Abnormal Psychology, 2nd Edition by James H Hansell and Lisa K Damour , Solution Manual

Abnormal Psychology, 2nd Edition By

by James H. Hansell and Lisa K. Damour

Email: Richard@qwconsultancy.com

Instructor’s Resource Manual (2nd edition)

Chapter 1: Defining Abnormality: What Is Psychopathology?

Learning Objectives: By the end of this chapter, students should be able to: • Understand the importance of context in defining and understanding abnormality.

• Recognize that there is a continuum between normality and abnormality.

• Cite the advantages and limitations of diagnosis.

• Understand the difference between reliability and validity, and apply these concepts to the issue of diagnosis.

• Identify multiple factors that may contribute to psychological distress.

• Understand the concept of reductionism and how it applies to the idea of multiple causality.

• Recognize the difference between “predisposing” and “precipitating” factors.

• Understand the mind-body connection as it applies to abnormal psychology.

• Understand that, since there is no universally accepted definition of mental illness, psychologists must rely on a series of guidelines in defining abnormal behavior.

• Identify common criteria used to define abnormality. o Specifically, identify the components of the HIDES acronym (help seeking, irrationality/dangerousness, deviance, emotional distress, significant impairment) o Cite specific strengths and weaknesses of each criteria • Define the concept of “culture-bound syndromes,” and understand how this exemplifies the issue of cultural relativism.

• Define “historical relativism,” and provide examples of how changes over time might affect our view of abnormality.

• Understand the arbitrariness of the definition of “abnormality,” using the continuum between normality and abnormality to illustrate this.

• Identify specific practical solutions used by psychologists to define abnormality: o Define the following: “working definition”; “fuzzy categories”; “continuum”; and be able to use these as examples of practical solutions. o Be familiar with the DSM-IV definition of “mental disorder,” while being aware of its fuzziness and broadness.

Lecture Outline: I. The core concepts in abnormal psychology (also called “psychopathology”) a. The importance of context in defining and understanding abnormality i. Context helps to…

• Define whether behavior is abnormal • Explain abnormality • Recognize biases regarding demographic factors race, class, gender, etc.) b. The continuum between normality and abnormality i. Many forms of abnormality can be seen as exaggerations of normal feelings and behaviors (e.g., depressed mood, anxiety). ii. The possibility of experiencing mental illness is part of our common humanity.

Instructor’s Resource Manual (2nd edition)

c.

d.

e.

f.

iii. There is no clear-cut defining line between “normality” and “abnormality.”

The role of cultural and historical relativism in defining abnormality i. Definitions of abnormality change over time and vary across cultures.

• Homosexuality is an example; it was defined as a mental disorder until 1973.

The advantages and limitations of diagnoses i. Advantages: • Diagnostic categories allow clinicians to study and treat disorders.

• These categories give clinicians a common language. ii. Disadvantages • The complexity of abnormal behavior makes it difficult to develop reliable (consistent) and valid (accurate) diagnostic categories.

• Overemphasis on diagnosis can oversimplify and/or dehumanize the people behind the labels.

• Diagnoses can be highly stigmatizing.

The principle of multiple causality i. Mental disorders involve precipitating (triggering) and predisposing (underlying) causes. ii. Different theoretical orientations can each offer useful contributions to our understanding of abnormality.

• Combining components from several orientations is common and useful.

• Sometimes our explanations are reductionistic; they rely too heavily on just one theory or concept.

The connection between mind and body in abnormality i. The mind and body are highly interrelated.

II. The Core Concepts: A View from the Past a. Case study – Charlotte Perkins Gilman i. The origin of her symptoms illustrates the importance of context. ii. Cultural and historical relativism are important to consider; being a woman in the 19th century may have contributed to her symptoms. iii. The questionable validity of her diagnosis demonstrates the limitations of diagnosis. iv. The interplay of multiple causes and the mind-body connection were not sufficiently appreciated in Gilman’s treatment. b. Modern clinicians commonly rely on these core concepts in understanding and treating abnormality.

III. Defining Abnormality: What Is Psychopathology? a. There is no agreed upon or precise definition of abnormal behavior, mental illness, or psychopathology. b. Several criteria are typically used in understanding whether behavior is abnormal or not.

Instructor’s Resource Manual (2nd edition) IV. Five Commonly Used Criteria for Defining Abnormality (Acronym: HIDES) a. Help seeking i. “Help seeking” is not a useful criterion by itself – some people never seek help, and some people with “normal” issues do ask for help. ii. David Rosenhan’s study of “being sane in insane places” illustrated the dangers of diagnostic labeling and the limitations of “help seeking” as a criterion for abnormality. b. Irrationality/dangerousness i. Most people with mental disorders are neither highly irrational nor dangerous. ii. Some people may act in an irrational and dangerous manner without having a mental disorder. iii. Equating irrationality with insanity is a culturally relative assumption – for example, falling “madly” in love, particularly in Latin cultures, is not at all a sign of pathology. c. Deviance i. Not all mental illness involves extreme behaviors; mild anxiety and depression, for example, are common. ii. In some cases, over-conformity rather than deviance may be a sign of pathology. iii. A danger of the “mental illness” label is that it can be used to persecute and stigmatize people who are politically, culturally, or socially different. d. Emotional distress i. Some people with mental disorders, such as those diagnosed with personality disorders, may not experience distress per se, but they may inflict distress upon others. ii. Some forms of emotional distress, such as grieving in response to the death of a loved one, are within the normal range of behaviors. e. Significant Impairment i. Some impairments may be caused by physical injuries or diseases, rather than by psychopathology. ii. Some people may be able to function adequately even while they are suffering from a mental disorder. iii. Defining “impairment in functioning” can be difficult and subjective. f. None of these five criteria (HIDES) are useful by themselves, but they are very useful when used together. i. Emotional distress and significant impairment are more useful markers of psychopathology than help seeking, irrationality/dangerousness, and deviance V. Core Concepts in Defining Abnormality a. Cultural and Historical Relativism i. Relativism: what is considered normal and abnormal differs widely across cultures and over time

Instructor’s Resource Manual (2nd edition) •

Cultural relativism: Culture-bound syndromes (see Table 1.2) illustrate how certain cultures may view abnormality differently than others.

• Historical relativism: Historical events and shifts may affect how we view abnormality – homosexuality is one example of this. b. The Continuum between Normality and Abnormality i. Abnormal behaviors are often exaggerations of normal states. ii. The distinction between “normality” and “abnormality” is often fuzzy and subjective. iii. “Medical student syndrome” – a common pitfall among abnormal psychology students.

VI. Defining Abnormality: Practical Solutions a. Misdefining abnormality and misdiagnosing individuals can have serious consequences. b. Most clinicians don’t need to decide whether a person is sane or insane; rather, they are more concerned with how to help the individual. c. Clinicians often use working definitions of abnormality when making diagnoses. d. Clinicians often rely on “fuzzy categories,” which are imprecise yet still useful. e. The DSM-IV-TR provides a working (operational) definition of mental disorder, although it notes that the concept of “mental disorder” is imprecise. f. The DSM-IV-TR definition includes the following components: i. Clinical significance ii. Distress or disability iii. Increased risk of suffering death, pain, disability, or important loss of freedom iv. Not an expectable/culturally sanctioned response to a stressor v. Behavior is considered to be a manifestation of dysfunction vi. Neither deviance nor conflicts with societal norms are mental disorders unless they are symptoms of dysfunction. g. The DSM-IV-TR definition highlights the fuzziness of the term “mental disorder.” h. This definition focuses mostly on distress and impairment. i. This definition is very similar to Wakefield’s definition of mental illness as a “harmful dysfunction” (box 1.4) j. “Mental disorder” is a broad concept that applies to many people. i. Over 46% of Americans experience at least one mental disorder during their lifetimes (Kessler et al. 2005 epidemiology study) Lecture Extensions: 1. Defining mental disorders. The Rosenhan study of “being sane in insane places” illustrates some of the limitations of our current diagnostic system. Specifically, Rosenhan’s study brought out the importance of context in identifying abnormality; if a person is in a mental institution, then that person must be mentally ill! Rosenhan’s research was published at a time where significant scrutiny was building up against the

Instructor’s Resource Manual (2nd edition) field of psychiatry and clinical psychology. Critics of the tradition of psychiatric diagnosis argued that most, if not all, forms of individual “psychopathology” are actually manifestations of serious social ills; thus, mental illness is a “red herring,” and not necessarily the true, underlying issue. On the one hand, some embrace this perspective and view “mental illness” as a value judgment. On the other hand, some see this perspective as highly unethical and dangerous, obfuscating the biological basis of many psychological disorders. For further reading, I suggest the following: Foucault, Michel. (1988). Madness and civilization: A history of insanity in the age of reason. Vintage.

Szasz, Thomas. (1984). The myth of mental illness (revised edition). Quill.

2. Cultural relativism in psychology. Identification, diagnosis, and treatment of psychological disorders have been complicated by the fact that different cultures have different conceptualizations of personality and abnormality. Carolyn Zerbe Enns (1994), for example, describes how Western cultures value individualism, independence, and self-containment, whereas other cultures may place a stronger emphasis on group identity, harmony, and collectivism. These cultural values point to differences in healthy personality development as well as in the diagnosis and treatment of mental illness. Some differences you might want to share with your students include the following: •

Members of some Native American tribes interpret “hearing voices” as a celebration of communion with the spirit world. They view this phenomenon as a form of communication and as a sign of interconnectedness. Euro-Americans, however, are likely to interpret this phenomenon as a symptom of schizophrenia or other psychotic disorder.

•

In the United States, it is common for people to express psychological distress emotionally. In fact, we speak a language that has many emotional terms. In contrast, many people from East Asian societies are likely to express psychological distress in terms of physical complaints. People from East Asian societies complaining about physical distress may not necessarily be seen as suffering psychologically.

•

Healing processes can look very different from culture to culture. In the United States, it is common for people to see a physician for physical health problems, and a psychotherapist for psychological concerns. Other cultures may utilize different forms of healing, including shamans, medicine men, religious ceremonies, and other types of healing ceremonies. Jerome Frank’s, Persuasion and Healing presents a compelling discussion of these different forms of healing and the commonalities they share with Western forms of psychological treatment.

To better understand the role of culture in abnormality, I recommend the following readings:

Instructor’s Resource Manual (2nd edition) McGoldrick, M., Giordano, J., & Garcia-Preto, N. (Eds.). (2005). Ethnicity and family therapy (3rd Edition). New York: Guilford Press.

Sue, Derald Wing, and Sue, David. (2002). Counseling the culturally diverse (4th Edition). Hoboken, NJ: John Wiley and Sons.

Tseng, Wen-Shing. (2001). Handbook of cultural psychiatry. San Diego: Academic Press.

3. Culture-bound syndromes. The DSM-IV-TR contains an extensive list of disorders found only in specific cultural contexts, defined as “culture-bound syndromes.” For example, many culture-bound syndromes exist in China, where theories of medicine and healing are quite different from those in the U.S. Qi-gong psychotic reaction is described as "an acute, time-limited episode characterized by dissociative, paranoid, or other psychotic or non-psychotic symptoms", and that "especially vulnerable are individuals who become overly involved" in qi-gong. Qi-gong is a regimen that draws upon the ancient practice of tai chi. Koro is another interesting culture-bound syndrome. It involves the erroneous belief that one’s genitals are shrinking.

4. Historical Relativism in African-American Psychology. An excellent resource for discussing the history of African-Americans in psychology is Robert Guthrie’s Even the Rat Was White. In this text, Guthrie addresses topics such as the “scientific” measure of racial differences, the assumption of minority inferiority, cultural bias in psychological assessment tools, and the contributions of African-American psychologists to the field.

This lecture extension can spark discussion about how history can shape our understanding of normality and abnormality.

5. Application of “Deviance” Criterion to Ethnic Minority Groups. While deviance can be a useful criterion in differentiating between normality and abnormality, it has been used inappropriately at times throughout history. An excellent example of this is a “disorder” called drapetomania. This term was coined by Dr. Samuel Cartwright during the American Civil War, and it combines the Greek words for “runaway slave” and “crazy.”

It was used to describe a disorder that involved an uncontrollable urge to escape from slavery. Of course, through our current perspective we would view this behavior as expected; however, during the Civil War, this behavior was seen as deviant and pathological. Another example involves the “father of modern psychiatry,” Dr. Benjamin Rush. Rush believed that African-Americans suffered from a form of “congenital leprosy” that caused them to have dark skin. African-Americans were also diagnosed with “dyaesthesia aethiopica," which involved not paying attention to property. Again, we now see these “disorders” as racist and inappropriate, yet at the time they were widely accepted definitions. Additional information about these and other conditions can be found at: Brown, P. (1990). "The Name Game." Journal of Mind and Behavior, 11, 385-406.

Instructor’s Resource Manual (2nd edition) Szasz, T. (1997). The Manufacture of Madness A Comparative Study of the Inquisition & the Mental Health Movement. Syracuse: Syracuse University Press.

6. Gender and abnormality. Gender has been an important dimension in considering the symptoms, causes, and treatments of psychological disorders. Karen Horney, in Feminine Psychology, was one of the first to argue that women develop in a context of oppression and discrimination, and that gender differences in personality need to be framed within this context. Contemporary feminist psychologists share Horney’s original understanding and suggest that gender issues underlie a range of diagnostic and treatment concerns. For example, a number of DSM-IV-TR diagnoses have been challenged on the basis of gender bias, illustrating some of the limitations of formal diagnosis. Some personality disorders (borderline, histrionic, and dependent) are more commonly diagnosed in women, and some argue that these disorders share a number of “hyperfeminine” traits and behaviors. In fact, some feminist psychologists suggest that deviations from traditional sex roles underlie the majority of “diagnosable” psychological disorders.

Moreover, some feminist psychologists argue that women who have suffered from abuse are unfairly diagnosed with a psychological disorder, pathologizing the individual rather than societal factors. Phyllis Chesler’s Women and Madness is an excellent introduction to this line of thought, and spearheaded the field of feminist therapy. The film Dialogues with Madwomen (available from Women Make Movies) is also a useful tool for illustrating how abuse and discrimination can influence diagnosis and treatment.

7. Excessive help-seeking and psychopathology. Your textbook discusses some of the limitations of the “help-seeking” criterion for abnormality. Interestingly, for some individuals, excessive help-seeking might be an indication of psychopathology. Disorders in which one is likely to see excessive or inappropriate help-seeking include, for example, dependent personality disorder, borderline personality disorder, and some of the anxiety disorders. Similarly, individuals suffering from somatoform disorders may underutilize mental health services, yet overutilize physical health care.

Interestingly, one could argue that “help-seeking” is a culture-bound criterion.

Individuals from some cultures view seeking help for psychological concerns as a sign that one is “crazy” or “insane.” These include individuals from Latin American cultures and from East Asian societies.

Classroom Activities/Discussion Topics 1. Homosexuality was classified as a mental disorder until 1973. Now, it is seen as a normal variant of sexual behavior. Today, another diagnosis called gender identity disorder is undergoing a similar debate. Present the diagnostic criteria of GID to the class, and ask them to consider the role of cultural and historical relativism in understanding the diagnosis. Should this diagnosis be removed from the DSM? 2. Divide the class into groups of five or six students. Ask half of the students to generate a list of words that come to mind when they think of a “normal” individual. Ask the other half to generate a list of words that come to mind when they think of someone with a

Instructor’s Resource Manual (2nd edition) mental illness. This is a useful activity to illustrate the stigmas and negative stereotypes associated with mental illness.

3. Myths of mental illness. Many students harbor a number of myths about people who are mentally ill. Often, these myths come from the movies and TV, although a number of students may have had personal experience with a mental illness. Construct a quiz about the “myths of mental illness” and administer it to students on the first day of class. Your quiz could include items such as the following: Mental illness is due to emotional weakness.

Mental illness is due to bad parenting.

Sinful behavior causes mental illness.

The mentally ill could recover if they really wanted to.

The mentally ill are dangerous.

Mental illnesses are incurable.

Mental illnesses require medications.

People who are mentally ill are just looking for attention.

People who are mentally ill are trying to avoid responsibilities.

Your quiz could be scored on a Likert scale or on a dichotomous true-false scale. Tally the results and report the average scores back to the class. This exercise can be a useful tool to stimulate discussion about the definition of “mental illness” and “abnormality.”

Students will probably find that some of these statements are true in certain circumstances, which can lead to a discussion about the continuum between normality and abnormality, historical and cultural relativism, and the importance of context in defining and understanding abnormality.

4. Reading about mental illness. Students often enjoy reading personal accounts of mental illness. The following is a list of recommended readings for abnormal psychology students.

1. Greenberg, J. (1964). I never promised you a rose garden. New York: Penguin.

2. Jamison, K. R. (1995). An unquiet mind. New York: Knopf.

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

4. Plath, S. (1972). The bell jar. New York: Bantam.

5. Axline, V. (1964). Dibs in search of self. New York: Ballantine.

6. Kaysen, S. (1993). Girl, interrupted. New York: Vintage.

7. Sheehan, S. (1982). Is there no place on earth for me? New York: Vintage.

8. Schreiber, F. R. (1973). Sybil. New York: Warner.

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

10. Rapoport, J. (1997). The boy who couldn’t stop washing. New York: New American Library.

Instructor’s Resource Manual (2nd edition) From Schwartz, D. J. and Abell, S. C. (2003). The most recommended book-length accounts of abnormality: Readings for abnormal psychology. Teaching of Psychology, 30, 63-65.

5. Mental Illness in Films. Many classic and recently-released films contain themes of mental illness, or feature characters suffering from a psychological disorder. Show a clip from a film in which the main character is suffering from a “mental disorder,” and ask the class to identify whether any or all of the HIDES criteria appear to be present. The following reference contains an extensive list of films that might be useful to utilize throughout the term: Livingston, Kathy. (2004).Viewing popular films about mental illness through a sociological lens. Teaching Sociology, 32, 119-128.

6. Divide the class into five separate groups. Assign each group one of the HIDES criteria, and ask students to generate a list of exceptions to their assigned criterion. Also ask students to discuss how, in specific situations, this particular criterion might be useful.

7. Ask students to review the DSM-IV-TR definition of “mental disorder.” In class, lead students in a discussion, addressing the following questions: What are the strengths of this definition? What are the weaknesses? How would you improve upon this definition?

8. Social Norms and Mental Illness. Many psychological disorders are characterized by violations of social norms. Ask students to choose a specific social norm to violate, engage in that behavior, and record others’ reactions to them. Make clear to students that these norm violations should not involve breaking the law or harming other people.

Some possible norm violations might include: • Wearing an item of clothing that is intended for the opposite sex.

• Eating a specific type of food in an odd way (for example, eating a banana like corn on the cob).

• Drink water out of a baby bottle instead of a regular water bottle.

• Wear sunglasses inside.

• Sit on the floor in a classroom in a cross-legged yoga position.

You may come up with other norm violations. Ask your students how they felt as others reacted to them. Did they feel self-conscious, or insecure? This exercise can help students appreciate the role of conformity in our behavior. It can also spark a discussion about the difference between normal and abnormal forms of nonconformity. Interestingly, students may bring up the idea that over-conformity may also be a sign of mental illness.

Instructor’s Resource Manual (2nd Edition)

Chapter 2: Explaining Abnormality: What Causes Psychopathology?

Learning Objectives: By the end of this chapter, students should be able to: • Identify theories of abnormal behavior that were prevalent in pre-modern societies.

• Provide examples of the biological/scientific perspective that rose to popularity with the ancient Greeks.

• Identify the dangers of reductionism in abnormal psychology, and apply the concept of precipitating and predisposing factors in understanding psychopathology.

• Understand how the mind and body are connected, and apply this concept to explanations of abnormality.

• Identify the key components of the central nervous system and the peripheral nervous system, and explain how these components contribute to psychopathology.

• Discuss the role of hormones and endocrine functions in psychopathology.

• Explain how psychologists study the genetic basis of psychopathology.

• Identify the major components of psychoanalytic/psychodynamic psychotherapy.

• Identify and apply the following Freudian concepts: topographical model, structural model, stages of psychosexual development, defense mechanisms.

• Explain how Freud’s theories shifted throughout his career.

• Be familiar with contemporary psychodynamic theories, including Kleinian psychoanalysis, object-relations theory, and self psychology.

• Using humanistic principles, identify the causes of psychopathology.

• Describe the techniques used by humanistic therapists.

• Using the existential perspective, explain the origin and treatment of psychopathology.

• Identify the principles of classical conditioning, using key terms.

• Discuss how principles of operant conditioning influence behavior.

• Define the key concepts involved in social learning theory.

• Explain how behavioral principles are used in specific treatments.

• Understand the major treatment principles used in cognitive therapy.

• Discuss why cognitive approaches emerged in reaction to previous therapeutic models.

• Define the basic tenets of the sociocultural approach to psychopathology.

• Understand how family systems perspectives explain psychopathology.

• Identify the major family systems approaches that have developed since 1950.

Lecture Outline: I. Explaining Abnormality: The Core Concepts a. Cultural and Historical Relativism i. Many pre-modern/primitive societies explained abnormality in terms of evil spirits.

1. Animism 2. Trephination 3. Exorcism ii. The ancient Greeks turned to more biological and scientific explanations.

1. Hippocrates’ four humours

Instructor’s Resource Manual (2nd Edition) a. Blood – moodiness b. Phlegm – lethargy c. Black bile – melancholia/depression d. Yellow bile – anxiety iii. Hysteria – the development of symptoms that are usually caused by neurological damage (e.g., paralysis, loss of sensation, confusion), but have no neurological origin.

1. The word “hysteria” is derived from the word for “uterus”; a common treatment was to try to lure the uterus back to the abdomen by placing sweet-smelling flowers there! iv. Approaches to explaining psychopathology have changed throughout history; modifications of theories as well as worldviews/paradigms. b. The Principle of Multiple Causality i. Reductionism ii. Precipitating cause iii. Predisposing cause iv. Diathesis-stress model c. The Connection Between Mind and Body i. The psychological and the biological paradigms are not mutually exclusive; the mind and body are interconnected.

1. Monism and dualism 2. Examples of the mind-body connection: a. General paresis b. Psychosocial dwarfism 3. The mind-body connection allows us to understand that the causes of disorders don’t necessarily dictate the treatments.

4. Principles regarding the mind-body connection: a. The causes of disorders are not all the same b. Both biology and psychology are always involved in the manifestation and form of the disorder (biopsychosocial model) c. Every emotion/behavior has a psychological and a biological aspect 5. Every mental disorder has biological and psychological correlates; remember that correlation does not imply causation!

6. Longitudinal studies can help us clarify the causal sequence of psychopathology.

II. The Theoretical Perspectives a. Biological Perspectives i. Central nervous system (CNS) – brain and spinal cord 1. Neurons and glial cells 2. Structures of the hindbrain and forebrain 3. Lobes of the brain – frontal, parietal, occipital, temporal 4. Subcortical structures – thalamus, hypothalamus, basal ganglia a. Abnormalities in brain structure may play a role in some

Instructor’s Resource Manual (2nd Edition) disorders and diseases (e.g., Huntington’s disease, Alzheimer’s disease, Korsakoff’s syndrome, Schizophrenia) 5. Neurons and neurotransmitters (see Visual Essay 2) a. Neuronal structures i. Synapses, cell body, axon, terminal buttons, dendrites, synaptic cleft, receptors b. Neurotransmitters i. Catecholamines – dopamine, epinephrine, norepinephrine ii. Serotonin • SSRIs iii. Amino acids – glutamate, GABA iv. Acetylcholine ii. Peripheral nervous system (PNS) 1. somatic nervous system 2. autonomic nervous system a. sympathetic and parasympathetic divisions iii. The endocrine system 1. hormones (e.g., adrenaline, cortisol) – regulate a variety of behaviors iv. Genetics 1. Genetically influenced mental disorders appear to be polygenic.

2. Research methods in genetics a. Family pedigree studies b. Twin studies/concordance rates i. Monozygotic and dizygotic twins c. Adoption studies d. Genetic linkage studies 3. Evolutionary psychology – the role of natural selection in presentday behaviors v. Biological treatment interventions 1. Psychosurgery 2. ECT 3. Recent experimental treatments -- transcranial magnetic stimulation, magnetic seizure therapy, magnetic spectroscopy, deep brain stimulation 4. Psychotropic medications – agonists and antagonists b. Psychodynamic perspectives i. Psychoanalytic (Freudian) vs. psychodynamic (broader term) ii. Freud’s Early Model 1. Use of hypnosis to treat hysteria – Jean Charcot, Pierre Janet 2. The case of Anna O. 3. Mind is divided into an “acceptable” (conscious) and “unacceptable” (nonconscious) part – tension between these two parts results in mental symptoms

Instructor’s Resource Manual (2nd Edition) a. This model of the mind was known as the topographic theory (unconscious, preconscious, conscious) 4. Repression of traumatic childhood events and desires, feelings, and fantasies that are considered unacceptable 5. Psychosexual development – children go through a variety of normal stages in the development of their libido 6. Thantos – destructive/aggressive instincts are also repressed iii. Freud’s Later Model 1. Freud became dissatisfied with his topographic theory 2. Developed a new theory -- structural model of the mind a. id, ego, superego 3. Freud’s daughter, Anna Freud, clarified that the mind uses many defense mechanisms, in addition to repression iv. Contemporary psychodynamic approaches 1. Kleinian school of psychoanalysis 2. Object-relational perspective 3. Self-psychology v. Psychodynamic Treatment Interventions 1. free association 2. resistance 3. transference 4. countertransference 5. interpretation 6. working through c. Humanistic/Existential Theories i. Humanistic Explanations and Treatment Interventions 1. Emotional health depends on self-actualization, which depends upon receiving unconditional positive regard.

2. Psychopathology results from a lack of unconditional positive regard, which also leads to the development of a false self.

3. Conditions of worth that are imposed on the child can cause feelings of inadequacy and lead to emotional problems.

4. Therapeutic techniques involved active listening, empathy, and, unconditional positive regard – developed by Carl Rogers in his client-centered therapy. ii. Existential Explanations and Treatment Interventions 1. Based on the existential tradition in philosophy, assumes that everyone eventually faces the reality that life has no inherent meaning and that death is inescapable.

2. Emotional health involves accepting these facts and taking personal responsibility in our lives.

3. Emotional disorders are caused by a lack of acceptance of these realities, leading to anxiety, inauthenticity, and depression. d. The Behavioral Perspectives i. Overarching principle: most behavior is learned ii. Classical conditioning – the process of learning via automatic associations

Instructor’s Resource Manual (2nd Edition) between a reflex-triggering stimulus and a neutral stimulus.

1. Developed by Ivan Pavlov – often called “Pavlovian conditioning.”

2. Temporal contiguity 3. Classical conditioning terms: a. unconditioned stimulus b. unconditioned response c. conditioned stimulus d. conditioned response 4. Classical conditioning has helped us to understand and treat phobias. iii. Operant conditioning – based on reinforcements and punishments 1. Developed by B.F. Skinner.

2. Law of effect 3. Reinforcement – increases the probability that a behavior will be repeated.

4. Positive reinforcement 5. Negative reinforcement 6. Punishment – decreases the probability that a behavior will be repeated. iv. Modeling/Social Learning Theory 1. also known as vicarious conditioning 2. Learning occurs through observing the behavior of others and imitating it.

3. Developed and studied by Albert Bandura, who conducted the famous “Bobo Doll” study. v. Behavioral Treatment Interventions 1. Classical conditioning interventions a. Extinction/counterconditioning b. Exposure therapies 2. Systematic desensitization 3. Aversion therapy – controversial 4. Operant conditioning interventions a. Contingency management b. Token economies c. Social skills training e. Cognitive Perspectives i. Focus is on thoughts, beliefs, and schemas that influence feelings and behavior. ii. Developed in reaction to the psychodynamic and behavioral perspectives.

1. Reject psychodynamic idea that change involves focusing on deeper causes. Cognitive restructuring, in contrast, is a treatment that involves changing irrational and maladaptive beliefs and thoughts.

2. Reject behaviorists’ focus on external factors; internal attributions may play a significant role.

Instructor’s Resource Manual (2nd Edition) a. Attributions b. Explanatory styles 3. Albert Ellis – focuses on irrational assumptions beliefs.

4. Aaron Beck – focuses on cognitive distortions. a. Negative automatic thoughts b. Cognitive triad iii. Cognitive treatment interventions 1. Beck’s cognitive therapy 2. Ellis’ rational emotive behavior therapy 3. Albert Bandura – self-efficacy iv. The cognitive-behavioral approach integrates both traditions. f. Sociocultural and Family Systems Perspectives i. Sociocultural theorists see mental disorders as real, but influenced by social factors.

1. Example – anorexia nervosa ii. Family systems theorists focus on the family as a unit rather than on individuals.

1. Changes in a family system will disrupt homeostasis and cause pathology.

2. Interpersonal boundaries may be problematic – enmeshed or disengaged.

3. Genograms are useful in therapy in order to establish patterns. iii. Treatment interventions 1. Gregory Bateson – the role of double-bind communication 2. Salvador Minuchin – structural family therapy Lecture Extensions: 1. Teaching psychodynamic concepts in the classroom. It is not uncommon for students new to psychology to have a critical and one-dimensional understanding of psychodynamic principles. Oftentimes, concepts such as Freud’s psychosexual stages of development seem abstract and silly, and students may have received mixed or wholly negative messages regarding psychodynamic psychology from other psychology professors and experts in the field. Thus, many students “throw the baby out with the bathwater” and discount psychodynamic psychology altogether without having a comprehensive understanding of its theories. In order to broaden your students’ perspectives, an excellent resource for introducing psychodynamic concepts in the classroom is www.teachpsychoanalysis.com.

2. Alternative therapeutic practices. More and more individuals are seeking out alternative forms of physical and mental health care. Some of these approaches include acupuncture, homeopathy, massage, herbology, biofeedback, and art/music therapies. Utilization has increased in recent times, although questions still remain regarding the efficacy of these therapies. Moreover, very few psychologists have training in these areas, and there is little state regulation of these therapies. Students will likely find it interesting to learn of these alternative therapies, and to engage in a discussion about their appropriateness and

Instructor’s Resource Manual (2nd Edition) effectiveness. The following is a useful reference on the topic: Bassman, Lynette E., and Uellendahl, Gail (2003). Complementary/alternative medicine: Ethical, professional, and practical challenges for psychologists. Professional Psychology: Research and Practice, 34, 264-270.

3. Therapy with children. Children, just like adults, can benefit from psychotherapy.

However, young children lack some of the cognitive abilities required for traditional “talk therapies.” Many psychologists believe that children express and deal with their emotions through their play activities. Thus, play therapies are commonly utilized in treating psychological difficulties in children. The following is an excellent resource on the topic that clearly describes a number of play therapy techniques: Hall, Tara M., Kaduson, Heidi Gerard, and Schaefer, Charles E. (2002). Fifteen effective play therapy techniques. Professional Psychology: Research and Practice, 33, 515-522.

Another resource regarding integrating cognitive behavior techniques in play therapy is the following: Knell, S. M. (1998). Cognitive-behavioral play therapy. Journal of Clinical Child Psychology, 27, 28-33.

4. Jungian approaches to psychotherapy. Students who are interested in philosophy, mythology, and spirituality will likely find the ideas of Carl Jung to be very interesting.

Many of Jung’s classic texts are readily available; however, there have been many recently published applications of Jung’s ideas. Some of these include: Bolen, Jean Shinoda. (1985). Goddesses in Everywoman Reissue: A New Psychology of Women. New York: Harper Perennial.

Bolen, Jean Shinoda. (1990). Gods in Everyman Reissue: Archetypes that Shape Men’s Lives. New York: HarperCollins.

Both of these texts draw from Jung’s theories of archetypes and the collective unconscious, and apply these ideas to the experience of males and females.

Joseph Campbell and the Power of Myth (DVD) This is a six-part series of interviews between Joseph Campbell and Bill Moyers. It includes The Hero's Adventure, The Message of the Myth, The First Storytellers, Sacrifice and Bliss, Love and the Goddess, and Masks of Eternity. Campbell’s themes focus on mythology and archetypal symbols, and many of his ideas are drawn from Jung’s theories.

Jung, C. G. (1976). Psychological Types (Collected Works of C. G. Jung, vol. 6).

Princeton University Press.

This text outlines Jung’s theory of psychological types. The Myers-Briggs Type

Instructor’s Resource Manual (2nd Edition) Indicator, which is widely used in career and personal counseling, is based on Jung’s typology.

Jung, C. G. (1981). The archetypes and the collective unconscious (Collected Works of C. G. Jung, vol. 9, part 1). Princeton University Press.

5. Use of the Socratic method in psychotherapy. Aaron Beck’s cognitive therapy is noted for its extensive use of the Socratic method. While this method is traditionally used in academic settings, its principles can be applied to the psychotherapy situation. Typically, the Socratic method involves “teaching by asking”; the questions that are asked are designed to move the client in a particular direction. This method is often used to help clients recognized maladaptive thinking patterns and cognitive distortions, and to assist them in modifying these thoughts. The following is a good resource describing the specific aspects of the Socratic method: Overholser, James C. (1992). Socrates in the classroom. College Teaching, 40, 14.

Interestingly, the use of “leading” questions in psychotherapy has come under fire, particularly in cases of repressed memory and among clients who are eventually diagnosed with dissociative identity disorder. Students may find it useful to learn about the Socratic method in this chapter, and later to debate its merits when learning about dissociative identity disorder.

6. Transcranial magnetic stimulation. The use of ECT for the treatment of depression has been quite controversial. In fact, some critics consider its use to be unethical, given the history of its use, potential side effects, and unknown mode of action. Students may find it helpful to view historical and current footage of the use of ECT. The film Back From Madness (Films for the Humanitites and Sciences) presents excellent footage of ECT, and depicts a depressed individual who undergoes this form of treatment. Studies suggest that the use of ECT is extremely effective in the treatment of severe depression.

Recently, a new variation of this therapy has been developed called transcranial magnetic stimulation (TMS). TMS involves placing a powerful electromagnet on the scalp in order to alter brain activity. A number of peer-reviewed theoretical and efficacy studies have been published; a list of references and abstracts can be found at the following link: http://www.psycom.net/tms.html A mainstream article on the subject is listed below: Travis, John. (2000). Snap, crackle, and feel good? Science News, 158(13), p. 204.

Classroom Activities/Discussion Topics 1. Compare/contrast theoretical orientations. There are several excellent documentary films which conceptualize a client’s difficulties using a range of perspectives. Two of these

Instructor’s Resource Manual (2nd Edition) films are listed below: The World of Abnormal Psychology: Psychotherapy (Annenberg/CPB). This is an excellent series that can be utilized throughout the course. This particular tape features psychotherapy from a psychodynamic, cognitive, Gestalt, and couples approach.

Three Approaches to Psychotherapy (available from Psychological Films, Inc.). There are six parts to this film, featuring the following therapists: Carl Rogers, Fritz Perls, Albert Ellis, Arnold Lazarus, Donald Meichenbaum, and Aaron Beck.

2. Family systems theory. Show students a clip from a television show that depicts a family, and ask them to observe their behaviors, patterns of interaction, and communication styles. If there is an “identified patient,” ask students to note who this character is, and why they are labeled as such. Then ask students to think about how each family member may be contributing to the overall family “functionality” or “dysfunctionality.” This can be a useful way of demonstrating concepts in family systems theory.

3. Changing campus behaviors. Have students identify a campus issue that requires behavior change. These might include cheating, participation in recycling programs, antiprejudice programs, or binge drinking, for example. Divide students into groups, and ask them to select specific behavioral modification techniques to address these situations.

How effective do they think these techniques might be? What might be some potential barriers to effectiveness?

4. The Role of Self-Help in Treating Psychological Disorders. A very common yet often neglected approach to psychopathology is self-help. Many people who do not seek help from psychotherapists may consult books, videos, audiotapes, and television shows. The recent hit show “Dr. Phil” is an excellent example of self-help. For a paper assignment, you might ask students to choose a self-help book and evaluate it based on specific criteria. For example: • What theoretical orientation(s) appear(s) to be used in the book?

• Is the book written by a licensed professional or by a layperson?

• Does the book contain research evidence, accounts of clinical experiences, or personal stories?

• Does the book contain useful exercises?

You might also ask students to visit a bookstore and notice what topics are more heavily covered in the self-help literature. Are there psychological disorders for which no selfhelp materials are available?

Students might also find it interesting to debate the merits and ethical surrounding the use of self-help materials, including Internet-based materials.

5. Keeping a Thought Record. Develop a thought record form for your students and distribute it in class. Ask your students to complete the thought record over a specified

Instructor’s Resource Manual (2nd Edition) period of time. It is often useful to ask your students to focus on specific types of thoughts. For example, you might ask your students to record their thoughts a few days before an exam, during an exam, and after they receive their graded exams. Then ask them to identify maladaptive thoughts and cognitive distortions, and to replace the distorted thoughts with more realistic ones.

Instructor’s Resource Manual (2nd edition)

Chapter 3: Classifying Abnormality: Diagnosis, Assessment, and Research Learning Objectives: By the end of this chapter, students should be able to: • Identify the major advantages and limitations of diagnoses.

• Understand the difference between reliability and validity, and provide examples of how they are measured.

• Discuss the history of current diagnostic systems, referring to Philippe Pinel, Emil Kraepelin, and the shifts in the DSM classification system.

• Describe the “DSM-III revolution,” and discuss the advantages and limitations of this new approach.

• Explain the current DSM-IV multiaxial system, and discuss what information is coded on each axis.

• Describe the methods used to gather information from a client in a clinical setting.

• Explain the difference between a structured and an unstructured interview, noting the advantages and disadvantages of each.

• Identify the most commonly used symptom and personality questionnaires/inventories, and discuss the strengths and weaknesses of these tools.

• Describe the types of cognitive tests that are used, and discuss how these are useful for certain disorders and concerns.

• Discuss the strengths and weaknesses of behavioral observations as a means of gathering clinical information.

• Understand how clinicians integrate information from a wide variety of sources in order to gain an understanding of their clients.

• Describe some of the most common critical thinking errors in abnormal psychology with regard to research • Describe the three major types of research designs: experimental, descriptive, and correlational • Explain the difference between statistical and clinical significance • Identify ethical issues that are important to consider when conducting research on human subjects Lecture Outline: I. The advantages and limitations of diagnoses a. Advantages i. Enables effective communication between clinicians, researchers and teachers ii. Facilitates research iii. Aids in decisions and research regarding treatment b. Limitations i. No diagnostic system can do justice to the uniqueness of individuals’ emotional problems ii. Potential to dehumanize people with oversimplified and stigmatizing “labels”

Instructor’s Resource Manual (2nd edition) c. The DSM has emerged to be the standard classification system for psychopathology d. Reliability – assesses the consistency of diagnoses i. Interjudge/interrater reliability – agreement between two raters or interviewers ii. Test-retest reliability – the consistency of results produced by a test given more than once iii. Correlation – strength of relationship between two phenomena (test scores) – the higher the correlation, the higher the reliability e. Validity – assesses the accuracy of these diagnoses i. Many tests are reliable but have questionable validity – IQ tests and polygraph tests are two examples. ii. Difficult to have good reliability and validity when dealing with complex human behaviors. iii. Forme fruste – an incomplete expression of a disorder. Common occurrence, yet a problem with respect to validity. f. Dimensional vs. categorical systems i. Dimensional – assesses to what degree a person exhibits characteristics of a disorder. ii. Categorical – assesses whether or not a person has a disorder. The DSMIV system is categorical.

II. The history of diagnostic systems for psychopathology a. Philippe Pinel and moral treatment i. Four types of abnormality: melancholia (depression), mania (extreme excitability), idiocy (mental retardation), and dementia (mental confusion). b. Emil Kraepelin – father of modern psychiatric diagnosis i. Proposed a system including 13 disorders c. The advent of DSM i. DSM-I (1952) – contained 108 disorders. ii. DSM-II (1968); 182 disorders iii. DSM-III (1980); 265 disorders iv. DSM-IV-TR (2000) – the most current edition; almost 300 disorders.

III. The DSM-III revolution and controversy a. Until the 1960s, the psychodynamic perspective dominated the mental health field and categories in the DSM-I and DSM-II relied on abstract psychodynamic concepts b. The DSM-III approach i. To improve reliability and validity, diagnostic criteria were made as simple, descriptive, and clear as possible ii. An atheoretical, rather than psychodynamic, approach was taken c. Advantages of the DSM-III approach i. Improved reliability and validity ii. Increased emphasis on diagnosis and research d. Limitations of the DSM-III approach

Instructor’s Resource Manual (2nd edition) i. Remaining reliability and validity problems 1. Some argue that disorders have been invented and normal behaviors have become pathologized.

2. Limiting diagnoses to observable criteria leads to a superficial approach that overlooks the complexity of abnormal beahvior ii. Theoretical bias 1. Although intended to be atheoretical, the DSM may subtly favor the biological approach iii. Cultural insensitivity (although DSM-IV-TR contains a section about “culture-bound syndromes”).

IV. Using the DSM-IV-TR: Making a multiaxial diagnosis a. Axis I and Axis II i. Symptom disorders – involves emotional distress and impairments in functioning; listed on Axis I 1. Tend to be episodic/acute 2. Specific focus 3. Ego-dystonic – symptoms are unwelcome, distressing, and puzzling. ii. Personality disorders – characterized by extreme and rigid personality traits; listed on Axis II 1. Tend to be long-term and chronic 2. Pervasive effects 3. Ego-syntonic – unwelcome, distressing, and puzzling feelings are absent. b. Axes III, IV, V i. Axis III – general medical conditions relevant to the disorder ii. Axis IV – psychosocial/environmental stressors – may affect prognosis iii. Axis V – Global Assessment of Functioning (GAF) – from 100 (excellent) to 1 (extremely impaired).

V. Assessment a. Assessment refers to the process of gathering information for the purpose of making a diagnosis and understanding a client’s emotional problems b. Interviews i. Structured interviews involve following a script – the SCID and MSE are two examples.

1. The consistent structure improves reliability, but may compromise validity. ii. Unstructured interviews involve gathering information through wideranging exploration.

1. May have low reliability iii. Semi-structured interviews may help maximize reliability and validity. c. Tests – not always used, but may help to answer specific diagnostic questions. i. Symptom and personality questionnaires 1. Beck Depression Inventory – II (BDI-II)

Instructor’s Resource Manual (2nd edition) 2. MMPI-2 – most widely used personality inventory 3. Advantages and limitations – these measures are highly standardized, but flexibility may be compromised ii. Projective tests 1. Based on projective hypothesis – assumption that people’s responses to ambiguous stimuli reveal about how their personalities operate in general 2. Produces qualitative data, which can be difficult to translate into quantitatively-based interpretations 3. Examples: Rorschach test, Thematic Apperception Test (TAT), projective drawings (e.g., Draw-A-Person Test) 4. Advantages: assess less observable emotional and personality patterns.

5. Disadvantages: problems with standardization, low reliability and validity. iii. Cognitive tests 1. Intelligence tests a. Examples: WAIS-III, Stanford-Binet, 4th edition a. Useful for assessing mental retardation b. May provide information about other disorders 2. Achievement tests a. Examples: WIAT-II, Woodcock-Johnson b. Help to assess learning disabilities 3. Neuropsychological tests a. Helps distinguish between neurological and psychological factors b. Useful in assessing disorders with neuropsychological symptoms c. Two examples: Halstead-Reitan Neuropsychological Battery, Luria-Nebraska Neuropsychological Battery 4. Biological tests a. Brain scanning and mapping techniques i. Tools for studying the brain (Visual Essay 3): brain dissection/autopsy; ablation/lesions; EEG; electrical brain stimulation, CAT, PET, MRI, fMRI b. Psychophysiological tests i. EMG, biofeedback c. Genetic tests d. Behavioral observations i. Self-monitoring – observations conducted by the client (also known as self-observation) ii. Controlled observations – conducted in a laboratory iii. Naturalistic observations – conducted in everyday environment iv. Provide rich data, yet may be biased.

VI. Diagnosis and Assessment in Perspective: Classifying and Understanding Dave

Instructor’s Resource Manual (2nd edition) a. Review of interview data, test results, and behavioral observations.

VII. Research Methods in Abnormal Psychology a. The Goals of Research and Scientific Thinking i. Accurately describe and understand our world ii. Psychologists use critical thinking skills and research design skills to accomplish this task b. Critical Thinking: the application of sound logic to ideas, beliefs, theories, and accepted “truths” i. Common critical thinking errors 1. Failing to distinguish between correlation and causation 2. Reductionism 3. Dichotomization 4. Fundamental Attribution Error 5. Reification c. Research Design i. Sound research depends on appropriate sampling and appropriate research design 1. Sampling issues a. Proper sampling = the selection of the part of the population of interest that will actually be studied 2. Research design issues a. Experimental designs i. Includes representative sample, easily manipulated variables (independent and dependent variables), and clear hypotheses to test ii. Placebo controls, randomization, double-blind studies b. Descriptive designs i. Aim is to provide an accurate overview or a detailed example of a topic of interest ii. Can be the first step toward the later development of an experimental design iii. Can involved quantitative data, qualitative data, or both c. Correlational designs i. Assess the association or relationship between variables ii. Can be positive or negative iii. Correlation coefficient (-1.00 to +1.00) d. Statistical and Clinical Significance i. Statistical significance does not necessarily mean clinical significance (e.g., antidepressant improvement from severe depression to moderate depression) ii. Importance of replication iii. Meta-analysis

Instructor’s Resource Manual (2nd edition) e. Research Ethics i. Some of the most common ethical issues regarding the use of human subjects involve informed consent, avoidance of physical or psychological harm to participants, and the protection of confidentiality Lecture extensions: 1. Revision of the DSM. Developing revisions to the DSM is an arduous, exhaustive process that can take many years. Students will likely be interested in the theoretical changes that have occurred across editions of the DSM. Once they become familiar with the DSM-IV-TR, they may develop their own opinions about issues such as categorical vs. dimensional diagnoses, the inclusion or exclusion of certain diagnostic categories, and the theoretical underpinnings (if any) of the future DSM-V. A resource to consult in preparation for this discussion is the following: Kupfer, David J., First, Michael B., and Regier, Darrel A. (Eds.). (2002). A research agenda for DSM-V. American Psychiatric Press.

2. Use of the Internet as an Intervention Tool. With the growth of Internet use, the use of online assessment tools and interventions is becoming a controversial topic among psychologists. Some psychologists see the use of the Internet as advantageous. For example, the Internet can reach people who may not otherwise seek psychotherapy, such as individuals suffering from agoraphobia or social phobia. Additionally, web sites can potentially provide useful information about psychological disorders and treatment. On the other hand, some psychologists have voiced concern about ethical issues surrounding Internet assessment and interventions. For example, are online assessment tools reliable and valid? Is there a higher potential for misuse of these tools? Is confidentiality secure with the use of these tools? Two sources to consult about these issues are the following: Buchanan, Tom. (2002). Online assessment: Desirable or dangerous? Professional Psychology: Research and Practice, 33, 148-154.

Ritterband, Lee M., Gonder-Frederick, Linda A., Cox, Daniel J., Clifton, Allan D., West, Rebecca W., and Borowitz, Stephen M. (2003). Internet interventions: In review, in use, and into the future. Professional Psychology: Research and Practice, 34, 527-534.

3. Scoring Systems for Projective Tests. Students may hold the assumption that all projective measures are interpreted by using “intuition.” In fact, in response to criticisms regarding low reliability and validity, scoring systems for several projective tests have been developed. The most widely used scoring system for the Rorschach, for example, is the Exner Comprehensive System. The Comprehensive System does not rely on traditional, idiographic psychoanalytic interpretations; rather, it was an attempt to standardize the test and assign scores to different types of responses, depending on how the blot was perceived, what features of the blot contributed to the response, and the content of the response. Despite the attempts at standardization, many criticisms of the test remain. The following is an interesting resource on the topic:

Instructor’s Resource Manual (2nd edition)

Wood, James M., Nezworksi, M. Teresa, Lilienfeld, Scott O., and Garb, Howard N. (2003). What’s wrong with the Rorschach? Science confronts the controversial inkblot test. Jossey-Bass.

4. More on the Advantages and Limitations of Diagnosis. This chapter discusses some of the strengths and weaknesses surrounding the use of diagnosis. Rosenhan’s study of “being sane in insane places” clearly illustrates some of the dangers of diagnostic labeling; in particular, his study highlights the problem of “becoming” the diagnosis. Yet diagnosis can be very useful, and in some cases, it can be quite liberating and validating for the client. For example, if a client is experiencing a range of symptoms, she may feel a sense of relief in knowing that her cluster of symptoms has a name. In a sense, because her symptoms have been recognized by other clinicians, she may feel extremely validated and relieved. Two readings that further discuss these issues are listed below.

Brown, Laura. (1994). Subversive Dialogues: Theory in Feminist Therapy. New York: Basic Books.

Brown’s chapter “Naming the Pain: Diagnosis and Distress,” is particularly relevant to this topic.

Pitman, Gayle E. (1999). The politics of naming and the development of morality: Issues in feminist therapy. Women and Therapy, 22, 21-38.

5. Assessment techniques with special populations. Sometimes traditional assessment techniques may not be particularly reliable or valid for certain populations. Of course, the most common example cited involves the use of clinical assessment tools with racial and ethnic minorities, particularly those individuals who speak English as a second language. Although some “culture-fair” tests have been developed, some argue that a truly “culture-fair” or “culture-free” tests can never be developed, particularly since psychological constructs are culturally relative. Students may benefit from looking at items included on traditional psychological tests and determining how or whether they are culturally relative.

A good reference on the subject is cited below: Gopaul-McNicol, Sharon-Ann and Armour-Thomas, Eleanor. (2001). Assessment and culture: Psychological tests with minority populations. San Diego, CA: Academic Press.

Classroom activities/discussion topics 1. Evolution of the DSM. Pass around copies of the different editions of the DSM (most academic libraries have all editions) for the students to peruse. Have them identify similarities and differences between editions and/or read sample diagnostic categories from early versions for their critique.

Instructor’s Resource Manual (2nd edition) 2. Categorical vs. Dimensional Debate. Divide class the into groups with one side arguing the advantages for considering mental disorders on a continuum and the other side arguing in favor of a categorical approach.

3. Role-play an interview. Students may find it helpful to see the interviewing process “in action.” Ask for a student volunteer who is willing to be interviewed. The interview material doesn’t have to be clinical, but can be about interests, hobbies, career plans, etc.

Prior to conducting the interview, ask half of the class to record nonverbal behaviors of subject, and the other half to record the nonverbal behaviors of the interviewer (you, the instructor). At the end of the interview, ask students what information they gathered based on their observations of nonverbal behavior. This exercise is useful for demonstrating the strengths of a clinical interview.

4. Evaluating Response Inventories. Show students items from a commonly used response inventory, such as the Beck Depression Inventory or the State-Trait Anxiety Inventory.

How might they improve upon these response inventories? Are there questions that should be included, but aren’t? What are the strengths of these response inventories?

5. Response bias on psychological tests. Students are often intrigued by projective tests such as the Rorschach. Make a few of your own “inkblots” and bring them into class. Ask students what they see in the inkblot. Often, students will take a few moments to respond, or many students won’t respond at all, or students may respond with nervous laughter. After listening to their responses, share your observations of their behavior with your students, and ask them what they were thinking when they responded. Were they worried about giving a strange response, or were they concerned about being labeled as “crazy”? This is a good exercise to point out some of the limitations of psychological testing.

Alternatively, you may choose to discuss response bias on objective tests such as the MMPI-2. Ask your students to think of situations in which a person might want to “fake good” or “fake bad” on a personality test.

6. Psychological tests on the Internet. Many websites offer free “personality” tests that students can easily take and score. Ask students to collect some of these tests and bring them to class. Divide students into groups, and ask them to evaluate the tests in terms of reliability and validity.

A couple of websites where students can find such tests include: www.queendom.com www.tickle.com 7. Research design. Distribute the abstracts for a number of empirical articles representing the three different types of research design (experimental, descriptive, and correlational).

Have students identify the design of each study.

8. Assessment and ethics. The new APA ethics code allows psychotherapy clients to raw

Instructor’s Resource Manual (2nd edition) test data, an ethical guideline that was not included in the previous code. The 1992 ethics code stated that psychologists refrain "from releasing raw test results or raw data to persons, other than to patients or clients as appropriate, who are not qualified to use such information." The spirit of this guideline focused on protecting the client from harm, as many believe that seeing raw test data without understanding how to interpret it may be upsetting to some clients. Yet some felt that the ethics code language was vague and overly general, and created confusion surrounding who is “appropriate” or “qualified.”

The 2002 ethics code revision states that psychologists must release raw test data pursuant to a client release, which is a radical change from the previous ethics code. Yet the 2002 code does state, "Psychologists may refrain from releasing test data protect a client/patient or others from substantial harm, recognizing that in many instances release of confidential information under these circumstances is regulated by law" Present this information to your students, and ask them to debate the pros and cons of client access to raw test data. Some useful readings to support this discussion are included below: Behnke, Stephen. (2003). Release of test data and APA’s new ethics code. Monitor on Psychology, 34, 70.

Bersoff, Donald N. (2003). Ethical conflicts in psychology (3rd edition). Washington, D.C.: American Psychological Association.

Doverspike, William F. (2003). The 2002 APA ethics code: An overview. http://www.division42.org/MembersArea/Nws_Views/articles/Ethics/ethics_code.html The entire text of the American Psychological Association’s Ethics Code can be accessed at the following website: http://www.apa.org/ethics/

Instructor’s Resource Manual (2nd edition) Chapter 4: Anxiety and the Anxiety Disorders Learning Objectives: By the end of this chapter, students should be able to: • • • • • • • • • • • • • •

Differentiate between “fear” and “anxiety,” as well as make the distinction between “state” and “trait” anxiety.

Identify the basic symptom criteria for generalized anxiety disorder, panic disorder, phobias (social phobia, agoraphobia, and specific phobia), obsessivecompulsive-disorder, posttraumatic stress disorder, and acute stress disorder.

Discuss the advantages and limitations of the DSM-IV-TR anxiety disorder diagnoses.

Demonstrate familiarity with the demographic correlates of the various anxiety disorders.

Identify and describe those “culture-bound syndromes” that resemble the DSMIV-TR anxiety disorder diagnoses, and discuss cultural differences with respect to anxiety states.

Using theories of classical conditioning, operant conditioning, social learning theory, and multiple causality, explain how various anxiety disorders develop and are maintained.

Describe the treatment of anxiety disorders from a behavioral perspective, particularly the use of exposure therapies.

Explain the causes and treatments of anxiety disorders from the cognitive perspective.

Identify the various biological components that may contribute to anxiety disorders, including the role of the autonomic nervous system, neurotransmitter activity, genetics, and specific brain structures.

Discuss the available biologically-based treatment options for anxiety disorders.

Using Freud’s structural model of personality, identify the main causes of anxiety and the various defense mechanisms employed during these anxiety states.

Describe the psychodynamic approach to treating anxiety disorders, noting the strengths and weaknesses of this approach.

Using the theme of “multiple causality,” discuss how various approaches may be combined in the treatment of anxiety disorders.

Discuss the relevance of the “mind-body connection” with respect to the anxiety disorders.

Lecture Outline: I. Defining Anxiety and Anxiety Disorders a. Fear vs. anxiety – specific danger vs. general sense of danger i. Fear and anxiety may be considered evolutionarily adaptive b. The importance of context in defining anxiety disorders i. Most anxiety disorders involve minor threats, not clear and imminent danger. c. The continuum between normal and abnormal anxiety i. Trait anxiety

Instructor’s Resource Manual (2nd edition) ii. State anxiety iii. High risk-takers – More likely to engage in dangerous activities, suffer injuries, engage in risky sexual practices, smoke, and use drugs; antisocial personality disorder (APD) linked to low levels of anxiety and high risk-taking.

II. Classifying Anxiety and Anxiety Disorders a. Prevalence of Anxiety Disorders i. Some of the most common mental disorders (18% of Americans suffer from anxiety disorders in any given year) b. Generalized anxiety disorder i. Chronic and pervasive anxiety c. Panic disorder i. Involves the presence of panic attacks (i.e., discrete episodes of acute terror and physiological symptoms; most commonly occur "out of the blue") ii. Fear of future panic attacks often leads to agoraphobia d. Phobias i. Social phobia • Fearful of social situations in which there is a possibility of being observed and judged (e.g., public speaking, attending social events, meeting new people) ii. Agoraphobia • Fearful of wide-open, crowded spaces • People with agoraphobia are often housebound iii. Specific phobia – fall into four categories: • Animal type • Natural environment type • Blood-injection-injury type • Situational type e. Obsessive-compulsive disorder i. Involves the presence of obsessions (i.e., repetitive and unwanted thoughts) and compulsions (i.e., repetitive rituals) ii. Obsessions often involve fears of contamination, disorganization, aggression, sex, or socially inappropriate behavior. iii. Compulsions may or may not be connected to the obsessions they are intended to counteract. f. Posttraumatic Stress Disorder and Acute Stress Disorder i. Posttraumatic stress disorder • Person has experienced a highly traumatic event. a. Trauma – an emotionally overwhelming experience in which there is a real or perceived possibility of death or serious injury to oneself or a loved one b. Traumatic events – war, natural disaster, humanmade disasters (e.g., sexual or physical assault) • Re-experiencing, avoidance, and arousal symptoms

Instructor’s Resource Manual (2nd edition) a. Re-experiencing symptoms i. flashbacks, intrusive memories, nightmares, emotional and physiological distress when confronted with reminders/triggers) b. Avoidance symptoms i. avoiding thinking about the trauma or being around reminders of trauma, feeling detached and numb c. Arousal symptoms i. Feel jumpy, hypervigilant, sleep and concentration problems, anger outbursts • Diagnosed if symptoms continue for more than one month or begin after a month has elapsed since the trauma. ii. Acute stress disorder • Similar symptoms to PTSD, but occur shortly following the traumatic event, last more than two days but less than one month, and are accompanied by dissociative symptoms g. The advantages and limitations of the DSM-IV-TR anxiety disorder diagnoses i. Reliability and validity of these diagnoses are good ii. Anxiety disorder diagnoses are highly co-morbid with other diagnoses. iii. Some clinicians favor a dimensional rather than a categorical approach, since anxiety is present in almost all mental disorders. h. Classification in demographic context i. Age • Adults tend to describe anxiety in terms of emotional, cognitive and/or physiological reactions.

• Children show anxiety behaviorally – crying, tantruming, freezing up, clinging, physical complaints.

• Childhood phobias are common; unlike adults, children rarely view their fears as excessive • Children with PTSD re-experience traumatic events through their play.

• Separation anxiety disorder occurs exclusively in children • Panic disorders may manifest differently in children (e.g., fears of suddenly becoming ill or vomiting) • Anxiety disorders in older adults -- anxiety frequently accompanies dementia ii. Gender • Women 2-3 times more likely to be diagnosed with GAD, panic disorder, specific phobias, and PTSD. a. Lack of assertiveness and self-sufficiency may play a role. b. Genetic and hormonal differences – panic linked to mitral valve prolapse, hyperthyroidism, menstrual

Instructor’s Resource Manual (2nd edition)

• •

cycle. c. Men more likely to be exposed to trauma, but women more likely to develop PTSD symptoms.

OCD occurs equally between men and women, but may manifest itself differently.

Prevalence of trauma types (PTSD) differs between men and women; when exposed to the same trauma, women more likely to develop PTSD

iii. Class • People living in poor urban environments at higher risk for PTSD. a. More likely to experience trauma b. More likely to experience additional risk factors i. Cultural and historical relativism in defining and classifying anxiety disorders i. Nervios ii. Ataque de nervios iii. Shenjing shuairuo iv. Taijin kyofusho v. Many cultures experience anxiety physically rather than emotionally; emotional distress tends to be stigmatized in these cultures. vi. PTSD is a relatively recent addition to the DSM; prior to the Vietnam War, symptoms were thought to be due to cowardice and malingering. vii. Should PTSD be classified as an anxiety disorder or a dissociative disorder?

III. Explaining and Treating Anxiety and Anxiety Disorders a. Biological components i. The autonomic nervous system - two divisions • Sympathetic nervous system ("fight-or-flight") • Parasympathetic nervous system (returns body to resting state) ii. The limbic system • Amygdala – processes sensory information associated with fear • Hypothalamus – plays a role in the expression of conditioned emotional responses a. Hippocampus – involved in memory of fears iii. Neurotransmission • GABA – suppresses nervous system activity (inhibitory) a. Appears to work ineffectively in people with high levels of anxiety. Benzodiazepines bind to GABA receptors and relieve anxiety.

• Norepinephrine – plays a role in the functioning of the

Instructor’s Resource Manual (2nd edition) locus coeruleus – associated with sympathetic nervous system a. Hypersensitive norepinephrine pathways involved in panic attacks and PTSD. • Serotonin – can cause or ameliorate anxiety depending on brain region a. Low levels linked to panic attacks, OCD • Primitive brain structures may be overactive in people with OCD. iv. Autoimmune disorders • PANDAS - unusual condition; children who recently suffered from strep throat develop OCD symptoms v. Genetic factors • High concordance rates (30%-50%) of anxiety disorders among monozygotic twins • Panic disorder, OCD, specific and social phobias appear to be highly heritable. vi. Biological interventions • Barbiturates used until the 1950s, but are highly addictive.

• Benzodiazepines widely used (especially for short term anxiety), but are also addictive.

• Antidepressants (SSRIs and tricyclics) helpful for panic disorder; SSRIs helpful for OCD, PTSD, Social Phobia, GAD • Beta-blockers increase norepinephrine activity – useful for social phobia.

• Azaspirones regulates serotonin – useful for GAD. b. Behavioral components i. Classical conditioning • The case of “Little Albert” – illustrates the role of classical conditioning in the acquisition of an irrational fear • Temporal contiguity – the automatic association of two events that occur at the same time. ii. Operant conditioning • Once people develop a phobic response, they avoid what they fear a. Avoidance behaviors are negatively reinforced (i.e., person is removed from feared/unpleasant situation) b. Avoidance reduces the likelihood of extinction iii. Modeling/vicarious conditioning – some may develop fears by watching others who have the fear. iv. Prepared conditioning – modern-day humans may have a biological predisposition to fear once-dangerous objects. v. Principle of Multiple Causality • Modern behavioral theories of anxiety emphasize

Instructor’s Resource Manual (2nd edition) importance of variables that precede, accompany, and follow anxiety-provoking experiences a. Preceding variables i. genetic factors, early life events, previous learning experiences b. Accompanying variables i. perception of control when faced with a frightening experience c. Postevent variables i. Inflation/reinstatement of fear ii. Reevaluation effect vi. Behavioral interventions • Phobias a. Systematic desensitization – uses principles of classical conditioning i. Teach client relaxation strategies ii. Develop a fear hierarchy 1. Pair relaxation with each item on the hierarchy 2. Can be done in vivo (actual exposure) or covertly (in imagination) b. Virtual reality (exposure via computer-generated environments) c. Flooding – directly confront client with feared situation or object, but without working through a hierarchy. d. Exposure therapies have been found to be generally effective in treating phobias.

• Panic disorder a. Systematic desensitization b. Interoceptive exposure • Obsessive-compulsive disorder a. Exposure and response prevention b. Covert response prevention • PTSD a. Prolonged imaginal exposure c. Cognitive components i. Correct maladaptive beliefs • Fixation on perceived dangers/threats • Overestimation of severity of danger/threat • Underestimation of ability to cope ii. Cognitive schemas – general thought patterns that include beliefs and assumptions. Dysfunctional cognitive schemas tend to be rigid, simplistic, and negative.

Instructor’s Resource Manual (2nd edition) • • •

Cognitive distortions – biased thought processes (e.g., dichotomous reasoning, catastrophizing, labeling, personalization) Anxious thoughts can lead to avoidance behaviors.

Interventions: a. Identify negative automatic thoughts/cognitive schemas b. Evaluate evidence for/against thoughts and schemas c. Identify cognitive distortions d. Challenge and correct distortions e. Combined cognitive and behavioral interventions may be the most effective treatment for anxiety disorders; some studies suggest cognitive interventions alone are as effective as combined approaches

d. Psychodynamic components i. Freudian concepts • Repression is caused by anxiety • Anxiety signals the presence of danger to the ego; the ego responds by initiating defense mechanisms. ii. Phobias • Displacement and projection • In the case of Little Hans, the “horse phobia” developed out of his unresolved Oedipus complex. iii. Obsessive-compulsive disorder • Isolation of affect • Undoing iv. Other anxiety symptoms • Disruptions in early parent-child relationships v. Psychodynamic interventions • Free association • Exploration of underlying emotional conflict • Use of resistance and transference e. Humanistic and Existential Components i. Parents who fail to provide their children with unconditional positive regard may promote the development of maladaptive emotional schemes ii. Existential perspective -- anxiety is useful when accepted and explored; existential anxiety iii. Humanistic and existential interventions • Strong therapeutic alliance • Foster client's curiosity and insight about personal existence

Instructor’s Resource Manual (2nd edition) f. The multiple causality of anxiety disorders i. Cognitive and behavioral strategies are often combined.

• E.g., Exposure and response prevention for OCD • E.g., David Barlow – cognitive-behavioral technique for panic attacks: a. Relaxation training b. Planned exposure to anxiety-provoking situations c. Cognitive interventions ii. Medications may help reduce anxiety so a person can engage in psychotherapy. g. The connection between mind and body in anxiety disorders i. The role of the HPA (hypothalamic-pituitary-adrenal axis) ii. Brain-related changes appear to occur in PTSD. iii. Exposure-based therapies for OCD appear to lead to changes in the brain.

IV. Case Vignettes – Treatment a. Arthur – Panic disorder b. Greg – Obsessive-compulsive disorder Lecture Extensions: I. Alternative treatments for anxiety disorders. Many clinicians, in addition to using traditional psychological interventions such as medication and cognitivebehavioral therapy, have begun to incorporate various alternative therapies into their repertoire. Such therapies are grounded in our understanding of the mindbody connection, and can be used either to prevent anxiety states altogether or to reduce existing feelings of tension and anxiety. Some common alternative treatments include the following: a. Progressive muscle relaxation (PMR). This approach, which involves systematically tensing and relaxing muscles throughout the body while engaging in deep breathing, is very effective for reducing and preventing physical symptoms of anxiety. It is particularly useful for treating bruxism (grinding of the teeth), Raynaud’s syndrome (chronically cold hands and feet, due to blood circulating away from the extremities), tension headaches, neck and shoulder pain, and back pain. An excellent PMR script can be found in The Relaxation and Stress Reduction Workbook. b. Meditation. There are many approaches to meditation, although the primary goal in all of these approaches is to develop focus. Most people meditate by choosing a quiet place and time of day, sitting on the floor or in a chair where upright posture can be maintained, and engaging in deep breathing techniques. Before meditating, one chooses a mantra, which can be a word, a phrase, or a mental image. This mantra is either chanted aloud or inwardly. Whenever other thoughts, worries, concerns, or images

Instructor’s Resource Manual (2nd edition) creep into one’s consciousness, the focus is turned away from these intrusions and toward the mantra. Many people report that this is difficult to do at first, and thus they may begin by meditating for a short period of time (10 minutes). Gradually, as one becomes accustomed to focusing, the meditation period can be extended. c. Guided imagery. This approach involves bringing oneself into a relaxed state by breathing deeply, then imagining various scenes that promote relaxation and empowerment. For example, individuals with fears of flying may use guided imagery during takeoff or landing. They may close their eyes and imagine themselves in a safe, relaxing environment Interestingly, while all of these techniques utilize the mind-body connection by reducing autonomic nervous system activity, they also appear to create a mild state of dissociation. These techniques can be excellent examples of using dissociation for therapeutic purposes.

The following are useful self-help and clinician resources: Bourne, Edmund J. (2005). The anxiety and phobia workbook (4th Edition). New Harbinger Publications.

Bourne, Edmund J. (2001). Beyond anxiety and phobia: A step-by-step guide to lifetime recovery. New Harbinger Publications.

Davis, Martha, McKay, Matthew, and Eshelman, Elizabeth Robbins.

(2000). The relaxation and stress reduction workbook (5th Edition). New Harbinger Publications.

Overholser, J. C. (1991). The use of guided imagery in psychotherapy: Modules for use with passive relaxation training. Journal of Contemporary Psychotherapy, 21(3), 159-172.

Overholser, J. C. (1990). Passive relaxation training with guided imagery: A transcript for clinical use. Phobia Practice & Research Journal, 3(2), 107-122.

II. PTSD or Traumatic Brain Injury? Women in battering relationships frequently report symptoms of PTSD. In fact, many abused women report a cluster of symptoms commonly referred to as battered women’s syndrome (a phrase coined

by Lenore Walker), which can include sleeping difficulties, headaches, dizziness, irritability/aggression, anxiety, depression, affective lability, changes in social/sexual behavior, memory problems, dissociation, isolation, and avoidance.

Some researchers have noted the similarity between some symptoms of PTSD and symptoms of traumatic brain injury (TBI) and postconcussive syndrome (PCS). In one study of battered women, 49 out of 53 women (92%) had been hit in the head, and 21 (40% had lost consciousness). Seventy-seven percent showed signs of postconcussive syndrome, and researchers founds that the number of blows to the head correlated significantly with the severity of cognitive symptoms (Jackson,

Instructor’s Resource Manual (2nd edition) Philp, Nuttall, and Diller, 2002). These studies suggest that women in battering relationships should be assessed routinely for head injury and traumatic brain injuries.

Additional readings on this subject include the following: Jackson, Helene; Philp, Elizabeth; Nuttall, Ronald L., and Diller, Leonard. (2002).

Traumatic brain injury: A hidden consequence for battered women. Professional Psychology: Research and Practice, 33(1), 39-45.

Kubany, Edward S., Hill, Elizabeth E., Owens, Julie A., Iannce-Spencer, Cindy, McCaig, Mari A., Tremayne, Ken J., and Williams, Paulette L. (2004). Cognitive trauma therapy for battered women with PTSD (CTT-BW). Journal of Consulting and Clinical Psychology, 72(1), 3-18.

Valera, Eve M. and Berenbaum, Howard. (2003). Brain Injury in Battered Women. Journal of Consulting and Clinical Psychology, 71(4), 797-804.

III. Interventions Post Mass Trauma. In the wake of atrocities such as the September 11 terrorist attacks, Hurricane Katrina, and the Virginia Tech shooting there is an increased awareness about the potential psychological sequelae among victims and witnesses of mass trauma. However, there has been no evidence-based consensus regarding effective interventions in the immediate aftermath of a trauma. Research has not definitively shown that psychological debriefing prevents PTSD or long-term distress; debriefing may even be harmful for direct survivors of disasters. See the references below for more information regarding these issues. Mental health professionals are also not immune to the symptoms of stress and trauma. The APA article, “Tapping Your Resilience in the Wake of Terrorism: Pointers for Practitioners” (October 2001) is an excellent resource on this topic. It can be found at http://www.apa.org/practice/practitionerhelp.html.

Additional readings on these matters include the following: Eidelson, Roy J., D’Alessio, Gerard R., and Eidelson, Judy I. (2003). The impact of September 11 on psychologists. Professional Psychology: Research and Practice, 34(2), 144-150.

Gersons, B. P. & Olff, M. (2005). Coping with the aftermath of trauma. British Medical Journal, 330(7499), 1038-1039.

Litz, B. T. & Gray, M. J. (2002). Early intervention for mass violence: What is the evidence? What should be done? Cognitive and Behavioral Practice, 9(4), 266272.

Instructor’s Resource Manual (2nd edition) McNally, R. J., Bryant, R. A., & Ehlers, A. (2003). Does early psychological intervention promote recovery from posttraumatic stress? Psychological Science in the Public Interest, 4(2), 45-79.

Classroom Activities/Discussion Topics: 1. Overcoming Test Anxiety. Many students are unfortunately very familiar with the experience of test anxiety. Ask students to describe what happens when they have test anxiety. Explain to students the biological basis of test anxiety (a very helpful resource for understanding the biology of anxiety and stress is "Why Zebras Don’t Get Ulcers" by Robert Sapolsky). Then, divide students into groups and ask them to develop a self-help plan for people with test anxiety.

2. Eye Movement Desensitization and Reprocessing (EMDR). This form of therapy, developed by Francine Shapiro, is used in the treatment of PTSD. It is an extremely controversial therapy, largely because there is no clear-cut explanation of why it works. You might choose to describe this form of therapy in a lecture extension (an excellent overview of the treatment can be found at www.emdr.com). After describing the therapy, divide students into groups and ask them the following questions: a. How do you think this therapy works? b. How would you go about designing a research study to test how this therapy works?

This exercise can give students experience with critical thinking, hypothesis formation, and the limitations of traditional clinical research methods. Students will likely generate multiple hypotheses, yet have difficulty identifying ways of testing or measuring these hypotheses.

Additional readings regarding the EMDR controversy: Maxfield, L., Lake, K., & Hyer, L. (2004). Some answers to unanswered questions about the empirical support for EMDR in the treatment of PTSD. Traumatology, 10(2), 73-89.

Rubin, A. (2003). Unanswered questions about the empirical support for EMDR in the treatment of PTSD: A review of research. Traumatology, 9(1), 4-30.

Rubin, A. (2004). Fallacies and deflections in debating the empirical support for EMDR in the treatment of PTSD: A reply to maxfield, lake, & hyer.

Traumatology, 10(2), 91-105.

Davidson, P. R., & Parker, K. C. H. (2001). Eye movement desensitization and reprocessing (EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, 69(2), 305-316.

Instructor’s Resource Manual (2nd edition) DeBell, C., & Jones, R. D. (1997). As good as it seems? A review of EMDR experimental research. Professional Psychology: Research and Practice, 28(2), 153-163.

3. Self-medication of anxiety disorders. Many people who abuse substances suffer from an underlying anxiety disorder. This can be a good opportunity to introduce the concept of “self-medication” to your students. Ask your students what kinds of behaviors or substances (legal or illegal) can help to alleviate anxiety. What are the short-term and long-term advantages and disadvantages of these behaviors?

Bolton, J., Cox, B., Clara, I., & Sareen, J. (2006). Use of alcohol and drugs to self-medicate anxiety disorders in a nationally representative sample. Journal of Nervous and Mental Disease, 194(11), 818-825.

4. Anxiety disorders in film. There are some excellent films, both classic and contemporary, that can be used to illustrate the symptoms of anxiety disorders.

Some of those films include the following: a. As Good As It Gets – Jack Nicholson portrays a character that shows the classic symptoms of obsessive-compulsive disorder. b. Copycat – Sigourney Weaver gives an excellent portrayal of a forensic psychologist suffering from agoraphobia. c. What About Bob? - A comedy in which Bill Murray's character suffers from a variety of fears d. The English Patient – Juliette Binoche’s character suffers from signs of acute stress disorder. e. Vertigo – This film is useful for helping students understand the concept of derealization. Jimmy Stewart’s character displays this symptom whenever he is in high places. f. Ordinary People – Timothy Hutton portrays an adolescent suffering from PTSD and depression 5. Anxiety Disorders in Literature. There are many literary examples of psychological disorders that provide rich material for the classroom. One particularly good example is a Dorothy Parker story entitled “A Telephone Call.”

In this story, the main character is a young woman who is awaiting a phone call from a man she had met at a social gathering, who had promised to call her. The entire content of the story involves this character obsessively and anxiously waiting for the phone to ring. Ask your students to read this story, and use the story to identify cognitive distortions and maladaptive thinking patterns. You could also ask students to reframe the situation and modify the character’s cognitive distortions. This story can be found in The Complete Stories of Dorothy Parker, edited by Colleen Breese and Mikki Breese. As of this writing, the story could also be found at the following website: http://www.classicshorts.com/stories/teleycal.html

Instructor’s Resource Manual (2nd edition)

Instructor’s Resource Manual (2nd edition)

Chapter 5: Mood and the Mood Disorders Learning Objectives: By the end of this chapter, the student should be able to: • Describe the difference between normal and pathological mood states.

• Identify the historical shifts that have taken place regarding the classification of mood disorders.

• Identify the types of mood episodes required for a DSM-IV-TR diagnosis of a mood disorder.

• Discuss the various demographic factors that appear to contribute to or correlate with depression, including age, gender, and culture.

• Explain how children, adolescents, and adults may exhibit mood disorder symptoms differently from one another.

• Discuss the reasons why females are twice as likely to be diagnosed with depression as males.

• Describe how depression may manifest differently among people in Asian, Native American, Middle Eastern, and Mediterranean cultures, as compared to individuals in the United States.

• Explain how socioeconomic factors may contribute to symptoms of depression.

• Identify the role of genetics in major depressive disorder and the bipolar disorders.

• Describe the neurochemical factors that may contribute to depression and the bipolar disorders, including neurotransmittes and the role of the endocrine system.

• Identify the various abnormalities in brain structure that are associated with depression and the bipolar disorders.

• Identify the biologically-based interventions used to treat mood disorders, noting the specific mode of action, if known.

• Describe the role of negative automatic thoughts, cognitive distortions, and attributional/explanatory styles in major depressive disorder.

• Discuss the types of cognitive interventions used to treat mood disorders.

• Using the behavioral perspective, describe the role of reinforcement and punishment in the development of depression, and discuss the various behavioral treatment strategies.

• Identify the various psychodynamic factors associated with depression, and discuss how psychodynamic psychologists treat mood disorders.

• Describe the sociocultural and family systems approaches to understanding and treating mood disorders.

• Explain how multiple perspectives may be combined to effectively understand and treat mood disorders.

Lecture Outline: I. Defining Mood and Mood Disorders a. The importance of context in defining mood disorders i. Mood variations are expectable and normal ii. Pathological mood states involve emotional extremes that are inappropriate to the person’s context or circumstances. b. The continuum between normal and abnormal mood

Instructor’s Resource Manual (2nd edition) II. Classifying Mood Disorders a. Historical relativism in the classification of mood disorders i. Documented as early as 2600 B.C. in Sumerian and Egyptian writings; the Bible cites examples of depression as well. ii. Hippocrates attributed depression (melancholia) to an abundance of black bile. iii. Emil Kraepelin differentiated between bipolar disorder and schizophrenia in the late 19th century. iv. Karl Leonhard made the distinction between unipolar and bipolar mood disorders in the mid-1950s. b. DSM-IV-TR categories i. Mood episodes – the “building blocks” for the various mood disorder diagnoses. ii. Major depressive episode – requires the presence of at least five symptoms for at least two weeks.

• Symptoms • Cognitive distortions, loss of perspective, and extreme pessimism.

• Depressed individuals may interpret their symptoms as a sign of personal failure.

• Last an average of 6 months.

• High risk for suicide. a. Risk factors for suicide attempts b. Risk factors for completed suicide c. Case example (from Jamison, 1999) d. Facts about attempted suicide, facts about completed suicide, myths about suicide iii. Manic episode – involves a period of elevated, expansive, irritable mood lasting at least one week and including at least three symptoms.

1. Symptoms 2. Mania also involves emotional, cognitive, motivational, and physical symptoms.

3. Manic episodes can evolve into psychotic states.

4. Episodes typically begin and end suddenly, just before or after a major depressive episode. iv. Hypomanic episode – similar to a manic episode, but less severe and of shorter duration.

1. Mood states don’t interfere with functioning v. The DSM-IV-TR mood disorders 1. Major depressive disorder – involve one or more major depressive episodes, but no history of a manic or hypomanic episode. a. Subtypes of major depressive disorder include the presence of catatonic features, melancholic features, atypical features, postpartum onset, and seasonal pattern 2. Dysthymic disorder – less severe but more chronic than major depressive disorder; requires fewer symptoms and lasts for at least 2 years.

Instructor’s Resource Manual (2nd edition) a. “Double depression” – dysthymia with a major depressive episode.

3. Bipolar I disorder – requires the presence of at least one manic or mixed episode a. “Rapid cyclers” have four or more mood episodes in a single year.

4. Bipolar II disorder – involves hypomanic and major depressive episodes 5. Cyclothymic disorder – involves hypomanic and depressive/dysthymic states; less severe but more chronic that Bipolar I or II. c. Classification in demographic context i. Age 1. In children, depression manifests as a loss/delay of developmental achievements.

2. Children also may show physical symptoms and behavioral problems.

3. Depressed adolescents often have trouble in school – common symptoms include irritability, argumentativeness, aggressiveness, withdrawal, hypersensitivity, and increase in risk-taking behaviors.

4. Elderly individuals may be distracted and experience physical complaints; depression is often mistaken for delirium or dementia.

5. Depression is the most common psychiatric disorder among the elderly, although the elderly are less depressed than younger people. ii. Gender 1. Females are twice as likely to be diagnosed with depression as males. a. Some suggest that women may seek help more than men, artificially inflating the risk – most research suggests that the gender difference is real. b. Role stress and discrimination c. Internalization of distress (rumination and self-criticism) d. Increased risk for victimization 2. Bipolar I disorder occurs equally among men and women; bipolar II may be more common among women.

3. Women are at increased risk for all types of mood episodes immediately after giving birth. iii. Culture 1. African-Americans are at lower risk for depression than EuroAmericans; Latinos fall somewhere in the middle.

2. Americans communicate distress using emotional terms 3. Members of traditional Asian cultures experience physical symptoms.

4. Latino/Mediterranean individuals describe depression in terms of “nerves” or frequent headaches.

Instructor’s Resource Manual (2nd edition) 5. Some Native American and Middle Eastern groups describe depression in terms of problems with the heart. iv. Class 1. Depression is associated with poverty, low levels of education, unemployment, limited economic resources.

2. Depression may be worsened by the stress of living in high-crime neighborhoods.

III. Explaining and Treating Mood Disorders a. Biological Components – unipolar depression i. Genetic factors – link supported by family studies, adoption studies, twin studies.

1. Twin studies suggest that heritability is correlated with the severity of the depression.

2. Short form of the 5-HTT gene (“mood gene”) identified as playing a role in depression. ii. Neurochemical factors 1. Monoamines – include norepinephrine, serotonin, and dopamine. iii. Monoamine hypothesis 1. Medications that elevate monoamine levels often relieve depression, although they take effect only after several weeks. iv. Endocrine system 1. The HPA (hypothalamic-pituitary-adrenocortical) axis may play a role.

2. The HPA releases cortisol into the bloodstream during times of stress – high levels of cortisol associated with depression. b. Biological components – bipolar disorders i. Genetic factors 1. Twin studies suggest a high concordance rate.

2. Family and adoption studies also support a genetic role. ii. Neurochemical factors 1. Monoamines appear to increase during mania and decrease during depression.

2. The “switch mechanism” (transition from one mood state to another) is not well understood. iii. Brain structure 1. Major depressive disorder – abnormalities in the prefrontal cortex, basal ganglia, cerebellum, and hippocampus.

2. Bipolar disorders – defects in sodium ion channels. c. Biological Interventions i. Antidepressant medications (see Visual Essay 5) 1. Tricyclics – block reuptake of monoamines a. Effective at relieving depression, but cause many side effects, and don’t take effect for several weeks.

2. MAOIs – block the enzyme that breaks down monoamines. a. Don’t take effect for several weeks.

Instructor’s Resource Manual (2nd edition) b. These drugs have more side effects than the tricyclics, including the inability to metabolize tyramine. c. Both the tricyclics and the MAOIs can be fatal in overdose, which is a concern when treating suicidal individuals.

3. SSRIs – block reuptake of serotonin. a. Take effect more quickly than the tricyclics and MAOIs. b. SSRIs tend to show fewer side effects. ii. ECT – electroconvulsive therapy 1. Triggers a seizure by sending an electric current through the brain.

2. ECT is highly effective for severe depression, although it is not well understood why it works.

3. The practice of ECT has changed considerably over time.

4. Side effects include retrograde and anterograde amnesia, although these effects are usually temporary. iii. Medications – bipolar disorder 1. Lithium – acts as a mood stabilizer. a. The mode of action is still not well understood. b. Often used in combination with certain anticonvulsant, calcium channel blockers, or second-generation antipsychotic medications c. The “therapeutic dose” is dangerously close to the “toxic dose.” d. Lithium often has unpleasant side effects. e. Lithium must be taken consistently in order to work. d. Cognitive components i. The “negative cognitive triad” (Aaron Beck) – an irrationally negative view of the self, the world, and their future. ii. Negative automatic thoughts and self-schemas iii. Cognitive distortions (see Table 5.10) iv. Pessimism and learned helplessness 1. Martin Seligman – studied dogs who were subjected to shocks and who subsequently became “helpless” – this study has been applied to depressed individuals.

2. Pessimistic explanatory (attributional) style – involves the consistent use of internal, stable, and global attributions. v. Cognitive vulnerability 1. A predisposing use of cognitive distortions, negative automatic thoughts, and a pessimistic explanatory style 2. The presence of stressful life events. e. Cognitive interventions i. Sacco and Beck’s interventions 1. Identify/monitor dysfunctional automatic thoughts 2. Recognize the connection among thoughts, emotions, and behavior 3. Evaluate the reasonableness of negative automatic thoughts 4. Substitute more reasonable interpretations for the distorted attributions

Instructor’s Resource Manual (2nd edition)

f.

g.

h.

i.

j.

5. Identify/alter dysfunctional assumptions ii. Treatment of bipolar disorders – involve many of the above interventions 1. Management of hypomanic/manic episodes 2. Suicide prevention 3. Impact on family members 4. Medication compliance Behavioral components i. B.F. Skinner – depression caused by disruptions in reinforcements and punishments. ii. Lewinsohn – identified three conditions for depression: 1. Poor social skills 2. A low-reinforcing environment 3. Diminished capacity to enjoy positive events/heightened sensitivity to negative events Behavioral interventions i. Emphasis is on increasing reinforcement of non-depressive behaviors. ii. “Behavioral activation” – the process of replacing depressive passivity with more active behaviors that are reinforced. iii. Meta-analyses suggest that behavioral and cognitive therapies are more effective than other therapies, medication, and no therapy. iv. Cognitive-behavioral treatment of bipolar disorder 1. Psychoeducation 2. Teach patients how to monitor symptoms 3. Facilitate medication compliance 4. Development of coping strategies to deal with symptoms 5. Teach coping strategies to deal with common precipitating events Psychodynamic components i. Freud – Mourning and Melancholia 1. Depression has its roots in early loss or disappointment.

2. Individuals internalize their anger about the loss, resulting in selfcriticism and depression. ii. Structural theory of personality - depression may be induced by an overly harsh superego. iii. For narcissistic individuals, depression may be triggered by feelings of inadequacy. iv. Object relations theory and self-psychology – depression is rooted in early losses and interpersonal stresses.

Psychodynamic interventions i. Free association, development of insight regarding losses, anger directed at the self, problematic childhood experiences, and an overly harsh superego. ii. Facilitation of a normal grieving process.

Sociocultural and family systems components i. Sociocultural approaches focus on increasing social support and improving self-esteem. ii. Family systems approaches are helpful in treating childhood depression.

Instructor’s Resource Manual (2nd edition) iii. Family therapy can also be useful for helping family members of depressed individuals.

1. IFI model – inpatient family intervention; involves psychoeducation, identification of life stressors, and management of family conflicts. iv. Interpersonal psychotherapy (IPT) – incorporates object relations theory, cognitive and behavioral perspectives.

1. IPT is time-limited and structured.

2. IPT focuses on losses, role disputes, role transitions, and interpersonal deficits.

IV. Case Vignettes – Treatment a. Tamara – major depressive disorder b. Mark – Bipolar I disorder Lecture Extensions: 1. Does Taking an Antidepressant Increase the Risk of Suicide? In recent years, there has been growing concern reported in the media of a possible connection between use of SSRIs and risk of suicide. Interestingly, this is not a new concern; it was expressed as early as the 1970s. Paul Meehl, in his 1973 publication, “Why I Do Not Attend Case Conferences,” expressed the concern that people might be at a higher suicide risk once they start to gain energy from depression. Simply put, he thought that people with depression may entertain thoughts of suicide, but lack the motivation to carry it out.

Once they enter treatment, the physical symptoms may begin to disappear, but the cognitive and emotional symptoms may remain. At this point, clients may still feel depressed and hopeless, but now they have enough energy to carry out a suicide plan.

This has become a commonly accepted piece of “clinical lore,” and clinicians are often advised to pay close attention to their depressed clients during the beginning stages of recovery. Recent studies, however, have begun to challenge this notion, and instead suggest that people who are at heightened risk for suicide are those with more severe depressions to begin with, and not necessarily because they now have the energy to carry out a suicide plan.

Joiner, Thomas E., Jr., Pettit, Jeremy W., and Rudd, M. David. (2004). Is there a window of heightened suicide risk if patients gain energy in the context of continued depressive symptoms? Professional Psychology: Research and Practice. 35, 84-89.

2. Gender Issues and Depression. It is well-known that women are diagnosed with depression twice as commonly as men are. Although many explanations have been offered for this phenomenon, a number of researchers argue that men also suffer from depression, but that the DSM-IV-TR diagnostic criteria are more likely to fit for women.

This argument illustrates the limitations of DSM-IV-TR diagnosis. Symptoms commonly seen in men might include interpersonal conflict, gender role conflict, workrelated issues, threats to self-esteem, narcissistic and antisocial traits, and alcohol and drug use. It is also common for men to mask their depression through the use of

Instructor’s Resource Manual (2nd edition) externalizing behaviors (such as alcohol use, aggression, etc.), rather than through internalizing behaviors (those behaviors more commonly documented in the DSM-IVTR). There appear to be symptom differences between men and women in the United States; interestingly, symptom differences also appear to exist among men in different cultural groups, highlighting the importance of acknowledging cultural relativism.

Cochran and Rabinowitz (2003) suggest ways of assessing depression more accurately in men, and they describe a variety of therapeutic approaches that can be used effectively with men. These approaches include cognitive-behavioral interventions, encouragement of emotional expression, processing issues of loss, couples-oriented approaches, and management of suicide risk.

Additional readings: Cochran, Sam V. and Rabinowitz, Fredric E. (2003). Gender-sensitive recommendations for assessment and treatment of depression in men. Professional Psychology: Research and Practice, 34, 132-140.

Cox, Deborah L., Stabb, Sally D., and Hulgus, Joseph F. (2000). Anger and depression in girls and boys. Psychology of Women Quarterly, 24, 110-112.

Klonoff, Elizabeth A., Landrine, Hope, and Campbell, Robin. (2000). Sexist discrimination may account for well-known gender differences in psychiatric symptoms.

Psychology of Women Quarterly, 24, 93-99.

3. Alternatives to antidepressant medication. St. John’s Wort (hypericum) is an herbal alternative to some of the traditional antidepressant medications. Yet it is a treatment option that is still mired in controversy. The following website, from the National Center of Complementary and Alternative Medicine, provides extensive information about the use of St. John’s Wort, its effectiveness, and safety issues. http://nccam.nih.gov/health/stjohnswort/ This website is particularly well-balanced in its presentation of information about St. John’s Wort. It also cites research studies from Europe and the United States, the major U.S. study finding St. John’s Wort to be ineffective in the treatment of major depression.

The press release for this study can be found at the following website: http://nccam.nih.gov/news/2002/stjohnswort/pressrelease.htm 4. Seasonal affective disorder. Seasonal affective disorder (SAD) is a subtype of major depressive disorder. SAD is a cyclical form of depression; most people who suffer from SAD are more prone to depression during the winter months, when they are less exposed to sunlight. Interestingly, some individuals experience the opposite pattern; they become depressed during the summer months, and their depression lifts during the wintertime.

Rates of SAD appear to be higher in geographical areas that are further from the equator.

Researchers believe that melatonin production is linked to SAD. Melatonin is a hormone produced by the pineal gland that is released at increased levels in the dark. Phototherapy

Instructor’s Resource Manual (2nd edition) (or light therapy), which is used to help suppress levels of melatonin, has been found to be relatively effective in the treatment of SAD. Students might find it interesting to locate websites of companies that sell light boxes or other phototherapy devices.

The following is a helpful book on seasonal affective disorder: Rosenthal, Norman E. (1998). Winter blues: Seasonal affective disorder: What it is and how to overcome it. New York: Guilford.

5. Postpartum depression. Postpartum depression is an often misunderstood disorder. The Andrea Yates case and 2002 verdict brought this syndrome to national attention, albeit in a sensationalized manner. It is common for women to experience the “baby blues” in the days following birth. However, postpartum depression persists for more than a few days, and can significantly impair her everyday functioning. In her recently published book, Natasha Mauthner (2002) noted that, based on her research, many women with postpartum depression felt a strong sense of inadequacy as mothers, an inability to connect with their newborns, anger towards their children and family members, and severe lack of motivation and energy. Unfortunately, it is uncommon for health care practitioners to routinely assess for postpartum depression.

A smaller percentage of women experience postpartum psychosis, which may involve a loss of touch with reality, auditory hallucinations, and delusional beliefs. This is a less common phenomenon, yet the publicity surrounding the Andrea Yates case may have led the public to believe that it occurs frequently.

The following are some resources about postpartum depression. Mauthner (2002) reviews the major theories of postpartum depression and presents research findings from a qualitative study, whereas Clark, Tluczek, and Wenzel (2003) review psychotherapeutic approaches for treating postpartum depression.

Clark, Roseanne, Tluczek, Audrey, and Wenzel, Amy. (2003). Psychotherapy for postpartum depression: A preliminary report. American Journal of Orthopsychiatry, 73, 441-454.

Mauthner, Natasha S. (2002). The darkest days of my life: Stories of postpartum depression. Cambridge, MA and London, England: Harvard University Press.

Classroom Activities/Discussion Topics: 1. How to help a friend who is suicidal. Some students may know of someone who is suicidal, or they may have been suicidal themselves at some point. Students may feel overwhelmed (understandably!) with the idea of preventing someone from committing suicide. Engage students in a discussion of how to help a friend who is suicidal. During this discussion, be sure to inform your students of campus and community resources, such as the health center, counseling services, suicide hotline, etc. A useful article on the subject is:

Instructor’s Resource Manual (2nd edition)

Hubbard, Richard W. (1992). Integrating suicidology into abnormal psychology class: The Revised Facts on Suicide Quiz. Teaching of Psychology, 19, 163-166.

2. National Depression Screening Day. A number of mental health screening days take place on an annual basis, the most widespread one being National Depression Screening Day. Some basic information about the screening can be found at the following website: http://www.mentalhealthscreening.org/depression.htm Divide students into groups, and ask them to design their own “depression screening day.” What kinds of activities do they think are important to plan? What resources should they make available to participants? How might they modify their materials and activities to address bipolar disorder and suicide?

3. Adolescence and depression. Many people erroneously believe that teenagers are inherently morose and moody. In fact, it can sometimes be difficult to distinguish between moodiness and depression. Ask your students to identify behaviors, thoughts, and feelings that might help to identify whether an adolescent is experiencing depression.

Ask them to consider gender issues; might adolescent girls who are depressed look different from depressed adolescent boys?

Broderick, Patricia C. and Korteland, Constance. (2002). Coping style and depression in early adolescence: Relationships to gender, gender role, and implicit beliefs. Sex Roles: A Journal of Research, 46, 201-213.

Cox, Deborah L., Stabb, Sally D., and Hulgus, Joseph F. (2000). Anger and depression in girls and boys. Psychology of Women Quarterly, 24, 110-112.

Marcotte, Diane; Fortin, Laurier; Potyin, Pierre; and Papillon, Myra. (2002). Gender differences in depressive symptoms during adolescence: Role of gender-typed characteristics, self-esteem, body image, stressful life events, and pubertal status. Journal of Emotional and Behavioral Disorders, 10, 29-42.

4. Self-help on the Internet. Many informational sites about bipolar disorder exist on the Internet. Ask your students to locate three informational websites about the disorder, and to evaluate them based on the following criteria: • Is the information accurate? Is it consistent with what is presented in your textbook?

• Does the author of the website cite research studies in support of his or her claims? What is the quality of the supporting evidence?

• Are national and local educational and treatment resources provided?

• Does the website present comprehensive information?

• Is there anything on the website that may potentially be harmful to viewers? If so, what?

Remind your students that Internet materials are not subjected to the same level of pre-

Instructor’s Resource Manual (2nd edition) publication scrutiny that books, articles, and peer-reviewed publications are.

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Chapter 6: Psychological Stress and Physical Disorders Learning Objectives: By the end of this chapter, students should be able to: • Define psychological stress and understand the role of cognitive appraisal.

• Categorize the various types of stressors (life events, daily hassles, chronic stress, catastrophic events).

• Describe the fight-or-flight response and the general adaptation syndrome.

• Discuss the study of psychoimmunology and the effects of stress on the immune system.

• Describe the connection between stress and cardiovascular disease and other medical disorders.

• Identify the major personality traits associated with styles of coping with stress.

• Discuss the major relaxation techniques used in stress reduction.

• Explain how biofeedback can be useful in reducing stress-related physical symptoms.

• Describe the cognitive interventions that are commonly used in treating stress-related disorders.

• Discuss the role of social support in treating stress-related disorders, citing specific types of support.

• Differentiate between the somatoform disorders and the factitious disorders, citing specific examples.

• Define the term “malingering,” and understand how it differs from the factitious disorders.

• Discuss the history of the term “hysteria” and how its conceptualization has changed from Freud’s time to the present.

• Identify and describe the major somatoform disorders: conversion disorder, somatization disorder, pain disorder, hypochondriasis, body dysmorphic disorder.

• Describe the advantages and limitations of the DSM-IV-TR somatoform disorder diagnoses.

• Discuss the cultural factors that relate to the somatoform disorders, particularly with respect to age, gender, and class.

• Understand the psychodynamic view of somatoform disorders, particularly the role of defense mechanisms and the concept of primary vs. secondary gain.

• Describe the cognitive-behavioral view of somatoform disorders, and cite examples of cognitive-behavioral interventions.

• Identify the major sociocultural and biological components of somatoform disorders.

• Cite examples of the mind-body connection with respect to the somatoform disorders.

Lecture Outline: I. Psychophysiology: Defining Psychological Stress a. Stress is a reaction to physically and psychologically taxing events. b. Stress also involves an interaction between people and their environments. c. Cognitive appraisal of stress i. Cognitive appraisals focus on 2 factors: • Whether the event poses a threat to immediate or long-term wellbeing

Instructor’s Resource Manual (2nd edition) • Whether adequate resources are available to manage the threat. ii. The most stressful events are those that are: felt to be negative, uncontrollable, ambiguous, unpredictable, and/or require significant adaptation.

II. Categorizing Stressors a. Life events – first researched in the 1960s. i. Social Readjustment Rating Scale (SRRS) – includes a range of positive and negative life events (Table 6.1) b. Chronic stress i. Chronic stressors such as low-quality neighborhoods, caring for a spouse, and household density are associated with poorer health and psychological distress. c. Daily hassles i. “Microstressors” are associated with physical and emotional symptoms. ii. Major life events trigger a cascade of daily hassles. iii. Daily hassles are largely subjective; what affects one person may not affect another. d. Catastrophic events i. Events are perceived to be traumatic depending on the duration, severity, proximity, the degree of psychological difficulty, and the availability of social support. ii. Symptoms can persist in the form of posttraumatic stress disorder (PTSD). iii. Studies of the 9/11 attacks and the Oklahoma City bombing show major posttraumatic effects.

III. Explaining Stress and Health: Psychophysiological Disorders (i.e., illnesses significantly influenced by emotional factors) a. Effects of psychological stress on health-related behaviors i. Psychological stress decreases health-promoting behaviors and increases unhealthy behaviors. b. Effects of psychological stress on physiological reactions i. Fight-or-flight response – first described by Walter Cannon (1932) • Involves the sympathetic branch of the autonomic nervous system ii. General Adaptation Syndrome (GAS) – Hans Selye • Alarm phase – mobilization of bodily defenses • Resistance phase – body attempts to adapt to the stressor • Exhaustion phase – body loses the ability to adapt to chronic stress; suffers physical damage. iii. Stress and the immune system • Psychoneuroimmunology – the study of the effects of stress on the immune system.

• Viral challenge studies – participants are evaluated for the degree of stress in their lives, then deliberately exposed to cold or flu viruses; higher levels of stress are associated with increased illness rates.

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Illness usually results from a combination of factors (multiple causality).

• Stress may have an effect on B cells, T cells, and natural killer cells (example: HIV virus) • Immunosuppression can result from chronic stress (see Visual Essay 6). iv. Stress and cardiovascular disorders (CVDs) • There is a great deal of variation in cardiovascular reactivity; this can be assessed using the Stroop task or the cold pressor task.

• Stress and hypertension a. Chronically elevated blood pressure increases the risk for stroke, coronary heart disease, and kidney failure. b. Essential hypertension is hypertension not primarily caused by biological factors.

• Stress and coronary heart disease (CHD) a. CHD is the leading cause of death in the U.S. b. CHD occurs disproportionately among African-Americans (see Box 6.1) c. CHD can include arteriosclerosis, atherosclerosis, and myocardial infarction (heart attack). d. Type A personality, particularly when it includes hostile, irritable, and antagonistic behavior, poses a significant risk for CHD. v. Stress and other medical disorders • Stress has been found to contribute to asthma, migraine headaches, and cancer.

• Earlier research suggested a “cancer personality” profile; current research suggests no such profile.

• Stress-related behaviors and immunosuppression may contribute to cancer. c. Effects of certain personality traits on the management of psychological stress and, consequently, on health-related beahviors i. Pessimism and optimism • A pessimistic explanatory style involves the tendency to attribute negative events to stable, internal, and global factors.

• Longitudinal studies suggest a link between pessimistic explanatory styles and poor health.

• People with optimistic explanatory styles may engage in healthpromoting behaviors because they are optimistic that their choices will have a positive effect. ii. Repressive coping • Involves actively suppressing negative emotions to the point where they are unaware that they’re experiencing these feelings.

• People with a repressive coping style tend to underreport feelings of subjective distress and exaggerate cheerful, happy feelings.

Instructor’s Resource Manual (2nd edition) IV. Reducing Stress and Treating Psychophysiological Disorders a. Relaxation and Meditation i. Relaxation training, progressive muscle relaxation, meditation, and breathing exercises can reduce and prevent physiological signs of stress. ii. The benefits of meditation and mindfulness have been shown via brain imaging techniques b. Exercise i. Physical exercise reduces psychological stress and thereby helps to prevent the occurrence of stress-related mental and physical health problems ii. Exercise can also help with the treatment of psychological disorders iii. Exercise may reduce depression by stimulating the adaptive regulation of serotonin receptors, improving the quality of sleep, and increasing feelings of mastery and self-efficacy c. Biofeedback i. Teaches people to attend to and partially control problematic physiological responses with the help of feedback. ii. Biofeedback is used for a variety of disorders including temporomandibular disorders, asthma, essential hypertension, migraine headaches, GI disorders, Raynaud’s disease, and insomnia. d. Cognitive retraining i. Help to reduce thoughts that contribute to stress and susceptibility to disease, and help ill people adopt adaptive attitudes and behaviors. ii. Cognitive-behavioral stress management (CBSM) has been found to improve the health status of those diagnosed with an illness. iii. Cognitive-behavioral interventions can help people reduce catastrophizing cognitions, which may prevent them from engaging in health-promoting behaviors. e. Social support i. Emotional support – reduces stress by providing an outlet for emotions. ii. Instrumental support – reduces stress by providing practical and tangible support. iii. Informational support – reduces stress through the availability of advice and feedback. iv. Table 6.3 – Possible ways that social support reduces stress and improves health outcomes v. Social support protects from the onset of disease, and it improves physical/mental health outcomes among those who are already ill.

V. Defining the Somatoform Disorders a. Somatoform disorders – involve the presence of physical symptoms or concerns that are not due to a medical disorder. b. Factitious disorders – symptoms are intentionally produced because the person wants to be perceived as sick. i. Box 6.3 – describes factitious disorders (Munchausen’s syndrome and Munchausen’s syndrome by proxy) and malingering.

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VI. Classifying the Somatoform Disorders a. Hysteria – Freudian term used to denote any disorder involving physical symptoms resulting from the repression of anxiety-provoking impulses. b. DSM-III moved away from the diagnosis of hysteria (which had been associated with psychoanalysis) towards more symptom-based diagnoses; somatoform disorders were thus included as a separate diagnostic category. c. DSM-IV-TR categories i. These disorders are encountered primarily in medical settings, and all possible medical explanations need to be ruled out. ii. Conversion disorder • Involves specific symptoms or deficits in voluntary motor or sensory functions with no physiological cause • Once known as hysteria.

• The case of Anna O. (Sigmund Freud and Josef Breuer) • Physician’s are able to detect conversion symptoms because they “typically do not conform to known anatomical pathways and physiological mechanisms” • La belle indifference – common among people with conversion disorder; physical symptoms do not seem to bother them. iii. Somatization disorder • Involves a collection of physical symptoms over a long period of time.

• People with somatization disorders are heavy utilizers of health care services.

• The first two versions of the DSM called this disorder Briquet’s syndrome. iv. Pain disorder - characterized by complaints of physical pain that cannot be accounted for by a medical condition. v. Hypochondriasis - preoccupation with and misinterpretation of minor symptoms. vi. Body dysmorphic disorder – preoccupation with an imagined deficit in appearance. d. The advantages and limitations of the DSM-IV-TR somatoform diagnoses i. The somatoform disorders were once lumped together with the dissociative disorders; currently they are a separate, unique diagnostic category. ii. Although the somatoform disorders are characterized by a focus on bodily concerns, they don’t necessarily have any causal features in common. e. Cultural and historical relativism in defining and classifying somatoform disorders i. Different somatic complaints exist from culture to culture. ii. Body dysmorphic disorder appears to remain consistent across cultures. f. Classification in demographic context i. Gender • Conversion symptoms occur disproportionately among women.

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•

ii. Age •

a. Ancient Greeks believed that hysteria was caused by a “wandering uterus.” b. Contemporary theories address whether women are more likely to internalize symptoms, whereas men are more likely to externalize symptoms. c. Men with conversion disorder also tend to exhibit characteristics of antisocial personality disorder.

Hypochondriasis and body dysmorphic disorder occur equally among men and women. a. Women with body dysmorphic disorder tend to focus on hips and weight, use makeup to hide perceived flaws, and to suffer from bulimia nervosa. b. Men with body dysmorphic disorder tend to focus on body build, genitalia, or thinning hair; they also tend to be single and to abuse alcohol.

Children often show occasional somatic complaints, although somatoform disorders usually don’t develop until adolescence or early adulthood.

iii. Class • Somatization disorder and hypochondriasis occur more frequently among members of lower socioeconomic classes.

• Conversion disorder occurs more in rural areas, among low-SES individuals, and those less fluent in medical/psychological concepts.

VII. Explaining and Treating the Somatoform Disorders a. Psychodynamic components i. Freud and Breuer’s work with hysteria (Anna O.) – “hysterical conversion” involved the conversion of uncomfortable emotions into physical symptoms. ii. Modern psychodynamic theorists emphasize the role of repression. iii. Conversion symptoms may offer some advantages: • Primary gain – alleviating distress • Secondary gain – eliciting attention and concern from others, or bringing on another type of reward. iv. Other somatoform disorders are seen as a metaphor for psychological distress. v. Psychodynamic interventions: • “Meeting the client where he/she is” and developing a therapeutic alliance.

• Using free association, reflections, memories, dreams, and transferences.

• Therapists watch for the use of repression, displacement, and regression. b. Cognitive-behavioral components

Instructor’s Resource Manual (2nd edition) i. Emphasize behavioral and cognitive processes by which somatic symptoms are developed and maintained (e.g., modeling, reinforcement) ii. Children whose parents express emotional pain physically may learn to do the same. iii. Parents may reinforce children’s somatic complaints by exhibiting warmth and caring, and by making fewer demands on children who are not feeling well. iv. Symptom amplification and catastrophizing are common cognitive distortions, particularly among hypochondriacs v. Cognitive-behavioral interventions: • Provide rationale reasons for clients to consider addressing their physical symptoms differently than they have in the past • Provide behavioral prescriptions to reduce the reinforcement of symptoms • Provide alternative coping skills • Discourage client from seeking reassurance about their physical complaints • Exposure and response prevention effective in treating body dysmorphic disorder.

• Cognitive restructuring is useful for all of the somatoform disorders, particularly for body dysmorphic disorder (see the A-BC-D-E model). c. Sociocultural components i. Somatization disorder in adults is highly correlated with a history of sexual abuse and with being raped as an adult. d. Biological components i. Since somatization disorders often co-occur with depression and anxiety, medications can sometimes be helpful. ii. People with somatization disorders tend to experience more medication side effects, are at risk for abusing medications, and may already be taking other medications. e. The connection between mind and body in somatoform disorders i. There may be some similarities in the neurological basis of hypnosis and conversion disorder. ii. Some clinicians view conversion disorder as an autosuggestive disorder – they have hypnotized themselves into believing that they have lost some form of physical functioning. iii. Freud and Breuer initially used hypnosis to treat conversion disorder/hysteria.

VIII. Case Vignettes – Treatments a. Robert – coronary heart disease b. David – somatization disorder

Instructor’s Resource Manual (2nd edition) Lecture Extensions: 1. Emotional expression and mental health. In the United States, being “emotional” is often seen as a negative (and overly feminine) characteristic. Males, in particular, are discouraged from expressing distressing emotions such as sadness, fear, vulnerability, and shame. A number of studies have documented a link between emotional inhibition and physical and mental illnesses. James Pennebaker is probably credited the most for his research on the psychological benefits of writing about emotions. His popular book Opening Up (The Guilford Press) discusses the effect of trauma and inhibition on the immune system, the connection between mind and body, and the ways in which writing can be used in treatment or as a self-help tool. Pennebaker also has a wonderful way of making research come to life; his book may stimulate some of your students to pursue a career in research!

Other resources on this topic include the following: Lepore, Stephen J. and Smyth, Joshua M. (2002). The writing cure: How expressive writing promotes health and emotional well-being. Washington, D.C.: American Psychological Association.

Pennebaker, James W. (1995). Emotion, disclosure, and health. Washington, D.C.: American Psychological Association.

2. Controversial stress-related disorders. Your textbook describes the history of the term “hysterical conversion,” particularly as it applied to the case of Anna O. This syndrome involved the “conversion” of emotional distress into physical symptoms.

While “hysteria” or “hysterical conversion” is not diagnosed today, there are some modern-day conditions that bear similarity to these early disorders. Two of the more controversial ones are chronic fatigue syndrome (CFS) and multiple chemical sensitivity syndrome (MCS). In fact, CFS in particular closely resembles “neurasthenia,” a term used in the 1860s to describe a disorder involving weakness and fatigue.

The symptoms of CFS typically resemble those of the flu, and may also include headaches, muscle aches, tender lymph nodes, and fatigue. Many report that bouts of CFS tend to be triggered by stress, illustrating the mind-body connection. MCS symptoms may include fatigue, difficulty concentrating, depression, memory loss, dizziness, headaches, and weakness. MCS can be triggered by exposure to chemical agents, including fragrances, insecticides, household cleaners, paints, or fuel exhaust.

Interestingly, both CFS and MCS are comorbid with a number of psychological disorders, depression being the most common. MCS in particular appears to share a link with posttraumatic stress disorder, and some suggest that there are marked similarities between the two syndromes.

Unfortunately, as was the case with conversion disorders and neurasthenia, it is commonly believed that CFS and MCS are “all in the patient’s head,” or

Instructor’s Resource Manual (2nd edition) “overexaggerated.” Clearly, more research needs to be conducted on the causes and treatments of these two disorders. The following are further resources on these issues: http://www.niaid.nih.gov/factsheets/cfs.htm This is a fact sheet about CFS that is published by the National Institute of Allergies and Infectious Diseases.

Bell, Iris. (2003). Multiple chemical sensitivities. Psychiatric Times, 20.

Magill, Michael K. and Suruda, Anthony. (1998). Multiple chemical sensitivity syndrome. American Family Physician.

The movie, Safe, portrays a woman (Julianne Moore) with MCS. 3. Stress reduction clinics. Increasingly, psychologists are recognizing the connection between the mind and the body, particularly as it relates to stress and health. More specifically, the development of the diathesis-stress model has led psychologists to understand the connection between predisposing factors and precipitating factors (i.e., stressors) as they pertain to psychological disorders. In an effort to prevent psychological distress from worsening and to provide clients with long-term coping strategies, “stress clinics” are beginning to emerge as viable interventions. Jon KabatZinn pioneered this approach with his Stress Reduction Clinic at the University of Massachusetts Medical Center. His approach utilizes what is referred to as mindfulness-based stress reduction, which applies mindfulness meditation in order to maximize one’s capacity to cope with stress. Interestingly, Kabat-Zinn’s ideas have caught on and been applied to other treatment approaches, most notably Marsha Linehan’s Dialectical Behavior Therapy (DBT). More about Kabat-Zinn’s clinic can be found at the following website: http://www.umassmed.edu/behavmed/clinics/ A number of other stress reduction clinics have been established to serve other populations. The Behavioral Health Stress Clinic at the University of California, Santa Cruz provides college students with psychological approaches to reducing and managing stress. These include cognitive therapy techniques, relaxation training, mindfulness activities, biofeedback, and encouraging the use of social support. Of course, students are at a high risk for stress-related psychological and physical disorders, as the demands of academia require them to withstand high levels of stress.

More about the Behavioral Health Stress Clinic can be found at the following website: http://www2.ucsc.edu/counsel/stress_reduction_clinic_guidelines.html 4. “Fight-or-flight” or “tend and befriend”? Until recently, most researchers have accepted unquestioningly the concept of the “fight-or-flight” response. Shelley Taylor, a health psychologist at UCLA, began to challenge that concept, particularly as it applies to women. As she began to research this idea, she and her graduate students noticed that all of the available research on stress had been conducted with male subjects, and that no information had been derived from females. Based on that observation, Taylor recognized a gender bias in the research and began to develop her

Instructor’s Resource Manual (2nd edition) own theory of stress, which is based largely on evolutionary theory. Her theory, which she calls the “tend and befriend” response, suggests that women in particular may be biologically programmed to tend to their young and seek out social support in times of intense stress. Although she applies this theory primarily to women, Taylor emphasizes the idea that humans would most highly benefit if they drew upon both styles of dealing with stress – at times going it alone, and at other times seeking out support and caring for others.

Although Taylor’s theory has received widespread support, it is not without its critics.

Some feminists, for example, embrace the fact that Taylor recognized a blatant gender bias in the research on stress and coping. However, others suggest that Taylor’s theory may be promoting and reinforcing gender stereotypes, particularly the idea of “woman as nurturer” and “woman as relational.” Nevertheless, Taylor’s theory is groundbreaking and has paved the way for further exploration of the stress-response system in both males and females.

Taylor, Shelley E. (2002). The tending instinct: How nurturing is essential to who we are and how we live. New York: Holt.

Classroom Activities/Discussion Topics: 1. What are your “red flags”? Many people recognize that they are experiencing excessive levels of stress when they begin to experience physical symptoms. Ask students to make a list of physical symptoms that they commonly experience during periods of extreme stress. These symptoms might include headaches, shoulder and neck tension, back pain, insomnia, changes in appetite, changes in motivation and energy level, etc. Then ask your students to keep a “stress log.” Each day, ask students to keep track of the various stressors they experience, as well as their physical symptoms.

After a period of two weeks, ask students to evaluate their “stress log.” Were their physical symptoms associated with high stress levels? It may also be useful to ask students to track their “patterns of consumption” – eating, smoking, drug/alcohol use, exercise, sleeping, etc. – to see whether those patterns change during times of stress.

2. Using biofeedback to manage stress. Students have an easier time understanding the concept of biofeedback if they can see it “in action.” If your psychology department has access to biofeedback materials, bring them to class to use for this exercise. If you don’t, a simple heart rate monitor is sufficient for this exercise. Ask for a student volunteer, and demonstrate with this volunteer how the monitor merely provides information about heart beats per minute. Based on this information, the student can increase or decrease activity in order to raise or lower his or her heart rate. This exercise can help to demystify the concept of biofeedback. It is also a powerful tool in demonstrating the connection between the mind and the body.

3. Resources for health care practitioners treating somatoform disorders. Because people with somatoform disorders are more likely to seek help from a physical health care practitioner rather than from the mental health system, health care practitioners need to

Instructor’s Resource Manual (2nd edition) be familiar with the symptoms of these disorders. More importantly, practitioners need to understand the psychological characteristics of these individuals, particularly the fact that they are likely to be resistant to the idea that their distress has a psychological component. Divide your students into groups, and ask each group to develop a list of tips for health care practitioners. Things for your students to think about may include the following: • Is it possible that there is an undiagnosed physical disorder that has not been ruled out? This can occur particularly with neurological disorders.

• How can a health care practitioner encourage the person to seek psychological help without provoking defensiveness? How can psychologists assist in this process?

• How can health care practitioners prevent the problem of overutilization of health care services?

• How can health care practitioners address cultural factors that may be contributing to the somatoform disorder? In some cultures, individuals may be more likely to express psychological distress through physical symptoms.

4. Somatic complaints across cultures. Refer your students to the list of culture-bound syndromes listed in the DSM-IV-TR. Ask them to identify the syndromes that have a somatic component to them. Then ask your students to perform a content analysis. As they do this, they might note the following: • Are these disorders represented across a range of cultures, or are they more prevalent in specific cultures?

• What themes do students notice in these disorders? For examples, do some of the disorders involve issues of sexual functioning? Do some involve symptoms of weakness or fatigue?

• Do any of the disorders bear similarity to disorders seen in the U.S.? In this component of the analysis, you might ask students to consider the somatoform disorders as well as disorders like CFS, MCS, and fibromyalgia.

Instructor’s Resource Manual (2nd edition)

Chapter 7: Dissociation and the Dissociative Disorders Learning Objectives: By the end of this chapter, the student should be able to: • Understand the difference between adaptive and maladaptive forms of dissociation.

• Define the DSM-IV-TR dissociative disorder diagnoses, noting specific criteria.

• Differentiate between organic and psychogenic amnesia, and identify the various types of amnesia.

• Describe the various types of personalities common in individuals with DID. • Identify the various age, gender, and cultural factors that contribute to or correlate with dissociative disorders.

• Describe the various culture-bound syndromes that involve dissociative symptoms.

• Discuss the historical shifts that have occurred with respect to our understanding of dissociative disorders.

• Explain the difference between the posttraumatic model (PTM) and the sociocognitive model (SCM), and use these models to address research findings on dissociative disorders.

• Using psychodynamic theories, identify the major defense mechanisms used in people with dissociative disorders, and discuss specific psychodynamic interventions.

• Explain the behavioral approach to understanding dissociative disorders, and identify the strengths and limitations of this approach.

• Describe the self-hypnosis theory and peritraumatic dissociation effects on memory and attention, and discuss the various cognitive interventions used to treat dissociative disorders.

• Discuss various drug-induced dissociative states and how they contribute to our understanding of dissociative disorders.

• Describe the various biologically-based treatments that have been used in the past as well as currently.

• Using the concept of multiple causality, describe the stages of treatment for dissociative disorders, and provide examples of what takes place during each stage.

Lecture Outline: I. Defining Dissociation and the Dissociative Disorders a. Dissociation – disruption in consciousness, memory, and/or sense of identity when caused by psychological, not biological, factors b. The continuum between normal and abnormal dissociation i. Déjà vu and daydreaming are normal and common. ii. On the abnormal end – extreme and chronic dissociative states in which people literally forget who they are and shift involuntarily between alternate identities iii. In the middle of the continuum are mildly disruptive dissociative symptoms include “spaciness” c. The importance of context in defining dissociative disorders i. Adaptive forms of dissociation exist – are the symptoms assisting the person in a particular situation?

Instructor’s Resource Manual (2nd edition) ii. Maladaptive forms of dissociation – are the symptoms interfering with one’s ability to function?

II. Classifying Dissociative Disorders a. DSM-IV-TR categories i. Depersonalization disorder – involves persistent feelings of detachment and unreality ii. Dissociative amnesia – forgetting basic information about identity or recent past; usually follows a traumatic event.

1. Types of amnesia: a. localized amnesia b. selective amnesia c. generalized amnesia d. continuous amnesia e. systematized amnesia 2. Is the amnesia biologically-based or psychogenic (dissociative)? a. Organic amnesia usually involves personal and general information; also may involve anterograde amnesia. b. Dissociative amnesia usually involves only personal information; also may involve retrograde amnesia. iii. Dissociative fugue – involves loss of memory, confusion about identity, and an abandonment of one’s previous life/identity.

1. Usually occurs after a traumatic event 2. Person often recovers spontaneously 3. Person usually cannot recall the fugue state iv. Dissociative identity disorder – also known as multiple personality disorder; involves the presence of two or more distinct identities.

1. “Host” personality – retains person’s name and identity and functions in the outside world.

2. “Persecutory” personalities may be aggressive and hostile.

3. “Protector” personalities may try to protect the host personality 4. “Lost time” – loss of memory for events during which another personality was present.

5. Mind-body connection – studies suggest that different personalities may have distinct physiological differences (e.g., EEG). v. Classification in demographic context 1. Age a. Dissociative symptoms may be normal and common among children and adolescents. b. Children with dissociative disorders exhibit more extreme symptoms.

2. Gender a. Females are overwhelmingly diagnosed with dissociative identity disorder; may be due to higher rates of sexual abuse among girls. b. Males with DID may be more likely to be involved with the

Instructor’s Resource Manual (2nd edition) legal system than with the mental health system. b. Cultural and historical relativism in defining and classifying dissociative disorders i. Culture-bound syndromes 1. South Asian cultures – “spirit possession” 2. African/Asian cultures – “possession trance” 3. Eskimo/Central American cultures – running amok (Malaysia) 4. African-Americans/inhabitants of the Bahamas – “falling out” or “blacking out” ii. Historical shifts 1. Hysteria – seen in ancient Greece up to the mid-20th century; involved dissociative symptoms 2. DSM-I – dissociative disorders combined with somatoform disorders 3. DSM-III – dissociative and somatoform disorders were divided into separate categories. c. The advantages and limitations of the DSM-IV-TR dissociative disorder diagnoses i. Posttraumatic model (PTM) – DID viewed as a response to early childhood trauma; dissociative symptoms serve as survival strategies. ii. Sociocognitive model (SCM) – DID is inadvertently created and maintained by well-meaning therapists.

1. iatrogenic – “doctor-borne”; DID may be created in suggestible individuals by clinicians. iii. PTM/SCN positions on dissociative identity disorder 1. Fact. The majority of people with DID report histories of childhood abuse a. PTM: there is objective documentation of these histories (see Table 7.7) b. SCN: there are problems with retrospective research (see Box 7.2 and Box 7.3) 2. Fact. The diagnosis of DID has increased dramatically since 1980 a. PTM: may be due to clearer diagnostic criteria b. SCN: may be due to increasing public fascination with the concept of multiple personalities 3. Fact. DID is diagnosed primarily within the U.S. and Canada a. PTM: it may be underreported in other countries b. SCN: DID may be highly influenced by cultural factors.

4. Fact. DID symptoms can be faked in people who do not really have the disorder a. PTM: Whether or not the symptoms of a disorder can be created in a laboratory has nothing to do with the legitimacy of the diagnosis b. SCN: Studies show that people can convincingly enact multiple identities – people may develop DID symptoms in response to external cues and prompts

Instructor’s Resource Manual (2nd edition) III. Explaining and Treating Dissociation and the Dissociative Disorders a. Psychodynamic components i. Repression is thought to be the underlying defense mechanism. ii. Splitting – the tendency to see people as all good or all bad. iii. Identification – an excessive use of imitating/adopting admired qualities in others. iv. Psychodynamic interventions 1. Provide a safe and supportive environment for the exploration of past traumas and the defense mechanisms developed to protect against overwhelming emotions 2. Identifying more adaptive coping strategies 3. Focus on restoring a client’s sense of personally safety, developing a strong therapeutic alliance, and understanding the effects of trauma on the client’s general functioning b. Behavioral components i. Operant conditioning – splitting of consciousness relieves anxiety, which is reinforcing. ii. Behavioral interventions – may be combined with other interventions, but are rarely used alone. c. Cognitive components i. Self-hypnosis theory – people who dissociate may be self-hypnotizing in order to mentally remove themselves from painful experiences. ii. A large number of people who have been traumatized experience peritraumatic dissociation (i.e., alterations in consciousness at the time of the trauma) 1. Associated with disrupted or disorganized memory for the trauma itself 2. Associated with disruptions in normal attentional processes posttrauma iii. Cognitive interventions 1. Schema-focused cognitive therapy (SFCT) – assumes that emotionally-charged schemas developed in childhood and lead to cognitive distortions. a. DID due to schema maintenance, schema avoidance, and schema compensation.

2. Hypnosis – clients undergo a controlled form of dissociation in order to recall and process traumatic experiences. a. Hypnosis may involve cognitive restructuring. b. Use of hypnosis is controversial – may have iatrogenic effects, and memories may be inaccurate. d. Biological components i. Visual essay 7 – neurological and physiological aspects of depersonalization ii. Certain drugs produce dissociative experiences – NMDA receptor antagonists, THC, LSD. iii. Dissociation may involve abnormalities in thalamic activity.

Instructor’s Resource Manual (2nd edition) iv. Biological interventions 1. Narcosynthesis – use of barbiturates to gain access to repressed memories; “amytal interviews” rarely used today.

2. Antidepressants and anti-anxiety drugs may be used to treat associated depression and anxiety symptoms. e. The multiple causality of dissociative disorders i. Multi-modal approaches: 1. Stage One: Establishing the psychotherapy 2. Stage Two: Preliminary interventions 3. Stage Three: History gathering and mapping 4. Stage Four: Metabolism of the trauma 5. Stage Five: Moving toward integration-resolution 6. Stage Six: Integration-resolution 7. Stage Seven: Learning new coping skills 8. Stage Eight: Solidification of gains and working through 9. Stage Nine: Follow-up IV. Case Vignettes – Treatment a. John – Depersonalization disorder b. Margaret – Dissociative identity disorder Lecture Extensions: 1. Use of dissociation in therapy. Hypnosis, which is often seen as a form of dissociation, has been used since the 18th century, stemming from the practice of “mesmerism” developed by Franz Anton Mesmer. Before shifting to the practice of psychoanalysis, Freud himself initially practiced hypnosis with his colleague Josef Breuer (their Studies of Hysteria document case studies utilizing this practice, including the case of Anna O.).

Yet the use of hypnosis is rife with controversy. Some, for example, question the very nature of hypnosis, suggesting that one is not entering a hypnotic state. Rather, they suggest that what looks like a hypnotic state is actually the result of expectancies and beliefs. Clearly, the PTM and the SCM are quite applicable to the use of hypnosis.

In particular, the use of hypnosis for the purpose of recovering repressed memories has come under fire. Many questions abound regarding the accuracy of these memories and the utility of this procedure. In fact, some suggest that memories recovered through the use of hypnosis may be iatrogenic, or they may be the result of source amnesia (an inability to recall where a memory came from; for example, a memory may not be a “true” memory, but may have come from TV, a dream, a story, or a photograph.).

There are many readings on this particular subject. Several are included below: Lynn, S. J., Kirsch, I., Barabasz, A., Cardena, E., & Patterson, D. (2000). Hypnosis as an empirically supported clinical intervention: The state of the evidence and a look to the future. International Journal of Clinical and Experimental Hypnosis, 48, 239-259.

Instructor’s Resource Manual (2nd edition) Lynn, S. J., Lock, T., Loftus, E. F., Krackow, E., & Lilienfeld, S. O. (2003). The remembrance of things past: Problematic memory recovery techniques in psychotherapy.

In S. O. Lilienfeld, S. J. Lynn & J. M. Lohr (Eds.), Science and pseudoscience in clinical psychology. (pp. 205-239). New York, NY: Guilford Press.

2. Assessment and diagnosis of dissociative disorders. A number of assessment tools have been developed in order to identify symptoms of dissociative identity disorder. Probably the most well-known assessment tool is the Dissociative Experience Scale (DES), a short questionnaire assessing the frequency of dissociative experiences. The Multiscale Dissociation Inventory (MDI), developed by John Briere, is a 30-item measure producing scores on six scales: Disengagement, Depersonalization, Derealization, Emotional Constriction, Memory Disturbance, and Identity Dissociation. Other checklists and questionnaires include the Cambridge Depersonalization Scale, the Steinberg Depersonalization Questionnaire, and the Dissociative Features Profile. Structured interviews are commonly used in conjunction with questionnaires. Two examples are the Dissociative Disorders Interview Schedule (DDIS) and the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R). Some of these measures can be found on the following website: http://www.neurotransmitter.net/dissociationscales.html After presenting this material, discuss with your students the strengths and weaknesses of each type of assessment tool. What combination of assessment strategies would be most useful in diagnosing dissociative disorders accurately and reliably? What are some potential difficulties with assessing these disorders?

3. The strengths and weaknesses of the case study method. Multiple personality disorder came to the attention of the general public largely through the dissemination of case histories. Two of the most widely known accounts are Sybil and The Three Faces of Eve. While case studies can be very useful in allowing us to better understand human behavior, case histories can sometimes be misleading. Specifically, case studies are shaped by the interpretations of the storyteller and are not necessarily unbiased.

According to Loftus and Guver (2002), Cornelia Wilbur’s account of Sybil contained a number of inaccuracies. Most importantly, they suggest that Sybil likely suffered from a form of hysteria, but Wilbur’s publisher believed that multiple personality would be more interesting and compelling. Interesting, it was after the publication of Sybil that diagnoses of multiple personality disorder began to increase.

Students may find it interesting to debate the strengths and limitations of this research method. The following is a useful article that discusses the case study method and applies these issues to the case of Jane Doe, a woman who claimed to have recovered memories of childhood sexual abuse.

Loftus, Elizabeth, and Guver, Melvin J. (2002). Who abused Jane Doe? The hazards of the single case history. http://faculty.washington.edu/eloftus/Articles/JaneDoe.htm

Instructor’s Resource Manual (2nd edition) Classroom Activities/Discussion Topics: 1. Dissociative disorders in film. Dissociative identity disorder (or multiple personality disorder) is featured in a number of classic and contemporary films. Show clips from one or more of the following films, or ask students to view these films on their own: Primal Fear The Three Faces of Eve Sybil Ask students whether the portrayals of DID are consistent with the discussion in the textbook. What myths about DID might arise from viewing these films?

A useful case example of an individual with multiple personality can be seen in the documentary film Dialogues with Madwomen (Women Make Movies). Interestingly, her story may raise questions among students regarding the Post-Traumatic Model (PTM) and the Sociocognitive Model (SCM).

Other dissociative disorders have been portrayed in contemporary films as well. Nurse Betty, for example, involves a character who enters a fugue state after witnessing a traumatic murder.

2. Dissociative disorders in literature. In addition to Sybil and The Three Faces of Eve, several personal accounts of multiple personality disorder have been published in recent years. The following are two of the more widely read publications: When Rabbit Howls by the Troops for Truddi Chase My Life as a Multiple by Cameron West As an assignment, you might ask students to read one of these accounts. Ask students to identify specific dissociative symptoms. Also ask your students to think about the case using both the Post-Traumatic Model (PTM) and the Sociocognitive Model (SCM).

3. The continuum of dissociative symptoms. Develop a list of dissociative experiences, and place each item on a separate piece of paper. It might be useful to take some items from the Dissociative Experiences Scale, as some of these items include forms of dissociation more commonly seen in the population. More common forms of dissociation include the ability to ignore pain, absorption in a television show, or missing part of a conversation.

More severe forms of dissociation include finding notes or drawings one doesn’t remember creating, feeling as if one’s body is not one’s own, and finding oneself someplace but not remembering how they got there. More dissociative experiences can be found at the following website: http://www.rossinst.com/des.htm Once you’ve written each item on a separate piece of paper, distribute these items among

Instructor’s Resource Manual (2nd edition) a group of your students. Ask them to construct a “human continuum” by standing in a row from least severe symptoms to most severe symptoms. This exercise can help to illustrate the continuum between normality and abnormality.

4. Classification of Posttraumatic Stress Disorder. Now that students are familiar with symptoms of anxiety and dissociative symptoms, they are likely better equipped to debate whether PTSD should be classified as an anxiety disorder or a dissociative disorder. Ask a group of your students to argue in favor of maintaining its current classification as an anxiety disorder, and ask another group to argue in support of categorizing it as a dissociative disorder. Have a third group of independent observers rate the quality of the arguments and to draw a conclusion based on the evidence.

5. Evaluating Internet information on dissociative disorders. There are many websites about dissociative disorders geared towards professionals and the general public. Ask students to locate three separate websites that contain information about dissociative disorders.

Some sites, for example, may be geared towards professionals; others may offer support for individuals with dissociative disorders. Ask students to evaluate the accuracy of information and the quality of the websites.

Instructor’s Resource Manual (2nd edition)

Chapter 8: Eating, Weight, and the Eating Disorders Learning Objectives: By the end of this chapter, students should be able to: • Understand the difference between a “diagnosable” and a “subclinical” eating disorder.

• Identify specific contextual factors that play into the manifestation of eating disorders.

• Describe the physical and psychological consequences of anorexia nervosa and bulimia nervosa.

• Identify the diagnostic differences between anorexia nervosa and bulimia nervosa, and describe the various subtypes of the two disorders.

• Explain how age, gender, and class affect the prevalence and symptomatology of the eating disorders.

• Describe the role of Western media and values on the development of eating disorders, citing specific cross-cultural examples.

• Cite the advantages and disadvantages of the DSM-IV-TR eating disorder criteria.

• Using psychodynamic principles, particularly the ideas of Hilde Bruch, explain how eating disorders develop and are treated.

• Drawing upon the work of Salvador Minuchin and other family systems theorists, explain the function that an eating disorder has in a family, and discuss how eating disorders are treated.

• Identify common cognitive distortions present among individuals with eating disorders, and describe specific cognitive-behavioral interventions.

• Discuss the feminist and sociocultural perspective on eating disorders, and describe the strengths and limitations of this approach.

• Identify the various biological correlates of anorexia nervosa and bulimia nervosa.

• Explain how the core concepts of “the connection between mind and body” and “multiple causality” apply to the eating disorder diagnoses.

Lecture Outline: I. Defining Eating Disorders a. The continuum between normal and abnormal eating i. Up to 4% of American women suffer from eating disorders; many more suffer from “subclinical” eating disorders; a third of American adults are dieting at any given time. ii. Eating disorder diagnoses reflect an extreme version of common behaviors. b. The importance of context in defining abnormal eating i. Members of “low-weight” subcultures (gymnasts, jockeys, etc.) may maintain low weights but not suffer from an eating disorder.

II. Classifying Eating Disorders a. The DSM-IV-TR categories i. Anorexia nervosa – involves maintaining low body weight, fears of gaining weight, and distorted body image.

1. Psychological consequences – irritability, depression, anxiety,

Instructor’s Resource Manual (2nd edition) insomnia and perfectionistic traits 2. Physical consequences – slow metabolism, hypotension, electrolyte imbalances, heart problems (see Table 8.4 and Visual Essay 8) a. Amenorrhea – cessation of menstrual cycle 3. Two sub-types: restricting type and binge-eating/purge type ii. Bulimia nervosa – involves a cycle of bingeing and compensatory behaviors; typically sufferers are at or above normal weight.

1. Psychological consequences – mood instability, impulsivity, drug/alcohol abuse, personality disorders 2. Physical consequences – dental problems, dehydration, anemia, electrolyte imbalances (see Table 8.4 and Visual Essay 8) 3. Two sub-types: purging and nonpurging types iii. Psychologists once believed that there existed an “anorexic personality” and a “bulimic personality”; now clinicians recognize that there is significant overlap. iv. Eating disorder not otherwise specified (EDNOS) – includes disordered eating behaviors that don’t meet the criteria for anorexia or bulimia nervosa.

1. Binge eating disorder (binge eating without compensatory behavior) – included in the DSM-IV-TR appendix for diagnostic categories under consideration b. Classification in demographic context i. Age 1. Most common among teenage/young adult women 2. Rates are increasing among pre-adolescent girls and older women ii. Gender 1. About 90% of eating disorders diagnosed among women – due to societal standards of beauty 2. Men may be underdiagnosed due to a reluctance to seek help.

3. Reverse anorexia (muscle dysmorphia) – a concern that muscles are too small and underdeveloped. This may be more common among males.

4. Female athletes at risk – “appearance” sports and “endurance” sports 5. Male athletes – wrestlers iii. Class 1. Prevalence of eating disorders does not seem to vary by class 2. Subclinical eating problems may be higher among members of higher socioeconomic groups 3. Eating disorders more common in affluent cultures where food is abundant iv. Culture 1. Although originally thought to occur more frequently among Caucasian women, rates of EDs among ethnic minority women may be comparable or higher c. Cultural and historical relativism in defining and classifying eating disorders

Instructor’s Resource Manual (2nd edition) i. Bulimia rates rise in non-Western cultures that are exposed to Western media (see Box 8.3) ii. Preoccupation with thinness is a culture-bound phenomenon that increases the incidence of anorexia, but it is not a necessary condition for anorexia 1. Cases of deliberate self-starvation occur in a variety of cultures that don’t glorify thinness and are not subject to Western beauty standards 2. Religious asceticism and digestive discomfort may account for cases of anorexia in non-Western cultures d. The advantages and limitations of the DSM-IV-TR eating disorder diagnoses i. Diagnoses facilitate communication among clinicians and researchers ii. Very few people fit the narrowly defined criteria iii. Is obesity an eating disorder?

1. Extremely common in the U.S. 2. Not currently included in the DSM-IV-TR 3. Although binge-eating disorder may account for obesity, there is no DSM-IV-TR category to capture the chronic overeating (not necessarily bingeing) that may also account for obesity III. Explaining and Treating Eating Disorders a. Psychodynamic components i. Hilde Bruch 1. Conceptualizes young women with anorexia as over-focused on the needs and desires of others that they lose awareness of what they want for themselves; anorexia represents their strive for the perfection they believe their parents want, while simultaneously asserting their independence. ii. Eating disorders are more likely to occur in families that are preoccupied with appearance and high achievement. iii. EDs are fueled by complex, unconscious feelings – anorexia may provide the sufferer with an opportunity to retain a childlike physical form and thereby avoid the sexual anxieties that accompany the physical and psychological move into adolescence iv. Possible history of childhood sexual abuse (anorexic symptoms may allow individual to regain control of her body; bulimic symptoms may represent an unconscious reenacting of a sexual trauma whereby the purging behavior is an “undoing” of the trauma) v. Psychodynamic interventions: mainly involve exploratory techniques such as free association, dream analysis, and analysis of transference b. Family systems components i. Salvador Minuchin – eating disorders occur in families that are overly enmeshed; the eating disorder becomes a statement of independence, yet paradoxically engages the family even more. ii. Critics suggest that enmeshment may be the result rather than the cause of eating disorders. iii. Family systems interventions: 1. identified patient – person who is exhibiting psychological

Instructor’s Resource Manual (2nd edition)

c.

d.

e.

f.

symptoms; family systems theorists view these symptoms as an index of difficulty in the family Cognitive-behavioral components i. Table 8.6 – illustrates common cognitive distortions in anorexia ii. Use of “black and white thinking” – “good” and “bad” foods, arbitrary and rigid rules about eating, etc. iii. Cognitive-behavioral model of bulimia (Figure 8.2) – cognitive processes trigger behavioral responses, which lead to emotional reactions, and the cycle is repeated. iv. Cognitive-behavioral interventions: 1. Behavioral techniques used to facilitate weight gain; useful as an immediate intervention, but not in the long term.

2. Self-monitoring charts – monitor eating, purging, and exercising behaviors; used to identify and change cognitive distortions 3. Prescribing normal eating patterns and monitoring thoughts 4. CBT has been found to be highly effective in treating eating disorders Sociocultural components i. Naomi Wolf – equates trends in eating disorder rates with shifts in feminism and women’s history; restrictive standards of beauty co-exist with increased economic independence. ii. Limitations of this model: many women who live in this culture do not develop eating disorders. iii. Sociocultural interventions: education, media activism Biological components i. Identical twins have high concordance rates for anorexia and bulimia ii. Eating disorders often co-occur with depression and OCD, both of which have a genetic component iii. Hormonal abnormalities 1. Levels of leptin (a hormone that suppresses appetite) and ghrelin (a hormone that stimulates hunger) have been shown to be abnormal in individuals with anorexia and bulimia (unclear if this is the cause or result of disorder) 2. Release of endorphins (natural opiates that produce feelings of pleasure) in response to purging and/or self-starvation may reinforce eating-disordered behavior iv. Anorexia and bulimia both associated with unusually low levels of serotonin (unclear if this is the cause or result of disorder) v. Evidence of structure brain abnormalities in people suffering from EDs -several areas of the brain shrunken or atrophied (unclear if this is the cause or result of disorder) vi. Biological interventions: 1. SSRIs – effective in treating bulimia; less data available for the efficacy of SSRIs for anorexia The connection between mind and body in eating disorders i. The effects of starvation make it difficult to treat people with anorexia; starvation leads to significant cognitive impairment

Instructor’s Resource Manual (2nd edition) g. The multiple causality of eating disorders h. Most treatments involve techniques from a variety of perspectives, in order to address the multiple causes.

IV. Case Vignettes a. Megan – anorexia nervosa b. Theresa – bulimia nervosa Lecture Extensions: 1. Eating disorders in atypical populations. When most people think of eating disorders, an image of a young, White, heterosexual woman often comes to mind. Interestingly, research indicates that this stereotype is becoming more inaccurate, as the rates among older women, women of color, and males are rising. Some suggest that the rates of eating disorders in these populations are lower because they are less likely to seek treatment, and that the available treatment resources are geared specifically towards the needs of the prototypical eating disordered client. The following is a list of readings addressing eating disorders in other populations: Older women: Bellafante, Gina. (2003, March 9). When midlife seems just an empty plate. The New York Times.

Males: Pope, Harrison, Phillips, Kate, and Olivardia, Roberto. (2000). The Adonis complex: The secret crisis of male body obsession. The Free Press.

Eliot, Alexandra O., and Baker, Christina Wood. (2001). Eating disordered adolescent males. Adolescence, 36, 535-543.

Women of Color: Cachelin, Fary M., Veisel, Catherine, Barzegarnazari, Emilia, and Striegel-Moore, Ruth H. (2000). Disordered eating, acculturation, and treatment-seeking in a community sample of Hispanic, Asian, Black, and White women. Psychology of Women Quarterly, 24, 244-253.

Thompson, Becky. (1994). A hunger so wide and so deep: American women speak out on eating problems. Minneapolis: University of Minnesota Press Lesbian women: Heffernan, Karen. (1996). Eating disorders and weight concern among lesbians.

International Journal of Eating Disorders, 19, 127-138.

2. Eating disorders in athletes. As mentioned in the text, individuals who compete in certain sports tend to be at a higher risk for developing eating disorders. These sports include running, gymnastics, swimming, wrestling, dancing, and jockeying, all of which involve a strong focus on body weight. Interestingly, some suggest that many of these sports

Instructor’s Resource Manual (2nd edition) have a potential for becoming addictive, particularly running and other endurance sports.

Brownell, Kelly D., Rodin, Judith, and Wilmore, Jack H. (Eds.). (1992). Eating, body weight, and performance in athletes: Disorders of modern society. Philadelphia: Lea and Febiger.

McNulty, Kimberly Y., Adams, Cynthia H., Anderson, Jeffrey M., and Affenito, Sandra G. (2001). Development and validation of a screening tool to identify eating disorders in female athletes. Journal of the American Dietetic Association, 101, 886-894.

Yates, Alayne. (1991). Compulsive exercise and the eating disorders: Toward an integrated theory of activity. New York: Brunner/Mazel, Inc. 3. How to help someone with an eating disorder: The IMAD approach. Helping someone with an eating disorder can be quite challenging. It is common for people who want to help to get involved in a power struggle and a battle of wills with the eating disordered individual, and unfortunately this often results in the eating disordered person becoming even more resistant to help. A useful approach for addressing eating disordered behavior is called the IMAD approach, which focuses on the Inefficiency, Misery, Alienation, and Disturbance that the individual’s eating disorder is causing in her life.

For example: Inefficiency – is your friend experiencing physical and psychological consequences that affect her daily activities?

Misery – is your friend angry, anxious, depressed, or sad?

Alienation – is your friend’s eating disordered behavior causing her to become isolated from family and friends?

Disturbance – is your friend doing things that are frightening, upsetting, or disturbing to her and to others?

In addressing each of these, it is important to focus on specific behaviors, and to remain respectful, supportive, and non-judgmental. Provide the individual with a variety of resources and referrals if you have them available, and offer to go with her. More information can be found at the following website: http://www.sedop.org/pages/fast_facts#can_i_help Classroom Activities/Discussion Topics 1. Assessment of eating disorders. Provide your students with copies of either the Eating Disorders Inventory or the Eating Attitudes Test. Ask students to evaluate the items, and discuss whether these tools are valid for males, older women, and people of color. How would you revise these tools to accommodate these populations?

2. The continuum of eating disordered behaviors. Make a list of behaviors that fall along

Instructor’s Resource Manual (2nd edition) the continuum of eating behaviors. Some of these behaviors might include the following. a. Diets to lose weight before a prom or summer vacation b. Spends 2 hours a day at the gym c. Eats junk food when stressed d. Vomits three times a day after meals e. Hoards food but refuses to eat it f. Cooks food for others but refuses to eat it g. Refuses to consume any type of animal product. h. Refuses to eat any fat.

Make a list of about 20 different behaviors, and write each one separately on a small piece of paper or index card. Choose 20 students in the class, and give each one a separate behavior. Ask students to come to the front of the room and place themselves along a continuum ranging from “normal” to “abnormal.” You will likely find that students have difficulty ranking all but the most extreme behaviors, and students are likely to disagree with one another. This is a useful exercise for demonstrating “the continuum between normality and abnormality” and “the importance of context.”

3. Weight discrimination. Weight discrimination is extremely common in our culture, even in the face of increasing rates of obesity. Ask students to brainstorm examples of weight discrimination, providing them with a few examples to begin with (such as the size of bus seats, movie theater seats, or classroom desks; clothing sizes offered in retail stores; name-calling and taunting by young children). Differentiate between overt (obvious) and covert (subtle) forms of discrimination, and ask students how they think these forms of discrimination might affect overweight individuals. Why do they think we as a culture participate in weight discrimination? Students are likely to cite media influences, fears of the overweight, and values regarding self-control.

4. National Eating Disorders Awareness Week. Because eating disorders often go undiagnosed and untreated until they reach a severe point, many psychologists have focused on the need for prevention and early intervention efforts. National Eating Disorders Awareness Week is an annual event that involves education, advocacy, and screening of eating disorders. Ask your students to list some activities that might be important to implement during this week. Some potential activities might include the following: • A workshop on how to help a friend or family member with an eating disorder.

• A screening day sponsored by the college or university counseling center.

• An informational session with a nutritionist who is knowledgeable about eating disorders.

• A discussion of eating disorders among racial and ethnic minorities.

The following website provides more information about National Eating Disorders Awareness Week. http://www.nationaleatingdisorders.org/p.asp?WebPage_ID=767 5. Eating disorders and public policy. Although eating disorders are among the most deadly of all the psychological disorders, there has been a limited focus on these

Instructor’s Resource Manual (2nd edition) disorders on the part of the federal government and large funding organizations.

Unfortunately, this has resulted in a lack of available and affordable treatment options, high mortality rates, and a limited understanding of effective prevention and treatment efforts. The Eating Disorders Coalition for Research, Policy, and Action was formed to provide policymakers with more accurate information and to lobby the federal government to dedicate more attention and resources toward sound and effective eating disorders policies. Ask students to look at the Coalition’s website (http://www.eatingdisorderscoalition.org/), particularly the links for “Congressional Briefings” and “Legislative Updates.” This may be a useful introduction to the role of public policies in the diagnosis and treatment of psychological disorders.

If your students are particularly interested in the eating disorders, ask them to brainstorm ways of making their concerns known to others and addressing these concerns. For examples, students could write or call their legislators, they could participate in an educational initiative on campus, or they could raise money for nonprofit eating disorder organizations.

6. Educational films about eating disorders. Many documentary films have been produced about the various eating disorders. Unfortunately, many educational materials run the risk of glamorizing eating disorders and contributing to eating disorder symptomatology.

Many eating disordered individuals, for example, commonly state that they learned strategies for weight loss and purging from movies, television, magazines, and educational materials. The following are three films that provide sound education about eating disorders and that, in my opinion, are less likely to contribute to the “boomerang” phenomenon: NOVA: Dying to be Thin (available at www.pbs.org ) This hour-long film addresses the psychological and social consequences of eating disorders, and it depicts the treatment of individuals suffering from anorexia and bulimia.

There is very good coverage of the physical consequences of eating disorders.

Perfect Illusions (available at www.pbs.org ) This documentary explores the lives of three women who suffered from eating disorders, one of whom lost her battle and died. This is a very well-produced and moving film.

Thin (http://www.hbo.com/docs/programs/thin/index.html) This is a HBO documentary that aired in 2006 and profiled four women residing in a Florida treatment center.

Instructor’s Resource Manual (2nd edition)

Chapter 9: Drug Use and the Substance Use Disorders Learning Objectives: By the end of this chapter, students should be able to: • Understand the diagnostic changes that have taken place across various editions of the DSM. • Understand the difference between normal and excessive substance use.

• Identify the “three Cs” of substance misuse, and differentiate between substance abuse and substance dependence.

• Explain the concept of dual diagnosis.

• Define “behavioral addiction,” and discuss why these are not included in the DSM-IVTR. • Identify specific substances that fall into the following categories: depressants, stimulants, and hallucinogens; and name substances that do not fall into a specific category.

• Discuss the short- and long-term effects of alcohol, and define the following terms: Wernicke’s encephalopathy, Korsakoff’s syndrome, fetal alcohol syndrome.

• Describe the short- and long-term effects of the barbiturates, benzodiazepines, and opioids, defining the following terms: cross-tolerance, synergistic effect, endorphins and enkephalins.

• Describe the specific short- and long-term effects of cocaine, amphetamines, nicotine, and caffeine, addressing specific historical factors contributing to substance misuse.

• Applying the concept of cultural and historical relativism, discuss the history of hallucinogen availability and use in the United States, and describe cross-cultural uses of hallucinogens.

• Identify the specific short- and long-term effects of hallucinogenic drugs.

• Describe the specific short- and long-term effects of drugs such as marijuana, PCP/ketamine, GHB, inhalants, anabolic steroids, and Ecstasy.

• Identify the demographic factors, including age, gender, and class status, that contribute to substance misuse.

• Describe the historical shifts and tensions between the disease/medical model and the moral/legal model of addiction.

• Discuss the 20th century view of addiction in contrast to the disease model.

• Identify the various biological correlates of substance misuse, including neurochemical components and genetic factors.

• Describe the various biologically-based treatments available for substance misuse.

• Discuss the family systems and sociocultural factors involved in substance misuse.

• Explain how classical conditioning, operant conditioning, and social learning influence the development of substance misuse, and describe treatments based on these behavioral theories.

• Identify the cognitive correlates of substance misuse, and describe the cognitive interventions used to treat substance misuse.

• Using the psychodynamic perspective, describe how substance-related disorders develop, and identify specific defense mechanisms that may be present.

• Describe the Twelve-Step approach to treating substance-related disorders, and identify

Instructor’s Resource Manual (2nd edition)

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the strengths and weaknesses of this approach.

Explain how the core concepts of “multiple causality” and “the connection between mind and body” play a role in the substance use disorders.

Lecture Outline: I. Defining Substance Use Disorders a. Prevalence of substance use – Table 9.1 i. Substance misuse is a serious problem among high school and college students – Binge drinking ii. Denial – commonly found among drug users iii. “Drugs” include any psychoactive (i.e., brain affecting) substance 1. Includes legal and prescription drugs 2. Caffeine, alcohol, and nicotine are all considered to be drugs iv. Drug use is universal across history and culture. b. The importance of context in defining substance use disorders i. DSM-I and DSM-II – classified “addiction” and “drug dependence” under the personality disorders 1. Clinicians focused on crude, quantitative criteria to make diagnoses (i.e., how much, how often, and when during the day was the drug used) ii. DSM-III – recognition of substance misuse as a distinct syndrome 1. Quantitative approach to defining drug problems fell into disfavor—problem with this approach is that it disregards context 2. Focused on the relationship between the user and the drug. iii. Current DSM definitions view substance abuse as a pattern of use that causes distress or impairment. c. The continuum between normal and abnormal substance use i. Some substance use is extreme; other use may be less extreme but still maladaptive. ii. The relationship approach cannot provide an absolute definition of substance abuse.

II. Classifying Substance Use Disorders a. The DSM-IV-TR substance use disorders i. The three “C”s of substance misuse: 1. Continued use despite negative consequences 2. Compulsive use 3. Loss of control over use ii. Substance abuse consists only of the first “C” iii. Substance dependence usually involves all three “C’s” 1. Physiological dependence – involves the presence of tolerance and withdrawal iv. Substance abuse and dependence can apply to any psychoactive substance; polysubstance abuse involves the misuse of three or more substances. v. Dual diagnosis – substance use disorders have high co-morbidity with other Axis I and II disorders.

Instructor’s Resource Manual (2nd edition) b. Advantages and limitations: i. “Behavioral addictions” not found in the DSM-IV-TR (e.g., food, sexual, work); many are skeptical as to whether these are true addictions ii. Gambling addiction is included in the DSM-IV-TR as “pathological gambling” and included in the Impulse Control Disorders NOS c. Commonly abused substances (see Appendix for histories of commonly abused substances) i. Depressants – slow down CNS activity; include alcohol, sedativehypnotics, and opioids 1. Alcohol – most commonly abused substance in the U.S. a. Produces a biphasic response (i.e., stimulant effects during initial intoxication and depressant effects thereafter) b. Increases activity of serotonin, dopamine, GABA, norepinephrine, and glutamate (see Visual Essay 9 for more on effects of alcohol on neurotransmission) c. Decreases activity of neurological systems responsible for emotional and physical self-control – disinhibiting effects cause a person to become louder and more impulsive, and to have problems with memory, balance, speech, and coordination. d. Degree of intoxication determined primarily by amount of alcohol consumed i. Metabolism of alcohol varies widely ii. Women have lower levels of alcohol dehydrogenase; they are twice as affected by alcohol as men e. Chronic misuse – vitamin B/thiamine deficiency; Wernicke’s encephalopathy; Korsakoff’s syndrome; GI problems, hypertension, cardiomyopathy i. Fetal alcohol syndrome – caused by intrauterine exposure to alcohol; symptoms include mental retardation, growth impairment, facial distortions ii. Psychological damage to self and others 2. Sedative-hypnotics a. Substances used to promote relaxation (sedatives) and sleep (hypnotics) b. Barbiturates – used to treat anxiety; dangerously addictive c. Benzodiazepines – enhance GABA activity i. Cross-tolerance – when tolerance develops for one drug in this class, it may automatically be present for others ii. Synergistic effects – multiplication of effects when two or more drugs from the same class are taken together iii. Addictive; produce tolerance and withdrawal iv. Flunitrazepan (Rohypnol) – used as a “date rape”

Instructor’s Resource Manual (2nd edition) drug (“roofies”) 3. Opioids – refers to all derivatives (natural and synthetic) of the opium poppy a. Morphine and codeine – natural products of the opium plant b. Heroin, methadone, painkillers – synthetic opioids that mimic morphine’s action on the CNS c. Opioids also referred to as “narcotics” d. Opioids are CNS depressants – result in analgesia (pain relief), euphoria, and sedation e. Mimic effects of body’s endogenous opioids neurotransmitters (e.g., endorphins/enkephalins) f. Physical/psychological tolerance and cross-tolerance develop quickly g. Withdrawal is extremely uncomfortable; severe flu-like symptoms ii. Stimulants – increase CNS activity 1. Enhance arousal, alertness, and energy 2. Widely used throughout history and across cultures; Mahuang/ephedrine (China), cocaine (Incas), nicotine (Native Americans) 3. Cocaine a. blocks reuptake of dopamine, norepinephrine, serotonin b. leads to euphoria, confidence, energy, excitement c. short-lived, intense high; very reinforcing d. High danger of overdose; treatment is difficult e. Crack = smoking cocaine; Freebasing = inhaling the heated vapors of pure cocaine 4. Amphetamines a. Increase availability of norepinephrine and dopamine b. 1930s – billed as “wonder drugs”; used as “pep pills” c. Used to enhance performance during WWII; U.S. government established stricter controls in the late 1940s/early 1950s d. Medical uses – treatment for narcolepsy, ADHD, weight loss e. Potent high, unpleasant withdrawal effects (depression, decreased energy, increased appetite, irritability, cravings) 5. Nicotine a. Highly addictive, toxic in large doses b. Highly reinforcing, unpleasant withdrawal effects (depression, irritability, insomnia, restlessness, increased appetite, weight gain) c. Nicotine ingested through smoking makes it the world’s deadliest drug d. Treatment often involves psychological and biological

Instructor’s Resource Manual (2nd edition) interventions 6. Caffeine a. See Table 9.11 – caffeine doses in common foods, beverages, and medicines b. Highly reinforcing, physical/psychological dependence, tolerance/withdrawal c. Links between caffeine intake and physical illnesses d. Caffeinism (caffeine dependence syndrome) – involves irritability, insomnia, nervousness, twitching, heart arrhythmias/palpitations, GI disturbances 7. Hallucinogens – also known as psychedelics, psychotomimetics, entheogens (term used by enthusiasts) a. Produce internally generated sensory perceptions (hallucinations) b. Used for centuries; can be part of religious practices 8. LSD (Acid) a. Chemical structure similar to serotonin; effects include SNS effects, perceptual changes, depersonalization, enhanced emotionality b. Albert Hoffman/Sandoz Labs – discovered LSD; had a “bad trip,” with symptoms including synesthesia (mixing of sensory experiences, such as “seeing” sounds) c. Research was sponsored by Sandoz Labs until it became a popular street drug; U.S. government and CIA continued research despite the dangers d. LSD usage was popular in the 1960s (Timothy Leary and the League of Spiritual Discovery); it is again becoming popular. e. LSD doesn’t cause physical dependence, but it does cause tolerance, cross-tolerance, and psychotic symptoms.

9. Psilocybin (mushrooms) a. Similar to LSD but less potent b. Chemical structure similar to serotonin c. Used by Aztecs in religious ceremonies; became popular in U.S. in 1960s 10. Peyote/mescaline a. Causes hallucinatory experiences, euphoria b. Chemical structure is like norepinephrine and dopamine c. Tolerance occurs, but dependence and withdrawal are rare d. Used by Native American tribes; legal protections exist in some states when used for tribal religious purposes 11. Other drugs a. Marijuana i. Most widely used illegal drug in the world; THC is the active ingredient ii. Marijuana is rapidly absorbed, but it metabolizes

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b.

c.

d.

e.

f.

slowly and has a long half-life iii. Common effects involve depressant, hallucinogenic, and stimulant properties; THC appears to bind at endogenous cannabinoid receptors. iv. Marijuana may have beneficial medicinal effects. v. Tolerance, withdrawal, and physical/psychological dependence can occur. vi. Chronic marijuana use can lead to long-term physical and psychological effects.

Ecstasy i. MDMA – chemical compound in Ecstasy; used legally until 1985. ii. Effects include increased empathy, closeness, and connection with others; tolerance can occur. iii. Ecstasy may cause permanent damage to serotonin neurons; Ecstasy-related deaths caused by hypothermia and dehydration.

PCP and ketamine i. PCP was originally developed as an anesthetic; ketamine is still used for that purpose. ii. Some do not view PCP as a true hallucinogen; it causes bizarre and violent behavior, and users are impervious to pain. iii. Acute PCP intoxication can lead to psychosis.

GHB i. Also developed as an anesthetic; currently used as a bodybuilding drug, sleep aid, and a club drug. ii. GHB is similar to a depressant and has synergistic effects with alcohol. iii. GHB has been implicated as a “date rape” drug.

Inhalants i. Involve a wide variety of chemicals, including solvents and medical drugs. ii. Inhalants cause a variety of short-lived effects. iii. Most inhalants are toxic and can lead to permanent organ damage.

Anabolic steroids i. Synthetic steroid resembling testosterone ii. Often abused in the service of enhancing athletic performance. iii. Until the 1970s, steroid use was widespread; testing in athletic competition began during that time. iv. Casual athletes began abusing these drugs in the 1980s; since 1990, steroids only available through the black market. v. Steroids do have legitimate medical uses.

Instructor’s Resource Manual (2nd edition) vi. Long-term health risks and withdrawal symptoms occur with ongoing use d. Classification in Demographic Context i. Age 1. Adolescent risk-taking behavior contributes to substance misuse.

2. Substance misuse problems are under-diagnosed and under-treated among the elderly. ii. Gender 1. Men are more likely to abuse drugs and alcohol; may have a stronger genetic tendency to alcoholism.

2. Nicotine consumption has increased among women since the 1960s. iii. Class 1. High rates of drug use in the U.S. are correlated with being White, well-educated, and living in certain geographical areas.

2. High rates of alcoholism associated with being young, male, and underemployed.

3. Since the 1980s, cocaine (in the form of crack) use has increased in low-income, inner-city communities.

III. Explaining and Treating Substance Use Disorders a. Historical relativism i. Throughout history, explanations have vacillated between the moral/legal approaches and the disease/medical approaches. ii. Moral approach -- Benjamin Rush (“father of American psychiatry”) argued that alcoholism is a disease, with abstinence being the cure; the American Temperance Society viewed alcoholism as a sin and a disease. iii. Symptom model (20th century explanations) – substance abuse is a symptom of an underlying motivational, emotional, cognitive, or learning problems. iv. Currently – the disease model dominates the field of substance use disorders 1. The “recovery movement” focuses on the disease model (e.g., selfhelp groups, AA) 2. Advantages of disease model: Eases shame and stigma, people more willing to seek treatment, medical professionals can treat 3. Disadvantages of disease model: more ideological than scientific, disease model goal of total abstinence is controversial b. Biological components i. Neurochemical explanations – people may use substances to compensate for neurochemical deficiencies (self-medication) 1. Research evidence that virtually all drugs affect the dopamine neurotransmitter system and activate the “reward pathway” 2. With repeated drug use, normal dopamine and glutamate regulation and other pleasure pathways are disrupted – individual at risk for development of an addictive cycle of drug craving

Instructor’s Resource Manual (2nd edition) particularly during times of stress ii. Genetic factors 1. ~50% of vulnerability to drug addiction is due to genetic factors 2. Family studies – alcoholism runs in families (may be due to genes or the environment) 3. Adoption studies – heritability may be greater in males than females 4. Twin studies – suggest a high concordance rate between identical twins.

5. Genes may determine a person’s susceptibility to the reinforcing effects of alcohol; they may also affect sensitivity to alcohol.

6. Flipped switch theory – after a drug is used for a period of time, a person may cross over from controlled use to addiction. iii. Biological interventions 1. Alcohol – use of disulfiram (Antabuse), benzodiazepines (to ease withdrawal), SSRI medications, naltrexone/opiate antagonists.

2. Opioids – naltrexone/opiate antagonists, substitution/maintenance therapy (Methadone) a. Substitution therapy is very controversial (part of the total abstinence vs. harm reduction debate); some argue that one addiction is substituted for another, although many believe the advantages outweigh the disadvantages.

3. Cocaine – tricyclic/SSRI antidepressants, dopamine agonists, opiate agonists/antagonists, anti-seizure medications; none have been particularly effective.

4. Nicotine – aversive agents, nicotine delivery systems (patch, gum, etc.), buproprion (Wellbutrin/Zyban). c. Behavioral components i. Operant conditioning – drug use is positively and negatively reinforcing (i.e., tension reduction motivation for substance misuse) ii. Classical conditioning – cues associated with drug use can become conditioned stimuli provoking cravings. iii. Social learning – effects of the family, peers, and the media. iv. Behavioral interventions 1. Exposure therapies – exposure to conditioned stimuli in the absence of the drug.

2. Covert sensitization – association of unpleasant emotional images with thoughts about drug use.

3. Aversion therapies – inducement of an unpleasant state associated with drug use.

4. Contingency management – systematic effort to reward healthy behavior and punish/withhold rewards for drug-oriented behavior.

5. Relapse prevention model – involves identifying/avoiding highrisk situations, while promoting healthier modes of coping.

6. Behavioral self-control training – careful recording of drug use patterns, development of social skills, planning of healthy

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e.

f.

g.

h.

activities.

7. Prevention – anti-drug attitudes, peer pressure resistance.

Cognitive components i. Cognitions heavily involved in the subjective experience of drug effects.

1. Assess drug use expectancies ii. Poor self-esteem and low self-efficacy expectations are risk factors for drug problems iii. Albert Ellis’ Rational Emotive Therapy – stress and negative thinking patterns can lead to relapses iv. Emphasis on negative cognitive schemas and negative automatic thoughts. v. Cognitive interventions include cognitive restructuring.

Sociocultural and family systems components i. Sociocultural components/interventions 1. Substance misuse is highly correlated with social/demographic variables.

2. Network therapy – engagement of client’s social network in treatment. ii. Family systems components/interventions 1. Family characteristics – denial, codependency (colluding with/enabling a family member’s substance misuse).

2. Therapists try not to focus on the identified patient, but rather on the entire family.

Psychodynamic components i. Psychodynamic model somewhat at odds with the disease model ii. Psychodynamic interventions alone are not considered effective for substance dependence iii. Early psychoanalytic theories – focus on oral phase needs and fixations. iv. Current theories focus on relationships, attachments, self-esteem, and coping/defense strategies.

1. Substance misuse is viewed as a way of numbing or avoiding painful emotions that the ego cannot tolerate (self-medication model) v. Alexithymia – a profound difficulty identifying and verbalizing feelings. vi. Defense mechanisms – denial, omnipotent thinking vii. Psychodynamic interventions – help client develop better skills for dealing with troublesome emotions; improve self-esteem, self-acceptance, ego skills and relationships The Twelve-Step approach i. Focuses on spirituality and adheres to the disease model. ii. Alternative self-help groups, such as Rational Recovery (based on Ellis’ RET), use parts of the Twelve-Step model but reject others. iii. Twelve-Step programs show mixed results: 1. Project MATCH – compared 12-step approaches to cognitivebehavioral treatment and motivational enhancement therapy; all three were found to be reasonably effective.

Multiple causality and the connection between mind and body in substance use

Instructor’s Resource Manual (2nd edition) disorders i. The most effective explanations draw from multiple theoretical orientations. ii. Motivational interviewing – uses a blend of humanistic, cognitivebehavioral, and psychodynamic principles 1. Work with clients’ ambivalence and conflicts about change in an empathic, exploratory manner to help clients move toward greater motivation for changing problematic behaviors iii. Drug use can lead to a vicious cycle of behavioral responses and neurochemical changes.

IV. Case Vignettes a. Rob: substance abuse b. Dr. Bryce: substance dependence Lecture Extensions: 1. The “stages of change” model. Prochaska and DiClemente developed a “stages of change” model that illustrates the process most addicts go through in their treatment.

This model can be quite helpful to clinicians, as it suggests that treatment goals need to be adapted to each stage. The stages are as follows: Precontemplation – in this stage, the individual denies that he has a problem, and is not considering any change.

Contemplation – the individual recognizes that there is a problem, but is ambivalent about change.

Preparation – at this point, the individual is “testing the waters,” either by attempting to cut back use, or by planning future treatment attempts.

Action – the individual is committed to and actively involved in treatment.

Maintenance – the individual is committed to maintaining sobriety, and may be learning relapse prevention techniques.

Relapse – often a part of the recovery process; after the relapse, the individual assesses the situation and begins to develop stronger or alternative coping strategies.

More about this model can be found in the following article: Prochaska, J.O., DiClemente, C.C., and Norcross, J.C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102-1114.

2. Models of recovery for women. Women who have substance use disorders may have very specific treatment needs. For example, women may use substances in order to deal with post-traumatic reactions to abuse, as a reaction to family crisis, or in conjunction with a substance-abusing partner. Women substance abusers may also be at a higher risk for sexually transmitted diseases, as they tend to engage in more risky sexual behaviors and are more likely to inject drugs intravenously. Additionally, women substance abusers may have primary childcare responsibilities, they may be pregnant and in need of prenatal treatment, or their abuse histories may create barriers to seeking treatment. For

Instructor’s Resource Manual (2nd edition) those reasons, psychologists have called for more gender-specific approaches to treating substance use disorders. The following articles discuss factors that are unique to women substance abusers and address the specific needs of women in treatment.

Ashley, Olivia Silber; Marsden, Mary Ellen; and Brady, Thomas M. (2003).

Effectiveness of substance abuse treatment programming for women: A review.

American Journal of Drug and Alcohol Abuse, 29, 19-53.

Knight, Danica Kalling; Logan, Sarah M., and Simpson, D. Dwayne. (2001). Predictors of program completion for women in residential substance abuse treatment. American Journal of Drug and Alcohol Abuse, 27, 1-18.

3. More about “behavioral addictions.” As discussed in the textbook, “behavioral addictions” are not included as diagnostic categories in the DSM-IV-TR. Yet many individuals seek treatment for these types of addictions. Recently, addiction to the Internet has become an increasing problem; in fact, some go as far to say that there now exists an “Internet Addiction Disorder” (Davis et al., 1999). These individuals may suffer from tolerance- and withdrawal-like symptoms, a decrease in social activities, and ineffective attempts at decreasing Internet use. The following article describes this syndrome in more detail: Davis, F. Stephen; Smith, Brandy G.; Rodriguez, Karen; and Pulvers, Kim. (1999). An examination of Internet usage on two college campuses. College Student Journal, 33, 257-260.

While some individuals may engage in a wide range of Internet activities, a subset of people with signs of Internet addiction engage specifically in sexual activities on the Internet. Many ethical issues abound regarding the use of the Internet for sexual purposes, including issues of consent and the age of participants. Several books and articles have recently been written on the subject, including the following: Cooper, Al. (Ed.). (2002). Sex and the Internet: A guidebook for clinicians. Philadelphia: Brunner-Routledge.

Griffiths, Mark. (2001). Sex on the Internet: Observations and implications for Internet sex addiction. Journal of Sex Research, 38, 333.

4. The harm reduction model. A recently developed alternative to the disease model of substance abuse treatment is the harm reduction model. This approach focuses on decreasing use as well as associated risky behaviors, rather than setting abstinence as the goal. The harm reduction model has been controversial among clinicians as well as in the formulation of public policy. Students may find it interesting to engage in a debate about this topic. Two excellent resources on the subject are listed below: Dimeff, Linda A., Baer, John S., Kivlahan, Daniel R., and Marlatt, G. Alan. (1998). Brief alcohol screening and intervention for college students: A harm reduction approach.

Instructor’s Resource Manual (2nd edition) New York: Guilford.

Marlatt, G. Alan. (Ed.). (2002). Harm reduction: Pragmatic strategies for managing high-risk behaviors. New York: Guilford.

Classroom Activities/Discussion Topics: 1. Addictions among students. Introduce this chapter by asking students to list substances and activities that they couldn’t possibly live without. Write these substances and activities on the board, and ask students to identify whether they constitute an addiction, a habit, or just a behavior. In determining whether the substances and activities constitute an addiction, ask students to identify signs of tolerance, withdrawal, and increasing energy directed towards obtaining, using, or recovering from the substance use or behavior. When using this activity with my students, I engage in a bit of self-disclosure; I tell them about my unabashed addiction to caffeine, how it has increased in recent years, the withdrawal symptoms I experience when I don’t consume caffeine, and the various ways I have engaged in “drug-seeking behavior.” This activity can help students better understand the characteristics of an addiction, and will also illustrate the continuum between normality and abnormality.

2. The continuum of alcohol use. Make a list of alcohol-related behaviors, and place each one on a separate piece of paper. Give each of your students (or a sample of your students) one of these items, and ask them to line themselves up along a continuum from least severe to most severe. Students will likely find that many of these behaviors are difficult to classify clearly, as they depend on the person, the context, and whether the behavior occurs in conjunction with other behaviors. This exercise is useful for illustrating the importance of context and the continuum between normality and abnormality.

3. Attend a 12-Step meeting. Ask your students to attend an Alcoholics Anonymous or Narcotics Anonymous meetings. Many of these meetings are “open meetings,” meaning that they are open to members of the general public. “Closed meetings,” on the other hand, are reserved for members of these organizations. Before they attend these meetings, provide your students with some background information about the twelve-step model of recovery. Also ask your students to think about the following questions: • • • • •

What types of people did you see at the meeting? Did they fit your expectations?

How did you feel before and during the meeting? Did you feel anxious, or scared, or comfortable?

How was the meeting conducted?

What elements of the meeting do you think would potentially be helpful for an alcoholic or an individual addicted to drugs?

Was there anything about the meeting that you disliked?

4. National Alcohol Screening Day. Because alcohol use and binge drinking have become so widespread on college and university campuses, many institutions have begun to

Instructor’s Resource Manual (2nd edition) provide education and treatment of alcohol and drug abuse. National Alcohol Screening Day is one example of such an intervention. Ask your students to access the NASD website (http://www.nationalalcoholscreeningday.org/events/nasd/index.aspx) to get more information. Also ask them to think about the following issues: • • •

What assessments should be conducted during the screening?

In your opinion, what would be the most effective approaches to educating students about the dangers of alcohol and drug use?

What treatment resources and referrals should be provided to students?

5. Is marijuana a “gateway drug”? Some clinicians believe that, relatively speaking, marijuana is among the less harmful substances of abuse. In fact, many cite beneficial uses of marijuana, particularly as an appetite stimulant for individuals with AIDS and other illnesses. Yet other clinicians argue that marijuana is a “gateway drug”; people may begin with marijuana and then move on to use “harder” drugs such as amphetamines, cocaine, or heroin. Engage your students in a discussion of this topic 6. Educational films about substance abuse. A number of very good films have been produced that address issues of substance use. One of the best is Close to Home: Moyers on Addiction (available from www.pbs.org). This five-part series covers the science, treatment, prevention, and public policy issues surrounding addiction.

Instructor’s Resource Manual (2nd edition)

Chapter 10: Sex, Gender, and the Sexual Disorders Learning Objectives: By the end of this chapter, students should be able to: • Understand the continuum between normality and abnormality with respect to the sexual disorders.

• Discuss historical views of sexuality, particularly with respect to masturbation, homosexuality, and classification of sexual abnormalities.

• Describe the normal sexual response cycle, and identify the disorders that fall within each stage.

• Identify the psychological and biological factors that may contribute to the sexual disorders.

• Describe the recent changes that have taken place with respect to the treatment of male erectile disorder, and discuss some concerns about the recent interest in this disorder.

• Discuss the possible reasons for the high rates of female orgasmic disorder.

• Describe the causes and available treatments for premature ejaculation.

• Identify the genital pain disorders, and describe the various causes of these disorders.

• Understand the continuum between normality and abnormality with respect to the paraphilias, and identify the criteria necessary for diagnosing a paraphilia.

• Identify the various DSM-IV-TR paraphilia diagnoses, and discuss the advantages and limitations of these diagnoses.

• Describe the characteristics common to those who engage in pedophilia.

• Using the psychodynamic perspective, discuss the paraphilias in terms of fixations and defense mechanisms.

• Explain how classical conditioning and social learning may play a role in the development of paraphilias.

• Identify the biological components that appear to contribute to the paraphilias.

• Describe some of the difficulties of treating individuals with paraphilias.

• Describe the specific psychodynamic, behavioral, cognitive, and biological interventions used in the treatment of paraphilias.

• Be able to differentiate between gender identity disorder and gender nonconformity, intersex conditions, transvestism, and homosexuality.

• Identify the demographic factors common to those with gender identity disorder.

• Drawing upon the principle of multiple causality, identify the psychodynamic, behavioral, sociocultural/family systems, and biological factors that may contribute to gender identity disorder.

• Describe the available treatments for gender identity disorder, including sex reassignment, and discuss the potential ethical concerns of these treatments.

Lecture Outline: I. Defining Sexual Disorders a. The continuum between normality and abnormality and the importance of context i. Diagnosing sexual disorders is often fuzzy, given the cultural context, situational factors, and level of distress. ii. In some contexts, sexual behavior may be viewed as normal; in others, it

Instructor’s Resource Manual (2nd edition) may be seen as aberrant and disordered. b. Cultural and historical relativism in defining abnormal sexuality i. Masturbation 1. Generally considered to be a harmless and normal activity, although tension and anxiety still surround the topic.

2. Throughout history, masturbation has been viewed as pathological; examples include the views of S.D.D. Tissot, Benjamin Rush, Sylvester Graham, J.H. Kellogg, and Freud. ii. Homosexuality 1. Until 1973, it was listed in the DSM-II as a mental disorder; the diagnosis of ego-dystonic homosexuality replaced it, although it too was eventually removed.

2. Some cultures still view homosexuality as aberrant; others see homosexual behavior as normative.

3. Culture-bound syndromes: exhibitionism (Western cultures), dhat (East Asian societies).

II. Classifying Sexual Disorders a. Historical perspectives i. Krafft-Ebing’s Psychopathia Sexualis ii. Freud –viewed homosexuality as a developmental fixation, not a disorder b. The DSM-IV-TR categories i. Sexual disorders refer to phenomena in which the symptoms (not causes) are sexual; the actual causes may have little to do with sex itself. ii. The sexual dysfunctions 1. Normal sexual response process (4 stages)– (1) sexual interest/desire, (2) sexual excitement/arousal, (3) orgasm, (4) resolution (see Visual Essay 10) 2. Sexual dysfunctions involve persistent problems at the first, second, or third stage or pain related to sexual activity 3. Psychological and biological factors: a. Psychological factors: performance anxiety and spectatoring; treatments addressing these may include sensate focus, non-demand pleasuring, and emotional exploration. b. Biological factors: medical illnesses, medications, diet, aging, substance abuse. c. Sexual desire disorders i. Hypoactive sexual desire ii. Sexual aversion. d. Sexual arousal disorders: include female sexual arousal disorder and male erectile disorder (also known as erectile dysfunction and impotence). i. Viagra revolutionized the treatment of male erectile disorder; prior to 1998, major treatments were invasive and uncomfortable.

Instructor’s Resource Manual (2nd edition) ii. “Erectile dysfunction” replaced the term “impotence,” which implied inadequate masculinity. iii. Some argue that male erectile disorder is overemphasized and female sexual disorders are underemphasized. iv. Assessment may involve use of a snap gauge to determine nocturnal penile tumescence. e. Orgasmic disorders: include female orgasmic disorder, male orgasmic disorder, and premature ejaculation. i. Only about half of all women regularly have orgasms during intercourse; direct clitoral stimulation is the most effective way of achieving orgasm. ii. Many women have unfairly been diagnosed with orgasmic disorder; current diagnosis requires difficulty achieving orgasm even with direct clitoral stimulation. iii. Premature ejaculation is the most common male sexual dysfunction; a variety of psychological and biological factors may contribute.

1. Treatment of premature ejaculation: stopstart method, penile squeeze technique. f. Sexual pain disorders: include vaginismus and dyspareunia. i. Vaginismus involves vaginal muscle spasms that interfere with intercourse. ii. Dyspareunia involves genital pain during intercourse; although genital pain usually has a physical basis, the DSM-IV-TR excludes these situations. iii. The paraphilias – involve disordered sexual relationships and aberrant sexual preferences.

1. Several paraphilias are illegal; people with these disorders may only seek treatment when ordered to do so.

2. Many sexual practices involved in paraphilias are normal when practiced consensually and in moderation; paraphilias require: a. Persistence of the questionable sexual behavior b. Distress as a result of the sexual behavior/fantasy c. Behaviors are compulsive, maladaptive, and extreme.

3. Paraphilias more common in males in Western cultures.

4. Rape is not included as a DSM-IV-TR diagnosis, although it is a subtype of sexual sadism; this illustrates some of the advantages and limitations of diagnosis.

5. Exhibitionism – exposing one’s genitals to an unsuspecting stranger, usually to shock, humiliate, or sexually arouse women; this is the most common paraphilia.

Instructor’s Resource Manual (2nd edition) 6. Voyeurism (scoptophilia) – watching unsuspecting others as they engage in sex or disrobe.

7. Fetishism – intense, recurrent sexual arousal involving inanimate objects. a. Drawing the line between a normal sexual response and a fetish is difficult; in fetishism, the object is necessary in order to experience arousal.

8. Transvestic fetishism – occurs in males; involves sexual arousal by wearing women’s clothing. a. Does not involve gender dysphoria. b. Sexual arousal may be associated with autogynephilia (love of oneself as a woman); some are aroused by being in public, while others do it privately.

9. Sexual sadism – recurrent need to act out or imagine the infliction of pain/suffering in order to become sexually aroused. a. In extreme cases, may involve rape and other acts which are dangerous to the victim; can occur in conjunction with antisocial personality disorder. b. Many Americans enjoy mildly sadomasochistic activities; the diagnosis requires that the behavior is recurrent and necessary for arousal.

10. Sexual masochism – need/preference for physical or psychological suffering in order to become aroused.

11. Pedophilia – sexual attraction to/activity with prepubescent children. a. Young boys are the more common victims; victims may be family members or strangers whom the pedophile “befriends.” b. Sexual contact can involve a range of behaviors. c. Pedophiles often rationalize their behaviors and see them as harmless, yet they threaten the victim to prevent them from telling others. d. By the time the time they reach adulthood, 10-20% of children have been victims of child sexual abuse.

12. Frotteurism – rubbing up against or touching a stranger for sexual gratification.

13. Other paraphilias (Table 10.5) 14. Related disorders – “sexual addiction” III. Explaining and Treating Sexual Abnormality: The Paraphilias a. Treating paraphilias i. Treatment is difficult, and clinicians tend to be pessimistic about outcomes. ii. Barriers to treatment: client resistance, lack of response to treatment, therapist countertransference. b. Psychodynamic components

Instructor’s Resource Manual (2nd edition) i. Freud’s explanations initially involved fixation during particular developmental phases; he shifted his theory to include defense mechanisms in response to castration anxiety. ii. Contemporary psychodynamic theories focus more strongly on defense mechanisms.

1. Robert Stoller – paraphiliacs typically experienced profound humiliation during childhood that threatened their masculinity; they, in turn, turn passive into active/identify with the aggressor. iii. Psychodynamic interventions: 1. Address the roots of the problem in sexual trauma, humiliation, defense mechanisms, ineffective emotional/moral self-regulation.

2. A strong therapeutic alliance is necessary, yet can be challenging to cultivate due to client ambivalence and restrictions in confidentiality. c. Cognitive-behavioral components i. Classical conditioning – normal physical reactions are paired with inappropriate stimuli, provoking a conditioned response. ii. Social learning – children who observe sexually aberrant behaviors, who lack social/cognitive skills, and who are rewarded for inappropriate sexual behavior may have a tendency towards paraphilias. iii. Behavioral and cognitive interventions 1. Phallometric assessment 2. Conditioning techniques: aversion therapies, covert sensitization, systematic desensitization, masturbatory satiation/orgasmic reconditioning.

3. Cognitive restructuring, empathy training, social skills training, impulse control, healthy coping strategies. d. Biological components i. Some injuries/illnesses may have a disinhibiting effect. ii. Mental retardation, along with a history of abuse, are common. iii. Biological interventions 1. In the past, surgical castration was performed - legal and ethical questions have almost eliminated its use.

2. Chemical castration/suppression of testosterone levels - these also have raised ethical questions.

3. Antidepressants are used as a partial treatment.

IV. Gender Identity Disorders (also known as “transsexualism”) a. Sex refers to the biological fact of being male or female; gender refers to the psychological sense of being male or female b. Two major symptoms: i. Gender identity is opposite of biological sex. ii. Person is uncomfortable with biological sex. c. Gender nonconformity is not sufficient for GID diagnosis; nor are cross-gender identifications related to intersex conditions. d. Differential diagnosis: transvestism involves cross-dressing for sexual arousal;

Instructor’s Resource Manual (2nd edition)

e. f.

g.

h.

GID involves cross-dressing in order to feel in harmony with gender identity.

People with GID often experience relationship and emotional difficulties, often in conjunction with discrimination.

Demographic factors: i. GID more common in males than females; may be due to higher levels of stigma against males with cross-gender identifications. ii. Most women with GID are sexually attracted to women; sexual orientation varies widely in GID men. iii. GID occurs more often in children than in adults; many boys with GID later identify as homosexual or bisexual.

Explaining gender identity disorders i. Biological components 1. Temperament – boys with GID tend to have lower activity levels and less rough-and-tumble play.

2. Effect of hormones on gender identity: a. Girls with CVAH/CAH often develop more masculine personality traits. b. Males with androgen insensitivity syndrome tend to be hyper-feminine. c. Both of these are intersex conditions (ruling out a GID diagnosis), but point to the role of hormones. ii. Psychodynamic components 1. Emphasize disturbed mother-son relationships, although there is disagreement regarding the nature of these relationships. iii. Behavioral components 1. Operant conditioning/reinforcement and punishment may shape cross-gender behaviors. iv. Sociocultural and family systems components 1. GID boys tend to have many brothers and are younger siblings.

2. Families of children with GID tend to have family psychopathology, stress/frustration, and difficulty with limit setting. v. The principle of multiple causality in gender identity disorders 1. Biopsychodevelopmental explanations are useful; different factors may be present for girls than for boys.

Treating gender identity disorders i. Treatment of GID is controversial in children and adults ii. Gender identity appears to be somewhat changeable during childhood; less changeable in adults iii. Treatment for children involves trying to readjust gender identity to fit biological sex.

1. Behavioral conditioning paradigms involving reinforcement and punishment are used; their effectiveness is questionable.

2. Psychodynamic interventions: developing trusting relationship with the child, increasing parental concern about cross-gender behavior, increasing father’s involvement with son, improving

Instructor’s Resource Manual (2nd edition) marital relationship.

3. Some believe treatment of childhood GID is unethical; since many GID children later identify as gay, many see this as another “treatment” for homosexuality.

4. Others believe GID children experience emotional difficulties, stigmatization, and other related problems and would benefit from treatment. iv. Treatment for adults may involve sex reassignment.

1. The sex change process is long, involved, and expensive, and inappropriate for some GID adults.

2. Sex-change surgery was widely available during the 1960s and 1970s; there is less enthusiasm today.

3. Surgical techniques have improved, although mixed psychological effects have been reported.

4. The ethics of sex change surgery have been hotly debated.

V. Case Vignettes: Treatment a. Laurie – sexual dysfunction b. Rick – exhibitionism c. Phil – gender identity disorder Lecture Extensions: 1. Is it possible to change one’s sexual orientation? Although the diagnosis of homosexuality was officially removed from the DSM in 1973, psychologists still disagree on whether it is possible or ethical to change one’s sexual orientation. Those who are in favor of changing one’s sexual orientation from homosexual to heterosexual tend to cite religious and moral factors. Some suggest that it is up to the individual client to decide whether to remain gay or to try to change, which rests upon the assumption that sexual orientation is chosen and can be changed. On the other hand, those who argue against it cite evidence suggesting that most individuals who are in therapy to change their sexual orientation are unsuccessful in doing so. In fact, many individuals report having been harmed in the context of this therapy, and some report that this form of therapy was implicitly or explicitly forced upon them. This topic would likely result in a lively debate among your students. The articles cited below can give students some background in preparation for this discussion: Throckmorton, Warren. (2002). Initial empirical and clinical findings concerning the change process for ex-gays. Professional Psychology: Research and Practice, 33, 242248.

Shidlo, Ariel, and Schroeder, Michael. (2002). Changing sexual orientation: A consumers’ report. Professional Psychology: Research and Practice, 33, 249-259.

2. Sex offender treatment programs. It is well-known in the psychological community that sex offenders tend to be among the most difficult to treat. For one thing, clinicians often

Instructor’s Resource Manual (2nd edition) have strong countertransference reactions toward sex offender clients, which can prevent the formation of an effective therapeutic alliance. Additionally, sex offenders have an exceptionally high recidivism rate; many sex offenders will complete treatment and then reoffend. Thirdly, sex offenders may not necessarily choose to be in treatment; often they are mandated to be in therapy by the courts, and mandated therapy tends to be less effective than treatment that is freely chosen.

The following articles provide excellent background information into the above issues.

Beech, Anthony R., Fisher, Dawn D., and Thornton, David. (2003). Risk assessment of sex offenders. Professional Psychology: Research and Practice, 34, 339-352.

Polaschek, Devon L. L. (2003). Relapse prevention, offense process models, and the treatment of sexual offenders. Professional Psychology: Research and Practice, 34, 361367.

Serran, G., Fernandez, Y., Marshall, W. L., and Mann, R. E. (2003). Process issues in treatment: Application to sexual offender programs. Professional Psychology: Research and Practice, 34, 368-374.

Interestingly, most therapies tend to focus on risk management - the goal being to stop the offending behavior – but don’t necessarily place strong emphasis on improving the client’s quality of life. The following article provides an interesting contrast to traditional approaches to sex offender treatment, and suggests that a combination of risk management strategies and improvement of quality of life is most beneficial for sex offender clients.

Ward, Tony and Stewart, Claire A. (2003). The treatment of sex offenders: Risk management and good lives. Professional Psychology: Research and Practice, 34, 353360.

3. Feminist perspectives on sexual dysfunction in women. Although the DSM classification has changed considerably from the earlier editions to the present, feminist psychologists argue that our current understanding of female sexual dysfunctions is limited. Ellyn Kaschak and Leonore Tiefer (2001), who propose “a new view of women’s sexual problems,” suggest that female sexual dysfunctions need to be understood within their relational, cultural, and gender constructs. Moreover, Kaschak and Tiefer note some of the limitations of the medical model, particularly that it focuses solely on biological and performance factors and ignores the above-stated contextual factors. From this perspective, Kaschak and Tiefer rely on a multidimensional and comprehensive definition of “sexual problems,” which includes discontent with emotional, physical, or relational aspects of sexual experience in one or more areas (sociocultural, political, or economic; partner/relationship; psychological; medical). This perspective might be useful to present to students, particularly in conjunction with early views that relied on concepts of “hysteria” and “frigidity.”

Instructor’s Resource Manual (2nd edition) Kaschak, Ellyn and Tiefer, Leonore. (2001). A new view of women’s sexual problems.

Binghamtom, NY: The Hawthorne Press.

4. Online Sexual Predators. As Internet use among children and teenagers has become commonplace, many parents show increasing concern about their potential interaction with online sexual predators. This is a relatively recent phenomenon that is not clearly delineated in the DSM-IV-TR, and little has been written in the professional literature about this issue. An article by Dombrowski et al. (2004) addresses some of the characteristics of sexual predators, the behaviors they are likely to engage in, and suggestions for preventing this type of sexual offense and protecting children.

Interestingly, the authors note that sexual predators exhibit many of the same behaviors as other sex offenders, including “grooming” the child and choosing vulnerable youth, although unique characteristics are difficult to assess. More on this issue can be found in the following article: Dombrowski, Stefan C., LeMasney, John W., Ahia, C. Emmanuel, and Dickson, Shannon. (2004). Protecting children from online sexual predators: Technological, psychoeducational, and legal considerations. Professional Psychology: Research and Practice, 35, 65-73.

Classroom Activities/Discussion Topics: 1. Sexual male/female exercise. The prevalence of sexual dysfunctions can be partly attributed to cultural prescriptions for “normal” male and female sexual activity. The following exercise is useful in illustrating the cultural expectations that may become internalized and affect sexual pleasure and behavior. Ask your students to imagine a prototypical “highly sexually active male,” and have them “free associate” to that image (stating whatever words or phrases come to mind as they think about this prototype). Do the same with a “highly sexually active female.” Then ask your students to free associate to the image of a non-sexual male and a non-sexual female. As they engage in this activity, your students may begin to notice themes emerging. For example, students commonly note that there is enormous pressure on males to be sexually active, whereas females have to tread a very thin line between sexual activity and inactivity. Some students may also bring up racial and ethnic issues. For example, stereotypes about African-Americans and sexuality, cultural prescriptions about sex within Latino and Asian communities, etc.

2. “Normal” vs. “abnormal” sexual activities. Many of the paraphilias involve extremes of common sexual behaviors. For example, it is common for couples to engage in mild and consensual sadomasochistic activities, or to fetishize an object and use that object during sexual activity. For this exercise, you might choose to engage in a variation of the “continuum” activity described in previous chapters. Divide your students into groups of five or six, and have the groups brainstorm a range of atypical sexual behaviors. Then ask them to rank-order these behaviors from “more socially acceptable” to “less socially acceptable.” As they engage in this exercise, students will likely discuss factors such as the pervasiveness of the behavior, whether consent is granted, and whether the activities

Instructor’s Resource Manual (2nd edition) are harmful.

3. Gay/lesbian/transgender panel. Many college and university campuses have an active gay, lesbian, bisexual, and transgender organization. Invite members of this organization to your class, and have the panel talk about issues such as coming out, internalized and societal homophobia, gay and lesbian community resources, family acceptance, etc.

Students might ask questions directly to panel members, or you might have them write questions anonymously and submit them to you to read to the panel. This exercise can be extremely valuable for students, as you may have students who identify as gay, lesbian, bisexual, or transgender. You may also have students in your class who are intolerant of homosexuality, or who lack knowledge and information. When conducting this panel, be sure to remind the class that differences of opinion are acceptable and even welcomed, but that students need to respect the panelists and each other.

4. Media messages about sexuality. In the age of Viagra, commercials and print ads abound touting the new “sexual wonder drug.” Record a Viagra commercial and show it to your students. Ask your students: What messages are conveyed regarding male sexuality? Are they realistic or unrealistic? Is male sexuality discussed openly, or is it presented in a euphemistic and veiled manner?

5. Gender identity disorder in the media. Several films and books have emerged recently addressing issues of gender identity. The following are among the most useful: Personal accounts of gender identity disorder/transsexualism.

The Last Time I Wore a Dress by Daphne Scholinski She’s Not There by Jennifer Finney Boylan Films Boys Don’t Cry Ma Vie En Rose (My Life in Pink) You Don’t Know Dick: Courageous hearts of transsexual men Other books My Gender Workbook by Kate Bornstein This book includes aspects of Bornstein’s own experience as a transgendered individual.

It also engages the reader in a number of activities and thought-provoking exercises regarding gender identity.

As Nature Made Him: The Boy Who was Raised as a Girl by John Colapinto This biography chronicles the life of a man who was raised as a girl due to a botched circumcision. The life-long maladjustment of the book’s main character (David Reimer) in response to being raised the opposite of his biological sex provides a compelling case against the assumption that gender is primarily a social construction. On a sad note, 3 years after publication of this book David Reimer committed suicide.

Instructor’s Resource Manual (2nd edition)

Chapter 11: Personality and the Personality Disorders Learning Objectives: By the end of this chapter, students should be able to: • Differentiate between ego-dystonic and ego-syntonic traits.

• Understand the continuum between normality and abnormality with respect to the personality disorders.

• Name the common characteristics of Cluster A personality disorders, and identify the disorders that fall into this category.

• Discuss the psychodynamic and the cognitive-behavioral components contributing to paranoid personality disorder.

• Describe how schizoid personality disorder differs from other disorders involving problematic social relationships, and discuss the biological, psychodynamic, and cognitive-behavioral components underlying this disorder.

• Explain how schizotypal personality disorder differs from schizophrenia, and discuss the psychodynamic, cognitive-behavioral, and biological factors underlying this disorder.

• Name the common characteristics of Cluster B personality disorders, and identify the disorders that fall into this category.

• Describe the biological, psychodynamic, and cognitive-behavioral components of antisocial personality disorder, and discuss the challenges of treating individuals with this disorder.

• Using psychodynamic theory, describe the developmental issues and defense mechanisms employed by individuals with borderline personality disorder.

• Describe the biological and cognitive-behavioral factors associated with borderline personality disorder, and discuss the components of Dialectical Behavior Therapy.

• Identify the psychodynamic and cognitive-behavioral components of histrionic personality disorder.

• Discuss the various psychodynamic views of narcissistic personality disorder, and identify the common defense mechanisms seen in this disorder.

• Differentiate between Kohut’s and Kernberg’s approaches to treating narcissistic personality disorder.

• Name the common characteristics of Cluster C personality disorders, and identify the disorders that fall into this category.

• Discuss the psychodynamic, cognitive-behavioral, and biological components involved in avoidant personality disorder.

• Describe the causes and treatments of dependent personality disorder, using psychodynamic and cognitive-behavioral theories.

• Be able to differentiate between obsessive-compulsive disorder and obsessivecompulsive personality disorder.

• Identify the psychodynamic and cognitive-behavioral factors that may contribute to obsessive-compulsive personality disorder.

• Describe the types of outcome studies used to determine treatment effectiveness, and discuss the findings of these studies with respect to the personality disorders.

• Identify the age-related factors that must be taken into consideration when diagnosing personality disorders.

Instructor’s Resource Manual (2nd edition) • • • •

Address the issue of potential gender stereotyping in the personality disorder diagnoses.

Identify the socioeconomic factors that appear to be associated with various personality disorder diagnoses.

Identify cultural and historical factors that may have made some personality traits more or less acceptable.

Discuss the advantages and limitations of the DSM-IV-TR personality disorder diagnoses.

Lecture Outline: I. Defining Personality and the Personality Disorders a. Personality traits – stable patterns of inner experience and behavior i. Ego-dystonic traits are unwanted, uncomfortable, and inconsistent with sense of self. ii. Ego-syntonic traits are consistent with one’s self-concept. iii. Personality disorders are trait-based disorders (vs. symptom based disorders found in Axis I of the DSM-IV-TR) b. Personality – an individual’s unique and stable way of experiencing the world; reflected in a predictable set of reactions to a variety of situations. c. Personality disorder – characterized by rigid, extreme, and maladaptive personality traits (DSM-IV-TR – Axis II) d. The continuum between normal and abnormal personality i. Traits such as narcissism and dependency are normal in moderation; personality disorders are exaggerated versions of normal traits.

II. Classifying, Explaining, and Treating Personality Disorders a. Cluster A (odd or eccentric) = paranoid, schizoid, schizotypal b. Cluster B (dramatic, emotional, erratic) = antisocial, borderline, histrionic, narcissistic c. Cluster C (anxious or fearful) = avoidant, dependent, obsessive-compulsive d. Cluster A: Odd or eccentric PDs i. Paranoid personality disorder – characterized by extreme suspicion and distrust, yet are still grounded in reality; tend to “take things the wrong way.”

1. Psychodynamic components a. Focus is on problematic childhood relationships and maladaptive defense mechanisms. b. Paranoids may have experienced humiliation, criticism, and ridicule during childhood; fosters “attacking” style. c. Projection – a defense mechanism in which hostile feelings are unconsciously attributed to others. d. Transference occurs when patterns from other relationships are repeated in the therapeutic relationship; useful in the treatment of paranoid personality disorder. e. Developing a therapeutic alliance with paranoids can be challenging.

2. Cognitive-behavioral components

Instructor’s Resource Manual (2nd edition) a. Emphasize maladaptive cognitive schemas formed early in life; also emphasize the power of self-fulfilling prophecies. b. Treatment – identify/challenge distorted cognitive schemas, and change problematic behaviors. c. Therapists do not try to change the client’s fundamental assumptions, but instead encourage the client to evaluate specific situations. ii. Schizoid personality disorder – involves detachment from social relationships and a restricted range of emotional expression.

1. Unlike people with autism and Asperger’s disorder, people with schizoid personality disorder can function in social situations.

2. Psychodynamic components a. Withdrawal may be used as a defense mechanism. b. Focus on difficult early childhood attachments, resulting in avoidance in adulthood. c. Ambiguous or confusing parental communications may play a role. d. Intellectualization – a defense mechanism in which emotions are thought about, but not felt.

3. Cognitive-behavioral components a. People with schizoid personality disorder are unresponsive to and have difficulty interpreting interpersonal cues; may not experience gratification through human interaction.

4. Biological components a. Temperament may play a role; “difficult” temperament is linked with schizoid and schizotypal personality disorders. iii. Schizotypal personality disorder – involves pervasive, chronic, and dysfunctional eccentricity in behavior, appearance, and thinking.

1. Schizotypal personality disorder resembles schizophrenia, although people with the disorder are not as fully out of touch with reality.

2. Eccentricities in thinking include ideas of reference and magical thinking.

3. Some symptoms overlap with those of paranoid and schizoid personality disorders.

4. Psychodynamic components a. Psychodynamic theorists posit that schizoid PD, schizotypal PD, and schizophrenia form a continuum that ranges from social isolation and detachment to paranoia and magical thinking b. Cognitive and perceptual schizotypal features occur when the ego fails to function in its adaptive role and primary process thought breaks through consciousness i. In healthy people, secondary process thought dominates over primary process thought 5. Cognitive-behavioral components a. People with schizotypal personality disorder tend to make

Instructor’s Resource Manual (2nd edition) strange connections among disparate phenomena. b. Treatment using cognitive-behavioral strategies can be challenging, since clients may not be able to use reason, logic, and objectivity. c. Treatment focusing on improving social skills and social problem solving appears to be helpful.

6. Biological components a. Enlarged ventricles (although not as enlarged as in schizophrenia) b. Neurotransmitter abnormalities similar to those in schizophrenia c. Low doses of antipsychotic medications appear to be helpful. e. Cluster B disorders: Dramatic, emotional, or erratic PDs i. Antisocial personality disorder – involves a pattern of disregard for and violation of the rights of others.

1. Formerly termed “psychopath”, “sociopath” 2. Although the DSM-IV-TR emphasizes criminality, some people with the disorder do not break laws.

3. Psychodynamic components a. Families tend to be emotionally turbulent, cruel, and physically abusive. b. Identification with the aggressor – a defense mechanism in which a person causes other to experience what they did as a child. c. People with antisocial personality disorder tend to act instead of feel. d. Abnormal superego functioning 4. Cognitive-behavioral components a. Parents who model antisocial behaviors to children are likely to produce antisocial children. b. Impairment in the ability to connect actions with consequences. c. Therapists tend to be pessimistic about treatment; most who enter treatment are mandated to do so. d. Behavioral interventions may be more effective than cognitive approaches.

5. Biological components a. Deficiency in normal anxiety reactions b. Exposure to prenatal drug use c. Structural brain abnormalities: smaller prefrontal areas d. See Visual Essay 11 for brain processes implicated in reactive and instrumental aggression 6. Sociocultural components a. Low SES and poor neighborhoods are risk factors for development of antisocial behaivor

Instructor’s Resource Manual (2nd edition) ii. Borderline personality disorder – marked by instability of interpersonal relationships, self-image and emotions; and impulsivity. (Box 11.1 addresses the origin of the term “borderline”) 1. Depersonalization/dissociative and self-injurious symptoms, fears of abandonment are common.

2. Psychodynamic components a. Difficulties in mother-child relationship; unreliable and inconsistent primary caregivers. b. People with borderline personality disorder often have histories of abuse. c. Splitting – a defense mechanism in which others are seen as all good or all bad.

3. Cognitive-behavioral components a. Focus on dichotomous thinking and dramatic, impulsive behaviors. b. Therapy usually begins with a set of concrete behavioral goals.

4. Biological components a. Impulsivity associated with low levels of serotonin. b. Antidepressants are sometimes helpful for managing emotional symptoms.

5. Dialectical Behavioral Therapy (DBT) – combines cognitivebehavioral, psychodynamic, biological, and Zen Buddhist principles. a. Four areas are addressed: improving attentional focus, increasing emotional control, improving interpersonal effectiveness, tolerating distress. b. Therapy addresses: life-threatening behaviors, therapyinterfering behaviors, quality of life interfering behaviors, behaviors related to PTSD, and behaviors that interfere with self-respect/quality of life. iii. Histrionic personality disorder – involves excessive emotionality and attention-seeking; emotions tend to be shallow and labile.

1. Psychodynamic components a. Freud – hysterical/histrionic traits may stem from repression of traumatic experiences or sexual conflicts. b. Psychodynamic therapists usually use transference-based interventions.

2. Cognitive-behavioral components a. Engaging in self-dramatizing behaviors may elicit attention from others. b. Histrionic cognitive style relies on vague impressions; therapists need to remain specific and concrete. c. Therapy focuses on teaching clients to ask specifically for what they want, rather than resorting to indirect and attention-seeking behaviors.

Instructor’s Resource Manual (2nd edition) iv. Narcissistic personality disorder – involves a pattern of grandiosity, need for admiration, and lack of empathy for others.

1. Psychodynamic components a. Disorder seen as an attempt to counteract feelings of inadequacy. b. Lorna Benjamin – argues that narcissism can stem from parental indulgence. c. Idealization and devaluation are common defenses. d. Treatment approaches: i. Kohut – emphasis on providing empathy to clients and tolerating grandiosity. ii. Kernberg – stresses the importance of gentle yet consistent confrontation of grandiosity.

2. Cognitive-behavioral components a. Clients usually seek therapy for symptoms other than narcissism; therapists begin by addressing symptoms, which eventually leads to a focus on personality patterns. f. Cluster C disorders: Anxious or fearful PDs i. Avoidant personality disorder – involves social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

1. Differs from social phobia because it is pervasive and chronic – people with avoidant PD feel anxious and inadequate in almost all social situations over many years and can engage in interpersonal intimacy only when they feel assured of uncritical acceptance.

2. Psychodynamic components a. May have been excessively shamed by their parents during childhood. b. Withdrawal and escape into fantasy are common defenses. c. Psychotherapy may be difficult due to clients’ sensitivity to criticism.

3. Cognitive-behavioral components a. People with avoidant personality tend to scan their environments and be overly attuned to minute details. b. Selective attention to details fitting negative assumptions. c. Therapy helps clients recognize positive feedback, and increase clients’ tolerance for painful emotions. d. Group therapy can be particularly helpful.

4. Biological components a. Temperament may play a role, particularly a “slow-towarm-up” temperament. b. Antidepressant medications are useful as an adjunct to help people make better use of therapy. ii. Dependent personality disorder – involves an excessive need to be taken care of; leads to submissive and clinging behaviors and fears of separation.

1. Psychodynamic components a. Early psychodynamic theory emphasized a fixation at the

Instructor’s Resource Manual (2nd edition) oral stage, resulting from overindulgence or insufficient gratification. b. Regression and idealization are common defense mechanisms. c. Transference-based therapies can be helpful.

2. Cognitive-behavioral components a. Dependent adults may have been punished as children for independent and assertive behaviors and rewarded for clingy behaviors. b. Assertiveness training iii. Obsessive-compulsive personality disorder – involves preoccupation with orderliness, perfectionism, and mental/interpersonal control.

1. Differs from OCD in that the symptoms are pervasive and chronic, rather than involving specific obsessions and compulsions.

2. Many symptoms may be highly valued by the person and by society.

3. Psychodynamic components a. Freud – fixation at the anal stage of development. b. Defense mechanisms include reaction formation, undoing, and isolation of affect.

4. Cognitive-behavioral components a. Cognitive style involves focusing on details and missing the point of the overall activity. b. People with this disorder often embrace the cognitivebehavioral perspective, since they are so oriented toward rational analysis. g. Evaluating the treatment of personality disorders i. Tables 11.12, 11.13, and 11.14 summarize the psychodynamic, cognitivebehavioral, and biological components of personality disorders. ii. Three types of outcome studies: uncontrolled clinical reports, single-case design studies, and controlled outcome studies. iii. Single-case design/controlled outcome studies have found psychodynamic therapies to be useful for avoidant, obsessive-compulsive, and borderline personality disorders. iv. Controlled outcome studies have not confirmed the utility of psychodynamic approaches for other personality disorders. h. Classification in demographic context i. Age 1. DSM-IV-TR specifies that an individual must be over 18.

2. Adolescents may commonly show narcissistic and borderline traits; these may be developmental in nature.

3. Many adults with personality disorders show the symptoms throughout their childhood. a. Antisocial personality disorder is often preceded by oppositional defiant disorder or conduct disorder. ii. Gender

Instructor’s Resource Manual (2nd edition) 1. Many personality disorder diagnoses have been challenged on the grounds of gender bias. a. Stereotypically feminine traits are seen in borderline, histrionic, and dependent personality disorders; these are more commonly diagnosed among women. b. Stereotypically masculine traits are seen in paranoid, schizoid, schizotypal, antisocial, narcissistic, and obsessive-compulsive personality disorders; these are more commonly diagnosed among men. iii. Class 1. Most personality disorders occur across socioeconomic lines.

2. Borderline and dependent personality disorders occur more commonly among members of lower socioeconomic classes.

3. Criminal behaviors associated with antisocial personality disorder are linked to lower socioeconomic classes. i. Cultural and historical relativism in defining and classifying personality disorders i. In certain cultures, some personality traits may be more acceptable than in other cultures (example: lack of interpersonal relationships among Buddhist priests) ii. Some personality traits might have been more acceptable (or not as acceptable) at different points in time (example: dependency among 1950s housewives). iii. Personality disorder diagnoses have changed across editions of the DSM. j. The advantages and limitations of the diagnosis of personality disorders i. DSM personality disorder diagnoses show weak reliability and validity. ii. Many personality disorders have overlapping diagnostic criteria. iii. DSM-IV-TR relies on polythetic (multiple) criteria sets; no one criterion is critical to the overall diagnosis. iv. Some experts have proposed that personality disorders be reclassified in dimensional terms, rather than using categorical methods.

III. Case Vignettes: Treatment a. Tyler – paranoid personality disorder b. Beth – dependent personality disorder Lecture Extensions: 1. Borderline personality disorder or posttraumatic stress disorder? Borderline personality disorder is quite common among individuals who have experienced childhood sexual abuse or trauma. Because of this significant overlap, clinicians have debated whether borderline personality disorder is actually a variant of PTSD. Other clinicians have questioned where PTSD ends and where BPD begins. Judith Herman (1997) proposed a diagnostic category called “complex PTSD,” which manifests in individuals who suffer from longstanding, untreated post-traumatic effects, most commonly from child sexual abuse. Many feminist psychologists have embraced the proposed change in terminology, as BPD tends to be a stigmatized diagnosis in the psychological community. Moreover,

Instructor’s Resource Manual (2nd edition) calling the syndrome “complex PTSD” removes the burden of responsibility from the individual and places it outside of the self, whereas personality disorders are, by definition, an inherent part of the individual. The following resources present a variety of perspectives on this issue: Golier, Julia A.; Yehuda, Rachel; Bierer, Linda M.; Mitropoulou, Vivian; et al. (2003).

The relationship of borderline personality disorder to posttraumatic stress disorder and traumatic events. The American Journal of Psychiatry, 160, 2018.

Herman, J. (1997). Trauma and recovery: The aftermath of violence from domestic abuse to political terror. New York: Basic Books.

Roth, S., Newman, E., Pelcovitz, D., van der Kolk, B., & Mandel, F. S. (1997). Complex PTSD in victims exposed to sexual and physical abuse: Results from the DSM-IV field trial for Posttraumatic Stress Disorder. Journal of Traumatic Stress, 10, 539-555.

2. Gender bias in personality disorder diagnosis. In 1970, Broverman et al. conducted a landmark study on gender bias in perceptions of psychological health. In their study, they noted vast differences between individuals’ perceptions of a “psychologically healthy male,” a “psychologically healthy female,” and a “psychologically healthy adult.”

While Broverman’s study has been countered by more recent replication attempts, the issue of gender bias in diagnosis still rages on, particularly with respect to the personality disorders. Many clinicians argue, as stated in the textbook, that the diagnostic criteria for many of the personality disorders are biased either towards the extremes of masculine behavior or the extremes of feminine behavior. For example, individuals with schizoid personality disorder tend to be detached from relationships and emotional experience (stereotypically masculine traits), whereas individuals with dependent personality disorder tend to rely too strongly on others in making decisions and gaining a sense of self-worth (stereotypically feminine traits). Paula Caplan (1991), in her critique of the current personality disorder nosology, proposed a hypothetical personality disorder diagnosis called “delusional dominating personality disorder,” which might be seen in individuals who present with extremely masculine traits.

Your students might find it interesting to review Caplan’s “delusional dominating personality” criteria and debate the issue of gender bias. Some useful resources on the subject are listed below: Broverman, I. K., Broverman, D., Clarkson, F. E., Rosecrantz, P., and Vogel, S. (1970).

Sex role stereotypes and clinical judgments of mental health. Journal of Consulting and Clinical Psychology, 34, 1-7.

Brown, Laura S. (1992). A feminist critique of the personality disorders. In Laura S. Brown and Mary Ballou (Eds.), Personality and psychopathology: Feminist reappraisals (pp. 206-228). New York: Guilford.

Caplan, Paula J. (1991). Delusional dominating personality disorder. Feminism and

Instructor’s Resource Manual (2nd edition) Psychology, 1, 171-174.

Flanagan, Elizabeth H. and Blashfield, Roger K. (2003). Gender bias in the diagnosis of personality disorders: The roles of base rates and social stereotypes. Journal of Personality Disorders, 17, 431.

3. Which personality disorders do we see in therapy? Many individuals with personality disorders may never be seen in therapy. For one thing, some of the personality disorders by definition involve a lack or fear of relationships, including a therapeutic connection.

These disorders might include paranoid, avoidant, or schizoid personality disorder. Other individuals with personality disorders may not necessarily seek treatment because they don’t experience distress, or they don’t see themselves as having a problem; antisocial personality disorder is a good example of this. Tyrer et al. (2003) proposed a subclassification of personality disorders as either Type R (treatment rejecting) or Type S (treatment seeking). According to Tyrer et al., Cluster A personality disorders are the most likely to fall into the Type R category, whereas Cluster C personality disorders are commonly Type S. Clinical lore suggests that several of the Cluster B personality disorders, most notably borderline personality disorder, are more likely to be treatmentseeking, as they commonly experience intense psychological distress.

Students may find it interesting to discuss the application of the Type R/Type S classification with respect to Axis I as well as Axis II disorders.

Tyrer, Peter; Mitchard, Sarah; Methuen, Caroline, and Ranger, Maja. (2003). Treatment rejecting and treatment seeking personality disorders: Type R and Type S. Journal of Personality Disorders, 17, 263.

4. Cultural vs. functional paranoia. Individuals suffering from paranoid personality disorder tend to mistrust others, read into the statements and behaviors of others and assume ulterior motives to be present, and believe that others wish to harm or subvert them in some way. While in many cases these behaviors are maladaptive, they may actually be healthy and functional among individuals who are subjected to covert prejudice and discrimination. African-Americans, for example, repeatedly need to judge whether a situation potentially involves racism. Over time, these individuals may develop what is called “cultural paranoia,” which refers to mistrust and hypervigilance due to racism and other contextual factors. “Functional paranoia,” on the other hand, involves paranoid reactions that occur independently of contextual factors. The challenge for clinicians, of course, is to distinguish accurately between the two. This can be particularly difficult if a Euro-American clinician is working with a client from a racial or ethnic minority group, for mistrust may manifest immediately in the therapeutic situation. Some useful resources on this subject include the following: Ponterotto, J.G. & Casas, J.M. (1991). Handbook of racial/ethnic minority counseling research. Springfield: Charles C. Thomas Publishers.

Sue, D.W., & Sue, D. (1997). Counseling the culturally different (3rd ed.) New York:

Instructor’s Resource Manual (2nd edition) Wiley.

Whaley, A.L. (2001). Cultural mistrust and mental health services for AfricanAmericans: A review and meta-analysis. The Counseling Psychologist, 29, 513-531.

Classroom Activities/Discussion Topics: 1. Using DBT to treat borderline personality disorder. A very useful tool for demonstrating the principles of DBT is Marsha Linehan’s Skills Training Manual for Borderline Personality Disorder. This manual contains numerous worksheets and exercises for clients, and many of then are useful to duplicate and distribute to students. Linehan has also produced a number of excellent videos that can be used as teaching tools as well as with clients. Several of these videos are listed below: Crisis Survival Skills, Part One: Distracting and Self-Soothing: What do you do when a crisis comes?

Crisis Survival Skills, Part Two: Improving the Moment and Pros & Cons: Making Choices That Help Opposite Action: Changing Emotions You Want to Change: Dialectical Behavior Therapy Skills Training Video This One Moment: Skills for Everyday Mindfulness: Achieving awareness of what really is.

All of the above videos are from the From Chaos to Freedom series.

2. Countertransference in therapists working with personality disordered clients. The topic of personality disorders lends itself well to a discussion and demonstration of countertransference. Provide students with a refresher on the concept of transference and countertransference. You might choose to ask students to anticipate countertransference reactions and to have a large group discussion. A more effective technique, however, might be to role-play an interaction with a student. Assume the role of a client with a personality disorder, and ask a student in the class to play the role of interviewer. In playing the client role, you might need to exaggerate symptoms and behaviors in order to evoke a response from the student interviewer. As the interaction progresses, you might step out of role and ask the student (and the rest of the class) how they are feeling. Are they feeling inadequate? Frustrated? Are they inclined to pull away from the client? This exercise can help students better understand the concept of countertransference, and it may give them more empathy for personality disordered clients.

3. Adaptive vs. maladaptive personality traits. Some of the personality disorder criteria involve counterproductive traits and behaviors, yet others may involve a range of useful and adaptive traits, at least in certain situations. Choose a particular personality disorder diagnosis and ask students to discuss the advantages and disadvantages to possessing these traits. For example, someone with narcissistic personality disorder may drive

Instructor’s Resource Manual (2nd edition) people away, yet they may also accomplish things that others perceived to be unachievable. This exercise can help students understand the importance of context and the continuum between normality and abnormality. Interestingly, this exercise may also provide some students with insight into why these disorders might develop in the first place. Some clinicians suggest that personality disorder traits develop in early childhood as a coping mechanism against a chaotic, traumatic, or otherwise difficult context.

4. Personality disorders in film. Many personality disorders lend themselves well to Hollywood films, as they might involve drama, emotionality, and/or eccentricity. Below are listed a range of films in which one or more characters suffer from a personality disorder: Fatal Attraction – Glenn Close’s character exhibits some borderline characteristics.

Girl, Interrupted – Winona Ryder’s character was diagnosed with borderline personality disorder (perhaps erroneously, as discussed in the original novel); Angelina Jolie’s character displays a number of antisocial qualities.

Taxi Driver – Robert De Niro’s character shows a range of schizotypal characteristics.

Sleeping With the Enemy – displays a number of features including antisocial and obsessive-compulsive personality traits.

Instructor’s Resource Manual (2nd edition)

Chapter 12: Psychosis and Schizophrenia Learning Objectives: By the end of this chapter, students should be able to: • Define the following terms: psychosis, hallucinations, delusions • Identify the social and economic costs associated with schizophrenia.

• Recognize commonly held myths about schizophrenia.

• Explain how the diagnosis and our understanding of schizophrenia have changed throughout history.

• Describe the difference between Type I/positive and Type II/negative symptoms, and provide specific examples of each.

• Identify the subtypes of schizophrenia.

• Name and describe the other disorders that lie on the “schizophrenia spectrum.”

• Identify the age, gender, class, and cultural factors associated with schizophrenia.

• Discuss how our explanations and treatments of schizophrenia have changed over time.

• Identify the various biological correlates of schizophrenia, including brain function, brain structure, neurochemical factors, and genetic components.

• Describe the available biologically-based treatments, noting their strengths and weaknesses.

• Explain why the deinstitutionalization movement took place, and describe the ramifications of these policies.

• Identify the cognitive factors associated with schizophrenia, and describe specific cognitive treatments of the disorder.

• Describe the behavioral components of schizophrenia, and discuss specific behavioral interventions.

• Describe the sociocultural/community-based treatment resources available for individuals with schizophrenia.

• Discuss research on family interaction patterns and communication styles of individuals with schizophrenia.

• Discuss the psychodynamic perspective of schizophrenia, noting the contributions of Frieda Fromm-Reichmann.

• Discuss the “diathesis-stress” model and how it applies to schizophrenia and the psychotic disorders.

Lecture Outline: I. Defining Psychosis and Schizophrenia a. Psychosis – profound loss of touch with reality b. Hallucinations – abnormal sensory experiences c. Delusions –fixed, false, bizarre beliefs d. Schizophrenia – closely associated with psychosis i. Costs of schizophrenia are enormous e. Myths about schizophrenia i. “Split personality” – schizophrenia involves a split from reality, but not distinct personalities. ii. Dangerousness – most people with schizophrenia are not violent, and may

Instructor’s Resource Manual (2nd edition) be withdrawn.

II. Classifying Psychosis and Schizophrenia a. Cultural and historical relativism i. Psychosis has been documented throughout history, although people with psychosis were not always viewed as sick ii. Western tradition 1. Phillipe Pinel – early 19th century reformer; produced written descriptions of chronic psychotic states 2. Emil Kraepelin – “father of modern psychiatry”; distinguished between manic-depressive psychosis and dementia praecox 3. Eugen Bleuler – coined the term “schizophrenia” in the early 1900s a. The “4 A’s” – ambivalence, abnormal associations, disturbed affect, autism b. Believed that schizophrenia was not a single disorder, but a group of related disorders.

4. DSM approaches a. DSM-I and II contained vague criteria b. Criteria were narrowed and clarified in DSM-III b. The DSM-IV-TR Categories i. Schizophrenia 1. Type I/positive symptoms – behavioral excesses a. Delusions – can be bizarre or non-bizarre i. Delusions of persecution ii. Delusions of grandeur iii. Delusions of reference iv. Other themes: guilt, illness, nihilistic delusions b. Hallucinations i. auditory hallucinations are the most common in schizophrenia; visual hallucinations occur often as well c. Disorganized speech/thought – formal thought disorder i. Loose associations ii. Clang associations iii. Neologisms iv. Echolalia v. Echopraxia vi. Incoherence/word salad d. Grossly disorganized behavior i. Includes dishevelment, agitation, childlike silliness. ii. Catatonia/waxy flexibility 2. Type II/negative symptoms – deficits a. Affective flattening b. Alogia/poverty of speech c. Avolition

Instructor’s Resource Manual (2nd edition) d. Anhedonia 3. Other diagnostic criteria a. Temporal criteria i. Disorder must last for 6 months, with at least one month of clear symptoms ii. Significant impairment/deterioration over time iii. “Downward drift” – trend towards declining socioeconomic status among those with schizophrenia, compared to their families 4. Subtypes of schizophrenia a. Paranoid b. Disorganized c. Catatonic d. Undifferentiated e. Residual 5. Other related disorders a. Schizophrenic spectrum – a group of related/overlapping disorders with a common etiological basis i. Paranoid, schizoid, and schizotypal personality disorders may fall on the spectrum b. Schizoaffective disorder – includes mood symtoms c. Schizophreniform disorder – hasn’t lasted 6 months d. Brief psychotic disorder e. Delusional disorder f. Shared delusional disorder/folie a deux c. Classification in demographic context i. Class and culture 1. Prevalence higher among African-Americans in the U.S. and Britain, and 2nd-generation African-Caribbeans in Britain 2. High rates correlated with low SES 3. Highest risk among those with biological relatives with schizophrenia ii. Age and gender 1. Course of schizophrenia: prodromal, active, residual 2. Prodromal phase can be sudden or gradual 3. 60% follow chronic course 4. Men – onset typically occurs in early 20s, more negative symptoms, poorer pre-morbid levels of functioning 5. Women – onset typically occurs in late 20s, fewer negative symptoms, better pre-morbid levels of functioning, better prognosis III. Explaining and Treating Schizophrenia a. Historical perspectives i. Until 1950s, no useful treatments were readily available ii. Biological research transformed treatment – although much of this

Instructor’s Resource Manual (2nd edition) research had been conducted by German scientists during the Nazi era iii. Since the 1970s, biological explanations have dominated the field b. Biological components i. Brain function abnormalities 1. Hypofrontality – decrease in prefrontal cortex activity 2. Abnormalities in several neurotransmitter systems: dopamine, glutamate, serotonin, GABA 3. Dopamine hypothesis – high levels of dopamine may contribute to symptoms of schizophrenia a. Chlorpromazine was found to reduce delusions and hallucinations; also caused Parkinsonism b. Stimulant drugs can produce psychosis c. Some people with schizophrenia have an abundance of D2 receptors d. Researchers now see this as a partial explanation i. Revisions to dopamine hypothesis have focused on glutamate’s role in changing dopamine transmission and the different dopamine pathways affected in schizophrenia (e.g., mesolimbic, mesocortical pathways) – see Visual Essay 12.1 for more on the different dopamine pathways ii. Brain structure abnormalities 1. Enlarged ventricles (negative symptoms) 2. Abnormalities in the temporal, frontal, and parietal lobes; these findings have not been consistently replicated iii. Neuropsychological and neurophysiological abnormalities 1. Impaired cognitive abilities 2. Impaired sensory gating 3. Abnormal visual tracking, slow reaction time, abnormal brain wave patterns iv. Predisposing causes (distal causes) 1. Schizophrenia appears to be neurodevelopmental rather than neurodegenerative 2. Schizotaxia – halfway point on the schizophrenia continuum; involves mild negative symptoms, deviant eye tracking, brain abnormalities, but not psychosis 3. Genetic and environmental factors appear to be involved a. Risk of schizophrenia is higher among those born in the winter/spring b. Genetic factors i. Schizophrenia runs in families ii. Twin studies, adoption studies, and genetic linkage studies all suggest an interaction between genes and the environment. iii. Schizophrenia involves a polygenic (multiple genes) transmission of a vulnerability to the

Instructor’s Resource Manual (2nd edition) disorder that depends heavily on environmental triggers for expression. iv. Diathesis-stress model – disorders are caused by a combination of predisposing factors and precipitating circumstances v. Biological interventions 1. Introduction of antipsychotic medications during the 1950s created a revolution in treatment of schizophrenia 2. Phenothiazines (also called major tranquilizers and neuroleptics) work by blocking D2 receptors 3. Prior to the 1950s, treatments included ECT, insulin-induced coma, and prefrontal lobotomy, none of which were very effective.

4. 1960s – deinstitutionalization movement; because antipsychotics were seen as a “magic bullet,” patients were rapidly discharged from hospitals into community life. a. Problems associated with deinstitutionalization: i. Phenothiazines do not improve negative symptoms ii. Side effects: tardive dyskinesia, neuroleptic-induced parkinsonian symptoms, neuroleptic malignant syndrome iii. Lack of adequate social services 5. Second-generation antipsychotics (1980s) a. Clozapine - reduces positive and negative symptoms by increasing dopamine transmission in the prefrontal cortex b. In 1-2% of patients, clozapine can cause agranulocytosis – potentially fatal lowering of white blood cell counts c. Other “atypical” antipsychotics were developed that targeted certain serotonin and norepinephrine receptors, and had a smaller effect on dopamine receptors i. Major advantage of atypicals – modest improvement in negative symptoms and less severe side effects ii. There still remain problems – e.g., significant weight gain, noncompliance with medicatino 6. Prevention efforts – focus on treatment during the prodromal phase c. Cognitive components i. Abnormal attentional processes 1. Positive symptoms linked to impaired sensory gating 2. Negative symptoms linked to abnormal orienting responses ii. Cognitive interventions: cognitive rehabilitation, cognitive restructuring d. Behavioral components i. Reinforcement-based techniques used to increase appropriate behaviors and decrease inappropriate behaviors 1. Token economy 2. Social skills training e. Sociocultural components

Instructor’s Resource Manual (2nd edition) i. Focuses on larger social and institutional forces that may have a role in the development of the disorder (e.g., urban poverty) ii. Sociocultural interventions include milieu treatment in inpatient settings – clients take active responsibility for making decisions about their treatment and management of their environment; developed in response to concerns about the potentially dehumanizing effects of institutional treatment iii. Partial/day hospitalization/halfway houses iv. Assertive community treatment (ACT) – offers clients frequent and coordinated outpatient contact with a team of professionals f. Family systems components i. Bateson developed theory that ongoing double-bind communications (contradictory messages) from parents to children may lead to cognitive confusion and emotional paralysis characteristic of schizophrenia ii. Contemporary researchers focus more on specific, measurable variables related to pathological family communication in families with severe mental illnesses 1. Communication deviance – odd or idiosyncratic communications within families 2. High levels of expressed emotion – high levels of criticism and overinvolvement predict relapse in affected family members iii. Family systems interventions include family therapy to reduce communication deviance and expressed emotion g. Psychodynamic components i. Freud – schizophrenia involves withdrawal of emotional investment in the external world; fixation at the infantile stage. ii. Frieda Fromm-Reichmann – the “schizophrenogenic mother” theory iii. Contemporary psychoanalytic perspectives look at biological factors, yet see psychotherapy as a helpful adjunct h. The multiple causality of schizophrenia i. Diathesis-stress model ii. Personal therapy (Hogarty) – combines cognitive, behavioral, psychodynamic, and humanistic principles IV. Case Vignettes a. Peter – schizophrenia, paranoid type Lecture Extensions: 1. Culture-bound syndromes. Although schizophrenia is seen worldwide, a number of culture-bound syndromes involving psychotic symptoms exist. Some of the following include: boufée deliriante: (West Africa and Haiti) sudden outburst of agitated and aggressive behavior, marked confusion, and psychomotor excitement. It may sometimes be accompanied by visual and auditory hallucinations or paranoid ideation. It is similar to

Instructor’s Resource Manual (2nd edition) DSM-IV brief psychotic disorder. qi-gong psychotic reaction: (China) an acute, time-limited episode characterized by dissociative, paranoid, or other psychotic or nonpsychotic symptoms that occur after participating in the Chinese folk health-enhancing practice of qi-gong. Especially vulnerable are individuals who become overly involved in the practice. spell: (southern U.S.) a trance state in which individuals "communicate" with deceased relatives or with spirits. At times this is associated with brief periods of personality change. Spells are not considered medical events in the folk tradition, but may be misconstrued as psychotic episodes in a clinical setting. zar: (Ethiopia, Somalia, Egypt, Sudan, Iran, and elsewhere in North Africa and the Middle East) experience of spirit possession. Symptoms may include dissociative episodes with laughing, shouting, hitting the head against a wall, singing, or weeping.

Individuals may show apathy and withdrawal, refusing to eat or carry out daily tasks, or may develop a long-term relationship with the possessing spirit. Such behavior is not necessarily considered pathological locally.

2. “Mother-blaming” in psychology. Historically, the field of psychology has been criticized for placing responsibility for mental illness on mothers. A classic example is Bettelheim’s “refrigerator mother” – the term he coined in his theories of the development of autism. Although today we understand schizophrenia to be largely biologically based, prior to this understanding this diagnosis was not immune to motherblaming. Frieda Fromm-Reichmann, who utilized psychoanalytic concepts in the treatment of schizophrenia, believed that a major cause of the disorder was a “schizophrenogenic mother”; essentially, a mother who is cold, aloof, domineering, and overprotective. Most of her theories are documented in her 1950 work Principles of Intensive Psychotherapy. More recently, feminist psychologists have challenged and addressed the sexism inherent in these views. Two excellent resources on the subject are Paula Caplan’s Don’t Blame Mother (1990) and The New Don’t Blame Mother (2000).

3. The Continuum of Psychotic Symptoms. Most students don’t realize that a sizable percentage of individuals with schizophrenia lead independent, productive lives. It might be useful to present the following statistics to students: After 10 years, of the people diagnosed with schizophrenia: • 25% Completely recover • 25% Much improved, relatively independent • 25% Improved, but require extensive support network • 15% Hospitalized, unimproved • 10% Dead (Mostly Suicide) After 30 years, of the people diagnosed with schizophrenia: • 25% Completely recover • 35% Much improved, relatively independent

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15% Improved, but require extensive support network 10% Hospitalized, unimproved 15% Dead (Mostly Suicide)

Approximately: • 6% are homeless or live in shelters • 6% live in jails or prisons • 5% to 6% live in Hospitals • 10% live in Nursing homes • 25% live with a family member • 28% are living independently • 20% live in Supervised Housing (group homes, etc.)

(Source: www.schizophrenia.com. The National Alliance for the Mentally Ill [NAMI] also has an excellent website at www.nami.org.)

4. Documentaries of Individuals with Schizophrenia. People who suffer from schizophrenia may range from high-functioning to extremely disabled. The film Back from Madness (available from Films for the Humanities and Sciences) provides an excellent example of a high-functioning young woman with schizophrenia. This segment can also provide a segue into a discussion about the diathesis-stress model; the young woman begins to have a psychotic break at a very stressful time, while she is in college preparing for exams.

Students may find it interesting to contrast this example with the documentary film The Brain: Madness (also available from Films for the Humanitites and Sciences), which includes an example of a man with severe and chronic schizophrenia. His symptoms include delusions of reference, loose associations, flattened affect, and paranoia.

5. More about Deinstitutionalization. As discussed in the textbook, during the Kennedy administration many individuals with mental illness were discharged from psychiatric hospitals into the community through the deinstitutionalization movement. Although these policies were viewed as idealistic and humanitarian, potentially allowing people with mental illness to lead independent lives, the deinstitutionalization movement resulted in significant social and economic costs. Some of the reasons these policies were inadequate include the following: • Insufficient community resources. At the time, it was thought that psychiatric institutions would be replaced by community mental health centers (CMHCs) and rehabilitation centers that would allow the mentally ill to access outpatient treatment. Unfortunately, there was an insufficient investment in these centers, and the demand for services overwhelmed the available treatment options.

• Medication noncompliance. Because of the unpleasant side effects, medication noncompliance is quite common. Unfortunately, insufficient patient follow-up often resulted in noncompliance, thus leading to symptom relapse.

Some of the social costs of deinstitutionalization include: • Increased homelessness • Lack of adequate physical and mental health care

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Insufficient diagnosis and treatment of comorbid disorders Higher jail and prison populations

A useful article on the subject, with a list of references, can be found at http://www.drronaldlevant.com/longterm.html Classroom Activities/Discussion Topics 1. Writing a Self-Help Manual. Self-help materials about for individuals who suffer from depression, anxiety, eating disorders, and addictions. However, very few exist for individuals suffering from psychotic disorders. Ask student if they think individuals with schizophrenia would benefit from self-help materials. Divide students into groups, and have them develop specific self-help interventions for individuals suffering from schizophrenia.

2. Myths about Schizophrenia. Many students hold erroneous beliefs about individuals who suffer from schizophrenia. One is that people with schizophrenia have a “split personality.” Another is that most people with schizophrenia are dangerous and violent.

Ask students to “free associate” to the word “schizophrenia,” and write their responses on the board. Students will likely voice both of these myths; additionally, they will also likely use value-laden words such as “crazy,” “lunatic,” and “straitjacket.”

3. What is delusional? Delusional symptoms are one of the hallmarks of schizophrenia. Yet many beliefs may be odd, eccentric, or illogical, but not necessarily delusional. Ask your students to brainstorm a list of potentially delusional beliefs. Students will likely identify a number of outlandish beliefs, yet they may also name some beliefs that are more commonly held, such as religious beliefs, miracles, faith healing, etc. Can students come to a consensus about what is delusional and what is not? What cultural factors might influence whether a belief is normative or whether it is delusional?

4. Schizophrenia in the media. Many current films depict characters who suffer from schizophrenia. Examples include Shine, Benny and Joon, and, most recently, A Beautiful Mind. Interestingly, each of these films portray accurate as well as inaccurate information. Show clips from any (or all) of these films, and ask students to identify the accuracies and inaccuracies.

Instructor’s Resource Manual (2nd edition)

Chapter 13: Disorders of Childhood Learning Objectives: By the end of this chapter, students should be able to: • Apply the HIDES criteria to childhood disorders.

• Cite examples of the role of context in defining childhood psychopathology.

• Understand the continuum between normality and abnormality when applied to childhood disorders.

• Provide an overview of the historical views of child development and psychopathology.

• Describe the symptoms and levels of severity of mental retardation.

• Explain the biological, sociocultural, and family systems components that contribute to mental retardation.

• Define the various types of learning disorders, and explain the biological, family systems, behavioral, and cognitive components that contribute to these disorders.

• Define the term “pervasive developmental disorder,” and identify the disorders that fall within this classification.

• Describe the major areas of impairment in autism, and discuss the biological, behavioral, and family systems approaches.

• Explain the differences between the various treatment approaches to autism.

• Be familiar with the criteria for Rett’s disorder, childhood disintegrative disorder, and Asperger’s disorder.

• Describe the criteria required to diagnose ADHD, and be familiar with the various subtypes.

• Identify the various biological correlates of ADHD, and describe the biologically-based treatments for this disorder.

• Discuss the family systems, psychodynamic, and behavioral perspectives as they apply to our understanding of ADHD. • Describe the most commonly used treatments for ADHD, and discuss the controversy surrounding these treatments.

• Citing the MTA study, discuss the most effective treatments for ADHD. • Explain the difference between oppositional defiant disorder and conduct disorder.

• Discuss the sociocultural/family systems, psychodynamic, biological, and cognitive components of oppositional defiant disorder and conduct disorder.

• Identify the diagnostic criteria for separation anxiety disorder, and explain this disorder from the psychodynamic, sociocultural/family systems, biological, and cognitivebehavioral perspectives.

• Discuss issues of reliability and validity as they apply to childhood disorders.

• Describe the alternative diagnostic systems that are used to understand childhood psychopathology, and compare them to the DSM-IV-TR system.

• Discuss the age, gender, and class-related factors as they apply to childhood disorders.

• Discuss the biological and sociocultural/family systems components of the above disorders, and identify the available treatments.

Lecture Outline: I. Defining Disorders of Childhood

Instructor’s Resource Manual (2nd edition) a. HIDES criteria i. Help seeking – children are more likely to act out distress than seek help for it. ii. Irrational/dangerous behavior – many normal childhood behaviors are irrational. iii. Deviant behavior – some forms of adult “deviance” are normal and expected in children. iv. Emotional distress – some childhood disorders involve distress, whereas other childhood behaviors cause distress in others. v. Significant impairment in functioning – delays or disruptions in ageappropriate functioning can indicate psychopathology b. The importance of context in defining childhood psychopathology i. In order to recognized childhood disorders, one must understand normal childhood developmental processes. ii. Anna Freud defined childhood psychopathology as behavior that interferes with normal, progressive development. iii. Developmental psychopathology – a subfield which focuses on understanding troublesome behavior in the context of developmental tasks. c. The continuum between normal and abnormal childhood behavior i. Behaviors may be on the normal side of the continuum as long as they do not interfere with development. ii. Children develop along several different lines simultaneously; one line of development may be normal, while another may be delayed. iii. Terms like “delay,” “age-appropriate,” and “advanced” are useful.

II. Classifying, Explaining and Treating Disorders of Childhood a. Historical views i. John Locke – viewed children’s minds as blank slates ii. Jean-Jacques Rousseau – children are good by nature, but are corrupted by the environment. iii. G. Stanley Hall and Arnold Gesell proposed a maturationist view – developmental and behavioral stages unfold in a sequential, predictable fashion. iv. John Watson’s behaviorism – children are shaped almost entirely by the environment. v. Freud’s theory was more interactionist, combining biology and environment. vi. DSM-I contained only two childhood disorders; classification of childhood disorders increased in DSM-III; DSM-IV-TR contains 10 general categories of disorders specific to childhood and adolescence. b. Mental retardation (MR) – listed on Axis II. i. Usually present at birth and persists throughout life. ii. IQ score below 70 + trouble functioning independently iii. Four levels of mental retardation: mild, moderate, severe, and profound. iv. Biological components

Instructor’s Resource Manual (2nd edition) 1. Genetic abnormalities a. Down syndrome/trisomy 21 is the most common cause of mental retardation. b. Fragile X syndrome is the second most common genetic cause.

2. Metabolic deficiencies a. Phenylketonuria (PKU) – inability to break down phenylalanine; unmetabolized PKU is toxic to humans and causes retardation, hyperactivity, and seizures; effectively treated if gene is detected before 3 months of age b. Tay-Sachs disease – caused by a recessive gene from both parents; causes deterioration of the nervous system and death; gene prominent among Jewish populations; untreatable 3. Pre- and post-natal complications a. Exposure to drugs, toxins, diseases (example: fetal alcohol syndrome) b. Shaken baby syndrome – most common physical trauma associated with brain damage. v. Sociocultural and family systems components 1. Cultural-familial retardation – extreme poverty accompanies inadequate prenatal care, poor nutrition, substandard schools, and overwhelmed families.

2. Intervention programs focus on the effects of chronic poverty and sensory deprivation (example: Head Start).

3. Prior to the 1960s, warehousing was common; currently, the focus is on normalization.

4. Special education vs. mainstreaming is a current controversy.

5. Mentally retarded individuals live in a variety of supervised or unsupervised situations; may work in sheltered workshops. c. Learning disorders i. LDs are diagnosed when there is a significant discrepancy between a child’s general intellectual ability and what the child actually achieves in specific academic subjects. ii. Diagnoses include reading disorder (dyslexia), disorder of written expression (dysgraphia), and mathematics disorder (dyscalculia). iii. The DSM-IV-TR offers simple diagnoses, yet the cognitive difficulties underlying them are complex. iv. Biological components 1. Learning disorders often have a genetic component, although specific genes and chromosomes have not been identified.

2. Brain imaging techniques (e.g., MRI) have found a relationship between dyslexia and abnormal functioning in two systems in the posterior left hemisphere 3. No biological interventions exist for learning disorders, learning disorders are highly comorbid with ADHD and medications for

Instructor’s Resource Manual (2nd edition) ADHD may help improve academic performance by increasing attention and focus v. Sociocultural and family systems components 1. Interactivity theory – family problems interact with school systems that may make problematic assumptions about student abilities, which teach students accordingly.

2. Many children with learning disorders feel anxious, depressed, and embarrassed; family interventions addressing these issues can be helpful. vi. Cognitive and behavioral components 1. Most interventions involve cognitive and behavioral principles a. Academic skills are broken down into specific components that are modeled by teachers and rewarded when properly executed b. Cognitive interventions for LDs help children learn to identify their problem areas and to develop techniques for tackling specific academic problems c. Children learn to develop new problem-solving strategies, assess the effectiveness of the strategy, and try alternative strategies. d. Pervasive developmental disorders (PDDs) i. PDDs are lifelong conditions usually diagnosed in childhood ii. In addition to exhibiting intellectual deficits, children with PDDs fail to develop normal social and communication skills and fail to engage in typical childhood behaviors, interests, and activities iii. Autism 1. Three major areas affected: social interaction, communication, and behaviors, interests, and activities.

2. Autistic individuals are often repetitive in speech and engage in echolalia.

3. Often have unusual and narrow areas of interest.

4. Many erroneously believe that autistic individuals are savants; while this is not true in most cases, some have isolated but highly developed skills. iv. Rett’s disorder – similar to autism, except it occurs only in girls, and begins after a period of normal development (~ after the first 6 months of life). v. Childhood disintegrative disorder – similar to Rett’s disorder, but occurs in both boys and girls after 2 years of development. vi. Asperger’s disorder – similar to autism, except individuals have unimpaired language and cognitive skills.

1. Some argue that Asperger’s disorder is a high-functioning variant of autism. vii. Biological components (see Visual Essay 13 for more on brain structures and neurochemistry implicated in autism) 1. Twin studies suggest that autism has a strong genetic component.

Instructor’s Resource Manual (2nd edition) a. Individuals with autism have unusually high rates of other genetically based disorders such as seizures, Fragile X syndrome, and tuberous sclerosis. b. Some recent evidence that autism may more common among children born to men over the age of 40.

2. Brain abnormalities exist in individuals with autism, although we don’t know how common these abnormalities are among nonautistic individuals. a. Several researchers have noted that brain growth appears to be disrupted in people suffering from autism i. Infants who go on to develop autism have been shown to be born with smaller heads than average, and then have spurts in brain growth at 1-2 months of age, and again between 6 and 14 months of age resulting in abnormally large brains b. It has also been observed that the white matter in the brains of people suffering from autism grows excessively and asymmetrically – white matter is thought to help facilitate communicate between distal areas of gray matter, allowing for smooth and efficient brain functioning; in people suffering from autism it is thought that the white matter is failing to perform in its typical role 3. Prenatal, birth, and neurochemical factors a. Maternal bleeding, rubella, prematurity, breech birth, and forceps deliveries b. Autistic individuals tend to have high levels of serotonin.

4. Biological interventions a. There is currently no effective biological treatment; medications may be used to address behavioral symptoms. viii. Behavioral components 1. Operant conditioning-based interventions can be very effective in the treatment of autism; they typically involve shaping behaviors in a particular direction.

2. Lovaas’ Early Intervention Project teaches autistic children a wide range of skills and behaviors in a 40-hour a week program. a. Some hail this treatment as a “cure.” b. Others criticize it for being too time-intensive. c. Still others criticize the teaching of “affection.”

3. TEACCH – focuses on promoting home adjustment and community adaptation.

4. Adults with autism may live in a variety of supervised or unsupervised situations. ix. Psychodynamic components 1. Historically, psychodynamic theorists blamed parents for the disorder (example: “refrigerator mothers.”); contemporary psychodynamic theorists and clinicians reject this view

Instructor’s Resource Manual (2nd edition) e. Attention-Deficit and Disruptive Behavior Disorders i. Attention-Deficit/Hyperactivity Disorder (ADHD) 1. Frequently diagnosed disorder, and controversial largely due to this frequency.

2. Subtypes include predominantly inattentive, predominantly hyperactive, or combined type.

3. ADHD is often first diagnosed when children enter school and are required to pay attention to teachers and sit quietly for extended periods of time. a. Children with ADHD may also stand out in school when surrounded by their peers.

4. Children must exhibit symptoms in at least 2 settings.

5. ADHD symptoms tend to decline with age; however, 40-60% of children with ADHD continue to have some symptoms as adults 6. Children with ADHD are more likely than their peers to suffer from mood and anxiety disorders as adults and to engage in antisocial behavior and substance abuse 7. Biological components a. Genetic components i. ADHD may be partly inherited; high concordance rates have been found in twin studies (i.e., genetic factors have been shown to account for 80% of the causation of ADHD) b. Neurological factors i. 1930s and 1940s – ADHD thought to result from “minimal brain dysfunction”; brain damage is not currently thought to be a major cause of the disorder ii. ADHD is associated with congenital abnormalities in regions of the brain that regulate vigilance and sustained attention (e.g., frontal cortex, cerebellum, and striatal regions of brain) iii. ADHD also associated with a smaller right prefrontal cortical region and a smaller caudate nucleus c. Prenatal factors i. Not well documented, although exposure to alcohol and tobacco may be related. d. Biological interventions i. Stimulant medications are the most common biological treatment of ADHD; they appear to promote activity in the prefrontal and striate regions of the brain. ii. A positive reaction to Ritalin should not be taken as “proof” that the ADHD diagnosis is accurate, since many non-ADHD people react positively to it. iii. Strattera is a non-stimulant medication used to treat

Instructor’s Resource Manual (2nd edition) ADHD. 8. Family systems components a. Some families may allow their child to be overstimulated, and/or they don’t instill self-regulation skills. b. Children with ADHD may elicit less-than-optimal parenting skills from an otherwise competent parent.

9. Psychodynamic components a. Symptoms of ADHD overlap with symptoms of childhood depression and anxiety; clinicians try to rule these diagnoses out. b. When ADHD symptoms result from emotional conflict, psychodynamic interventions address the root of the conflict.

10. Behavioral and cognitive components a. Barkley’s parent training program – establish appropriate reinforcements/punishments, correcting problematic assumptions about parenting a child with ADHD. b. Behavioral interventions tend to be specific and concrete. c. Behavioral management programs work well in the short term but not in the long run or across situations.

11. Evaluating and comparing interventions for ADHD a. The Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (MTA study) i. Compared the effectiveness of medication alone, behavioral interventions alone, a combination of both, or routine community care. ii. During the first 14 months, all groups demonstrated some improvement. iii. Children in both medication groups showed more improvement in inattentiveness, hyperactivity, and impulsivity. iv. Children with both medication and behavioral interventions showed reduced anxiety and oppositional symptoms. v. Parents and teachers preferred the behavioral interventions. vi. Recent MTA data analyses: having a depressed parent undermined the efficacy of medication alone but not the efficacy of combined treatment; children with severe ADHD were less likely to experience a strong response to any treatment ii. Oppositional defiant disorder (ODD) – involves consistently negativistic, hostile, and defiant behavior.

1. Involves exaggerations of normal childhood behaviors.

2. High comorbidity with ADHD 3. ODD behaviors usually begin in the preschool years

Instructor’s Resource Manual (2nd edition) a. 50% continue to be diagnosed with ODD in adolescence b. 25% outgrow the ODD diagnosis c. 25% develop conduct disorder (CD) iii. Conduct disorder (CD) – involves violations of the rights of others.

1. Usually involves criminal behaviors.

2. 25-40% of children and adolescents diagnosed with CD are diagnosed with antisocial personality disorder in adulthood.

3. The diagnostic criteria encompass a wide range of behaviors; individuals who have little in common may be lumped together in one diagnostic category.

4. A mental health label may be inappropriately placed on a legal and social problem. iv. Explaining and treating ODD and CD 1. Sociocultural and family systems components a. Children living in poverty, dangerous neighborhoods, and substandard housing are at increased risk, particularly when combined with family dysfunction. b. Parents of children with ODD/CD tend to be harsh and inconsistent in discipline, abusive and/or aggressive, and less supportive, warm, and accepting. c. Sociocultural interventions take a preventative approach (see Box 13.2: Primary, Secondary, and Tertiary Prevention) d. Functional Family Therapy and Parent Management Training can be helpful.

2. Cognitive components a. Cognitive distortions and deficiencies are often present. b. Cognitive interventions focus on: i. Making more accurate attributions about other people’s behaviors ii. Generating options for how to respond to situations iii. Evaluating the consequences of each option before acting c. Biological components i. Twin studies have found high concordance rates. ii. The behavioral inhibition system in the brain may be impaired. iii. Serotonin and norepinephrine deficiencies may be associated with aggressive and impulsive actions; medications are sometimes helpful for reducing behaviors. d. Psychodynamic components i. Superego deficiencies may occur on three levels 1. Extreme deficiencies associated with aggression and lack of remorse.

2. Moderate superego impairments associated

Instructor’s Resource Manual (2nd edition) with a weak and inconsistent conscience.

3. Some children have poor impulse control but feel guilty. ii. Identification with the aggressor is a common defense mechanism. v. Separation anxiety disorder (SAD) 1. Many children experience some separation anxiety; the disorder is age-inappropriate and extreme.

2. Biological components a. Some cases of SAD lead to adult anxiety disorders such as agoraphobia and social anxiety disorder, suggesting a common genetic basis among these disorders b. Different genes may play a role in SAD in males vs. females; it may be more easily inherited by girls than boys c. Children with temperaments marked by intense shyness in novel situations (behavioral inhibition) are at a heightened risk for developing anxiety disorders d. Benzodiazepines and antidepressants can help relieve anxiety, although benzodiazepines are addictive.

3. Sociocultural and family systems components a. Many children develop symptoms of SAD in response to traumatic events such as war and natural disaster b. Nervous and overprotective parents can contribute to SAD by indicating to their children that separations are potentially dangerous 4. Psychodynamic components a. Children who are clingy may be using the defense mechanism of projection (i.e., they are coping with rejecting or angry feelings towards their parents) b. Therapy involves exploring underlying anger and other associated feelings 5. Cognitive-behavioral components a. Kendall’s cognitive-behavioral training program i. Relaxation techniques ii. Coping self-talk iii. Evaluation of how they handled a situation and providing self-rewards. f. The advantages and limitations of childhood diagnoses i. Questions about reliability and validity ii. Many DSM-IV-TR childhood disorders have high comorbidity rates. iii. Some believe there are too many diagnoses for children in the DSM-IVTR. iv. Alternative diagnostic systems 1. Developmental approaches – Anna Freud 2. Empirically-derived systems and behavioral checklists a. Externalizing vs. internalizing behaviors

Instructor’s Resource Manual (2nd edition) b. Child Behavior Checklist (CBCL) g. Classification in Demographic Context i. Age 1. Learning disorders and some forms of mental retardation may go unnoticed until school-age.

2. ADHD tends to become less severe as children get older.

3. Aggressive children with ODD are likely to develop CD symptoms.

4. Symptoms may differ depending on the child’s age. ii. Gender 1. Except for SAD, all of the childhood disorders occur more commonly among males.

2. Boys with ODD/CD tend to display aggressive behaviors; girls tend to show non-violent forms of delinquency.

3. Some of these disorders may be linked to the Y chromosome.

4. Boys may be more likely to externalize distress, whereas girls may internalize distress. iii. Class 1. Some forms of retardation occur among poorer people.

2. Harold Skeels’ studies of institutionalized children h. Cultural and historical relativism in defining and classifying childhood disorders i. Different cultures value and emphasize different qualities in children. ii. None of the childhood disorder diagnoses existed in its same form 50 years ago.

III. Case Vignettes –Treatments a. Molly – autism b. Shane – attention deficit/hyperactivity disorder Lecture Extensions: 1. Conduct disorder among adolescent girls. It is commonly believed that conduct disorder is overwhelmingly more common among males than females. However, more recent research suggests that conduct disorder is not rare among girls, and it may manifest differently than in boys. Studies suggest, for example, that conduct disorder is the second most common psychological disorder among adolescent females. While girls may engage in some of the same behaviors as boys, their acting-out behaviors more often involves non-violent crimes such as drug-related crimes and high-risk sexual behavior. Risk factors among girls who go on to develop conduct disorder include abuse and victimization, substance abuse, difficulties in school, and gang-related activities. Because so many girls with conduct disorders have histories of victimization, mental health practitioners need to address the specific issues conduct disordered girls may experience.

For example, girls in juvenile detention facilities may escalate their acting-out behaviors when in the presence of males, during restraints, when being searched, or if forced to take medications.

Instructor’s Resource Manual (2nd edition) Clearly, more work needs to be done in order to better understand the etiology and treatment of conduct disorder among females. The following resources provide excellent information on the subject: Pajer, K.A., Gardner, W., Rubin, R.T., Perel, J., & Neal, S. (2001). Decreased cortisol levels in adolescent girls with conduct disorder. Archives of General Psychiatry, 58, 297302.

Pajer, K.A. (1998). What happens to "bad" girls?: A review of the adult outcomes of antisocial adolescents. American Journal of Psychiatry, 155, 862-870.

Keenan, K., Loeber, R., & Green, S. (1999). Conduct disorder in girls: A review of the literature. Clinical Child and Family Psychology Review, 2, 3-19.

Prescott, L. (1997). Adolescent girls with co-occurring disorders in the juvenile justice system. Delmar, NY: The GAINS Center. (can be found at www.prainc.com or http://www.tyc.state.tx.us/prevention/adolescent_girls.html) 2. Studying and treating autism spectrum disorders. The UC Davis MIND Institute, which was launched in 2002, is devoted to the prevention, treatment, and potential cures for neurodevelopmental disorders. The MIND Institute includes an assessment and treatment clinic, a comprehensive research program, and educational programs that are available to professionals and to the general public. The MIND Institute website (http://www.ucdmc.ucdavis.edu/mindinstitute/) contains a tremendous amount of information about pervasive developmental disorders and other childhood disorders, which can be invaluable in preparing for lectures on these topics.

3. Bipolar disorder in children. Although once thought to be rare among children and adolescents, there has been a dramatic increase in youth being diagnosed with bipolar spectrum disorders in the last two decades. Diagnosing children with bipolar disorder is controversial considering that it is a serious diagnosis often treated with medications that have severe side effects (e.g., significant weight gain). Also, children with bipolar disorder often don’t exhibit the classic episodic manic and depressive mood states; instead, their moods often fluctuate between and within days. Thus, some question whether the childhood manifestation of bipolar disorder is truly a variant of the adulthood disorder. On the other hand, not identifying bipolar disorder in children may lead to iatrogenic treatments (e.g., prescribing a stimulant medication to a child with bipolar disorder may trigger mania) and/or may prolong the time to recovery. The following is a list of helpful articles and websites regarding bipolar disorder in children and adolescents: Pavuluri, M. N., Birmaher, B., & Naylor, M. W. (2005). Pediatric bipolar disorder: A review of the past 10 years. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 846-871.

Carlson, G. A. (2005). Early onset bipolar disorder: Clinical and research considerations.

Journal of Clinical Child and Adolescent Psychology, 34, 333-343.

Instructor’s Resource Manual (2nd edition) Geller, B., Zimerman, B., Williams, M., DelBello, M. P., Frazier, J., & Beringer, L. (2002). Phenomenology of prepubertal and early adolescent bipolar disorder: Examples of elated mood, grandiose behaviors, decreased need for sleep, racing thoughts and hypersexuality. Journal of Child and Adolescent Psychopharmacology, 12, 3-9.

Lewinsohn, P. M., Seeley, J. R., Buckley, M. E., & Klein, D. N. (2002). Bipolar disorder in adolescence and young adulthood. Child & Adolescent Psychiatric Clinics of North America, 11, 461-476.

Youngstrom, E. A., & Duax, J. M. (2005). Evidence based assessment of pediatric bipolar disorder, part 1: Base rate and family history. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 712-717.

Child and Adolescent Bipolar Foundation (CABF) http://www.bpkids.org/site/PageServer Classroom Activities/Discussion Topics 1. Support for families with children suffering from autism. Children with autism, particularly the more severe forms, often demand a tremendous amount of attention and supervision from parents and caregivers. Moreover, parents are typically in the position of having to coordinate treatment and advocate for their child. In a sense, many parents of autistic children find themselves in the role of “case manager,” which can be extraordinarily stressful. Have your students identify the major stressors parents of autistic children might experience, and ask them to come up with ways of alleviating some of this stress. They might, for example, identify the need for self-help materials, parent support groups, increased support in schools, etc.

2. Evaluating advocacy groups for childhood disorders. Ask your students to locate the websites for groups that advocate on the behalf of children with neurodevelopmental disorders and other disorders. One of the most well-known advocacy groups is CHAAD (Children and Adults with Attention Deficit Disorder). Others can be found on the UC Davis MIND Institute website. Ask your students to read the materials presented on the website and to critically evaluate them. For example: • Is the information presented accurately and in a well-balanced fashion?

• Is the information written in an accessible manner? Can a layperson understand the material?

• What is the tone of the information? Does the tone appear to be professional or sensationalistic?

3. Films and radio programs about childhood disorders.

Frontline: Medicating Kids (available at www.pbs.org). This is an excellent documentary that portrays several children who suffer from ADHD. Some of the children have been taking stimulant medications, while other children are not. This film effectively presents the controversy surrounding diagnosis and treatment of this disorder.

Instructor’s Resource Manual (2nd edition) POV: Refrigerator Mothers (available at www.pbs.org). This film focuses on autism and covers historical and current perspectives on the disorder.

A fascinating radio documentary of children with bipolar disorder (“A Mind of Their Own”) can be found at http://americanradioworks.publicradio.org/features/bipolarkids/index.html

Instructor’s Resource Manual (2nd edition)

Chapter 14: Cognitive Disorders Learning Objectives: By the end of this chapter, students should be able to: • Explain the difference between delirium and dementia.

• Define the terms “aphasia,” “apraxia,” “agnosia,” “executive functioning,” “sundowning”, “anterograde amnesia”, and “retrograde amnesia.”

• Explain the difference between dissociative amnesia and organic amnesia.

• Identify the precipitating causes of delirium.

• Identify the major interventions used to treat delirium.

• Describe the progression and biological correlates of Alzheimer’s disease, and discuss the available treatments for this disorder.

• Distinguish among the other forms of dementia, including vascular dementia, Parkinson’s disease, Huntington’s disease, and HIV. • Discuss caregiver burden as it is related to Alzheimer’s disease.

• Identify the various causes of organic amnesia: encephalitis, physical trauma, Korsakoff’s syndrome.

• Discuss age, gender, class, and cultural factors as they apply to the cognitive disorders.

Lecture Outline: I. Defining and Classifying Cognitive Disorders a. DSM-IV-TR categories i. Delirium – involves a disturbance in consciousness and marked changes in cognitive capacity; onset is rapid. ii. Dementia – involves a gradual and permanent decline in cognitive functioning; impairments include aphasia, apraxia, agnosia, loss of executive functioning. b. Amnesia i. Dissociative amnesia (covered in Chapter 7) 1. Characterized by retrograde amnesia (inability to remember what happened before the event that caused their amnesia) ii. Organic amnesia 1. Results from a physical cause 2. Characterized by anterograde amnesia (inability to recall new information) 3. Working memory and semantic memory usually remain intact 4. Occurs in the absence of other cognitive impairments II. Explaining and Treating Cognitive Disorders a. Delirium i. Older adults particularly susceptible to delirium because their physical health is often quite fragile ii. Biological components and interventions 1. Many precipitating causes associated with delirium – see Table 14.4 a. Adverse drug reactions are the most frequent cause of

Instructor’s Resource Manual (2nd edition) delirium 2. Once diagnosed, clinicians aim to address the cause of the delirium which is often a medical condition iii. Other interventions 1. Family and social support is helpful for mild symptoms of delirium.

2. “Sundowning” – a phenomenon in which a person is more lucid in the morning and declines as the day goes on; exposure to bright light throughout the day can help. b. Dementia i. People with dementia also suffer from high rates of depression and anxiety; relationships among depression, anxiety, and dementia unclear ii. Biological components and interventions 1. Alzheimer’s dementia a. Brain shrinkage (see Visual Essay 14 for more on Brain Abnormalities in Alzheimer’s disease) b. Neuritic plaques and neurofibrillary tangles noted upon autopsy c. Sometimes confused with Pick’s disease d. Studies suggest a genetic component, although genetic studies are complicated by the difficulty of definitive diagnosis and the late age of manifestation. e. Medications that prevent the breakdown of acetylcholine appear to slow the progression of Alzheimer’s. i. Recent research into the use of estrogen therapy, anti-inflammatory drugs, ginkgo biloba to prevent dementia f. Behavioral and emotional symptoms may be treated with other psychotropic medications. g. Recent developments in the early detection of Alzheimer’s disease through word recall tests, PET, and MRI scans.

2. Vascular dementia a. Vascular diseases block blood flow to areas of the brain (i.e., stoke), resulting in the death of brain tissue b. Often comes on suddenly c. Hypertension and coronary artery disease increase the risk.

3. Parkinson’s disease a. Involves the deterioration of the substantia nigra which produces dopamine. b. Synthetic dopamine can help Parkinson’s patients live longer. c. Deep brain stimulation is also a highly promising intervention 4. Huntington’s disease a. Involves deterioration of certain brain areas, including the caudate nucleus which helps to inhibit physical movements

Instructor’s Resource Manual (2nd edition) b. People with Huntington’s disease develop jerky, involuntary movements c. Caused by a single dominant gene located on the fourth chromosome – every child born to someone with Huntington’s disease has a 50% chance of developing the disease.

5. HIV a. Causes AIDS b. As disease progresses the immune system becomes compromised and the virus replicates within the central nervous system causing damage to a number of areas in the brain. iii. Family Systems Interventions 1. Residential care facilities can provide safe housing for those needing constant care and supervision 2. A majority of Alzheimer’s sufferers in the U.S. live at home where they are cared for by their children and spouses 3. Interventions with the “sandwich generation” – supportive group therapy is helpful. a. Alzheimer’s disease has become the focus of major medical and legislative efforts due to the economic and caretaker burden and because the average life span has increased c. Amnesia i. According to the DSM-IV-TR, transient amnesias last less than one month; chronic amnesias last more than one month ii. Biological components and interventions 1. Some organic amnesias, such as those caused by exposure to toxins, can resolve completely as soon as the toxic substance leaves the body; other amnesias are more pervasive and longlasting 2. Encephalitis a. Inflammation of the brain; caused by various infectious agents b. Nature and extent of memory loss varies widely 3. Physical trauma a. Severity of amnesia depends on severity of the head injury 4. Korsakoff’s Syndrome a. Involves anterograde amnesia caused by chronic alcoholism b. Alcohol interferes with the body’s ability to metabolize vitamin B (thiamine) c. People suffering from Korsakoff’s syndrome often confabulate to downplay the extent of their amnesia d. Administering thiamine to recovering alcoholics improves the functioning of working memory within a matter of days d. Classification in demographic context

Instructor’s Resource Manual (2nd edition) i. Age 1. Neural cells dies, and the brain shrinks in size and decreases in weight as a function of aging a. Whereas mild forgetfulness is normally associated with aging, the degree of cognitive impairment is much more severe in dementia and delirium 2. Alzheimer’s disease rarely develops before age 50; the risk increases with age.

3. Huntington’s disease appears in people in their 40s and 50s.

4. Delirium usually occurs among the elderly as a result of medical illnesses; can also occur among younger people with high fevers, medical illnesses, or brain-altering conditions.

5. Organic amnesia can occur in people of any age ii. Gender 1. Mental disorders of old age occur more often in women, largely because women outlive men. iii. Class and culture 1. Tools used to assess cognitive impairments may be biased against people who are poorly educated.

2. Educational activity may have a preventative effect against dementias; learning may add dendrite arbors.

3. Alzheimer’s disease occurs at equal rates among people of various ethnic backgrounds but begins earlier in certain populations (e.g., Hispanics) 4. Vascular dementia occurs more often in people of Asian, African, or Hispanic descent 5. Parkinson’s disease occurs most frequently among members of Hispanic populations, followed by non-Hispanic whites, Asians, and people of African descent III. Case Vignette – Treatment a. Joseph – Alzheimer’s dementia Lecture Extensions: 1. Working with older adults. Individuals over the age of 65 often present with a range of psychological concerns. While some of these concerns may involve memory-related and other cognitive impairments, it is common for older adults to present with symptoms of depression and anxiety. Special considerations need to be taken into account when working with an older population. For example, the symptoms of depression among the elderly may look quite different from those in a younger adult; in older individuals, depression may look quite similar to dementia. Yet the risk of depression and suicide is highest among the elderly, necessitating a correct assessment, diagnosis, and treatment.

Similarly, anxiety disorders are quite common among the elderly. Factors contributing to anxiety may include recognition of mortality, loss of loved ones, and isolation and loneliness.

Instructor’s Resource Manual (2nd edition)

The following resources discuss a variety of issues when working with an older population: Molinari, V., Karel, M., Jones, S., Zeiss, A., Cooley, S.G., Wray, L., Brown, E., and Gallagher-Thompson, D. (2003). Recommendations about the knowledge and skills required of psychologists working with older adults. Professional Psychology: Research and Practice, 34, 435-443.

Nordhus, I.H. & Pallesen, S. (2003). Psychological treatment of late-life anxiety: An empirical review. Journal of Consulting and Clinical Psychology, 71, 643-651.

Stanley, M.A., Beck, J.G., Novy, D.M., Averill, P.M., Swann, A.C., Diefenbach, G.J., and Hopko, D.R. (2003). Cognitive-behavioral treatment of late-life generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 71, 309-319.

Rothermund, K. & Brandtstadter, J. (2003). Depression in later life: Cross-sequential patterns and possible determinants. Psychology and Aging, 18, 80-90.

2. Psychological distress among caregivers. Caring for an ailing relative, particularly one suffering from a form of dementia, can be physically and psychologically taxing. As the individual worsens, the caregiver may receive little or no sense of reward, and in fact may experience a range of distressing emotions. Some of these reactions may include ambivalence, sadness, anger, frustration, and despair. Until recently, there had been very little acknowledgement of “caregiver stress” and the potential for severe psychological distress. The following articles address the psychological issues experienced by caregivers. You may wish to invite a guest speaker to participate in this discussion; the speaker might be an individual specializing in gerontology or a mental health worker who does hospice work.

Gaugler, J.E., Zarit, S.H., and Pearlin, L.I. (2003). The onset of dementia caregiving and its longitudinal implications. Psychology and Aging, 18, 171-180.

Gitlin, L.N., Belle, S.H., Burgio, L.D., Czaha, S.J., Mahoney, D., Gallagher-Thompson, D., Burns, R., Hauck, W.W., Zhang, S., Shulz, R., and Ory, M.G. (2003). Effect of multicomponent interventions on caregiver burden and depression: The REACH Multisite Initiative at 6-month follow-up. Psychology and Aging, 18, 361-374.

Pinquart, M. & Sorensen, S. (2003). Differences between caregivers and noncaregivers in psychological health and physical health: A meta-analysis. Psychology and Aging, 18, 250-267.

3. Mental health and spirituality. For many, suffering from a mental illness can be an extremely isolating experience. Up until recently, subscribing to a religious or spiritual belief system was not necessarily seen as a sign of mental health; in fact, some viewed it as a sign of pathology, psychological rigidity, or lower intellectual functioning. Recent

Instructor’s Resource Manual (2nd edition) studies, however, have documented the physical and psychological health benefits of spirituality. This is particularly relevant for older adults, whose most pressing issues may be of an existential nature. The following article provides more specific information about the role religion and spirituality may play during late adulthood.

Wink, P. & Dillon, M. (2003). Religiousness, spirituality, and psychosocial functioning in late adulthood: Findings from a longitudinal study. Psychology and Aging. 18, 916-924 Classroom Activities/Discussion Topics 1. Psychological interventions for caregivers. After discussing the issues caregivers face, divide your students into several groups. Ask each group to identify a range of problems and potential treatment goals in working with caregivers. Then ask them to choose one specific goal and develop a self-help activity around that goal. After the groups are finished, collect each of the self-help activities and share them with the class.

2. Cross-cultural differences in perceptions of aging. If your class has students from diverse backgrounds, some of them may be interested in sharing how aging is viewed in their families and within their culture. Lead a discussion about how aging is viewed in the United States, and contrast that with views shared from your students (or that you discuss). You might bring in advertisements of anti-aging products, or lead a brainstorming session about stereotypes of older men and women.

3. Books and films about cognitive disorders Alzheimer’s: The Help You Need. This documentary, narrated by David Hyde Pierce, is a program that features a number of experts on Alzheimer’s disease The Forgetting: A Portrait of Alzheimer’s. This PBS documentary portrays the real-world experiences of Alzheimer’s patients as well as research and clinical information about the disease.

The Secret Life of the Brain: The Aging Brain. This is the fourth segment of The Secret Life of the Brain series. It portrays several individuals who are experiencing “successful aging” as well as age-related difficulties, such as Alzheimer’s disease, stroke, and Parkinson’s disease.

All of the above films are available at www.pbs.org.