one hand, the film nicely illustrates some of the more salient features of autistic behavior. On the other, it also misrepresents the nature of autism spectrum disorder. (133 min) Raymond’s portrait. (Fanlight Productions). Raymond Hu is an accomplished artist who was born with Down syndrome. This moving documentary looks at what can happen when a child is encouraged to develop to his full potential. (27 min) What’s eating Gilbert Grape. This film portrays a 17-year-old boy with intellectual disability and how he and his family attempt to cope with his problems. (128 min)

ONLINE RESOURCES The American Academy of Child and Adolescent Psychiatry Homepage http://www.aacap.org/ This site provides information for children and their families (including research, education, and treatment) on many childhood disorders.

Attention-Deficit/Hyperactivity Disorder https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorderadhd/index.shtml This site contains a wealth of scholarly information and links related to ADHD.

Autism Spectrum Disorder http://mentalhealth.com/home/dx/autistic.html This site contains a wealth of scholarly information and links related to autistic disorder.

Autism Center http://www.oreilly.com/medical/autism/ This webpage, in addition to providing links to other related sources on the Web, gives information on the symptoms of autism, guidelines for families and caregivers, and relevant books and resources.

CH.A.D.D. (Children and Adults with Attention-Deficit/Hyperactivity Disorder) http://www.chadd.org/ CH.A.D.D. is a non-profit organization devoted to educating the public about attention deficit and hyperactivity disorders. This site includes information on the symptoms of ADHD, treatments, and as well as CH.A.D.D. chapters throughout the country.

The Division for Early Childhood http://www.dec-sped.org/ This website provides links related to early intervention information for developmental disorders.

Learning Disabilities Association of America http://www.ldanatl.org/ This website provides information and news updates on learning disabilities. This site is aimed at parents, teachers, and other professionals.

Center for Autism and Related Disabilities http://www.albany.edu/psy/autism/autism.html This site provides a wealth of information related to research and treatment of autism.

SUPPLEMENTARY READING MATERIAL Additional Readings: Barkley, R. A. (1997). ADHD and the nature of self-control. New York: Guilford.

Christophersen, E. R., & Mortweet, S. L. (2001). Treatments that work with children.

Washington, DC: American Psychological Association.

Clipson, C., & Steer, J. (1998). Case studies in abnormal psychology. Boston, MA: Houghton Mifflin Company. Chapter 14, Attention-Deficit Hyperactivity Disorder: All Wound Up and Out of Control.

Cohen, S. (1998). Targeting autism: What we know, don’t know, and can do to help young children with autism and related disorders. Berkeley, CA: University of California Press.

Fouse, B. A. (1997). Treasure chest of behavioral strategies for individuals with autism.

Arlington, TX: Future Horizons.

Frith, U. (Ed.) (1991). Autism and Asperger’s syndrome. New York: Cambridge University Press.

Jordan, D. R. (1992). Attention deficit disorder: ADHD and ADD syndromes. Austin, TX: PRO-ED. Kazdin, A. E. (1990). Psychotherapy for children and adolescents. Annual Review of Psychology, 41, 21–54.

Klin, A., Volkmar, F. R., & Sparrow, S. S. (Eds.) (2000). Asperger syndrome. New York: Guilford.

Kozloff, M. A. (1998). Reaching the autistic child: A parent training program.

Cambridge, MA: Brookline Books.

Kurlan, R. (Ed.) (1993). Handbook of Tourette’s syndrome and related tic and behavioral disorders. New York: Dekker.

Meisels, S. J., & Shonkoff, J. P. (Eds.) (1990). Handbook of early childhood interventions. New York: Cambridge University Press.

Pliszka, S. R., Carlson, C. L., & Swanson, J. M. (1999). ADHD with comorbid disorders: Clinical assessment and management. New York: Guilford.

Quay, H. C., Routh, D. K., & Shapiro, S. K. (1988). Psychopathology of childhood: From description to validation. Annual Review of Psychology, 38, 491–532.

Sattler, D., Shabatay, V., & Kramer, G. (1998). Abnormal psychology in context: Voices and perspectives. Boston, MA: Houghton Mifflin Company. Chapter 12, Disorders of Childhood and Adolescence, Mental Retardation, and Eating Disorders.

Seifert, C. D. (1990). Theories of autism. Lanham, MD: University Press of America.

Shapiro, E. S. (1996). Academic skills problems. New York: Guilford.

Siegel, B. (1996). The world of the autistic child: Understanding and treating autistic spectrum disorders. Oxford: Oxford University Press.

Silverman, H. H. (1992). Stuttering and other fluency disorders. Englewood Cliffs, NJ: Prentice Hall.

Teeter, P. A. (2000). Interventions for ADHD: Treatment in developmental context. New York: Guilford.

.

Handouts WARNING SIGNS OF ATTENTION-DEFICIT/HYPERACTIVITY DISORDER  Often fidgeting with hands or feet, or squirming while seated  Difficulty remaining seated when required to do so  Easily distracted by extraneous stimuli  Difficulty awaiting turn in games or group activities  Often blurting out answers before questions are completed  Difficulty in following instructions  Difficulty sustaining attention in tasks or play activities  Often shifting from one uncompleted task to another  Difficulty playing quietly  Often talking excessively  Often interrupting or intruding on others  Often not listening to what is being said  Often forgetting things necessary for tasks or activities  Often engaging in physically dangerous activities without considering

possible consequences

.

WARNING SIGNS OF SPECIFIC LEARNING DISABILITY (PRESCHOOL) Does the child have trouble with or delayed development in the following?  Learning the alphabet  Rhyming words  Connecting sounds and letters  Counting and learning numbers  Being understood when he or she speaks to a stranger  Using scissors, crayons, and paints  Reacting too much or too little to touch  Using words or, later, stringing words together into phrases  Pronouncing words  Walking forward or up and down stairs  Remembering the names of colors  Dressing self without assistance

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WARNING SIGNS OF SPECIFIC LEARNING DISABILITY (ELEMENTARY SCHOOL) Does the child have trouble with the following?  Learning new vocabulary  Speaking in full sentences  Understanding the rules of conversation  Retelling stories  Remembering newly learned information  Playing with peers  Moving from one activity to another  Expressing thoughts orally or in writing  Holding a pencil  Handwriting  Computing math problems at his or her grade level  Following directions  Self-esteem  Remembering routines  Learning new skills  Understanding what he or she reads  Succeeding in one or more subject areas  Drawing or copying shapes  Understanding what information presented in class is important  Modulating voice (may speak too loudly or in a monotone)  Keeping notebook neat and assignments organized  Remembering and sticking to deadlines  Understanding how to play age-appropriate board games

..

WARNING SIGNS OF SPECIFIC LEARNING DISABILITY (ADULTHOOD) Does the adult have trouble with the following?  Remembering newly learned information  Staying organized  Understanding what he or she reads  Getting along with peers or coworkers  Finding or keeping a job  Sense of direction  Understanding jokes that are subtle or sarcastic  Making appropriate remarks  Expressing thoughts orally or in writing  Following directions  Basic skills (such as reading, writing, spelling, and math)  Self-esteem  Using proper grammar in spoken or written communication  Remembering and sticking to deadlines

..

WARNING SIGNS OF AUTISM SPECTRUM DISORDER  Difficulty interacting with other children  Insistence on sameness; resists changes in routine  Inappropriate laughing and giggling  No real fear of dangers  Little or no eye contact  Sustained odd play  Apparent insensitivity to pain  Echolalia (repeating words or phrases in place of normal language)  Prefers to be alone; aloof manner  May not want cuddling or act cuddly  Spins objects  Not responsive to verbal cues; acts as though deaf  Inappropriate attachment to objects  Difficulty in expressing needs; uses gestures or pointing instead of words  Noticeable physical overactivity or extreme underactivity  Tantrums; displays extreme distress for no apparent reason  Unresponsive to normal teaching methods  Uneven gross/fine motor skills (e.g., may not want to kick ball but can stack blocks)

.

“EARLY” WARNING SIGNS OF AUTISM SPECTRUM DISORDER If your child displays any of these signs, bring it to the attention of your doctor:  No babbling by 12 months  No pointing, waving, and other gesturing by 12 months  No single words by 16 months  No two-word spontaneous (not echoed) phrases by 24 months  Any loss of language or social skills at any age  Inability to make or hold eye contact  Inability to respond to the child’s name being called  Inability to look where you point  Lack of interest in pretend play by 18 months  Arches back to avoid touch  Rocks or bangs head  Makes little attempt to communicate

CHAPTER 15 NEUROCOGNITIVE DISORDERS CHAPTER OVERVIEW This chapter outlines the primary features of neurocognitive disorders, which involve delirium and major and mild neurocognitive disorders. In so doing, we describe cognitive disorders, with an emphasis on Alzheimer’s Disease. Coverage also includes discussion of known biological, environmental, and psychosocial factors that cause, maintain, or are related to the prevention and treatment of neurocognitive disorders.

CHAPTER OUTLINE PERSPECTIVES ON NEUROCOGNITIVE DISORDERS

DELIRIUM Clinical Description and Statistics Treatment Prevention MAJOR AND MILD NEUROCOGNITIVE DISORDERS Clinical Description and Statistics Neurocognitive Disorder Due to Alzheimer’s Disease Vascular Neurocognitive Disorder Other Medical Conditions That Cause Neurocognitive Disorder Substance/Medication-Induced Neurocognitive Disorder Causes of Neurocognitive Disorder Treatment Prevention

DETAILED OUTLINE Delirium  Delirium is a temporary state of confusion and disorientation that can be caused by brain trauma, intoxication by drugs or poisons, surgery, and a variety of other stressful conditions, especially among older adults.  DISCUSSION POINT: Delirium was one of the first psychological disorders to be recognized and described over 2,500 years ago. Why might this be the case?

Major and Mild Neurocognitive Disorders  Neurocognitive disorder is a progressive and degenerative condition marked by gradual deterioration of a range of cognitive abilities including memory, language, and planning, organizing, sequencing, and abstracting information.  Mild neurocognitive disorder is a condition in which there are early signs of cognitive decline such that it begins to interfere with activities of daily living.  Alzheimer’s Disease is the leading cause of neurocognitive disorder, and the incidence is expected to rise with an aging population. There is currently no known cause or cure.  DISCUSSION POINT: What are some of the ethical issues involved in the nun study? Do the findings from this study outweigh these ethical considerations?  To date, there is no effective treatment for the irreversible neurocognitive disorder caused by Alzheimer’s disease, Lewy bodies, vascular disease, Parkinson’s disease, Huntington’s disease, and various less common conditions that produce progressive cognitive impairment.

Treatment often focuses on helping patients cope with the continuing loss of cognitive skills and helping caregivers deal with the stress of caring for affected individuals.  DISCUSSION POINT: How can non-medical clinicians aid in the treatment and prevention of neurocognitive disorder?

KEY TERMS delirium, 554 major neurocognitive disorder (dementia), 556 mild neurocognitive disorder, 556 agnosia, 558 facial agnosia, 558 Alzheimer’s disease, 559 neurocognitive disorder due to Alzheimer’s type, 559 vascular neurocognitive disorder, 556 head trauma, 563 frontotemporal neurocognitive disorder, 563 Pick’s disease, 553 traumatic brain injury (TBI), 563 neurocognitive disorder due to traumatic brain injury, 563

neurocognitive disorder due to Lewy body disease, 563 neurocognitive disorder due to Parkinson’s disease, 563 Parkinson’s disease, 563 human immunodeficiency virus type 1 (HIV-1), 564 neurocognitive disorder due to HIV infection, 5564 aphasia, 565 Huntington’s disease, 565 neurocognitive disorder due to Huntington’s disease, 566 neurological disorder due to prion disease, 566 Creutzfeldt-Jakob disease, 566 substance/medication-induced neurocognitive disorder, 567 deterministic, 568 susceptibility, 568

IDEAS FOR INSTRUCTION 1.

Activity: How Is Your Memory? It is easy for students to be lulled into thinking that memory problems are unique to people with the disorders covered in this chapter. Indeed, memory problems are quite common and are quite often related to inattention. Ask students in the class to answer the following simple questions, originally posed by Kenneth Higbee, and then read the correct answers and ask for a show of hands as to how many in the class got each question wrong. This activity may be used as a springboard to a discussion of attention and memory, including the role of increasing attention in assisting people with various neurocognitive disorders. a. Which color is on top of a stoplight? (Answer: red) b. Whose image is on a penny? (Answer: Lincoln); Is he wearing a tie? (Answer: yes, a bow tie) c. What five words besides “In God We Trust” appear on most U.S. coins? (Answer: United States of America and Liberty) d. When water goes down the drain, does it swirl clockwise or counterclockwise?

(Answer: counterclockwise in the Northern Hemisphere; clockwise in the Southern Hemisphere) e. What letters, if any, are missing on a telephone dial? (Answer: Q, Z)

2. Invite a guest speaker from your local Council on Aging organization or Alzheimer’s support group to talk to the class about the many problems that face the elderly in the areas of health and mental health. The speaker should also discuss the kinds of services available in your area for individuals with Alzheimer’s and their families, as well as other services for the elderly. Several of your students might work for assisted living or nursing homes, so ask them for their input on cognitive disorder and old age. Use http://www.alz.org/we_can_help_we_can_help.asp as a reference site for your lectures on Alzheimer’s disease and old age.

Uh Oh! Plan B Although instructors are skilled professionals in creating classroom experiences, things don’t always go as planned. The chapter-related lecture and activity suggestions in this section are for instances when your planned lecture or activity idea do not go as planned. Implement these to recover student interest and enhance student reading.

Living a Beautiful Life with Alzheimer’s Disease. Given the high prevalence of the disease, it is likely that your students will be personally acquainted with some of its devastating effects.

Yet, even a life with a severe neurocognitive disorder has value and meaning. The Notebook by Nicholas Sparks tells the loving story of a husband who helps his wife remember their life together.

YOUTUBE CLIPS: CHAPTER 15 TedEd reviews the causes, characteristics, and potential treatments of Alzheimer’s Disease. https://www.youtube.com/watch?v=yJXTXN4xrI8 (03:49)_.

What does Alzheimer’s Disease feel like? Experience a few minutes in Alzheimer’s Dementia with ABC News https://www.youtube.com/watch?v=LL_Gq7Shc-Y (08:03).

The Mayo Clinic reports on diagnosis and prognosis of Creutzfeldt-Jakob Disease https://www.youtube.com/watch?v=lS9jKVM7ZXo (02:14)

SUGGESTED VIDEOS As many of the names of these disorders have changed, some of these videos may appear to be out of date. Please be selective in which you choose to use based on good information with older names and advise your students of such.

Agitation...it’s a sign. (Fanlight Productions). A variety of caregivers share their experiences and thoughts on providing for residents with Alzheimer’s disease while providing vivid examples of the techniques and concepts that have worked in their facilities. (14 min) Communicating with older adults: Dementia. (Insight Media). This program explores the communication barriers posed by sensory and memory impairments. It outlines the principles of good communication and shows how to clarify one’s message when communicating with dementia patients. (30 min) Dress him while he walks. (Fanlight Productions). This sensitive and realistic video addresses several difficult behavior patterns of Alzheimer's patients. It demonstrates practical ways of dealing with behaviors such as wandering, angry outbursts, and delusions. For example, in the case of one patient who constantly paces around the facility, staff have developed methods of dressing him "on the run." Another patient is offered finger food while she wanders.

Although not easy to watch at times, this video shows caring and concerned staff dealing with difficult situations in a practical manner and with a sense of humor. Though designed primarily for nursing home staff, it will be a valuable training and discussion tool for family caregivers as well. (20 min) He’s doing this to spite me. (Fanlight Productions). In this frank video, three caregivers openly share their experiences of conflict and frustration in interactions with their loved one who has neurocognitive disorder. These scenes are integrated with comments and guidance from professionals in neurocognitive disorder care. The result is a program that teaches both family and professional caregivers how to reframe the dynamic into one that is more comfortable and productive for both caregiver and patient. (22 min) Philadelphia. This film, starring Tom Hanks, depicts a young man who suffers from AIDS and the effects of the illness on his neurological functioning. (126 min) Regarding Henry. This film depicts a man who experienced a stroke as a result of a gunshot wound and the impact it had on his family and how they learned to cope. (108 min) Wandering: Is it a problem? (Fanlight Productions). A variety of caregivers share their experiences and thoughts on providing for residents with Alzheimer’s while providing vivid examples of the techniques and concepts that have worked in their facilities. (14 min)

ONLINE RESOURCES Alzheimer’s Association http://www.alz.org/ The Alzheimer’s Association website contains information on local chapters, coping strategies for caregivers, and scientific progress toward effective treatment and understanding of this disorder.

Delirium http://mentalhealth.com/home/dx/delirium.html This webpage provides diagnostic and clinically relevant research information and links about delirium.

Neurocognitive Disorder http://mentalhealth.com/home/dx/dementia.html This webpage provides diagnostic and clinically relevant research information and links about neurocognitive disorder.

Neurocognitive Disorder Due to Alzheimer’s Disease http://www.mentalhealthamerica.net/alzheimers-disease This webpage provides diagnostic and clinically relevant research information and links about dementia of the Alzheimer’s type.

Dementia Web https://www.dementiauk.org/ This is a good site with information and links on a wide variety of topics, including current research. It also includes a support database for the United Kingdom.

SUPPLEMENTARY READING MATERIAL Additional Readings: As many of the names of these disorders have changed, some of these references may appear to be out of date. Please be selective in which you choose to use based on good information with older names and advise your students of such.

Caplan, L. R., Dyken, M. L., & Easton, J. D. (1994). American Heart Association family guide to stroke treatment, recovery, and prevention. New York: Time Books.

Clipson, C., & Steer, J. (1998) Case studies in abnormal psychology. Boston, MA: Houghton Mifflin Company. Chapter 16, Dementia of the Alzheimer's Type: Descent into Darkness.

Cummings, J. L. (Ed.) (1990). Subcortical dementia. New York: Oxford University Press.

Davies, P. (1994). Starting again: Early rehabilitation after traumatic brain injury or other severe brain lesion. New York: Springer.

Edwards, A. J. (1994). When memory fails: Helping the Alzheimer’s and dementia patient.

New York: Plenum.

Eide, M. (1987). Alzheimer’s disease. Phoenix, AZ: Oryx Press.

Fisher, J. E., & Carstensen, L. L. (1990). Behavior management of the dementias.

Clinical Psychology Review, 10, 611-629.

Gatz, M., & Smyer, M. A. (1992). The mental health system and older adults in the 1990s. American Psychologist, 47, 741–751.

Hantz, P., Caradoc-Davies, G., Caradoc-Davies, T., Weatherall, M., & Dixon, G. (1994).

Depression in Parkinson’s disease. American Journal of Psychiatry, 151, 1010–1014.

Jackson, J. E., Katzman, R., & Lessin, P. J. (Eds.) (1992). Alzheimer’s disease: Long term care. San Diego: San Diego State University Press.

Mace, N. L., & Rabins, P. (1981). The 36-hour day: A family guide to caring for persons with Alzheimer’s disease, related dementing illnesses, and memory loss in later life.

Baltimore: Johns Hopkins University Press.

McGowin, D. F. (1993). Living in the labyrinth: A personal journey through the maze of Alzheimer’s. New York: Delacorte.

Sacks, O. (1985). The man who mistook his wife for a hat and other clinical tales. New York: Summit.

Sattler, D., Shabatay, V., & Kramer, G. (1998). Abnormal psychology in context: Voices and perspectives. Boston, MA: Houghton Mifflin Company. Chapter 11, Cognitive Disorders.

Storandt, M., & VandenBos, G. R. (Eds.) (1994). Neuropsychological assessment of dementia and depression in older adults: A clinician’s guide. New York: American Psychological Association.

Weiner, M. F. (Ed.) (1995). The dementias: Diagnosis, management, and research (2nd ed.). Washington, DC: American Psychiatric Press.

Wright, L. K. (1993). Alzheimer’s disease and marriage: An intimate account. Newbury Park, CA: Sage.

Zigler, E., & Hodapp, R. M. (1991). Behavioral functioning in individuals with mental retardation. Annual Review of Psychology, 42, 29–50.

Handout WARNING SIGNS OF ALZHEIMER’S DISEASE  Memory loss that affects job skills  Difficulty performing familiar tasks  Problems with language  Disorientation of time and place  Poor or decreased judgment  Problems with abstract thinking  Misplacing things  Changes in mood or behavior  Changes in personality  Loss of initiative

CHAPTER 16 MENTAL HEALTH SERVICES: LEGAL AND ETHICAL ISSUES CHAPTER OVERVIEW This chapter outlines the primary legal and ethical issues associated with the study, assessment, and treatment of abnormal behavior. In addition, changing societal views about those with mental illness are discussed. Specific issues such as civil and criminal commitment, dangerousness, homelessness, deinstitutionalization, insanity defense, competency to stand trial, duty to warn, expert witnesses, and patient and research participant rights are discussed.

Contemporary issues in mental health are also covered, with an emphasis on practice guidelines for efficacy and effectiveness of psychosocial interventions. .CHAPTER OUTLINE PERSPECTIVES ON MENTAL HEALTH LAW

CIVIL COMMITMENT Criteria for Civil Commitment Procedural Changes Affecting Civil Commitment An Overview of Civil Commitment

CRIMINAL COMMITMENT The Insanity Defense Reactions to the Insanity Defense Therapeutic Jurisprudence Competence to Stand Trial Duty to Warn Mental Health Professionals as Expert Witnesses

PATIENTS’ RIGHTS AND CLINICAL PRACTICE GUIDELINES The Right to Treatment The Right to Refuse Treatment The Rights of Research Participants Evidence-Based Practice and Clinical Practice Guidelines

CONCLUSIONS

DETAILED OUTLINE Perspectives on Mental Health Law  Societal views of people with mental illness change with time, often as responses to perceived problems with and as intended improvements of relevant laws. According to researchers, a “liberal era” between 1960 and 1980 in the United States was characterized by a commitment to individual rights and fairness; the “neoconservative era” that followed focused on majority concerns and on law and order.  DISCUSSION POINT: Do you agree with the sentiment that the way individuals with mental illness are treated by a society is an important measure of the success of that society?

Civil Commitment  Civil commitment laws determine the conditions under which a person may be certified legally to have a mental illness and therefore to be placed in a hospital, sometimes in conflict with the person’s own wishes.  Historically, states have permitted commitment when several conditions have been met: (1) the person has a mental illness and is in need of treatment, (2) the person is dangerous to himself or to others, or (3) the person is unable to care for himself.  Mental illness as used in legal system language is not synonymous with psychological disorder; each state has its own definition of mental illness, usually meant to include people with severe disturbances that negatively affect their health and safety.  Having a mental illness increases the likelihood of dangerousness when specific factors are present, such as a high anger predisposition, recent stressors, and substance abuse.  The combination of the lack of success with deinstitutionalization, which has resulted instead in transinstitutionalization; the rise in homelessness; and the criminalization of people with severe mental illness led to a backlash against the perceived causes of these factors, including the strict civil commitment laws.  DISCUSSION POINT:

Why might the deinstitutionalization movement have failed? What resources are still needed at this time to improve the well-being of seriously mentally ill individuals?

Criminal Commitment  Criminal commitment is the process by which people are held for one of two reasons: (1) they have been accused of committing a crime and are detained in a mental health facility until they can be determined fit or unfit to participate in legal proceedings against them, or (2) they have been found not guilty of a crime by reason of insanity.  DISCUSSION POINT: What do the changing criteria for the insanity defense tell us about different eras in our society?  The insanity defense is defined by a number of legal rulings: The M’Naghten rule states that people are not responsible for criminal behavior if they do not know what they are doing, or if they are aware of their actions yet they don’t know it is wrong. The Durham rule broadened the criteria for responsibility from knowledge of right or wrong to the presence of a “mental disease or defect.” The American Law Institute criteria concluded that people were not responsible for their criminal behavior if, because of their mental illness, they lacked either the cognitive ability to recognize the inappropriateness of their behavior or the ability to control their behavior.  The concept of diminished capacity holds that people’s ability to understand the nature of their behavior and therefore their criminal intent could be lessened by their mental illness.  A determination of competence must be made before an individual can be tried for a criminal offense. To stand trial, people must be competent and able to understand the charges against them. They also must be able to assist with their own defense.  Duty to warn is a standard that sets forth the responsibility of the therapist to warn potential victims that a client may attempt to hurt or kill them.  Individuals who have specialized knowledge and who assist judges and juries in making decisions, especially about such issues as competence and malingering, are called expert witnesses.

Patients’ Rights and Clinical Practice Guidelines  One of the more fundamental rights of patients in mental facilities is their right to treatment.

Patients have a legal right to some sort of ongoing effort to both define and strive toward treatment goals. By contrast, a great deal of controversy exists over whether all patients are capable of making a decision to refuse treatment. This is an especially difficult dilemma in the case of antipsychotic medications that may improve patients’ symptoms but bring with them severe negative side effects.

 DISCUSSION POINT:

What are the benefits of establishing a standard of care for people with a specific psychological disorder, such as depression? Are there drawbacks to using the research base to specify clinical practice guidelines?  Subjects who participate in any research study must be fully informed of the risks and benefits and formally give their informed consent to indicate they have been fully informed.  Clinical practice guidelines can play a major role in providing information about types of interventions that are likely to be effective for a specific disorder, thereby setting the stage for evidence-based practice. Critical to such a determination are measures of clinical efficacy (internal validity) and clinical utility (external validity). In other words, efficacy is a measure of whether a treatment works, and utility is a measure of whether the treatment is effective in a variety of settings and can be implemented in those settings.  There is an international governmental interest in improving health outcomes as they also decrease cost by the State.

KEY TERMS civil commitment laws, 581 mental illness, 583 dangerousness, 583 deinstitutionalization, 584 transinstitutionalization, 585 criminal commitment, 587

diminished capacity, 588 competence, 591 duty to warn, 591 expert witnesses, 591 clinical efficacy axis, 595 clinical utility axis, 5596

IDEAS FOR INSTRUCTION 1.

Activity: Defining Mental Illness. The text discusses how the laws defining mental illness vary from state to state. Ask your students to research your state laws regarding the definition of mental illness as well as the topic of persecution of those with mental illness.

You may also ask them to research how ethical concerns are handled in your state. For example, what course of action must a consumer take to file a charge against a psychologist who has violated ethical or legal practices? Have your students write a brief paper indicating who they spoke with to receive information and what they learned about this process.

2.

Activity: Discuss the Nature of Manualized Psychotherapy. Practice guidelines are increasingly pointing toward flexible use of psychotherapy manuals in routine clinical practice. Yet, there are many misunderstandings and myths surrounding manualized treatments, most of them negative. Obtain a copy of an empirically supported psychosocial treatment manual and present some of it to the class, including why such manuals are used in efficacy trials, and the assets and liabilities of such manuals in routine clinical practice.

3.

Activity: Invited Lecture by Expert Witness or Forensic Psychologist. Students will often be curious as to the role of psychologists in their capacity as expert witnesses, including the routine work of forensic psychologists. Invite someone who has extensive experience in these areas to come and speak to the class. Prior to the invited lecture, ask students to prepare one or two confidential questions that they are curious about and provide them to the guest lecturer beforehand.

4.

Invite a guest speaker from the local community to discuss the ethics of treatment. Also have this person describe the rights of mental patients under treatment in your state. It may be particularly useful to invite a mental health professional from a treatment facility that assists those who have been civilly or criminally committed to discuss the issues of this chapter. A professional who works with law enforcement—a mental health advocate for the local police precinct, for example—may be particularly interesting to hear.

Uh Oh! Plan B Although instructors are skilled professionals in creating classroom experiences, things don’t always go as planned. The chapter-related lecture and activity suggestions in this section are for instances when your planned lecture or activity idea do not go as planned. Implement these to recover student interest and enhance student reading.

Finishing Strong. Chapter 16 marks the end of the textbook. What have your students learned?

Which chapters were very helpful or interesting to them and why? Many schools provide ways for students to give confidential feedback to professors. However, this feedback is often focused on the teaching and assessment areas of the class (e.g. How well did the instructor explain things? Do you think that you test grades fairly reflected your knowledge of the chapter material?) rather than content. Feel free to develop some additional questions and ask students to assess their progress toward your own learning outcomes. This feedback will help you continuously improve the class!

YOUTUBE CLIPS: CHAPTER 16 For an interesting international look on the value of expert witnesses and how psychologists assess whether someone is “mad or bad,” watch this video from the British Psychological Society: https://www.youtube.com/watch?v=tSPR93gTeE8 (32:43).

The Stanford School of Medicine presents a patient’s experience in a clinical trial for breast cancer treatment: https://www.youtube.com/watch?v=hgAWbvhP9ro (03:37).

Pablo de la Rosa Santiago narrates a graphically rich history of deinstitutionalization in the United States. https://www.youtube.com/watch?v=Z_e_LMroGGA (07:20).

Need a quick psychology methods review of the internal validity discussed in this chapter? This straightforward video (https://www.youtube.com/watch?v=_UPUtlHDM0A) provides detail on this concept. (18:48)

SUGGESTED VIDEOS A fine madness. This film stars Sean Connery as Samson, an eccentric poet who is hospitalized and later lobotomized because of his sexual exploits and his failure to conform to societal expectations. This film depicts important issues about the rights of people with mental illness. (104 min) Anatomy of a murder. This film depicts a courtroom case involving rape and promiscuity and an interesting analysis of the irresistible impulse defense. (161 min) Dark side of the moon. (Fanlight Productions). This video documents the struggles and successes of three formerly homeless men with mental illnesses. (25 min) Ethics for the mental health professional. (Insight Media). This video teaches the basics of ethical behavior for psychologists, social workers, and counselors. It discusses licensing law and violations of ethical guidelines, and shows how to terminate treatment, make referrals, and maintain records. It also considers malpractice. (160 min) Introducing TJ Therapeutic Jurisprudence. (Fanlight Productions). Therapeutic Jurisprudence represents a new approach to meeting the needs of mentally ill people confronting a judicial system which frequently sends them to jail for minor offenses when they, and their communities as well, would be better served by referrals to good mental health programs. (27 min) King of hearts. This film illustrates societal attitudes about mental illness. (102 min) Nuts. This film, starring Barbara Streisand and Richard Dreyfuss, portrays a woman’s fight to defend her claims of sanity, and illustrates issues related to the process of commitment.

(79 min) Mental health and the law. (Insight Media). This DVD explores the intersection of mental health and criminal justice. It covers such topics as the 1984 Insanity Defense Reform Act, legal tests for criminal responsibility, and the California law regarding diminished capacity. (30 min) Rampage. This William Friedkin film depicts a sociopath arrested and tried for murder.

The film raises important issues about capital punishment, the not guilty by reason of insanity plea, and the role of the expert witness in the courtroom. (97 min)

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ONLINE RESOURCES American Psychological Association (APA) Ethics Office http://www.apa.org/ethics/ This is the official APA ethics website, with links to the ethical principles and code of conduct and related topics about ethical violations.

Forensic Psychiatry Resource Page http://www.psymeet.com/psymeet/forensic.htmlThis website entitled “Forensic Psychiatry Resources on the Web” is maintained by DrMyron Pulier at the Rutgers-New Jersey Medical School.

Forensic Science Resources http://www.tncrimlaw.com/forensic/f_psych.html This website provides several links to topics related to mental health and the law.

National Alliance for the Mentally Ill (NAMI) http://www.nami.org This website provides information and status reports about state and federal laws that affect people with mental illness, including their families.

Violence and Mental Illness http://ontario.cmha.ca/public_policy/violence-and-mental-health-unpacking-a-complex-issue/ This Canadian site presents a comprehensive review and data regarding the relationship between violence and mental illness.

SUPPLEMENTARY READING MATERIAL Additional Readings: American Psychological Association (1992). Ethical principles of psychologists and code of conduct. Washington, DC. Annas, G. J. (1989). The rights of patients: The basic ACLU guide to patient rights (2nd ed.). Carbondale, IL: Southern Illinois University Press.

Appelbaum, P. A. (1994). Almost a revolution: Mental health law and the limits of change. New York: Oxford University Press.

Bersoff, D. N. (1995). Ethical conflicts in psychology. Washington, DC: American Psychological Association.

Corey, G., Corey, M. S., & Callanan, P. (1993). Issues and ethics in the helping professions (4th ed.). Pacific Grove, CA: Brooks/Cole.

Crespi, T. D. (1989). Child and adolescent psychopathology and involuntary hospitalization: A handbook for mental health professionals. Springfield, IL: Thomas.

Kleespies, P.M. (2012). Behavior emergencies : An evidence-based resource for evaluating and managing risk of suicide, violence, and victimization. Washington, D.C. : American Psychological Association.

La Fond, J. Q., & Durham, M. L. (1992). Back to the asylum: The future of mental health law and policy in the United States. New York: Oxford University Press.

Lilienfeld, S. O. (1995). Seeing both sides: Classic controversies in abnormal psychology.

Pacific Grove, CA: Brooks/Cole.

McNeil, D. E., & Binder, R. L. (1986). Violence, civil commitment, and hospitalization.

Journal of Nervous and Mental Disease, 174, 107-111.

Mindell, J. A. (1993). Issues in clinical psychology. Madison, WI: Wm. C. Brown.

Nietzel, M. T., & Dillehay, R. C. (1986). Psychological consultation in the courtroom.

New York: Pergamon.

Spring, R. L. (1989). Patients, psychiatrists, and lawyers: Law and the mental health system. Cincinnati, OH: Anderson.

Steadman, H. J., McGreevy, M. A., & Morrisey, J. P. (1993). Before and after Hinckley: Evaluating insanity defense reform. New York: Guilford.

Winick, B. J. (1997). The right to refuse mental health treatment. Washington, DC: American Psychological Association.

Greene, E., & Heilbrun, K. (2014). Wrightsman’s Psychology and the legal system (8th ed.).

Belmont, CA: Wadswoth.

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Handouts WARNING SIGNS OF TEEN VIOLENCE The following signs indicate the potential for violent behavior. Note that having a mental illness is not a warning sign of violent behavior!  Loss of temper on a daily basis  Frequent physical fighting  Significant vandalism or property damage  Serious drug or alcohol use, or an increase in such use  Increase in risk-taking behavior  Detailed plans to commit acts of violence  Announcing threats or plans for hurting others  Enjoying hurting animals  Carrying a weapon  A history of violent or aggressive behavior  Gang membership or strong desire to be in a gang  Access to or fascination with weapons, especially guns  Threatening others regularly  Trouble controlling feelings like anger  Withdrawal from friends and usual activities  Feeling rejected or alone  Having been a victim of bullying  Poor school performance  History of discipline problems or frequent run-ins with authority  Feeling constantly disrespected  Failing to acknowledge the feelings or rights of other

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