Abnormal Psychology, 6th Canadian Edition Flett, Kocovski, Davison, Neale Solution Manual

Abnormal Psychology, 6th Canadian Edition By Flett, Kocovski, Davison, Neale

Instructor’s Manual to accompany Abnormal Psychology, Sixth Canadian Edition by Flett et al.

CHAPTER 1 INTRODUCTION: DEFINITIONAL AND HISTORICAL CONSIDERATIONS AND CANADA’S MENTAL HEALTH SYSTEM

CHAPTER SYNOPSIS While many people are intrigued by the prospect of finding explanations for the causes of abnormal behaviour, explorers in the field of psychopathology must have great tolerance for ambiguity in order to be comfortable with the tentative, often conflicting information available. This text focuses on addressing the study of abnormal psychology using objective rules of science.

Societies have different fundamental beliefs, values and social institutions. Canada has evolved a health and mental health care system that is universally available and funded by taxes. Because of these values and the resulting social institution of Medicare, mental patients have access to a relatively advanced level of care. However, Canada is at a critical juncture as in the process of looking at its current health care system and planning for the future through the Commission on the Future of Health Care in Canada.

What is Abnormal Behaviour?

Definitions of abnormal behaviour involve several components. For example, abnormal behaviour may be defined as statistically infrequent behaviour that falls at the extremes of the normal curve. Abnormality may also be defined as behaviors that violate norms, cause personal suffering, result in disability or dysfunction, or involve an unexpected response to a stressor. No one definition will fit every psychiatric diagnosis or be consistent across every culture.

Focus on Discovery 1.1: The Mental Health Professions A clinical psychologist holds either a Ph.D. degree or a Psy.D. (Doctor of Psychology). Ph.D. degrees involve intensive research training in addition to specialized training in diagnosis and psychotherapy. The Psy.D. places less emphasis on research and more on clinical training.

A psychiatrist holds an M.D. and receives the same medical training as other physicians, in addition to a residency in psychotherapy. Because of their medical training, psychiatrists are able to prescribe psychoactive drugs. Recently, debate has arisen regarding the merits of allowing suitably trained clinical psychologists to prescribe psychoactive medications as well.

Psychoanalysts have received specialized training at a psychoanalytic institute. Although Freud maintained that a medical degree was not a necessary prerequisite to psychoanalytic training, until recently most psychoanalytic institutes have required an M.D. and psychiatric residency.

A psychiatric social worker has a Master of Social Work degree. There are also masters and doctoral programs for counselling psychology, somewhat similar to graduate training in clinical psychology but usually with less emphasis on research.

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Clinicians are people who, regardless of professional degree, provide diagnostic and therapeutic services to the public. Psychopathologists, in contrast, are a diverse group of people from various disciplines who conduct research into the nature and development of various mental disorders.

History of Psychopathology The doctrine that an evil being may control the behaviour of another person is called demonology. Demons were thought to be the cause of abnormal behaviour in many ancient societies, and various rituals, sometimes tortuous ones, were performed to exorcise them. Hippocrates was one of the earliest proponents of somatogenesis—the belief that something wrong with the "soma" or physical body causes a disturbance in thought and action. This is in contrast to psychogenesis—the belief that the cause has its basis in psychological origins. Although his conception of brain functioning based on the balance of "humours" or fluids in the body was rather crude, Hippocrates' basic premise relating human behaviour to bodily functioning foreshadowed modern thinking.

The decline of the Roman Empire and the rise of various religious groups eventually led to a return to concern about demonology. Thousands of men, women and children were tried as witches and subjected to torture and possible execution.

For some time the prevailing interpretation has been that all the mentally ill of the later Middle Ages were considered witches. More careful analyses reveal that although some accused witches were mentally disturbed, trials of sane people outnumbered those of the insane. Records of lunacy trials in Britain suggest that the most common explanations for abnormal behaviour were physical illness or injury or emotional shock; only one case was attributed to demonic possession.

When leprosy gradually disappeared from Europe during the 15th century, many former leper hospitals were turned into asylums. Despite the inclusion of abnormal behaviour within the domain of hospitals and medicine, conditions in many of the asylums were deplorable. "Treatment" for the insane included drawing large quantities of blood and frightening patients by convincing them of their impending death. Philippe Pinel was among the first to advocate moral treatment of the mentally ill in the late 18th century; he removed the chains of patients imprisoned in his hospital and treated them as sick human beings in need of compassion and understanding, rather than as beasts. However, recent reviews of the records of these hospitals suggest that drugs were the most common treatment used, and most of the patients did not improve or recover.

The history of asylums in Canada is a good illustration of the interactions between colonial governments (England and France), religious institutions, legislation and local social conditions that has shaped many of Canada's social programs. The first precursor to 19 th-century asylums was established in Quebec in 1714 and was manned by religious orders. Dorthea Dix played a role in the development of asylums in Canada and is featured in Canadian Perspectives/1.1 (p. 11). The mental hospital in Canada during the twentieth century versus the hospitals of today are discussed in Canadian Perspectives/1.2 (p.

13).

Progress in understanding mental illness was fostered by the discovery in the Middle Ages that the long accepted presentation of human anatomy by Galen was incorrect. The ensuing emphasis on an empirical approach to classifying mental disorders and studying their etiology marks the beginning of contemporary thought about psychopathology. Emil Kraepelin, a proponent of the somatogenic hypothesis, pointed out that groups of symptoms, called syndromes, appear together regularly in mental illnesses as in physical ones. His classification system became the basis for the present diagnostic categories (discussed in Chapter 4).

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The discovery that the germ theory of disease could explain the connection between general paresis, with its deterioration in mental and physical health, and the medical condition of syphilis greatly promoted the somatogenic hypothesis, if one type of psychopathology had a biological cause, then so could others. The search for somatogenic causes has dominated psychiatry well into the 20th century.

The psychogenic viewpoint—the belief that mental illness is due to psychological malfunction— appeared in the late eighteenth century. Mesmer believed that hysterical disorders, such as physical incapacities that defied anatomical rules, were caused by magnetic fluids in the body that could be influenced by other people; he used hypnotism to treat such disorders. While Mesmer viewed hysterical symptoms as purely physical, Charcot became convinced that such phenomena were caused by psychological factors; Breuer developed the cathartic method to release the emotional tension presumably underlying the paralysis.

Current Attitudes toward People with Psychological Disorders This section discusses the history of societal attitudes towards individuals with mental illnesses and traces the evolution of Canadian institutions that have helped shape a more compassionate attitude toward this group. In Canadian history several minority groups have faced the negative effects of stereotyping and stigmatization and mental patients are no exception. The twentieth century in Canada saw the rise of large mental institutions and the reduction in their size as chemotherapy (drug therapy) aided with symptom reduction and community mental health care evolved. However, these changes also gave rise to abuse (see a discussion of the CIA involvement in brainwashing experiments at the Allan Memorial Institute in Montreal, described in Canadian Perspectives 1.3.

STUDENTS SHOULD KNOW . . .

Key Points 1.

The textbook takes a scientific approach to understanding abnormal behaviour.

2.

There are a number of components involved in the definition of abnormal behaviour, including statistical infrequency, violation of norms, personal suffering, disability or dysfunction, and unexpectedness.

3.

The different types of professionals involved in the field of mental health, including clinicians from various training backgrounds and psychopathologists.

4.

While there have been differing views on the causes of abnormal behaviour throughout the course of history, the roots of contemporary thought are embedded in the past. The somatogenic viewpoint was first postulated by Hippocrates more than 2,000 years ago, and the psychogenic point of view emerged in the late 18th century. These remain the major points of view regarding the causes of abnormal behaviour.

5.

Abnormal behaviour has been treated differently and sometimes inhumanely in the past. However, past practices were not as inhumane nor are current practices as enlightened as they are sometimes portrayed.

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6.

Public perception of the mentally ill can have a significant effect on the behaviour and feelings of those suffering from a mental disorder and can profoundly affect public policy.

7.

Canada’s mental health care system is part of an overall system of publicly financed health care called “Medicare.” Currently, a resident of Canada can received the assistance of a physician, psychiatrist, or public mental health facility without charge. While this system is under review and pressure for change, the latest report on the system, the Romanow Report, recommends the continuance of a publicly financed system.

Key Terms abnormal behaviour (p. 2) accountability (p. 23) assessment (p. 4) asylums (p. 8) bedlam (p. 8) Canadian Mental Health Association (p. 18) Cathartic method (p. 14) clinical psychologist (p. 4) clinicians (p. 4) community psychology (p. 28) community treatment orders (p. 13) counselling psychologists (p. 4) deinstitutionalization (p. 26) demonology (p. 5) diagnosis (p. 4) dissociative identity disorder (p. 17) evidence-based treatment (p. 24) exorcism (p. 5) general paresis (p. 13) germ theory (of disease) (p. 13) medicare (p. 23) mental health literacy (p. 20)

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moral treatment (p. 9) normal curve (p. 2) prevention (p. 28) prescriptive authority (p 5) provincial psychiatric hospitals (p. 12) psychiatrist (p. 4) psychoactive drugs (p. 4) psychoanalyst (p. 4) psychogenesis (p. 5) psychopathology (p. 1) psychotherapy (p. 4) schizophrenia (p. 16) self-stigma (p. 20) social worker (p. 4) somatogenesis (p. 5) stereotyping (p. 16) stigmatization (p. 16) syndrome (p. 13) trepanning (p. 5) transinstitutionalization (p. 12)

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New Names Hippocrates, Galen, Philippe Pinel, Thomas Sydenham, Wilhelm Griesinger, Emil Kraepelin, Louis Pasteur, Franz Mesmer, Jean Charcot, Joseph Breuer, Dorthea Dix, Ewen Cameron, Roy Romanow.

LECTURE LAUNCHERS 1. Careers in Mental Health Most students are extremely interested in the different mental health professions. Many may be considering careers in one of these fields, making more detailed review of the professions interesting and worthwhile.

Each profession can be listed on the board and compared on various dimensions, such as years of training required, difficulty of acceptance into training programs, criteria for acceptance (courses, grades, national exams, outside activities), focus of academic training, and career possibilities. Students are often focused on becoming clinical psychologists and unaware of opportunities in social work and psychiatric nursing, or even the many post-degree college diplomas in addictions counseling. Current topics of interest in the mental health field might be discussed, such as: (1) Should clinical psychologists be allowed "admitting privileges" at psychiatric hospitals? (2) Which professionals should be eligible to receive medicare payments for their services? (3) Should professionals other than psychiatrists be allowed to prescribe psychotropic medications? (See first Discussion Stimulator) (4) Should training of clinical psychologists focus on clinical or research training, or both?

2. Law and Lunacy in the Middle Ages As discussed in the text, Neugebauer (1979, Medieval and early modern theories of mental illness. Archives of General Psychiatry, 36, 477-483) reviewed English legal documents dating back to the 13th century, at a time when the Crown assumed the right and responsibility for caring for the property and person of the mentally disabled. Contrary to the popular view that demonology was the primary explanation for mental illness, Neugebauer found only one reference to demonological possession in all the cases he examined.

Two groups of incompetents were distinguished: idiots or natural fools and lunatics. These terms seem to roughly correspond to our terms "mentally retarded" and "insane." For instance, a 16 th-century source defined idiot as: he that is a fool natural from his birth and knows not how to account or number 20 pence, nor cannot name his father or mother, nor of what age himself is, or such like easy and common matters; so that it appears he has no manner of understanding or reason, nor government of himself, what is for his profit or disprofit.

Commonsensical explanations were offered for the person's disturbed state. Consider the following cases: In July, 1490, John Fitzwilliam was said to be mentally disabled starting when he was "gravely ill." In 1502, John Norwick "lost his reason owing to a long and incurable infirmity" and on September 18, 1291, a jury declared Bartholomew de Sadewill mentally deranged and attributed that condition to "a blow received on the head." Robert Barry's insanity was, in 1366, thought to have been "induced by fear of his father."

Similarly, a 1568 hearing found James Benok to have been "afflicted by reason of a fright on 20 Oct. 1556 and has so continued from that time to the present."

3. Masturbatory Insanity E.H. Hare (1962, Journal of Mental Science, 108, 2-25—now British Journal of Psychiatry) presents a scholarly review of a seemingly outlandish hypothesis: masturbation causes insanity. The historical

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documentation of the rise and fall of this hypothesis affords the opportunity to illustrate an interesting bit of history, while demonstrating how many errors and biases can enter into the pursuit of "objective" information.

The notion that masturbation causes insanity arose among the 18th century political and religious beliefs that masturbation was wrong, as the purpose of sex was procreation. A popular book was written about the evils of masturbation—Onania or the Heinous Sin of Self-Pollution. Not surprisingly, the book, which went into many editions, also offered a "cure" for an additional price. For reasons that are unclear, some leading medical authorities adopted and elaborated upon the masturbatory insanity hypothesis. One explanation offered as a link between masturbation and insanity was that blood flow was drawn away from the brain. The writings of the authorities of the time served to spread the belief further among medical professionals that masturbation did indeed cause insanity, thus reinforcing the popular view. Once widely held, like any theory, the hypothesis was difficult to disprove With the rise of more plausible hypotheses, the gathering of some data, and the gradual change in attitudes about sex, the masturbatory insanity hypothesis faded. Still, from the 18th through the early 20th century the hypothesis had managed to survive in one form or another. Such leading figures in the history of psychopathology as Freud, Rush, and Maudsley each, at least temporarily, adopted the hypothesis.

The history of the masturbatory insanity hypothesis can be used to illustrate several important points about the scientific enterprise. It demonstrates the intrusion of popular beliefs into "objective" science. Finally, some points about the scientific method are illustrated: the fact that correlation does not mean causation (insane masturbating openly); the need for comparison groups (the base rate of private masturbation); limitations on case history data; and the value of considering rival hypotheses.

4. Hysteria or Malingering?

To lay the groundwork for discussion in Chapter 4 of the problems of diagnosis and classification, the historical roots of the concept of mental illness, traced by Thomas Szasz in The Myth of Mental Illness (1961, New York: Harper and Bros.), might be presented at this point in the course. Szasz reviews Charcot's influence on psychiatry and on the public's view of mental disorders. Before Charcot's time, hysteria was considered to be a form of malingering (faking real physical illness), and such counterfeiters were treated with anger and hostility by physicians who resented the deception. After Charcot had lent his expertise and authority to the problem of hysteria, it was elevated to the status of "illness;" Szasz asserts that this shift has led to the present-day classification of all human conduct as falling within the purview of mental illness.

Discussion might focus on the following questions: What are the consequences of labelling a phenomenon an "illness?" How does such a label obscure or clarify that which it describes? Should psychiatry be considered a branch of medicine? What is the value of distinguishing "conscious" from "unconscious" malingering? Would it be considered malingering if organically based symptoms are exaggerated by psychological factors? How can such a distinction be made? The story of hysteria may also be discussed in the context of a shift from somatogenic to psychogenic viewpoints in psychiatry. If hysteria had continued to be seen as simple malingering, would the psychogenic hypothesis of psychopathology have been advanced?

5. The Mental Hospital in Canada Many students will not be familiar with Canadian mental hospitals. With the advent of neuroleptic drugs and the subsequent movement to de-institutionalize patients, the population of institutionalized mental patients dropped from 50,000 psychiatric beds to 15,000 between 1960 and 1976 (Wasylenki, Goering, and MacNaughton (1994), the central role of these institutions in Canadian society has been dramatically reduced. It might be interesting for students to try to get a feel for the size and culture of one of these institutions. Background information on the Riverview Hospital outside of Vancouver can be found an Ombudsman's report on the Internet at:

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https://bcombudsperson.ca/sites/default/files/Public%20Report%20No%20%2033%20Listening%20A%20review%20of%20Riverview%20Hospital.pdf L’Institut Phillippe Pinel de Montréal may be of some interest to students. Named after Phillippe Pinel (Chapter 1, p. 9) this psychiatric facility works hand in hand with Canadian Correctional Services. L’Institut Pinel is a maximum security psychiatric hospital in the east of Montréal. Federal inmates in need of psychiatric assessment or care are referred for assessment and treatment to Pinel. www.pinel.qc.ca/

6. The Nature of the Canadian Health Care System Many students are unaware of the nature of the Canadian health care system, and particularly how it is funded. The difference between the situation in the United States, where many mental patients lack either basic health or mental health care, due to the lack of a universally funded system, is one way to illustrate the Canadian system. A clear overview of the current Canadian health care system may be found at the website for the Commission on the Future of Health Care in Canada: http://www.hc-sc.gc.ca/hcs-sss/com/fed/romanow/documents-eng.php

DISCUSSION STIMULATORS Pre-Post Assessment of Students' Views of Abnormal Behaviour Students have many reasons for taking a course in abnormal psychology. They may need to fulfill major subject requirements, have a free hour when the course is given, possess a copy of the textbook handed down from someone, want to learn "how to help people," or want to learn to understand themselves better.

The latter motivation is probably the most prevalent, and may be responsible for the immense popularity of courses in abnormal psychology. You may want to explain to students that they may gain insight into their own behaviour through taking the course, but this is not the major purpose of the course.

The goal of the course is to expose students to a wide range of human behaviours, conventional and bizarre, and to illustrate the scientific research being conducted on the causes and methods of changing abnormal behaviour. Furthermore, it can be emphasized that process is being taught as much as content is. Students are not just learning information; they are learning a method of scientific inquiry.

The questionnaire presented here may be useful for helping students examine their biases and expectations at the beginning of the course. Students can be asked to write their answers to the questions and hand them in; at the end of the course, they can be given a blank copy of the questionnaire to fill out again, and the two sets of answers can be compared and discussed.

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VIEWS ON ABNORMAL PSYCHOLOGY Name: ________________________ (circle one:)

pre

post

1) How would you define "abnormality"?

2) Where do you think "mental illness" comes from? Is the root of abnormal behaviour primarily physical/organic, early childhood experiences, current environmental forces, or some other factor?

3) How do you think mentally disturbed people should be treated? What treatment approach(es) do you think work best?

4) How would Canadian society and the plight of mental patients be changed should Canada choose to go to a private health and mental health system such as the one used in the United States?

5) What do you hope to learn from this course? (Or, if post-course, what have you learned that is most valuable?)

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Prescription Privileges for Psychologists Controversy has emerged in recent years over whether or not psychologists should be allowed to prescribe psychotropic drugs. Several recent articles discuss the pros and cons of such a change and might provoke interesting class discussions. For an example of this discussion see American Psychological Association (2011). Practice guidelines regarding psychologists' involvement in pharmacological issues. American psychologist, 66(9), 838-839. See: http://www.apa.org/monitor/jun03/pc.aspx See also, http://www.ncbi.nlm.nih.gov/pubmed/16396524 The Canadian Psychological Association set a Prescriptive Authority Task Force and released a report in November, 2010. Students can read it here: http://cpa.ca/docs/File/Task_Forces/CPA_RxPTaskForce_FinalReport_Dec2010_RevJ17.pdf

Is it Really Abnormal?

The text discusses five “characteristics” of abnormal behaviour: statistical infrequency, violation of norms, personal distress, disability or dysfunction, and unexpectedness. Discussion might focus on how each of these definitions could be misused. Examples: In a repressive society that values neighbours spying on neighbours, could those who do not spy on their neighbours be classified as abnormal? The text discusses personal suffering as another characteristic of abnormal behaviour. In the above example, it is not difficult to imagine that one could become distressed either as an individual who spies on neighbours or as the spied upon neighbour. Would either case be within the realm of abnormal psychology? In addition, some forms of abnormal behaviour are more distressing to others than to the individual who presents for therapy. For example, children may be brought to a therapist because their behaviour is distressing to the parents. How do we know that it is the child’s behaviour that is abnormal rather than a lack of parenting skills? Finally, an absence of personal suffering is not necessarily a sign of mental health. Psychopaths generally lack empathy and a sense of guilt and do not seem to suffer for the suffering they inflict on others. For some examples of psychopathy as portrayed in popular cinema see, Jordan Belfort (the movie character as portrayed by Leonardo DiCaprio) in Martin Scorsese’s The Wolf of Wall Street (2013) William Munny (Clint Eastwood) in Clint Eastwood’s The Unforgiven (1992) Earl Brooks (Kevin Costner) in Bruce A. Even’s Mr. Brooks (2007) Anton Chigurh (Javier Bardem) in David Fincher’s No Country for Old Men (2007)

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It is of note that these films are equally useful in discussions of the personality disorders and psychopathy (Chapter 13).

"Medical Student's Syndrome" Just as medical students often "diagnose" themselves as having many of the diseases they read about in such detail, students of Abnormal Psychology frequently see themselves in the symptoms of mental illness described in this course. It is important to be sensitive in lecturing about various topics, as some students will be wondering if they are in need of therapy, or they may have a friend or relative who has emotional problems and want to do something to help. It is good practice to give the class information about a student counselling centre or other psychological services early on in the course. Still, be prepared during office hours to answer questions that are more personal than academic in nature, and have referral sources available for such times. An interesting seminar can involve asking students to predict which syndrome they would most likely take on should they fall victim to "Abnormal Psychology Student Syndrome."

Mental Patient's Association The Mental Patient's Association of Vancouver BC is quite active. Their website (www.mpa-society.org) contains a great deal of information. By looking around you get a feel for the breadth and depth of their activities. The provide advocates for individuals who are in care, often former patients advocate for current patients, they educate the public about mental patients' rights, they even provide housing and job placement services. This is a far cry from the plight of individuals with mental problems who were executed in the Middle Ages, or housed in giant warehouses in the 1950s and it makes an enormous difference to public attitudes and the plight of these patients. Berger and Luckman's concept of the "social construction of reality" is relevant here.

Ask students to consider the difference it would make to them if they were to be diagnosed with a mental disorder, remembering that many of them will be at some point in their life, if they were perceived by society to be "possessed by the devil", "dangerous", or "suffering from a treatable disease".

If you live in an area with a mental patient's association they will generally be quite willing to provide a guest speaker on the experience of institutionalization, their advocacy role, mental patients' rights and other topics.

Student’s Ideas on the Future of Health and Mental Health Care in Canada While it is too late for students to have a direct impact on the Romanow Report, it is still a good exercise to have them consider what changes they would recommend with regard to the future of health care in Canada, particularly from the perspective of mental health. Ask students to write a brief position paper as if they were presenting it for consideration by the Commission on the Future of Health Care in Canada.

You could also have students review Steven Lewis’ report on Canadian Health Care since Romanow and discuss how it applies to mental health. http://www.queenshealthpolicychange.ca/resources/Discussion_PaperCanadian_Health_Policy_Since_Romanow_Easy_to_Call_for_Change_Hard_to_Do-Steven_Lewis.pdf

STUDENT COMPANION SITE A student companion site is available to students. This site contains practice quizzes and PowerPoint presentations.

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Davison 6e Student Companion Site

ADDITIONAL READING There is a wealth of resources on the Internet that can provide students with access to additional readings in abnormal psychology. As students begin to access some of these readings they inevitably notice that at any given site there are many more articles and even whole books available to them and it often dawns on them that through the Internet they have direct access to many primary and secondary sources of psychological literature. I have included some of these resources and some suggestions as to how they could be used.

Mental Health: The Surgeon General's Report (US) This is a large report but it contains interesting statistics and discussion of theory. You can focus on specific sections and assign it as reading or have students search through the site looking for information that they are interested in. What they find can form the basis of interesting seminar discussions. http://www.surgeongeneral.gov/library/mentalhealth/home.html

Mental Health Website, Health Canada This site contains, among other resources, a paper on the "risk/vulnerability/resiliency approach" that students could consider and debate. http://profiles.nlm.nih.gov/ps/retrieve/ResourceMetadata/NNBBHS This paper raises the issue of whether or not psychology or psychiatry as a science has the ability to predict behaviour. A good scientific theory should be able to explain and predict future phenomenon based on current situations.

Commission on the Future of Health Care in Canada This site contains a wealth of information on the current state of health care in Canada and the full Romanow report with the Commission’s recommendations for future changes to the Canadian health care system. http://www.hc-sc.gc.ca/hcs-sss/hhr-rhs/strateg/romanow-eng.php

SOME IDEAS FOR UTILIZING THE INTERNET Scavenger Hunt The resources of the Internet lend themselves to exercises in which students are turned loose to find various bits and pieces of information, often without the instructor really knowing what will be turned up.

The health care systems in the United States and Canada are VERY different. See if you can find some statistics or indications of what the effects of these differences are. You may want to find comparisons on the infant mortality rate, life expectancy, death rates for various diseases, childhood disease rates, suicide rates, incarceration rates, etc.

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Aboriginal groups in Canada have been the victims of a variety of social policies. Residential schools were a particularly disastrous experiment in social assimilation. See what evidence you can find with regard to the extent of the use of residential schools, the rates of physical and psychological abuse, or recent attempts by First Nations to deal with the effects.

Canadian First Nations and Aboriginal groups had social systems including mental health systems that had been used for thousands of years. See what information you can find about the nature of these methods and the extent to which they have survived t the present. Try to compare some traditional First Nations treatments with current treatments. Try to understand each system using the terminology and assumptions of the other.

Health Canada’s Mental Health Issues Site www.hc-sc.gc.ca/hl-vs/mental/index_e.html Health Canada’s mental health website provides information on the planning, delivery, cost and evaluation of mental health programs and services in Canada, as well as information on the mental health issues, problems, and disorders Canadians can encounter in their lifetimes.

Have your students explore this site and see what they can find that is of interest. Ask them to prepare a summary of a finding in which they are particularly interested to be presented in class or in an online or seminar discussion. This is particularly useful early in a term where a research paper is assigned for later in the term.

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CHAPTER 2 CURRENT PARADIGMS AND INTEGRATIVE APPROACHES

CHAPTER SYNOPSIS This chapter is concerned with the principal paradigms that have been used to conceptualize the etiology and treatment of abnormal behaviour—the biological, cognitive-behavioural, psychoanalytic, and humanistic paradigms. The goal of this chapter is to convey the general assumptions made by each paradigm to lay the groundwork for the examination of diagnostic categories in later chapters. It considers recent attempts to find an integrative paradigm in the Diathesis-Stress/biopsychosocial model and eclectic models of psychotherapy.

The Role of Paradigms According to Thomas Kuhn, paradigms are an inevitable part of the scientific endeavour. A paradigm is the agreed set of assumptions and legitimate questions that forms the boundaries of an empirical science. Psychology is at a stage in its evolution that Kuhn describes as "preparadigmatic." This is to say it still contains competing schools that have not yet coalesced into a dominant paradigm. The particular paradigm that a mental health worker adopts will have a profound influence on their definition of "normal," the type of therapy they adopt and the methods of prevention that they legitimize.

For a more general discussion of the role of paradigms in science see: http://plato.stanford.edu/entries/thomas-kuhn/

The Biological Paradigm The historical link between medicine and abnormal behaviour has led to a medical or disease model which, in a continuation of the somatogenic hypothesis, likens abnormal behaviour to a physical disease. As our knowledge of bodily functioning has increased, it has become more meaningful to say that a psychological abnormality may be attributed, at least in part, to a disruption in a biological process. Biological research includes behavioural and molecular genetics, and brabrain chemistry and structure.

Contemporary Approaches to the Biological Paradigm Behaviour genetics is the study of individual differences in behaviour that are attributable in part to differences in genetic makeup. The total genetic makeup of an individual, consisting of inherited genes, is called the genotype. This unobservable, physiological genetic constitution is contrasted with the phenotype, the totality of observable characteristics. While the genotypes of clinical syndromes may be inherited, the appearance of a phenotypic behaviour disorder depends on environment and experience.

Molecular genetics attempts to specify the particular gene or genes involved and the precise functions of those genes. Gene-environment interactions were once thought to be rare. It

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appears, however, that they are both ubiquitous and significant. Current research suggests that genetic differences may be identified through temperament. Temperament is defined as differences in reactivity and self-regulation and is detectable soon after birth.

The nervous system is composed of billions of neurons. When stimulated, nerve impulses travel down the axon to the terminal endings of the neuron. To cross the small synapse between neurons, the terminal buttons of each neuron contain synaptic vesicles filled with chemical substances called neurotransmitters. These neurotransmitters flood the synapse and transmit the impulse by fitting into receptor sites in the postsynaptic neuron.

Several neurotransmitters have been implicated in various psychopathologies, either when too much or too little of a particular transmitter is available. The amount of neurotransmitter might be altered because of errors in the metabolic pathways resulting in synthesis, alterations in the deactivation of released transmitters, or postsynaptic receptors which are too numerous or too easily excited.

An important implication of the biological paradigm is that somatic treatments may be effective. Most biological interventions, such as psychoactive drugs and ECT, do not follow from knowledge about etiology. In addition, nonbiological treatments can have beneficial effects on the biology of the individual.

Biological Approaches to Treatment One of the implications of the biological paradigm is that mental disorders can be treated by altering bodily functions either through psychoactive drugs or through direct intervention in the brain.

Evaluating the Biological Paradigm While biologically based research has made great progress in exploring causes and treatments of psychopathology, reductionism is a concern in this paradigm. Reductionism advocates reducing whatever is being studied to its most basic elements. In psychopathology, this stance reduces complex mental responses to simple biology.

Focus on Discovery 2.1: The Neuroscience of Attention-Deficit Hyperactivity Disorder (ADHD) There is some evidence that implicates the frontostriatal circuitry in ADHD. Other research has focused on the role of dopamine and noradrenalin. Unfortunately, there is a lack of theoretical models to explain the causes of ADHD. A recent and perhaps encouraging development has been the creation of a research group ADHD-200 that has formed a consortium of functional neuroimaging investigators. This consortium has already released a large data set that enabled researcher at Johns Hopkins to develop a predictive tool in the diagnosis of ADHD.

The Cognitive-Behavioural Paradigm The Behavioural Perspective The learning paradigm assumes that abnormal behaviour is learned in the same way as other human behaviour. The roots of behaviourism lie in the dissatisfaction of John Watson and others with introspection as a means of experimental investigation, and the development of a new approach focusing on observable behaviour rather than consciousness.

Classical conditioning is a form of learning discovered by Pavlov: he paired the presentation of food (unconditioned stimulus) with ringing a bell (conditioned stimulus) and found that the ringing of the bell alone came to evoke salivation. Salivation in response to food is

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a natural event (unconditioned response), but in response to the bell it is a conditioned event (conditioned response). Watson and Rayner induced Little Peter to fear a white rat through the use of classical conditioning, suggesting a possible etiology of certain disorders.

Skinner's operant approach focused on the relationship between responses and their consequences. Positive reinforcement refers to the organism's tendency to repeat a behaviour that has been followed by a reward, while negative reinforcement strengthens a response by removing an aversive stimulus.

Modelling is a third type of learning in which observing someone perform certain behaviours can increase or decrease the likelihood that the observer will perform that behaviour.

For example, children may acquire behaviour patterns such as phobias or substance abuse through observation of their parents or significant other models.

Finally, the mediational theory of learning holds that an environmental stimulus does not initiate an overt response directly; rather some internal response plays the role of a mediator. In avoidance conditioning experiments, the animal learns to fear the CS through classical conditioning, and to avoid the CS and the fear through operant conditioning. Fear and anxiety, thus, though internal responses, become learned as observable responses are learned. According to this theory, fear may be both a learned internal response and a drive that can mediate avoidance behaviour.

Behaviour therapy encompasses a number of therapeutic techniques that are outgrowths of the learning paradigm. Counterconditioning involves associating a classically conditioned anxiety response with a non-fearful response. Wolpe's systematic desensitization is one example of counterconditioning, as people are taught to replace fear with relaxation in a step-by-step learning process. Another type of counterconditioning, aversive conditioning, pairs an attractive but socially inappropriate stimulus with an unpleasant event. Operant conditioning principles typically alters the consequences of the problem behaviour. Modelling can also be used in behaviour therapy, including techniques such as role-playing and behaviour rehearsal.

Canadian Contributions 2.1: Albert Bandura: The World’s Greatest Living Psychologist?

Some have argued that Albert Bandura is the world’s greatest living psychologist; fourth in terms of his impact (behind, Skinner, Piaget and Freud). Bandura’s social learning theory was a major contribution to psychology. Later, his work on self-efficacy has contributed to the development of concepts such as self-regulation self-observation and self-judgement.

The Cognitive Perspective Cognition encompasses the mental processes of perceiving, recognizing, conceiving, judging, and reasoning. In the cognitive paradigm, the focus is on how people structure and organize their experiences. According to this view, the learner plays an active role, fitting new information into an organized network of accumulated knowledge or schema. Researchers in the cognitive paradigm suggest that cognitive sets may lead to psychopathology; a pre-existing set toward hopelessness, for example, may cause depression.

Cognitively oriented behaviour therapists attempt to change patients' thinking processes through cognitive restructuring in order to influence their emotions and behaviour. For example, Aaron Beck proposed that depressed individuals distort experience in ways that focus on negative happenings. The therapist offers counterexamples to persuade the person to change his or her opinions of the self and the way life events are interpreted. Albert Ellis holds that maladaptive feelings are caused by irrational beliefs, and he challenges these beliefs in the process of rationalemotive behaviour therapy.

Aaron Beck developed a cognitive therapy (CT) for depression in the 1970’s. He observed that many depressed individuals diagnosed with depression had a similar way of

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thinking which involved a number of negative assumptions and a negative way of perceiving the world. Beck hypothesised that these cognitive biases were learned and were the cause, not the result of, depression. His therapy involves observing cognitive habits, pointing them out to the client, and giving the client methods of altering their ways of thinking and perceiving.

Albert Ellis also developed a cognitively based therapy called rational-emotive behaviour therapy in which he encourages a client to alter the way they use language, both internally and in conversation. He asks them to avoid the use of “irrational beliefs” as a way of altering their internal cognitive habits which he sees as the cause of depression.

Applying a learning view of psychopathology increases the precision of observation and thus forges a bridge between experimental and abnormal psychology. While many disorders have a learning component, many have not been linked to particular learning experiences; it is not clear that the causes of all mental illnesses can be elucidated through learning principles.

Some of the concepts employed by cognitive theorists are not well defined. Further, the cognitive paradigm has shed little light on the etiology of mental disorders, focusing instead on current determinants. There is controversy as to whether the learning and cognitive paradigms should be combined or treated separately, especially since many cognitive behaviour therapists use both cognitive and learning techniques.

Focus on Discovery 2.2: What is Psychotherapy?

In its simplest form, psychotherapy is an interaction between a trained professional who attempts to aid another person to behave, feel and/or think differently. Beyond this simple definition there is little general agreement as to what is psychotherapy. London (1986) divided therapies into two categories: insight therapies (allowing people to gain an understanding of what motivates them or what causes their distress) and action based therapies in which the emphasis is often on changing behavior

The Psychoanalytic Paradigm Classical Psychoanalytic Theory Probably the most widespread paradigm of psychopathology historically, though it is gradually being replaced by more contemporary theories, is Sigmund Freud's psychoanalytic or psychodynamic view, which assumes that psychopathology results from unconscious conflicts that originate during child development.

According to Freud's classical psychoanalytic theory, the mind is divided into three principal parts, the id, ego, and superego. The id, present at birth, is fuelled primarily by lifeintegrating sexual energy or libido. Operating on the pleasure principle, the id seeks immediate gratification via reflex activity and primary process (the satisfaction of needs in fantasy). The ego operates on the reality principle, mediating between the instinctual demands of the id and the demands of reality through secondary process, or logical planning. The superego is the carrier of society's moral values. It is the complex, fluid and dynamic interplay between these three competing psychic forces that gives rise to the term.

Within the psychodynamic the personality is thought to develop through four psychosexual stages: the oral, anal, phallic, and genital. Between the phallic and genital stages is the latency period during which id impulses do not play a major role. Life-long personality traits are determined by the child's resolution of conflicts at each stage of development.

According to Freud, most of the important determinants of behaviour are unconscious, such as the defence mechanisms that protect the ego from anxiety. Some defence mechanisms are: (1) repression, whereby impulses unacceptable to the ego are pushed out of consciousness; (2) denial, disavowing a traumatic experience; (3) projection, attributing unacceptable impulses to

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external agents; (4) displacement, redirecting emotional responses from a dangerous object to a safer substitute; (5) reaction formation, converting one feeling, such as hate, into its opposite, love; (6) regression, retreating into the behavioural patterns of an earlier age; (7) rationalization, inventing a reason for an unreasonable action or attitude; and (8) sublimation, converting sexual or aggressive impulses into socially acceptable behaviours.

Psychoanalytic Therapy The goal of psychoanalytic therapy is to remove earlier repressed memories, help the client to face the childhood conflict and resolve it. A number of techniques are used to examine repressed memories including free association and dream analysis.

An important element of psychoanalytic therapy is transference. Transference refers to the client reacting to the therapists in a way that reflects feeling, emotions or thoughts concerning a significant person in their life. Countertransference refers to the analyst’s reactions toward the client Ego analysts adapted Freud's ideas in forging their own therapeutic approaches placing increased emphasis on the individual’s ability to control the environment and select the time and the means to satisfy instinctual drives.

Brief psychodynamic therapies are time-limited treatments that target specific problems and have concrete goals. Harry Stack Sullivan pioneered a form of brief therapy that focused on disorganized interpersonal relationships. A contemporary brief therapy known as Interpersonal Therapy (IPT), concentrates on the individual's current difficulties in relationships using both empathic listening and behavioural prescriptions.

Criticisms of classical psychoanalytic theory encompass both methodological and conceptual problems. Freud's case study approach used small, non-representative samples of patients and relied on recollection. His paradigm probably influenced both his patient's reports and the inferential leaps he made. While he was influential in considering biological explanations for abnormal behaviour and perceptive in his observations of human nature, many of his theories are inherently untestable and therefore non-scientific.

The Humanistic Paradigm Humanistic therapy is insight focused, placing on free will and little focus on how a problem developed.

Carl Rogers' Client-Centred Therapy Carl Rogers made the following assumptions about human nature: (1) we must adopt a phenomenological view to understand people; (2) healthy people are aware of their behaviour; (3) healthy people are innately good and effective; (4) healthy people are purposive and goaldirected; and (5) therapists should not attempt to manipulate events for clients. When people make decisions independent of demands and preferences of others they are guided by an innate tendency for self-actualization. Therapists facilitate the client's return to independent decision making by providing unconditional positive regard and empathy, rather than using specific procedures. Advanced accurate empathy helps the client to acquire a new phenomenology, whereas in primary empathy, the therapist restates the client's thoughts, feelings, and experiences from their point of view.

Evaluating the Humanistic Paradigm Client-centred therapy relies upon the client's phenomenology. It is difficult to evaluate whether the therapist truly understands the patient's perception of the world. The humanists' basic premise

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that man is inherently good has also been challenged. In addition, no effort is made to determine whether the patient has the necessary skills for effective change.

Rogers should be credited for the origination of psychotherapy research. He pioneered the evaluation of therapists' behaviours and their relationship to therapeutic outcome. The results of research on the relationship of empathy to clinical improvement, however, have been mixed.

Consequences of Adopting a Paradigm The paradigm a clinician or theorist adopts influences their interpretation of data about a client and the type of treatment recommended.

Eclecticism in Psychotherapy: Practice Makes Imperfect While it may appear, and often textbooks seem to imply, that psychological and psychotherapy schools are distinct, in reality most psychotherapist practice in an eclectic way to some degree. A trend toward integrating psychotherapies has culminated in a combined approach known as prescriptive eclectic therapy and a recent survey of therapists treating eating disorder patients suggests that an eclectic approach may be the norm rather than the exception.

Psychosocial Influences on Mental Health The Paradigms discussed often appeal to factors within the individual. There are, however, a number of important external influences that can have an influence on mental health.

Family Factors Family factors include parenting styles, parental marital discord and parental mental illness.

Parenting styles can be authoritarian, permissive and authoritative parenting. Marital discord can create a stressful atmosphere; in its extreme, children can be exposed to both violence and abuse.

Growing up in the presence of parental mental illness can also have a negative impact on children. Cumulative risk refers to multiple risk factors are present in the same child. The strongest predictors of mental health problems are parental mental illness, child abuse and neglect

Peers and the Broad Social Environment The research on the influence of peers tends to emphasize two factors: peer status and peer victimization. Children who enjoy high peer status are generally better adjusted; low peer status can lead to loneliness that, in turn, can lead to depression. Peer victimization has also been associated with loneliness and depression. It should be noted that it is difficult to determine whether status and victimization precede mental health difficulties or are the consequences of such difficulties.

The Cultural Context Canadian society is considered to be culturally diverse. This diversity should be taken into account when considering approaches to the assessment, diagnosis and treatment of mental disorders.

Mental Health Implications of Cultural Diversity in Canada

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Cultural diversity has implications for clinical practice. For example, although Aboriginal people constitute only 4% of the Canadian population, they present proportionally higher levels of mental health problems (see Canadian Perspectives 2.1). On the other hand, there appears to be a lower level of mental health problems among immigrants. The screening process of immigrants to Canada may have an effect on what is known as the healthy immigrant effect. Nevertheless, minority groups and diverse cultures have some unique mental health problems. The ratio of various mental health issues varies from culture to culture. Seeking help for mental health issues is relatively acceptable for the majority of Canadians, but is problematic for some groups. South Asian and Chinese Canadians have been observed to seek help for mental health concerns at lower rates than other groups. Some of the barriers to seeking help may be problems with language proficiency, cultural attitudes toward mental disorders and a lack of knowledge concerning the availability of mental health services.

Canadian Perspectives 2.1: Origins of Mental Health Problems among Canada’s Aboriginal People Both provincial and federal Canadian governments attempted the cultural assimilation of Aboriginal people through forced attendance at residential schools followed by adoption outside of the aboriginal community. In retrospect it seems that these policies were short-sighted leading to trauma and grief (both for the children and their families). Some protective factors in aboriginal communities may be maintaining close community contacts and spending time hunting and fishing in the bush

Diathesis-Stress and Biopsychosocial: Integrative Paradigms The Diathesis-Stress Paradigm The diathesis-stress model is a step towards and integrative paradigm in abnormal psychology.

This model addresses biological and psychological factors and considers how these factors may interact. In this model predisposing factors can be biological, either the result of genetics or damaging biological events such anoxia or psychological, such an inconsistent parenting or exposure to abnormal role models. A given mental disorder is triggered when a current stressor interacts with previously established diatheses (see Student Perspectives 2.1)

The Biopsychosocial Paradigm In the biopsychosocial paradigm, biological, psychological, and social factors are conceptualized as different levels of analysis or subsystems that interact to effect human cognition and behaviour. An example might include the effects of socio-economic status and poverty. It is generally accepted that extreme poverty is a risk factor for mental health problems. However, it is difficult to determine the directionality in the correlation between poverty and mental health. As with any correlation there is also the danger that a third variable may be implicated.

Student Perspectives 2.1: Diathesis and Stress in a Student with Borderline Personality Disorder This student perspective describes a case study of a first year university student who was diagnosed as having a borderline personality disorder following the termination of a romantic relationship.

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STUDENTS SHOULD KNOW Key Points 1.

Students should know what a paradigm is and how it influences proponents' collection and interpretation of clinical data.

2.

The biological paradigm assumes that psychopathology is caused by an organic defect, and the role of behaviour genetics and neurochemistry in explaining abnormal behaviour.

3.

The cognitive-behavioural paradigm emphasizes certain schemata and irrational interpretations as major factors in abnormal behaviour. Cognitive interventions attempt to alter an individual’s way of thinking, perceiving or speaking. The learning perspective asserts that abnormal behaviour is learned much the way normal behaviour is learned.

Classical conditioning, operant conditioning, and modelling are the major learning processes proposed, and behaviour therapists apply learning principles to the direct alteration of behaviour.

4.

The psychoanalytic paradigm traces psychopathology to unconscious conflicts. Students should be aware of Freud's ideas about the structure of the mind, the stages of psychosexual development, anxiety, and the defences. New brief psychodynamic therapies are time-limited and focus on specific problems.

5.

The humanistic paradigm focuses on creating an empathetic therapeutic environment that will allow the patient to make new choices.

6.

Paradigms often determine how problems will be conceptualised, what data will be collected and how the data will be interpreted. In clinical practice, paradigms will have an influence on how the client’s problems are perceived and what form treatment will take.

7.

There are a number of important psychosocial influences on mental health including family factors and peer groups.

8.

Culture is an important factor in the perception of mental disorders, the construction of the course of mental disorders, the extent to which help will be sought and the appropriateness of therapeutic interventions.

9.

Canadian social policy that promotes cultural diversity has social policy implications with regard to assimilation, language, immigration, and the future of First Nations and their cultural institutions.

10.

In a diverse society there are unique psychiatric problems for minority groups, differences in the rates at which groups seek help, and considerations of diagnosis and treatment that need to be addressed.

11.

The diathesis-stress paradigm integrates some of the views of different paradigms, assuming that a biological or psychological predisposition interacts with life stress to produce disorder.

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12.

The biopsychosocial paradigm looks at how biological, psychological and social variables interact to affect human cognition and behaviour.

Key Terms action (behavioural) therapies (p. 50) adoptees method (p. 34) assertion training (p. 56) authoritarian parenting (p. 57) authoritative parenting (p. 57) aversive conditioning (p. 43) behaviour genetics (p. 33) behaviour modification (p. 41) behaviour therapy (p. 41) behavioural (or learning) paradigm (p. 39) behaviourism (p. 39) biological paradigm (p. 33) biopsychosocial paradigm (p. 65) brief therapy (p. 51) classical conditioning (p. 39) client-centred therapy (p. 54) cognition (p. 43) cognitive behaviour therapy (CBT) (p. 46) cognitive paradigm (p. 43) cognitive restructuring (p. 46) concordance (p. 34) conditioned response (p. 40) conditioned stimulus (p. 40) counterconditioning (p. 41) countertransference (p. 51) cultural diversity (p. 59) cumulative risk (p. 58) deep brain stimulation (p. 37) defence mechanism (p. 49) denial (p. 49) diathesis–stress paradigm (p.63) differential susceptibility (p.65) discriminative stimulus (p. 40) disease model (p. 33) displacement (p. 49) dizygotic (DZ) twins (p. 34) dream analysis (p. 50) eclecticism (p. 56) ego (p. 49) ego analysis (p. 51) extinction (p. 40) family method (p. 34) free association (p. 50) genes (p. 33) genotype (p. 33)

healthy immigrant effect (p. 62) humanistic therapies (p. 54) id (p. 49) index cases (probands) (p. 34) insight therapies (p. 50) interpersonal therapy (IPT) (p. 52) interpretation (p. 51) introspection (p. 39) irrational beliefs (p. 45) latent content (p. 51) law of effect (p. 40) libido (p. 49) linkage analysis (p. 35) medical model (p. 33) modelling (p. 41) monozygotic (MZ) twins (p. 34) moral anxiety (p. 49) multicultural counselling and therapy (p. 60) negative reinforcement (p. 40) nerve impulse (p. 36) neuron (p. 36) neurotic anxiety (p. 49) neurotransmitters (p. 36) objective (realistic) anxiety (p. 49) operant conditioning (p. 40) overcontrolling type (p. 36) paradigm (p. 32) permissive parenting (p. 57) phenotype (p. 33) pleasure principle (p. 49) positive reinforcement (p. 40) primary process thinking (p. 49) projection (p. 49) psychoanalytic (psychodynamic) paradigm (p. 48) psychodynamics (p. 49) psychotherapy (p. 50) rational-emotive behaviour therapy (REBT) (p. 45) rationalization (p. 49) reaction formation (p. 49) reality principle (p. 49) reductionism (p. 39) regression (p. 49) repression (p. 49)

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resilience (p. 66) resilient type (p. 36) resistances (p. 50) reuptake (p. 36) risk (p. 66) role-playing (p. 53) schema (p. 43) secondary process thinking (p. 49) self-actualization (p. 54) self-efficacy (p. 42) sublimation (p. 49) successive approximations (p. 44)

superego (p. 49) sympathetic nervous system (p. 37) synapse (p. 36) systematic desensitization (p. 41) temperament (p. 35) transference (p. 51) twin method (p. 34) unconditional positive regard (p. 55) unconditioned response (p. 39) unconditioned stimulus (p. 39) unconscious (p. 49) undercontrolling type (p. 36

New Names Carl Rogers, Sigmund Freud, Harry Stack Sullivan, Heinz Hartmann, John B. Watson, Ivan Pavlov, B. F. Skinner, Joseph Wolpe, Albert Ellis, Aaron Beck, Albert Bandura.

LECTURE LAUNCHERS 1. Is Psychology "Pre-paradigmatic"?

Biology (Darwin and evolution), Chemistry (the Periodic Table), Geology (the evolution of continents), Physics (Newton, Einstein, relativity, Quantum Theory); all of these sciences have a central organizing paradigm. But does psychology? Try to get your students to formulate the current paradigm. It isn't easy. Try to formulate one. Clearly it will be a model that can integrate genetics, biological experience, the main learning theories (operant, classical and observational), and social psychology (Migram, Asch, Zimbardo, etc.) into one interactive model. There are examples to draw from starting with the "biopsychosocial" models of the etiology of alcohol addiction. See "An Overview of Biopsychosocial Disorders" at Health Psychology and Rehabilitation. www.healthpsych.com/research/research.html

2. The Manufacture of a Human Chromosome For years, scientists have been able to create artificial chromosomes for very simple living organisms, such as yeast. A mouse chromosome was created in the lab in 1996. But in 1997, the first artificial human chromosome was created at a lab at Case Western Reserve University in Cleveland (reported in Nature Genetics, April, 1997).

What are the implications of this new technological leap? While researchers involved in the federal Human Genome Program have been mapping the location of specific genes on specific chromosomes, creating artificial ones will enable scientists to study the functioning of genes within their normal context. The next big step would be packaging therapeutic genes in an artificial chromosome to introduce them to a cell. The new gene could either generate a medicinal protein or replace a defective gene. The first step in treatment would be using artificial chromosomes to treat blood diseases and diseases that affect the human immune system.

Eventually, a wide range of inherited or infectious diseases might be amenable to such gene therapy.

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3. Does Everything Come Down to Serotonin?

"Does everything come down to serotonin?" "Yes." (U.S. News & World Report) "Environment is key to serotonin levels." (APA Monitor, April 1997, p.26) As readers work their way through the textbook, they will notice that serotonin features prominently in etiological theories for many mental disorders. Low levels of serotonin have been associated with everything from eating disorders, depression, and alcoholism to suicide and aggression. Many students are likely to hold a highly deterministic approach to serotonin (e.g., “low levels cause depression”). For an in-depth discussion of the role of serotonin see: www.medicalnewstoday.com/articles/232248.php www.ncbi.nlm.nih.gov/pmc/articles/PMC2077351/

4. Does the Biological Paradigm Make Other Paradigms Obsolete?

As the "decade of the brain" has highlighted the impact of neuroscience on our understanding of mental illness, students might expect that finding biochemical causes for various disorders make the psychological paradigms obsolete. If symptoms can be explained by neurochemical changes or a "chemical imbalance," is there still a role for paradigms that emphasize talking, thinking, and behaving in the etiology and treatment of these same disorders? If students struggle, they could be reminded of the predominance of the biological paradigm in the past, following publication of Darwin’s Origin of the Species, and the discovery that “General Paresis of the Insane” was a curable bacterial infection.

5. Social and Ethical Implications of Genetic Knowledge In 2016, the Canadian Senate unanimously passed a bill that would protect the privacy of Canadians who get genetic testing. Until this legislation is adopted, Canada remains the only G7 country without these protections. Have the students discuss the implications of not having a legal right to such privacy. For example, would you get a genetic test that might show you are genetically predisposed to a disease (e.g., breast cancer) if your employer and insurance company might find out? If students have seen the movie “Still Alice,” they will likely be aware of testing for the gene related to early onset familial Alzheimer’s disease. Would this information be helpful to them?

What could happen if their employer found out about a positive result? Would lack of privacy influence their decision to participate in medical research?

The Canadian Coalition for Genetic Fairness maintains a website with educational information about genetic discrimination and relevant policies. http://ccgf-cceg.ca/en/about-ccgf/

6. Can Positive Regard Be Unconditional?

Rogers argues that the task of therapy is to create conditions under which the client's natural tendency to self-actualize will flourish. Since self-actualization is inhibited when the client is overly concerned with pleasing others, the therapist should let the client take the lead in directing therapy, should avoid imposing his or her values on the client, and the esteem and caring of the therapist for the client should not depend on anything the client does; positive regard should be given unconditionally.

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Does this actually happen in client-centred therapy? In a frequently cited study, Truax tested whether empathy and acceptance were in fact, dispensed unconditionally by the therapist (1966, Journal of Abnormal Psychology, 71, 1-9). Truax randomly selected 40 therapist-client exchanges from tape recorded sessions of therapy conducted by Carl Rogers and had five experienced clinical psychologists, blind to the study's hypotheses, rate the segments to describe what the client said and how Rogers had responded. Therapist responses were rated for empathy, acceptance of the client, and directiveness.

When these ratings were correlated with those describing client behaviour, it was found that the therapist's behaviours were not unconditional; the extent to which the client expressed new discriminations among old feelings and behaviours correlated .47 with empathy and .37 with acceptance. Therapist empathy and acceptance were also found to be more common after clients expressed insight and when they expressed themselves in the therapist's style. When the client's statement was ambiguous, the therapist tended to be directive and not empathic or accepting.

Other client behaviours, including catharsis, blocking, anxiety, and expressing negative feelings, were not significantly correlated with any of the rated therapist behaviours.

The pattern of empathic and accepting responses by the therapist was clearly nonrandom, and appeared to depend on the type of statement by the client. This raised the possibility that these therapist responses served to selectively reinforce certain types of client behaviour. If so, one would expect client behaviours more often followed by empathy and acceptance to become more frequent as therapy progressed, and those less often reinforced to decrease in frequency. Truax tested this hypothesis by comparing the frequency of the different types of client statements in early and later sessions. For 7 of the 9 statement types the prediction was borne out; the frequency of those statements that correlated with therapist responses changed appropriately whereas the others did not change.

This is not to say that therapist empathy and acceptance are important only as reinforcers, or that verbal reinforcement is the "active ingredient" of Rogerian therapy. It does show, however, that even when intending not to, therapists may directly change clients' behaviour. If influence in inevitable, it may be best that therapists recognize it as such and use it deliberately.

7. Setting the Record Straight: The Social Views of Skinner Skinner's death in August of 1990 rekindled both recognition of his accomplishments in psychology and renewed criticism of his views. Many of his critics were journalists in the popular press who were both confused and inflamed by his social views as espoused in Walden Two and Beyond Freedom and Dignity. Since your students may have read one of these books (or, more likely, formed an opinion of Skinner without having read his books), discussion of some of the points raised by Dinsmoor in "Setting the record straight: The social views of Skinner" (1992, American Psychologist, 47, 1454-1463) may be helpful. The following points are especially illuminating: While many misinterpreted Skinner as a totalitarian, interested only in controlling the behaviour of humans, he may more accurately be seen as a libertarian. His point is that humans are already being controlled by their governments, and other social institutions, and the important issue to address is what form that control should best take. One of Skinner's primary concerns, then, was to criticize the use of aversive control, or punishment, as oppressive and ineffective.

Students might be encouraged to discuss the nature of control present in our society, and ways in which control could be altered. What utopian societies would result from the ideas of writers in other psychological paradigms?

Further, students might be interested in this account from Deborah Skinner Buzan, describing her warm, affectionate upbringing, and her outrage at stories that she was raised in an experimental box:

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https://www.theguardian.com/education/2004/mar/12/highereducation.uk

DISCUSSION STIMULATORS Personal Consequences of Paradigms The view of behaviour that a student adopts has an effect not just on the student's view of psychology, but also on the student's view of him or herself. Do I want to think of my own behaviour as being caused by unconscious processes, by my biological make-up, by past learning experiences, or by the way I construe the world? How can I change myself, if I can change myself at all? Can I learn new ways of behaving, must I have my biological make-up altered if I want to change, will change only occur after many years of analysis, or do I really need some understanding and caring? While scientists (and students) are striving to be objective, personal values can affect the answers we seek and those we accept; at times our values may persuade us more than the data we find.

The Rise and Fall of Behaviourism?

The APA Monitor is a monthly publication of the American Psychological Association. The December 1999 issue celebrated the first 100 years of psychology by looking back at significant events of the past century. An article entitled "Behaviourism: the rise and fall of a discipline" (p.

19) makes the claim that behaviourism has lost favour in the scientific community, partially because "behaviour theories were overly simplistic and inadequate, particularly as they applied to human beings." The article concludes with the statement that while behaviour modification has been "fruitful" it has lost grown in the clinical area to cognitive therapies.

It is unclear that behaviourism has "fallen" as the article asserts. Students might be stimulated to gather evidence over the course of the term to determine what the dominant paradigm is. For example, the class might be divided into teams based on the paradigms described in the text. As the course progresses, each team gathers evidence in support of their paradigm as a "better" explanation for abnormal behaviour. They could supplement the text with articles from professional journals and the popular media. At the end of term you might consider oral presentations, a poster session, or even a debate amongst the teams as they present the data to support their paradigm.

Applying Paradigms to People Students often enjoy and learn from applying the material in this course to actual cases. Divide the students into four sections, and have each group adopt one of the paradigms described in the chapter. Using any particular case study, have the groups discuss how their paradigm might be used to understand the client. The competition between paradigms should become clear as students become wedded to particular views and attempt to persuade their peers of their ideas.

Somatogenesis vs. Psychogenic Hypotheses in Modern Psychology The relationship between the somatogenic and psychogenic hypotheses described in Chapter 1 and the major paradigms presented in this chapter could be made explicit by asking the class to categorize the paradigms as either somatogenic or psychogenic. The biological paradigm is a clear example of the modern version of the somatogenic viewpoint, and psychoanalysis clearly grew out of the psychogenic hypotheses of Charcot and Breuer. More dissent might arise in classifying the learning and cognitive paradigms; they may represent a new view of abnormal behaviour (environmentogenic?) which is not neatly defined as somatogenic or psychogenic.

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In addition to recognizing their own biases regarding which paradigm is most appealing or "makes sense," students could be encouraged to think about what type of evidence would convince them of the value of one paradigm over another.

Exercise in Types of Therapeutic Communication To help students get a flavour for the actual interchange of therapy, it is helpful to give them a chance to talk with each other in purposeful ways and observe the different effects. One method is to conduct the following exercise using different "response modes" which are commonly used in therapy.

1) Questions. For the first exercise, have students sit in a circle (or several smaller circles if you have a large class).

A. Closed-ended questions. Have students go around the circle, asking the person next to them a closed-ended question (can be yes-no, specific, or multiple-choice). That person replies, and then asks the next person a closed question. Continue this for a few minutes, or until everyone has had a turn.

B. Open-ended questions. Go around the circle again, but this time, only open-ended questions may be asked. (Spend some time explaining what an open-ended question is and give a few examples yourself.)

Discuss students' experiences with this exercise, including the following questions: •

• • •

What differences did you observe in the types of responses generated to the two types of questions? (Closed-ended questions usually yield briefer answers and a narrower range of responses; open-ended questions allow for a broader range of responses, longer answers, and usually have a longer latency, as the responder needs more time to think.)

From the point of view of the responder, how did it feel to be asked the two types of questions? (Most people find answering closed-ended questions more frustrating, as they are constricted in how they are allowed to answer.)

From the point of view of the questioner, how did it feel to be asked the two types of questions? (Most people find open-ended questions more difficult to think of.)

In the context of therapy, which type of question would be used for what purpose?

(Closed-ended questions might be useful in assessment, where a large amount of information needs to be collected; open-ended are usually preferable for building rapport, encouraging the client to give his or her own perspective, etc.)

2) Silence.

A. "Silence is poison." For this exercise, the group has to keep talking for 5 minutes and avoid any silence at all costs. They should be encouraged to interrupt and overtalk.

Briefly discuss their reactions afterward.

B. "Silence is golden." Now, have another 5-minute discussion, but this time there must be at least 5 seconds silence between speakers (advise them not to count out the seconds, though).

In discussing their reactions to this exercise, consider again what happens in the group and how the individuals feel about the different types of talking. "Poison" leads to talking faster, listening less, thinking less, and quieter students usually feel frustrated. "Golden" allows the talker more time and thought, and also provokes more anxiety. You might spend some time talking about how silence is used in psychotherapy.

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3) Interpretation. When giving an interpretation, the therapist speaks from another frame of reference, pulls in related pieces of information, and makes connections for the client. You might pass out a case description (or use the Ernest case in the text) and have the class come up with interpretations of the behaviour or personality described.

4) Advisement. Advice giving is a controversial aspect of therapy, and interesting to discuss with students. In some forms of therapy, such as behavioural, "advice" might be common in the form of specific suggestions for behaviour change. In other forms of therapy, such as client-centred, advice would never be given. You might try an exercise similar to that used for reflections, but this time only advice can be given. Discuss with students what it feels like to be on the receiving end of advice, when advisement might be appropriate, etc.

Psychotherapy in Other Cultures There are many different approaches to helping people deal with emotional problems around the world. Students often find it interesting to compare some of these differences and consider the links between culture, history and contemporary models of helping. In Japan there are well developed schools of psychotherapy that have their roots in Japanese culture and Shinto and Buddhist traditions rather than Western philosophy. Student can get a feel for some of these schools here, at “Japanese Psychotherapy”: http://sophia.smith.edu/~jhubbard/syllabi/ContempJapan/JapanesePsychotherapy.htm Comparing and contrasting the roots, methods, assumptions and paradigms of other cultures can often lead to interesting discussions.

Residential Schools The legacy of the effects of experiences in "Residential Schools" on First Nations/Aboriginal communities in Canada is an opportunity to review issues of culture, and issues of intergenerational effects of trauma and abuse. Here is a good summary: www.religioustolerance.org/sch_resid.htm.

There will be former residential schools in most provinces and often in a class there will the relative of someone who attended a residential school. The Truth and Reconciliation Commission of Canada spent six years travelling across Canada and listening to Aboriginal people who had been victims of the residential school system. The final report was released in 2015 and is available on the Truth and Reconciliation website. http://www.trc.ca/websites/trcinstitution/index.php?p=3 The aftermath of the residential school system leads to opportunities for discussion abut the effects of separation and loss (family and culture), childhood trauma, and attachment theory in the field of mental health.

Mastering New Material A large number of new terms are introduced to students in this chapter. This may be a bit overwhelming to students so early in the class, yet many of the terms and concepts in this chapter form the backbone of the text. Going through a brief discussion of each of the Key Terms from

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this chapter may be of considerable use to students. Terms can be discussed in class, or this may be a good time to give a short quiz on the definitions of some of the Key Terms from chapter.

SOME IDEAS FOR UTILIZING THE INTERNET Internet Search for Treatments Almost every major treatment paradigm has many resource sites on the Internet. Have groups of students take on a particular paradigm or school and see what they can find online. Remind students of the importance of finding credible information, although certainly they could incorporate blogs and personal stories of individuals with disorders.

Individuals with Mental Disorders and Self Help It is often surprising to students to find that individuals with mental disorders (current and past) are quite organized in many parts of Canada. The MPA web site is quite interesting: www.mpa-society.org/ Have students visit the site and summarize the activities of the organization. Discuss the implications of a group such as this. There is a video that is available from the MPA that can also be used.

Students might also be very interested in what they can learn on the internet about Pat Capponi, author of fiction and non-fiction, Order of Canada recipient, psychiatric survivor, and activist.

Health Canada Online Health Canada has an extensive site. www.hc-sc.gc.ca/english/search/a-z/a.html Have students visit this site and look for specific issues and programs that address the mental health issues of Aboriginal or First Nations peoples in Canada.

Biopsychosocial Paradigm Students can be asked to search for examples of the application of the biopsychosocial paradigm.

For example, the Biopsychosocial Model of Pain: www.informaworld.com/smpp/content~db=all~content=a714016986

Bandura’s Model Applied to Social Problems Albert Bandura continues to work on both the development of theory and the application of his model to significant social problems. The following site contains many articles, audio files and press information about Bandura and his work. Under “Self Efficacy and Social Cognitive Theory” there is a link to “Changing Behaviour through TV Heroes” that summarizes the application of social learning theory in African countries where the spread of HIV is a very serious public health problem. Bandura’s work has demonstrated that prosocial, safe sex behaviour can be increased through the presentation of prosocial models on TV.

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www.apa.org/monitor/oct04/tvheroes.html

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CHAPTER 3 CLINICAL ASSESSMENT, CLASSIFICATION, AND DIAGNOSIS

CHAPTER SYNOPSIS Clinical assessment procedures are more or less formal ways of finding out what is wrong with a person (i.e., diagnosis), what may have caused a problem, and what steps may be taken to improve the individual's condition. Diagnosis is a critical aspect of the field of abnormal behaviour, allowing professionals to communicate accurately with one another about the types of cases they are treating or studying. This chapter focuses on classification and diagnosis and the most recent edition of the leading classification system in North America, the DSM-5 published in 2013.

Reliability and Validity in Assessment Reliability Reliability refers to consistency of measurement. Several types of reliability are important to assessment: Interrater reliability refers to the degree to which two independent observers agree; test-retest reliability measures the extent to which two people being observed twice or taking the same test twice will score in generally the same way; alternate-form reliability concerns the agreement between two forms of the same test; and internal consistency reliability assesses whether the items on a test are related to one another. With each of these types of reliability, a correlation is calculated between the two measurements to quantify the estimate of reliability.

Validity Validity refers to the extent to which an assessment procedure is measuring what we intend it to measure.

Content validity concerns the extent to which a measure samples the domain of interest. Criterion validity is the degree of association between a test and a known criterion. Construct validity refers to the place of a measure within a theoretical framework. Finally, case validity has recently been proposed to describe the extent to which a judgment or interpretation is accurate for a particular person. A pattern of relationships between measures may confirm or disconfirm a particular theory about the construct being measured.

Psychological Assessment Clinical Interviews Clinical interviews differ from other interpersonal encounters in that the clinician pays close attention to how the person answers questions, rather than only to content. The clinical interview varies depending on the paradigm adopted by the interviewer. While it is clear that much information can be obtained by means of the interview, the dependability of the information has been questioned. Situational factors may exert strong influences over what is said, and many interviews are unstructured, leading clinicians to rely on intuition and general experience. As a consequence, reliability for clinical interviews is probably low, and validity is not usually established. These problems may be corrected by the clinician's revision of initial impressions over the course of several interviews.

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Structured interviews, such as the Structured Clinical Interview for DSM-5(SCID), have been developed to facilitate the collection of standardized information for making diagnostic judgements based on operational criteria. Structured interviews tend to be highly reliable and valid.

Psychological Tests Psychological tests are standardized procedures designed to measure a person's performance on a particular task or to assess his or her personality. Statistical norms are established for tests by analysing the responses of many people; this process is called standardization.

In personality inventories, examinees are asked to give their self-report indicating whether statements assessing habitual tendencies apply to them. The Minnesota Multiphasic Personality Inventory (MMPI) is a well-known test designed to detect psychopathology. In designing the test, items that empirically distinguished between different diagnostic groups were selected from a large number of items suggested by clinicians. The revised MMPI-2 used a broader standardization sample, removed some objectionable items and sexist wording, and added new items The Rorschach Inkblot Test and the Thematic Apperception Test are examples of projective tests, in which a set of standard stimuli, ambiguous enough to allow variation in responses, is presented to the individual. These tests assume that the unstructured stimulus materials will reveal unconscious material about the client's attitudes, motivations, and modes of behaviour (the projective hypothesis). Projective techniques tend to be favoured by psychoanalytically oriented clinicians, and the projective hypothesis may be extended to interpret aspects of client behaviour outside a test situation.

Intelligence tests are a standardized means to assess a person's current cognitive ability. Designed to predict school performance, they are also used in diagnosing intellectual and learning disabilities, identifying strengths and weaknesses for academic planning, identifying intellectually gifted children, and as part of neuropsychological evaluations. On most IQ tests, scores have a mean of 100 and standard deviation of 15 or 16; persons scoring below 70 are "significantly subaverage," while those scoring above 130 are "intellectually gifted." It must be remembered that "intelligence" as measured by the tests is an invention of psychologists, and other factors play an important role in how people will do in school.

Canadian Perspectives 4.3: IQ Testing and Aboriginal Canadians A number of research projects have attempted to ascertain if IQ tests are inherently biased with regard to Canada’s Aboriginal peoples. For example, the Inuit Norming Study found that approximately 75% of Inuit children scored so low on standard verbal IQ tests as to be classified as having an intellectual disability. This study concluded that “using the Wechsler Verbal and Full Scale norms for the WISC-R would result in misclassification of a great number of Inuit children.”

Behavioural and Cognitive Assessment and Case Formulation Cognitive and behavioural clinicians make use of direct observation of behaviour, interviews and self-report inventories. In addition to the personality tests already described, many measures have a situational focus.

They sometimes measure cognitions, including tendencies to think irrationally and to make negative inferences.

Focus on Discovery 3.1 Cognitive-Behavioural Case Formulation This type of formulation or case plan is based on a general cognitive-behavioural theory (e.g., Beck’s cognitive theory of psychological disorders). A key purpose of the formulation is to explain how a client’s problems relate to one another in order to help the therapist select treatment “targets,” since it is usually appropriate to first focus on issues that seem to play a causal role in other problems (e.g., depression causes © Wiley Canada

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marital problems, which contribute to behaviour problems in a child). Five components are usually included in this method; problem list, working hypothesis, strengths and assets, and treatment plan.

Biological Assessment Brain Imaging: "Seeing" the Brain New techniques for viewing the structure and function of the brain have led to advances in our understanding of both medical and mental disorders. Computerized axial tomography, the CAT or CT scan, helps us assess structural brain abnormalities. The CT scan involves a moving beam of X-rays that detects subtle differences in tissue density. Newly developed magnetic response imaging (MRI) produces pictures of higher quality than CT and does not expose the patient to radiation. A functional MRI (fMRI) can detect metabolic changes providing a picture of the brain at work. Positron emission tomography, the PET scan, allows measurement of both brain structure and function through measuring the metabolic rates of different parts of the working brain. The fMRI has been used recently in Canadian studies to demonstrate functional differences in the brains of schizophrenic patients and psychopaths.

Neuropsychological Assessment A neurologist is a physician who specializes in medical disorders that affect the nervous system, whereas a neuropsychologist is a psychologist who studies how dysfunctions of the brain affect the way we think, feel, and behave. Psychologists have developed a number of neuropsychological tests assessing behavioural disturbances that are caused by organic brain dysfunctions. By analyzing a pattern of performance, psychologists can use test batteries like the Halstead-Reitan and Luria-Nebraska to determine whether a person is brain-damaged and help locate the affected area of the brain. Increasingly sophisticated measures have been developed for detecting negative effects of even minor head injuries. However, there is no one-toone relationship between a score on a given neuropsychological test or finding on a PET or CAT scan and psychological dysfunction. The way in which an individual has coped with the brain damage and the support of the social environment also contribute to the clinical picture.

Psychophysiological Measurement The discipline of psychophysiology is concerned with the bodily changes that accompany psychological events or that are associated with a person's psychological characteristics; physiological measures include skin conductance and heart rate.

Several electrical and chemical measurements of the autonomic nervous system are used to study emotion. These include heart rate, graphically depicted in an electrocardiogram, electrodermal responding, tracking of blood pressure in vivo, and the electroencephalogram, or EEG, a graphic recording of the electrical activity of the brain.

A Brief History of Classification Early Efforts at Classification By the nineteenth century the study of abnormal psychology was a fledgling science and, like many sciences of the time, categorization was a starting point. Just like biology and chemistry, this led to a variety of competing systems. Systems were developed in England, France, and the United States.

Development of the WHO and DSM Systems In 1939, the World Health Organization (WHO) added mental disorders to the International List of Causes of Death. The first edition of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric © Wiley Canada

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Association was published in 1952, and the United Kingdom used its own glossary of definitions. Consensus eluded the field until 1988 when the development of the new DSM-IV was begun. This process lead to the publication that is substantially consistent with the current ICD. A major innovation was introduced in the third and subsequent revisions of the DSM, a multiaxial classification system in which each individual is rated on five separate dimensions. Axis I included all diagnostic categories except for the personality disorders, and what was then called “mental retardation” (“intellectual disability” in DSM-5). Both of these diagnoses were reserved for Axis II. This distinction was made so that long-term disturbances would not be overlooked. Axis III was used to indicate any current physical disorders believed to be relevant to the mental disorder. Axis IV coded psychosocial and environmental problems experienced by the patient, and Axis V was used to indicate the patient's level of adaptive functioning. This multiaxial system was removed in DSM-5.

Issues in the Classification of Abnormal Behaviour The Value of Classification and Diagnosis Classification and diagnosis is supposed to advance the science of mental disorders. Ideally, a disorder is first hypothesized to exist. It is then found to be relatively consistent from one individual to another; the etiology is discovered and then specific treatments and preventative measures are designed, tested and applied to the disorder. Bipolar disorder, for example, is now recognized as being distinct from depression, and with this distinction came recognition that lithium is an effective treatment.

Criticisms of Classification Some critics assert that classification per se is irrelevant to the field of abnormal behaviour, because it leads to a loss of information and hence overlooks the uniqueness of the person being studied. While such simplification may be useful depending on the purpose of the classification system, the classified individual may be stigmatized. Assuming that various types of abnormal behaviour do differ from one another, however, it is essential to classify them; the differences may constitute keys to discovering causes and inventing treatments. Furthermore, classification can have negative effects on an individual, in that a diagnostic label could be stigmatizing.

Categorical vs. Dimensional Classification The DSM represents a categorical approach to classification, in that an individual has a disorder or they do not. Some argue that the distinction between normal and abnormal behaviour is a matter of degree or intensity rather than kind. A dimensional classification would allow symptoms to be ranked in a quantitative fashion, either on degree or frequency. Anxiety, depression, and the personality traits associated with personality disorders would seem, in particular, to lend themselves to a dimensional classification system.

Reliability and Validity The two components of reliability are sensitivity (agreement on the presence of a specific diagnosis) and specificity (agreement on the absence of a diagnosis). DSM-5 field trials showed that inter-rater reliability varied depending on the diagnosis. For example, PTSD, autism spectrum disorder, and borderline personality disorder diagnoses had good to very good reliability, whereas the reliability for major depressive disorder and generalized anxiety disorder were in the questionable or unacceptable range.

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Construct validity is the most important type of validity for diagnosis. The greater the number and strength of lawful relationships into which a diagnosis enters (e.g., causes, associated characteristics, predictions about course of the disorder, probable response to treatments), the greater the construct validity.

The DSM and Criticisms of Diagnosis Beginning with DSM-III, an effort was made to improve the reliability and validity of diagnostic categories.

Improvements included more extensive descriptions of characteristics and symptoms of each category, cultural differences in expression of symptoms (see Focus on Discovery 3.2 for DSM-5 ethnic and cultural considerations), and precise diagnostic criteria for each category.

The Diagnostic System of the American Psychiatric Association (DSM-5) Development of the DSM-5 Planning of the DSM-5 began in 1999. One of the major objectives was to improve the reliability and validity of diagnosis. A second objective was to eliminate disparities between the DSM system and the World Health Organisation’s ICD system (scheduled for publication in 2015). Some specific goals were to: update the system based on research development; reduce the number of diagnoses falling into the “otherwise not specified” category; and begin replacing the categorical approach with a dimensional approach.

Currently, there is also an attempt to streamline the DSM-5 to facilitate its use by primary care workers. Because family doctors are usually the first and often the only point of contact for people needing psychological help, the American Psychiatric Association is preparing the DSM-PC (primary care) scheduled to appear in 2015.

Overview of Changes in the DSM-5 A distinction can be made between proposed changes to the DSM-5 and adopted changes. For example, a number of proposals for change were considered for ADHD. The actual changes were largely based on research and included the removal of exclusion criteria and sub-types; the age required of children was moved from 7 to 12 and the threshold criterion in adults was reduced to five symptoms rather than six.

Because the scientific evidence supports the distinction between Inattention and Hyperactivity these two symptom clusters were retained. On the other hand, although many thought that Internet Addiction Disorder should be in DSM-5, it was ultimately not included (see Student Perspectives 3.1).

Changes to the DSM were accompanied by considerable controversy. With the advent of Internet and blogs both the general public and experts were able to advance opinions concerning the proposed changes – opinions were often quite divergent.

Controversial Changes in DSM-5 There are five example of controversy generated by changes to the DSM-5. The first is the creation of the autism spectrum disorder that combined several disorders and eliminated Asperger’s syndrome (a less severe form of autism). A second was the introduction of a new disorder among children, the disruptive mood dysregulation disorder (DMDD is characterized by severe and frequent temper tantrums disproportional to the situation). The introduction of DMDD as a diagnostic category is also an example of the contribution of research to the development of the DSM. A third controversy was created by the elimination of the bereavement exclusion from the diagnosis criteria of major depressive disorder. The last © Wiley Canada

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minute decision to retain the categorical approach in the diagnosis of personality disorders generated considerable discussion; the approach to personality disorders was included in Section III, of the DSM, Emerging measures and models. A fifth controversial issue was the relegation of the diagnosis non-suicidal self-injury to Section III, Conditions for further study (see Student Perspectives 3.2) In addition to these specific controversies, DSM-IV Chair Allen Frances has been quite vocal in his criticism of DSM-5. In particular, Frances is concerned that DSM pathologizes normal behaviour. For example, Frances is concerned that the increasing number of children being diagnosed with autism is a function of over diagnosis as opposed to any real increase in the prevalence of autism.

STUDENTS SHOULD KNOW Key Points Key Points

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1.

Assessment tools are used to describe patients, search for causes of their disturbance, and design preventive or remedial treatments. Such methods invariably reflect the paradigm of the investigator.

2.

Whatever the mode of assessment used, measures must be evaluated for their reliability and validity.

3.

Psychological assessment measures include structured or unstructured clinical interviews; these assessment methods are widely used, but may be strongly influenced by situational factors.

4.

Psychological tests range from structured self-report personality inventories such as the MMPI-2 to presentation of ambiguous stimuli such as the Rorschach Inkblot Test.

5.

Intelligence tests are used to help identify intellectual disabilities, learning disabilities, and giftedness, as well as predict progress in school and aid in academic placement and planning. They are also used in neuropsychological assessments.

6.

Behavioural and cognitive assessments focus on situational specificity, organismic variables, responses of the individual, and consequences of the behaviour. Approaches include direct observation of behaviour, interviews and self-report measures, and specialized cognitive measures that attempt to uncover beliefs, attitudes, and thinking patterns.

7.

Biological assessment approaches include imaging techniques that examine the structures and functions of the living brain, neurochemical assays, neuropsychological tests, and psychophysiological measurements.

8.

Cultural factors among Aboriginal peoples affect responses of clients to assessment techniques as well as clinician biases in interpreting results.

9.

The recent editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) are quite different from earlier classification systems, and their multiaxial structure was perhaps the most distinctive innovation The DSM-5, however, has eliminated the multiaxial system of diagnosis.

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10.

Some critics object to the concept of classifying abnormal behaviour, raising issues of losing information, overlooking individual uniqueness, and creating social stigmatization.

11.

Other critics see value in classifying abnormal behaviour, but question the categorical classification system and the reliability and validity of past and current classification systems. Many researchers and clinicians are suggesting the use of a dimensional system in place of the current categorical system.

12.

The new editions of the DSM are more reliable than their predecessors because they contain specific diagnostic criteria, but validity remains less well established.

13.

The DSM is constantly under revision and will likely incorporate significant changes in the future, including a more expanded form of dimensional classification.

Key Terms alternate-form reliability (p. 72) Asperger’s syndrome (p. 103) case validity (p. 72) categorical classification (p. 97) clinical interview (p. 74) cognitive-behavioural case formulation (p. 83) comorbidity (p. 103) construct validity (p. 73) content validity (p. 72) criterion validity (p. 73) CT scan (p. 86) cultural bias (p. 81) Cultural Formulation Interview (CFI) (p. 100) Diagnostic and Statistical Manual of Mental Disorders (DSM) (p. 93) dimensional classification (p. 97) disruptive mood dysregulation disorder (DMDD) (p. 103) DSM-5 (p. 93) DSM-5 V codes (p. 101) DSM-IV (p. 95) DSM-IV-TR (p. 95) electrocardiogram (p. 91) electrodermal responding (p. 91) electroencephalogram (EEG) (p. 91) epidemiology (p. 103) evidence-based assessment (p. 76) faking bad (p. 79)

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functional magnetic resonance imaging (fMRI) (p. 86) intelligence test (p. 80) inter-rater reliability (p. 72) internal consistency reliability (p. 72) kappa (p. 99) lifetime prevalence (p. 103) magnetic resonance imaging (MRI) (p. 86) mental disorder (p. 95) Minnesota Multiphasic Personality Inventory (MMPI) (p. 76) multiaxial classification (p. 95) neurologist (p/ 88) neuropsychological tests (p. 89) neuropsychologist (p. 88) Outline for Cultural Formulation (p. 100) personality inventory (p. 76) PET scan (p. 87) prevalence (p. 103) projective hypothesis (p. 79) projective test (p. 79) psychological tests (p. 76) psychophysiology (p. 91) race norms (p. 81) reliability (p. 72) Rorschach Ink Blot Test (p. 79) sensitivity (p. 98) specificity (p. 98) standardization (p. 76) Ch3, pg.7

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stereotype threat (p. 81) structured interview (p. 74) test norms (p. 76)

test–retest reliability (p. 72) Thematic Apperception Test (TAT) (p. 79)

New Names Aleksandr Luria, Hermann Rorschach, Alfred Binet, American Psychiatric Association, and World Health Organization

LECTURE LAUNCHERS 1. The History of the Inkblot: An Illustration of Changing Paradigms The history of the Rorschach Inkblot Test provides an excellent illustration of the influence of paradigms on assessment approaches and the changes occurring in paradigms in the United States over the last 50 years.

Exner (1995, The Rorschach: A Comprehensive System, Volume I. New York: John Wiley & Sons) reviews changes in the scoring and interpretation of the test since its early development, revealing influences of the psychoanalytic, behavioural, and cognitive paradigms: Original Rorschach: When Hermann Rorschach began studying the inkblot test in the 1920s, he used empirical methods to develop the test as a diagnostic tool. He was particularly interested in determining how the responses of schizophrenics differed from those of non-schizophrenics.

Psychoanalytic Paradigm Influences: After Rorschach's untimely death at the age of 37, numerous clinicians became interested in the inkblot test. In the United States, the strong influence of psychoanalytic theory in the 1930s and 40s led to the practice of interpreting Rorschach responses for their symbolic content, and the "projective hypothesis" was born.

Behavioural Paradigm Influences: In the 1950s, as behaviourism became influential in the United States, strong criticism was made of the weak psychometric properties of the Rorschach and its inability to predict behaviour. The Rorschach test fell into disfavour in academic circles, although many clinicians continued to use it in their work.

Cognitive Paradigm Influences: Most recently, the cognitive paradigm, gaining prominence in the 1970s and 80s, has led to a view of the Rorschach as a cognitive-perceptual problem-solving task, rather than a stimulus to fantasy. Exner developed the "Comprehensive System," widely taught in training programs today, which bases its scoring and interpretation on empirical data about the responses of different clinical groups (coming full circle, in fact, to Rorschach's original work). The current system includes standardized administration and scoring methods and extensive normative data for use in interpretation. In spite of Exner's work, many academic psychologists continue to challenge the use of the Rorschach, particularly when used for forensic purposes.

For more information on the Rorschach see "Does Popularity Imply Utility?" in Discussion Stimulators.

2. Integrated Assessment in Clinical Practice Students will likely be interested in learning about how the several assessment approaches described in the text are integrated in clinical practice. The following steps may be outlined in class to give an overview of the clinical use of assessment.

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(1) Referral Question(s). A good assessment begins with a carefully formulated referral question. Possible goals might be to diagnose a client, to recommend appropriate placement, to aid in treatment planning, or to provide baseline data at the beginning of a planned intervention.

(2) Data Collection. The collection of information often begins with meeting with the referral source and examining the client's file (if available) for relevant historical information, cultural background, and results of previous testing. In addition to an interview with the client, "significant others" such as teachers, parents, or individual therapists are often contacted to obtain additional information. Finally, test materials are used to collect standardized data for comparison with normative groups. This step may include personality testing, intelligence testing, neuropsychological evaluation, behavioural assessment, or, most often, some combination of approaches.

(3) Interpretation and Integration of Data. Keeping the referral question in mind, the hypothetico-deductive method may be used to generate hypotheses about the client and use the test data collected to look for evidence for and against the hypotheses. More information may need to be gathered to clarify conflicting information.

(4) Recommendations. The assessment culminates in practical suggestions related to the referral question.

Usually, a summary of the test results and recommendations is offered to the referral source, the client, and, if indicated, significant others such as teachers and parents. Feedback sessions are held to share test results and recommendations.

3. The Barnum Effect P. T. Barnum created circuses that had "a little something for everybody." He also declared "there is a sucker born every minute." Both of these quotes likely played a role in Paul Meehl's honouring Barnum in naming a psychological phenomenon for him. The "Barnum effect" refers to the tendency for people to accept vague and generally applicable personality descriptions as being characteristic of them personally; thus the popularity of horoscopes, handwriting analysis, and the like. Rather than recognizing that interpretations or predictions such as those found in the horoscope column could apply to most anyone, people tend to view these brief paragraphs as characterising them in particular (See the section, ‘Discussion Stimulators’ for an exercise demonstrating the Barnum effect).

4. The Assessment of Anxiety: In Pursuit of an Elusive Construct

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HANDOUT Many issues in assessment can be appreciated by considering efforts to measure anxiety - one of the most prevalent emotions and one of great interest to psychopathologists and therapists. They have generally relied on three modes of measurement: self-report questionnaires, observations of overt behaviour, and physiological measurements.

Allowing people to describe the phenomena of their emotions in their own terms, as in clinical interviews, provides useful information about the one individual interviewed; but this strategy alone makes it difficult to compare the experiences of a number of people and, even more important, to quantify what they say. Researchers have therefore devised various self-report questionnaires that attempt to direct the individual's impressions into standardized terms.

A second means of assessing anxiety is to observe overt behaviour for reactions and movements that are believed to reflect the internal emotional state-trembling, perspiring, nail biting, fleeing from a situation.

For example, observers trained to administer Paul's (1966) Timed Behavioural Checklist for Performance Anxiety time-sampled the overt behaviour of subjects in a structured situation, recording instances of twenty indexes of anxiety whenever they were observed.

Physiological measurements of activities of the autonomic nervous system and the output of certain endocrine glands also indicate levels of anxiety. The availability of these measurements has encouraged researchers to define anxiety in physiological terms. The situation in which physiological measurements are taken is very important, however. What would be revealed, for example, if recording electrodes were attached to a woman who is about to become very angry? Both before and during a period of anger the heartbeat is very likely to be faster, blood pressure higher, perspiration greater, and breathing more rapid, all physiological responses that are generally regarded as indicators of anger as well as of anxiety. But why would we not conclude that our subject is, indeed, anxious as she is confronted by an anger producing stimulus? Many people are debilitated by fear in social situations. How can an investigator distinguish rapid breathing that reflects anger from rapid breathing that reflects anxiety? Part of the answer necessarily lies in observations made concurrently. If at the time physiological measures are taken the angry subject convincingly reports that she is very disturbed by a particular situation and is anticipating an unpleasant confrontation, we would almost certainly choose to interpret her rapid breathing and other physiological responses as indicating anger. The situation and self-report of it must be taken into consideration.

Not only are the physiological indicators of anxiety evident in other emotional states, but also the many measures of anxiety have been found time and again not to correlate well with one another (see Martin, 1961; Lang, 1969). In a stressful situation such as being threatened with painful electric shock, many people report being very nervous, but their heart rates may be lower rather than elevated. An individual taking an important examination for which he or she is ill prepared may deny feeling anxious and yet be observed trembling. Moreover, if people are asked to report on their awareness of various symptoms of anxiety, such as a feeling of tightness in the neck, avoidance of social gatherings, and worrying, their selfreports tend to cluster into one of three fairly independent groups-somatic, behavioural, and cognitive (Lehrer & Woolfolk, 1982). Thus the anxiety reported by people appears to be made up of one of three relatively separate components. One person may have bodily indicators, such as muscle tension and acid stomach, and yet not experience cognitive signs, such as ruminating about an alarming event. As a scientific construct, anxiety must be tied to observables, the conditions that produce it and the effects that follow its induction.

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5. On Being Sane in Insane Places D. L. Rosenhan (1973, Science, 1979, 250-258) conducted one of the best-known and most controversial studies about the ability of mental health professionals to define abnormality. Rosenhan had several individuals who showed no signs of any emotional problems try to get themselves admitted to mental hospitals. These normal "pseudo-patients" acted like themselves during their screening interviews and simply reported on the events that had occurred in their lives. There were two ways in which they acted atypically, however. First, they contacted and asked to be admitted to a psychiatric ward, something that most people who consider themselves to be well adjusted do quite rarely. Second, when asked by the admitting psychiatrist to describe their problems, the pseudo-patients claimed that they were hearing voices that said "empty," "hollow," or "thud." Such a complaint is not a symptom of any known mental disorder.

In every instance in which they tried, the pseudo-patients got themselves admitted to the mental hospital, and in eleven out of twelve cases they were diagnosed as suffering from schizophrenia. Even more surprising, although they immediately stopped complaining of their "symptom" following admission, none of the pseudo-patients was suspected of being a fake by the hospital staff. (Several fellow patients harboured these suspicions, however.) In fact, the behaviour of the pseudo-patients while they were "patients" on the psychiatric ward, as well as their accounts of their life experience, were often interpreted by the ward staff as being consistent with their "mental disorder."

Rosenhan has argued that the results of his study indicate that sanity and insanity cannot be distinguished, and he suggests that when mental health professionals make such distinctions, they do so on the basis of pre-existing expectations. He asserts that the label that is given to a person is very sticky and sets up a self-fulfilling prophecy.

Rosenhan's criticisms suggest that we should not attempt to classify mental disorder, but whether or not his study suggests this conclusion is a matter of considerable debate. (See replies to the study, 1973, Science, 180, 1116-1122.) If I prove that it is possible to fool a physician into falsely believing that I am suffering from a physical disease, does that mean that physical illness does not exist? Did the pseudopatients really behave normally? Wouldn't the normal thing to do be to never try to get admitted to a mental hospital or to try to get out immediately upon admission?

While flawed in many respects, this interesting study illustrates many important points: the question of whether we should attempt to classify mental disorder, issues about the reliability and validity of the diagnoses used at the time of the study, concern about the ill-effects of labelling, and evidence regarding the treatment of patients on a psychiatric ward. Not only are these broad and important issues, but also the study can be used to illustrate limitations in research design and interpretation of findings.

6. Symptom, Syndrome, Disorder, Disease In medical taxonomies, the terms symptom, syndrome, disorder, and disease are carefully defined concepts that imply knowledge at increasingly higher order levels of analysis. Understanding the definitions and implications of these terms is important to students in its own right, and this should aid in their understanding of the DSM-5 and the implications of the manual. Numerous discussions of these terms can be found. Alan Kazdin (1983, Behavior Therapy, 14, 73-99) wrote a particularly clear and useful exposition of these levels of classification and their implications for child behaviour therapy.

A symptom refers to an observable behaviour or state. When the term is used, there is no implication that an underlying problem necessarily exists or that there is a physical etiology. Rather, a symptom is the simplest level of analysing a presenting problem. Depressed affect is a symptom; a sore throat is a symptom too.

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A syndrome is the next higher level of analysis, and this term is applied to a constellation of symptoms that occur together or co-vary over time. Again the term carries no direct implications in terms of underlying pathology. Whether, in fact, certain sets of symptoms co-vary with one another is an empirical question.

A disorder, like a syndrome, refers to a cluster of symptoms, but the concept includes the idea that the set of symptoms is not accounted for by a more pervasive condition. For example, a depressed mood, vegetative symptoms, and a sense of helplessness may be a syndrome that could be subsumed under some specific disorder. Bipolar illness, on the other hand, appears to be independent of other problems and is not readily accounted for by another problem. It is therefore appropriately thought of as a disorder. So is the common cold, whereas a sore throat, running nose, and a headache are a syndrome. As with symptom and syndrome, there is no implication of etiology associated with the term disorder.

A disease is a disorder where the underlying etiology is known. It is the highest level of conceptual understanding. A cold is not a disease as its etiology is unknown. Bipolar illness is not a disease either. Strep throat is a disease, as are some of the organic mental disorders. For the most part, however, the categories of emotional problems listed in DSM-IV are appropriately thought of as being syndromes and disorders.

7. Alternative Purposes for Diagnostic Decision-Making "What's the use of their having names," the Gnat said, "If they won't answer to them?" "No use to them," said Alice, "but it's useful to the people that name them, I suppose." (Lewis Carroll, Through the Looking Glass.)

So begins Kirk and Kutchins' The Selling of DSM: The Rhetoric of Science in Psychiatry (1992, NY: Walter de Gruyter, Inc.). This fascinating account of the political and social implications of the revisions of "the new bible" (DSM) includes a provocative discussion of uses for diagnosis other than the traditional ones such as planning treatment, discussed at more length in the textbook (see pp. 228-238 in Kirk & Kutchins).

Considering that clinicians using the DSM have considerable discretion in deciding on a particular diagnosis, the following purposes for diagnostic decisions may apply: (1) Regulating Client Flow. For example, in diagnosing potential clients, an agency offering a "mood disorders clinic" may liberalize their interpretation of the criteria for Major Depression when they need more clients, and narrow their criteria when caseloads are full. The subjective judgement required to make decisions such as whether a client has "diminished interest in all activities" or "psychomotor agitation" makes such variations in diagnostic practice easy to accomplish.

(2) Protecting Clients from Harm. As discussed in the textbook, concerns about stigmatization are handled by many clinicians and agencies by choosing the least harmful label to apply to a client, even at the expense of accurate clinical decision-making. The present author was told at a training placement: "Don't 'give' that child a Conduct Disorder—she's only 9 years old!" I quickly learned that Adjustment Disorder was the only acceptable diagnosis for children being seen at the agency.

(3) Acquiring Fiscal Resources. Studies have indicated that clinicians frequently misdiagnose (generally over diagnose) in order to help their clients receive insurance reimbursement for services. For example, imagine a couple being seen for marital therapy, in which neither partner actually evidences psychopathology. In order for the therapy to be covered by insurance, someone must have an illness. Voila! The wife now has "Major Depression."

(4) Rationalizing Decision-Making. "If it was pounded by a hammer, it must have been a nail" (p. 235).

The authors note that diagnoses may be used to justify treatments that have already been applied; for

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example, a psychiatrist may prescribe several medications until one works, and then base the diagnosis on that successful treatment—e.g. if lithium works, the patient has bipolar disorder.

(5) Advancing a Political Agenda. Political realities frequently shape decisions about what diagnoses are included in the DSM. Homosexuality was dropped as a diagnosis after years of heat from gay activists; post-traumatic stress disorder was created under pressure from Vietnam veterans.

Extensive lists of mental disorders help the mental health profession to gain legitimacy, fund programs, and allocate research money, as more and more problems come under the purview of mental health.

DISCUSSION STIMULATORS Rorschach Demonstration Most students are interested in seeing Rorschach cards and trying their hand at answering and interpreting them. A demonstration might accompany a lecture on the influence of paradigms on Rorschach interpretation. Show several examples of inkblots similar to the Rorschach stimuli to the class, ask them, "What might this be?" and have students write down their associations. (Brave students might volunteer to have their responses written on the board, but have them wait until others have had a chance to respond in writing.) This exercise alone exposes students to the discomfort of responding to an ambiguous stimulus, as many will ask for more structure (Can I look at the card upside down? Can I give more than one answer?

Am I supposed to use the whole thing? How did they make these?).

As in standard Rorschach administration, follow with an inquiry: "What makes it look like that to you?" and again have students write down their explanations.

In conjunction with the lecture above, students' answers could be used to illustrate the psychodynamic, stimulus to fantasy approach (try offering wild symbolic interpretations) as compared to Exner's perceptual-cognitive approach. You might explain how some of the structural elements are scored, such as Human Movement, Form Quality, Use of Colour, and Location of the response, and what they mean about a person's structuring of experience.

Does Popularity Imply Utility?

Projective tests continue to maintain their popularity with clinicians despite recent challenges from academicians. The Rorschach is the most widely used of the projective instruments with the Exner Comprehensive System the most common scoring method. Interestingly, scientifically oriented graduate programs in clinical psychology continue to teach the Rorschach because of its popularity in the practice community. What do students think accounts for this apparent contradiction? Should future clinicians be taught what the community expects or should training be limited to those practices that have strong empirical support?

Practice in Integrating Assessment Approaches To expose students to the use of assessment procedures in clinical practice, you might present a case from your own practice, or refer to the case of Ernest H. described in Chapter 1 of the text. Students could be asked to formulate a referral question for the case and choose appropriate measures for collecting data relevant to the referral question. This might best be done in small groups, with the class reconvening to discuss their suggestions.

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Demonstrating the "Barnum Effect" To familiarize students with the "Barnum effect" and illustrate the form of personality inventories, give students a "personality test" (you could invent an MMPI-like test, or lift one from Cosmopolitan Magazine, introducing them as real tests). In the next class meeting, tell them you have scored their tests and have feedback for them. Hand out two forms of feedback (one form to each student) such that half the class receives negative feedback, and half receives positive feedback. Ask the students whether or not they agree with the feedback. By keeping track of which type of feedback they received, you should be able to demonstrate that people accept positive feedback as accurate (along with other "Barnum effect" findings).

Be sure to fully debrief students after the demonstration. The debriefing should also provide fuel for a discussion of the impact of psychological test results on people's self-perceptions and self-esteem.

Vocational Interest Test For an alternative way to expose students to personality inventories, you could try giving them a vocational interest test. Like the MMPI, most of these inventories have been validated using a contrasted groups criterion. Students who find that the inventory tells them they want to be a psychologist, for example, have answered questions in a manner similar to the way psychologists answer. The student counselling centre at many colleges and universities will give these tests for free, or perhaps you could arrange for a group administration in class. Also, note that Pozzebon, Visser, Ashton, Lee, and Goldberg (2010; Journal of Personality Assessment, 92, 168-174) provide a public-domain vocational interest inventory. The Oregon Vocational Interest Scales evaluate your students’ interest in eight vocational domains: leadership, organization, altruism, creativity, analysis, producing, adventuring, and erudition.

Self-Monitoring Exercise Self-monitoring is an interesting and easily used assessment technique which students can try themselves.

You could photocopy the attached materials and pass them out in the class before the session on assessment.

In class, after the students have tried self-monitoring for a week, discuss their experiences. What was it like to monitor themselves? How faithfully did they keep records? Did they experience reactance?

What are some advantages and disadvantages of self-monitoring as an assessment tool? How might students use the data they collected to change their behaviour? More complicated records, such as (for someone trying to eat less) where food is eaten, with whom, and at what time, might help in developing a behaviourchange plan.

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HANDOUT Self-Monitoring Exercise INSTRUCTIONS: 1. Select one of your own behaviours that you find troublesome or undesirable (Examples: biting your fingernails, smoking, eating between meals, swearing in front of your grandmother, etc.).

A. Choose a behaviour that occurs relatively frequently.

B. Choose a behaviour that you have tried to change in the past or would like to change.

2. Starting tomorrow, record the frequency of your target behaviour every day for one week on the form provided.

3. Before class, graph the frequency of your target behaviour on the grid provided.

4. Bring your self-monitoring records to class for discussion.

SELF-MONITORING RECORD TARGET BEHAVIOUR: ___________________________________________ ESTIMATED FREQUENCY OF BEHAVIOUR BEFORE MONITORING: ____________ UNIT OF MEASUREMENT (e.g. number of cigarettes, hours of T.V., etc.): __________ FREQUENCY OF TARGET BEHAVIOUR (Mark each time behaviour occurs): _________

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 GRAPH (on a separate page, plot a graph of the frequency of behaviour for each day of the week, using your own units on the frequency axis)

On Being Sane in Insane Places

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Rosenhan's article, "On being sane in insane places," is engaging for students to read and can be counted on to provide material for classroom discussion (1973, Science, 179, 250-258). Replies to the article are also particularly valuable to assign, as they present a wide variety of viewpoints on the study (1973, Science, 180, 1116-1122). A few questions should be sufficient to sustain discussion on this controversial piece of research, such as: Was Rosenhan setting up the psychiatrists? Is insanity in the eye of the beholder? What are the effects of the label "insane?" Can medicine detect liars?

DSM and the Case of Homosexuality In the DSM-III homosexuality was a diagnostic category. It was removed, through the voting procedure that determines what diagnoses will appear in the DSM. This was, and is, a controversial decision. For some arguments for and against this decision see: http://psychology.ucdavis.edu/faculty_sites/rainbow/html/facts_mental_health.html Students could be asked to summarize arguments both for and against the inclusion of various diagnostic categories in the DSM (e.g., gender dysphoria). They could also be asked to consider what types of diagnoses may be removed, or attempts made to remove, in the future for what reasons. To what extent are political and scientific interests at odds in this debate and which should hold sway in the DSM?

Developing Diagnostic Criteria To help students understand the task faced by the committee to revise the DSM, try presenting them with the diagnostic criteria for one of the disorders in DSM-I or DSM-II. For example, the criteria for obsessive compulsive reaction (DSM-I) and neurosis (DSM-II). Students could be divided into groups and asked to come up with better operational definitions of the criteria listed. Following an attempt at group consensus in this exercise, give the students the DSM-IV criteria for the same disorder; this will give them an opportunity to see how diagnostic classification has changed and to compare their attempts to those of the "experts."

Controversial Diagnoses Discussing several of the tentative diagnoses included in an appendix of DSM-5 is likely to generate lively controversy, as it did when the committee to revise the DSM-IV considered including them in the body of the manual. For example, Student Perspectives 3.1 in the text describes Internet Addiction Disorder, a category that was not included in DSM-5. Two disorders suggested for DSM-IIIR and no longer on the list to be considered are self-defeating personality disorder and sadistic personality disorder; those disorders have been criticized as blaming abused women for their suffering (they are mentally ill for staying in the relationship) and then giving a legally acceptable mental defence—sadistic personality disorder—to their abusers. Other controversial diagnoses to discuss might include homosexuality (included as ego-dystonic homosexuality in DSM-III and then dropped altogether in DSM-IIIR and -IV and learning disabilities (are these mental disorders?).

Reliability and Chance Agreement The concept of accounting for chance agreement in evaluating reliability is an important idea to convey to students. Ask them this: Two psychiatrists are engaged in a study of the reliability of the diagnosis of schizophrenia. They are only making the diagnosis of schizophrenic or not schizophrenic, and each psychiatrist assigns the diagnosis of schizophrenic to 10% of the cases she sees. After seeing 1000 cases the psychiatrists discover that they agreed on the diagnosis in 82% of the cases. Is this reasonable reliability? On © Wiley Canada

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the surface it doesn't sound too bad, but in reality the two diagnosticians would be agreeing at a purely chance level. (Given the base rates, this is exactly chance—draw a Chi-square contingency table on the board for the students.) You can go on to discuss different statistical measures of reliability (e.g. Kappa coefficient) or simply make the point that students should have a general idea of random joint probabilities when evaluating reliability statistics.

Confirmatory Bias in Clinical Decision Making Confirmatory bias can be problematic in clinical decision making. This bias occurs when the clinician pays particular attention to data that supports his or her beliefs while discounting or ignoring contradictory information. Biases can result from a number of factors including treatment setting, patient characteristics (i.e., race or socioeconomic status), or the clinician's personal experiences and training. Smith and Dumont (1995) spoke to this problem in their examination of the Draw-A-Person test: "It would seem that therapists tend to find in projectives that they use whatever they are already disposed to find..." How might these factors prejudice a clinician's judgement? What safeguards might result in more valid assessment? Students could be asked to contribute examples of confirmatory bias in their own lives.

Smith, D. & Dumont, F. (1995). “A cautionary study: The unwarranted interpretations of the Draw-APerson Test” Professional Psychology: Research and Practice, 26, 298-303.

Improving Clinical Judgement A useful and well-written article, "Representative thinking in clinical judgement" (1986, Dawes, R. M., Clinical Psychology Review, 6, 425-441), demonstrates to the reader the common fallacy of basing clinical judgements (particularly probability estimates) on the degree to which characteristics are representative of our cognitive schemas while ignoring the rules of probability theory. For example, hand out the following question, and have students write down their answer and the reasoning behind it before discussing the problem: Linda is 31 years old, single, outspoken, and very bright. She majored in philosophy. As a student, she was deeply concerned about issues of discrimination and social justice, and also participated in antinuclear demonstrations. Which is a more likely description of Linda's current life?

1) Linda is a bank teller.

2) Linda is a bank teller and active in the feminist movement. (from Tversky, A. and Kahneman, D., 1983, Psychological Bulletin, 90, 293-315.)

Most students will answer (2), because their "schema" of Linda is compatible with "feminist" but incompatible with "bank teller." Point out to them that it is never more likely for two possibilities to be true than for one of them to be true. While we might expect that experts making judgements in their field would be unlikely to make these kinds of logical errors, Tversky and Kahneman found that 91% of medical experts thought it would be more likely that a woman with a blood clot in the lung would have both shortness of breath (an associated symptom) and partial paralysis (an unassociated one) than partial paralysis alone.

Both the Dawes article and another by Arkes (1981, Journal of Consulting and Clinical Psychology, 49, 323-330) conclude with suggestions for minimising errors in clinical judgements. Students might

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discuss and practice such ideas as considering alternatives to one's hypothesis, considering base rate information, and decreasing reliance on memory, using more examples selected from the articles.

SOME IDEAS FOR UTILIZING THE INTERNET “Seeing” the Brain Several websites have excellent images of normal and diseased brains. Two such sites are: www.cbc.ca/news2/interactives/brain www.med.harvard.edu/aanlib/home.html Also, Medline Plus offers a website with the opportunity to see images associated with numerous disorders: www.nlm.nih.gov/medlineplus/ency/encyclopedia_B.htm Have students scroll down to the following categories: • • • • • • • • • • • •

Brain abscess Brain bleeding see Hemorrhagic stroke Brain hemorrhage see Hemorrhagic stroke Brain herniation Brain injury see Head injury Brain lymphoma see Primary lymphoma of the brain Brain surgery Brain tumor - metastatic see Metastatic brain tumor Brain tumor - primary see Primary brain tumor Brain tumor - secondary see Metastatic brain tumor Brain wave test see EEG Brainstem glioma see Posterior fossa tumor

Here they can find information about brain imaging procedures and images of brains with several disorders, some in the form of illustrations, some autopsied brains, some scans.

Psychological Tests for Student Use Ron Okada of York University has provided a number of short, paper and pencil tests that may downloaded. www.yorku.ca/rokada/psyctest/ You could devise an assignment that had students download a test for use between two comparison groups or in the manner of public opinion survey. If you are using an online learning environment, you could easily program one or more of these tests into the testing program as a "survey" and have a class of students fill them in anonymously and then do some statistical work with them. By the way, an excellent online statistics site that not only allows for easy data entry and the calculation of many different types of statistics, but also explains them and provides the calculations for each step, is found at

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http://vassarstats.net/

Mental Status Exam A summary of the items used on the “Mini Mental Status Exam” can be found here: www.fpnotebook.com/Neuro/Exam/MnMntlStExm.htm Students can be asked to give this exam to one or two other students. While it is unlikely that any college student will miss any of the items it is interesting to see the types of items that are used and that are missed by someone with a variety of neurological disorders. Unlike other exams there is no problem in revealing these items because they are so simple and obvious. If you have no deficit they are very easy, whereas if you have certain neurological deficits they are next to impossible whether you know what they are or not.

An alternate site and broader exam can be found there: www.psychpage.com/learning/library/assess/mse.htm

Statistics Canada: Mental Health Survey Canadian Community Health Survey Mental Health and Well-being, Statistics Canada www.statcan.gc.ca/daily-quotidien/130918/dq130918a-eng.htm This site provides free data tables and general information on the Mental Health and Well-being component of the Canadian Community Health Survey (CCHS).

The survey was conducted in 2012 with approximately 25,100 respondents 15 years of age and older living in Canadian provinces. It provides information on: • • •

the health status of the population including physical, mental and social well-being; access to, and the need for, mental health care services such as visits to the doctor, admissions to hospitals, and the use of medications the factors that influence mental health such as work and lifestyle.

Looking around this site will give you a pretty good idea of how frequently various conditions are diagnosed in Canada. An exercise for students could be to report on various aspects of the data contained in this report.

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CHAPTER 4 Research Methods in the Study of Abnormal Behaviour

CHAPTER SYNOPSIS Science and Scientific Methods Science, as currently practiced, is the pursuit of systematized knowledge through observation. Scientific propositions must be amenable to systematic testing that could show them to be wrong. In addition, scientific observations must be reliable—they must occur repeatedly under prescribed conditions.

A theory is a set of propositions meant to explain a class of phenomena; a primary goal of science is to test the adequacy of theories. Theories themselves guide research by permitting generation of hypotheses that are tested in research. Inferred from observational data, theories go beyond what can actually be seen or measured. In this way they may bridge spatiotemporal relations, or summarize already observed relationships. Theoretical concepts are best defined by sets of operations, rather than a single one.

Case Study, Qualitative, and Epidemiological Research Methods The Case Study In developing a case study, the clinician collects historical and biographical information on a single individual or situation (see Brief Case Example for “the three faces of Eve,” a description of a woman with dissociative identity disorder). While they may lack control and objectivity, case studies have played an important role in the study of abnormal behaviour. They have been used (1) to describe rare or important phenomena; (2) to disconfirm allegedly universal aspects of theories; (3) to generate hypotheses; and (4) as tools in psychotherapy training. The case history fares less well in providing evidence in favour of a theory, as the means for ruling out alternative hypotheses are usually absent. The case study is useful in clinical settings with individuals, but it is not helpful for illuminating universal laws or cause-effect relationships.

Qualitative Research As with the case study, the focus is on studying a small group of people in depth. Although qualitative research is subject to some of the criticisms of the case study, this method can be effective in identifying common themes that can help to understand a particular group.

Epidemiological Research Epidemiology is the study of the frequency and distribution of a disorder in a population; data are gathered about the rates of disorder and its possible correlates in a large sample or population. Prevalence refers to the proportion of the population that has the disorder at a given point in time; incidence is the number of new cases of a disorder that occur in some period; and a risk factor is a condition that, if present, increases the likelihood of developing the disorder. Lifetime prevalence rates refer to the proportion of a sample that had ever experienced a disorder up to the time of an interview.

Epidemiological research is important for documenting the rates of various disorders and contributes to

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understanding the causes of illness. As an example of epidemiological research, the role of abuse in the etiology of mental disorders in Canada is explored.

Canadian Perspectives 5.1 Early Risk Factors and Psychological Disorders in a Canadian Setting The 1990 Ontario Mental Health Supplement study examined the relation between early risk factors and mental health problems. A parent with a mental disorder and severe abuse were found to be the two most significant variables that correlate with later mental health problems.

The Correlational Method The correlational method establishes whether there is a relationship between or among two or more variables as they exist in nature. The correlation coefficient (r) has values from -1.00 to +1.00 and reflects both the magnitude and direction of a relationship. The statistical significance of correlation coefficients must be evaluated to determine the likelihood that the obtained relationship happened by chance. In psychological research, a correlation is typically considered statistically significant if the likelihood that it is a chance finding is 5 or less in 100.

While correlational studies are often performed in laboratories, they are not experiments; classificatory variables like diagnosis are naturally occurring and cannot be manipulated by the researcher. The correlational method does not allow us to determine cause-effect relationships because of two major problems of interpretation: directionality and third variables. The directionality problem refers to the fact that we do not know which of two correlated variables caused the other. Longitudinal designs in which the hypothesized "cause" is measured before the "effect" help avoid this problem. The “high-risk method” means that only individuals with a greater than average risk of developing a disorder of interest are included in the longitudinal research sample.

While correlation does not imply causation, causation does imply correlation. As for the thirdvariable problem, it may be that neither of the two variables studied in the correlation produces the other; rather, some unspecified variable may be responsible for the correlation. An important trend in clinical research has been the study of developmental trajectories (levels of a behaviour over time) and groupbased trajectory models (distinguishing groups with different patterns of a behaviour over time).

The Experiment The experiment is considered the most powerful tool for determining causal relationships between events.

The experimenter typically begins with an experimental hypothesis and chooses an independent variable that can be manipulated by the experimenter. The dependent variable is expected to vary with manipulations of the independent variable. When variations in the independent variable lead to differences between groups, an experimental effect has been produced.

At least one control group is included in an experiment to secure internal validity. The control group does not receive the experimental treatment, and serves to rule out confounds—variables other than the independent variable that can influence the dependent variable. Random assignment of subjects to groups is used to minimize pre-treatment differences between groups.

Because of the importance of the placebo effect, psychotherapy research often uses placebo control groups where patients have regular contact with therapists but do not receive the active ingredient of the therapy being studied. Even with both a control group and random assignment, the potential biasing influence of the experimenter may still make the results of the experiment invalid. To avoid bias, many studies use double-blind procedures in which both the subject and the person administering the treatment are unaware of what the treatment is. Finally, the extent to which the results of a particular piece of research can be generalized beyond the immediate experiment is a measure of their external validity.

Practical and ethical issues prohibit the use of the experiment as a means of addressing many questions related to abnormal behaviour. The analogue experiment is commonly used to study a related

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phenomenon, or analogue. While internally valid results may thus be obtained, the external validity of such experiments is more difficult to ensure.

Single-Subject Experimental Research Single-subject experimental designs involve studying a single subject who experiences a manipulated variable. While relying on a single subject prohibits the use of a control group and limits generalizability, it can be effective for certain purposes. Reversal (ABAB) designs obtain a baseline, introduce treatment, reinstate the baseline conditions, and finally reintroduce the treatment. This design allows one to attribute experimental effects to the independent variables, but cannot be employed when the baseline state is not recoverable or when ethical considerations prohibit reversing a treatment.

Mixed Designs The mixed design combines experimental and correlational techniques: subjects who can be divided into two or more discrete populations are assigned as groups to each experimental condition, thereby identifying which particular treatment applies best to which group of subjects.

Focus on Discovery 4.1: Meta-analysis and the Effects of Psychotherapy and Beyond Smith, Glass, and Miller (1980) originally devised meta-analysis as a new way to evaluate the effects of psychotherapy. They devised a way of combining the results of similar studies into on larger sample. This method is now widely used to evaluate effects over a variety of studies and methodologies.

STUDENTS SHOULD KNOW Key Points 1.

Science, as currently practised, is the pursuit of systematized knowledge through observation.

2.

In order to be considered scientific, theories must be testable and reliable. Theoretical concepts must be operationalized. They must be exposed to tests that could disconfirm the theory.

3.

The case study lacks control and objectivity, but is useful for (1) describing unusual phenomena; (2) disconfirming supposedly universal aspects of a theory; (3) generating hypotheses; and (4) psychotherapy training.

4.

Epidemiological research gathers data about the prevalence of disorder and about risk factors that increase the probability of the disorder.

5.

The correlational method is a valuable means of systematically studying the association between two or more variables, but third variable and reverse causality interpretations prohibit causal inferences.

6.

Diagnosis is a classificatory variable, and all comparison made between groups of patients with different diagnoses are correlation studies.

7.

Statistical significance refers to the likelihood that the results of an investigation were due to chance.

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8.

The experiment begins with a hypothesis that the manipulation of independent variables will effect changes of the dependent variables that can be measured. Control groups, random assignment, and double-blind procedures help ensure internal validity.

9.

Internal validity refers to whether the results obtained can be confidently attributed to the independent variable. External validity concerns whether the results of a particular study are generalizable.

10.

Placebo control groups are used in psychotherapy research to control for the placebo effect.

11.

Analogue experiments are frequently used to study psychopathology.

12.

Single-subject experimental designs such as the reversal or ABAB design are less generalizable, but can provide internally valid results.

13.

Mixed designs combine experimental and correlational techniques, usually dividing subjects into two discrete populations and assigning them as groups to each experimental condition.

14.

Meta-analysis is a method of statistically combing the results of several similar studies into one large sample.

Key Terms analogue experiment (p. 123) case study (p. 110) classificatory variables (p. 118) confounds (p. 122) control group (p. 122) correlation coefficient (p. 116) correlational method (p. 116) dependent variable (p. 121) developmental trajectories (p. 119) directionality problem (p. 118) double-blind procedure (p. 121) epidemiology (p. 113) experiment (p. 120) experimental effect (p. 121) experimental hypothesis (p. 121) external validity (p. 122) group-based trajectory models (p. 119) high-risk method (p. 119) hypotheses (p. 109) idiographic research (p. 119) incidence (p. 113) independent variable (p. 121)

internal validity (p. 122) latent class growth analysis (p. 120) meta-analysis (p. 126) meta-meta-analysis (p. 127) mixed design (p. 125) moderator variables (p. 127) nomothetic research (p. 119) parental mental disorder (p. 114) placebo effect (p. 121) prevalence (p. 113) qualitative research (p. 113) quantitative research (p. 113) random assignment (p. 121) reversal (ABAB) design (p. 124) risk factors (p. 113) science (p. 108) severe abuse (p. 114) single-subject experimental design (p. 123) statistical significance (p. 117) theory (p. 109) theory-building case studies (p. 112) third-variable problem (p. 119)

New Names None.

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LECTURE LAUNCHERS 1. Threats to Internal Validity Campbell and Stanley's classic, Experimental and Quasi-experimental Designs for Research (1966, Chicago: Rand McNally), is an invaluable source for understanding the factors that limit internal validity. Their list of plausible alternative hypotheses to the conclusion that the independent variable caused the change observed makes the concept of internal validity clear. Before providing the examples here (or your own), students might be encouraged to think of examples on their own.

(1) History. All things that may have happened to the subjects between Time 1 and Time 2 in addition to the independent variable may affect the dependent variable. For example, in addition to the psychotherapy treatment she received (the independent variable), a manic-depressive subject may view a television program on bipolar illness, which influences her behaviour.

(2) Maturation. Subjects may change from Time 1 to Time 2 because of autonomous growth or development. For example, a subject who is rated as hyperactive at Time 1 (age 3) may grow out of his over activity by Time 2 (age 4). The problems of history and maturation increase the longer the time period between Time 1 and Time 2.

(3) Testing. Taking the pre-test itself may affect the dependent variable. For example, taking a practice test for the SAT before an educational intervention (the independent variable) not only assesses the subjects' pre-treatment skills, but also teaches them something about test-taking and would improve their post-treatment performance even without the treatment.

(4) Instrumentation Change. The measuring instruments may change between Time 1 and Time 2. For example, during a longitudinal study, it is likely that the DSM diagnostic criteria will have been revised, resulting in changes in diagnosis that are not due to the independent variable.

(5) Statistical Regression. Extreme scores will regress toward the mean from Time 1 to Time 2, apart from independent variable effects. For example, people who do extremely poorly on an IQ test at the first testing are likely to do somewhat better on the second test (and vice versa) because of imperfect testretest reliability and the random component to the abilities tested.

(6) Selection. Non-random selection may influence the independent variable. For example, if subjects are self-selected for an SAT course, those who take the course are likely to vary from the no-treatment group on some factor (like achievement motivation) in addition to the independent variable (SAT course).

(7) Experimental Mortality. Non-random loss of subjects influences the independent variable: schizophrenic subjects who drop out of a medication treatment study may have been responding less well to the treatment (causing them to quit); the resulting post-treatment group will not include those subjects who responded least well.

2. Skinner on the Scientific Method Students may enjoy reading Skinner's entertaining account of the scientific process in action (1955, American Psychologist, 11, 221-233). In his conversational tone ("imagine that you are all clinical psychologists—a task which becomes easier and easier as the years go by—while I sit across the desk from you or stretch out upon this comfortable leather couch" [p. 222]), Skinner elucidates the following "unformalised principles" of scientific practice as he describes his early conditioning research: (1) "When you run into something interesting, drop everything else and study it" (p. 223).

(2) "Some ways of doing research are easier than others" (p. 224). Tiring of carrying rats around and delivering reinforcement, Skinner developed apparatuses to take care of these tasks. Later, tiring of preparing food for reinforcement, Skinner discovered the powers of periodic reinforcement.

(3) "Some people are lucky" (p. 225). Skinner reveals how his mistakes led him to new ideas and ways of measuring phenomena.

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(4) "Apparatuses sometimes break down" (p. 225). The jamming of Skinner's food magazine led him to study the extinction curve.

(5) "Serendipity—the art of finding one thing while looking for something else" (p. 227). Trying to find a way to keep rats at a constant level of food deprivation, Skinner discovered instead the phenomenon of fixed-ratio reinforcement.

Skinner's irreverence for traditional scientific method ("I never attacked a problem by constructing a Hypothesis. I never deduced Theorems or submitted them to Experimental Check." [p. 227]) provides a thought-provoking counterpoint and compliment to the text.

3. Rogers on the Scientific Method In his article, "Toward a More Human Science of the Person," (1985, Journal of Humanistic Psychology, 25, 7-24), Carl Rogers addresses the need for more research within the humanistic paradigm, and presents examples of studies employing a more phenomenological model of scientific inquiry. He notes common elements among several recent books and articles calling for a new model of science, including (1) the "Newtonian, mechanistic, reductionistic, linear cause-effect, behaviourist view of science is not thrown out but it is seen as simply one aspect of science . . . decidedly inappropriate for [investigating certain questions]" (p. 12); (2) recognition that our knowledge will always be uncertain; (3) the assertion that no one methodology is best, and approaches should be chosen to fit the question asked; (4) the importance of a methodology that includes an "indwelling" in the experience of the participants; and (5) the use of "participants" or "co-researchers" rather than "subjects" in studies.

Students might enjoy contrasting the perspective of Rogers with that presented by Skinner (above).

4. The Case Study and the Need for Care Michelle Remembers by Michelle Smith (a pseudonym) and Dr. Lawrence Pazder, (1983) is a book that essentially initiated a sudden increase in the reports of childhood sexual abuse that had been forgotten for years, "recovered memories," and reports of satanic cults in North America. This has led to a debate within the psychological community about the dangers of "false memories" and about the acceptance or even encouragement of testimony from children about past, long forgotten incidents of abuse. Eventually the FBI published a report in which they felt compelled to state that they could find very little evidence of such abuse. For a copy of the 1992 FBI Report—“Satanic Ritual Abuse” by Kenneth V. Lanning, Supervisory Special Agent Behavioral Science Unit National Center for the Analysis of Violent Crime National Center for the Analysis of Violent Crime, go to this website: http://www.religioustolerance.org/ra_rep03.htm. The "Sceptic's Dictionary" is also a good discussion of this issue with pointers to papers by Elizabeth Loftus who would eventually publish the first empirical evidence of the creation of "false memories" in a controlled situation. http://skepdic.com/satanrit.html There is a good deal of information available at Dr. Loftus' website, http://faculty.washington.edu/eloftus/.

The basis of this lecture can be how one case study from Victoria, BC led to years of work on the part of the FBI, thousands of cases of "recovered memory", the creation of a new sub-field in cognitive psychology "false memory"; and the false imprisonment or prosecution of thousands of individuals. A huge debate was generated in society and within the field of psychology that continues today.

5. Crisis? What Crisis?

For the past few years, psychologists have been discussing the “replication crisis” in psychology. The field of social psychology, in particular, has been shaken by the failure of many classic findings to hold up when subjected to preregistered replications by multiple labs. Examples of findings that have not replicated include the association of “power posing” with hormonal changes (original article Carney, Cuddy, & Yap, 2010), the finding that a smile created by holding a pencil in your mouth makes you feel happy (Strack,

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Martin, & Strepper, 1988), or that priming with “elderly” words leads to people walking more slowly (Bargh, Chen, & Burrows, 1996). As early as 2012, Perspectives on Psychological Science devoted an issue to the issue of replicability in psychological science (see Pashler & Wagenmakers, 2012, 7, 528-530 for an introduction to the special issue).

Students will likely need to be given some background on factors associated with unreliable findings being published. They could be told about the “file drawer” problem (non-publication of “failed” or non-significant findings), as well as the issue of “p-hacking” (authors reporting one potentially fluke statistically significant result and not informing readers of all the non-significant results). However, students should be able to readily see the potential dangers of these issues in relation to abnormal psychology. This should help students to understand the importance of rigorous science when it comes to identifying best treatments for various mental disorders.

DISCUSSION STIMULATORS The Coke-Pepsi Experiment An engaging method of teaching the concepts of the experiment is to conduct a taste-test in class. Get a few cans of Coke or Pepsi and pour them into cups that you have marked to identify the soda (but which students can't identify, of course). Select 20 or so student volunteers and pass out the cups at random. Next have students provide some ratings on the drinks, such as whether they drank Coke or Pepsi, how much they liked the soda on a scale of 1 to 10, etc. While students will get caught up in which soda wins the challenge, conclude by asking questions like: What was the independent variable? What were the dependent variables?

What was the experimental hypothesis (if you have one)? Is the study internally valid? Externally valid?

Was this a double-blind study? If you compared results for men and women, would this be a mixed design?

The Great Chocolate Diet Hoax Students will enjoy the story of how John Bohannon fooled millions into believing that chocolate facilitates weight loss. Bohannon tells the story here http://io9.gizmodo.com/i-fooled-millions-into-thinking-chocolatehelps-weight-1707251800 of conducting a clinical trial, complete with random assignment and different diets. Of their 18 different measurements (weight, sodium, sleep quality, etc.), and found a presumably spurious but significant correlation between chocolate and weight loss. They quickly published it in a “predatory journal” (journals that will publish without peer review for a fee https://scholarlyoa.com/2016/01/05/bealls-list-of-predatory-publishers-2016/) then sent out press releases.

Numerous websites, magazines (including Shape), and newspapers published the story, with most doing no fact checking at all. This story can be used as an example of bad science and students could be asked to bring in an example of poorly conducted research that they’ve seen in the popular media (including their social media accounts). Having students critique media reports of psychological research will teach them to apply some of their newly-learned concepts, make them a bit more sceptical about what they read.

Reliability and ESP The concept of reliability of an experimental finding and the importance of this criterion can be easily demonstrated to the class by having them take part in an "ESP" experiment with you. Think of a number between 1 and 10 and ask the entire class to use ESP to divine the number. About 10% of the class will guess correctly, but after being amazed at the number of psychics in your class, you might begin to wonder aloud if the finding is reliable. Replications of the experiment will eventually eliminate all of the numbers of the first group of psychics and demonstrate why a finding must be reliable before the community of scientists accepts it.

Falsifiability

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Present the class with your "theory" of human behaviour. Your theory goes like this: we each have an invisible little Martian sitting on our shoulder and whispering into our ears telling us what to do. Can the class disprove your theory? No—nor could you prove it. The students' attempts to disprove your theory can be used to point out why theories, in order to be scientific, must be testable. This demonstration also illustrates why, in scientific research, the null hypothesis is that no effect is accepted until it is demonstrated.

If I assert that schizophrenia can be cured by hemodialysis, that fluorescent lights cause hyperactivity, or that masturbation causes insanity, it is my obligation to prove the assertion to be true, not your obligation to prove me wrong. You may ask the class to apply some of their newly learned rules of science to some of the theories discussed in Chapter 2.

Ethics in Research The ethics of doing research on human subjects is discussed in the last chapter of the text, but discussion of the issues might begin now. Some students may have served as subjects in psychology experiments. How do they feel about their experience? Were they deceived as a part of an experimental manipulation? Past experiments such as Milgram's obedience to authority studies can be discussed from an ethical perspective.

While certain studies are obviously unethical, there is a conflict between the benefit of advancing knowledge and the protection of research participants. When discussing this topic, be prepared to answer questions about the ethics of animal experimentation as well.

Ethics in Research Part II The Canadian Psychological Association provides an on-line copy of its code of ethics: www.cpa.ca/aboutcpa/committees/ethics/codeofethics/ Have students design an experiment that involves human subjects. Then have them evaluate the design of another group or individual using the "Canadian Code of Ethics for Psychologists" as a reference point. Ask them to provide written comments on the requirements that the design in question met and failed to meet. This can lead to a discussion about the interpretation of points of the code or the need for such restrictive language in the code. What could be the harm in ignoring a given requirement? What must have happened in the past in order for this to be included?

SOME IDEAS FOR UTILIZING THE INTERNET LSD Experiments at McGill in the 60s If you do a web search for LSD and McGill or Dr. Cameron and LSD you fill find a number of accounts of the use of Canadian federal prisoners in LSD experiments conducted by McGill scientists and funded by the US CIA. One example is "Brainwash victims win cash claims" by Karin Goodwin, The Sunday Times. www.timesonline.co.uk/tol/news/uk/scotland/article495413.ece These make for quite interesting reading. Have your students do their own searches or start with these and then join in an on-line discussion via an on-line bulletin board about how these experiments would be viewed by a contemporary ethics committee.

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Online Psychology Experiments There are several sources of on-line psychology experiments. If you or your students do a search for "psychology experiments online" you will find several. You may have your students participate as a subject in one or two that have something to do with abnormal or personality psychology. If you have a course policy that students can participate in research for extra credit, have them discuss their experiences. For example, you could have them discuss ethical standards, deception, methodology, etc. Be sure to ask your students whether they read the consent form or retained a copy for their records.

Ethics: Research with Human Participants Issues www.research.utoronto.ca/for-researchers-administrators/ethics/human/ This site at the University of Toronto contains a great deal of information about the issues and procedures involved in using human subjects in experiments. There is a model consent form and the Tri-council Policy Statement. Students can be asked to discuss several topics based on the information presented here or design an experiment and discuss if it would pass the procedures established at the University of Toronto.

Students who are very keen may want to complete the Tri-Council course on Research Ethics. Many Canadian Research Ethics Boards require all researchers to complete this training, which is an excellent review of historical ethical abuses and modern standards. http://tcps2core.ca/welcome

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CHAPTER 5 ANXIETY DISORDERS

CHAPTER SYNOPSIS Anxiety, an unpleasant feeling of fear and apprehension, is sufficiently severe and debilitating to be diagnosable as an anxiety disorder in about 16% of women and 9% of men, according to Canadian statistics. Anxiety disorders, as a group, are the most common psychological disorders. Anxiety has a physiological component (e.g., increase in heart rate, shortness of breath) and a cognitive component (e.g., worry and rumination). Everybody feels anxious sometimes, but individuals with anxiety disorders tend to perceive threat and feel apprehension in ambiguous or even objectively non-threatening situations.

Changes to the Anxiety Disorders in DSM-5 include moving obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) to separate chapters, and including separation anxiety disorder and selective mutism in the anxiety disorders chapter. It is often the case that someone with one anxiety disorder will also meet the diagnostic criteria for a second one (comorbidity).

Specific Phobias Specific phobias are unwarranted fears caused by the presence or anticipation of a specific object or situation. The fear and avoidance are out of proportion to the danger posed by the object or situation, and recognized by the sufferer as groundless. Psychologists tend to focus on different aspects of phobia, depending on the paradigm they have adopted; whereas psychoanalysts tend to focus on the content of the phobia, behaviourists focus on its function.

Specific Phobia Subtypes In DSM-5, specific phobias are categorized by the source of the fear: blood, injuries, and injections; situations (e.g., planes, elevators, enclosed spaces); animals (e.g., snakes, spiders, dogs); the natural environment (e.g., heights, water); and other (for all other phobias – e.g., clowns, vomiting). There is a lack of research on specific phobias, in part because many people are able to avoid feared objects and situations rather than seeking treatment and also because adults may be embarrassed to admit to holding such strong fears. An American study (Stinson et al., 2007) revealed that specific phobias are enduring (mean duration was 20 years) and that only 8% of individuals with specific phobias received treatment.

The most common specific phobias in this study were: (1) animal phobias (including insects, snakes, and birds); (2) heights; (3) being in closed spaces; (4) flying; (5) being in or on water; (6) going to the dentist; (7) seeing blood or getting an injection; and (8) storms, thunder, or lightning.

Social Anxiety Disorder (Social Phobia) Social Anxiety Disorder (SAD; formerly known as social phobia) is characterized by persistent, irrational fears of being judged by other people. Individuals with SAD often try to avoid situations in which they might be evaluated. People with SAD tend to be particularly concerned about the observable symptoms of anxiety, such as blushing, shaking, and sweating. The types of situations that people with SAD fear and avoid can be broadly categorized as (1) public speaking or other types of performance, (2) social interactions, and (3) being observed in public.

Instructor’s Manual to accompany Abnormal Psychology, Sixth Canadian Edition by Flett et al.

Prior to the DSM-5, SAD was classified as generalized or specific, depending on the range of situations that were feared and avoided. In DSM-5, the “generalized” qualifier was dropped in recognition of the fact that people with SAD can have a range of social fears. However, public speaking anxiety seems to be qualitatively and quantitatively distinct as opposed to merely a milder form of SAD. Thus, DSM-5 allows a “performance only” specifier to SAD diagnosis.

Etiology of Specific Phobias and SAD The primary assumption of all behavioural accounts of phobias is that such reactions are learned. The avoidance conditioning model asserts that phobias result first from learning to fear a situation through classical conditioning, and second, learning to avoid the situation as a result of operant conditioning. The fear then becomes generalized to a whole class of stimuli. While some clinically reported phobias seem to fit this model, research has not supported the model as explaining all phobias.

Vicarious learning, or learning phobic reactions by observing others, is supported by experimental evidence as an explanation for phobias. In addition, phobic reactions can be learned through another’s description of what could happen. The anxious-rearing model suggests that anxiety disorders in children can occur when constant parental warnings induce anxiety in children. Prepared learning reflects the fact that we seem to have a biological predisposition to be sensitive to particular stimuli (prepared stimuli) and not others. Thus, natural selection may have led to our being predisposed to fear snakes, spiders, heights, and enclosed places, as opposed to cars and electrical outlets. Again, however, the model is not sufficient to explain all phobias. In addition, it seems that some individuals may have a cognitive diathesis that predisposes them to believe that traumatic events are likely to occur in the future. Another diathesis may be a history of not being able to control the environment.

Inappropriate behaviour, or a lack of social skills, has also been proposed as the cause of social anxiety. This behavioural model suggests that socially anxious people have not learned how to behave with others, leading to inept social behaviour and criticism from social companions. According to cognitive theories, social anxiety is associated with (1) an attentional bias to negative social information and to interpret ambiguous social situations as negative, (2) perfectionistic standards for accepted social performance, and (3) a high degree of public self-consciousness. Treatment implications of cognitive models of SAD include behavioural experiments and role plays in order to facilitate a focus on other people (as well as recognizing that others are typically not rejecting and punitive) as opposed to oneself.

Biological theories suggest that people who develop unrealistic fears may have a biological malfunction (a diathesis) that predisposes them to develop a phobia following a particular stressful event. For example, a person's autonomic nervous system may be easily aroused (autonomic lability). Family and twin studies also suggest that genetic factors may be involved in the etiology of phobias.

Psychoanalytic theories emphasize unconscious processes. According to Freud, phobias are a defence against the anxiety that is produced by repressed id impulses. The anxiety is displaced onto the feared object and avoidance of the object enables the person to avoid dealing with the repressed conflicts.

More recent psychoanalytic theory (Arieti, 1979) has proposed that an interpersonal problem is repressed, not an id impulse.

Panic Disorder and Agoraphobia In DSM-5, panic disorder and agoraphobia became two separate (but linked disorders), whereas previously panic disorder was diagnosed with or without agoraphobia.

Panic Disorder In panic disorder, a person experiences frequent panic attacks including physiological symptoms, depersonalization, derealization, fears of losing control, going crazy, or even dying. Only four of a possible 13 symptoms are required for a diagnosis of panic disorder, and thus, symptoms vary widely

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among individuals with the disorder. Types of panic attacks include uncued/unexpected (“out of the blue”), cued/expected, situationally predisposed, and nocturnal. For a diagnosis of panic disorder, a person must have recurrent unexpected attacks and either worry about having attacks in the future, or a change in behaviour (typically avoidance) as a result of the attacks.

Comorbidity of panic disorder and other psychiatric disorders (e.g., depression, generalized anxiety disorder, alcohol and drug use, and personality disorders) is common and results in poorer outcomes. More than 80% of people diagnosed as having one of the other anxiety disorders also experience panic attacks. Because panic attacks may be a marker of severe psychopathology (independent of a diagnosis of panic disorder), DSM-5 includes a panic attack specifier. Thus, a person could be diagnosed with “social anxiety disorder with panic attacks.” Other cultures have also been found to have variations of panic disorder.

Agoraphobia Agoraphobia (from the Greek “fear of the marketplace”) is a cluster of fears centering on public places and being unable to escape or find help should one become incapacitated. People with agoraphobia are anxious about at least two types of situations out of five: public transportation, open spaces, enclosed spaces, lines/crowds, and being out of the house alone. Typically, people with agoraphobia are concerned about having panic-like symptoms and not being able to escape the situation, but it could also be a fear of other embarrassing symptoms. Many but not all people with panic disorder go on to develop agoraphobia, and not everyone with agoraphobia has panic disorder.

Etiology of Panic Disorder and Agoraphobia Explanations of the disorder's etiology include a genetic diathesis and biological theories, such as overactivity in the noradrenergic system and hyperventilation leading to panic attacks. However, research suggests that biological sensitivities do not explain the original development of panic disorder, and occur in only a small proportion of panic attacks in those with the disorder.

Psychological explanations include the fear-of-fear hypothesis, suggesting that agoraphobia is not a fear of public places, but rather, a fear of having panic symptoms in public. Panic attacks themselves may be a function of having an autonomic nervous system that is predisposed to be overly active coupled with a psychological tendency to misinterpret and become overly concerned with changes in arousal level. These individuals tend to fear losing control. Research has supported the idea that unexplained physiological arousal in someone who is fearful of such sensations leads to panic attacks.

Generalized Anxiety Disorder Individuals with generalized anxiety disorder (GAD) tend to experience all-encompassing worry. They are persistently anxious, often about minor issues, and experience accompanying somatic complaints, apprehensiveness, and muscle tension. GAD is highly comorbid with other anxiety disorders and with mood disorders. People with GAD typically do not seek treatment and when they do, only a minority of individuals experience full remission of symptoms over time.

Etiology of Generalized Anxiety Disorder Learning theorists examine the environmental elicitors of the anxiety, and cognitive-behavioural models focus on the role of control and helplessness. Unpredictable aversive stimuli can lead to chronic vigilance and anxiety. Most people find that predictable events are less threatening than unpredictable events, and people with GAD may experience greater intolerance of uncertainty than most people. Another hypothesis is that people with anxiety disorders, particularly GAD, are highly sensitive to and preoccupied by threat cues. Another cognitive theory focuses on the fact that worrying might be negatively reinforcing, in that it distracts people from their negative emotions. Further, people hold

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different metacognitive beliefs about worry – it may be that individuals with GAD believe that worry helps to solve a problem.

Behavioral genetics studies suggest that GAD has a genetic and an environmental component.

People with GAD showed greater activation in the bilateral dorsal amygdala when they anticipated seeing aversive pictures. Some research shows white matter abnormalities in the amygdala and cingulated cortex in individuals with GAD. Further, the fact that benzodiazepines, a group of drugs that enhance GABA levels, are effective for the treatment of anxiety suggests that GAD may result from some defect in the GABA system.

Psychoanalytic theory attributes generalized anxiety to unconscious conflict between the ego and id impulses. Because the source of anxiety is unconscious, the person is not aware of the source of their apprehension and distress.

Therapies for Anxiety Disorders In general, many (but not all) treatment strategies are broadly applicable to the various anxiety disorders.

People with anxiety disorders are less likely than people with other disorders (including depression) to seek treatment, perhaps partly due to a lack of information and recognition of anxiety disorder symptoms.

Behavioural Approaches to Treatment Behavioural treatment of phobias often involves systematic desensitization, which is based on classical conditioning. The individual imagines a series of increasingly frightening scenes while in a state of deep relaxation. Many clinicians believe in vivo exposure to be superior, but it is also associated with high dropout and low treatment acceptance. Virtual reality (VR) exposure has been found to also be effective and augmented reality exposure is a more recent approach that combines VR and in vivo techniques.

Social skills training and role-playing can help people with SAD to handle interpersonal encounters. Flooding is a technique in which the client is exposed to the source of the phobia at full intensity, while operant techniques reward approach behaviour.

Because it can be difficult to find specific causes of anxiety associated with GAD, more generalized approaches have been used, such as intensive relaxation training. Clients are taught to relax away low-level tensions, to respond to incipient anxiety with relaxation rather than alarm.

Cognitive Approaches Cognitive approaches are not particularly well suited to treatment of specific phobias, because such individuals are already aware that their anxiety is excessive. With SAD, these approaches are more promising. Clark’s cognitive therapy program focuses on behavioural experiments in an effort to challenge a client’s beliefs. Another empirically supported approach for treating SAD is Heimberg’s cognitive behavioural group therapy (CBGT), which is a combination of cognitive restructuring and situational exposure typically delivered in groups of six to eight clients.

A well-validated treatment for panic disorder is panic-control therapy. This treatment has three principal components: (1) relaxation training, (2) CBT interventions, including cognitive restructuring; and (3) exposure to the internal cues that trigger panic, known as interoceptive exposure. Meta-analyses have supported the utility of CBT in the treatment of anxiety disorders, with some suggesting that CBT is more effective than drug treatments because they create lasting change.

Biological Approaches Medications that reduce anxiety (anxiolytics) have been found to be effective. Drugs that have traditionally been used to treat depression may also be effective in treating many of the anxiety disorders.

Selective serotonin reuptake inhibitors (SSRIs), originally developed to treat depression, have been found

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to be effective for SAD, GAD, and panic disorder. There are a number of problems that arise when using medications, e.g., lack of treatment response and undesirable side effects.

Psychoanalytic Approaches Psychoanalytic approaches view phobias as symptomatic and attempt to identify the underlying conflicts that are held to cause them. Contemporary ego analysts focus less on historical insights and encourage their patients to confront the phobia.

STUDENTS SHOULD KNOW Key Points 1.

People with anxiety disorders feel an overwhelming apprehension or fear that seems unwarranted or exaggerated.

2.

Social Anxiety Disorder (SAD) is fairly common, with a lifetime prevalence in the Canadian Community Health Survey 1.2 (CCHS) of 7.5% in men and 8.7% in women.

3.

Specific phobias, social anxiety disorder, panic disorder, agoraphobia, and generalized anxiety disorder are the major categories of anxiety disorders listed in DSM-5 but separation anxiety disorder and selective mutism are in this chapter as well. Obsessive-compulsive disorder, and posttraumatic stress disorder are discussed in separate chapters of the DSM-5.

4.

Specific phobias are unwarranted fears caused by the presence or anticipation of a specific object or situation. The fear and avoidance are out of proportion to the danger actually posed and are recognized by the sufferer as groundless.

5.

Behavioural theories of phobias include classical conditioning, operant conditioning, modelling, and cognition. Physiological diatheses such as autonomic lability have also been implicated.

Psychoanalytic theory views phobias as a defence against the anxiety produced by repressed conflicts.

6.

Panic disorder involves sudden inexplicable and periodic attacks of intense anxiety; panic disorder frequently precedes the onset of agoraphobia. Both physiological and psychological causes have been implicated.

7.

In Generalized Anxiety Disorder (GAD) the individual's life is beset with virtually constant tension, apprehension, and worry.

8.

Therapies for anxiety disorders include lifting repression so that childhood conflicts can be resolved (psychoanalytic), systematic desensitization, in vivo exposure, and modelling to reduce fear and avoidance (behavioural), and substituting more realistic self-statements for irrational beliefs (cognitive). Some form of exposure to the feared stimulus is a common thread in most therapies for these disorders.

9.

Anxiolytic drugs are widely employed, although they may have negative side effects, and usually result in relapse after their discontinuation. SSRIs are also used for most anxiety disorders.

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Key Terms agoraphobia (p. 143) anxiety (p. 130) anxiety disorders (p. 131) anxiety sensitivity (p. 146) anxiolytics (p. 153) augmented reality (AR) exposure (p. 151) autonomic lability (p. 141) depersonalization (p. 142) derealization (p. 142) flooding (p. 151) generalized anxiety disorder (GAD) (p. 147) in vivo exposure (p. 149) interoceptive exposure (p. 152)

intolerance of uncertainty (p. 148) nomophobia (p. 134) panic disorder (p. 142) post-event processing (PEP) (p. 141) selective mutism (p. 137) separation anxiety (p. 132) social anxiety disorder (p. 135) specific phobias (p. 133) test anxiety (p. 131) test-irrelevant thinking (p. 131) vicarious learning (p. 139) virtual reality (VR) exposure (p. 150)

New Names None.

LECTURE LAUNCHERS 1. The Red Effect Several recent studies have identified “the red effect”: that is, the colour red is associated with reduced achievement in lab settings. The underlying mechanism has been proposed to be increased anxiety and/or a primed avoidance orientation. Smajic, Merritt, Banister, and Blinebry (2014, The red effect, anxiety, and exam performance: A multistudy examination. Teaching of Psychology, 41, 37-43) investigated the effect in real classroom exam situations (students were randomly assigned an exam colour). They found no significant effects of exam colour on performance, and no association between red exams and anxiety or negative effect. The authors suggested that instructors need not remove red or any particular colour from the test situation, but recommended that instructors avoid systematically assign particular colours to students.

2. Little Hans A classic case of phobia, reported by Freud in 1909, was that of a five-year-old boy, Little Hans, who was afraid of horses and thus would not venture out of his home.

Freud's analysis of Little Hans was based on information reported in letters written to Freud by the boy's father; Freud actually saw the child only once. Two years before the development of his phobia, when he was three, Hans was reported to have "a quite peculiarly lively interest in the part of his body which he used to describe as his widdler." When he was three and a half his mother caught him with his hand on his penis and threatened to cut it off if he continued "doing that." At age four and a half, while on summer vacation, Hans is described as having tried to "seduce" his mother. As his mother was powdering around his penis one day, taking care not to touch it, Hans said, "Why don't you put your finger there?" His mother answered, "Because that would be piggish." Hans replied, "What's that? Piggish? Why?" Mother: "Because it's not proper." Hans, laughing, "But it's great fun." These events were taken by Freud as proof that Hans

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had strong sexual urges, that they were directed toward his mother, and that they were repressed for fear of castration. According to Freud's first theory of anxiety, this sexual privation would ultimately be transformed into neurotic anxiety.

The first signs of the phobia appeared about six months later while Hans was out for a walk with his nursemaid. After a horse-drawn van had tipped over, he began crying, saying that he wanted to return home to "coax" (caress) with his mother. Later he indicated that he was afraid to go out because a horse might bite him, and he soon elaborated on his fears by referring to "black things around horses' mouths and the things in front of their eyes."

Freud considered this series of events to reflect Hans' Oedipal desire to have his father out of the way so that he could possess his mother. His sexual excitement for his mother was converted into anxiety because he feared that he would be punished. Hans' father was considered the initial source of his son's fear, but the fear was then transposed to a symbol for his father-horses. The black muzzles and blinders on horses were viewed as symbolic representations of the father's mustache and eyeglasses. Thus, by fearing horses, Hans was said to have succeeded unconsciously in avoiding the fear of castration by his father-even though it was the mother who had threatened this punishment-while at the same time arranging to spend more time at home with his principal love object, his mother.

There are many other details in the case study, which occupies 140 pages in Freud's Collected Papers. In our brief account, we have attempted to convey the flavour of the theorizing. We agree with Wolpe and Rachman (1960) that Freud made large inferential leaps from the data of the case. First, the evidence for Hans' wanting sexual contact with his mother is minimal, making it debatable that Hans wanted to possess his mother sexually and replace his father. Second, there is little evidence that Hans hated or feared his father, and in the original case report, it is stated that Hans directly denied any symbolic connection between horses and his father. This denial was interpreted as evidence for the connection, however. Third, there is no evidence, or any reason to believe, that sexual excitement was somehow translated into anxiety. Indeed, the fact that Hans became afraid of horses after being frightened by an accident involving a horse may be more parsimoniously explained by the classical conditioning model, although this interpretation has its own problems.

3. Whatever Happened to Little Albert? (It may not be what you think.)

Little Albert has been a subject of fascination to Psychology students and their professors. Textbooks summaries of the study often included mistakes and distortions, including misspelling Rayner, getting Albert's age wrong, and substituting a rabbit for a rat. More serious errors include falsely reporting that Albert's fear of the white rat generalized to a fur pelt, a man's beard, a cat, a teddy bear, all white furry things, his aunt who wore fur, and his mother's fur coat. Some accounts managed to combine Watson and Rayner's study with Mary Cover Jones's report of deconditioning a child's fear of a rabbit, giving Little Albert's story a happy ending.

In fact, the experiment with Little Albert was not nearly as successful as it has been portrayed. It has been difficult to replicate, it did not contain proper controls, and the extent to which the fear generalized to other objects is not clear. This does not mean, however, that Watson and Rayner were wrong; it does suggest that they were not necessarily right. Given the historical significance of Little Albert, it is not surprising that there have been efforts to track down the real Little Albert (efforts were hindered by the fact that Watson burned his papers).

Hall P. Beck, an Appalachian State University psychologist, together with a team of students and colleagues investigated the identity of Little Albert over a period of seven years. Eventually, they concluded that Little Albert was Douglas Merritte, son of a wet nurse who worked at a campus hospital. Sadly, Beck and colleagues reported that little Douglas died of acquired hydrocephalus at the age of six years. (http://www.apa.org/monitor/2010/01/little-albert.aspx). A troubling aspect of this explanation is that little Douglas might have had neurological deficits at the time of the experimental sessions.

However, Richard Griggs (2015, Psychology’s lost boy: Will the real Little Albert please stand up?

Teaching of Psychology, 42, 14-18) evaluated the evidence and concluded that there is greater evidence that

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Albert Barger is the real Little Albert. If so, the Little Albert saga finally has a happy ending. Barger lived to the age of 87, having a long and happy life, but a mild aversion to animals.

4. Virtual Reality CBT and Public Speaking Anxiety Many people with Social Anxiety Disorder (SAD) are fearful of public speaking. Cognitive Behaviour Therapy (CBT) is known to be highly effective in the treatment of public speaking anxiety, but the exposure component can be challenging. For example, the individual may lack the ability to imagine the audience, and a therapist loses much control with a real audience. Wallach, Safir, and Bar-Zvi (2009, Virtual reality cognitive behavior therapy for public speaking anxiety: A randomized control trial. Behavior Modification, 33, 314-338) compared Virtual Reality CBT to standard CBT (imaginal exposure) to a wait list control group. CBT and Virtual Reality CBT were equivalent in effectiveness and both were superior to the wait list condition, but twice as many participants dropped out of CBT as from Virtual Reality CBT. The authors interpreted the results as support for both Virtual Reality CBT and CBT with imaginal exposure, and noted that with prices dropping, Virtual Reality equipment was becoming affordable for many clinics.

DISCUSSION STIMULATORS Developmental Changes in Fears Specific fears and phobias are common during the childhood years, however, they seem to increase or decrease in prevalence over time. Have the class discuss some of the implications of the developmental changes in fears such as fear of falling, separation anxiety, fear of the dark, anxiety over death, accident, or injury, and so on. Issues about biological predispositions, preparedness, outgrowing fears, common cultural myths and experiences, and overcoming fear should come out of this discussion.

Case Studies in Abnormal Psychology Oltmanns, Martin, Neale, and Davison (2015) have written a book of illustrative cases that provides interesting examples of the various disorders, as well as offering supplementary material on most of the psychological problems presented in the text. Students really appreciate the way a case can bring material alive, and Case Studies in Abnormal Psychology is something to seriously consider as a supplement to the text. The book includes a case of panic disorder and agoraphobia as well as disorders that previously fell into the Anxiety Disorders chapter, such as OCD (and the related Hoarding Disorder), and PTSD: Rape Trauma.

Anxiety in the Classroom The textbook discusses text anxiety. Most instructors have students who report having test anxiety or who state that they just “froze” or “blanked” when they saw the test. Given what students have learned in this chapter, what would they suggest to a student who says that they experience overwhelming test anxiety and request accommodations to not write tests? Should the student be granted the accommodation on the basis of a disorder? (Students might think this is absurd, but certainly, a case could be made that the student could and should be provided with essays or take-home exams). What strategies might help the student deal with test anxiety? Would their response be different if it was a high school student? An elementary school student?

Note: here is a link to a publication developed by several organizations and individuals in British Columbia to help high school students deal with test anxiety: https://www.anxietybc.com/sites/default/files/Test_Anxiety_Booklet.pdf

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Disorders on the Big (and small) Screen At the risk of letting your students know that you occasionally do something as mundane as watching T.V., you can help to illustrate some of the disorders (and what does not constitute a disorder) discussed in this and subsequent chapters by "diagnosing" various characters from T.V., movies, and novels. Most students will be familiar with Raj on Big Bang Theory and his inability to speak to women. Students might enjoy and be familiar with Adaptation, Aviator, Eternal Sunshine of the Spotless Mind, Lars and the Real Girl, PunchDrunk Love, and The Net.

SOME IDEAS FOR UTILIZING THE INTERNET Anxiety Network International The following is a very interesting web site that contains information and links on three topics; generalized anxiety, panic and social anxiety. www.anxietynetwork.com/ You could break your class into three teams or groups and send them off to answer different questions about the three disorders in which ultimately they have to decide if there is evidence for different models of cause for each disorder, different treatments that are effective, different rates of incidence, etc. This information can be gathered in class or on-line via a course website.

Applied Ethology: Separation Anxiety in Dogs www.usask.ca/wcvm/herdmed/applied-ethology/behaviourproblems/anxiety.html This is not a large site, but it has a nice summary of separation anxiety as it applies to dogs, a video of a dog reacting to separation, and it introduces the field of “applied ethology” which is fascinating in and of itself.

A quick visit to this site raises the issue of the overlap between human and non-primate behaviour and the application of behavioural principles in real life. The source is the University of Saskatchewan and it contains many links to other sources of information on ethology and applied ethology.

Centre for Addiction and Mental Health (CAMH): Anxiety Disorders CAMH maintains a website with up-to-date Canadian information and resources about various mental health issues, including anxiety disorders. http://www.camh.ca/en/hospital/health_information/a_z_mental_health_and_addiction_information/anxiety _disorders/Pages/Anxiety_Disorders.aspx

NIMH Anxiety Disorders www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml The US National Institute of Mental Health maintains links to many sources of the cause and treatment of anxiety disorders.

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CHAPTER 6 OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

CHAPTER SYNOPSIS Obsessive Compulsive Disorder (OCD) was previously grouped with the anxiety disorders, but the repetitive behaviours of OCD and related disorders are not a feature of other anxiety disorders. This new DSM-5 category also includes hoarding disorder, body dysmorphic disorder, somatoform disorder, trichotillomania (hair pulling), and excoriation (skin picking). This re-organization has been controversial with some arguing that all of the disorders of this new category do not share enough features to be grouped together.

Obsessive-Compulsive Disorder Obsessive-compulsive disorder is a chronic disorder in which the mind is flooded with persistent and uncontrollable thoughts (obsessions) or the individual is compelled to repeat certain acts over and over (compulsions). The symptoms cause significant distress, interfere with everyday functioning, and often have a negative impact on the individual's relationships with other people.

Etiology of Obsessive-Compulsive Disorder Behavioural and Cognitive Theories Behaviour theorists view compulsions as learned behaviours reinforced by fear reduction. However, not all compulsions reduce anxiety, and obsessions actually increase anxiety. Cognitive views suggest that obsessive-compulsives work hard to suppress unacceptable thoughts, leading paradoxically to preoccupation with the thought. Other cognitive research suggests that obsessive-compulsive individuals suffer from a memory deficit for actions performed.

Biological Factors Several biological factors have been associated with obsessive-compulsive disorder. Brain damage, particularly to the frontal lobes and the basal ganglia, is suggested by PET studies and by the association between OCD and Tourette's syndrome. The role of neurotransmitters, including serotonin, dopamine, and acetylcholine, are being considered. Finally, genetic transmission has been posited. Some theorists suggest that in OCD the obsessions and compulsions come first, causing the anxiety rather than the reverse.

Psychoanalytic Theory In psychoanalytic theory, obsessions and compulsions are viewed as resulting from instinctual forces that are not under control because of excessively harsh toilet training. Adler suggested instead that compulsive acts are attempts to gain a sense of mastery, which is missing because of excessively doting or dominating parents.

Therapies for OCD

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Behavioural Approaches Behavioural treatment of OCD focuses on stopping the compulsive acts from occurring. Exposure and response prevention (ERP) involves people exposing themselves to situations that typically elicit the behaviour, but refraining from the ritual. Clients generally find this treatment challenging and unpleasant, so refusal to enter treatment and treatment dropout are problems.

Cognitive Approaches Cognitive approaches are combined with behavioural therapy (i.e., CBT) because exposure and response prevention are necessary elements. CBT approaches may focus on the irrational sense of personal responsibility that people with OCD report. A modified CBT called an “inference-based approach” targets the obsessional inference constructed by the client. CBT is effective in treating OCD and studies have shown it to be superior to medication. One study showed that CBT was similar to medication in changing volumes of brain regions that are abnormal in people with OCD. Canadian Perspectives 6.1 discusses reported benefits in adding exercise to CBT in the treatment of OCD.

Biological Approaches Selective Serotonin Reuptake Inhibitors (SSRIs) discussed in Chapter 5 are also useful in the treatment of OCD. Although SSRIs are well tolerated, up to half of people with OCD do not respond to this medication.

Psychosurgery is considered a treatment of last resort. Cingulotomy involves destroying white matter in the cingulum, an area near the corpus callosum. Deep brain simulation has been successful in reducing symptoms in severe, treatment-resistant OCD clients.

Psychoanalytic Approaches Psychoanalytic approaches involve lifting repression and allowing the client to confront true fears. These approaches have not been very effective in treating OCD, so analytic clinicians may use analytic understanding as a way to increase compliance with behavioural treatments.

Hoarding Disorder

Hoarding disorder was previously diagnosed with OCD, but DSM-5 includes hoarding as a disorder “related” to OCD. People with hoarding disorder have difficulty discarding objects to the point that clutter dominates their lives, often creating an unsafe environment. The majority of people with hoarding disorder also excessively acquire items. People with hoarding problems seem to exist worldwide, and it sometimes develops in older people. Some research suggests that hoarding is dimensional rather than categorical.

Etiology of Hoarding Disorder There is evidence of a genetic contribution to hoarding disorder. Cognitive explanations focus on faulty information processing, erroneous cognitions about the importance of belongings, and misguided attachments with objects, perhaps to compensate for deficits in attachment to people. People with hoarding disorder show deficits in cognitive performance, including perceiving more categories, taking longer to sort objects, and experiencing more anxiety in doing so.

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Treatment of Hoarding Disorder Medication is effective in the treatment of hoarding. Venlafaxine is a selective serotonin and norepinephrine reuptake inhibitor (SSNRI) that is used to treat people with hoarding disorder.

Hoarding disorder is often treated like OCD, but the presence of hoarding is associated with poorer outcomes. CBT for hoarding typically includes exposure and cognitive restructuring tailored to hoarding.

Unique to CBT for hoarding is skills training, focusing on organizing, problem solving, and decisionmaking. The clinician may also make use of motivational interviewing techniques. CBT is generally effective for hoarding, yet outcomes are typically not as positive as those observed with CBT in other conditions. One issue might be that people with hoarding disorder are older, possibly indicating that their symptoms are long-standing and less responsive to treatment.

Body Dysmorphic Disorder People with body dysmorphic disorder (BDD) are preoccupied with an imagined or exaggerated defect in appearance, frequently in the face. Some individuals with the disorder spend hours a day looking in the mirror whereas others avoid being reminded of the defect but avoiding mirrors or wearing loose clothing.

BDD tends to be chronic, with few individuals experiencing full remission.

BDD was considered a somatoform disorder prior to DSM-5, and some experts believe it should be a subtype of OCD. Others have suggested it should be a variation of social anxiety disorder, a mood disorder, or an eating disorder.

Etiology of Body Dysmorphic Disorder Biological components of BDD include a genetic basis, as well as differences in brain volumes as compared to healthy controls.

According to one cognitive behavioural model, people with BDD strongly attend to appearancerelated thoughts and make catastrophic interpretations, leading to negative emotions. People may get temporary relief by avoiding social situations, engaging in mirror checking, or avoiding imperfections but these behaviours negatively reinforce the maladaptive beliefs. This model acknowledges the role of life experience, personality, genetic factors, and triggers (i.e., body changes during adolescence).

Treatment of Body Dysmorphic Disorder Psychological interventions for BDD typically involve CBT or cognitive or behavioural strategies alone.

Behavioural strategies include exposure and response prevention. Cognitive strategies focus on maladaptive, self-defeating thoughts, and core beliefs.

Pharmacological interventions for BDD have generally included SSRIs. A meta-analysis concluded that both CBT and medications are effective, although CBT was more effective. In another study, CBT was more effective than anxiety management. Some approaches to CBT include core elements for all BDD clients and optional modules for specific symptoms applicable to a subset of clients. Another trial supported the efficacy of inference-based therapy in the treatment of ODD.

Body-Focused Repetitive Behaviours: Trichotillomania (Hair-Pulling) and Excoriation (Skin-Picking) Trichotillomania (Hair-pulling Disorder)

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Trichotillomania (hair-pulling disorder) was previously categorized as an impulse control disorder. The main feature is repetitive hair pulling, typically from the scalp, eyebrows, or eyelids, often resulting in significant hair loss.

Excoriation (Skin-picking Disorder) Excoriation is new in DSM-5 although it previously appeared as an impulse control disorder – not otherwise specified. Skin picking can take place anywhere but typically people pick their faces, hands, and/or arms.

The picking leads to skin lesions and can cause scarring and infection.

Etiology of Body-Focused Repetitive Behaviours Trichotillomania and excoriation share a common genetic factor, which is different from that of OCD, hoarding disorder, and BDD. Extra cortical thickness in areas related to inhibitory control have been identified in trichotillomania. Studies of brain volumes and cortical thickness indicate differences between the two disorders, with excoriation being more related to the reward system.

Neurocognitive risk factors for these disorders include poor cognitive flexibility. Planning and organization were not different between people with these disorders and controls but they were related to symptom severity.

Two models focus on triggers for hair-pulling and skin-picking, with the emotion regulation model stating that both are triggered by negative emotions. The behaviours decrease the negative emotions, thus providing negative reinforcement for the behaviours. The frustrated action model states that the behaviours are triggered by frustration and boredom. A recent study compared the two models and found stronger support for the frustrated action model.

Therapy for Body-Focused Repetitive Behaviours Habit reversal training is a behavioural treatment for body-focused repetitive behaviour disorders. This training includes self-monitoring, identification of triggers, and identification of competing responses – that is, other things people can do that are inconsistent with the repetitive behaviour.

A review showed promising pharmacological treatments for trichotillomania include acetyl cysteine, clomipramine, and olanzapine. Behavior therapy was more effective than a non-treatment control but no better than control conditions with supportive therapy. When clinicians were surveyed on how to best treat trichotillomania, most recommended some form of CBT.

STUDENTS SHOULD KNOW Key Points 1.

Obsessive Compulsive and related disorders are organized as a new chapter in DSM-5 although all but excoriation appeared elsewhere in DSM-IV.

2.

Obsessive-compulsive disorder (OCD) involves intrusive and recurring thoughts and the irresistible impulse to repeat acts over and over.

3.

Psychoanalytic theory views obsessions and compulsions as resulting from uncontrolled instinctual forces. Behavioural theories view compulsions as learned behavior reinforced by fear reduction.

Cognitive theories suggest that people with OCD work hard to suppress unacceptable thoughts.

Biological theories focus on genetic diatheses, brain damage, and neurotransmitters.

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4.

Therapies for OCD include lifting repression (psychoanalytic), exposure and response prevention (behavioural), CBT and an inference-based modification (cognitive), and SSRIs (biological).

5.

Hoarding disorder is characterized by difficulty discarding objects to the point that clutter dominates the person’s life.

6.

Hoarding disorder seems to have a genetic component. People with hoarding disorder often have faulty information processing, erroneous cognitions, and misguided attachments.

7.

Therapies for hoarding disorder include medication, CBT, and skills training.

8.

People with Body Dysmorphic Disorder (BDD) are preoccupied with an imagined or exaggerated defect in appearance.

9.

BDD has a genetic basis as well as differences in brain volume. Cognitive-behavioural models focus on the role of attention in appearance related thoughts as well as catastrophic interpretations.

10.

Treatment of BDD includes SSRIs (biological), exposure and response prevention (behavioural), and maladaptive, self-defeating thoughts, and core believes (cognitive).

11.

Body-focused repetitive behaviours include trichotillomania (hair-pulling) and excoriation (skinpicking). These disorders seem to share a common genetic factor but have differences in brain structure. Poor cognitive flexibility may be a risk factor.

12.

Treatments for body-focused repetitive behaviors include pharmacological approaches and habit reversal training.

Key Terms body dysmorphic disorder (BDD) (p. 170) body-focused repetitive behaviours (p. 173) compulsion (p. 160) excoriation (skin-picking disorder) (p. 173) exposure and response prevention (ERP) (p. 164) habit reversal training (p. 174) hoarding disorder (p. 167) obsessions (p. 159)

obsessive-compulsive and related disorders (OCRDs) (p. 159) obsessive-compulsive disorder (OCD) (p. 159) prospective memory (p. 161) retrospective memory (p. 161) trichotillomania (hair-pulling disorder) (p. 173)

New Names Randy Frost

LECTURE LAUNCHERS 1. “Pathologic grooming” in four generations

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Khumalo and colleagues (2016; Pathologic grooming [acne escoriee, trichotillomania, and nail biting) in 4 generations of a single family, JAAD Case Reports) describes a South African family in which the index case is a 41-year-old woman who has picked acne lesions since the age of 15. Prior to the onset of skinpicking, she was a nail biter. One of her daughters has trichotillomania and nail-biting, and the other daughter bites her nails. The patient’s grandmother had trichotillomania until she died at 98 years. There is no evidence of other psychiatric disorders in the family.

This article would present an opportunity to discuss the strengths and weaknesses of the case study methodology. It provides us with tantalizing clues around genetic associations, which would have to be further explored with other methodologies (e.g., behavioural genetics, molecular genetics). It also provides the opportunity to discuss nail-biting, which many think of as quite innocuous. Nail biting is mentioned in the DSM-5 as a body-focused repetitive behavior disorder in a single paragraph. It might be worth exploring at what point a bad habit becomes a clinical disorder.

2. Body Dysmorphic Disorder and Suicide Angelakis, Gooding, and Panagioti (2016; Suicidality in body dysmorphic disorder (BDD): A systematic review with meta-analysis; Clinical Psychology Review, 49, 55-66) conducted a meta-analysis and found that BDD is more strongly linked to suicidality than other related disorders are, including OCD and anorexia nervosa. Not only were people with BDD were four times more likely to experience suicidal ideation than other people, but they were more than two and a half times more likely to attempt suicide. The authors concluded that suicidality is a major and under-recognized concern with BDD.

3. OCD Subtypes Baer (1994; Factor analysis of symptom subtypes of obsessive compulsive disorder and their relation to personality and tic disorders; Journal of Clinical Psychiatry, 55, 18-23) used factor analysis on data from child and adult clinical samples, and found that OCD symptoms (about 70) could be best explained with four dimensions. The first factor was symmetry. Compulsions associated with symmetry obsessions included counting, ordering, and repeating. The second factor was taboo thoughts, which comprised aggressive, religious, sexual, and somatic obsessions, and was associated with checking compulsions. The third factor was contamination, which was associated with cleaning compulsions. The fourth factor involved hoarding obsessions, and hoarding compulsions. It was this kind of evidence (as well as brain imaging and treatment research) that led to hoarding being identified as a separate category in DSM-5 as opposed to being under the umbrella of OCD.

DISCUSSION STIMULATORS Is Body Dysmorphic Disorder truly a “related disorder”?

The textbook presents evidence that suggests BDD may or may not be appropriately place with OCD and related disorders. Have the students review evidence and determine which category they think it belongs in.

Alternatively, students could be placed in groups (eating disorder, social anxiety disorder, mood disorder, delusional disorder) and asked to find support for the inclusion of BDD in “their” category.

Superstitious Behaviour and Compulsions Skinner drew an analogy between what he described as "superstitious behaviour" resulting from chance reinforcement and compulsions. We all engage in a certain amount of superstitious behaviour; students might be encouraged to consider ritualistic superstitions they may hold—professional athletes are prime examples of this. What similarities or differences are there between these behaviours and compulsions? © Wiley Canada

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Hoarding on T.V. Many of your students will have seen television shows such as Hoarders and Hoarding: Buried Alive. Have them discuss the value of these televised interventions with regard to bringing attention to the disorder but also to possibly increasing stigmatization with portrayals of extreme cases.

Destigmatizing OCD (and other mental disorders) Students could be introduced to the young adult novel, “The Unlikely Hero of Room 13B” by Teresa Toten.

This Canadian book introduces young readers to Adam, a delightful and yes, heroic, young man who is drawn to Robyn, a girl he meets at his OCD support group. OCD is described realistically, with support group members having different severity levels of the disorder. This might be a good opportunity for students to discuss the idea of destigmatizing OCD and other mental disorders through children’s and young adult media – presenting characters who have rich, likeable personalities as opposed to being caricatures.

Students might also find it interesting that Adam’s mother has hoarding disorder.

SOME IDEAS FOR UTILIZING THE INTERNET Canadian Mental Health Association http://www.cmha.ca/mental_health/obsessive-compulsive-disorder/ The Canadian Mental Health Association maintains a current website, with information on OCD, it’s symptoms, and where to find help.

The TLC Foundation for Body-Focused Repetitive Behaviors http://www.bfrb.org/index.php This website includes research, personal stories, and many other resources including information for hair and skin care professionals.

Cosmetic Surgery and Body Dysmorphic Disorder Have students search the internet for Alicia Douvall. The glamorous British model has been described as “the world’s most surgically-enhanced woman” but she has spoken out about her surgeries being driven by undiagnosed BDD. People with BDD often seek out cosmetic surgery, but are typically displeased with the results. Have students discuss what training in BDD should be required of cosmetic surgeons, and whether they should be required to screen for BDD. (Students can also refer to the description in the textbook of Reid Ewing, actor from the popular sitcom Modern Family).

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CHAPTER 7 SOMATIC SYMPTOM DISORDERS AND DISSOCIATIVE DISORDERS

CHAPTER SYNOPSIS Somatic Symptom Disorders and Dissociative Disorders Somatic Symptom and Related Disorders Somatic symptom disorders involve bodily symptoms that suggest a physical dysfunction but for which no known physiological explanation can be found. The symptoms are not under voluntary control and appear to be linked to psychological factors, presumably anxiety. Illness anxiety disorder refers to people who are preoccupied with fears of having a serious disease, possibly because they overreact to ordinary physical sensations.

Conversion Disorder In conversion disorder, symptoms suggest an illness related to neurological damage, although the organs and nervous system are sound. For example, a physiologically normal individual may experience paralysis, seizures, or anaesthesias. Conversion symptoms usually appear suddenly in stressful situations, allowing patients to avoid some activity or to get attention. The term "conversion" is derived from Freud's thinking, reflecting the belief that anxiety and psychological conflict are converted into physical symptoms. Hysteria is an earlier term for the disorder, dating back to Hippocrates' view that it was caused by the uterus travelling through the body. True neurological problems may be misdiagnosed as conversion disorders, and patients diagnosed with the disorder have high rates of subsequent physical disorders.

Focus on Discovery 7.1: Malingering and Factitious disorder, discusses malingering, and factitious disorders. Malingering presents a problem in diagnosis as some people may intentionally fake incapacity to avoid responsibility. La belle indifference may help make this distinction—some patients with conversion disorders act unconcerned about their symptoms and talk about them at length, while a malingerer is likely to be more guarded. Factitious disorders involve conversion-like symptoms that are under voluntary control, but the motivation for adopting the symptoms is not clear. In factitious disorder by proxy, Munchausen syndrome by proxy, a parent creates physical illness in a child.

Somatization Disorder This syndrome, first described by Pierre Briquet, is characterized by recurrent, multiple somatic complaints which have no known physical cause. These patients may have frequent medical treatments, gastrointestinal symptoms, pain, and sexual indifference. Somatization disorder was dropped from DSM-5, but many individuals previously diagnosed with somatization disorder will meet diagnosis for somatic symptom disorder.

Etiology of Somatic Symptom Disorders Theories about somatic symptom disorders have been dominated by psychoanalytic thinking. Breuer and Freud proposed that conversion disorders are caused by a traumatic emotional experience that remains unexpressed and cut off from conscious experience. Freud later proposed that sexual impulses stemming

Instructor’s Manual to accompany Abnormal Psychology, Sixth Canadian Edition by Flett et al.

from the Electra complex were primary. The primary gain of conversion disorder was avoidance of sexual impulses, while secondary gain or real-life benefits from the symptoms were also considered.

A behavioural account of somatic symptom disorders suggests that the problem is a role enactment of how a person with such a problem should behave, similar to malingering. However, this interpretation is at odds with evidence that the symptomatic behaviour appears to be unconscious. Behaviourists have also explained somatization disorder as unrealistic anxiety manifesting itself in particular bodily systems.

Socio-cultural theories are based on the supposed decrease in conversion disorders over the last century. The repression of sexual attitudes in Freud's day is implicated in the disorders, while modern psychological and medical sophistication or differences in diagnostic practices are proposed explanations for the current decreased incidence.

Biological theories implicate the role of brain structures, and fMRI studies support these ideas.

There is little support, however, for a genetic basis for conversion disorder.

Therapies for Somatic Symptom Disorders Most people with somatic symptom disorders contact physicians for help, presenting a dilemma to medical personnel as to whether to treat them or refer to an (unwanted) mental health professional. Cognitivebehavioural approaches, exposure therapy, and psychodynamic therapies have all been shown to be effective with these disorders.

Dissociative Disorders Three dissociative disorders discussed in this section all involve changes in the person's sense of identity, memory, or consciousness. In dissociative amnesia, the person becomes unable to recall important personal information, usually following a stressful episode. Depersonalization/derealization disorder is diagnosed when the person's perception or experience of the self is disconcertingly and disruptively altered; unlike the other dissociative disorders, it involves no disturbance of memory. Dissociative identity disorder is characterized by the existence of two or more independent ego states that come into control at different times. The very existence of multiple personality disorder has been the subject of much controversy.

Canadian Perspectives 7.1: Everyday Dissociative Experiences in Winnipeg Psychiatrist Colin Ross looked for experiences typical of DID among the general population of Winnipeg.

His research indicates that some experiences associated with dissociation are quite common. While dissociative experiences are infrequent and transient in the general population it does suggest that even DID consists of an exaggeration or increase in frequency of normally occurring experiences.

Etiology of Dissociative Disorders The trauma model of dissociation proposes childhood onset resulting from severe physical or sexual abuse.

The fantasy model of dissociation suggests that people who develop DID are very prone to engaging in fantasy. At this point, there is greater support for the trauma model. Another theory considers DID to be a learned behaviour, often due to suggestions by psychotherapists.

Therapies for Dissociative Disorders Because dissociative disorders are widely believed to arise from repressed memories of trauma, psychoanalytic therapies to lift repression (including hypnosis) are often used. The therapeutic goal is typically to integrate the several personalities. A recommended three-stage approach consists of (1) safety, stabilization, and symptom reduction, (2) working with traumatic memories, and (3) integrating personalities.

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Canadian Contributions 7.1: Nicholas P. Spanos and a Sociocognitive Perspective on DID Spanos challenges the validity of DID as a distinct psychiatric disorder. His cognitive behavioural model of hypnosis led him to the conclusion that DID is basically role playing encouraged by clinicians who encourage the patient to take on this particular role. Spanos would present the transcripts of interviews with Ken Bianchi (The Hillside Strangler) in which he points out the leading questions on the part of the clinician interviewing Bianchi.

Focus on Discovery 7.2: Repressed Memories of Childhood Sexual Abuse Since the late 1800’s when Freud and his followers suggested that sexual fantasies were relevant to the etiology of mental disorders and that traumatic memories were often repressed from consciousness by mental activity, the question of whether or not traumatic events could first be forgotten and then remembered or recovered has been debated in the fields that focus on abnormal psychology. Only recently has any empirical evidence been presented to address the relevant issues. This focus summarizes some of this literature. The authors suggested that the forgetting or repression of traumatic events is likely rare and that a significant percentage of what appear to be recovered memories are artificially induced or false memories derived from popular writings, therapists’ suggestions and the constructive nature of memory itself.

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STUDENTS SHOULD KNOW Key Points 1.

A group of prominent researchers recently presented the radical argument that somatoform disorders should be removed from the pending DSM-5. The authors listed several concerns, many of which apply to other diagnostic categories.

2.

Disorders related to somatic symptom disorder include illness anxiety disorder and conversion disorder. In DSM-5, body dysmorphic disorder has been moved from this section to OCD and Related Disorders.

3.

Illness anxiety disorder involves a preoccupation with having acquired a serious undiagnosed illness.

A related disorder, hypochondriasis is now classified as a somatic symptom disorder.

4.

Conversion disorder is a category of somatic symptom disorder, in which the patient presents with physical symptoms for which no physiological basis can be found

5.

Conversion disorders occupy a central place in psychoanalytic thinking, as some of Freud's major ideas, particularly regarding the unconscious, were based on his work with patients with this problem

6.

Freud suggested that the primary gain of a conversion disorder was avoidance of repressed id impulses, but he also allowed for secondary gain or direct reinforcement for the symptoms.

7.

The sensory and motor dysfunctions of conversion disorder suggest a neurological cause, but ones that do not always make anatomical sense.

8.

It is often difficult to distinguish conversion disorders from true physical illnesses and from malingering.

9.

Somatization disorder is characterized by recurrent, multiple somatic complaints for which medical attention is sought but which have no apparent physical basis.

10.

Evidence from experimental psychology supports the notion that many mental processes are unconscious; this is distinguished from Freud's notion of an entity called "the unconscious."

11.

Behavioural theories of somatic symptom disorders focus on conscious adoption of symptoms to obtain a desired goal.

12.

Psychodynamic therapies for somatic symptom disorders focus on helping the patient face repressed impulses while behaviour therapies attempt to reduce anxiety and reinforce alternative behaviors.

13.

Dissociative disorders involve disruptions of consciousness, memory, and identity. They include dissociative amnesia (a sudden loss of memory), dissociative identity disorder (the existence of two or more complex egos in the same person), and depersonalization/derealization disorder (marked alterations in the sense of self).

14.

Psychoanalytic theory regards dissociative disorders as instances of massive repression of some undesirable event or aspect of the self. In DID, the role of childhood trauma has been supported. The therapeutic goal is typically the integration of personalities. © Wiley Canada

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Key Terms anaesthesias (p. 180) conversion disorder (p. 180) depersonalization/derealization disorder (p. 190) derealization (p. 190) dissociative amnesia (p. 187) dissociative disorders (p. 177) dissociative fugue (p. 189) dissociative identity disorder (DID) (p. 190) factitious disorder (p. 178)

hypochondriasis (p. 179) hysteria (p. 180) illness anxiety disorder (p. 179) la belle indifférence (p. 178) malingering (p. 178) pain disorder (p. 177) somatic symptom disorders (p. 177) somatization disorder (p. 181)

New Names Pierre Briquet, Colin Ross, Nicholas Spanos, Elizabeth Loftus.

LECTURE LAUNCHERS 1. Dissociation in Winnipeg Colin Ross's data on the frequency of dissociative experiences in the general population raises some interesting questions and ideas. Ross, C.A. (1997) Dissociative Identity Disorder: Diagnosis, Clinical Features, and Treatment of Multiple Personality. N.Y.: John Wiley & Sons. Once again, this data suggests that even quite exotic and extreme syndromes, like DID, may be seen as an exaggeration of everyday phenomena. With DID, however, these findings raise other questions. The existence of DID is controversial in the field. Some have raised the possibility that DID is an example of an iatrogenic disorder, one created by the suggestions of the professional who interviews the client. See for example: Powell, R. A., & Gee, T. L. (1999). “The effects of hypnosis on dissociative identity disorder: A re-examination of the evidence”.

Canadian Journal of Psychiatry, 44, 914-916. Powell suggests that hypnosis may have a significant iatrogenic effect on DID. If many people who are not experiencing emotional problems experience experiences that are similar to the symptoms of DID it would not be out of the question that a mental health professional who is looking for these symptoms could encourage them. Add to this the inherent dangers of hypnosis as a diagnostic tool and a model for an iatrogenic cause is plausible.

2. Hypochondriasis and Functional Somatic Symptoms While discussed only briefly in Chapter 7, hypochondriasis and various functional somatic symptoms are important public health phenomena. Various estimates suggest that somewhere between 20% and 84% of the patients who consult medical practitioners fit into one of these two categories, and the prevalence of hypochondriasis is between 3% and 13% of the population. A review of the topic provides some additional interesting information on the disorders (Kellner, R., 1985, Archives of General Psychiatry, 42, 821-829).

Anxiety and depression are two complaints commonly associated with hypochondriasis to such an extent that some investigators suggest that hypochondriasis is not a separate entity. Most experts on the topic suggest, however, that there is a subgroup of patients for whom the physical symptoms constitute the major complaint. Finally, it has been noted in several investigations that hypochondriacal patients are generally more sensitive to their physiological functioning.

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Little in the way of controlled research has been conducted on the treatment of functional somatic symptoms and hypochondriasis. Several investigators have suggested that the presence of hypochondriasis is an indication of poor prognosis in therapy, but treatment successes have also been reported using both psychotherapy and antidepressant and anti-anxiety medications. It has also been noted that simple reassurance is often sufficient. Perhaps what is most surprising is the relative neglect of a topic.

3. Sexual Histories of Women with Somatic Symptom Disorder Studying the sexual histories of women with somatic symptom disorder is important for several reasons.

First, such women typically report sexual dissatisfaction and unhappy marriages. In addition, historical inquiry into hysterical disorders, beginning with Freud, focused on experiences with sexual molestation in childhood, though later dismissed as fantasy by Freud. An interesting study by Morrison (1989, American Journal of Psychiatry, 146, 239-241) involved in-depth interviews with 60 women diagnosed as having somatization disorder by DSM-III criteria, and a control group of 31 women with primary affective disorder.

While the groups did not differ in their reports of the usual childhood sexual experiences, including, for example, age at which they first played "doctor," masturbated, kissed, or had voluntary intercourse, (indicating that the women with somatic symptom disorder were not globally exaggerating their sexual experiences), women with somatic symptom disorder were significantly more likely to have been sexually molested as children. Over half of the women with somatic symptom disorder had been molested, as compared to 16% of the control group. These results suggest that sexual abuse is a common event in the childhood histories of women with somatization disorder.

4. Issues in Multiple Personality Disorder/Dissociative Identity Disorder Kluft (1987, Hospital and Community Psychiatry, 38, 363-373) reviews a range of issues involved in multiple personality disorder, including controversy over its prevalence and phenomenology, etiology, diagnostic criteria and differential diagnosis, and treatment: Prevalence: An exchange of letters in the American Journal of Psychiatry (Ludolph, 1985, 142, 1526-1527; Bliss, 1985, 142, 1527; Kluft, 1986, 143, 802-803; Chodoff, 1987, 144, 124; and Kluft, 1987, 144, 124-125) explores the controversy surrounding the prevalence of multiple personality. One group of clinicians asserts that the disorder is rare or nonexistent; they suggest that the recent increase in reported cases is due to loose diagnostic criteria, the over enthusiasm of a few diagnosticians, or even the creation of the disorder through hypnosis treatments, and conceptualize the disorder as maintained and perhaps created by secondary gains. Those who believe that the prevalence of the disorder is much higher than previously believed conceptualize it as a child's attempt to cope with trauma through inward flight; a child who cannot physically escape extreme abuse, for example, may find that dissociation provides an inner escape.

Etiology: Support for the view that dissociative identity disorder is a kind of post-traumatic stress reaction to childhood trauma comes from findings that up to 97% of cases of multiple personality have experienced child abuse, usually sexual. A combination of the following factors is seen as leading to development of the disorder: (1) the child is dissociation-prone (for example, multiple personalities have been found or have high hypnotisability), (2) she is harshly abused or molested, (3) she cannot escape the abuse, perhaps because it is perpetrated by a member of her family, (4) the child dissociates, thus escaping psychically from a physically inescapable, ongoing trauma. Once established, this mode of coping may be repeated to deal with less traumatic events in the future. The author suggests that the disorder may be treated with much greater success if it is discovered in childhood near its onset, before the pattern has become an ingrained mode of coping.

Treatment: As described in the text, most treatment methods involve attempting to integrate the split personalities. In addition, Kluft points out the importance of teaching the client new ways of coping with stress, to replace the previously ingrained dissociation pattern. Thus, after integration has been achieved, coping skills such as relaxation and assertion training and new interpersonal skills become an important aspect of treatment to prevent relapse. Interestingly, Braun (1984, Psychiatric Annals, 14, 34-40) reports that

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integration may result in physiological changes; patients report changes in allergies, colour blindness, eyeglass prescription, and insulin requirements (in diabetics) following integration.

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5. Dissociative Identity Disorder and Malingering There has always been some questions as to whether DID is a true disorder rather than a conscious effort to avoid punishment or to achieve gains not otherwise available. Is DID little more than malingering? This issue gained prominence in the early 1980s during the trial of serial murderer, Ken Bianchi who came to be known as the Hillside Strangler. The differing views of expert witnesses in this highly publicized trial were the subject of three articles in the International Journal of Clinical and Experimental Hypnosis (Allison, 1984; Orne, Dinges, & Orne, 1984; Watkins, 1984 – see also Canadian Contributions 7.1 Nicholas P. Spanos and a sociocognitive perspective on DID).

6. Internal Group Therapy for Multiple Personality Disorder Students may be intrigued by the use of "internal group therapy" in treating multiple personality disorder: the therapist "invites" the alter personalities to attend a therapy session and communicate with one another directly (Caul, D., 1984, Psychiatric Annals, 14, 43-50). The goals of such an intervention include arriving at an agreement between the personalities as to the goals and directions of therapy (to prevent one personality from sabotaging treatment), reducing "sibling rivalry" between the personalities, and encouraging the alters to work out conflicts which may interfere with integration. In the procedure described

by Caul, the patient is put in charge of the session, determining who will attend, the subject matter, and the length of the session. The therapist's presence helps to maintain structure and safety, though he or she does not intervene except in an emergency.

DISCUSSION STIMULATORS Dissociative Experience Scale The list of dissociative experiences investigated by Ross (1997) is on page 205 of the text. This can be made into a handout or a lecture slide, or it can be read in class. It could be made into a "survey" in any on-line course support system. A survey is set up just like a quiz, except that the results are anonymous. Statistics are available on responses. With the results you can compare the responses of your students with the general population of Winnipeg. This might be an opportunity to mention "Medical Students Syndrome" in which students take on the symptoms of the disorder they are studying. You wouldn't want students leaving a class having been induced to believe they have DID, though that would be a vivid demonstration of what many clinicians believe to be the iatrogenic nature of DID..

For a description of Medical Students Syndrome see: www.en.wikipedia.org/wiki/Medical_students'_disease

Distinguishing Multiple Personality and Schizophrenia As discussed in the text, students (and the popular media) frequently confuse the concepts of multiple personality and schizophrenia. It is worthwhile to spend some time at this point in the course explaining the difference. Pointing out the derivation of the term "schizophrenia" will help to clarify the source of confusion: "Schizo" means split and "phrenia" means mind, thus the interpretation that schizophrenia means split personality. The term was coined by Bleuler, however, and indicates his view that the central problem

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in schizophrenia is the "breaking of associative threads" or the loss of connections between thoughts (see Chapter 11). In fact, schizophrenia and dissociative identity disorder are two very different disorders.

Dissociative Identify Disorder in the Media Many students will be familiar with the television series United States of Tara (2009-2011) in which the title character has DID. Have students evaluate this depiction of DID and how it might relate to public perception of the disorder as compared to earlier characterizations (Dressed to Kill; Me, Myself and Irene; Sybil).

Demonstrating Hypnotic Suggestibility Many theorists and researchers have reported that individuals with dissociative identity disorder are more susceptible to hypnosis, making them more likely to dissociate as a means of coping with trauma. Hypnotic suggestibility may have other, less pernicious, associations with creativity, imagination, and ability to relax.

People who are able to vividly imagine may be better candidates for systematic desensitization. Students may be interested in finding out how susceptible to hypnosis they are; try the following demonstration with the class (based on Hadley, J. and Staudacher, C., 1985, Hypnosis for Change, Oakland, CA: New Harbinger Press, pp. 22-23).

Make sure you are seated in a comfortable position. Gently shake out your legs and then your arms as you begin to relax. Close your eyes and take a deep breath . . . and exhale and relax. Inhale again and feel yourself begin to float into a state of complete relaxation. As you sit, become aware of the rhythm of your breath. Begin to flow with the rhythm of your breathing, and as you inhale, relax your breathing and begin to feel your body drift and float into relaxation. If you hear any sounds around you, just let them go and relax. Let every muscle in your body completely relax, starting at the top of your head.

Relax your face, your neck, your shoulders … Relax your chest, your stomach… hips, thighs, knees…. ankles and feet. Just let your entire body relax. Take another deep breath . . . and exhale slowly. . . letting go. As you inhale, breath in calm energy, and as you exhale, breath out any tension or stress you are feeling in your body or your mind. You are completely relaxed.

Now lift your arms up in front of you to shoulder height. Imagine you are holding the handle of a reusable cloth bag in each hand; like the kind you use to go carry your groceries home from the store.

Curl your fingers around the handles and hold onto the two cloth bags. The bag in your left hand is empty and so it feels very light. The bag you are holding in your left hand feels very, very light. The bag in your left hand is really light because it has nothing in it. It’s as though it isn’t even there. Hold onto that empty bag in your left hand.

The bag you are holding in your right hand has two large jugs of milk in it so it is pretty heavy. The jugs of milk are heavy. And as you hold the bag, a bottle of laundry detergent is added. And a big bag of potatoes. And a few large cans of beans. The bag is completely full of heavy groceries, it is stuffed to the top of the bag until it can fit nothing more. The bag is so heavy, you’re having a hard time holding it up any longer. The bag of heavy groceries pulls your arm down and your arm goes down because the heavy bag is so heavy, so very heavy.

In this exercise, the students' arms will begin to move some distance from their original position at shoulder level. The further the distance between the left and right arms, the greater their suggestibility. Discuss students' experiences.

SOME IDEAS FOR UTILIZING THE INTERNET Supreme Court of Canada © Wiley Canada

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The Supreme Court of Canada website is quite easy to search. www.scc-csc.gc.ca The site allows you to search for a disorder, or "section 16", or mental disorder, etc. This can be done for subject matter of many of the text’s chapters. Have your students look for rulings that involve various mental disorders and see what impact they have had on Canadian law. This can lead to a classroom or Internet discussion about the overlap between abnormal psychology and Canadian law.

Dissociative Identity Disorder While most clinicians now view DID as something other than a distinct psychiatric disorder, much as Nicholas Spanos did before his untimely death, the reality of DID is still debated. An Internet search for "dissociative identity" will yield students a wide variety of sites, many of which argue for the validity of this disorder, and some of which argue from the perspective of individuals who believe they have DID, that it is not only real, but something to be supported and encouraged. This gives students an opportunity to view conflicting views on a topic and challenges them to try to ascertain the validity of competing ideas and Internet sites.

Nicholas Spanos at Skeptic's Dictionary http://skepdic.com/refuge/spanos.html This site contains a review of Multiple Identities & False Memories: A Sociocognitive Perspective by Nicholas P. Spanos, American Psychological Association, 1996. By directing your students to this review, you give them a good overview of Spanos's work. The site hosting this review, The Skeptic's Dictionary, has over 400 skeptical articles on the occult, the supernatural, the paranormal, and the pseudoscientific. This general source can be used at various junctures in a course.

Repressed Memories of Child Sexual Abuse This is a very controversial topic that can generate a good deal of thought and debate. An Internet search for "Repressed Memories" or "False Memory" will yield a good deal of material.

If you would like to provide some guidance in this search here are some suggestions: The APA has a variety of resources about this topic. Do a search of the APA site of repressed or false memory. www.apa.org With regard to the Myth of Repressed Memory the Elizabeth Loftus site has audio lectures, full text articles, etc. http://faculty.washington.edu/eloftus/ SIDRAN is an organization that works with victims of trauma and so is somewhat more sympathetic to the possibility of "repressed memory." Their reading list, however, is quite balanced. www.sidran.org

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There are a variety of ways that you can ask students to address this issue. You can have each of them do searches, find evidence and come to their own conclusions. You can divide them in groups and ask them to find evidence to support one position or another or you can give them the three sites above and ask them to draw conclusions from a narrower range of resources and ideas. Again, it is a very good introduction to the magnitude of information available via the Internet on some topics, and the difficulty in deciding which sources are valid and which are not.

Factitious Disorders The following site has an interesting article that outlines a current view of factitious disorders: www.emedicine.com/med/topic3125.htm Click on Psychiatry; in Psychiatric articles look for Psychosomatic and click on Factitious disorder It also provides a fairly comprehensive bibliography. Students can be referred to this site and then asked to consider several questions with regard to the basic concept of factitious disorders. One significant issue is the nature of diagnosis. What this article indicates is that first a health care provider tries to come up with evidence for a physical disorder, and failing that considers this psychiatric diagnosis. This puts considerable burden on the validity of physical diagnostic procedures, which most people believe to be 99% valid and reliable. In fact the levels of true reliability and validity for the diagnosis of physical conditions is considerably lower than that.

Munchausen’s by Internet This link to Selfhelp Magazine’s site has a list of articles that discuss, briefly, the concept of Munchausen’s Syndrome. Have students select an aspect of Munchausen syndrome that interests them. http://www.selfhelpmagazine.com/search/node/munchausen

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CHAPTER 8 MOOD DISORDERS AND SUICIDE

CHAPTER SYNOPSIS General Characteristics of Mood Disorders Depression is an emotional state marked by sadness, feelings of worthlessness and guilt, withdrawal from others, changes in sleep and appetite, and loss of sexual desire, or interest and pleasure in usual activities.

Symptoms of depression vary across the life span and cross-culturally.

Some people who suffer from periods of depression also experience mania, which is an emotional state of intense but unfounded elation accompanied by irritability, hyperactivity, impractical grandiose plans, and distractibility.

Focus on Discovery 8.1: Depression in Females vs. Males: Why is There a Gender Difference?

Major depression is diagnosed in women at about twice the rate of men. A fundamental question is whether this accurate or an artifact of social norms. If it is accurate, a question still remains as to the cause. Is it genetic, biological or due to social conditions? All of these possibilities are under active investigation.

Formal Diagnostic Listings of Mood Disorders Two major mood disorders are listed in DSM-5, major depression and bipolar disorder. Major depression, formally unipolar disorder, is characterized by profoundly sad mood or loss of interest and pleasure, along with disturbances of appetite, sleep, and activity level, negative self-concept, and suicidal ideation. The symptoms must last at least two weeks. Controversy exists over whether the number and duration of symptoms accurately distinguish people in need of clinical attention. It is more likely that depression exists on a continuum of severity.

The critical symptoms of bipolar I disorder include episodes of mania or mixed episodes of both mania and depression. Manic episodes involve elated or irritable mood, along with hyperactive and risktaking symptoms that impair functioning.

Heterogeneity within the Categories Heterogeneity exists within each category of mood disorder. Patients with "bipolar II" disorder experience both depression and hypomania, an above-normal elevation of mood less extreme than mania. Current subclassifications of major depression include psychotic depression, involving delusions and hallucinations, a melancholic subtype, in which individuals find no pleasure in any activity, and seasonal mood disorder, in which episodes of mood disturbance coincide with the seasons of the year. Two chronic mood disorders listed in DSM-5 are persistent depressive disorder (formally known as dysthymic disorder) involving chronic depression and cyclothymic disorder, involving frequent periods of a milder form of depression and hypomania.

Canadian Perspectives 8.1: Postpartum, Perinatal, and Prenatal Depression in Canadian Women

Instructor’s Manual to accompany Abnormal Psychology, Sixth Canadian Edition by Flett et al.

A variety of Canadian studies have looked at postpartum depression in different social and ethnic groups.

Links have been found between stress, low perceived social support, and low SES. Infants with an irritable temperament have been found to be a significant stressor. Whiffen (1992) suggests that this form of depression is not significant different from other forms of depress and is best seen as an "adjustment disorder" to the stress of pregnancy, birth and early child care.

Psychological Theories of Mood Disorders Psychoanalytic Theory of Depression Freud hypothesized that the process leading to depression begins with fixation at the oral stage, which leads to excessive dependency. Following the loss of a loved one, the mourner introjects the lost person into him or herself and, through mourning work, separates again by reliving memories. For an overly dependent person, the mourning work might fail, and the anger felt at the loved one for desertion might turn inward to become depression. Little evidence is available to support this theory.

Cognitive Theories of Depression Aaron Beck has suggested that people become depressed because they have acquired a negative schema together with cognitive biases or distortions that maintain the negative triad: negative views of the self, the world, and the future. A number of investigations have demonstrated that cognitive bias does accompany depression, although these biases are not always distortions; it is also not clear whether the cognitions are a cause or a consequence of depression. Recent work has focused on how specific cognitions might interact with particular life stressors and lead to the onset of depression.

The learned helplessness theory of depression suggests that unpleasant life experiences that the individual has been unable to control lead to a sense of helplessness and, thus, to depression. Beginning as a noncognitive learning theory based on observations that dogs exposed to inescapable shock fail to learn avoidance, the theory was later revised to incorporate people's attributions of their failures as due to internal, global, and stable causes. The latest version of the theory considers other diatheses, such as hopelessness, in addition to this attributional style.

Canadian Perspectives 8.2: Research on Personality Orientations in Depression Research based in Canada has focused on important aspects of depression including links with perfectionism (Blatt, 1995). The "congruency hypothesis," which looks for a link between stress induced by rejection and depression has received mixed support in the literature. Clearly autonomy, self-criticism, and socially prescribed perfectionism are related to depression, the question remains as to whether they are cause, effect, or both.

Interpersonal Theory of Depression Interpersonal aspects of depression may be relevant to both its etiology and its course. Reduced social support contributes to depression, although evidence suggests that the depressed person plays a role; they tend to be low in social skills and their interpersonal style and constant seeking of reassurance may elicit negative reactions from others. There is some evidence to indicate that poor interpersonal skills in children and adolescents predict the onset of depression.

Focus on Discovery 8.2: Stress Generation and Depression Hammen (1991) suggests that some people are more susceptible to depression due to their habit of generating stress for themselves. This is known as stress generation and there is empirical evidence that links certain forms of stress generation to depression. © Wiley Canada

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Psychological Theories of Bipolar Disorder Life stress and cognitive factors may be important in mania. People who experience mania have low selfesteem, and mania may serve a defensive function. Another promising theory holds that people with mania are overly response to reward cues due to behaviour activation system dysfunction.

Biological Theories of Mood Disorders Genetic Vulnerability Evidence from both family and twin studies supports a heritable component to bipolar disorder and a less strong role for genetics in major depressive disorder. Recently, linkage analysis has been applied to genetic research on mood disorder; this technique involves studying the occurrence of a mood disorder over several generations in a family and simultaneously assessing a genetic marker. While one study has found evidence that a particular gene is involved in bipolar disorder, later studies have failed to replicate this finding.

Neurochemistry, Neuroimaging, and Mood Disorders Two major theories have been proposed relating depression to neurotransmitters. One theory suggests that the depressive episodes of bipolar disorder result from low levels of norepinephrine (with an excess causing mania); the other points to low levels of serotonin in causing depression. Evidence supporting these theories comes from the effectiveness of the tricyclic drugs and monoamine oxidase inhibitors in the treatment of depression and from research on neurotransmitters and their metabolites. However, more recent findings about the action of antidepressant medication cast doubt on the theory that they cause a simple increase in neurotransmitters. It is currently thought that the medications might work by regulating and changing the sensitivity of postsynaptic receptors.

In brain structure and imaging studies, the amygdala, hippocampus, prefrontal cortex, and anterior cingulate have been most implicated in both MDD and bipolar disorder.

The Neuroendocrine System The limbic area of the brain and the hormones of the hypothalamus and pituitary have also been implicated in depression. Evidence from the dexamethasone suppression test and from Cushing's syndrome supports the hypothesis that the hypothalamic-pituitary-adrenal cortical axis may be overactive in depressives. In explaining bipolar disorder, researchers point to the role of thyroid in mania. While such data suggest a biological basis for mood disorders, the interaction of such factors with psychological processes is of great importance for understanding these disorders.

Therapies for Mood Disorders Psychological Therapies Psychoanalytic treatment attempts to help the patient achieve insight into the inward anger believed to cause depression. Interpersonal therapy, a form of psychodynamic therapy that concentrates on present-day interactions between the depressed person and the social environment, has been shown to be quite effective for alleviating unipolar depression and maintaining treatment gains.

Beck's cognitive therapy focuses on altering thought processes through verbal techniques, along with more behavioural components such as encouraging patients to be more active. Research has demonstrated this treatment to be effective, and it also prevents recurrences of depression. Mindfulness© Wiley Canada

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based cognitive therapy (MBCT) was developed to prevent relapse in people who have been depressed. This combination of mindfulness meditation and cognitive techniques is effective in the treatment of anxiety and depression as well as relapse-prevention. Behavioural approaches to depression have included assertion and social skills training.

Psychological treatments for bipolar disorder focus on educating the patient and family about the importance of medication compliance, the need for social support, and the effects of expressed emotion on relapse.

Biological Therapies Biological treatments for mood disorders include electroconvulsive therapy (ECT); despite side effects such as memory loss and confusion, ECT may be the optimal treatment for severe depression. While early studies used bilateral ECT, which allowed the current to pass through both hemispheres, unilateral ECT is more commonly used today.

Deep brain stimulation and repetitive transcranial magnetic stimulation are new treatments which have shown promise with treatment-resistant depression.

Antidepressant drugs, including tricyclics, selective serotonin reuptake inhibitors, and MAO inhibitors, have demonstrated effectiveness. However, side effects can be severe, and patients often relapse after the drug is withdrawn if the treatment does not also include psychotherapy. Lithium carbonate has been shown to control the mood swings of bipolar disorder; it must be monitored carefully because of the possibility of dangerous side effects. In addition, discontinuation of lithium increases a person's risk for relapse.

Suicide Many people with depression or bipolar disorder have suicidal thoughts, and more than half of people who attempt suicide are depressed. It is estimated that 15% of people diagnosed with major depressive disorder will eventually commit suicide. Suicide is also associated with borderline personality disorder, alcoholism, and schizophrenia.

Focus on Discovery 8.3: Some Myths About Suicide Six of the most relevant misconceptions about the nature of suicide are discussed in this focus.

Canadian Perspectives 8.3: Suicide among Canadian Aboriginal People The Innu people of Labrador and Quebec are 13 times more likely to commit suicide than other people in Canada and the Innu of Davis inlet have the highest suicide rate in the entire world. A study of Innu youth between the ages of 14 and 25 found that 34% had attempted suicide. Recommendations have been made to include changes to family and community systems.

Perspectives on Suicide The topic of suicide is complex and a number of theories have been proposed.

Freud proposed a theory of suicide as an act directed against an introjected lost person. Durkheim offered a sociological theory of suicide, distinguishing egoistic suicide, altruistic suicide, and anomic suicide. Baumeister has proposed that suicide represents an escape from aversive self-awareness. Joiner suggested that attempts to commit suicide result from a thwarted need to belong and the perception of being a burden. Shneidman proposed a psychological approach to suicide, in which the act is seen as a conscious effort to seek a solution to a problem that is causing intense suffering. Links between serotonin, suicide, and

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impulsivity suggest a neurochemical basis of suicide. In a risk factor model there are four categories of relevant factors: predisposing, precipitating, contributing and protective.

Research on personality variables and cognitions has identified other factors in the course and the development of suicidal behavior. Scales such as Linehan's Reasons for Living Inventory can help clinicians plan intervention. Prediction of suicide remains inexact, particularly given that we cannot predict the stressors a person may experience.

Recent attention has been devoted to physical factors in suicide. In Canada, researchers are examining the role of brain injury in sports that may cause a degenerative neurological disease: chronic traumatic encephalopathy.

Preventing Suicide Many experts believe that suicide prevention should focus on treating the underlying psychological disorder but recent research casts doubt on the effectiveness of this approach. Application of Shneidman's theories can be useful in prevention. Suicide prevention centres, typically staffed by nonprofessional volunteers, provide around-the-clock consultation to suicidal persons but research on the effectiveness of these centres shows mixed results.

Clinical and Ethical Issues in Dealing with Suicide Ethically, clinicians have to make decisions about breaking confidentiality to prevent a suicide. The issue of physician-assisted suicide for competent, terminally ill individuals has come to the fore since Dr. Jack Kevorkian has assisted a number of people in suicide.

STUDENTS SHOULD KNOW Key Points 1.

The two major mood disorders listed in DSM-5 are major depressive disorder and bipolar disorder.

Cyclothymic and persistent depressive (dysthymic) disorders are two chronic but less severe mood disorders.

2.

Freud viewed depression as resulting from a complex process including fixation at the oral stage, loss, incomplete mourning work, and anger turned inward.

3.

Beck's cognitive theory suggests that depression results from making certain logical errors and negative self-judgements.

4.

According to helplessness/hopelessness theory, early experiences in inescapable, hurtful situations instil a sense of hopelessness that can evolve into depression.

5.

Interpersonal theory focuses on deficits in depressed people and the negative responses they elicit from others.

6.

Psychological theories of mania propose that mania is a defence against depression.

7.

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8.

Neurochemical theories of mood disorders focus on the levels of certain neurotransmitters and on changes in the postsynaptic receptors.

9.

The hypothalamic-pituitary-adrenal axis has been suggested to be overactive in depression.

10.

Psychoanalytic therapy for depression focuses on insight into childhood loss and later self-blame, while Beck's cognitive therapy attempts to uncover negative patterns of thinking and teach more realistic ways of viewing events. Both interpersonal therapy and cognitive therapy have demonstrated effectiveness for treating unipolar disorder.

11.

Biological treatments for depression include electroconvulsive therapy and antidepressant drugs.

Lithium is useful in the treatment of bipolar disorder.

12.

While all people who commit suicide are not depressed, many people who are depressed think about or attempt to take their own lives. Suicide raises important ethical and clinical issues.

Key Terms altruistic suicide (p. 233) anomic suicide (p. 233) attribution (p. 214) autonomy (p. 209) bilateral ECT (p. 226) bipolar I disorder (p. 205) bipolar II disorder (p. 206) brooding (p. 205) chronic traumatic encephalopathy (CTE) (p. 237) congruency hypothesis (p. 210) cyclothymic disorder (p. 208) deep brain stimulation (p. 228) dependency (p. 209) depression (p. 201) depressive paradox (p. 214) depressive predictive certainty (p. 215) dysfunctional attitudes (p. 211) egoistic suicide (p. 233) electroconvulsive therapy (ECT) (p. 226) hypomania (p. 206) learned helplessness theory (p. 213) lithium carbonate (p. 229) major depressive disorder (MDD) (p. 203) mania (p. 202)

monoamine oxidase (MAO) inhibitors (p. 218) mood disorders (p. 201) negative schema (p. 210) negative triad (p. 211) overgenerality effect (p. 224) persistent depressive disorder (p. 204) phototherapy (p. 230) postpartum depression (PD) (p. 207) psychache (p. 236) psychologizers (p. 202) repetitive transcranial magnetic stimulation (p.

228) ruminative coping (p. 205) seasonal affective disorder (p. 208) selective serotonin reuptake inhibitors (SSRIs) (p.

218) self-criticism (p. 209) sociotropy (p. 209) Stroop task (p. 212) suicide prevention centres (p. 240) tricyclic drugs (p. 218) unilateral ECT (p. 226)

New Names Kay Jamison, Martin Seligman, Emile Durkheim, Shneidman, Marsha Linehan, Jack Kevorkian © Wiley Canada

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LECTURE LAUNCHERS 1. Cross Cultural Issues in the Treatment of Major Psychiatric Disorders; Lessons from India Patel et al. (2003) discuss various issues that point to a different set of experiences in the treatment of depression and other major psychiatric disorders in India from those of North America. This paper raises issues about the social construction of mental disorders, geo-politics and global economics akin to the problem of the provision of AIDS treatments in Africa. http://link.springer.com/journal/40263/17/15

2. Mindfulness Based Cognitive Therapies Mindfulness training is a technique that is common to a variety of religious and psychological systems that evolved in China, Tibet, India and other Asian countries. Variants of it are practiced in Buddhism, Hinduism, Taoism, various martial arts and other systems. This is a clear opportunity to discuss the possible connections between Eastern and Western psychologies and attempts to treat mental problems. Clearly many mental disorders, especially depression are universal and have been with mankind since before we evolved into primates. Thus, all cultures at all historical periods have had to devise both models to explain the cause of depression and methods of treatment and prevention. It is possible that cognitive psychology, through a somewhat separate route, experimental cognitive psychology arrived at similar conclusions with regard to the cause and treatment of certain types of depression as those of, for example, Tibetan psychology (Abhiddharma), Taoism, etc. http://psychcentral.com/lib/how-mindfulness-can-mitigate-the-cognitive-symptoms-of-depression/00016240

3. Depressive Self-Schemas and Life Stress One area now being pursued in research on cognitive theories of depression is how different schemata might interact with particular life stressors and lead to the onset of depression. The vulnerability model of depression proposed by Hammen, Marks, Mayol, and deMayo (1985, Journal of Abnormal Psychology, 94, 308-319) suggests that knowledge of a person's self-schema and stressful life experiences may enable us to predict which individuals become depressed in which stressful circumstances.

To test their theory, the investigators used a behavioural recall measure to classify college student subjects as possessing primarily a dependent self-schema (involving particular sensitivity to negative events affecting interpersonal relationships) or a self-critical self-schema (in which negative achievement events are particularly upsetting); subjects rated as having a self-critical schema, for example, were those who recalled more examples of negative experiences involving achievement than involving relationships. In addition, students' level of depression was rated using the Beck Depression Scale and the SADS. Once a month for four months after the above measures were taken, participants reported on their stressful life experiences through questionnaires and interviews, and their depression status was reevaluated. The authors hypothesized that schema-consistent negative life events would be associated with depression, whereas schema-inconsistent negative events would not be. For example, a person with a selfcritical schema would be more likely to become depressed following an academic failure (schemaconsistent) than following an interpersonal rejection (schema-inconsistent).

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schemas than were achievement life-events. The authors suggest that combining the research on life stress with theories of cognitive vulnerability may be useful for predicting the interaction between life events and depression in particular individuals.

4. I Can't Remember Anything But My Misery In line with the finding (above) indicating that depressed people seek negative feedback, evidence from a recent study of memory bias suggests that they also tend to remember information consistent with their negative mood (1996; Watkins, Vache, Verney, Muller, and Matthews, Journal of Abnormal Psychology, 10, 34-41). Further, evidence from this and earlier studies indicates that this memory bias operates at both conscious and unconscious levels.

Students may enjoy experiencing in modified form the procedures used in the study (the actual study was conducted via computer). In the priming phase of the study, say a cue word and ask the students to imagine themselves in a scene that involved themselves and the word presented. The words come from positive, negative, or neutral word sets (see below for a list of some of the cue and target words used in the study; you will say only the cue word in each pair, drawing from the A word list): Set

positive

neutral

negative

A

adored-admired attractive-desirable approval-supported hopeful-optimistic

clothing-sweater furniture-dresser kitchen utensils-spatula musical instrument-piccolo

blamed-punished bleak-hopeless criticized-judged discontent-unsatisfied

B

awarded-praised capable-competent fulfilled-gratified outstanding-superior

animals-giraffe colours-magenta fruits-peaches fuels-propane

downcast-gloomy empty-lonely guilty-accused humiliated-ashamed

Next, after a distracter task the experimenters presented the test phase. Give the students cue words from both lists (one at a time), and ask them to generate as many one-word associations to the word as possible in 30 seconds (perhaps they can write down their associations). The associations are then coded as a target if the participant produced one of the targets from either the studied or unstudied target list. This provided a measure of priming; in other words, it was expected that depressed people would have more associations to negative words that they had previously studied in the first task, demonstrating a memory bias. Results indicated that this was, in fact, the case. In contrast, nondepressed subjects showed more priming of positive words.

These results appear to support the notion of mood state-dependent recall; that is, depressed persons find it easier to recall information that fits with their negative mood.

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5. HANDOUT Depression in Women: A Consequence of Learned Helplessness and Style of Coping?

The following is also discussed in Focus on Discovery 10.1.

Depression occurs more often in women than in men. Research involving both patients in treatment and surveys of community residents consistently yields a 2:1 female:male ratio (Nolen-Hoeksema, 1987).

Understanding the cause of this gender difference may yield some further clues to the etiology of depression.

There has been some speculation that the higher levels of depression among women are best explained as a consequence of learned helplessness. The feminist literature would agree, for it blames the greater incidence of mental problems among women on their lack of personal and political power. Feminists take the position that more women than men become depressed because their social roles do not encourage them to feel competent. What women do does not seem to count compared with the greater power that men have in society. In fact, it may be that little girls are trained to be helpless. In her research on factors influencing the duration of depressive episodes, Nolen-Hoeksema (1987; 1990) proposed an equally plausible account of these gender differences, referring to characteristic differences in the way men and women cope with stress. When responding to depression, men typically engage in activities that will distract them from their mood, for example, engaging in some physical activity or watching television. Women, on the other hand, are less active, tend to ruminate about their situation, and blame themselves for being depressed (e.g., Kleinke et al., 1982). This ruminative reaction is then seen as amplifying the state of depression and negative mood, perhaps by interfering with attempts to solve problems.

Many studies support this hypothesis (Nolen-Hoeksema, 1991). People who report a tendency to ruminate over problems are less likely to engage in efforts at problem-solving (Carver, Scheier, and Weintraub, 1989; Nolen-Hoeksema and Morrow, 1991), and this tendency to ruminate over problems rather than solve them is associated with longer periods of depression (Morrow and Nolen-Hoeksema, 1990; Nolen-Hoeksema and Morrow, 1991). Moreover, women tend to ruminate more than men when depressed and to have longer periods of depressed mood, presumably as a result of their ruminative style (NolenHoeksema, Morrow, and Frederickson, 1991, cited in Nolen-Hoeksema, 1991). This "response style" view of depression is concerned with the ways people cope with a depressed mood once it is evident, rather than with the reasons people become depressed in the first place.

How does it come about that women have more of a ruminative response style to stress and sadness than do men? Nolen-Hoeksema seeks answers in sex-role learning that begins during childhood. It is part of the masculine stereotype to be active and coping rather than reflecting on one's feelings and the reasons for them. Men learn to be less emotionally tuned in than women.

The implications for treatment are clear according to this view. Depressed women and men should be encouraged to increase their coping and pleasure-producing activity rather than dwell on their moods and search for causes of depression. Problem-solving skills should also be nurtured. In a preventive vein, NolenHoeksema suggests that parents and other caretakers encourage girls to adopt active behaviour in response to negative moods.

6. Depression, Aboriginal (First Nations) Peoples and Residential Schools There are several sources of information on the negative outcomes of the residential school experience for First Nations groups below under Internet Resources. Most students will not be all that familiar with the process or experience of the attempt of the Government of Canada to assimilate First Nations peoples into mainstream society by placing several generations of children in residential schools. Some sites where good background information can be obtained include:

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The United Church of Canada Residential School archive project: http://thechildrenremembered.ca/ The Anglican Church of Canada truth and reconciliation site: http://www.anglican.ca/ministry/rs/ The Turtle Island Native Network, Healing and Wellness site: http://www.turtleisland.org/resources/resources001.htm In the context of aboriginal peoples, you may wish discuss the model of learned helplessness. This was practically an experiment in the creation of learned helplessness for both the children who were taken forcefully from their communities and the parents and extended families that were helpless to prevent it.

First Nations groups in Canada face a variety of problems today. They make up 2% of the population and 18% of inmates in prisons. Their suicide rates are much higher than the general population and their rates of substance abuse.

Based on the individuals’ experience in residential schools, psychological theory would predict these sad outcomes. Students can discuss the truth and reconciliation final report, and how to move forward.

DISCUSSION STIMULATORS Assisted Suicide In Canada, the controversial assisted dying Bill C-14 became law in June 2016. To be eligible, individuals must have a medical condition that implies their natural death is near. Many have argued that the bill unnecessarily excludes those who have illnesses that involve great suffering, but which will not necessarily lead to an imminent death. Have the students discuss individuals who are suffering from painful, treatmentresistant mental disorders who believe they should also have a right to physician assisted death. Should they be included in this legislation? For further discussion, see: http://www.medscape.com/viewarticle/858786

Evolution and Depression In the Scientific American article, “Depression’s Evolutionary Roots” from August 2009, scientists Paul W. Andrews and J. Anderson Thomson Jr. argue that depression should not be seen as a malfunction, but rather a mental adaptation that brings certain cognitive advantages.

Does depression play a role in promoting survival of the human race? www.scientificamerican.com/article/depressions-evolutionary/

Biochemical vs. Psychological Theories: An Either/Or? Students are often confused by the "levels of analysis" suggestion that neurochemical explanations of the mood disorders are not incompatible with psychological theories. In our reductionist world, we tend to discard more molar explanations for a phenomenon when more molecular theories are offered. Thus, when © Wiley Canada

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support is found for a neurochemical theory of depression, the immediate (but not necessarily correct) conclusion is that a somatic treatment is called for.

The levels of analysis concept can be conveyed to students with the following example: You are a Martian who has been sent to Earth in order to discover why these peculiar metal vehicles with four wheels move about the surface at varying speeds. Which would be the correct explanation?

(1) There are black surfaces of various widths, lengths, and curvature that contain signposts with symbols on them; these determine the speed of the vehicles.

(2) There are peculiar creatures that occupy these vehicles. Something about their leg movement determines the vehicle's speed, although different creatures appear to prefer to travel at very fast speeds.

(3) These vehicles contain an energy-consuming device that generates the motion of the vehicle.

Some vehicles contain larger or smaller devices in proportion to their total weight, and this influences the speed.

All three explanations would be correct, of course, each at a different level of analysis.

Psychologists make use of explanations at different levels of analysis, but the concept could be broadened to include the more molecular chemist or physicist and the more molar sociologist, economist, or historian.

Acceptance and Commitment Therapy Steven Hayes and his colleagues developed a form of behaviour therapy known as Acceptance and Commitment Therapy (ACT). ACT is based on the premise that it is unnecessary to change all negative feelings: in fact, it is psychologically unhealthy to do so. The central idea is that people often experience emotions as bigger than they really are and they try to avoid the unpleasant experience. Each avoidance strategy that is successful maintains the belief that unpleasant emotions should be avoided. ACT therapists ask patients to accept that unpleasant experiences are part and parcel of the human experience.

ACT raises interesting discussion questions: is our society overly focused on eliminating all feelings or thoughts that we perceive are negative? Does the quest to feel good limit our experience as humans?

Clinical, Ethical, and Philosophical Issues in Handling Suicide You are a psychology trainee (intern) in the gerontology section of a large hospital. Your task is to become familiar with the concerns and problems of the aged and to become more effective in various treatment modalities. One patient who suffers from numerous physical problems and who is taking considerable medication confides in you that he has an agreement with his treating physician to "let up on his medication so that he can die a natural death so that he will not be an excessive financial burden on his family." The patient insists that you not discuss this with his physician. Your supervisor believes very strongly that individuals have the right to make these kinds of decisions about themselves and suggests you accept the statement of the patient and deal with feelings involved. In checking the medical record, you find out that indeed, the medications administered have decreased over the last week. What, if anything, should you do?

Psychological Autopsies: Suicide Notes Suicidologists have been interested for some time in studying the suicide notes left by successful suicides in hopes of discovering the motivations or other characteristics that might provide a basis for predicting and therefore preventing suicides. In the course of such studies, they discovered that suicide notes typically differ from the popular stereotype of what a suicide note should be. As discussed in the text, actual suicide notes and simulated ones (written by normal subjects asked to write a suicide note as if they were going to take their own lives) can be differentiated (see pp. 257-258). Below are real and simulated suicide notes (cf.

Schniedman, E., Farberow, N., and Litman, R. (Eds.), 1970, The Psychology of Suicide. New York: Science House. Chapters 9, 13, and 14). First, read the notes in random order to the class and have them rate which they believe are real and which simulated.

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REAL NOTES: To whom it may concern: I live at 400 Oak Drive, Cincinnati, Ohio. You will find on the kitchen table a letter with instructions to my wife on the disposition of my estate. Please notify all of my friends. Do not mourn me. H. Smith.

I can't stand it any longer. Tell Jack he can have my golf clubs. Harry.

Dear Susan, Please take care of your mother and your brother. They won't be able to get along without you.

I've made a list of things that have to be done and bills to be paid. See if you can take care of things for me. I want you to be sure I'm cremated and my ashes scattered over the ocean. Daddy.

SIMULATED NOTES: To whom it may concern: I have looked and found that life is not worth living. What meaning is there anyway? Better this way. H. Smith.

Everything is so depressing. People talking, no one listening. One day comes, another day comes and goes, and still we're running in the rat race. Maybe someday people will understand why. Until then, goodbye.

Harry.

I thought things would work out between us, but now I see that they won't. I thought you were the only one for me, but now I see differently. Couldn't you have understood my unhappiness. Why didn't you care?

Perhaps we'll meet together in the next world. Bill.

Discuss with students the findings about differences between real and simulated notes (either after you tell them which notes were which, or giving them another chance to guess after they hear the following findings): Real suicide notes are usually more specific and concrete than simulated notes. They contain specific information, use names of people, places and things, make frequent mention of women and sexual themes, and give instructions specific enough to be carried out. In contrast, simulated notes were less specific and contain a number of "thinking" words. You might discuss the implications of these findings for predicting suicide.

SOME IDEAS FOR UTILIZING THE INTERNET Cognitive Styles and the Stroop Task Research (e.g., Gotlib & McCane, 1984) into the cognitive models of mood disorders that have used the “Stroop Task.” Students can be given an experience of this task at several Internet sites.

An explanation of Gotlib study can be found on a web site of the American Psychological Association. http://www.apa.org/monitor/oct04/depression.aspx This site for the University of Washington is a bit more sophisticated in the data collection and presents a good deal more information about the concepts involved.

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http://faculty.washington.edu/chudler/words.html Stroop’s original (1935) article can be read at this York University site. [Note: this site contains many historical psychology papers.] http://psychclassics.yorku.ca/Stroop/

Mood Disorder Associations Several provinces have mood disorder associations that are involved in research and public education. Have your students do a web search for "mood disorder association." They will find several of these organizations.

Have them prepare a comparison of the activities of these various organizations. This summary can be posted on the class website or could be used as the basis of seminar discussion.

Web Search for Famous Mood Disorder Sufferers Here is a site that list books and other writings by individuals with bipolar disorder: www.pendulum.org/information/information_famous_writers.html Have your students find the names of as many people as possible who have been diagnosed with mood disorders. This may turn out to be a bit easy, as there is at least one Internet site that simply lists them all; however, in order to find it students have to search for the right set of words (“mood disorders famous”) in a search limited to Canadian sites. Once you have the amazingly long list, then a discussion can ensue about the possible value of mood disorders in creating artistic and scientific motivation and Kay Jamison's position that bipolar disorder at least has been behind a great deal of the best art and science we have including her own.

Visions: Aboriginal "Psychotherapy" www.visions.ab.ca This site is presented by the Nechi Institute, which describes itself as “an Aboriginal movement committed to holistic healing and healthy, addictions-free lifestyles."

Many students are unfamiliar with the overall pattern of Aboriginal health problems. This site can be used in a variety of ways to introduce your students to the scope of Aboriginal health issues and groups in Canada. You may have them search this site and come up with a list of health issues that concern Aboriginal groups and then discuss these issues in an online discussion group or in a seminar.

Residential Schools: Circle Game Shadows and Substance Abuse in the Indian Residential School Experience in Canada.

Much of the research in Canada the looks for explanations of the relatively high incidence of social problems, especially poverty, drug abuse and suicide among First Nations/Aboriginal groups has focused on the social disruption caused by the attempts on the part of the government of Canada and England to assimilate these groups into a Eurocentric government and society. One of the main tools of the attempt at assimilation was the residential or industrial schools often run by church groups. From the preface: "The Circle Game as presented here is in essence the report on Residential Schooling which we submitted to the Royal Commission on Aboriginal Peoples in October, 1994."

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You may ask your students to read all or parts of this document and then consider what psychological theories could be applied to this experience that would explain why the procedures and experiences of residential schools could lead to future effects such as cultural confusion, depression, drug abuse, suicide, etc. www.columbia.edu/~lnp3/mydocs/indian/chrisjohn.htm Other sources of information on the residential school experience and aftermath include: The University of Saskatchewan http://iportal.usask.ca/index.php?sid=471577458&cat=39&t=sub_pages Indian and Northern Affairs Canada: Backgrounder on Residential Schools www.ainc-inac.gc.ca/ai/mr/nr/m-a2009/bk000000351-eng.asp

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CHAPTER 9 STRESS-RELATED DISORDERS AND HEALTH PSYCHOLOGY

CHAPTER SYNOPSIS Psychophysiological disorders, previously called psychosomatic disorders, are characterized by genuine physical symptoms that are caused or can be worsened by emotional factors. Unlike conversion disorders, psychophysiological disorders involve actual physical damage to the body. While these disorders are not specifically listed in DSM-5, clinicians can diagnose psychological factors affecting other medical conditions (found in the Somatic Symptom and Related Disorders section of the DSM-5). Psychological factors affecting other medical conditions are not considered a form of mental disorder.

It is now understood that any disease can be influenced by psychological factors, such as stress, psychiatric diagnoses, coping styles, and personality traits. The fields of behavioural medicine and health psychology focus on the study and treatment of psychophysiological disorders.

DSM-5 includes a new chapter called “Trauma- and Stressor-Related Disorders” which includes post-traumatic stress disorder (PTSD), formerly grouped with the anxiety disorders. Other disorders included in this new DSM-5 chapter include reactive attachment disorder, disinhibited social engagement disorder, acute stress disorder, and adjustment disorders – each involves a maladaptive response to stress.

Stress and Health Canadian Contributions 9.1: Hans Selye: The Father of Stress Hans Selye of McGill University is regarded as the originator of the modern scientific study of stress. As an endocrinologist he was interested in the general syndrome of being sick separate from the specifics of a given cause of disease. This led him to formulation of the concept of the general adaptation syndrome (GAS) or the body’s response to sustained stress.

Focus on Discovery 9.1: The Autonomic Nervous System and Stress The autonomic nervous system (ANS) is involved in the body’s reactions to stress and is itself impacted by chronic stress. The ANS stimulates the endocrine glands, the heart, and the smooth muscles found in the walls of the blood vessels, stomach, intestines, kidneys, and other organs. The ANS is divided into two parts, the sympathetic nervous system and the parasympathetic nervous system, which may work in tandem or in opposition to each other. The sympathetic nervous system, when energized, accelerates the heartbeat, dilates the pupils, inhibits intestinal activity, increases electrodermal activity, and initiates other smooth-muscle and glandular responses. The experience of stress or the anticipation of stress activates the sympathetic nervous system. The parasympathetic nervous system is involved in de-activation and restoring the organism to a lower state of activation.

Defining the Concept of Stress Selye proposed the general adaptation syndrome (GAS) as a model to describe the biological reaction to sustained and unrelenting physical stress, with phases including an alarm reaction, resistance, and

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exhaustion. More recently, the role of a person's appraisal of stress and coping efforts (e.g., problemfocused coping and emotion-focused coping) have been considered as influencing the experiences of and responses to stress.

Types of Stress and How it is Measured Measures of the stressfulness of life events (e.g., the Social Readjustment Rating Scale) have been shown to be related to a number of illnesses. However, the theory that stress and illness are causally related is limited by methodological weaknesses of the studies. Prospective research using the Assessment of Daily Experience measure demonstrates an increase in undesirable and a decrease in desirable daily life events in the days before onset of episodes of respiratory illness.

The Brief College Hassles Scale was developed to measure stress in university and college students. The scale attempts to tap three main themes: Academic, interpersonal and financial hassles.

Student Perspectives 9.1: The Health Status of Students The National College Health Assessment looked at the health concerns of American college students.

Only 7% of students list their health as fair or poor and over 33% believed that stress negatively impacted their health.

Assessing Coping Coping questionnaires attempt to identify a person's preferred strategies for handling stressors.

Prospective studies of people recently diagnosed with cancer have indicated that avoidant coping methods (e.g. denial, disengagement) lead to a worse prognosis, while people who accepted their diagnosis and retained a sense of humour had lower levels of distress.

Canadian Contributions 9.2: Norman Endler and the Interaction Model of Anxiety, Stress, and Coping Along with David Magussen, Norman Endler developed a model of anxiety in which an individual’s general level of anxiety interacts with situational factors to produced acute, experienced anxiety. Their work also aimed to provide assessment tools for use in devising therapies of anxiety prone individuals.

Other Moderators of Stress In addition to coping strategies, social support has been found to moderate the link between stress and illness. Structural social support, a person's network of social relationships, has been shown to be related to mortality, while both structural and functional social support, the quality of these relationships, have been shown to be related to diseases such as atherosclerosis and rheumatoid arthritis. Higher levels of social support may increase the occurrence of positive health behaviours or have a direct effect on biological processes such as the immune system. However, in situations involving severe stress, the person may be so overwhelmed that social support does no good.

Theories of the Stress–Illness Link Various biological theories have been offered to explain how stress causes illness. Somatic-weakness theory suggests that the weakest organ of the body is likely to be affected by stress. Specific-reaction theory hypothesizes that individuals respond to stress in their own idiosyncratic ways, with the most responsive body system being the likely candidate for disorder. Most people adapt to repeated exposure to

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stress but about 10% do not, putting them at high risk for disease. Stress has been shown to affect the functioning of the immune system, which increases risk for various illnesses.

Psychological theories of stress include Alexander's psychoanalytic theory that different stressrelated illnesses result from different unconscious emotional states, such as anger-in or unexpressed anger. Cognitive and behavioural theories consider the role of perceptions that stimulate sympathetic system activity and the ways people appraise potential stressors.

Cardiovascular Disorders Cardiovascular disorders (CVDs) are medical problems involving the heart and blood circulation system.

Essential Hypertension High blood pressure without an evident organic cause is called essential hypertension. Stressful conditions such as loss of employment, holding anger in, and high-stress jobs have been linked to hypertension.

Coronary Heart Disease Coronary heart disease (CHD) takes two principal forms: angina pectoris (periodic chest pains) and myocardial infarction (heart attack). Both diseases are caused by an insufficient supply of oxygen to the heart; in myocardial infarction, the shortage is so severe that the muscle is damaged.

Both acute and chronic stress has been implicated in CHD. Traditional factors such as cigarette smoking and hypertension have been estimated to explain about half the etiology of CHD. Psychological factors hypothesized to cause CHD include Type A behaviour pattern. Type A persons, reliably identified by means of a structured interview, are intense, competitive, time-urgent, and hostile. Recent studies have examined Type D personality, those who score highly on measures of anxiety, anger, and depression, as a risk factor for CHD. Research on biological factors in CHD point to cardiovascular reactivity as a likely diathesis for coronary heart disease.

Treating Hypertension and Reducing CHD Risk Non-pharmacological treatment of hypertension includes encouraging changes in health behaviours (particularly dietary changes that reduce cholesterol), and relaxation training, occasionally supplemented by biofeedback. Recent research indicates that such relaxation treatment might be most helpful for those hypertensives with high sympathetic arousal and for those who can also reduce their angry thinking.

Biofeedback Biofeedback provides information about heart rate, blood pressure, and other body functions and may be useful in changing physiological responses. Using sensitive instruments to monitor psychophysiological responses, biofeedback has been used in the treatment of hypertension, tension headaches, and for general stress reduction. There is little evidence, however, that biofeedback has any specific effects other than distraction, relaxation, and increased sense of control.

Cardiac Rehabilitation Efforts Frasure-Smith and her colleagues at the Montreal Heart Institute Research Centre have been evaluating the results of a long-term intervention program known as the Ischemic Heart Disease Life Stress Monitoring Program (IHDLSM) (Frasure-Smith & Prince, 1989). The IHDLSM is a cardiac rehabilitation program in which participants are assigned to a control condition or a stress-monitoring condition. This study found that, in general, women did less well with recovery efforts and that the main factor is coping styles. © Wiley Canada

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Post-Traumatic Stress Disorder (PTSD) PTSD involves an extreme response to a severe stressor. The new DSM-5 definition recognizes varied emotional reactions. There are now 20 diagnostic symptoms across four symptom categories: Intrusion symptoms associated with the traumatic event, persistent avoidance of stimuli associated with the event, marked alteration in arousal and reactivity associated with the traumatic event, and negative alterations in cognitions and moods associated with the traumatic event.

Canadian Perspectives 9.1: PTSD in Canadian Veterans and Peacekeepers Canadian soldiers were diagnosed with PTSD-like symptoms after the First World War. An alarming 65.4% of Canadian veterans reported PTSD symptoms during or after volunteering in the U.S. military effort in the Vietnam War. In 2000, the Canadian government recognized PTSD symptoms as a disorder that merits a psychological disability pension.

Etiology of PTSD Risk factors for PTSD include female gender, perceived threats to life, early separation from parents, family history of disorder, previous trauma exposure, and pre-existing disorder. Dissociative symptoms at the time of trauma also increases the risk of developing PTSD. Insecure attachment and tendency to take personal responsibility for failures have also been associated with PTSD. Psychological theories include learning theorists’ focus on classically conditioned fear, and cognitive theorists’ focus on memory disorder. A psychodynamic theory suggests that memories of the traumatic event are so painful that they are suppressed or repressed. Biological theories include behavioural genetics studies that show a possible genetic vulnerability to PTSD. One biological theory holds that the trauma activates the noradrenergic system, making the person startle and express emotion more readily than normal.

Tailoring Treatment for PTSD Exposure-based behaviour therapy involves structured exposure to the trauma through such techniques as visualization and systematic desensitization. Virtual reality exposure programs have been developed for veterans of Iraq. Stress management techniques, assertion training, and couples therapy have also been helpful. Horowitz's psychodynamic approach encourages the person to discuss and expose herself to the trauma in addition to considering the person's pre-trauma personality. A controversial treatment, EMDR, that is purported to be extremely rapid, combines eye movements with thoughts about the feared event.

Finally, some success has been reported for treating PTSD with antidepressants, and a recent clinical trial found support for the use of ecstasy (MMDA). Social support is considered essential regardless of the specific mode of intervention.

STUDENTS SHOULD KNOW Key Points 1.

Psychophysiological disorders are physical diseases produced in part by psychological factors, primarily stress.

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2.

Students should know the various theories linking stress and health, both physiological and psychological.

3.

Students should be familiar with the structure and function of the autonomic nervous system and its relationship to stress.

4.

Psychophysiological disorders are described in DSM-5 as Psychological factors affecting other medical conditions and are included in the DSM-5 section describing Somatic symptom and related disorders (Chapter 7)

5.

The general aim of psychotherapies for psychophysiological disorders is to reduce anxiety or anger.

Because psychophysiological disorders represent true physical dysfunctions, medications are often necessary.

6.

Treatment approaches have included changing health behaviours, relaxation training, changing cognitions and Type A behaviour, stress management, and environmental change.

7.

Post-traumatic stress disorder refers to the after-effects of a severe trauma. Most treatments incorporate exposure and social support.

Key Terms allostatic load (p. 248) anger-in theory (p. 261) angina pectoris (p. 265) autonomic nervous system (ANS) (p. 248) behavioural medicine (p. 247) biofeedback (p. 268) cardiovascular disorders (CVDs) (p. 262) cardiovascular reactivity (p. 267) coping (p. 250) coronary heart disease (CHD) (p. 265) daily hassles (p. 252) distress (p. 247) emotional support (p. 257) essential (or primary) hypertension (p. 263) eustress (p. 247) functional social support (p. 257) general adaptation syndrome (GAS) (p. 247) goodness of fit hypothesis (p. 250) health psychology (p. 247) instrumental support (p. 257-258) interactionism (p. 256) job burnout (p. 255)

job spillover (p. 255) job stress (p. 254) myocardial infarction (p. 265) palliative coping (p. 256) parasympathetic nervous system (p. 248-249) perseverative cognition (p. 256) perseverative cognition hypothesis (p. 256) post-traumatic stress disorder (p. 268) prolonged exposure therapy (p. 275) psychophysiological disorders (p. 246) psychosomatic disorders (p. 246) self-efficacy (p. 261) social gradient of health (p. 246) somatic nervous system (p. 248) somatic-weakness theory (p. 259) specific-reaction theory (p. 259) stress (p. 247) stressor (p. 248) structural social support (p. 257) sympathetic nervous system (p. 248-249) type A behaviour pattern (p. 265) vital exhaustion (p. 255)

New Names Norman Endler, Hans Selye, Roméo Dallaire, Edna Foa. © Wiley Canada

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LECTURE LAUNCHERS 1. Exposure to Stress Hormones There is growing evidence that a variety of psychological disorders are related, at least partially, to the damage caused to the central nervous system by stress hormones. See, for example, Martin Teicher’s article, “Scars that won’t heal: The Neurobiology of child abuse” in the March, 2002 Scientific American. This article can be found at: www.theannainstitute.org/stwh.pdf Teicher reviews evidence that suggests significant, wide-spread neurological damage to such areas of the brain as the hippocampus and frontal lobes. The title of this article is unfortunate because the data the author summarizes applies to a variety of causes of stress, not just child abuse. This model can be considered with regard to PTSD, childhood depression, the precipitation of schizophrenia, psychopathy and other disorders.

He even speculates that the symptoms of adolescent behaviour that derive from the neurological changes may have evolutionary adaptive value. Whether or not you accept this hypothesis it offers an excellent opportunity to discuss the basic assumptions of evolutionary psychology.

2. Laughter as Medicine It is widely believed that stress and the negative emotions that follow from it cause or exacerbate disease. If so, what about the converse? "Is it possible that love, hope, faith, laughter, and the will to live have therapeutic value?" This was the question Norman Cousins (1976, New England Journal of Medicine, 295, 1458-1463) posed as he pondered how to help himself recover from a rare, degenerative disease of the connective tissues of the joints. He was in the hospital, barely able to move or even speak. Gravel-like substances were growing under his skin, forming nodules on his body. When doctors told him that his chances for recovery were 1 in 500, Cousins took the news not as cause for despair, but as word that he was in a fight for his life. He would become personally and actively involved in his treatment in order to survive.

Drawing on the work of Cannon and other pioneers of psychosomatic medicine, Cousins reasoned that stress, by exhausting his endocrine system, had predisposed him to react as he did to some mild heavy metal poisoning. Consequently, he believed that if he could reactivate his endocrine system the body's natural processes would begin to work toward health rather than disease. He hypothesized that as negative emotions impair endocrine system function, positive emotions might activate it to its fullest, maximising its healing powers. Therefore, Cousins prescribed himself a program of affirmative emotions. A movie projector was set up in his room and instead of taking sleeping pills, he would watch "Candid Camera" reruns or have nurses read to him from humour books. "I made the joyous discovery that ten minutes of genuine belly laughter had an anaesthetic effect and would give me at least two hours of pain-free sleep" (p.

1461). Before and after measurements of certain blood characteristics also suggested that the laughter was having beneficial physiological effects.

Positive emotions were only part of his self-prescription: believing that the drugs he was given were toxic to his endocrine system, he persuaded his doctor to administer extraordinarily high doses of ascorbic acid. (These were not delusional ideas; Cousins was very well read in medicine and his ideas, if unconventional, did have some basis in the literature.) Also believing that hospitals were a poor place to be sick, he checked into a hotel instead, where he could sleep undisturbed and laugh without waking others. His recovery began soon after his self-treatment was implemented. Three weeks later, he was jogging on the beach in Puerto Rico, although joint pain and range of motion limitations bothered him for many years to come. Luck? Chance? Placebo effect? Cousins acknowledges each of these possibilities. But for him it was an affirmation of the tremendous capacity of the human mind and body to regenerate. Scientists could do © Wiley Canada

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well, he says, to turn their attention to "the chemistry of the will to live." It is to this realm that psychotherapeutic interventions are directed. For a detailed discussion of Cousin’s laughter therapy see: www.ncbi.nlm.nih.gov/pmc/articles/PMC2762283/

3. Strategies for Coping with Pain An important role for psychologists working in behavioural medicine is assisting medical patients to cope with pain. Many pain intervention strategies stress an avoidant approach, in which patients are taught distraction techniques to divert their attention from the pain. An interesting approach to the control of pain has been the use of mindfulness. The concept of mindfulness originated from a Buddhist tradition Given that mindfulness has been practiced in a variety of cultures over the centuries, it will be interesting to follow its development in psychology. For a discussion of mindfulness as an approach to chronic pain, see: http://psychcentral.com/lib/using-mindfulness-to-approach-chronic-pain/

4. PTSD in Syrian Refugees In the November 2016 issue of Canadian Psychology, Ghumman, McCord, and Chang (Posttraumatic stress disorder in Syrian refugees: A review, 57, 246-253) review evidence of PTSD symptoms in Syrian refugees, noting that women and children seem particularly vulnerable. This article would be a good way to make the PTSD literature relevant to a current crisis, and have students think about what other populations might be traumatized but feeling reluctant or unable to seek help.

DISCUSSION STIMULATORS Demonstrating the Stress-Illness Connection As discussed in the text, several rating scales have been constructed to measure life stress by asking subjects to identify typical life stressors that people often experience. These experiences are then given estimated stress values by another sample. Studies attempting to correlate such life stressors with the number of illnesses suffered during a specific period of time have usually found low positive correlations ranging from .2 to .4 (In the Kobasa et. al., 1982, study described above, the correlation was .24).

Holmes and Rahe's Social Readjustment Rating Scale is reproduced below, along with a health checklist, for use as a handout. Present the health checklist to the class first and have them check off any symptoms they have experienced in the past month, then totalling the number of items checked. Present the life events rating scale next and have the class total up the values of points for events they have experienced within the past year. You may leave the exercise at that, or for a more interesting demonstration, choose 10 students at random, ask them for their scores, and do a quick correlation on the board. Alternatively, find out the range of scores on the life events scale, then pick five or ten students from the upper and lower ends and record their health checklist scores; the means for each group can then be compared.

In discussing the results, emphasize that correlation does not prove causation, although here the assumption is that it is the life stress that causes the illness. Additionally, be aware that correlations done in class may not be particularly high because the rating scales were not constructed with a student sample. You might discuss with students the possible mediators that limit the impact of the life events, such as social support, hardiness, and the like.

Health Checklist minor accident

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cut bruise bloody nose blister pimples painful joints muscle strain eye strain painful urination headache earache toothache chest pain back pain athlete's foot

vomiting diarrhoea constipation indigestion dizziness sneezing coughing hay fever/allergy running nose hoarse voice sinusitis asthma shortness of breath skin rash

Social Readjustment Rating Scale Event

Life Change Unit Value

1. Death of a spouse 2. Divorce 3. Marital separation 4. Jail term 5. Death of a close family member 6. Personal injury or illness 7. Marriage 8. Fired from work 9. Marital reconciliation 10. Retirement 11. Change in health of family member 12. Pregnancy 13. Sex difficulties 14. New family member 15. Business readjustment 16. Change in financial state 17. Death of close friend 18. Change to a different line of work 19. Change in number of arguments with spouse 35 20. Mortgage over $10,000 21. Foreclosure of mortgage or loan 22. Change in responsibilities at work 23. Child leaving home 24. Trouble with in-laws 25. Outstanding personal achievement 26. Spouse begins or stops work 27. Begin or end school 28. Change in living conditions 29. Revision of personal habits 30. Trouble with boss © Wiley Canada

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31. Change in work hours or conditions 32. Change in residence 33. Change in schools 34. Change in recreation 35. Change in church activities 36. Change in social activities 37. Mortgage or loan less than $10,000 38. Change in sleeping habits 39. Change in number of family get-togethers 40. Change in eating habits 41. Vacation 42. Christmas 43. Minor violations of the law

20 20 20 19 19 18 17 16 15 15 13 12 11

Source: from Holmes and Rahe, 1967.

Measuring Stress The life events scale above can be used not only to demonstrate the link between stress and illness but as a jumping off point for discussing the measurement of stress. One controversial point concerns the weighting of the various stressors. Do the students agree with the weights that have been assigned? How would they weight items differently? Do they think averaging subjective ratings is a valid way of measuring the intensity of a stressor? What other methods might be used? Another point of controversy is the inclusion of positive events on the list of stressors. Is an outstanding personal achievement really nearly as stressful as the death of a close friend? Finally, the inclusiveness of the list can be discussed. What significant stressors are not on the list, and what stressors would the students eliminate? Should chronic stressors be distinguished from short-term ones?

As a class exercise, have students attempt to construct a new stressful life events scale that would include items more appropriate for college students. After constructing the scale, repeat the exercise above and see if the correlation between stress and health symptoms is higher using the new scale.

Coping Scale In conjunction with a lecture on strategies for coping with pain (see Lecture Launchers above), students might be interested in discussing ways in which they cope with pain and what strategies they find most helpful in different situations. Students could complete the Billings and Moos Coping Scale (1981, Journal of Behavioral Medicine, 4, 139-157), used in the Holmes and Stevenson study and reproduced below, could be completed by students to aid in this discussion.

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Coping Scale Take a moment to think of a recent personal crisis or stressful life event. Now, read the items below and for each one, mark "yes" or "no" to indicate how you coped with the crisis or stressful event.

YES

NO

1. Tried to see positive side.

2. Tried to step back from the situation and be more objective.

3. Prayed for guidance or strength.

4. Took things one step at a time.

5. Considered several alternatives for handling the problem.

6. Drew on my past experiences; I was in a similar situation before.

7. Tried to find out more about the situation.

8. Talked with professional person (e.g., doctor, clergy, lawyer) about situation.

the

9. Took some positive action.

10. Talked with spouse or other relative about the problem.

11. Talked with friend about the situation.

12. Exercised more.

13. Prepared for the worst.

14. Sometimes took it out on other people when I felt angry or depressed.

15. Tried to reduce the tension by eating more.

16. Tried to reduce the tension by smoking more.

17. Kept my feelings to myself.

18. Got busy with other things in order to keep my mind off the problem.

19. Didn't worry about it; figured everything would probably work out fine.

To score the Coping Scale, first count the number of "yes" answers in each of the following categories: Method of coping:

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Active cognitive: Active Behavioural: Avoidance:

Items #1-6 (6 items) Items #7-12 (6 items) Items #13-17 (5 items)

Focus of coping: Problem focused: Emotion focused:

Items #4-10 (7 items) Items #1-3 and 11-19 (12 items)

Next, calculate the percentage of items answered "yes" in each category.

From Billings, A.G. & Moos, R.H. (1981). “The role of coping responses and social resources in attenuating the stress of life events”. Journal of Behavioral Medicine, 4, 139-157.

Identifying Risk Factors for Cardiovascular Problems Students may be interested in filling out brief self-report measures that may inform them about psychological risk factors for cardiovascular problems. Spielberger's Anger Expression Scale (Spielberger, C. D., Johnson, E. H., Russell, S. F., Crane, R. J., Jacobs, G. A., & Worden, T. J. (1985) In M. A. Chesney and R. H. Rosenman (Eds.) Anger and Hostility in Cardiovascular and Behavioral Disorders, New York: Hemisphere Publishing Company) identifies anger-in and anger-out as modes of anger expression. The student version of the Jenkins Activity Survey (Krantz, D. S., Glass, D. C., & Snyder, M. L., 1974, Journal of Experimental Social Psychology, 10, 284-300) is used to assess the Type A Behaviour Pattern. Students may enjoy discovering whether they would be considered Type A or Type B and refuting or confirming the assessment, as well as discussing the reinforcement of Type A behaviour in our society.

"Reengineering" to Alter Type A Behaviour Finding that they are "Type A," some of your students may be interested in learning how they can reduce their Type A behaviour. Friedman and Rosenman's book, Type A Behavior and Your Heart (1974, New York: Fawcett Columbine Books), available in most bookstores, offers practical suggestions for reducing Type A behaviour. The following drills to reduce "hurry sickness" might be presented in class: "Each morning, noon, and midafternoon, remind yourself—preferably while looking at yourself in a mirror—that life is always an unfinishedness."

"Begin in your avocational hours to listen quietly to the conversation of other people. Quit trying to finish their sentences. . . Seek out a person who stutters and then deliberately remain tranquil."

"Whenever you catch yourself speeding up your car in order to get through a yellow light at an intersection, penalize yourself by immediately turning to the right at the next corner. Circle the block and approach the same corner and signal light again" (p. 206-208).

Stress and the First Gulf War The American Psychological Association and the Kent State University Applied Psychology Center Task Force on War-Related Stress formed a task force during the first Gulf war. This group developed strategies and guidelines for public policymakers, mental health professionals, and persons directly affected by the war. As a class exercise, students could be divided into "task forces" and, based on their readings on PTSD in the text, devise guidelines regarding the first Gulf war (or another traumatic event) in the following areas:

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1) Who is most likely to be at risk for experiencing stress regarding the traumatic event?

2) What common stress reactions would be expected?

3) What reactions would indicate more serious disorder such as PTSD? 4) What coping strategies should affected individuals be encouraged to use?

5) What role can psychologists take in helping alleviate stress following the traumatic event?

6) What can be done specifically to help children cope with the traumatic event?

Hobfoll, S.E., Spielberger, C.D., Breznitz, S., Figley, C., Folkman, S., Lepper-Green, B., Meichenbaum, D., Milgram, N.A., Sandler, I., Sarason, I., & van der Kolk, B. (1991). “War-related stress: Addressing the stress of war and other traumatic events”. American Psychologist, 46, 848-855.

Physician-Patient Relationship Given the increasing focus on psychological influences on health and health behaviour, the impact of the physician-patient relationship on illness has become an increasing area of interest. The dramatic increase in interest in family medicine among medical school students is one reflection of this trend. Did the old family doctor know something that has been forgotten during the technological boom in medicine? One interesting observation in this regard is that, before the advent of effective treatments by modern medicine, the history of medicine is considered to be a documentation of the effectiveness of the placebo effect. Perhaps the "placebo effect" is something that physicians want to capitalize upon more than they have in their recent, technological history.

Stress and the Immune System Recent literature has continued to demonstrate a link between stress and the mammalian immune system.

See: Kanitz, et al. (2004), “Consequences of repeated early isolation in domestic piglets (Sus scrofa) on their behavioural, neuroendocrine, and immunological responses”, Brain, Behaviour and Immunity, 18, 1, 35-36 or Madelon et al. (2003). “Moderation of physiological stress responses by personality traits and daily hassles: less flexibility of immune system responses”. Biological Psychology, 65. 1, 21-49.

Most students will have noticed that the general health of groups of students seems to suffer toward the end of a term, particularly a pre-Christmas term. Students can be asked to investigate this observation with a questionnaire and then discuss possible mechanisms for this effect.

Social Gradient of Health The article by Julie Kosteniuk, (2003), “Tracing the social gradient in the health of Canadians: primary and secondary determinants”. Social Science and Medicine, 57, 2, 263-277, is a good starting point for a discussion on the current state of health care in Canada and the link between a variety of social factors, such as poverty, and general health. This article suggests an ecological approach to health care in which a wide variety of factors interact, many of them mediated by psychological issues, to produce health or disease. It provides support of a general biopsychosocial model of health and disease. Kosteniuk’s paper can be found by going to http://www.sciencedirect.com/science/journal/02779536/57/2 Click on Volume 57 and go to issue 2.

Demonstration of Mindfulness

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Mindfulness training is used by many health care workers and, increasingly, by cognitive therapists as an adjunct to treatment for a variety of mental disorders. There are several Internet sites that provide simple instructions for beginning the practice of mindfulness.

The Ottawa Mindfulness Clinic: www.ottawamindfulnessclinic.com

Article from Shambala Sun on how to begin mindfulness meditation: www.shambhalasun.com/index.php?option=content&task=view&id=2125

SOME IDEAS FOR UTILIZING THE INTERNET PTSD Assessment The PTSD Association of Canada offers resources as well as an assessment for people who think they might suffer from PTSD. http://www.ptsdassociation.com/

Coping with Cancer The National Cancer Institute in the United States provides a website with a considerable amount of information. Included in this site is a section on “coping with cancer” that addresses a number of topics that are relevant to psychology. Students can be asked to visit this site and find examples of the application of psychology in the treatment of cancer and with helping patients and families of patients cope with the disease and the side effects of its treatment. www.cancer.gov

The Efficacy of Humour in Improving Psychological Well-being of Residents of Long-term Care Facilities Rosangela Boyd and Francis McGuire www.lin.ca/resource/html/Vol23/v23n4a7.htm This article is available on-line and can be used to stimulate a discussion around the efficacy of humour in effecting human mood and physiology. The conclusion of this study is that humour can have lasting effects on human health. Students can be asked to consider the actual mechanism that could be behind this effect in a face-to-face seminar discussion or an on-line discussion via the WebCT bulletin board system.

North American Chronic Pain Association of Canada www.chronicpaincanada.org

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This Canadian site has clear background information on the issue of chronic pain, and several helpful links.

The Interviews and Articles link is a good starting point. This is a site to which students could be sent with the task of ascertaining the basic issues and methods being used to cope with chronic pain. They could be asked to gather information on the types of problems that lead to chronic pain, the Canadian resources for sufferers of chronic pain and the treatments available for this problem. This is a good example of a set of disorders that do not readily respond to one type of treatment. What seems like an essentially physical or "medical" issue turns out to be quite complex and the most effective treatments are not pain killing drugs, but more subtle methods. This can lead to discussions about the real cause of these disorders, the interaction of mind and body, etc. Students may also be directed to the information available at the Victoria, BC Pain Clinic site: www.painbc.ca/content/pain-clinics-and-services

Canadian Centre for Victims of Torture http://ccvt.org/ The Canadian Centre for Victims of Torture aids survivors in overcoming the lasting effects of torture and war. Their website summarizes their activities and provides links for more information on this topic.

Hypnosis Students’ interest in hypnosis can explore its various uses including pain management at: www.apa.org/research/action/hypnosis.aspx

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CHAPTER 10 EATING DISORDERS

CHAPTER SYNOPSIS With the publication of DSM-IV, eating disorders became a separate category of disorder. Formerly, they had been listed as disorders beginning in childhood or adolescence.

Eating disorders, as a separate diagnostic category, has been retained in the DSM-5 in a chapter entitled Feeding and Eating Disorders. One of the most frequent diagnoses was not either anorexia or bulimia but rather Eating Disorder Not Otherwise Specified (EDNOS). However, the EDNOS general diagnostic category has been dropped from the DSM-5 in favour of new designations under the heading Other Specified Feeding and Eating Disorders. This category applies to feeding and eating disorders that cause clinically significant distress but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class. Included in the Other Specified is a new designation, night eating syndrome.

Clinical Description Anorexia Nervosa Anorexia nervosa typically involves serious weight loss, an intense fear of gaining weight, and a distorted sense of body shape. In the restricting type of anorexia, weight loss is due to food restriction; the bingeeating-purging type also involves regular binge eating and purging. The latter subtype has been found to be associated with behaviours that are more psychopathological.

Eating disorders are many times more common in young women than in men, and they usually begin during adolescence. Patients with anorexia are often diagnosed with depression and anxiety disorders.

Biological consequences of anorexia include changes in blood pressure, heart rate, bone mass, skin, nails, hair, and hormone and electrolyte systems. About 70% of patients recover but treatment takes years and relapse is common. Death is a particular risk, either by congestive heart failure or by suicide.

Focus on Discovery 10.1: Eating Disorders and Intentional Self-Harm Some models of the etiology of eating disorders see them as forms of self-harm. Research has found a correlation between the experience of an eating disorder and vulnerability to eating disorders and intentional self-injury.

Bulimia Nervosa Bulimia nervosa consists of episodes of gross overeating followed by induced vomiting, fasting, laxative abuse, or excessive exercise to prevent weight gain. There are many physical side effects of bulimia, including potassium depletion, diarrhea, tearing of tissue in the stomach and throat, and loss of dental enamel. Mortality is much less common with bulimia nervosa than anorexia nervosa.

Case Study 10.2: A Student Struggles with Bulimia Nervosa: A Case Study This case study provides a brief description of a woman college students and her eating behavior as it relates to bulimia.

Instructor’s Manual to accompany Abnormal Psychology, Sixth Canadian Edition by Flett et al.

Student Perspectives 10.1: Fat Talk and Why “Chewing the Fat” is a Risk Fat talk is a term that has been coined to reflect comments that express negative opinions about their bodies; fat talk is thought to be means of fitting in with peer group. However, fat talk appears to be associated with a highly defensive and negative sense of self.

Binge Eating Disorder DSM-5 has now incorporated binge eating disorder as a diagnosis. The disorder involves recurrent binges, lack of control during binges, distress about bingeing, rapid eating, and eating alone. It is distinguished from other eating disorders by absence of weight loss and purging, and is more prevalent (see also Night Eating Syndrome, p. 282 of the text).

Etiology of Eating Disorders Biological Factors Family and twin studies have strongly suggested that both anorexia and bulimia have a genetic component.

The lateral hypothalamus has been proposed to play a role in anorexia; however, research does not support a causal link. Endogenous opioids (substances produced by the body which reduce pain sensations) do appear to play a role in eating disorders; starvation may increase the level of endogenous opioids thus providing a powerful reinforcement in the form of a euphoric state. Finally, serotonin levels have been found to be low in bulimic patients and may stimulate carbohydrate craving.

Socio-cultural Variables The standards society has set for the ideal body have changed dramatically over time, resulting in very thin models for women conveyed by such images as Playboy centerfolds, beauty pageant contestants, and Barbie dolls. Many girls of normal size believe they are overweight, and dieting and liposuction have become increasingly common, especially in women. Obesity is associated with extreme negative stereotypes.

Gender Influences Eating disorders are far more prevalent in women than in men, due to the heavy influence on women of cultural standards of thinness. Risk for eating disorders is especially high among groups such as models, dancers, and gymnasts. Eating disorders are often preceded by dieting and other concerns about weight.

Cross-Cultural Studies Eating disorders are far more common in industrialized societies than in non-industrialized nations. Cultural differences have been attributed to differing ideals for body types, and other societal influences. However, other researchers have suggested that variants of eating disorders occur in non-industrialized nations.

Cognitive-Behavioural Views Cognitive-behavioural theories of anorexia emphasize the fear of fatness and body-image disturbance as motivating factors that make self-starvation and weight loss powerful reinforcers. Achieving or maintaining thinness is negatively reinforced by anxiety reduction. The drive for thinness is also influenced by personality and socio-cultural variables, and criticism from peers and parents about being overweight.

In bulimia, the binge-purge cycle stems from inability to restrict eating which leads to a fear of weight gain, which is relieved by the binge.

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Psychodynamic Views Most psychodynamic theories believe the core cause is disturbed parent-child relationship. Hilde Bruch proposed that anorexia results from children's attempts to gain competence and respect and ward off feelings of helplessness and powerlessness. Such a process is thought to begin with parents who impose their own wishes without consideration of the child's needs or desires.

Family Systems Theory Salvador Minuchin has proposed that eating disorders play the role of helping families avoid other conflicts.

He documented that families of children with eating disorders are characterized by enmeshment, overprotectiveness, rigidity, and lack of conflict resolution. However, the causal relationship between these characteristics and the eating disorder has not been established.

Characteristics of Families Studies focused on the families of individuals diagnosed with eating disorders are relevant to both psychodynamic and family systems theories, but results have been ambiguous. Studies that have looked at the somewhat gross measure of "family conflict" have found conflicting results. Studies that have attempted to support Minuchin's theory have tended to find patterns inconsistent with the predictions based on this model. Part of the problem with these studies is that they have almost exclusively been designed using patient and family perception rather than observations by neutral, trained observers.

Child Abuse and Eating Disorders Some studies have suggested a link between childhood sexual abuse and eating disorders, but again these are studies that use self-report methodologies. A Toronto study (DeGroot, et al., 1992) found a high incidence of women with eating disorders reporting sexual abuse, and Leonard, Steiger, and Kao (2003) found that Quebec women with bulimia had higher levels of childhood abuse. The Canadian Community Health Survey (Afifi et al., 2014) reported that physical and sexual abuse were predictors of having an eating disorder.

Personality and Eating Disorders Trait negative emotionality and perfectionism are risk variables for eating disorders. Other personality factors consistently linked with eating disorders include avoidance motivation, lower extraversion and selfdirectedness, neuroticism, perfectionism, and sensitivity to social rewards. Retrospective studies of personality before the onset of an eating disorder point to perfectionism, shyness, and compliance. A complication in this research is that eating disorders also affect personality. Although perfectionism dimensions are strongly implicated in eating disorders, longitudinal, prospective research on these dimensions still needs to be done.

Treatment of Eating Disorders The vast majority of people with eating disorders do not receive treatment. However, in extreme cases, hospitalization is required to treat anorexia and its medical complications.

Biological Treatments

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Antidepressants have been shown to have mixed results in the treatment of eating disorders. Fluoxetine (Prozac) is the only medication approved for treatment of an eating disorder. Fluoxetine has shown better results in the treatment of bulimia nervosa than anorexia nervosa.

Psychological Treatment of Anorexia Nervosa The immediate goal of treatment for anorexia, weight gain, is often met through inpatient behaviour therapy programs. The second goal is long-term maintenance of gains in body weight. Recent research has supported family therapy, cognitive behaviour therapy, and psychodynamic therapy in the treatment of anorexia.

Psychological Treatment of Bulimia Nervosa In cognitive behaviour therapy for bulimia, patients are encouraged to question society's standards for attractiveness, and uncover and change irrational beliefs about eating patterns. Fairburn's cognitivebehavioural treatment also focuses on teaching normal eating patterns. Patients eat forbidden foods in front of the therapist while practicing relaxation and addressing cognitive distortions.

While both cognitive-behavioural and interpersonal therapies have both achieved some success (and more success than drug treatments), overall success rates with bulimics are still less than 50 percent. The low success rates may be partly due to the comorbidity of eating disorders with other serious psychological disorders.

Canadian Perspectives 10.1: Eating Disorders in Canada In 2014, a federal report was published called “Eating Disorders Among Girls and Women in Canada.” The report included 25 recommendations, including supporting research on the impact of media endorsement of narrow definitions of beauty and a thin ideal, education on eating disorders among physicians, support and cooperation among various levels of government, creation of multidisciplinary care teams, and greater funding for research on eating disorder issues.

STUDENTS SHOULD KNOW Key Points 1.

Anorexia nervosa is characterized by refusal to maintain normal body weight, intense fear of becoming fat and a distorted sense of body shape.

2.

The symptoms of bulimia nervosa include episodes of binge eating followed by purging, fear of fat, and a distorted body image.

3.

Both anorexia and bulimia begin in adolescence and have high comorbidity with other psychological disorders.

4.

Binge eating disorder has been included as a separate diagnostic in DSM-5. It is characterized by symptoms similar to bulimia but without purging behaviours.

5.

Biological research on eating disorders suggests a genetic diathesis.

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6.

Psychological causes of eating disorders include cultural standards for thinness, cultural factors, gender issues, parent-child relationships, racial factors, and personality characteristics such as perfectionism and low self-esteem.

7.

The main biological treatment of eating disorders has been the use of antidepressants, particularly for bulimia.

8.

Behavioural interventions within hospital settings can achieve weight gain in anorexics, but long-term maintenance of weight gain has not been reliably achieved.

9.

Bulimia has been treated with some effectiveness using both cognitive-behavioural and interpersonal psychotherapy. However, only about half of patients show improvements that last over time.

Key Terms amenorrhea (p. 283) anorexia nervosa (AN) (p. 282) binge eating disorder (BED) (p. 289) body mass index (p. 288) bulimia nervosa (BN) (p. 286) diagnostic crossover (p. 288) eating disorder not otherwise specified (EDNOS) (p. 282)

fat talk (p. 287) lateral hypothalamus (p. 290) night eating syndrome (p. 282) overevaluation of appearance (p. 283) purging disorder (p. 282) Scarlett O’Hara effect (p. 292) social comparison orientation (p. 288) thinspiration effect (p. 295)

New Names Hilde Bruch, Salvador Minuchin

LECTURE LAUNCHERS 1. First Person Accounts of Anorexia and Bulimia The following first person accounts by adolescents with eating disorders appeared in Ms magazine (March/April 1993, Berman, N., “Disappearing Acts”, pp.42-43; reprinted by permission of Ms magazine, (c) 1993). The author interviewed the girls during a three week visit to the Eating Disorders Unit of Highland Park Hospital in Illinois. The names used are pseudonyms.

Cait, Age 17 I was going to make myself perfect. I thought I had control of it. I didn't think I had a problem. I thought I was happy, but I can't really figure out what happy is.

I ate every couple of days. Or I would have a rice cake. I was convinced that an orange was too much. I got to the point where everything was too much. I restricted everything. After a while you don't feel the hunger pains anymore. And you don't know when you're hungry. I started restricting more and more, and then after a while I was craving food and that's when the bingeing started.

In the beginning I was throwing up healthy food, broccoli, carrots, apples. And then I thought, if I'm going to do this, I might as well binge on what I like. I left a party early because I had to have a binge. I told

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my boyfriend I was tired, got in my car, and went to McDonald's. God, it was scary while I was doing it. I ate a Big Mac, a large fries, an apple pie, a hot fudge sundae with nuts, and I wasn't done. There was a grocery store right there. I got, like, a thing of Ben & Jerry's ice cream, a couple of candy bars, a big, like, two-pound bag of Peanut M&Ms. I ate at McDonald's, I ate in my car, and I ate the rest of it at home.

I felt good after because it was gone. But in the end it was not so much the bingeing, it was not eating at all. I wouldn't drink pop, not even diet pop. My logic was: why? I don't need it. It was something extra. I knew there were no calories, but I thought there had to be something in the pop.

I didn't want anybody to find out. I would make food, SpaghettiOs, and give it to my dog. My boyfriend has never seen me eat. I would say, "Oh, I just ate," or "I'm not hungry." I didn't want him to think that I was a cow or a pig or something. Like, if we were out and other girls were eating, I would get satisfaction out of the fact that I wasn't. It made me feel better than them.

I make people tired. I'm constantly on the go. I was doing a thousand and one things. It was easier to go a thousand miles an hour than to deal with anything. I think I wasn't really happy with the image I was living, but I didn't know what to do.

I practice being gentle. I practice in front of the mirror saying hello. I want to present myself in the best possible way, and if I can present myself better, as happier, as more energetic, then I want to know how to do it.

I want so badly to just be me. I want to get out of this person, this perfectionist that everyone admires.

Nicole, Age 16 It's like a huge feeling that I'm not right. That I could be better. I feel like I am a heavy person. You know how really, really fat people must feel? That's how I feel. I could not tell you how I look in jeans. I always had to go shopping with my mom so she could tell me how they looked. I honestly don't know what I'm supposed to look like.

It started the spring of sophomore year. People said I had a good body all the time, a nice butt. I would turn my head away and blush. I got compliments up until the time I came into the hospital. Guys said I looked hot and I was wearing children's size 14 jeans.

I hated the curves. I've got to get rid of the curves. I think my legs are fat. And this muscle here. I never sit with my legs crossed. I always look in the mirror sideways.

I used to spit out my food instead of throwing up. Tootsie Rolls, peanut butter, M&Ms, Starburst. I had Jane Fonda's Workout, Kathy Smith's Fat Burning Workout. They're addicting. I watched them in the basement. I did butt exercises, sit-ups, stretches. I was never too thin. I never had a goal weight; it was always just not yet.

My boyfriend couldn't bear to touch me. He stopped sleeping with me because he said I was just bones. I tried to get thinner to look better and win him back, but it just repulsed him. I thought I could be more appealing to him because all of the most beautiful women, the sexiest, are the thinnest. All the women men desire are thin. In the movies, the desired women are thin. Magazines. I would look through them at night: Vogue, Mademoiselle, Seventeen, Cosmopolitan, Elle, Harper's Bazaar.

I based how I felt about myself on the way a guy felt about me. I would try to be a good girlfriend and when I did get hurt, it was a big blow.

I was readmitted because I tried to kill myself. In my car, in the garage. It was the most real attempt. Everyone said I was doing so good, and then when I wasn't, when they build it up, I get sick.

A lot of it has to do with my relationship with my father. I was taught to be quiet. Girls should be quiet. I should not express myself. I've always wanted a father that I know I can never have. For 16 years, I've wanted a father that I can never have.

Sometimes I still wish I could fit into my old jeans. And that empty feeling—on top of the world, like you could conquer anything. I loved it.

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While a very small percentage of individuals meet criteria for a diagnosis of eating disorder, disordered patterns of eating that do not constitute full-blown disorders are quite common. Studying the course of eating patterns over time may assist in our understanding of eating disorders, while also exploring less pathological forms of disordered eating.

A study by Heatherton et al. does just that (1997, Journal of Abnormal Psychology, 106, 117-125).

In a collaborative effort between several universities, Heatherton and colleagues studied a cohort of 715 men and women who were teenagers in the last 1970s and early 1980s, a period when dieting and eating disorders were quite prevalent. The participants were studied during their college years and surveyed again 10 years later.

Results indicated that for women, body dissatisfaction, chronic dieting, and eating disorder symptoms generally diminished in the 10 years following college. Particularly dramatic declines were found for eating disorders, and the prevalence of binge eating and purging.

This article can be found at: http://sites.dartmouth.edu/thlab/files/2010/10/97_Heatherton_etal_JAP_106.pdf

3. Predictors of Recovery Following Treatment for Anorexia As discussed in the text (p. 271), eating disorders are notoriously difficult to treat. A study by Herzog, Schellberg, and Deter (1997, Journal of Consulting and Clinical Psychology, 65, 169-177) followed for 12 years a group of 69 patients in Germany who had undergone inpatient treatment for anorexia nervosa. The treatment consisted of a three month hospital stay combining behavioural and psychodynamic approaches.

Even with this intensive treatment (not likely to be available in the United States considering changes in insurance coverage for psychiatric hospital stays), 50% of the anorexic patients did not improve until after 6 years.

The study did reveal some factors that predicted recovery. Patients likely to recover sooner were those with restrictor-type anorexia and with low serum creatinine levels (high serum creatinine levels are a biological marker of poor renal function suggestive of frequent vomiting). Purging behaviour, particularly in combination with social disturbances, predicted poor probability of recovery. The social disturbances measured included low integration with a peer group, disturbed communication with family, exaggerated dependence on the family of origin (Minuchin's concept of enmeshment?), no steady relationship, no founding of a family of her own, and no professional integration.

Implications of the study include the long course of the illness, with recovery unlikely after one episode of treatment. It would seem that treatment planning should consider the stage of illness and the need for follow-up and aftercare services. Further, it appears that treatment needs to address social functioning in addition to symptom change. This suggestion would fit with the finding (cited in the text) that Interpersonal Therapy had an effect on bulimia even without addressing symptom change at all.

4. Treatment of Binge Eating Disorder Data are starting to come in regarding binge eating disorder and its treatment. As discussed briefly in the text, the disorder refers to a pattern of binge eating similar to that seen in bulimia, but without accompanying purging, fasting, or excessive exercise. The syndrome is complicated both psychologically and medically, since it usually combines disordered eating (with its comorbid psychopathology) and frank obesity (with its medical complications).

Agras and colleagues recently treated and followed 75 obese women with binge eating disorder (1997, Journal of Consulting and Clinical Psychology, 65, 343-347). The treatment involved 30 sessions of group therapy using a manualized treatment. The first 12 sessions involved cognitive-behaviour therapy for binge eating, and the subsequent 18 sessions focused on weight loss. The cognitive-behavioural interventions included reducing the intervals between meals or snacks, decreasing avoidance of feared foods and coping with the precipitants of binge episodes, and relapse prevention. The weight loss sessions stressed © Wiley Canada

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gradual weight loss with caloric restriction achieved mainly by reduced fat intake. For a copy of this article go to:

http://psycnet.apa.org/psycinfo/1997-07825-019

DISCUSSION STIMULATORS Is Force Feeding an ethical treatment?

The forced nourishment of individuals with anorexia nervosa (typically through a feeding tube) is a controversial treatment strategy. Have students discuss whether force-feeding is an ethical treatment for patients with anorexia and, if so, whether the feeding can be continued once the individual’s life is no longer in danger. (Students might want to think about decision-making capacity, age of the patient, effects of starvation, and quality of life—follow this link for a discussion from Psychology Today https://www.psychologytoday.com/blog/hunger-artist/201207/anorexia-and-the-right-die)

Gender Differences It should be possible to generate a lively class discussion by asking students their opinion on Davison, Blankstein, Flett and Neale’s assertion, “Women are typically valued more for their appearance, whereas men gain esteem more for their accomplishment” (p. 313)

Government Intervention in Eating It seems to be accepted that governments have the right and duty to intervene in the lives of individuals and families with regard to drug use, yet eating problems are an equally serious problem for governments. In a December, 2003 issue of the Economist, the question of whether or not governments should intervene in issues of nutrition is discussed. An abstract of the article: Obesity is the world's biggest public-health issue today--the main cause of heart disease, which kills more people these days than AIDS, malaria, war; the principal risk factor in diabetes; heavily implicated in cancer and other diseases. There's nothing radical about the idea that governments should intervene in the food business, but obesity is not about ensuring that people don't get poisoned: it is about changing people's behaviour. Should governments be trying to do anything about it at all? Britain's government is gesturing towards tough restrictions on advertising junk food to children. Insurance companies should be able to charge fat people more, because they cost more, but group health insurance schemes, which cover most Americans, are forbidden, by law, to discriminate against fat people. The health secretary, Tommy Thompson is trying to wiggle his way around this prohibition to allow health companies to give discounts to people on fitness programmes. Society has a legitimate interest in fat, because fat and thin people both pay for it. But it also has a legitimate interest in not having the government stick its nose too far into the private sphere Source: Economist; 12/13/2003, Vol. 369 Issue 8354, p11, 1p, 1c This issue is even more relevant in Canada where there still is a public funded health system and where the cost of treating eating disorders and the diseases that devolve from obesity are paid for by taxes. This general issue could lead to a lively discussion. There is a potential “catch 22” in this issue in that the attempts to get adolescents to consider their nutritional intact, avoid excess weight, etc. could encourage eating disorders in those predisposed. © Wiley Canada

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Bulimia on Campus Eating disorders are likely quite common among students in your class. Some estimates suggest that as many as 20% of college females engage in some form of bingeing and purging. Among some, it is the "perfect diet" and almost has a faddish quality. Other instructors have found it useful to ask students to tell about bulimia in their social context. This can lead into a discussion of feminism and what women value.

Dieting Survey Taking a survey of your students could illuminate societal pressures to diet, sex differences in dieting, and lead to a discussion of changing social trends. Pass out the following survey (adapted from Polivy and Herman's Restraint Scale discussed in the text). In addition to having students complete the questionnaire, you might ask them to have their parents complete it. This would provide some perspective about dieting issues in people from another generation, and lead to a discussion of age-related vs. cohort effects.

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HANDOUT Dieting Survey

Gender: _____ female _____ male 1. How often are you dieting? (Circle one) never

rarely

sometimes

often

always

2. At what age did you first start dieting? _______ 3. What is the maximum amount of weight (in pounds) you have ever lost in one month?

0-4

5-9

10-14

15-19

20+

3.1-5

5.1+

4. What is your maximum weight gain within a week?

0-1

1.1-2

2.1-3

5. Would a weight fluctuation of 5 pounds affect the way you live your life?

Not at all

slightly

moderately

very much

6. Do you eat sensibly in front of others and splurge alone?

Never

rarely

often

always

7. How conscious are you of what you are eating?

Not at all

slightly

moderately

extremely

8. How many pounds over your desired weight are you now?

0-1

1-5

6-10

11-20

21+

Instructor’s Manual to accompany Abnormal Psychology, Sixth Canadian Edition by Flett et al.

Prevention of Eating Disorders A good deal of effort in Canada has been put into programs that attempt to lower the incidence of eating disorders in the general population through primary prevention. You may ask your students to review the differences between primary, secondary and tertiary prevention and to consider the basic outlines of each type of program for eating disorders.

SOME IDEAS FOR UTILIZING THE INTERNET National Eating Disorders Information Centre www.nedic.ca/ “The National Eating Disorder Information Centre (NEDIC) is a Toronto-based, non-profit organization, established in 1985 to provide information and resources on eating disorders and weight preoccupation.

NEDIC began as a result of the concerted efforts of a group of health-care providers. Based on a national needs-assessment undertaken in 1983 by the Health League of Canada, a proposal was made for initial funding of an information centre which would focus on eating disorders and socio-cultural factors influencing the health-related behaviour of women.”

This site and their list of links offer a considerable amount of information on eating disorders and the status of models of cause and efforts at treatment. Students may be referred to this site to gather information, or compare notes with the information presented in the text.

Canadian Psychological Association “Psychology Works for Eating Disorders” www.cpa.ca/psychologyfactsheets/eatingdisorders/ This site is put together by the clinical group of the Canadian Psychological Association. While it does suggest that “psychology” works for eating disorders it fails to provide evidence to that effect. There is a link, however, which allows the student to look for resources in their area for the treatment of eating disorders. An interesting exercise is to assign various places in Canada to students and have them try to find professionals who will treat eating disorders, comparing availability, methods, etc.

Eating Disorder Resource Centre British Columbia (EDRCBC) www.bcchildrens.ca/ Enter ‘Eating disorders’ into the British Columbia’s Children’s Hospital search engine This site contains a good deal of information and many links to other sources of information. Students could be directed to this site with a specific task; such as to clearly differentiate treatment recommendations for anorexia vs. bulimia or to look for a comprehensive model of the cause of an eating disorder. This site makes reference to a number of problems that are related to, but not listed as, eating disorders. Students could be asked to come up with as many different descriptions of eating problems as they could from this site and its related links.

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A Single Laboratory’s Extensive Research on Eating Disorders A link given earlier provides an impression publication list of Todd Heatherton at Dartmouth College.

Students can browse a vast array of publications on eating disorders. Any article of interest can be accessed directly from the site. http://sites.dartmouth.edu/thlab/publications/

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CHAPTER 11 SCHIZOPHRENIA

CHAPTER SYNOPSIS Case Study 1.1 Case Excerpt: A Flight Attendant Copes with Psychosis Chapter 11 begins with Case Study 11.1: A flight attendant copes with psychosis that describes the struggles of a young woman suffering from schizophrenia and her difficulties in maintaining full time employment.

Clinical Symptoms of Schizophrenia Schizophrenia is a psychotic disorder characterized by major disturbances in thought, emotion, and behaviour. There is no essential symptom that must be present for a diagnosis of schizophrenia and, thus, there is great heterogeneity of symptoms amongst individuals with schizophrenia.

Positive Symptoms Positive symptoms consist of excesses, such as hallucinations, delusions, and bizarre behaviour.

Disorganized speech, also known as formal thought disorder, refers to problems in the organization of ideas and in speaking in a coherent manner. Disorders of speech include loose associations or derailment. People with schizophrenia also experience delusions, beliefs held contrary to reality. The most dramatic distortions of perception are hallucinations—sensory experiences in the absence of any stimulation from the environment. Particularly important hallucinations include audible thoughts, voices arguing, and voices commenting.

Negative Symptoms Negative symptoms consist of behavioural deficits. Included in this category are avolition (apathy), alogia (poverty of speech or content), anhedonia (inability to experience pleasure), flat affect (absence of emotional response), and asociality (severe impairment in social relationships). These symptoms tend to endure beyond an acute episode and have a profound effect on the patient's life.

Other Symptoms Several symptoms of catatonia do not fit into the positive-negative scheme, including catatonia, which refers to motor abnormalities. Individuals with catatonic immobility maintain unusual posture for long periods of time. Patients with waxy flexibility maintain strange positions with their limbs immobile after having been placed by another person. Others show an increased level of activity or flailing of limbs. Further, some people with schizophrenia have inappropriate affect, or emotional responses occurring out of context. Other forms of bizarre behaviour include talking to oneself in public, hoarding food, or collecting garbage.

History of the Concept of Schizophrenia

Instructor’s Manual to accompany Abnormal Psychology, Sixth Canadian Edition by Flett et al.

Early Descriptions Emil Kraepelin first presented his concept of dementia praecox in 1898, emphasizing the progressive intellectual deterioration (dementia) and the early onset (praecox) of the disorder that would come to be known as schizophrenia. Eugen Bleuler focused on the "breaking of associative threads" as the core of the disorder, rather than onset and course. Kraepelin's view led to a narrow definition of schizophrenia; Bleuler's led to a broad one with a much greater theoretical emphasis on "core symptoms."

The Historical Prevalence of Schizophrenia It is estimated that the world-wide rate of this disorder is 1% though the rate seems to be dropping in several countries including Canada. The cause of this apparent decline is unknown. Between the 1930s and the 1950s there were significant changes in reported rates due to alterations and trends in the definition of schizophrenia.

The DSM-IV-TR Diagnosis The DSM-IV definition of schizophrenia narrowed the concept in several ways: (1) explicit and detailed diagnostic criteria are given; (2) patients with symptoms of mood disorder are excluded; (3) the disturbance must last at least six months; (4) mild forms of schizophrenia are now seen as personality disorders; and (5) delusional disorder (a person with paranoid delusions without disorganized speech or hallucinations) is distinguished from paranoid schizophrenia.

Categories of Schizophrenia in DSM-IV-TR and Their Elimination in DSM-5 Kraepelin initially proposed three types of schizophrenic disorders that can be found in the DSM-IV. Disorganized schizophrenia is characterized by incoherent speech, disorganized behaviour, and neglect of self-care. Catatonic schizophrenia is characterized by motor disturbance and wild agitation; it is rarely seen today, perhaps because of the success of drug therapy or because previous cases were actually misdiagnoses.

Paranoid schizophrenia is the most common type, and includes prominent delusions that are usually persecutory but may be grandiose. Delusional jealousy or ideas of reference also may be present.

The subtypes of schizophrenia, including those listed above as well as the undifferentiated and residual types, exhibit low diagnostic reliability, considerable overlap among types, and limited predictive validity. For these reasons, the subtypes of schizophrenia, have been dropped from the DSM-5. In spite of the problems in developing subtypes, there is continued interest in distinguishing among the various forms of schizophrenia in terms of their neurocognitive features. The distinction between positive and negative symptoms appears to be a promising distinction and continues to be used in research on the etiology of schizophrenia.

Etiology of Schizophrenia The Genetic Data There now exists a convincing body of evidence indicating that a predisposition for schizophrenia is transmitted genetically. Family studies reveal an increased risk for schizophrenia in relatives of schizophrenic patients. Concordance rates for identical twins are much greater than for fraternal twins, while still less than 50% (indicating that non-genetic factors play a role). Studies of adopted children demonstrate a high rate of schizophrenia among the biological children of schizophrenics, even when they are reared by healthy adoptive parents. It does not appear that a single gene is responsible for the genetic component to the

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etiology of schizophrenia. Overall, it is clear that genetic factors do play a role in the etiology of schizophrenia, without explaining the whole picture. A diathesis-stress model appears to be the best fit.

Focus on Discovery 11.1 The Genain Quadruplets-Heredity or Environment in Schizophrenia?

This box discusses the Genain Quadruplets, all of whom developed schizophrenia though there were significant differences in the course of the disorder. This case study suggests that schizophrenia has both a biological, possibly genetic, component and psychological and social factors that influence its course.

Biochemical Factors The theory that schizophrenia is brought on by excess activity of the neurotransmitter dopamine is based principally on the mode of action of the phenothiazines, drugs which alleviate some symptoms of schizophrenia but also produce side effects similar to Parkinson's disease, a disease caused by low levels of dopamine. The literature on amphetamine psychosis supports the dopamine activity theory. Other evidence suggests that the theory may apply only to those schizophrenics with positive symptoms. More recent developments recognizing differences among the neural pathways that use dopamine as a transmitter may account for the simultaneous presence of positive and negative symptoms in a schizophrenic patient. To date, the excess dopamine hypothesis, while promising, has not been proven conclusively. Recent evidence suggests that other neurotransmitters, including serotonin and glutamate, may also play a role in schizophrenia.

Schizophrenia and the Brain: Structure and Function A percentage of schizophrenics, particularly those with chronic, negative symptoms, have been found to have observable brain pathology; the controversy is whether these abnormalities are localized in a small number of brain areas or are widespread. Autopsy studies indicate structural problems in limbic areas and the prefrontal cortex. CT scan and MRI studies reveal enlarged ventricles, suggesting a deterioration or atrophy of brain tissue. PET scans suggest atrophy in the prefrontal areas. Evidence supports the hypothesis that a viral infection occurring during the mid trimester of fetal development may cause this brain damage. It has been hypothesized that this early brain injury remains silent until the prefrontal cortex matures, typically in adolescence.

Psychological Stress and Schizophrenia Numerous studies have shown a relation between lower social class and schizophrenia. This correlation has been interpreted in both directions. The sociogenic hypothesis suggests that low social class may cause or contribute to schizophrenia, whereas the social-selection hypothesis argues that people with schizophrenia become poor because of their life difficulties. In general, there is more evidence to support the socialselection hypothesis than the sociogenic hypothesis; however, it is unlikely that social class plays no role in schizophrenia.

Although there is no conclusive evidence that family disturbance plays a causal role in the development of schizophrenia, families seem to play a role in the post-hospital adjustment of people with schizophrenia. Expressed emotion (EE) refers to hostility and/or emotional over-involvement, and people with schizophrenia in high EE families are more prone to relapse than those in low EE families.

Developmental/High-Risk Studies of Schizophrenia Mednick and Schulsinger conducted the first high-risk study of schizophrenia, following 207 young people with schizophrenic mothers and 104 low-risk subjects. Variables predicting schizophrenia in the high-risk group differed for those with predominantly negative vs. positive symptoms. The former was predicted by a © Wiley Canada

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history of pregnancy and birth complications and failure to show electrodermal responses to simple stimuli, whereas the latter was preceded by a history of family instability. Other high-risk studies have found attentional dysfunction, low IQ, and poor neurobehavioural functioning to predict schizophrenia.

Therapies for Schizophrenia Biological Treatments Insulin coma therapy, prefrontal lobotomy, and electroconvulsive therapy were early treatments for schizophrenia that are no longer used in treating the disorder because of dangerous side effects and ineffectiveness. The most important development in the treatment of schizophrenia was the use of neuroleptics, antipsychotic medications that are the most effective means of treating the positive symptoms of schizophrenia and reducing the need for long-term hospital treatment. However, the drugs cause serious extrapyramidal side effects in some patients treated over long periods. New drugs, including clozapine and resperidone, do not cause extrapyramidal side effects and are more effective in treating negative symptoms.

However, the newer drugs have other serious side effects, including impaired immune system functioning.

Canadian Contributions 11.1 Heinz E. Lehmann and the “Discovery” of Neuroleptics in North America In the early 1950’s, Dr. Heinz Lehman made significant contributions to the discovery of the effectiveness of chlorpromazine for the relief of some of the symptoms of schizophrenia. He published the first North American scholarly paper on the clinical trial of this neuroleptic on 200 patients in Montreal.

Psychological Treatments Harry Stack Sullivan pioneered the treatment of schizophrenics with psychotherapy. He focused on helping patients achieve insight and learn adult forms of communication. Research on analytically oriented psychotherapy with schizophrenics has not demonstrated its effectiveness.

Social skills training teaches patients behaviours that help them succeed in a variety of interpersonal situations. Role-playing, modelling, and reinforcement help patients improve but generalization to real life is unreliable.

Family therapy is currently aimed at helping to reduce the expressed emotion that has been demonstrated to predict relapse in schizophrenics. Evidence for this type of treatment has been quite positive. The combination of family therapy with medication has been shown to lower relapse rates. Family therapy helps to improve the monitoring of the effects of antipsychotic medication, improves communication and problem-solving skills, and offers families hope that the patient may not have to return to the hospital.

Cognitive-behaviour therapy approaches include social-skills training focused on teaching interpersonal skills, job skills, and other daily life skills. Cognitive-behavioural treatment (CBT) and personal therapy, teaches patients how to recognize inappropriate effects in the family and themselves.

Treatments focused on basic cognitive functions address deficits in cognitive functioning associated with schizophrenia. Cognitive enhancement therapy (CET) is computer-based training in attention, memory, problem-solving and social-cognitive skills. A meta-analysis showed that cognitive remediation yields moderate improvements in cognition in individuals with schizophrenia.

Case Management/Assertive Community Treatment A case manager is a new mental health professional that grew out of a 1977 NIMH program to provide assistance for patients in coping with the mental health system itself. Health Canada adopted a similar program in 1991. Two examples of the application of this approach are the Greater Vancouver Mental © Wiley Canada

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Health Service Agency and the Program for Assertive Community Treatment in Ontario. There are indications that a more intensive program reduces the time spent in care, improves housing stability and ameliorates symptoms.

Contemporary Trends and Issues Contemporary views of schizophrenia focus on a biological predisposition combined with a psychological stressor. Treatment emphasis is placed on sound information given to patients and their families, medications, early intervention and skills.

Canadian Perspectives 11.1: Early Detection and Prevention of Schizophrenia in Canada In recent years, early psychosis intervention projects have been developed in major centres across Canada on the hypothesis that early treatment of schizophrenia could reduce the severity and course of this disorder.

One example of these programs was designed at the First Episode Psychosis Clinic at the Clarke Division of the Centre for Addiction and Mental Health in Toronto. PRIME stands for Prevention Through Risk Identification Management and Education.

Further Issues in the Care of Patients with Schizophrenia Housing, unemployment and stigmatization are some of the problems that hamper the social functioning of people with schizophrenia.

Student Perspectives 11.1: Perception of Schizophrenia and the Presence of Stigma among Students This box discusses some of the problems caused by stigmatization in the general student population. One of the key outcome variables in research being conducted at the University of Western Ontario is social distance – a variable that assesses how close of far someone will situate themselves with respect to someone who suffers from schizophrenia

STUDENTS SHOULD KNOW Key Points 1.

The major clinical symptoms of schizophrenia include positive symptoms such as delusions, hallucinations, and disorganized speech, and negative symptoms such as avolition, alogia, anhedonia, and flat affect.

2.

Students should know the history of the diagnosis of schizophrenia, including Kraepelin's dementia praecox, Bleuler's associative threads, and the broadened American concepts.

3.

In the DSM-IV-TR, there were three major subtypes of schizophrenia: disorganized, catatonic, and paranoid. These subtypes have been eliminated in the DSM-5.

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4.

Evidence from family, twin, and adoption studies indicates that a predisposition for schizophrenia is transmitted genetically, although not by a single gene.

5.

Biochemical research suggests that increased sensitivity of dopamine receptors in the limbic area of the brain is related to the positive symptoms of schizophrenia; negative symptoms may be due to dopamine underactivity in the prefrontal cortex.

6.

The brains of schizophrenics, especially those with negative symptoms, have enlarged ventricles and prefrontal atrophies, as well as abnormalities in the temporal and limbic areas. Viral infections during the second trimester of foetal development may be the cause of these abnormalities.

7.

The link between schizophrenia and lower social class status has been explained by both the sociogenic hypothesis and the social-selection theory. The data, however, are more supportive of the social-selection theory.

8.

There is some evidence that communication deficiencies in the family play an etiological role in schizophrenia; in particular, high expressed emotion; these deficiencies may also predict relapse.

9.

High-risk studies of schizophrenia may shed light on factors that cause the illness in children with a biological disposition.

10.

Antipsychotic medications are effective in controlling the positive symptoms of schizophrenia and reducing long-term hospitalization.

11.

Family therapy has been found to be helpful in reducing expressed emotion and relapse in schizophrenics.

12.

Behaviour treatments such as social skills training have been shown to improve the functioning of schizophrenics.

13.

The best treatment package is an integration of medication with psychological treatments, particularly education of the family and patient and reduction of stress in the post-hospital environment.

14.

Case management programs may also be useful in assisting people diagnosed with schizophrenia

15.

Contemporary trends in care and treatment of schizophrenic include devoting more attention to factors that may impede social functioning such as homelessness, unemployment and stigmatization.

Key Terms alogia (p. 310) anhedonia (p. 311) antipsychotic drugs (p. 329) asociality (p. 311) atypical antipsychotics (p. 332) avolition (p. 310) catatonic immobility (p. 311) catatonic schizophrenia (p. 314)

cognitive enhancement therapy (CET) (p. 337) delusional disorder (p. 313) delusional jealousy (p. 314) delusions (p. 309) dementia praecox (p. 312) disorganized schizophrenia (p. 314) disorganized speech (thought disorder) (p. 308) dopamine theory (p. 320) © Wiley Canada

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expressed emotion (EE) (p. 326) flat affect (p. 311) grandiose delusions (p. 314) hallucinations (p. 310) ideas of reference (p. 314) inappropriate affect (p. 311) incoherence (p. 308) loose associations (derailment) (p. 308) negative symptoms (p. 310) paranoid schizophrenia (p. 314)

positive symptoms (p. 308) prefrontal lobotomy (p. 329) residual schizophrenia (p. 314) schizophrenia (p. 306) schizophrenogenic mother (p. 326) social distance (p. 344) social-selection theory (p. 325) sociogenic hypothesis (p. 325) undifferentiated schizophrenia (p. 314) waxy flexibility (p. 311)

New Names Emil Kraepelin, Eugen Bleuler, Paul Meehl, Sarnoff Mednick, Harry Stack Sullivan, Frieda FrommReichman.

LECTURE LAUNCHERS 1. Beyond the Dopamine Theory of Schizophrenia Tracing the history of models of the cause of schizophrenia can give a student a fascinating look at the evolution of a model. Since the introduction of the first neuroleptics, which altered the brain’s use of the neurotransmitters, dopamine has been the focus of research concerning the etiology of schizophrenia.

However, there has always been the problem that drugs that interfere with dopamine process work quite quickly on dopamine, but do not produce observable or experienced therapeutic effects for weeks or months.

Clearly some chain reaction is involved. Recent evidence points to the ubiquitous neurotransmitter glutamate as part of the chain of events that cause this disorder. For more information on the evidence that points to glutamate and the new causal model for schizophrenia that is being developed see below. www.biopsychiatry.com/glutamate.htm www.sciencedaily.com/releases/2002/08/020815073035.htm

2. Dead Ends on the Road to an Etiology of Schizophrenia It's good to admit to students that instructors can make some really faulty assumptions at times. I am old enough that I was taught a model of the etiology of schizophrenia that turned out to be embarrassingly wrong. I happened to go through a clinical program that clearly stated that schizophrenia was caused by "schizophrenogenic" mothers who "double-binded" their children. I have even sat in on family sessions in which it was pointed out to a mother how she was causing her son's delusions. If you have avoided such an embarrassing experience you may use me as an example. The evolution of a theory and the paradigm wars that raged over a model of the etiology of this disorder is a good example of the strange models that can evolve on the way to a scientifically valid theory.

For a scholarly consideration of double-bind theory: “Schizophrenia and the Family: Double Bind Theory Revisited”, Mathijs Koopmans, York College, City University of New York http://goertzel.org/dynapsyc/1997/Koopmans.html. © Wiley Canada

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3. A First Person Account: Problems of Living with Schizophrenia The following is an anonymous account of the personal problems of living with schizophrenia. The article appeared in the Schizophrenia Bulletin (1981, 7, 196-197). It is a good piece to read to students at the beginning or end of the lecture(s) on schizophrenia as it reviews many of the issues outlined in the chapter from a very human perspective.

"Living with schizophrenia creates problems for me that are not obvious or easy to explain. I am not entirely comfortable with the label 'schizophrenia' because it implies that I am different in some basic way from other people, when I feel I am not. The label has helped me, though, to feel less guilt about my inability to 'conquer' my problems, and to learn to make some allowances for my difficulties in handling situations. Unfortunately, other people often do not recognize the difficulties I face or make any attempt to make allowances for me.

The largest problem I face—I think the basic one—is the intensity and variety of my feelings, and my low threshold for handling other people's intense feelings, especially negative ones. I have quite often experienced a euphoric 'high' that is much like being in contact with some greater reality or meaning to life—accompanied by a kind of added brightness or extra dimension to everyday things around me. The other side of the coin, though, is a very intense anxiety from nowhere that typically hits me quite suddenly after a short period of time without medication. The two feelings are opposite, yet somehow connected.

Feelings are 'the stuff life is made of,' and I do not regret a lot of what I have experienced, but the terrible feelings are bad enough to make me opt for the medication—at least an adequate amount to give me control, even with some remaining discomfort. I have been taking one of the phenothiazines for almost 7 years, and I am concerned about the many potential problems with long-term use, particularly tardive dyskinesia. However, I feel there is no effective alternative to the drug, particularly if I am to maintain my normal lifestyle, with a husband and 9-year-old son.

My son—our son—is a very healthy, active boy, with a 'take things in stride' disposition and an interest in many things, among them fossils, reading, the weather, swimming, soccer, and drawing. He is doing very well in school, too. He has a sensitive nature, yet is quite self-sufficient. My husband is supportive of me, but in many ways I am supportive of him, too. We talk well together; he spends many hours listening to me philosophize, or talk about my problems.

I am convinced that my normal 'facade' arises mainly when other people expect me to become emotionally involved with them. I find emotions tremendously complex, and I am quite acutely aware of the many over- and undertones of things people say and the way they say them. Generally, I like direct, honest, kind people, and I have difficulty handling social situations that require me to be artificial or too careful.

Another problem I have to deal with to a greater or lesser degree is my 'runaway thinking.' I 'free associate' rather easily, and sometimes forget what I was saying because other ideas are in my mind. If I concentrate, however, this can be an advantage, because I have a ready supply of new ideas—I don't bore myself. Concentrating, though, is sometimes easier said than done.

Intimacy is an interesting problem in my life. In a way, I am capable of the deepest spiritual intimacy with people, yet I am less capable than most people of handling the demands of relationships. I cannot share negative feelings other people have, because I am too sensitive to them; yet I can give a great deal of love and concern when I am protected against feelings like anger and cynicism.

I used to think a great deal about unlikely, unreal things, like being watched or filmed and events being orchestrated around me by other people or outside forces, or being literally an alien, since I felt so different and basically unattached to the world. I still have similar feelings and thoughts, but less so than before. In any case, they come and go and don't affect me greatly. The only pervading feeling that is a problem sometimes—on too little medication—is a general one of unreality or being unattached. The particular ideas that stem from the feeling are not the problem for me.

Overall, I feel I have a good life, and I am, in spite of my frequent doubts, a success in many areas. I have good people as friends, and a fine family, and I am not forced into a position of taking on too much © Wiley Canada

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independence or of being too dependent. I am a unique and interesting person; I don't always quite fit in with the world, but I think I add something to it."

4. More First Person Accounts Many students enjoy reading first person accounts of the experience of mental illness, such as that quoted above. Each issue of Schizophrenia Bulletin contains a first person account from an individual with schizophrenia or a parent or other concerned layperson. The following poem, written by Lynne Morris, a woman with schizophrenia, appeared in a compilation of first person accounts in the 1988 issue of the journal.

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I am the rear tire of a bicycle, not trusted enough to be a front tire, expected to go round and round in one narrow rut, never going very far, ignored except when I break down.

Then I get lots of frightening, angry attention and I am put into a garage, sometimes for months, where I forget my function and I become afraid to function and all functions seem useless.

Next time out I think I will be an off-ramp from a freeway.

5. Kraepelin and the Diagnosis of Schizophrenia: Then and Now A demonstration of just how far the United States concept of schizophrenia has swung back toward Kraepelin's original definition of the disorder can be found in James and May's study involving rediagnosing the patients in 32 case histories that were presented in Kraepelin's textbooks (1981, American Journal of Psychiatry, 138, 501-504). Material relevant to Kraepelin's original diagnosis was stricken from the case histories so that the modern day raters were blind to his diagnoses. DSM-III diagnostic criteria were then used to make new, independent diagnoses. (In addition, independent diagnoses were made according to Spitzer's Research Diagnostic Criteria.) The results? Of 15 cases diagnosed as dementia praecox by Kraepelin, 14 were diagnosed as schizophrenic according to modern criteria. Of 13 cases diagnosed as manic, depressed, or manic-depression by Kraepelin, 11 were similarly diagnosed according to DSM-III. Two cases of paranoia were identically diagnosed by Kraepelin and DSM-III as was one case of © Wiley Canada

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somatization disorder (hysteria in Kraepelin's terms). Finally, one case that Kraepelin diagnosed as senile dementia was classified as "atypical psychosis" according to DSM-III. Overall, the reliability of diagnosis was 91% between raters making judgements 75 years apart. Kraepelin, apparently, would be quite comfortable making diagnoses according to modern criteria.

6. Cognitive/Neuropsychological Studies of Schizophrenic Children While schizophrenia usually has an onset in early adulthood, cases of schizophrenia in children have been found to indicate a more severe form of the disorder as well as a more homogeneous symptom picture. A summary of a series of cognitive/ neuro-psychological studies of schizophrenic children provides an interesting update to the material in the text on schizophrenia and the brain (Asarnow, Asamen, Granholm, Sherman, Watkins, and Williams, Schizophrenia Bulletin, 1994).

The first set of studies involved comparing schizophrenic children and controls (autistic or normal children) on a variety of neuropsychological tests. These studies revealed that schizophrenic children show impairments specifically on tasks, which make extensive demands on information processing capacity. For example, when asked to copy designs, schizophrenic children did as well as normals. However, when memory demands were added to the task (requiring the children to look at a design, then wait 15 seconds before beginning to draw the design), the schizophrenic children did significantly worse than the normal children.

These results, together with those of a second series of studies using a computer measure of visual information processing, indicated that children with schizophrenia have limited information processing capacity. The authors hypothesize that the brain structures underlying these impaired functions are part of a network that includes the frontal lobe and thalamus in interaction with the reticular activating system. http://schizophreniabulletin.oxfordjournals.org/content/20/4/647.short

12. Friends of Schizophrenia Canada has some very active mental patient associations and Friends of Schizophrenia groups that do a great deal to foster understanding and acceptance of individuals suffering from this medical condition. Two examples are the Schizophrenia Society of Ontario: www.schizophrenia.on.ca and the British Columbia Schizophrenia Society www.bcss.org/ You or your students can get a sense of the work these organizations do by visiting these sites. This is a good example of how a disorder can have a clearly biological/genetic component and yet still be influence by psycho-social factors. In societies where the stigma of having schizophrenia has been reduced through public education and advocacy, the course of the disorder and its cost to society is significantly reduced. An interesting discussion about how the situation can be improved in Canada. The BC Schizophrenia Society publication "Our Abandoned Citizens, Policies for Change" can be viewed on their web page and offers good suggestions for policy changes around which a lecture could be formulated.

13. Prevention through Risk Identification Management and Education As we don't really have a treatment for schizophrenia, neuroleptic drugs simply relieve the symptoms, prevention is the most important and effective way to reduce the harm of this disorder. A good deal of research in the last 20 years has been focused on the early detection of schizophrenia and assessing the © Wiley Canada

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outcome of early intervention. There are indications that with early diagnosis and support that relieves the exacerbating effects of stress, the course and severity of schizophrenia can be positively influenced. A Canadian program that attempts this type of early identification and intervention is the CAMH First Episode Clinic and the Focus on Youth Psychosis Prevention (FYPP) Clinic. Go to the Centre for Addiction and Mental Health and search for “psychosis.” www.camh.net This is a good topic to illustrate diathesis-stress or biopsychosocial models of etiology and to address the importance of prevention of mental disorders. Even a disorder with such a clearly defined genetic and biological component still has substantial variance residing in psychological and social factors.

Psychological and social interventions can reduce the severity of acute episodes and reduce the life-time course of the disorder.

DISCUSSION STIMULATORS Genetic Counselling What sort of genetic counselling would members of the class offer to an apparently healthy 25-year-old who wanted to have children but had a schizophrenic parent? Along the same lines, what sort of intervention programs (or childrearing experiences) would the class members want to provide to children at risk for developing schizophrenia? Encourage the students to try to apply research findings, not just speculate.

Schizophrenia in Mainstream YA Literature Many students will be familiar with the work of prolific Canadian YA author Kelley Armstrong. Her 2015 novel, The Masked Truth, features a main character with schizophrenia. Have students discuss the role of literature, music, movies, and television in presenting schizophrenia in a non-stigmatizing fashion.

Mental Hospitals Have any of the class members ever been in or worked in a mental hospital? What were their experiences like? What was the physical layout of the ward and how did this affect patient behaviour? Was there much contact between the patients and the professional staff? What would it be like to be a patient there?

Labels and Stigmatization Write these words on the board, and ask the class what associations each has. Explore feelings associated with sayings such as: "Label jars, not people;" "Nothing about me without me;" and "I am not a case, and you are not my manager."

In "The Mental Health System: Experiences from Both Sides of the Locked Doors," Bassman explores changing views of psychiatric survivors from his perspective as a former hospitalized mental "patient" and now clinical psychologist (Professional Psychology: Research and Practice, 28, 238-242). http://psycnet.apa.org/journals/pro/28/3/238.pdf He explores issues related to terminology used to talk about people with mental illness, liberation and empowerment of psychiatric survivors, goals for treatment in people with serious mental illness (quality of life over symptom reduction), and concerns about involuntary hospitalization. The following anecdote is particularly poignant: © Wiley Canada

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Edward Knight, a highly regarded sociologist and former homeless consumer/survivor who has organized, researched, and advocated for hundreds of self-help groups in New York, spoke candidly of his patient experience. Hoping to be released from a psychiatric hospital, he had to convince his treatment team that he had realistic goals. Knight was a research sociologist and told the team he wanted to do research on schizophrenia. The treatment team told him that this was a delusion of grandeur. He then said he would like to start self-help and advocacy groups. Again he was told it was a delusion of grandeur—he must accept where he is in life right now, a mental institution. A few weeks later, he went back to the staff and told them he hoped to become a filing clerk. This goal was acceptable for discharge. Shortly after the meeting, a psychologist from the treatment team took him privately aside behind closed doors in the nursing station and encouraged him, "Don't give up your delusions of grandeur. Those are your goals." (p. 241)

Patients’ Rights in Canada There has been much debate over the right to refuse treatment and the text will return to this issue in Chapter 18. However, for an advanced exposure to this topic, the Canadian Bar Association provides discussion material: Two aspects of the right to refuse treatment can be discussed: Refusal of treatment for a physical problem and the right to refuse treatment for a mental problem www.cbabc.org/For-the-Public/Dial-A-Law/Scripts/Health-Law/428 After consulting the Canadian Bar Association’s web site, students could be encourage to debate the issue: (a) from the perspective of a patients’ rights advocate (see Patients’ Rights Advocate); (b) from the perspective of the patient’s psychiatrist (see Concerned Clinician); (c) from the perspective of the patient’s parent (see Parent of a Schizophrenic Patient); or finally, (d) from perspective of the patient himself (see Schizophrenic Patient).

Patients' Rights Advocate You are a patients' rights advocate, working to protect the rights of chronically ill clients in mental hospitals.

The case of a schizophrenic patient who has refused medication has been brought to your attention, and you are arguing for a rights-driven approach to treatment in hospital settings. According to your view, a patient admitted to a mental hospital has the right to refuse treatment if they may reasonably be judged to be competent to make such a decision. In this case, a 34-year-old schizophrenic man, Mr. Johns, was admitted to the hospital involuntarily at his parents' request. He wants to be released from the hospital, but a judge denied his request upon recommendation of the psychiatrist in charge. Mr. Johns has been refusing to take antipsychotic medication, and the hospital wants to force him to take the medication by restraining him and administering it via injection.

Concerned Clinician You are a psychiatrist working in a state mental hospital with indigent clients. Your patient, Mr. Johns, was first diagnosed as paranoid schizophrenic at age 19; he is now 34 years old. Mr. Johns was admitted to the hospital involuntarily after his parents contacted the police. He had been living with them for several years following his last hospitalization, and they had supported him financially since he was unable to work.

However, 2 weeks prior to the hospitalization, Mr. Johns disappeared from the family home while his parents were at work. After searching for him for several days, his father found him wandering in the streets.

He was dishevelled and dirty, and he was sleeping on benches in a dangerous part of town. When his father approached him to try to encourage him to return home, Mr. Johns began yelling that his mother was trying to poison him and his father was listening to his thoughts while he was sleeping.

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As the psychiatrist on the case, you have prescribed an antipsychotic medication to control Mr. Johns' paranoid delusions. Given his past history of successful treatment with this medication, it is your professional opinion that Mr. Johns' florid symptoms could be controlled and he could be released from the hospital into his parents' care if he complied with the medication plan. However, Mr. Johns has refused to take the medication, claiming that the hospital staff is trying to poison him. No improvement in his symptoms has been observed following the behavioural milieu treatment provided in the hospital ward.

You are arguing for a treatment-driven approach, in which Mr. Johns will be forced to take the prescribed medication in an effort to manage his delusions and enable him to function more autonomously and independently than his current hospitalization allows.

Parent of Schizophrenic Patient You are the concerned mother of Mr. Johns, a 34-year-old man diagnosed with paranoid schizophrenia since the age of 19. You have provided a home and financial security for your son since he has been unable to work or care for his personal needs such as cooking. When last hospitalized two years previously, your son was prescribed an antipsychotic medication that resulted in dramatic improvement. While still displaying "negative symptoms" of schizophrenia (particularly apathy, flat affect, and poverty of speech), Mr. Johns no longer exhibited florid delusions when he was taking his medication. However, about one month before the hospitalization, Mr. Johns came down with the flu and as a result, vomited frequently and could not keep his medication down. After several days without medication, Mr. Johns became extremely paranoid. He claimed that you were trying to poison him, and that this was causing the vomiting he was experiencing. Further, he believed that his father was reading his mind when he tried to sleep, and thus he spent nights wandering the halls trying to keep himself from falling asleep when his father was home.

Two weeks prior to the hospitalization, Mr. Johns disappeared from the family home. After searching for him for several days, his father found him wandering in the streets. He was dishevelled and dirty, and he was sleeping on benches in a dangerous part of town. When his father approached him to try to encourage him to return home, your son began shouting his paranoid ideas and ran away. You decided to call the police and have him committed involuntarily, to keep him from getting hurt and to enrol him in the treatment program that had been so successful in the past.

Your son is now refusing to comply with the medication plan set up by the psychiatrist, and he is showing no improvement. You are arguing that he should be forced to take the medication, since you are convinced that once it takes effect and his delusions are under control, he will be able to be released from the hospital and resume the relatively comfortable and autonomous lifestyle that he could manage before he stopped taking the medication.

Schizophrenic Patient You are Mr. Johns, a 34-year-old man diagnosed with paranoid schizophrenia. You were first diagnosed at age 19, and have been hospitalized several times over the past 15 years. In between hospitalisations, you have lived with your parents, who have supported you financially and provided for your basic needs. While you recognize that you are unable to work and care for yourself, you also feel that your parents are overcontrolling and you desperately want to be able to live independently.

Currently, you are enraged at having been hospitalized against your will. As you see it, you decided to move out of your parents' home because your mother was trying to give you drugs in your food that would make you follow her wishes. In addition, whenever you fall asleep at home, your father comes into your room and reads your mind, using your thoughts against you the next day. Naturally, you have been unable to sleep or eat under these conditions, and so decided to move out on your own. However, when your father saw you walking in the street, he began trying to force you into his car and bring you back home.

When you refused to return, he called the police and had you admitted to the hospital.

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You are adamant in your opinion that you have the right to decide how to live your life. If you want to live on the streets or sleep on park benches, that is your right. You have been refusing to take medication because you know that it only poisons your mind and keeps you from thinking clearly.

Schizophrenia Society of Canada In light of the literature on the treatment of schizophrenia that suggests that social support and education are among the most effective interventions, the work of organizations such as the Schizophrenia Society of Canada are highlighted. The following website contains information on their “Reaching Out” program. This education program is “A complete, easy to teach educational program specially created for Canadian youth.

It is fully available in both English and French, and does not require that educators have prior knowledge of mental illness.” For teaching materials, fact sheets, lesson plans and an on-line video see the Internet link below. www.schizophrenia.ca Students can be referred directly to this site to view the video, read fact sheets, etc. This can then form the basis of seminar discussions.

SOME IDEAS FOR UTILIZING THE INTERNET

First Person Accounts and Web Pages The Internet is a source of many first person accounts of the experience of schizophrenia and web pages created by individuals diagnosed with this disorder and/or families who have experienced it. You may wish to have students search for these and see what they come up with, or you may send them to an example such as this Scientific American interview with legal scholar, Elyn Saks, who describes her experiences with schizophrenia: https://www.scientificamerican.com/article/diary-of-a-high-function/

John F. Nash and A Beautiful Mind The movie A Beautiful Mind has raised the profile of schizophrenia and generated some controversy of its own for failing to present a complete picture of the experiences of John F. Nash. Fewer will have seen the PBS documentary, A Brilliant Madness, which includes interviews with Nash as well as those close to him.

A good deal of information about John Nash can be obtained from the Internet. The following is a basic site with short biography: www-groups.dcs.st-and.ac.uk/~history//Mathematicians/Nash.html It is also interesting to visit the Nobel Prize site: The Prize: www.nobel.se/economics/laureates/1994/index.html John Nash Biography

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www.nobel.se/economics/laureates/1994/nash-autobio.html If students have seen the movie they can compare these biographies with those presented in the movie. You may also have your students search for other famous individuals who have had schizophrenia. www.schizophrenia.com/family/Famous.html Interestingly they won't find very many who did any significant work while suffering acute symptoms. This can be contrasted to the experience of Kay Jamison's observations of the work of individuals suffering from mood disorders.

Schizophrenia: People's Perceptions in Quebec This is a very interesting document (PDF file): www.cma.ca/cmaj/vol-164/issue-9/pdf/pg1299.pdf It asks people to associate various terms with their perception of schizophrenia. You may replicate a similar study with your class. Either on paper or in the form of a "quiz" on you class website, you may ask students to indicate terms that they feel "define schizophrenia." They could be asked to obtain 5 replies each from outside the classroom and combine the results. The results can then lead to a discussion between the beliefs about this disorder held by the general population compared with what students know about it after reading the chapter.

Mental Patients' Associations in Canada Several cities and provinces have active and effective mental patients' associations that advocate for improved mental health resources and assist mental patients in a variety of ways. cf. The Vancouver Mental Patients' Association: www.mpa-society.org/ Have your students look at the services and policies of this and similar organizations. They are very active in providing services for mental patients with an emphasis on reintegrating them into the community. There is an inevitable tension between an organization that advocates for mental patients and agencies that have other concerns. For a look at the more radical end of the spectrum try the Antipsychiatry Coalition: www.antipsychiatry.org/ A read of this site can lead to a lively discussion about the nature of contemporary services and models of cause and treatment for mental disorders that we really do not understand in any depth.

Jailing the Mentally Ill In July of 2000 John Biewen and Stephen Smith produced a radio program for American Radio Works and Minnesota Public Radio called Jailing the Mentally Ill. Their Internet site has some very useful information that could be used in a discussion around this topic. http://americanradioworks.publicradio.org/features/mentally_ill/index.html With a sound card you may listen to segments of this program. As I lecture from a computer hooked up to the Internet, I can play clips like this in lecture. You may also ask students to listen to Internet audio files © Wiley Canada

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outside of class. Many students have access to Internet audio files from their home computers and several of our labs are set up for audio, though students have to bring their own headphones to the computer lab.

While it is based on the U.S. experience, an excellent book on this topic is Torreys, E. Fuller (1997). Out of the Shadows: Confronting America's Mental Illness Crisis. N.Y. John Wiley & Sons.

Correctional Services of Canada has a number of publications available on-line about this topic. Go to: www.csc-scc.gc.ca/index-eng.shtml and use the CSC search engine to explore the problems of mental health within the Canadian Correctional Service

Prevention Through Risk Identification Management and Education www.camh.net/mental_health/prime_clinic.html This site has descriptions of programs designed to prevent or lessen the impact of schizophrenia. There are links to similar programs, etc. Students can be asked to visit this site and then design a prevention program for their community or school. An interesting question to ask is "How is it possible, short of genetic counselling, to 'prevent' a disorder that has such a clearly defined genetic component?" Hopefully this will remind the students of diathesis/stress and biopsychosocial models that recognized multi-factor models of etiology. A WebCT or classroom discussion can evolve out of this research.

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CHAPTER 12 SUBSTANCE-RELATED DISORDERS

CHAPTER SYNOPSIS Historically, substance-related disorders have been divided into two major categories: Substance dependence which involves excessive use of a drug, difficulty in reducing its use, inordinate time devoted to drug use, and continued use despite negative impact on life activities. Dependence also involves increased tolerance over time (larger doses of the substance are needed to reach the same effect) or withdrawal symptoms (negative physiological and psychological reactions are experienced when drug use is suddenly terminated). Substance abuse involves the use of a drug to such an extent that the person fails in important obligations, is exposed to physical dangers due to intoxication, or has legal problems or interpersonal problems related to substance use. The distinction between dependence and abuse was abandoned in the DSM-5 and replaced by a single diagnostic category: Substance-related and addictive disorders. People who are addicted often combine substances, sometimes with fatal consequences.

Alcohol Abuse and Dependence Delirium tremens (DTs) is a severe physiological withdrawal symptom from alcohol. Tolerance is evident following heavy, prolonged drinking, and may be caused by changes in GABA (or glutamate) receptors.

Polydrug abuse poses a particularly serious health problem: The effects of some drugs when taken together are synergistic.

Prevalence of Alcohol Abuse and Comorbidity with Other Disorders Hazardous drinking is evident among approximately 25% of men and 9% of women. Patterns of alcohol use vary; however, alcohol use is especially frequent among college-aged adults. Problem drinking is comorbid with several personality disorders, mood disorders, schizophrenia, anxiety disorders, and other drug abuse.

Alcohol consumption appears to be on the rise in Canada and binge drinking among students remains a problem (see Student Perspectives 12.1). A new report, “Alcohol Consumption in Canada” (Taylor, 2016) provides an important overview of drinking in Canada.

Nature of the Disorder It is important to consider how addictive disorders, in general, and alcohol abuse, in particular are conceptualized. A disease model views abuse as being related to vulnerabilities within the individual (e.g., a genetic disposition or brain chemistry). A moral model sees abuse as being related to personal failings and personal choice of the individual. It is also possible to view abuse as a coping response

Course of the Disorder Frequently cited, Jellinek's (1952) work described the male alcohol abuser as demonstrating a common, downhill progression from social drinking through living only to drink. However, data reveal considerable variation in the drinking patterns of many alcohol abusers, and Jellineck’s model does not apply well to women.

Instructor’s Manual to accompany Abnormal Psychology, Sixth Canadian Edition by Flett et al.

Costs of Alcohol Abuse and Dependence Alcohol abuse is a serious problem, linked with medical costs, highway deaths, hospital admissions, suicide, and family violence. Although alcohol related traffic deaths have declined in recent years, 1997 statistics indicate that 31% of fatally injured drivers were over the legal limit. Rape, assault, family violence, and homicide all tend to be alcohol-related crimes.

Short-terms Effects of Alcohol Alcohol is not digested, but is absorbed into the bloodstream and metabolized by the liver. Alcohol intake is initially stimulating; however as blood alcohol levels peak a depressive mood may predominate. Larger amounts interfere with motor coordination and thought processes and may lead to depression, social withdrawal, sedation and sleep. Alcohol stimulates GABA receptors, and increases levels of serotonin and dopamine. Expectations about the effects of alcohol on aggression, anxiety, and sexual arousal seem to have an important impact on behaviour.

Long-term Effects of Prolonged Alcohol Abuse Severe biological damage is a serious consequence of chronic drinking. Malnutrition, particularly a deficiency of B-complex vitamins, can cause amnestic syndrome, a severe loss of memory for both recent and past events. Cirrhosis of the liver is the ninth leading cause of death in the U.S. Heavy alcohol consumption during pregnancy can result in fetal alcohol spectrum disorders, which are characterized by cranial, facial, and limb abnormalities as well as intellectual disability. While light drinking has been hypothesized to have positive health benefits for some people, third variables, such as abstaining for health reasons, may also explain these findings.

Student Perspectives 12.1: Binge Drinking at Universities, Colleges and Schools The results of the first comprehensive survey of students on Canadian campuses was reported by Gliksman et al., (2000). This survey confirmed that binge drinking is a serious problem in Canada with 62.7 percent of students reporting drinking five or more drinks on a single occasion since the start of the school year.

Suggestions for alcohol abuse prevention include targeting high-risk groups for educational programs. More recent evidence continues to suggest that binge drinking remains a problem on university campuses

Inhalant Use Disorders Inhalant use is epidemic in some Northern and Aboriginal communities and is often a drug that is first by adolescents. Inhalant use is associated with other adjustment problems, such as family problems, criminal behaviour, and suicide.

Nicotine and Cigarette Smoking Nicotine, the principal alkaloid of tobacco, is a powerful addictive drug and there is growing evidence to suggest that it may be more addictive than previously thought. Of some interest some data suggest that nicotine may act differently on the brains of male versus females.

Health Consequences of Smoking It is estimated that smoking is responsible for 47,000 deaths annually in Canada alone. Smoking has been associated with lung cancer, emphysema, cancer of the larynx and esophagus, as well as a number of cardiovascular diseases. © Wiley Canada

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Prevalence of Smoking Although there is considerable variation in regions and age groups, approximately 17% of the Canadian population are smokers. On average, males smoke three cigarettes per day more than females

Consequences of Second-Hand Smoke Consequences of smoking include serious health hazards to both the smoker and non-smokers who inhale second hand smoke. The latter has led to city ordinances regulating smoking in public places and work settings.

Marijuana Marijuana consists of the dried and crushed leaves and flowers of the hemp plant, and removing resin from high-quality plants produces hashish.

Effects of Marijuana The immediate effects of marijuana generally makes the user feel relaxed and sociable. However, marijuana interferes with a wide range of cognitive functions. Short-term memory and state-dependent learning are particularly affected; Skills involved in driving are also impaired. Heavy use of marijuana may also be associated with psychological and physical health problems.

In terms of somatic effects, marijuana smoking elevates heart rate, posing a danger to people with abnormal heart functioning. Long-term use may seriously impair lung structure and function. Evidence suggests that marijuana use may interfere with fertility in both males and females. Debate continues as to whether marijuana is physically or psychologically addictive. On the positive side, marijuana can be used therapeutically to treat nausea and loss of appetite in cancer patients, is useful in treating glaucoma, and the symptoms associated with AIDS. Government agencies, however, have been inconsistent in developing policies regarding medical uses of the drug.

Focus on Discovery 12.1: The Stepping-Stone Theory: From Marijuana to Hard Drugs This Focus presents findings suggesting that marijuana is not necessarily a "stepping stone" to harder drugs.

Sedatives and Stimulants The major sedatives slow the activities of the body and reduce its responsiveness; Stimulants increase alertness and motor activity.

Sedatives Opiates represent a group of addictive sedatives that in moderate doses relieve pain and induce sleep. Opium has been known since 7000 B.C., but morphine and heroin, its more powerful derivatives, were only developed in the 1800s. While commonly available at first, their addictive properties became apparent and they were outlawed in the early 1900s. Opium and its derivatives produce euphoria, drowsiness, and reverie; heroin produces a "rush" as well. OxyContin, a prescription opioid painkiller, has become a growing concern in Canada. Rates of addiction and overdoses have increased dramatically since the introduction of OxyContin. © Wiley Canada

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Heroin is associated with serious physical withdrawal symptoms, deaths due to homicide, suicide, accidents, and overdoses, exposure to HIV through the sharing of needles, and social consequences, including illegal activity to obtain money for the drug. Heroin use is increasing among middle- and uppermiddle-class college students, partly because of changes in the form in which it is available.

Barbiturates were synthesized as aids for sleeping and relaxation, but their frequent prescription in the 1940s was reduced because of their addictive nature. Barbiturates are depressants, relaxing the muscles and producing a mildly euphoric state. Physical and emotional control is lost with large doses, however.

Withdrawal effects are particularly severe and long lasting: barbiturates are frequently chosen as a means to commit suicide.

Stimulants Stimulants act on the brain and sympathetic nervous system to increase alertness and motor activity.

The first amphetamines were synthesized in 1927, and the drug has been used to control mild depression, suppress appetite, and ward off fatigue. Amphetamines are sometimes used to treat hyperactive children (see text Chapter 15, p. 482). Amphetamines produce effects similar to those of norepinephrine (wakefulness, appetite reduction, increased autonomic activity) and can be addictive. Large doses taken over a period of time can produce a state similar to paranoid schizophrenia. Tolerance develops rapidly.

Amphetamine use in the workplace has been on the increase.

Cocaine is a pain-reliever that is used as a local anaesthetic; it also heightens sensory awareness and induces a brief state of euphoria. An overdose can produce chills, nausea, and tactile hallucinations, and may lead to death due to heart attack. Chronic use may lead to changes in personality and disturbances in eating and sleeping; ceasing cocaine use may cause severe withdrawal symptoms. Cocaine is ingested in many ways, including sniffing, smoking, swallowing, and injecting. Especially potent forms of the drug include "freebase," purified cocaine made by heating the drug with ether and then smoking it, and "crack," a less expensive form of freebase. Cocaine use increased dramatically in the 1970s and 1980s; while it now appears to be on the decline, use of crack has continued to be very prevalent. Recent data indicate that cocaine is addictive, inducing a particularly strong withdrawal syndrome.

For a New York Times Sunday Book Review of Sherwin Nuland’s (2011) book, Sigmund Freud’s Cocaine Years see: www.nytimes.com/2011/07/24/books/review/an-anatomy-of-addiction-by-howard-markel-bookreview.html?pagewanted=all&_r=0

Focus on Discovery 12.2: Our Tastiest Addiction: Caffeine and the Rise of Energy Drinks This box discusses two less risky and more prevalent stimulants: caffeine and energy drinks. Caffeine consumption results in increased body temperature and blood pressure; in addition appetite can diminish and weariness is reduced. Energy drinks with high levels of caffeine have the same results; however, when combined with alcohol pose increased health risks.

LSD and Other Hallucinogens Albert Hoffman, a Swiss chemist is credited with having first manufactured-lysergic acid diethylamide (LSD). LSD is considered a hallucinogen along with four other drugs: mescaline, psilocybin and synthetic compounds of MDA and MDMA. A fifth hallucinogen, ecstasy, was introduced to the ranks of illegal drugs in 1987. Of some interest is the fact that Drs. Timothy Leary and Richard Alpert, two psychologists at Harvard University, are credited with having a major influence on the use of psychedelic drugs during the 1960s © Wiley Canada

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Effects of Hallucinogens LSD, mescaline, psilocybin, and other hallucinogens were originally thought to produce effects similar to a psychotic state. They produce a marked slowing of time, a feeling that bodily boundaries are lost, detachment from reality, affective lability, heightened visual experience, and hallucinations. Use of hallucinogens has declined since the 1960s, although a new synthetic hallucinogen, Ecstasy (MDA and MDMA), though not a true hallucinogenic drug, has become popular on some college campuses. A number of deaths have been reported from accidental overdose. While LSD and other hallucinogens not necessarily addictive "bad trips" can occur, leading to panic and occasionally a psychotic state. Flashbacks are unpredictable recurrences of psychedelic experiences after the physiological effects of the drug have worn off occur in 15 to 30% of users.

Etiology of Substance Abuse and Dependence Becoming substance dependent is generally a developmental process that begins with a positive attitude towards the drug, experimentation, regular use, heavy use and physical dependence or abuse. This developmental model, however, does not account for all cases. Socio-cultural, psychological, and biological variables are also important.

Social Variables There are large cross-national and within-country variations in consumption of drugs: cultural and subcultural attitudes can influence the likelihood of substance abuse. Family variables such as exposure to parents' smoking and drinking, marital, psychiatric, or legal problems in the family, and lack of parental monitoring all lead to increased drug use among teenagers. The media plays a role as well, as when cigarette companies developed advertising campaigns targeting minors.

Psychological Variables A principal reason for using drugs is to alter mood; drug use is reinforcing. Studies suggest that the tension reduction produced by alcohol may be cognitive in nature; it may decrease self-awareness and thereby help individuals cope with failure and negative thoughts. In addition, people may drink after experiencing stress because they expect it will reduce their tension. Beliefs about the harmfulness of a drug also influence its use. Two personality characteristics, high levels of negative affect and an enduring desire for arousal have been associated with substance use.

Biological Variables There appears to be a genetic role in substance use. Some evidence suggests that the genetic component in drinking may be stronger in men than in women. Although it seems clear that there is a genetic predisposition toward becoming a problem drinker, it is also generally recognized that the contribution of environmental factors is important.

Therapy for Problem Drinking Admitting the problem Admitting that one has a problem is the first step to change. Research has shown that most problem drinkers are reluctant to seek help.

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Traditional Hospital Treatment The withdrawal from alcohol—detoxification—can be difficult both mentally and physically; while often supervised in a hospital setting. Evidence suggests that outpatient treatment is probably best for those who have limited social support and are living in environment that encourages alcohol abuse.

Biological Treatment Biological treatments include Antabuse, a drug used to prevent subsequent drinking by causing violent vomiting if alcohol is ingested. However, large scale studies have not shown Antabuse to be superior to placebo; in addition there are substantial drop-out rates and serious side-effects. Other drugs, including naltrexone, buspirone, and clonidine, have shown some therapeutic value when combined with a psychological intervention. However, metabolism of drugs is affected in people with liver damage, so side effects can be more pronounced in heavy drinkers.

Alcoholics Anonymous Alcoholics Anonymous (AA) is the largest self-help program in the world. Espousing complete abstinence, the AA model has been extended to assist family members of alcohol abusers and those with other problems related to addiction. Recent scientific studies of AA indicate that the program is effective for those who choose to participate and remain with it.

Cognitive Behavioral Treatment Cognitive and behavioural treatments include aversion therapy; this controversial method involves punishment for drinking, either directly or through covert sensitization. Contingency management, an operant approach to treating alcoholism, involves such techniques as involving significant others in reinforcement of behaviours inconsistent with drinking, and teaching behavioural self-control training.

Controlled drinking is a controversial procedure that does not prohibit all drinking but instead aims to teach moderate alcohol consumption.

Clinical Considerations in Treating Alcohol Abuse One of the problems in the treatment of alcohol abuse is an unspoken assumption on the part of therapists that all people drink for the same reasons – this assumption is likely incorrect. When people reduce or stop drinking altogether they need to mobilize other resources to confront the reason for drinking in the first place. Researchers are realizing that different kinds of drinkers may need different types of treatment.

Canadian Contributions 12.1 G. Alan Marlatt and Harm Reduction Therapy G. Alan Marlatt was a Canadian professor of psychology and director of the Addictive Behaviors Research Center at the University of Washington. Marlatt's model has several key components including a view that addiction is best conceptualized as an adjustment problem that responds best to treatment rather than a criminal behaviour that would respond best to punishment. Harm reduction is widely used as a social policy in Europe and even in North America and has been successfully applied to diverse behaviours including pedophilia and drug abuse.

Focus on Discovery 12.3 Matching Patient to Treatment—Project Match For many years, both practitioners and researchers have understood the importance of employing treatments that are suitable for particular patients. This notion goes beyond the question of the general kind of therapy best suited for a particular kind of problem; rather, it involves an approach called aptitude-treatment interaction (ATI), which focuses on characteristics of all patients with the same disorder that might make the group more suitable candidates for one generally effective treatment than for another. The question of

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matching patient to treatment was tested in Project Match, a large, eight-year, multi-site study on alcohol abuse (Project Match Research Group, 1997). This study failed to find what it was looking for—a way to match particular kinds of alcoholic patients with specific interventions.

Therapy for the Use of Illicit Drugs Biological Treatments Detoxification is central to the treatment of those who use illicit drugs and is the easiest part of the treatment process: long-term abstinence is often not achieved. Biological Treatments include methadone ass a heroin substitute. This approach converts the addiction to a legally available drug with less severe withdrawal symptoms. Heroin antagonists prevent addicts from experiencing a high when heroin is taken; patient compliance is very poor with these treatments. Drugs such as clonidine and bromocriptine may ease withdrawal and reduce craving.

Psychological Treatments Cognitive-Behavioral treatments in combination with biological treatments have been shown to be somewhat effective in reducing cocaine use. Motivational interviewing (discussed in more depth in Chapter 17) is a combination cognitive-behavioral treatment with a Rogerian approach.

Treatment of Cigarette Smoking Biological Treatments Two biological treatments aimed at satisfying the smoker's need for nicotine without the deleterious effects of smoking are nicotine gum and nicotine patches. While useful in a limited way, nicotine gum can be addictive itself and may lead to cardiovascular changes. Nicotine patches release the drug into the bloodstream, and compliance is easier than with gum. Nicotine inhalers and the antidepressant buproprion have also been shown to be effective. These treatments appear to be helpful for some smokers by temporarily easing the discomfort from smoking cessation, but psychological treatments are recommended as an adjunct.

Psychological Treatments Behavioural and cognitive-behavioural treatment programs have encouraging short-term but modest longerterm results. Rapid-smoking (quickly smoking successive cigarettes in a poorly ventilated room), focused smoking (smoking for a sustained period of time at a normal rate), and smoke holding (retaining smoke in the mouth without inhaling) are examples. A new approach termed scheduled smoking shows promise; it involves helping the smoker to gradually increase the time between cigarettes. Advice from physicians to stop smoking sometimes works in conjunction with nicotine gum.

Relapse Prevention Relapse prevention is important given the poor long-term effectiveness of any of the treatments described.

Research suggests that cognitions of recent ex-smokers can predict later relapse or abstinence.

Prevention of Substance Abuse Unfortunately, many prevention efforts aimed at adolescents (e.g. Project DARE) have shown disappointing results. Other prevention efforts are in place but have not been evaluated; for example, warning labels on

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alcoholic beverages, parental involvement in school programs, media warnings about drunk driving, and drug testing in the workplace.

Prevention of smoking is a top priority among health researchers. In 2000, then federal health minister, Alan Rock, introduced new regulations mandating that cigarette packaging carry health warnings that cover 50% of the front and back of the package. This strategy appears to have had considerable impact.

STUDENTS SHOULD KNOW Key Points 1.

Substance dependence involves maladaptive use of a drug, interference with social, familial, or occupational functioning, and may involve physiological dependence (tolerance and withdrawal).

2.

Addictive disorders such as alcohol abuse can be conceptualized according to a disease model in which the abuse is seen as a result of vulnerabilities within the person or a moral model in which the abuse is seen as a personal failing or a personal choice.

3.

Alcohol exacts a high cost from individuals and from society.

4.

Alcohol has biphasic effects: Initial consummation is stimulating followed by a depressed state that can include negative emotions.

5.

Long-term use of alcohol can have severe psychological and somatic consequences.

6.

Inhaling substances such as glue or gasoline is prevalent among youth in northern communities.

7.

Cigarette smoking poses a tremendous health problem; nicotine is highly addictive.

8.

Marijuana and hashish interfere with cognitive functioning and have adverse physical effects with long-term use. There are also several therapeutic applications of THC, the active ingredient in marijuana.

9.

Opiates—opium, morphine, and heroin—are highly addictive and have important social consequences, including criminal behaviour, occasioned by the high cost of the drugs. Heroin usage has increased recently, and stronger varieties are now available.

10.

Stimulants, including amphetamines and cocaine, heighten alertness and increase autonomic activity.

They are highly addictive and pose significant health risks.

11.

Both caffeine and energy drinks act as stimulants.

12.

Sedatives such as barbiturates slow the activities of the body and reduce its responsiveness. They are particularly lethal in combination with alcohol.

13.

LSD and other hallucinogens produce states that were once thought to mimic psychosis. These drugs sometimes produce dramatic changes in perception and cognition.

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14.

Theories of substance abuse and dependence consider socio-cultural, psychological, and biological variables. The common factor in all drugs that are addictive is their ability to fire the brain’s pleasure centre consistently.

15.

A variety of treatments have been used for alcoholism and illicit drug use, including self-help methods, medications, and cognitive and behavioural treatments.

16.

Controlled drinking and harm reduction programs may be useful in the treatment of alcoholism.

17.

Treatment of smoking has shown positive short-term but less impressive long-term results.

18.

Prevention approaches may be more promising, though most remain untested. The prevention of any disorder is always more efficient than treatment.

Key Terms amphetamines (p. 366) Antabuse (p. 374) barbiturates (p. 364) cocaine (p. 366) conditioning theory of tolerance (p. 373) controlled drinking (p. 376) covert sensitization (p. 375) cross-dependent (p. 380) delirium tremens (DTs) (p. 350) denormalization belief (p. 385) dependence susceptibility (p. 361) detoxification (p. 374) disease model (p. 353) Drug-Stroop Task (p. 372) ecstasy (p. 368) explicit cognition (p. 372) feedforward mechanisms (p. 373) fetal alcohol syndrome (FAS) (p. 355) flashbacks (p. 368) guided self-change (p. 376) hallucinogen (p. 367) harm reduction therapy (p. 376) hashish (p. 359) heroin (p. 363) heroin antagonists (p. 380) heroin substitutes (p. 380)

implicit cognition (p. 372) LSD (p. 367) marijuana (p. 359) mescaline (p. 367) methadone (p. 380) moral model (p.353) morphine (p. 363) motivational interviewing (p. 381) nicotine (p. 357) opiates (p. 362) opioids (p. 362) opium (p. 362) OxyContin (p. 362) polydrug (polysubstance) abuse (p. 349) psilocybin (p. 367) second-hand smoke (p. 359) sedative (p. 362) self-medication theory of addiction (p. 371) stimulant (p. 364) substance abuse (p. 348) substance dependence (p. 348) substance-related and addictive disorders (p. 348) tolerance (p. 348) withdrawal (p. 348)

New Names G. Alan Marlatt.

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LECTURE LAUNCHERS 1. Risks and Protective Factors in Adolescent Substance Use Among Hispanic eighth-graders, family support was found to reduce the influence of deviant peers on tobacco and marijuana use (1997; Frauenglass, Routh, Pantin, and Mason; Journal of Clinical Child Psychology, 26, 15-23). Participants in the study lived in a crowded, impoverished Miami neighbourhood where crime and substance abuse were the norm. While deviant peer modelling was strongly associated with substance use and gang involvement, perceived social support from the family remained a protective factor in reducing peer influences.

2. Update on Joe Camel In 1997, the Federal Trade Commission charged that R.J. Reynold's "Joe Camel" campaign illegally targeted children and adolescents. They asked an administrative law judge to order the second-largest cigarette manufacturer to stop using the cartoon camel in ways that "would have a substantial appeal to children and adolescents below the age of 18." (Fulwood and Weinstein, May 29, 1997, Los Angeles Times. It was discovered that 6-year-olds could identify Joe Camel as readily as Mickey Mouse.

3. "Designer Drugs" A recently evolving drug problem is the development of new "designer drugs"—synthetic analogs of organically found drugs, prepared by underground chemists to mimic the effects of other drugs (1986, U.S. Department of Health and Human Services, Public Health Service memo). Up to 3,000 times stronger than the drugs they mimic, designer drugs are less expensive to manufacture and, until recently, were legal because they were not structurally identical to their parent compounds. A heroin analog, Fentanyl, became widely available in 1979 and caused numerous overdose deaths Given its widespread use on college campuses, students may be familiar with MDA or MDMA, amphetamine analogs known as "ecstasy" (see text p. 389). Psychological difficulties associated with MDMA include confusion, depression, anxiety, and paranoia; physical symptoms include muscle tension, nausea, blurred vision, chills or sweating, and increased heart rate and blood pressure.

One particularly serious problem with designer drugs is their potential for overdose; "in animal studies, the doses of MDMA which produce neurotoxicity are only 2 to 3 times more than the minimum dose needed to produce a psychotropic response" (1986, U.S. Department of Health and Human Services).

4. Not an Upper or a Downer but an Inside-Outer In 1956, Parke Davis and Company, a large pharmaceutical firm, synthesized a new anaesthetic. Although effective in large doses, it was found to cause agitation and disorientation as a patient regained consciousness. When administered in smaller doses, it induced a psychotic-like state. In 1965 this new drug, phencyclidine (PCP), was taken off the market, and by 1978 its legal manufacture was discontinued in the United States.

PCP was first seen in illegal use in Los Angeles in 1965. It soon turned up in the Haight-Ashbury district of San Francisco under the name "PeaCe Pill" and was sold as a psychedelic, but it quickly gained a bad reputation because many users had negative reactions. In the late 1960s and early 1970s the drug spread to other parts of the country until, by 1979, it had turned up in most states. Its prevalence declined sharply in the 1980s.

On the street PCP is known by dozens of names, among them angel dust, elephant tranquillizer, cadillac, cozmos, detroit pink, embalming fluid, killerweed, horse crystal, PeaCe Pill, wac, and zombie, and has been marketed falsely as LSD, psilocybin, cocaine, and other drugs. It is available in many forms and

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degrees of purity and in most colours. In granular form it contains between 50 and 100 percent phencyclidine. The most popular ways of taking PCP are in mint or parsley flavoured joints and in commercial cigarettes that have been dipped in liquid PCP or had a string dipped in liquid PCP passed through them. But the drug can also be injected intravenously, swallowed, put in the eyes as drops, snorted like cocaine, and smoked in a pipe.

The effects of PCP depend largely on the dosage. The user generally has jerky eye movements (nystagmus) alternating with a blank stare, is unable to walk heel-to-toe in a straight line (gait ataxia), and has great rigidity of the muscles. Some also experience hallucinations and delusions. All the sensory systems become overly sensitive so that users are extremely susceptible to any stimulation and are best left alone.

When touched, they are likely to flail and become so agitated and combative that it takes several people to restrain them. Their incoherence and lack of communicativeness do not allow them to be talked down from their high. Very high dosages—actually, as little as a single gram—usually result in a deep and prolonged coma, seizures, apnea or periods of no breathing, sustained high blood pressure, and sometimes even death from heart and lung failure or from ruptured blood vessels in the brain. No medication to reverse the effects of PCP has yet been found. People seldom remember afterward what happened while they were on the drug.

Phencyclidine is not an upper or a downer, nor is it a psychedelic. Some workers refer to it as an inside-outer, a term that to some extent conveys the bizarre and extreme nature of its effects.

How long do the effects of PCP last? The way in which it is ingested and the dosage seem to play a role. Onset is usually between one and five minutes after smoking a treated cigarette; effects peak after about half an hour and then do not dissipate for up to two days. Since PCP remains in the body for several days, it can accumulate if ingested repeatedly. Chronic users who have taken the drug several times a week for six months experience cognitive distortions and disorientation for several months afterward, even for as long as two years after use has ceased. In addition, personality often changes, there can be memory loss, and the user may experience severe anxiety, depression, and aggressive urges (Aniline and Pitts, 1982). The addictiveness and other consequences are difficult to determine because most PCP users take other drugs as well, such as alcohol.

More than 100 deaths from ingesting PCP were reported in Los Angeles County in 1978 alone.

These fatalities were caused in a number of ways. One man who was swimming drowned because he lost his spatial orientation; others died because of severe respiratory depression or an uncontrollable increase in body temperature.

Those who use PCP are apparently very young, averaging fifteen years of age. Abusers tend to be arrested more often for substance-related offences than those taking the other drugs discussed in this chapter, and they tend as well to have overdosed on more occasions. The PCP user, then, seems to be more socially deviant, perhaps more often psychopathic, than abusers of other illicit substances.

In light of how terrifying and dangerous the drug is, it is not surprising that its popularity declined in the 1980s. More surprising perhaps is that it enjoyed a resurgence in the 1990s.

5. Prevention of Drug Use In 1997, the National Institute on Drug Abuse (NIDA) released the first science-based guide to preventing illicit substance use in young people. Twenty years of research are compiled in a format designed to encourage development of effective substance-abuse prevention programs. Some findings highlighted include: -

Boys who are shy, aggressive, or rebellious are more prone to substance abuse than peers without those characteristics.

Protective factors include close family relationships, academic achievement in school, and participation in after-school activities.

One of the most effective programs described in the guide is the "Strengthening Families" curriculum, developed by Karol Kumpfer. The 14-week program targets 6 to 10-year-olds whose parents have substance-abuse problems. Three components are included: (1) behavioural parent-training curriculum; © Wiley Canada

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(2) social skills-training curriculum for children that increases prosocial behaviour, and (3) family-skills training curriculum that involves practising within the family the skills learned in the other groups.

The NIDA guide ("Preventing Drug Abuse Among Children and Adolescents") is available on the Internet at: www.nida.nih.gov.

6. Science vs. Law: The Long Canadian Debate over Canadian Drug Laws Canadian drug laws offer an interesting contrast in the failure of scientific evidence to significantly affect social policy and legislation. After reading the chapter you may rank various drugs as to their cost to society—alcohol as the most costly followed by nicotine followed by heroin with marijuana near the bottom of the list. You may also rank drugs as to their addictive properties—nicotine as most addictive (measured by success rates of withdrawal), alcohol next followed by perhaps heroin and then cocaine, with marijuana near the bottom. You may rank them according to the damage they do to the body— probably nicotine at the top, alcohol next, though depending on the measures you may reverse these, followed by cocaine and marijuana low, heroin at the bottom. You may rank drugs according to their medical use—morphine at the top, a growing list of uses of marijuana, some uses for cocaine, don't forget the use of coca leaves in South America, with alcohol and nicotine with no uses. Now you may list the penalties for possession of these drugs, heroin at the top, cocaine and marijuana with alcohol and nicotine bearing no penalty. The pattern is clear, the most harmful and addictive drugs are legal and in most provinces your alcohol dealer is your provincial government, and the least harmful drug, marijuana, carries significant penalties for both possession and sale. You may review the history of attempts to bring laws more starting with the Le Dain Commission. Summary of recommendations: http://www.druglibrary.org/schaffer/library/studies/ledain/ldctoc.html. From June 30 to Aug. 29, 2016, the Government of Canada held public consultations on marijuana laws. At this point the government seems set to legalize, regulate, and restrict access to marijuana. For updates on this process, see: http://healthycanadians.gc.ca/health-system-systeme-sante/consultations/legalization-marijuanalegalisation/index-eng.php

DISCUSSION STIMULATORS Naloxone Kits To address the growing problem of fentanyl overdoses, Naloxone kits are becoming part of a Canadian harm reduction strategy. In March 2016, Health Canada removed the prescription status of naloxone, a drug that counteracts the effects of opioids almost immediately. In Ontario, as of June 24, 2016, pharmacists were permitted to provide naloxone without a prescription at no cost to opioid users or those likely to encounter opioid users at risk of overdose. In October 2016, University of British Columbia students were told they could pick up free naloxone kits and receive training from a nurse on how to administer this antidote. http://news.ubc.ca/2016/10/28/ubc-equipped-with-take-home-naloxone-kits-for-students/

Pre-Test on Alcohol Expectations Before the students read the chapter, discuss their impressions about the effects of alcohol and other drugs on aggression, sex, and anxiety, or have them write out answers on a questionnaire and compile the results.

After reading the chapter, these impressions can be discussed in terms of the impact that expectations about drug effects have on the behaviour of those under the influence of a drug. How might expectancies influence

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other responses to alcohol or to other drugs? What are the expectancies about the effects of cigarette smoking, marijuana use, or psychedelics?

Effects of Alcohol Please answer the following questions before reading the chapter on substance-related disorders.

1) How does alcohol affect aggression? Does drinking make people less aggressive, more aggressive, or have no effect on aggressiveness? Why do you think this occurs?

2) How does alcohol affect sexual responsiveness and arousal? Why do you think these effects occur?

3) How does alcohol affect anxiety? Why do you think these effects occur?

4) What other short-term effects does alcohol have?

Controlled Drinking vs. Abstinence Organizations like Alcoholics Anonymous assert that the only way to insure that a substance will not be abused in the future is to never again partake of the substance. Is it true that once you are an alcoholic, you always are an alcoholic? Is one drink sufficient to begin bingeing? Can alcoholics be taught to become social drinkers? What are the consequences of AA's stance, and what are the consequences of challenging that stance? While these appear to be straightforward questions, scientific evidence regarding their answers is equivocal and certainly controversial, as discussed in the text.

Personal Experiences with Smoking How did the smokers in the class get started? Do their parents smoke? Did they begin smoking with friends?

Was it "cool" to smoke? How did the non-smokers resist peer pressure? You might break the class into groups, including both smokers and non-smokers in each group, and ask them to come up with a smoking prevention program based on their own experiences. The following questions could be addressed: (1) what age group should be targeted? (2) In what setting(s) should the program be implemented? (3) Who should convey the message to the target group (mental health professionals, paraprofessionals, ex-smokers, peers, and parents)? (4) How could the mass media be used to help in the prevention program? (5) How would you measure the effectiveness of your program?

In order to avoid embarrassing students who smoke, you could ask students to conduct the interview, using the same questions, with a smoker. The results of the interview could then be discussed in a subsequent class meeting.

"Just Say No" Many of the students in your class may have been exposed to a drug prevention program during elementary school or junior high, ranging from a police officer coming to the class to show various drugs and caution the children about the adverse consequences and illegality of drug use, to a formal "Just Say No" or "DARE" program. Class discussion could involve sharing experiences regarding the effectiveness or lack of effectiveness of these prevention efforts, and ways that drug prevention could be most effective. The article

by Johnson et al. (1990) and the NIDA guide (see above in Lecture Launchers) describe drug use prevention research and may be a helpful impetus to class discussion.

Drug Use and the Law What are the social consequences of making a drug illegal when there is a continuing market for the drug despite the possibility of prosecution? At least three examples can be discussed in connection with this © Wiley Canada

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question. First is the experiment with the prohibition of alcohol in the United States in the 1920s, which resulted in prevalent law breaking, a rise in gangsterism, and eventual repeal of the constitutional amendment. Second is the continuing illegality of marijuana, which, at least in the 1960s, may have alienated young marijuana users from the law. Third is the different status of heroin in the United States, where it is illegal, and Britain, where heroin can be obtained in clinical settings. Some have argued that the British treatment of the drug has greatly reduced the profit available to underworld heroin dealers, and thus explains the lesser incidence of heroin addiction in Britain as compared to the United States. In a similar vein, students might debate the pros and cons of making sterilized needles easily available to IV drug users to prevent the spread of AIDS. While many people have expressed concern that such a practice would increase drug use and make it appear that the government is condoning illegal activity, research (see above, in lecture material) indicates that IV drug use has actually declined when sterile needles have been made more available.

Drug Testing Recent concern about drug abuse has led to wide-spread drug testing, at work, in athletics, and even within the home, as parents test their children. What do students think of this approach to the drug problem? Ask students to discuss the following case: You are a counsellor in a mental health clinic connected with a hospital. A man brings his 15-year-old son to see you because he suspects him of using drugs. The father insists that you arrange for drug testing, to confirm his suspicion. The son denies using drugs and insists that his only problems occur in relation to his father. He has refused to comply with his father's requests to take a drug test. What would you do? Would you agree to the father's request? If so, how would you get the son to comply with the plan? What would you propose as a treatment plan?

Harm Reduction Canada is home to several theorists who study and support the concept of "harm reduction." This concept can be applied to a variety of abnormal behaviours, but in the context of this chapter applies to drug laws and policies.

By doing an Internet search for "harm reduction" students can begin to get a sense of what these methods entail. This can lead to a discussion about what types of harm reduction procedures they could support. They could make a list of simple to complex and controversial harm reduction procedures that might range from providing pamphlets of safe ways to use various drugs, to providing sterile needles in jails or on the street, to the decriminalization or legalization of some drugs or all drugs. The group can then vote on the level of harm reduction that they could support.

SOME IDEAS FOR THE USE OF THE INTERNET The Biopsychosocial Theory: A Comprehensive Descriptive Perspective on Addiction American Scientist article "Reward Deficiency Syndrome" Kenneth Blum, John G. Cull, Eric R. Braverman and David E. Comings, March 1996. www.lifeskillsu.org/campus/campus_key/rdj/reward_deficiency.html

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Students can also do a web search for "etiology drug addiction" and come up with a variety of sources that look to the development of a model of drug addiction based on the biopsychology of the reward system (mesotelenchephalic reward system in the limbic system) in the brain.

EROWID A somewhat controversial site as it clearly advocates the reform of drug laws and point out benefits of using certain drugs. However, the site is a wealth of information on a wide variety of drugs used to alter consciousness. The site also has information concerning harm-reduction. www.erowid.org/ The Dutch example shows that liberal drug laws can be beneficial.

Students can find a variety of discussions and papers about the Dutch experiment with very liberal drug laws by searching for "Dutch” or “” and drug laws. One example of a discussion is here: www.cedro-uva.org/lib/reinarman.dutch.html

Behavioural Addictions?

DSM-5 includes Gambling Disorder in the substance abuse chapter. Have students explore internet links about gambling disorder and other behavioural additions (e.g., “sex addiction”, internet addiction) and discuss the similarities and differences of these disorders with addictions to alcohol and other substances. https://www.problemgambling.ca/EN/ResourcesForProfessionals/Pages/DSM5CriteriaGamblingDisorder.as px They might want to also search for European drug laws as Portugal, the UK, France and Switzerland are also in the process of rationalizing their laws. This can lead to a debate as to the how Canada should proceed. They will find a good deal of discussion about how countries all over the world are hamstrung by the US insistence on the continued enforcement of "single convention of 1961"; "the first, favoured by all members but incompatible with the 1961 Single Convention, was to make cannabis available legally; www.parl.gc.ca/37/1/parlbus/ca/37/1/parlbus/commbus/senate/com-e/ille-e/library-e/collin1-e.htm This is a quote from the Swiss paper on their reform of drug laws. The 1961 single convention can be read at: www.incb.org/ From this information they will be confronted with the complexity of passing laws that conform to scientific evidence.

Drug Policy Alliance www.drugpolicy.org/homepage.cfm “Drug Policy Alliance is the leading organization working to broaden the public debate on drug policy and to promote realistic alternatives to the war on drugs based on science, compassion, health and human rights. © Wiley Canada

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The Alliance was formerly known as The Lindesmith Center—Drug Policy Foundation. The Lindesmith Center, created in 1994, was the leading independent drug policy reform institute in the United States. The Drug Policy Foundation, founded in 1987, represented over 25,000 supporters and was the principal membership-based organization advocating for more sensible and humane drug policies. The two organizations merged on July 1, 2000, with the objective of building a national drug policy reform movement.”

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CHAPTER 13 PERSONALITY DISORDERS

CHAPTER SYNOPSIS Personality disorders are a heterogeneous group of disorders that are regarded as long-standing, pervasive, and inflexible patterns of behaviour and inner experience that impair social and occupational functioning.

Previously coded on Axis II in DSM-IV, they served to ensure that clinicians would not ignore them. The DSM-5 abandoned the multi axial system of diagnosis.

Classifying Personality Disorders: Clusters, Categories, and Problems Theodore Millon identified three criteria to distinguish disordered personalities from normal: (1) rigid and inflexible behaviour; (2) self-defeating behaviour; and (3) structural instability. While the diagnosis of personality disorders has been hampered by poor reliability, more recent work with structured interviews indicates that good inter-rater reliabilities can be achieved, even cross-culturally. Test–retest reliability (measuring stability of the disorders over time), however, is less strong, except in the case of anti-social personality disorder. A major problem is the overlap between personality disorders in a single individual.

Because personality traits exist on a continuum, many researchers have suggested using a dimensional approach to classification instead of the categorical approach historically used by the DSM. An alternate dimensional approach to personality disorders was proposed for DSM-5, but very late in the process this Alternative Model for Personality Disorders (AMPD) was relegated to DSM-5’s Section III (emerging measures and models) and the categorical model was retained.

Focus on Discovery 13.1: A Dimensional Approach to Personality Disorders The current DSM uses a categorical approach exclusively. Various theorists suggests that for some disorders, especially the personality disorders, a dimensional approach would be more appropriate in part because these disorders may represent extremes of personality traits found in everyone. A widely used personality theory, the five-factor model, is, in effect, a dimensional approach to personality theory. There has been substantial research support for the personality dimensions proposed in the DSM-5 AMPD.

Assessing Personality Disorders A major difficulty in assessing personality disorders is that many disorders are ego-syntonic meaning that the individual is unaware a problem exists and may not be experiencing any distress. In addition to clinical interviews and a set of MMPI-2 scales, the PSY-5 has been designed to assess five personality dimensions that are particularly relevant to personality disorders. The Millon Clinical Multiaxial Inventory, MCMI-III, is also widely used and provides measures of 11 clinical personality scales.

Student Perspectives 13.1: Personality Disorders Among Students There is some evidence that personality disorders may be quite prevalent among university students. The two most common personality disorders among students are obsessive-compulsive personality disorder and paranoid personality disorder.

Instructor’s Manual to accompany Abnormal Psychology, Sixth Canadian Edition by Flett et al.

Personality Disorder Clusters Personality disorders are grouped into three clusters: Cluster A or the odd/eccentric cluster (paranoid, schizoid, and schizotypic personality disorders); cluster B or the dramatic cluster (borderline, histrionic, narcissistic and anti-social personality disorders); and, and cluster C or the anxious/fearful cluster (avoidant, dependent and obsessive compulsive personality disorders).

Odd/Eccentric Cluster Paranoid Personality Disorder People with paranoid personality disorder are suspicious, secretive, and jealous. This personality disorder is diagnosed most frequently in men.

Schizoid Personality Disorder Individuals with schizoid personality disorder do not desire or enjoy social relationships and tend to be aloof and indifferent. Comorbidy is high with schizotypcal, avoidant, and paranoid personality disorders.

Schizotypal Personality Disorder Schizotypal personality disorder has been described as a mild form of schizophrenia, and is characterized by extreme social anxiety and eccentric symptoms such as magical thinking and illusions. A major problem with the schizotypal personality disorder is it’s comorbidy with other personality disorders.

The search for causes of these disorders has been guided by the idea that they are genetically linked to schizophrenia.

Dramatic/Erratic Cluster Borderline Personality Disorder Individuals with borderline personality disorder exhibit instability in relationships, mood, and self-image.

Their behaviour is unpredictable and impulsive; they alternate between idealization and devaluing in relationships, and they often attempt suicide and engage in self-mutilating behaviour. The disorder is more common in women than men. Mood disorders, substance abuse, eating disorders, and PTSD are often common in people with borderline personality disorder.

Object-relations theorists have proposed that adverse childhood experiences cause children to develop insecure egos and leads to the defence mechanism of splitting-dichotomizing objects into all good or all bad. Evidence for poor childrearing experiences in the histories of people with borderline personality have led to the suggestion that the disorder may be part of post-traumatic stress disorder or dissociative identity disorder arising from traumatizing abuse. Other likely factors in the etiology of borderline personality disorder include a genetic link, impairment in the frontal lobes, and low levels of serotonin.

Marsha Linehan, whose incredible story of being a hospitalized teenager with borderline personality disorder appears in this chapter, proposes that the disorder develops from a biological diathesis for emotional dysregulation combined with an invalidating environment. Childhood physical and sexual abuse is more common in this disorder than with most other personality disorders.

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Histrionic Personality Disorder Histrionic personality disorder refers to an overly dramatic, attention-seeking, shallow, and self-centred individual. They are often sexually provocative in their dress and behaviour, and their speech is impressionistic. The disorder is more common in women and is associated with depression and poor physical health. Regarding etiology, psychoanalytic theory points to fathers' encouragement of emotionality and seductiveness in their daughters.

Narcissistic Personality Disorder People with narcissistic personality disorder have a grandiose view of their own uniqueness and abilities.

They require constant attention and admiration and lack empathy. Psychoanalytic theories view the narcissistic personality as covering a very fragile self-esteem with an outward sense of self-importance.

Kohut's self-psychology view focuses on the impact of parents who value their child as a means to foster their own self-esteem rather than approving of their child's own competencies. The child then strives to bolster their sense of self through unending quests for approval from others.

Anti-social Personality Disorder and Psychopathy The terms anti-social personality disorder and psychopathy are often (but erroneously) used interchangeably.

In the DSM-5, anti-social personality disorder involves presence of a conduct disorder before the age of 15, and the continuation of this pattern of anti-social behaviour in adulthood through behaviours such as not working consistently, breaking laws, being physically aggressive, defaulting on debts, showing recklessness, and lacking in remorse. Psychopathy, as a diagnostic category, is not included in the DSM. Psychopaths are characterized by a number of features including poverty of emotions, no sense of shame, superficial charm, inability to learn from mistakes, and inadequate motivation. Most researchers use a checklist developed by Hare to identify psychopathy.

Family, twin, and adoption studies suggest that heredity plays a role in both criminality and antisocial personality disorder.

The family has been implicated as playing a role in the development of anti-social behaviour, with such factors as inconsistent or an absence of discipline, lack of affection, parental rejection, and anti-social behaviour in the father being identified as important. However, an issue is raised in this research by the difficulty of relying on retrospective reports from people known to be less than truthful.

Evidence also suggests that psychopaths have much lower levels of anxiety than most people, leading to the inability to profit from experience or learn from punishment. Psychopaths' pattern of physiological responses has been found to differ from controls, leading them to ignore aversive stimuli and effectively screen out anxiety and fear. Other researchers have proposed that psychopaths exhibit extreme impulsivity and do not reflect on feedback; therefore, they focus on immediately present stimuli rather than long-term goals.

It is of interest to note that anti-social personality disorder has a dual listing in the DSM-5.

Obviously, it is listed in the DSM chapter on Personality Disorders. However, it is also listed in the Disruptive, Impulse-Control and Conduct Disorder Chapter of the DSM-5

Canadian Contributions 13.1: Robert Hare and the Conceptualization and Assessment of Psychopathy Robert Hare's research at the University of British Columbia suggests that a new diagnostic category of "psychopath" should be identified separate from ant-social personality disorder. He has developed a diagnostic tool that seems to be valid and reliable and appears to assess two factors. Factor 1 focuses on affective and interpersonal characteristics; Factor 2 focuses on an unstable and anti-social lifestyle.

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Anxious/Fearful Cluster Avoidant Personality Disorder Avoidant personality disorder is characterized by keen sensitivity to criticism, rejection, or disapproval.

Such persons are restrained in social situations and exaggerate the risks in doing something outside their usual routine. The diagnostic criteria are strikingly similar to those of social phobia.

Dependent Personality Disorder Patients with dependent personality disorder lack self-confidence and self-reliance on others. They are passive in relationships and uncomfortable when alone, doing what is necessary to stay in a protective relationship.

Obsessive-Compulsive Personality Disorder The obsessive-compulsive personality is a perfectionist, preoccupied with details, rules, and work rather than pleasurable activities. They are serious, rigid, and inflexible, particularly regarding moral issues, and unable to discard useless objects. The disorder is apparently not strongly related to obsessive-compulsive disorder.

Etiology of the Anxious/Fearful Cluster Speculation as to the causes of disorders in this cluster has focused on parent-child relationships.

Attachment problems have been implicated in dependent personality disorder, reflecting a failure in the usual developmental process caused by a disruption in the early parent-child relationship. Avoidant personality disorder may be caused by modelling a parent's fears. Finally, Freud viewed obsessivecompulsive traits as rooted in fixation at the anal stage of psychosexual development. More contemporary theories stress a fear of loss of control.

Therapies for Personality Disorders There is little research-based information on treating personality disorders; most guidelines come from clinical case reports. Psychoactive drugs carefully matched to a particular personality disorder have shown some effectiveness. Psychodynamic therapists aim to correct the childhood problems assumed to underlie a personality disorder. Behaviour and cognitive therapists analyze the individual problems that taken together reflect a personality disorder. Beck has applied his cognitive therapy to analysing the logical errors and dysfunctional schemata evident in patients with personality disorders.

Therapy for the Borderline Personality The borderline patient's extreme difficulty relating to others extends to the therapy relationship, making this disorder quite difficult to treat. Hospitalization is often necessary when patients' behaviour is unmanageable or there is a threat of suicide. Medications have been tried in the treatment of borderline personality, with some evidence for effectiveness of antipsychotic drugs.

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Object-relations theory has been particularly important in the treatment of personality disorders.

Kernberg has developed a modified, more directive psychoanalytic approach which seeks to strengthen a borderline patient's weak ego through such techniques as analysing the defence of "splitting," or dichotomizing persons into all good or all bad.

Linehan's dialectical behaviour therapy combines client-centred empathy with cognitive-behavioural problem solving, and social skills training to treat borderlines. Linehan's approach requires therapists to accept the client while encouraging change. Recent research suggests the efficacy of this approach.

Therapy for Psychopathy As for treatment of psychopathy, there is unusual consensus: therapists of varying theoretical persuasions find it difficult, if not impossible, to treat. Because a primary problem in psychopathy is an inability to form relationships, the lack of therapeutic effectiveness is not surprising. Cognitive therapists attempt to challenge such beliefs as justification, personal infallibility, the impotence of others, and low-impact consequences.

Since many psychopaths spend time in prison, the discouraging results of imprisonment as rehabilitation are traced at least in part to the inability to modify psychopathic behaviour.

STUDENTS SHOULD KNOW Key Points 1.

Personality disorders are defined as enduring patterns of behaviour and inner experience that disrupt social and occupational functioning. The diagnoses of personality disorders are often unreliable and it has been suggested that a new method of diagnosis, a dimensional approach, should replace attempts to categorize these disorders.

2.

Personality disorders are grouped into three clusters in the DSM-5: odd/eccentric, dramatic/erratic, and anxious/fearful.

3.

The odd/eccentric cluster includes paranoid, schizotypal, and schizoid disorders. These disorders are generally, considered to be less severe variants of schizophrenia.

4.

The dramatic/erratic cluster includes borderline, histrionic, narcissistic, and anti-social personality disorders. Theories of etiology of the first three focus on early parent-child relationships. Linehan proposes that borderline personality disorder is the effect of an interaction between emotion dysregulation and an invalidating environment.

5.

Object-relations theory and dialectic behaviour therapy are two prominent approaches to treating borderline personality disorder.

6.

Anti-social personality disorder, is characterized by repeated anti-social behaviour which infringe upon the rights of others.

7.

Psychopathy appears to be related to the anti-social personality disorder; however, the two are not identical. Almost all psychopaths will be diagnosed as having anti-social personality disorder; however, only 20% of those diagnosed with anti-social personality disorder are high scorers on measures of psychopathy. © Wiley Canada

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8.

Robert Hare, a leading Canadian researcher developed a reliable and valid measure of psychopathy, the Hare Psychopathy Checklist-Revised.

9.

Attempts at treating psychopathy have been notably ineffective.

10.

The anxious/fearful cluster includes avoidant, dependent, and obsessive compulsive personality disorders. Theories of etiology focus on early experience, including modelling, and disruption of the parent-child relationship.

Key Terms obsessive-compulsive personality (p. 409) paranoid personality (p. 394) personality disorders (p. 389) personalized therapy (p. 393) psychopathy (p. 403) schema therapy (p. 411) schizoid personality (p. 394) schizotypal personality (p. 394)

anti-social personality (p. 402) avoidant personality (p. 408) borderline personality (p. 396) dark tetrad (p. 401) dark triad (p. 401) dependent personality (p. 409) dialectical behaviour therapy (p. 412) general personality disorder (p. 390) histrionic personality (p. 399) narcissistic personality (p. 400)

New Names Hervey Cleckley, Theodore Millon, Heinz Kohut, Otto Kernberg, Marsha Linehan, Robert Hare.

LECTURE LAUNCHERS

1. Childhood Sexual Trauma and Borderline Personality Disorder The diagnosis of borderline personality disorder carries a heavy burden of stigma; insurance carriers do not often cover treatment for the disorder because it is thought to be a lifelong condition, and therapists often share the pessimistic view that individuals with borderline personality are not amenable to treatment. An article by Landecker (1992, Psychotherapy, 29, 234-242) addresses the close relationship between symptoms of borderline personality disorder and those of post-traumatic stress disorder (PTSD), suggesting that the frequent finding of child abuse (particularly sexual abuse) in the history of individuals diagnosed as borderline may make PTSD a more useful formulation of the person's treatment needs. Neither diagnosis adequately describes the full picture of people with a history of sexual abuse trauma, leading to PTSD-like symptoms. However, viewing the symptoms in the context of trauma, as a PTSD diagnosis encourages, has important implications for treatment. For example, borderline symptoms such as use of primitive defences and self-mutilation might be viewed as once-adaptive responses to abuse. Students might be encouraged to consider the implications of choosing one diagnosis over another, in terms of varied degrees of stigma © Wiley Canada

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associated with one diagnosis vs. another, insurance coverage, treatment implications, and the patient's own view of the etiology and prognosis of their symptoms.

2. "Psychopathy or Psychopath" vs. APD Robert Hare of the University of British Columbia has argued that psychopathy is a distinct diagnostic category from Anti-social Personality Disorder. cf. Hart, S. D., & Hare, R. D. (1996). “Psychopathy and anti-social personality disorder”. Current Opinion in Psychiatry, 9, 120-132. Hare and his colleagues have spent several decades defining the concept, developing a diagnostic instrument (PCL-R), and then looking for a model of the etiology of the newly defined disorder. This process in itself is a good example of the evolution of a new syndrome or DSM diagnostic category. The PCL-R has proven to be a useful tool in the prediction of treatment outcomes and recidivism rates in treatment programs designed by Correctional Services of Canada. Go to the Correctional Services of Canada web site and use their search engine to explore various reports concerning the utility of the Hare Psychopathy Checklist in decisions related to treatment and release into the community. www.csc-scc.gc.ca/index-eng.shtml

3. Psychopathy and Anxiety The textbook chapter describes Hare’s early studies demonstrating that psychopaths were less responsive to impending punishment, in keeping with Cleckley’s description of psychopaths as being lacking in “nervousness”. Karpman’s (1941) early theory on psychopathy also proposed that true psychopaths had affective deficits, including low anxiety. Lykken’s (1995) “low fear hypothesis” suggested that it was this lack of responsiveness to impending punishment that was key to the development of psychopathy. Lykken suggested that children who are predisposed to lack harm avoidance are difficult to socialize. Only through extraordinary parenting, according to Lykken, could these children be socialized to be law abiding, prosocial citizens.

Other research has found that anxiety is unrelated to psychopathy in both forensic (Smith & Newman, 1990) and student (Visser, Ashton, & Pozzebon, 2012) samples. This issue is important because it has implications for the development, conceptualization, and measurement of psychopathy. For example, Hare’s Psychopathy Checklist Revised does not include low anxiety content because Hare found that low anxiety items did not correlate with other aspects of psychopathy. Other researchers continue to emphasize the importance of low anxiety, and thus, the Psycopathic Personality Inventory-Revised (PPI-R; Lilienfeld & Widows, 2005) does include low anxiety content.

4. Clinical Strategies with Borderline Patients Linehan's book, Cognitive-Behavioural Treatment of Borderline Personality Disorder, (1993, New York: Guilford Press) is full of clinical examples to illustrate the principles of dialectical behaviour therapy. Some examples of treatment strategies: Using metaphor: "Therapy, for the patient, is like climbing out of hell on a red-hot aluminium ladder with no gloves or shoes. Continually jumping off or letting go is therapy-interfering behaviour by the patient. Holding a blowtorch on the patient's feet to get her to climb faster is therapy-interfering behaviour by the therapist. The bottom of hell is usually hotter even than the ladder, so that after a while the patient always gets up, gets back on the ladder, and has to climb again" (p. 210).

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“Comfort with paradox and ambiguity is essential for the dialectical behaviour therapist.

The therapist needs to continually stress that things can be both true and not true at the same time. For example, when borderline patients become obsessed with who is right and who is wrong in a particular disagreement, the therapist maintains a stance that both (or neither) are right. For example, in the therapeutic relationship, the patient's need or desire is validated at the same time that the therapist maintains the limit they have set. An example of a paradoxical statement that requires the patient to think differently: "If I didn't care for you, I would try to save you" (p. 207).

The Devil's Advocate technique: Similar to the use of paradox, the therapist takes the extreme position to encourage the argumentative patient to adopt a more moderate stance. For example, at the beginning of treatment, the therapist may argue against change and commitment to therapy, since it will be too difficult and painful. This stance leads the patient to argue in favour of change.

Dialectical Assessment: A unique aspect of dialectical behaviour therapy is its attention to all the systems impacting on a patient's current behaviour. For example, the feeling of the borderline patient that they do not "fit in" is viewed, not necessarily as evidence that they need to change in order to fit in better, but as requiring assessment of the social context which may be wrong. This openness to exploring and analyzing the environment extends to looking at double-binds caused by sex-role, religious, social class, and racial expectations placed on the individual, as well as examining the therapy relationship itself.

DISCUSSION STIMULATORS Personality Disorders: Mental Disorders?

If personality disorders are maladaptive personality traits that interfere with functioning, should they be considered to be "mental disorders"? Are they disorders in the same sense as agoraphobia or bipolar disorder? Or are they instead just the individual's personality? Does calling such behaviour a disorder excuse it and allow the individual not to take responsibility for their behaviour? What trait, if it was maladaptive and interfered with functioning, wouldn't qualify as a personality disorder?

Evaluating and Refining Diagnoses To expose students to the finer points of attempting to devise reliable and consistent diagnostic criteria, try presenting them with the diagnostic criteria for one of the personality disorders in DSM-I. Reproduced here are the criteria for schizoid personality. Students could be divided into groups and asked to come up with better operational definitions of the criteria listed. Following an attempt at group consensus in this exercise, give the students the DSM-5 criteria for the same disorder; this will give them an opportunity to see how diagnostic classification has changed and to compare their attempts to those of the "experts."

DSM-I Diagnostic Criteria for Schizoid Personality Inherent traits in such personalities are (1) avoidance of close relations with others, (2) inability to express directly hostility or vent ordinary aggressive feelings, and (3) autistic thinking. These qualities result early in coldness, aloofness, emotional detachment, fearfulness, avoidance of competition, and daydreams revolving © Wiley Canada

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around the need for omnipotence. As children, they are usually quiet, shy, obedient, sensitive, and retiring.

At puberty, they frequently become more withdrawn, then manifesting the aggregate of personality traits known as introversion, namely, quietness, seclusiveness, "shut-in-ness," and unsociability, often with eccentricity.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. First ed.: 1952.

Washington, D.C.: American Psychiatric Association.

DSM-5 Diagnostic Criteria for Schizoid Personality Disorder A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: (1) neither desires nor enjoys close relationships, including being part of a family (2) almost always chooses solitary activities (3) has little, if any, interest in having sexual experiences with another person (4) takes pleasure in few, if any, activities (5) lacks close friends or confidants other than first-degree relatives (6) appears indifferent to the praise or criticism of others (7) shows emotional coldness, detachment, or flattened affectivity B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder with Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder and is not due to the direct physiological effects of a general medical condition.

Note: If criteria are met prior to the onset of Schizophrenia, add "Premorbid," e.g., "Schizoid Personality Disorder (Premorbid)."

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Fifth Ed. Washington, D.C.: American Psychiatric Association.

Psychopaths and Society 1 Given that psychopaths are by definition people who repeatedly engage in anti-social behaviour, and given also that they do not seem to learn from experience or respond to therapy, how should society treat psychopaths? Should they be punished the same as other lawbreakers? Would students consider the death penalty for psychopaths more appropriate (given that rehabilitation may be less likely) or less appropriate (given that they have a mental disorder) than for other criminals? Should they be considered insane and committed to treatment?

Psychopaths and Society 2 Not all psychopaths are found in the prison system. In fact, there is good reason to suppose that only a minority of psychopaths are incarcerated. In his initial description of psychopathy Cleckley also introduced the concept of the “successful psychopath”. The successful psychopath is someone who demonstrates the characteristics of a psychopath but has channelled these traits into a respected career. Superficial charm, a lack of remorse and empathy, manipulation and low anxiety are all useful in a wide variety of situations. For example, it would not be surprising to find that business people, bankers, CEO’s of large enterprises and politicians display number psychopathic traits. How would students re-evaluate their opinion of psychopath in light of this information? Students should be reminded that impulsivity is part of the constellation of © Wiley Canada

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psychopathic traits, and that psychopaths are typically quite poor at developing or pursuing long-term goals – thus, successful but manipulative individuals are more likely to be Machiavellian than psychopathic.

Machiavellians can see when cooperation is the more effective strategy, whereas psychopaths tend to pursue the cheating, short-term strategy regardless of whether it is most effective.

Criminal Justice What is the purpose of the criminal justice system? Is it our society's responsibility to rehabilitate those who break the law, or is punishment the only goal that we need to concern ourselves with? The issue is complicated by the fact that many criminals, particularly younger ones, are not psychopaths but are people who in some senses seem to be victims of poverty or other unfortunate life experiences. It is complicated further by the observation that, in fact, the system does not do much of a job of rehabilitating; if anything, the criminal justice system seems to produce criminals. This observation is so keen that some have suggested that the best thing the criminal justice system can do in order to facilitate rehabilitation is to keep offenders out of the system—divert them into restitution programs, community service, or some form of therapy.

SOME IDEAS FOR UTILIZING THE INTERNET

Correctional Service Canada Correctional Service of Canada has a very useful web site. [http://www.csc-scc.gc.ca/] They provide a variety of position papers and research papers that are relevant to this chapter. Students can be referred to the site in general or to a given paper in particular and asked to discuss or comment on what they find. Many of the papers raise controversial issues. Corrections Canada uses the PCL-R a good deal and has found that it is its best predictor of treatment outcome and recidivism. They have developed programs that students will find controversial, such as programs to keep pedophiles in their family to reduce the trauma to parents and children. There are many sources of discussion topics here.

See the list of research reports at this site: www.csc-scc.gc.ca/text/rsrch-eng.shtml

Robert Hare www.roberthare.org Robert Hare's site has some full articles and a lengthy bibliography. This is a useful research site for students. Students should also be encouraged to read Robert Hare’s 1993 book, Without Conscience.

Marsha Linehan and Dialectical Behaviour Therapy http://faculty.washington.edu/linehan/

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Have a look around this site for more information on the theory and practice of dialectical behaviour therapy.

Personality Disorders in the Media There are a number of popular films that portray personality disorders. For example, the move Girl Interrupted tells the story of Susanna Kaysen, who was diagnosed with Borderline Personality Disorder. Her friend, Lisa (Angelina Jolie) is psychopathic. Derek Zoolander from the movie Zoolander, might meet criteria for Histrionic Personality Disorder as would Blanche Dubois from Streetcar Named Desire.

Have students suggest characters that might depict individuals with personality disorders. For example, Dexter Morgan from the HBO series Dexter is a self-proclaimed psychopath. Would he meet criteria for a diagnosis?

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CHAPTER 14 SEXUAL DISORDERS AND GENDER DYSPHORIA

CHAPTER SYNOPSIS This chapter addresses sexual thoughts, feelings, and behaviors that are abnormal and dysfunctional.

Gender Identity Disorder and Gender Characteristics of Gender Identity Disorder Our sense of ourselves as male or female is called gender identity. There are, however, some people who are certain that they are of the other sex despite anatomical evidence to the contrary. The feeling or conviction of being a member of the other sex was sometimes referred to as transsexualism or gender identity disorder in the pasts. The DSM-5 abandoned the terminology of gender identity disorder in favor of the term gender dysphoria. There is considerable evidence suggesting a hormonal basis as the cause of gender dysphoria.

Focus 14.1 addresses the roles of nature and nurture in gender dysphoria.

Therapies for Gender Identity Issues Many transsexuals choose cosmetic surgery, and some also take hormones. Although some people go no further, others pursue sex-reassignment surgery. With this surgery, anatomical sex is surgically altered following therapy that addresses anxiety and depression that accompanies gender dysphoria. Evidence indicates that transsexuals do not later regret their decision to have surgery, but Danish study found that 1 in 4 individuals still had diagnosable psychiatric morbidity after the surgery.

Focus on Discovery 14.1 Joan/John: Nature vs. Nurture in Gender Identity This is a case in which the external genitalia of a young boy were destroyed during a botched circumcision.

Surgery was undertaken to construct female genitalia and he was raised as a girl. This procedure was done on the advice of Dr. John Money, who had invented such sex change operations, as a way of making life easier for the boy. Money suggested that this surgery, coupled with the administration of female hormones and the raising of the boy as if he were girl, should have been enough to convert him from a physical and psychological male to a female. That John never felt like a girl and eventually demanded to be changed back into a boy is evidence that something other than nurture is involved in gender identity.

The Paraphilias The paraphilias are a group of disorders which involve sexual attraction to objects or sexual activities that are unusual in nature. DSM-5 distinguishes between paraphilias, which to not cause anyone distress, and paraphilic disorders, which causes distress to the individual or harm or risk of harm to others.

Fetishism

Instructor’s Manual to accompany Abnormal Psychology, Sixth Canadian Edition by Flett et al.

Fetishism involves a reliance on an inanimate object for sexual arousal and has a compulsive quality to it.

Common sources of arousal include sheer stocking, shoes, undergarments, etc. Some carry out their fetish alone while other may ask their partner to wear the object during sexual encounters.

Transvestic Disorder Transvestic disorder refers to a man who is sexually aroused by dressing in women’s clothing, while still regarding himself as a member of his own sex. The extent of cross dressing can vary considerably from simply wearing women’s underclothes to full cross-dressing. However, cross-dressing is not considered transvestic unless it is associated with sexual arousal.

Pedophilia and Incest Pedophiles are adults, usually men, who derive sexual gratification through physical and often sexual contact with prepubertal children unrelated to them. Pedophiles are overwhelmingly male. Recently, the Internet has played an increasing role not only in the direct contact with children but also with the exchange of pornographic material involving children.

Incest is defined as sexual relations between close relatives. (most often siblings and father to daughter). The taboo against incest seems virtually universal. There is evidence that the structure of families in which incest occurs is usually patriarchal and traditional.

Voyeurism Voyeurism (peeping) is a marked preference for obtaining sexual gratification by watching others in a state of undress or having sexual relations, usually when risk is involved. A true voyeur does not find it exciting to watch a woman undressing for his benefit.

Exhibitionism Exhibitionists obtain sexual gratification by exposing their genitals to an unwilling stranger; there is usually a desire to shock or embarrass the observer without coming into actual physical contact.

Frotteursim Frotteurism involves sexually oriented touching of an unsuspecting person.

Sexual Sadism and Sexual Masochism Preferences for obtaining sexual gratification by inflicting pain (sexual sadism) or through subjection to pain (sexual masochism) are diagnosed when the person acts on these urges intensively or experiences marked distress because of them. The shared activities of a sadist and masochist are heavily "scripted," involving themes of submission and domination.

Other Specified Paraphilic Disorders Other specified paraphilic disorders include necrophilia (having sexual with a dead body), zoophilia (bestiality, sex with animals) coprophilia (the use of excrement for sexual arousal), uruophilia (the use of urine in a sexual act) telephone scatalogia (obscene telephone calls), etc.

Focus on Discovery 14.2: Child Sexual Abuse: Effects on the Child and Modes of Intervention Data collected in 1997 suggests that a high percentage of victims of sexual assault are children and youth.

Many of these victims are assaulted by people they trust, which leads to a sense of betrayal and future lack of trust. Advances in treatment and prevention programs are discussed in this Focus. © Wiley Canada

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Student Perspectives 14.1: The Prevalence of Child Sexual Abuse Among Students The case of football coach, Jerry Sandusky, at Pennsylvania State University brought into focus the problem of child abuse among university students. A number of older and more recent meta analytic studies suggest that about 1 in 7 students were sexually abused as children – with women reporting childhood abuse more than twice as frequently as men.

Etiology of the Paraphilias Psychodynamic theorists view paraphilias as defensive, guarding the ego from dealing with repressed fears and representing fixations at pregenital stages of psychosexual development. Behaviourists view paraphilias as arising from classical conditioning that has by chance linked sexual arousal with inappropriate stimuli.

Often paraphiliacs have histories of childhood abuse and distorted parent-child relationships. Cognitive distortions also play a role in paraphilias as well as poor social skills or unconventional behaviour that was reinforced. Finally, the influence of androgen has been considered, although evidence is inconclusive.

Focus on Discovery 14.3 Neuroimaging, Neurobiology, and Brain Systems and Structures in Sexual Disorders Advances in neurobiology offer a variety of new avenues for investigating the etiology of sexual disorders.

Recent research as suggested differences in the way the brain processes sexual stimuli in pedophiles.

Therapies for the Paraphilias Many people identified as having paraphilias are committed to mental hospitals or are imprisoned and courtordered into treatment. Outcomes for incarcerated sex offenders are highly variable and recidivism increases with the passage of time. Sex offenders often lack motivation to change and deny or minimize the seriousness of their problem. Motivation can be enhanced with therapist empathy for the offender, pointing out negative consequences of refusing treatment, and pointing out that psychophysiological assessment can reveal his sexual proclivities.

Aversion therapy and satiation have been shown to have some beneficial effects on controlling the behaviour involved in paraphilias. Orgasmic reorientation involves pairing sexual arousal with more conventional sexual stimuli. Social skills training and alternative behaviour competition, and cognitive procedures to counter distorted thoughts are also used to supplement treatment. Medical interventions, including castration and drugs to lower testosterone, have had mixed success.

Rape The Crime The specifics of rape as a crime vary widely. Some are more planned than others; alcohol is often involved.

Forced rape is sexual intercourse with an unwilling partner and statutory rape refers to sexual intercourse with a minor who is under the age of consent. Acquaintance, or date rape, is more prevalent than rape by strangers and may be facilitated by drugs and alcohol. Rape is considered as much an act of sexual aggression, violence, and domination, as an act of sex. Recent attention has turned to the response of colleges and universities when a student alleges that he or she has been sexually assaulted.

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There appears to be considerable heterogeneity among rapists. However, often rapists lack social skills, have low self-esteem and manifest little empathy toward their victims.

Therapy for Rapists and Rape Victims Therapies for rapists are usually multidimensional incorporating a number of cognitive behavioral techniques. Success of treatment for rapists can only be assessed after the rapist has been released from prison and has spent time back in the community. Meta analyses have shown that cognitive behavioral treatment programs may lower recidivism somewhat.

Victims are often physically and mentally traumatized by the experience, with consequences including difficulty in sexual relationships, anxiety, depression, substance abuse, and suicide risk. Victims of rape are helped through crisis centres and hot lines, as well as counselling focused on alleviating their feelings of responsibility and guilt and addressing effects on the woman's ongoing relationships Full-blown post-traumatic stress disorder can also result. Treatments for victims (cognitive processing therapy) are similar to those used for post-traumatic stress syndrome.

Canadian Perspectives/14.1 Canadian Research on Sex Offender Recidivism There are several programs in Canada for the treatment of sexual offenders. Hanson and Bussiere (1998) provide a meta-analysis of 61 follow-up studies. Measures of psychopathy seem the most powerful predictors of recidivism. Overall, there appears to be growing evidence that well designed programs that do some selection can significantly reduce the recidivism rates for this disorder/crime.

Sexual Dysfunctions Sexual dysfunctions include the range of sexual problems that are considered to represent inhibitions in the normal sexual response cycle.

Sexual Dysfunctions and the Human Sexual Response Cycle DSM-5 requires that sexual dysfunctions be persistent and recurrent, and cause marked distress or interpersonal problems, before being considered disorders. Four phases in the human sexual response cycle are identified: (1) appetitive (sexual desire), (2) excitement (sexual pleasure and accompanying physiologic changes such as tumescence), (3) orgasm (the peak of sexual pleasure), and (4) resolution (relaxation following orgasm). While dysfunctions can occur the first three phases of the response cycle there are no dysfunctions associated with the resolution phase.

Descriptions and Etiology of Sexual Dysfunctions In hypoactive sexual desire disorder, the person is lacking in sexual fantasies and urges. A more extreme form of the disorder is sexual aversion disorder, in which the person actively avoids genital contact – sexual aversion disorder has been removed from the DSM-5. Sexual desire disorders are difficult to define since it is unclear what normal desire should be. A variety of causes for the disorders have been proposed on the basis of clinical experience. A shortcoming of DSM-5 is that it does not include hypersexual disorder, a term which has been used to describe individuals who are seemingly addicted to sex.

Female sexual arousal disorder and male erectile disorder are diagnosed only if adequate sexual stimulation is provided without arousal occurring. This disorder may occur in women who have not learned what they find sexually arousing. A variety of causes are likely in men, including performance anxiety and organic factors.

Three kinds of orgasm disorders are described in DSM-5: female orgasmic disorder (inhibited female orgasm) refers to absence of orgasm after a period of normal sexual excitement. It may be that © Wiley Canada

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orgasm in women is a learned response; those who have not masturbated are more likely to be nonorgasmic.

Fear of losing control and problems in the relationship are other possible causes. Male orgasmic disorder (previously called inhibited male orgasm) and premature ejaculation are orgasm disorders in men. The former is rare, while the latter is quite common, present in 40% of men at some point in their lives and associated with considerable anxiety.

Two pain disorders associated with sex are dyspareunia (persistent or recurrent pain before, during, or after sexual intercourse, which is not due to lack of vaginal lubrication or vaginismus) and vaginismus (involuntary spasms of the outer third of the vagina which make intercourse impossible). Pain disorders associated with sexual activity are now referred to as genito-pelvic pain/penetration disorder in the DSM-5.

General Theories of Sexual Dysfunctions Masters and Johnson identify the adoption of a spectator role and fears of performance as the primary current variables maintaining sexual dysfunctions. Important historical antecedents include religious orthodoxy, psychosexual trauma, homosexual inclinations, inadequate counselling, and excessive intake of alcohol, biological causes, and socio-cultural factors.

Other theorists have pointed to factors not emphasized by Masters and Johnson, including marital conflict, the meaning of a sexual problem for a person (including secondary gain), lack of knowledge or skill, poor communication between partners, and fear of acquiring sexually transmitted diseases.

Therapies for Sexual Dysfunctions Behavioural and cognitive therapies have been particularly successful in treating sexual dysfunctions.

Masters and Johnson's pioneering treatment work involves a program that begins with a ban on sexual activity and a discussion of the couple's sexual value system. On the third day, sensate focus, or pleasurable touching without intercourse, begins, and couples are encouraged to communicate their desires to their partner. Finally, specific instructions for approaching intercourse are given, according to particular dysfunctions.

The following techniques are frequently used by sex therapists: anxiety reduction directed masturbation, sensory-awareness procedures, skills and communication training, couples therapy, psychodynamic insights, and medical and physical procedures.

STUDENTS SHOULD KNOW Key Points 1.

Gender Dysphoria refers to experiencing distress in relation to feeling a discrepancy between one’s anatomical makeup and one’s psychological sense of being male or female. The two major treatments include sex-change surgery and behavioural efforts to alter gender identity.

2.

In paraphilias, unusual imagery and acts are persistent and necessary for sexual gratification. These include fetishism, transvestic fetishism, pedophilia and incest, voyeurism, exhibitionism, sexual sadism, and sexual masochism. Theories of the etiology of paraphilias include fixations at an immature psychosexual stage, accidental classical conditioning, and social skills deficits.

3.

The most promising treatments for paraphilias involve behaviour therapies such as attempts to reorient sexual arousal to more conventional targets and social skills training.

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4.

Rape is a crime of sexual aggression and dominance. Incest, pedophilia, and rape all often have a tremendously adverse impact on the victim. Treatment for rape victims involves social support and frank discussion of the traumatic event.

5.

Over the years, there has been considerable effort directed at the counselling and treatment of rape victims.

6.

Four categories of sexual dysfunctions are identified: sexual desire disorders (hypoactive sexual desire disorder and its more severe form, sexual aversion disorder; sexual aversion disorder is no longer included in the DSM-5l , Sexual arousal disorders (female sexual arousal disorder and male erectile disorder), orgasm disorders (female orgasm disorder, male orgasm disorder, and premature ejaculation), and sexual pain disorders (dyspareunia and vaginismus) - now referred to as genitopelvic pain/penetration disorder.

7.

Adopting a spectator role and fears of performance are the primary current variables maintaining sexual dysfunctions. Historical antecedents are often important as well.

8.

Therapies for sexual dysfunctions include gradual, nonthreatening exposure to sexual encounters, education, anxiety reduction, couples therapy, and sometimes medical procedures.

Key Terms accommodation (p. 440) acquaintance (date) rape (p. 436) assimilation (p. 440) child sexual abuse (p. 426) delayed ejaculation (p. 444) dyspareunia (p. 444) exhibitionism (p. 431) fear of performance (p. 445) female orgasmic disorder (p. 443) female sexual interest/arousal disorder (p. 442) fetishism (p. 422) forced rape (p. 436) frotteurism (p. 431) gender dysphoria (p. 419) gender identity disorder (p. 417) hypersexual disorder (p. 443) hypoactive sexual desire disorder (p. 442) incest (p. 425) male erectile disorder (p. 442) medical forensic examination (p. 440)

orgasmic reorientation (p. 435) paraphilias (p. 421) pedophilia (p. 423) premature ejaculation (p. 444) sensate focus (p. 447) sensory-awareness procedures (p. 448) sex-reassignment surgery (p. 420) sexual aversion disorder (p. 442) sexual dysfunctions (p. 440) sexual masochism (p. 432) sexual sadism (p. 432) sexual value system (p. 447) spectator role (p. 445) statutory rape (p. 436) transsexualism (p. 417) transvestic disorder (p. 422) vaginismus (p. 445) voyeurism (p. 431)

New Names William Masters, Virginia Johnson, Kenneth Zucker © Wiley Canada

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LECTURE LAUNCHERS 1. Joan/John: Nature vs. Nurture in Gender Identity This case is worth a whole lecture in itself as it gets to the heart of the nature vs. nurture debate and allows you to point out how psychological development is never so simple as either nature OR nurture, but is always an interaction. John Money of Johns Hopkins Hospital was initially excited about the possibilities offered by sex change operations. He thought that a great deal of suffering would be alleviated and avoided because of it. Somehow he came to believe that all the variance for gender identity was in the environment, but of course things are never so simple. This case demonstrates how the dialectic of competing theories leads us too more sophisticated models, if we pay attention to the scientific data. This also raises another issue:

2. What if I want to be a hermaphrodite? Radical Intersexuality [Lecture or discussion or both] The Internet contains a number of sites that make the case for not interfering with individuals who are born with ambiguous sex, letting them grow up and then making the decision for themselves when they are adults. Examples of these sites include: Inside Intersexuality: www.healthyplace.com/communities/gender/intersexuals/ A typical article from this site is "Sex Police." www.healthyplace.com/communities/gender/intersexuals/article_sex_police.htm by Sally Lehrman, 1999.

This is a nice summary: “Specific Syndromes of Sex Differentiation” www.healthyplace.com/communities/gender/intersexuals/article_jh_page4.htm See Ideas for Using the Internet below.

A good starting point is to ask the class how many sexes they think they are. You will get various answers; then review an article from the Sciences, "The Five Sexes, Revisited"

by Anne Fausto-Sterling. Issue: July, 2000 http://frank.mtsu.edu/~phollowa/5sexes.html This article is an update of a previous article by the same author suggesting that there are at least five distinct and legitimate sexes. Typically, at least in countries with well-funded medical systems, we tend to do surgery to bring someone who is sexually ambiguous or is one of the "other three" sexes to a point where they simulate a standard male or female. Increasingly, this decision is being questioned. Philosophically, it can be argued that this is a decision that should be made by the individual when they are old enough to weigh the pros and cons. Medically and scientifically it can be argued that we can't predict from just the genotype what an individual's sexual identity will end up being. This can only be ascertained after the complex interaction of genetic, biological, learning and social factors have had their complex, interacting effects and a gender identity has been arrived at sometime in early to late adolescents. There are even models that suggest that gender identity and "sex" keep changing throughout one's lifetime. For a discussion make your class into an ethics committee for a hospital and have them vote on whether or not to allow a sex change operation like the one that was performed on "John" or on a child born with XX chromosomes, but a clitoris so large that it is essentially a penis.

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3. Characteristics of College Men who Aggress Against Women The text discusses the view that rape is considered to be a violent act more than a sexual act, and that high levels of hostility toward women are found in men who rape. Since over 27% of college-age men report having engaged in some form of physical aggression against their partner over the previous year, understanding the high rates of aggression against women in this age group is critical. A recent study used structural equation modelling to test a comprehensive theoretical model about factors, which lead to both sexual and nonsexual aggression against women in college men (1991, Malamuth, N.M., Sockloskie, R.J., Koss, M.P., and Tanaka, J.S., Journal of Consulting and Clinical Psychology, 59, 670-681). This model, tested in a sample of over 2500 men, revealed that childhood experiences involving child abuse and witnessing violence between parents affects involvement in delinquency.

This history then leads to aggression through two pathways. First, men who develop hostile attitudes and personality are more likely to be coercive in both sexual and nonsexual interactions. Second, men who are sexually promiscuous, particularly if they are also hostile toward women, engage in higher levels of sexual aggression. Both sexual and nonsexual aggression was also hypothesized to share a common underlying factor.

4. Denslow Lewis: The First Sexologist?

In 1983, the Journal of the American Medical Association published an article entitled "The Gynecological Consideration of the Sexual Act," by Denslow Lewis, M.D., which reached the conclusion that women were capable of having orgasm. What is remarkable about the article is that it was written 84 years earlier—and the editor of JAMA refused to print it at the time (and the president of AMA refused to allow a reprint of it to be circulated at the annual convention). Comments about the paper at the time included remarks by a leading contemporary figure in gynaecology, Dr. Howard Kelly of John Hopkins: "Its discussion is attended with more or less filth and we besmirch ourselves by discussing it in public."

Lewis's paper was remarkable primarily for his frank discussion of a topic that was not to be discussed at the time. He reached conclusions such as: "Sexual matters should be taught to the young at an early age. It is only fair for the girl to understand that there is no immodesty in her active participation." He argued, "The instinct that determines self-preservation is almost equalled in importance and in its control of the individual by the instinct that dictates the perpetuation of the species. It is therefore proper for medical men in their deliberations to take cognisance of this great factor in human life." Medical authorities of the time obviously disagreed, but times have changed sufficiently that JAMA published the paper as a part of its "landmark" reports that served as a celebration of the journal's centennial anniversary.

5. Treatment of Premature Ejaculation Description of the specific technique used in treating premature ejaculation will help students get a better picture of the way sex therapy works (and, in the process, may educate them further about a common sexual problem which they or their partner may be experiencing). The following account comes from Kaplan's The New Sex Therapy (1974, New York: Brunner/Mazel), an invaluable source.

While distracting oneself from the sensations being experienced during intercourse (thinking about garbage) is probably the most common folk remedy for premature ejaculation, in fact the most effective technique for this problem involves focusing the man's attention on the sensations preceding orgasm. Kaplan sees the primary factor in premature ejaculation to be the absence of voluntary control over orgasm, not simply a rapid ejaculatory reflex, and as in biofeedback, sensory feedback about orgasm is essential to learning voluntary control.

The most common technique prescribed for this purpose is the "stop-start" method, in which the man stimulates himself (or has his partner stimulate him), while focusing exclusive attention on the sensations he experiences. As soon as he feels that orgasm is near, he is to instruct his partner to stop stimulating him, and then wait for the sensation to subside (usually in a few seconds). This procedure is repeated numerous times, enabling the man to learn to recognize the sensations that precede orgasm, and © Wiley Canada

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postponing it by stopping stimulation before it occurs. The same approach is then used during intercourse.

Cure rates have been reported from 98% to 100% with men using this technique under the guidance of a sex therapist, and the benefits appear to be permanent in most cases.

6. HANDOUT Some Sexual Myths Dispelled by Masters and Johnson The impact of Masters and Johnson's work was considerable in contributing to our knowledge of the physiology of human sexuality. Perhaps more important, it helped make the scientific study of sex legitimate and acceptable. By knowing how the body functions to achieve maximum sexual response, Masters and Johnson were able to elaborate methods of treating sexual dysfunction. They were also able to provide firm data on certain controversial points and to dispel a few myths.

1. Although the clitoris is very important in transmitting sexual stimulation in the female, it has been a mistake to advise men to try to stimulate it continually during intercourse. During the excitement phase the clitoris retracts, making access to it extremely difficult and even painful for some women. In point of fact, it is very difficult to have intercourse without stimulating the clitoris indirectly, which is the type of stimulation that some women seem to prefer.

2. Masters and Johnson were able to document that orgasms in women obtained from stimulation of the clitoris, without entrance into the vagina, are as intense as and indeed physiologically indistinguishable from orgasms obtained by having an erect penis in the vagina.

Probably few pieces of misinformation have caused more consternation than Freud's insistence that the vaginal orgasm is superior to the clitoral orgasm. He asserted, and practitioners have parroted to hundreds of thousands of people for years since, that a woman who can have an orgasm only by stimulation of her clitoris is settling for second best; further, that failure to have an orgasm via stimulation of the vagina by the man's penis is a sign of psychosexual fixation and immaturity.

Even before the work of Masters and Johnson, some sexologists had been trying to disabuse people of this notion (e.g., A. Ellis, 1961), pointing out that the walls of the vaginal barrel are poorly supplied with sensory nerve endings, whereas the clitoris, like the glans of the penis, is amply supplied. The fact that orgasms achieved by masturbation and manual manipulation by the partner, both of which typically concentrate on the clitoris and surrounding areas, were found to create at least as much excitation as intercourse pretty much puts to rest the bugaboo about clitoral orgasms.

Many authorities now believe that all female orgasms are evoked by stimulation of the clitoris, whether the friction is applied directly or through coitus. The orgasm itself, however, is expressed by rhythmic contractions of vaginal muscles. This dichotomy may be the source of the myth of clitoral versus vaginal orgasms (Kaplan, 1974). Of course these findings in no way imply that the insertion of the penis and the movements of coitus are not extremely enjoyable to women.

3. Creative speculation continues on female orgasm. Perry and Whipple (1981) described a spot the size of a nickel located within the vagina, the stimulation of which was asserted to cause orgasm in some women without clitoral stimulation and to be accompanied by an ejaculation. Named the G-spot for the German physician, Grafenberg, who first described it, this location was touted as further evidence against the hegemony of Freudian viewpoints on female sexuality. Subsequent research has, however, not confirmed the initial and highly publicized findings (Rosen and Beck, 1988).

4. Having simultaneous orgasms, a goal held up in numerous marriage manuals as indicating true love and compatibility, was not shown to be a mark of superior sexual achievement. In fact, it can often distract each of the partners from his or her own sexual pleasure. © Wiley Canada

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5. It was also found that not only do most women not object to intercourse during menstruation, but they even tend to enjoy it more, particularly during the second half of the period.

6. During the second trimester of pregnancy, women seem to desire intercourse at least as much as when not pregnant. Although there is some danger of spontaneous abortion in the early stages, particularly for women who have a history of spontaneous miscarriage, most women continue to desire sexual stimulation, sometimes until they go into labour. At any rate, little harm seems to come to the woman or to the fetus through intercourse, at least during the first six months of pregnancy.

7. Various myths about the male's penis were also dispelled. The size of a man's erect penis was not found to be a factor in the enjoyment he can derive himself and impart to his sexual partner. The vagina is a potential, not an actual, space; that is, it distends just enough to accommodate the penis. Hence a very large penis will not create more friction for the man or the woman than a smaller one. Furthermore, penises that are small when flaccid may double in size when erect, whereas penises that are large in the limp state increase less proportionately. In other words, there does not seem to be as much variation in the size of the erect penis as had been assumed. The idea that the size of a man's penis is an index of his virility was completely dispelled.

DISCUSSION STIMULATORS Should “Sex Addiction” be a DSM disorder? (Could also be a Lecture Launcher) The textbook chapter describes the DSM-5’s failure to incorporate hypersexual disorder (sometimes called “sex addiction”) as a shortcoming of the manual. The diagnosis would have included distressful and/or dysfunctional intense sexual fantasies, urges, or behaviour that interferes with other goals and activities, disregards risk or harm to self and others, consists of a reaction to unpleasant moods, and is not under the individual’s control (for full description, see Kafka, 2010, Hypersexual disorder: A proposed diagnosis for DSM-V in Archives of Sexual Behavior, 39, 377-400). The DSM-5 field trial supported the reliability and validity of the proposed criteria for hypersexual disorder, but it was ultimately not included. Some of the concerns and controversies that led to its exclusion (including the potential for misuse in forensic settings) can be found in Reid and Kafka’s article, “Controversies About Hypersexual Disorder and the DSM-5 (2014; Current Sexual Health Reports, 6, 259-264).

"Tomboys" and "Sissies" The terms "tomboy" and "sissy" denote similar concepts: children of one sex who engage in behaviours that are stereotyped as being appropriate for the opposite sex. Interestingly, however, the two terms have very different connotations. A sissy is much more likely to be viewed negatively than a tomboy. What does this tell us about our social attitudes toward sex roles? We often think of females as having the more narrowly defined cultural sex-role, but is that really the case?

Sensate Focus Exercise To help students "get a feel" for what sex therapy techniques are like, you might suggest they try a simple sensate focus exercise outside of class, the "hand, face, foot caress." Students will need to ask a friend to participate in the exercise. They will take turns caressing their partner's hand, face, or foot, moving very slowly and gently. The person doing the caressing is to focus only on the sensation of touching, experimenting with different kinds of touches, not thinking about what the partner is experiencing. The © Wiley Canada

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person being caressed should likewise focus on the experience of being touched. As an exercise in communication, the person being caressed can try telling their partner what feels especially good, including what type of touch, how light or hard, how fast or slow. After the exercise, partners can talk with each other about what it felt like to caress and to be caressed.

Gender Identity in Children The textbook briefly discusses the controversial closure of Kenneth Zucker’s Child, Youth, and Family Gender Identity Clinic at CAMH after 30 years of operation because it was not keeping up with the times.

Indeed, many students will disapprove of Zucker’s approach to children’s gender dysphoria, which encourages a patient approach, encouraging the child to accept the sex he or she was born with. Critics and activists suggested that Zucker’s approach was akin to the old, unsuccessful reparative therapies for homosexuality and caused damage by not affirming the true gender identity of these children. For a highly accessible reading in support of Zucker’s approach, students could discuss this article by Alice Dreger (author of Galileo’s Middle Finger): http://alicedreger.com/gendermad.

Case Studies Helen Singer Kaplan's Disorders of Sexual Desire (1979, New York: Brunner/Mazel) contains numerous case examples of inhibited sexual desire and other sexual dysfunctions, complete with descriptions of therapeutic approaches and complex problems that sometimes develop during treatment. You might want to pass out copies of one or two cases and have the class discuss Kaplan's analysis of the problem and treatment approach.

Sex Education in Canada (Could also be an “Internet” activity). Have students do a web search of Canadian sites for sex education and see how curricula vary across the provinces. Ontario, for example, recently updated its sex education curriculum and was subjected to protests from parents. Students might examine provincial differences in the grade at which children are expected to know the names of all body parts (from kindergarten in BC and Alberta to grade six in New Brunswick and PEI) and the grade in which they are introduced to the concept of gender identity (grade 1 in Saskatchewan, grade 6 in BC and New Brunswick). Ask students when children are introduced to sexual orientation and internet safety. Students should find much to discuss from their searching.

Correctional Services Canada; Returning Pedophiles to their Families (see also in Ideas for Using the Internet) An example of controversial program that can lead to very heated debated is a program that has as its goal the reintegration of incest offenders into their families. An innovative treatment approach for incestuous fathers is outlined by Line Bernier, Marielle Mailloux, Gilles David and Hélène Côté at Montée SaintFrançois Institution (Quebec) and published by Correctional Service of Canada www.csc-scc.gc.ca/publications/forum/e082/e082i-eng.shtml This can lead to discussion of what the goals of correctional services are, punishment, treatment, reduction of recidivism, etc. It can lead to a discussion of the values of science vs. religion or families of victims, or to the observations of attachment theory or modelling theory, etc.

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SOME IDEAS FOR UTILIZING THE INTERNET

Trans Characters in the Media Students could look for depictions of trans people in the media. For example, Caitlyn Jenner has had a very high profile, including a reality television series I Am Cait. Students may also note Jeffery Tambor’s depiction of a trans woman in the Emmy-winning television show Transparent. This popular television series features many trans characters, including a trans man (played by trans actor Ian Harvie). Laverne Cox, a transgender actress, plays a trans woman on Orange is the New Black.

This internet search could lead to a discussion of how the media can be helpful or harmful in educating people or bringing awareness to issues in sexuality and mental health.

PsychCentral PsychCentral has compiled articles and resources for many sexual disorders. At this site, students will find symptoms and treatments associated with the various disorders. http://psychcentral.com/sex/

Canadian Rape Crisis Centres Canadian Association of Sexual Assault Centres: www.casac.ca/ Navigating through this site, students can get a sense of the resources available in this area and the types of issues these centres focus on.

Programs of Corrections Canada Correctional Service Canada has a number of reports and studies relevant to the topic of this chapter. The handling and treatment of various sex offenders is an on-going issue as the percentage of the prison population incarcerated for sexual offences increases due to longer mandatory sentences. Correctional Services would like to be able to predict who is more likely to re-offend and recent Supreme Court rulings put the burden of proof on the corrections system. In order to hold someone in custody because they are a "threat to society" the government must have some valid evidence that the offender is a threat. They would also like to treat offenders (as no matter how long you incarcerate them in Canada they will eventually be released) in an effective way that reduces the recidivism rate. You may have your students read several outcome studies and program descriptions at the Correctional Service Canada site: http://www.csc-scc.gc.ca/ An example of an extensive Quebec program for incest offenders can be found here: http://www.csc-scc.gc.ca/publications/lt-en/2004/no3/3-eng.shtml This program prepares the offenders for their eventual parole and community re-entry, with a focus on strategies to avoid re-offending.

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Students may discuss whether the goals of corrections services are, punishment, treatment, or reduction of recidivism, etc. It can lead to a discussion of the values of science vs. religion or families of victims, or to the observation of attachment theory or modelling theory, etc.

See also Relapse Prevention with Sex Offenders: www.csc-scc.gc.ca/text/pblct/so/conference/confe-eng.shtml

The Sexual Psychophysiololgical Laboratory For more detailed information concerning sexual dysfunctions, the University of Texas provides a site devoted to sexual dysfunctions www.mestonlab.com

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CHAPTER 15 DISORDERS OF CHILDHOOD

CHAPTER SYNOPSIS The Mental Health Crisis Among Children and Adolescents It is estimated that at any point in time 14% of children between the ages of 4 and 17 present symptoms of clinically important difficulty at home or at school; anxiety disorders appear to be the most prevalent.

Comorbidity with other difficulties is present in over 50% of these children; fewer than 25% receive specialized treatment. Some authors argue that these statistics are underestimates of the actual number of children in need. Many do not reach the threshold for an official diagnoses and others are able to mask their symptoms. Child and adolescent mental health services are currently inadequate in Canada. Attempts to rectify the situation will require a clear understanding of the problems faced by children and adolescents.

Classification of Childhood Disorders Disorders of childhood are viewed within the context of knowledge about normal life-span development and developmental psychopathology. Childhood disorders may be conceptualized by a dimensional rather than categorical model; for example, some disorders create problems for others (undercontrolled or externalized problems), while others are primarily problems for the self (overcontrolled or internalized problems).

Canadian Perspectives 15.1 discusses the role of culture in childhood problems of self-control.

Canadian Perspective 15.1 The National Longitudinal Survey of Children and Youth The National Longitudinal Survey of Children and Youth (NLSCY) involves approximately 23,000 children in Canada, ranging from birth to 11 years at the outset of the study. Some of the findings indicate that immigrant children show better adjustment than Canadian born children. Problems experienced by aggressive girls are similar to those experienced by aggressive boys. Family environment and poverty have an important influence on problems experienced by children.

Disorders of Undercontrolled Behaviour Two general categories of undercontrolled behavior are attention-deficit/hyperactivity disorder and conduct disorder.

Attention-deficit/Hyperactivity Disorder The term attention-deficit/hyperactivity disorder focuses on the difficulty concentrating and non-goaloriented motor movements that characterize this common behaviour problem. DSM-5 differentiates between children with attention deficits or hyperactivity alone and those with both problems.

Instructor’s Manual to accompany Abnormal Psychology, Sixth Canadian Edition by Flett et al.

The inattention and impulsiveness of these children are often associated with academic difficulties and problems with social interactions with peers. Between 15 and 30% of these children also have a learning disability. Children with both attention problems and hyperactivity are more likely to manifest conduct problems and oppositional behavior. The prevalence of ADHD is difficult to establish due to difference in definitions over time.

While it was previously thought that hyperactivity went away by adolescence, longitudinal studies have revealed that the problems usually persist. The DSM-5 has been modified to allow for diagnoses of adolescents and adults (specifically, a symptom cut-off has been added for adults – five or more symptoms instead of the six or more required for children.

Biological theories of the causes of ADHD include heredity, brain differences, environmental toxins, and dietary factors.

Psychological theories have generally not received wide support when compared with neurological and genetic factors. However, bi-directional influences between parents and children considered important.

There is a general consensus that less than 50% of children diagnosed with ADHD are receiving treatment.

Stimulant medication is a common treatment for hyperactivity, and has been shown to lead to dramatic short-term improvements. Treatments based on learning principles include operant reinforcement for classroom and home behaviour. The optimal treatment seems to require the use of both stimulants and behaviour therapy.

Student Perspectives 15.1: Using Adderal as a Study Aid: Prevalence and Motivations There is a growing trend for students to use Adderal or Ritalin as a study aid. Sometime labelled as “smart pills”, there is some evidence that these drugs may enhance declarative memory. Estimate vary widely on the use of such drugs but one study has shown that as many as 1 in 3 students report have used ADHD stimulants.

Canadian Contributions 15.1: Richard Tremblay and the Grip Research Unit Tremblay is perhaps best known because of his involvement in the Montréal Longitudinal-Experimental Study. The purpose of this study was to help prevent anti-social behaviour in boys who were disruptive in kindergarten (see Tremblay et al., 1992). The results after two years of treatment (when the children were 7 and 8) and after three years of follow-up were encouraging. The treated disruptive boys were less physically aggressive, more often in an age-appropriate regular classroom, had less serious school adjustment problems, and engaged in fewer delinquent behaviours. The research of Tremblay and his associates have important social implications.

Conduct Disorder The term conduct disorder covers a variety of undercontrolled behaviors, many of which are illegal and violate societal norms and the basic rights of others. There is some debate as to whether Oppositional defiant disorder is a milder form of conduct disorder or is a separate entity. Substance abuse, anxiety, and depression are common in children with conduct disorder. The prognosis for conduct disorder is mixed; one theory suggests that some individuals show a "life-course persistent" pattern of anti-social behaviour throughout childhood and adulthood, while others exhibit an "adolescence-limited" course.

It is of interest to note that anti-social personality disorder has a dual listing in the DSM-5.

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Obviously, it is listed in the DSM chapter on Personality Disorders. However, it is also listed in the Disruptive, Impulse-Control and Conduct Disorder Chapter of the DSM-5.

Etiology of Conduct Disorder Genetics appear to play a role in aggressive behavior. Other delinquent behavior such as stealing, running away from home and truancy may be less affected by genetic influences. Neuropsychological deficits have also been found in children with conduct disorder, Psychological factors such an inadequate, inconsistent and hostile parental discipline appear to have an influence on the development of a conduct disorder.

Aggression can be learned (from parents and others) and reinforced. Cognitive theories suggest that aggressive children interpret ambiguous acts as evidence of hostile intent. Integrative biopsychosocial models show multiple pathways to conduct disorder.

Treatment of Conduct Disorder Some of the most promising approaches to treating conduct disorder involve intervening with the parents of the anti-social child; they are taught social learning principles and learn to reward prosocial behaviour and limit anti-social behaviour consistently. Multisystemic treatment has been demonstrated to reduce behavioural problems and arrests, as well as improving family functioning. Anger-control training has been used to teach aggressive children self-control in anger-provoking situations, and anti-social children have been taught moral reasoning skills.

Prevention of Conduct and Related Disorders Few prevention programs for anti-social behavior or conduct disorder have been shown to be effective.

Petticlec and Tremblay (see Canadian Contributions 15.1) argue that early identification and intervention may be useful.

Canadian Perspectives/15.2 Multisystemic Treatment in Ontario and Alternative Canadian Approaches to the Rehabilitation of Young Offenders Multisystemic Therapy is an example of a Canadian treatment program designed to address many variables and many treatment models in young offenders' rehabilitation programs.

Learning Disorders The term Learning Disabilities, although not used by the DSM-5 is used by many health professional and signifies inadequate development in a specific area of academic, language, speech or motor skills.

Specific Learning Disorders DSM-IV-TR divided learning disorders into three categories: reading disorder (dyslexia), mathematics disorder, and disorder of written expression. The DSM-5 now subsumes these three categories into one: Specific Learning Disorder.

Communication disorders This group of disorders include language disorder (the child has difficulty in expressing him or herself), phonological disorder (involving immature articulation of speech), and stuttering. Social (pragmatic) communication disorder is a new category in the DSM-5 and involves difficulties in the social use of verbal and non-verbal communication.

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Motor Disorder Motor disorder includes the category, developmental coordination disorder in which children demonstrate poor motor coordination that cannot be explained by Intellectual Disability Disorder (formally, Mental Retardation) or physical causes.

Etiology of Learning Disorders and Communication Disorders Most of the research on learning disorders has focused on dyslexia. To date, there is no evidence to suggest that learning disabilities are related to a single factor. However, genetic and biological factors as well as ineffective learning strategies may constitute risk factors. While psychological theories have in the past focused on perceptual deficits such as underlying dyslexia, recent research points to language-processing problems.

Treatment of Learning Disorders Most treatment of learning disorders occurs within special education programs in public schools. Metaanalytic results suggest that applied behavioral analysis is the most effective treatment strategy .

Intellectual Disability Disorder Intellectual Disability Disorder is the term adopted by the DSM-5 to replace the term mental retardation.

Traditional and Contemporary Criteria for Intellectual Disability The DSM system has traditionally required a judgement of intelligence based on the administration of tests administered by a well-trained professional. Test scores have been interpreted based on cultural, linguistic and sensory or motor limitations. The DSM-5 focuses on deficits in adaptive functioning and age on onset – intellectual disability must be observed before the age of 18.

Classification of Intellectual Disability Four levels of intellectual disability are considered in the DSM-5. Mild, moderate, severe, and profound, based on the degree of deficit in adaptive functioning. These same levels of disability were used by the DSM-IV-TR but each level was defined primarily by IQ scores.

The Approach of the American Association of Intellectual and Developmental Disabilities The American Association of Intellectual and Developmental Disabilities has shifted the focus from identifying the severity of the intellectual disability to identifying remedial supports that will assist the individual within the limits of his or her capacities. Attention is directed toward making positive changes to the person’s life.

Etiology of Intellectual Disability No Identifiable Etiology: Between 30 to 40% of cases have no known risk factor or genetic marker that can explain the intellectual disability.

Hereditary disorders make up about 5% of cases and include inborn errors of metabolism (e.g., phenylketonuria, and Tay-Sachs disease).

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Early alterations of embryonic development account for approximately 30% of intellectual disabilities (Down syndrome due to trisomy 21 or prenatal damage due to toxins).

Later pregnancy and perinatal problems account for roughly 10% of intellectual disabilities. Such problems include fetal malnutrition, placental insufficiency, prematurity, hypoxia, etc.

Medical conditions acquired during childhood and accidents are responsible for about 5% of case. Some examples include infectious diseases and environmental toxins.

Environmental influences and other mental disorders explain 15-20% of intellectual disorders. These influences include deprivation of nurturance and of social stimulation as well as other disorders such as autism spectrum disorder.

Prevention and Treatment of Intellectual Disability In the early part of the 20th century large institutions were built to house retarded individuals. Current models promote the right of adults with intellectual disabilities to freedom of sexual expression, marriage and having children Community residences have enabled many individuals to live more independently, and the majority who remain in institutions are severely or profoundly retarded with physical handicaps. Behavioural interventions include early-intervention programs providing training in specific behavioural objectives, and teaching strategies such as applied behaviour analysis. Cognitive interventions such as self-instructional training as well as computer-assisted instruction have been found to be helpful as well.

Canadian Perspectives 15.3: Eugenics and the Sexual Sterilization of Canadians with Mental Retardation Two provinces (Alberta and British Columbia) performed much sterilization in the past. A number of individuals who were subjected to this procedure have sued and are suing these provincial governments.

Autism Spectrum Disorder Characteristics of Autism Spectrum Disorder In previous versions of the DSM Autistic disorder was characterized by extreme autistic aloneness, communication deficits, and ritualistic and compulsive activities. Childhood-onset schizophrenia and autism are now known to be distinct disorders, and the term pervasive developmental disorders was used in DSMIV to include autism and a number of other serious abnormalities in the developmental process. About 80% of autistic children score below 70 on tests of intellectual; ability and it is sometimes difficult to separate the two; however, the pattern of cognitive deficits is different.

The social development of autistic children is extremely deficient; they are less interested in their caregiver or other children, and caregivers must work harder to make contact. Children with autism may show more interest in inanimate objects than people. About 50% of autistic children never learn to speak, and even when they do, peculiarities such as echolalia, pronoun reversal, and neologisms are evident.

Ritualistic and self-stimulating acts are common. The prognosis for children with autistic disorder is generally poor, although follow-up studies have not been conducted since the passage of laws requiring the education of autistic children within the public schools. The picture is somewhat more optimistic for higher IQ, high-functioning autistic individuals. See Dr. Temple Grandin in the section entitled Discussion Stimulators.

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Etiology of Autism Spectrum Disorder Early theories of Autism Spectrum Disorder were psychological in nature emphasizing the role of parents who were cold and insensitive. More recently, evidence from family and twin studies strongly suggest a genetic basis to autism. Neurological dysfunction has been found in many autistic children, including EEG abnormalities, enlarged brains, underdevelopment of the cerebellum, and epilepsy; further, autism has been found in the aftermath of prenatal rubella, as well as diseases which affect central nervous system functioning.

Focus on Discovery 15.1: Mapping Autism Risk Loci Using Genetic Linkage and Chromosomal Rearrangements Researchers at the Offord Centre for Child Studies at McMaster University (led by Dr. Peter Zsatmari) and Sick Children’s Hospital in Toronto (led by Dr. Stephen Scherer) were leaders in an international consortium, the Autism Genome Project Consortium, which has discovered one gene and a previously unidentified region of another chromosome as the location of an additional gene that possibly contributes to risk for an autism spectrum disorder.

Treatment of Autism Spectrum Disorder Several problems make treatment of autistic children difficult: they do not adjust well to changes in routines, behaviour problems and stereotyped behaviour interfere with learning, effective reinforcers are difficult to find, their attention is often limited to one aspect of a stimulus, and they have extreme difficulty generalizing learning. Behaviour therapy techniques have had the most success; Lovaas's intensive operant program enabled many young autistic children to achieve normal functioning in school. More recently, a program called the Early Start Denver Model has demonstrated encouraging results after two years of intensive therapy.

At the moment, there is no medication that treats the central symptoms of autism spectrum disorder.

The current approach is to use drug that target specific behaviors or symptoms. An antipsychotic medication has been shown to reduce some autistic behaviours, but many children do not respond positively. Evidence of elevated serotonin levels in autistic children led to treatment with antidepressants. Stimulants have been shown to have some positive effects on hyperactivity.

Although treatment outcomes are variable most children with autism spectrum disorder remain within the spectrum as adults.

Disorders of Overcontrolled Behaviour: Anxiety Overcontrolled or internalizing behavior in children is seen in the form of anxiety and depression. Both genetic and environmental factors appear to play in important role in overcontrolled behaviors

Childhood Fears and Anxiety Disorders Most children experience fears and anxiety, as part of their normal development. Fears and phobias are reported more often in girls than boys. Anxiety disorders in children and adolescents can be chronic and can be comorbid with depression, conduct disorder and ADHD. Children can experience anxiety in the form of separation anxiety and phobias.

Separation Anxiety

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Separation anxiety involves an unrealistic or exaggerated concern about separation from a caregiver to whom a child has become attached. Separation anxiety is a normal experience of childhood and is even a defining characteristic of normal attachment. When it interferes with a child's day-to-day life or continues for too long a time, then it can be classified as an anxiety disorder. In order to diagnose separation anxiety, the DSM-5 requires a total of eight symptoms that must be present for a period of four weeks in children; these symptoms must result in significant distress. Canadian Contributions/15.2 summarizes the basic model of attachment as developed Dr. Mary D. Salter Ainsworth in collaboration with John Bowlby.

Social Phobia Almost all children express some anxiety in social situations, especially new ones, but for some the experience is so intense that it can be classified as a social phobia. Selective mutism is sometime present in extremely shy children who refuse to speak in unfamiliar social situation. Theories of social phobia in children are not well developed.

Canadian Contributions 15.2: Mary Ainsworth, Attachment Styles, and Distress Ainsworth was educated in Canada and went on to produce major contributions to the understanding of child development through her research into the nature of attachment. Recent research has provided evidence that mental health variables are associated with degree of attachment security.

Treatment of Childhood Fears and Phobias A variety of treatment models are applied to children who are fearful and anxious to the point that it interferes with their life. The most widely used procedure is a combination of classical and operant conditioning in which a child is gradually exposed to the object of fear but in a well-controlled situation that minimizes fearful emotions, or physiological responses to fear. At the same time the child is positively reinforced for appropriate behaviour. Treatment appears to be more successful when specific anxieties are targeted.

Prevention of Anxiety Disorders There are encouraging results from studies that aim to prevent anxiety in children. Australia is one of the leading nations in developing prevention programs using cognitive-behavioral techniques, coping strategies and assigned homework tasks.

STUDENTS SHOULD KNOW Key Points 1.

Attention-deficit/hyperactivity disorder is characterized by inattention, impulsivity, and hyperactivity, often with accompanying academic difficulties, conduct problems, and problems with peer relationships. Important etiological factors include neurological differences and parent-child relationships. It is ideally treated using a combination of stimulant medication and behaviour therapy.

2.

Conduct disorder is characterized by behaviours that violate laws and social norms. Its etiology is complex, including both biological and environmental factors, and it is best treated through approaches that include the family. Multisystemic treatment appears to hold some promise.

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3.

Learning disorders are diagnosed when a child fails to develop to the expected degree in a particular academic area, language, or motor skill, despite normal intellectual functioning. Genetic and biological factors are thought to be important, particularly in dyslexia. However, the most widespread interventions are educational.

4.

Intellectual Disability Disorder (previously mental retardation) is characterized by (1) significant subaverage intellectual functioning, (2) deficits in adaptive behaviour, and (3) onset during childhood.

Hereditary disorders, early alterations of embryonic development, problems during pregnancy and a variety of medical conditions, can all have an influence on intellectual deficits.

5.

Current treatment of intellectual disability includes early intervention for children at risk, mainstreaming in the educational milieu, and teaching strategies such as applied behaviour analysis, self-instructional training, cognitive therapy, and computer-assisted instruction.

6.

Autism spectrum disorder, one of the pervasive developmental disorders, is characterized by extreme autistic aloneness, failure to develop social relations, communication deficits, and ritualistic behaviours. Many autistic children are also mentally retarded. The prognosis for the disorder is very poor, except for some higher functioning individuals.

7.

The specific etiology of autism spectrum disorder appeals to evidence from family and twin studies strongly which suggest a genetic basis to autism.

8.

Highly structured social-learning treatments have been successful in reducing self-injury, improving communication and self-care skills, and, in some studies, improving social and academic functioning in autistic children.

9.

Disorders of overcontrolled behaviour include childhood anxiety and mood disorders. These disorders are similar in etiology and course to those of adults and there is a correlation between having a childhood disorder and subsequent adult disorder.

10.

The treatment generally used for treating childhood fears and anxieties is to gradually introduce the child the object of fear in a situation that does not produce full-blown fear combined with positive reinforcement for the effort to confront the fear.

11.

Treatments for childhood mood disorders are generally cognitively based with more emphasis on involvement of school and family in removing the sense of helplessness, and negative cognitive schemata that are diagnostic childhood mood disorders.

Key Terms anxiously attached (p. 489) applied behaviour analysis (p. 477) attention-deficit/hyperactivity disorder (ADHD) (p. 454) autism spectrum disorder (p. 479) avoidant attachment style (p. 489) conduct disorder (p. 461)

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developmental coordination disorder (motor disorder) (p. 472) disorder of written expression (p. 471) disorganized attachment style (p. 489) Down’s syndrome (trisomy 21) (p. 476) echolalia (p. 482) externalizing problems (p. 453) internalizing problems (p. 453) Ch15, pg.8

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language disorder (p. 471) learning disabilities (p. 470) learning disorders (p. 470) mathematics disorder (p. 470) mild mental retardation (p. 474) moderate mental retardation (p. 474) oppositional defiant disorder (ODD) (p. 461) pervasive developmental disorders (p. 480) phenylketonuria (p. 475) phonological disorder (p. 471) profound mental retardation (p. 474) pronoun reversal (p. 482) reading disorder (dyslexia) (p. 470)

securely attached (p. 489) selective mutism (p. 490) self-instructional training (p. 479) separation anxiety (p. 488) severe mental retardation (p. 474) social (pragmatic) communication disorder (p.

472) specific learning disorder (p. 470) stuttering (p. 471) theory of mind (p. 482) the Strange Situation (p. 489)

New Names Ivar Lovaas, Mary D. Salter Ainsworth

LECTURE LAUNCHERS 1. The NIMH Multimodal Treatment for ADHD On the one hand, ADHD treatment is an optimistic field: many interventions have been carefully studied, and many of them work. On the other hand, very little data is available to tell us which treatments, in which combinations, effective for which children, or in which areas of functioning. Longer-term effects of treatment are also unknown.

The good news is that the National Institute of Mental Health, with co-sponsor U.S. Department of Education, decided to answer these questions through a multisite study of multimodal treatment of ADHD. At each of six sites, 96 children were randomly assigned to one of four groups: 1. medication alone; 2. psychosocial treatment alone (including parent training, school consultation, intensive summer camp, and 12 weeks of assistance from a paraprofessional classroom aide; 3. both (1) and (2) in combination; or 4. community treatments of the family's own choosing.

A full description of the study design can be found in Richters, Arnold, Jensen, Abikoff, Conners, Greenhill, Hechtman, Hinshaw, Pelham, and Swanson (1995; Journal of the American Academy of Child and Adolescent Psychiatry, 34, 987-1000).

2. Early Detection of Childhood Problems and the Montreal Prevention Program There is a very interesting report available on-line: © Wiley Canada

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“Preventing Mental Disorders in School-age Children: A Review of the Effectiveness of Prevention Programs” Mark T. Greenberg Ph.D., Celene Domitrovich Ph.D., Brian Bumbarger Prevention Research Center for the Promotion of Human Development College of Health and Human Development Pennsylvania State University Submitted to: Center for Mental Health Services (CMHS) Substance Abuse Mental Health Services Administration U.S. Department of Health and Human Services June, 2000 (revised) prevention.psu.edu/pubs/documents/MentalDisordersfullreport.pdf Within this report you will find a nice summary of the Montreal Prevention Program; this is a program that first looked for indicators of future problems in children and then designed specific interventions designed to prevent those future problems.

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3. HANDOUT The Role of Marital Discord in Conduct Disorders The role that separation and divorce play in fostering conduct problems and delinquency has been an issue of debate. Rutter's (1971) classic study pointed to the association between marital discord and anti-social behaviour in sons. Although this connection has been confirmed in later studies (e.g., O'Leary & Emery, 1984), explaining it has been more difficult.

Most researchers agree that it is marital discord, not separation or divorce itself, that is related to problem behaviour in the children (e.g., Rutter, 1979). Emery (1982) discussed several theories proposed to explain how marital discord adversely affects children. The modelling hypothesis suggests that parental conflict sets an example of using hostility and aggression as a way of handling problems; the parents' behaviours are imitated by the children (particularly boys), who are then seen as conduct disordered. Another theory suggests that parents who have marital problems are less consistent in their discipline techniques, leading to undercontrolled behaviour in the children. A third possibility, proposed by Minuchin (1974), is that children develop problems as a way of distracting parents from their own conflict. Finally, it has been suggested that having a conduct-disordered child can create marital conflict.

An alternative to these hypotheses has been proposed by Frick and his colleagues in their study of the relationship between conduct problems in boys and maternal variables (Frick, Lahey, Hardagen, and Hynd, 1989). They suggest that a third variable, anti-social personality disorder in the parent, may explain both the marital discord and the child's conduct problems. Their data suggest that it may be that parents with antisocial personalities relate poorly to their spouses and pass on their inappropriate behaviour to their sons (perhaps through genetic mechanisms and not directly through the effects of marital discord).

Each of these theories may prove useful in describing the mechanism that links marital turmoil with children's problems. They all seem to suggest that parents should minimize their children's involvement in marital conflict, for example, by not arguing about marital or discipline issues in front of the children.

Emery, R.E. (1982), “Interparental conflict and the children of discord and divorce”, Psychological Bulletin, 92, 310-330.

Frick, P.J., Lahey, B.B., Hardagen, S., and Hynd, G.W. (1989), “Conduct problems in boys: Relations to maternal personality, marital satisfaction, and socioeconomic status”, Journal of Clinical and Consulting Psychology, 18, 11-12.

Minuchin, S. (1974), Families and family therapy, Cambridge, MA: Harvard University Press.

O'Leary, K.D. and Emery, R.E. (1984), “Marital discord and child behaviour problems”, in M.D. Levine and P. Satz (Eds.), Middle Childhood: Development and Dysfunction (pp. 345-364). Baltimore, MD: University Park Press.

Rutter, M. (1971), “Parent-child separation: Psychological effects on the children”, Journal of Child Psychology and Psychiatry, 12, 233-260.

Rutter, M. (1979), “Maternal deprivation, 1972-1978: New findings, new concepts, new approaches”, Child Development, 50, 283-305.

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4. What is Intelligence?

While traditional IQ tests have demonstrated their validity for predicting success in school (at least in Western societies), critics have argued that such a criterion does not capture the full meaning of the word "intelligence." Howard Gardner, in particular, has proposed a theory of "multiple intelligences" to encompass a broader vision of the nature of the mind (1999, Intelligence Reframed, New York: Basic Books). His prerequisites for an area of skill to be called an intelligence include (1) it must enable the individual to resolve genuine problems or difficulties and create (where appropriate) an effective product, and (2) it must include the potential for finding or creating problems. In other words, the skill must be useful in some way, although the value of particular abilities can vary across cultures and time frames: the navigational skills of an Indian sailor, the musical prowess of a Mozart, the language ability of a Dostoyevski, all may be seen as useful within the individual's culture (though perhaps not in another culture).

In addition, Gardner has outlined a number of criteria or "signs" which most often signal the presence of a separate intelligence: (1) potential isolation by brain damage, (2) the existence of idiot savants, prodigies, and other exceptional individuals within the domain of ability, (3) an identifiable core operation or set of operations, (4) a distinctive developmental history and definable set of "end-state" performances, (5) an evolutionary history and evolutionary plausibility, (6) support from experimental psychological tasks, (7) support from psychometric findings, and (8) susceptibility to encoding in a symbol system.

Finally, Gardner presents his provisional compilation of eight domains that qualify as separate intelligences: linguistic, musical, logical-mathematical, spatial, bodily-kinesthetic, interpersonal, intrapersonal, and naturalistic.

Students might be encouraged to evaluate this set of candidates for intelligence, arguing for the exclusion of any of the domains, the inclusion of other domains not listed, and the value of considering multiple areas of intelligence vs. the traditional conception of intelligence. Students are often quite enthusiastic about Gardner’s “intelligences” but there has been little empirical research let alone support. To date, the only investigation to measure all eight domains (Visser, Ashton, & Vernon, 2006) was not supportive of Gardner’s theory.

5. Home Videos and the Early Recognition of Children with Autism The very early development of children with autism is a topic of great interest, with Autism Canada suggesting that Autism Spectrum Disorders can be detected as early as 18 months, despite the fact that many autistic children are not diagnosed until much later. An innovative strategy to address this problem involves examination of home videotapes of children's first birthday parties (Osterling and Dawson, 1994; Journal of Autism and Developmental Disorders, 24, 247-257).

Home videos of 11 children with autism and 11 normally developing children were collected and coded; the coding system focused on social, affective, joint attention, and communicative behaviours, as well as specific autistic behaviours such as self-stimulatory behaviour and staring blankly.

Variables that distinguished between groups included joint attention behaviours such as pointing and showing, and social behaviours, including looking at the face of another, seeking contact, and imitating.

In addition, children with autism were much less likely to orient to their name being called. Using a stepwise discriminate analysis, 91% of the subjects were correctly classified based on the coding system. In addition, the variable of looking at the face of another, alone correctly classified 77% of the children.

The authors note that given the results of this study, efforts should be made to identify and intervene with autistic children at much younger ages than is currently the norm in the field.

6. The Savant

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Most students are intrigued by the savant syndrome, and the movie Rain Man, featuring Dustin Hoffman in the role of an "autistic savant," may have piqued their interest. In a fascinating and comprehensive article, Treffert (1988, American Journal of Psychiatry, 145, 563-572) reviewed the world literature on savants.

Definition: The term "idiot savant" was coined a century ago to describe individuals with very limited intellectual capacity who possess a remarkable island of ability, skill, or knowledge. The condition occurs in males more frequently than females in a ratio of approximately 6:1. (The higher male to female ratio could account for this ratio in autistic disorder.) The classic early work describing the syndrome is Tredgold's chapter in his textbook, Mental Deficiency (1914, New York: Williams Wood). Approximately 100 cases of savants have been described in the literature to date.

Categories of Skills: The following skills are found in case studies of savants: mechanical ability, lightning quick calculation and mathematical ability, exceptional mnemonic skills, calendar calculating, musical skills (in particular, a triad of blindness, musical genius, and mental retardation has been identified), map memorizing, visual measurement, extrasensory perception, unusual sensory discrimination, writing and composition based on memorization, and perfect appreciation of past or passing time without knowledge of a clock face. The abilities most commonly found in savants are music and memory, which are often linked in the same individual.

Theories to Explain the Savant: No single theory has been able to explain the savant syndrome; what follows is a brief description of the major theories advanced thus far. (1) Vivid eidetic imagery has been used to explain the skill of calendar calculation. (2) Savants may coincidentally inherit two sets of factors, one for mental retardation and one for special ability. (3) Sensory deprivation due to social isolation or defective sensory channels has been hypothesized to lead to boredom and thus sensitize the savant to minute changes in the environment and bizarre or trivial preoccupations, concentration, or rituals. (4) Unable to think abstractly, savants may come to rely on concrete thinking. (5) The savant's special abilities may be developed to compensate for limited general skills and be reinforced by praise. (6) A number of organic explanations have been proposed, including left brain damage (leading to intellectual disability) accompanied by compensatory development of the right hemisphere, and idiosyncratic brain circuitry.

Several cases of the savant syndrome have emerged in the literature: a 30-year-old sculptor with an IQ of 40 who creates life-size bronze works of animals (he was featured on a 60 Minutes television program), and several individuals with severe intellectual disabilities who are highly skilled musically, able to understand the rules of musical structure and to improvise. One 35-year-old man has perfect pitch and exceptional musical memory (he can reproduce lengthy piano compositions after a single hearing) despite blindness, intellectual disability, and extremely limited speech and language skills. Newly enhanced communication between researchers has enabled more sizeable samples to be gathered than was previously possible, providing the opportunity for controlled studies to be carried out in the future.

Hormonal effects on brain structure have recently been proposed to explain the predominance of males with the savant syndrome and the predominance of right brain skills in savants. This hypothesis is supported by findings of left hemisphere damage in savants, their unusual frequency of left-handedness, and evidence of motor and language functions being "taken over" by the right hemisphere. An abnormally high incidence of prenatal or perinatal complications in these patients suggests an ischemic-hypoxic injury as a cause of the syndrome. Other researchers have distinguished the savant's noncognitive "habit" formation system from a truly cognitive "memory" system, suggesting that different neuronal circuits underlie the two types of memory. Support for this hypothesis comes from findings of idiosyncrasies in the hippocampus, selected areas of the amygdala, the cerebellum, and other forebrain areas in savant subjects.

7. Multisystemic Treatment of Young Offenders “A community-based alternative for high-risk young offenders” by Alan W. Leschied

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Associate Professor, Faculty of Education, University of Western Ontario, and Alison Cunningham, Research Coordinator, London Family Court Clinic. www.csc-scc.gc.ca/text/pblct/forum/e112/112f_e.pdf This article contains some basic statistics and a good overview of a program designed to reduce the incarceration rate of Canadian youth, one of the highest in the world. It makes a case for the cost efficiency and higher success rate of community based programs for children and youth. It also has a useful bibliography. A number of lecture topics can use this article as a starting point. It discusses the need for empirical research, it suggests that prevention is much more efficient than treatment which is more efficient than incarceration, it suggests that an eclectic approach to treatment is effective, it shows how there are multiple causes for the behaviour of youth, and it makes the case for viewing youth as different than adults with different developmental needs and more potential for change.

DISCUSSION STIMULATORS Aboriginal Children’s Mental Health There have been several news stories about mental health and addictions issues among children and youth in remote Aboriginal communities. For example, the Attawapiskat First Nation in Northern Ontario received media attention in 2016 when they declared a state of emergency due to the number of attempted suicides, mostly by children and youth. The Centre for Suicide Prevention produced a resource toolkit in 2013 (available here: https://www.suicideinfo.ca/wp-content/uploads/2016/08/Indigenous-Toolkit_Print.pdf) which notes that the suicide rate for First Nations male youth (15 to 24 years) is 126 per 100,000 as compared to 24 per 100,000 for non-Aboriginal male youth. The comparable numbers for young women are 35 suicides per 100,000 for female Aboriginal youth, and 5 per 100,000 for non-Aboriginal female youth.

The toolkit could be provided to students as a handout, as it contains information that may counter stereotypes that some students may hold. For example, the toolkit describes the low rates of suicide in Aboriginal communities prior to colonization, and describes the effects of colonization that are related to the present crises in these communities.

Students may also be unaware that in 2016, the Canadian Human Rights Tribunal ruled that the support provided by the federal government to children on reserves is considerably lower than the support provincial governments provide to off-reserve children (the judgment can be accessed here: http://s3.documentcloud.org/documents/2698184/Jugement.pdf).

This 2014 Library of Parliament research publication provides some background on mental health in First Nations and Inuit communities: http://www.lop.parl.gc.ca/content/lop/ResearchPublications/2014-02-e.htm

Source for ADHD Updates An excellent resource for up-to-date information about research and clinical issues in ADHD is Russell Barkley's ADHD Report, published monthly. The publication contains brief research updates, longer articles on issues of clinical relevance, point-counterpoint articles on controversial subjects, and book reviews. This would be a good source for information for lectures or for students' term papers. www.russellbarkley.org/newsletter.html © Wiley Canada

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Should Learning Disabilities be Classified as Mental Disorders?

The DSM manual itself questions the inclusion of learning disorders within a classification of mental disorders, since many learning disabled children evidence no signs of emotional disturbance. Students might be asked to discuss the advantages, disadvantages, and implications of such a classification.

Treatment of Self-Injurious Behaviour As discussed in the handout above, there are times when psychologists and other mental health workers employ aversive means for controlling self-injurious behaviour (SIB), particularly with retarded and autistic children. In a manner similar to the work of the Association for the Advancement of Behavior Therapy task force, students might be asked to debate the ethical issues surrounding the use of aversive procedures for reducing SIB and come up with guidelines to govern the use of such techniques. They should consider in their discussion the conditions under which aversive punishment might be appropriate, alternatives to the use of aversives, the cost of not employing an effective though controversial treatment, the concerns of parents and other advocates for the rights of retarded individuals, and ways to evaluate the effectiveness of the procedures.

Literature on Autistic Individuals Students are often interested in reading more about autism. Clara Park's books about her daughter are moving and informative. Another book, Without reason: A Family Copes with Two Generations of Autism (1989, Hart, C., NY: Harper and Row), explores the experiences of the author, whose brother and son both had autism. In addition, the autobiographies of Temple Grandin are also fascinating.

Youth Criminal Justice Act www.justice.gc.ca/eng/pi/yj-jj/ycja-lsjpa/back-hist.html Canada has replaced the Young Offenders Act with a new Youth Criminal Justice Act and this is a good source of information about it. Reading it will raise a number of issues. For example, have your students read the new act, then find out what the incarceration rate is for Canadian youth and compare it to other countries in the world. Many students will be shocked to find that Canada has one of the highest incarceration rates in the world for its youth, higher even than the United States. Have students discuss the philosophy of the new provisions of the act, making it easier to apply adult sentences to 14 year olds for example. For each suggestion about what to do with children and youth who break the law try to keep them focused on what psychological theory would suggest. Many students will reflexively recommend the efficacy of punishment. Try to get them to back this up with psychological theory. I usually have my students find the e-mail address of their MP and one Senator from their province and e-mail their thoughts to them.

SOME IDEAS FOR UTILIZING THE INTERNET Down Syndrome: Paul’s Blog The Canadian Down Syndrome Society (CDSS) has a website full of information and resources.

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http://cdss.ca/ Students will find “Paul’s Blog” to be inspiring and educational. Paul Sawka is the Awareness Leader at the CDSS and as an individual with Down Syndrome, his voice is an important one in presenting issues relevant to this group. http://cdss.ca/blog/category/pauls-blog/

Mary Ainsworth Pages Here is the URL for the Adult Attachment Lab a UC Davis. It has many attachment links on it: http://psychology.ucdavis.edu/research/research-labs/adult-attachment-lab

Canada's Youth Criminal Justice Act The Department of Justice site has a good deal of background information http://www.justice.gc.ca/eng/cj-jp/yj-jj/tools-outils/back-hist.html For the John Howard Society submission at the hearings on the act see: http://www.johnhoward.ca/document/youthact/final.pdf

Autism Links Autism Canada has links to resources, research, and conferences. http://autismcanada.org/ Autism Treatment Services of Canada: www.autism.ca/ Autism Speaks Canada: http://www.autismspeaks.ca/ A web search for "autism" in Canadian pages will provide many resources from several provinces.

Temple Grandin and Autism Temple Grandin's web page: www.grandin.com/ Having students read about and discuss Temple Grandin is always interesting. She is autistic and yet leads a very creative and academic life. Trying to get a glimpse of her experience and trying to guess what is different about her brain is fascinating.

Here is an interview with her: www.youtube.com/watch?v=zt_G7Zw5I8c

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Children’s Mental Health (Anxiety) Children’s Mental Health Ontario offers resources and information about anxiety disorders in children. http://www.kidsmentalhealth.ca/parents/anxiety.php If students search for “anxiety disorders” and “children,” they should be able to locate many provincial associations and resources for Canadian children experiencing anxiety.

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CHAPTER 16 AGING AND PSYCHOLOGICAL DISORDERS

CHAPTER SYNOPSIS This chapter explores the psychological problems of older adults, which can be exacerbated by the discrimination of ageism. Older adults have been relatively neglected by mental health professionals despite their growing numbers, but a number of research projects are underway in Canada that are focusing on mental health issues of aging Canadians.

Issues, Concepts, and Methods in the Study of Older Adults

Diversity in older adults Chronological age is a complicated variable in psychological research and diversity is a particularly apt word for an older population: As age increases so do the differences between individuals.

Age, Cohort and Time of Measurement Effects Research into the effects of aging is also complicated because of the need to tease out such factors as age effects (the age of the sample studied), cohort effects (the consequences of being born in a particular year and having grown up in a particular time period), and time-of-measurement effects (confounding variables).

In cross-sectional studies, people of different ages (and different cohorts) are studied at the same time; age differences, but not age changes, can thus be studied. Longitudinal studies periodically re-test one selected cohort; while this allows age changes to be examined, conclusions are limited to one cohort, and selective mortality is a problem.

Diagnosing and Assessing Psychopathology in Later Life The diagnostic criteria for older adults are the same for younger adults. However, the assumption that mental disorders are the same as in younger adults has not been supported by research and few specifics are known about psychopathology in old age. It is important to develop assessment tools that are specific to an aging population.

Range of Problems The elderly have a wide range of problems associated with aging. With respect to stigmatization, one of the concerns about older people is that they are victims of a double jeopardy: There is not only a tendency to stigmatize the mental health issue but also the stigma of being older. Although older people have more problems in general, they also tend to have more positive life experiences.

Instructor’s Manual to accompany Abnormal Psychology, Sixth Canadian Edition by Flett et al.

Old Age and Brain Disorders

Cognitive and brain disorders were previously classified in the DSM-IV-TR under the heading, Dementia, Delirium, Amnestic and Other Cognitive Disorders; the DSM-5 chapter heading for these disorders is now Neurocognitive Disorders.

Dementia Dementia, which lay people call senility, is a gradual deterioration of intellectual abilities to the point that social and occupational functioning is impaired; memory difficulties are the most prominent symptoms. The prevalence of dementia increases with advancing age. Alzheimer's disease, which accounts for about half of all cases of dementia, involves irreversible deterioration of brain tissue, including plaques and neurofibrillary tangles. Neural pathways using acetylcholine are particularly affected.

Strong evidence has been found for a genetic basis for Alzheimer's, but genetically, it is quite complex. At the age of 80, people whose parents both developed Alzheimer’s disease are at 1.5 times the risk compared to those with one parent who developed the disease, and five times the risk of people whose parents did not. Environmental factors, including low education, also play a part, and depression was found to increase a person's risk for Alzheimer's. At the same time, environmental factors can be protective as is the case with nonsteroidal anti-inflammatory drugs. High levels of cognitive ability may also offer some protection.

Frontal-temporal dementias affect cognitive and motor functioning. Pick’s disease is one cause of frontal-temporal dementia.

Huntington's chorea, Parkinson's disease, and vascular dementia are forms of frontal-subcortical dementia.

Irreversible dementia can also be caused by a number of infectious diseases and neurological diseases, including encephalitis, meningitis, head traumas, brain tumours, and exposure to toxins.

Several studies have focused on finding drugs to slow the progression of Alzheimer's disease. A number of drugs have been suggested in the treatment of Alzheimer’s disease but only five have been approved: Tacrine, donepezil, rivastigmine, galantamine and memantine. These drugs do not stop the progression of the disease but they may slow down its progression.

Psychosocial interventions focus on education and support for both the patient and family members.

However, counselling Alzheimer's patients is difficult because of cognitive deficits and there is little evidence that it provides long-term benefits. Life review techniques may be helpful in the earlier stages of Alzheimer's. One of the problems is that not everyone has a caregiver. Those who are “home alone” have a much greater risk of accidents and injury than those who live with spouses.

Canadian Perspectives 16.1: The Canadian Study of Health and Aging and the Canadian Longitudinal Study of Aging The Canadian Study of Health and Aging (CSHA) began in 1991. Over 9,000 seniors aged 65 and over are involved in the longitudinal study of dementia and care for Canadians with dementia. The study’s four main goals were to: (1) use a common research protocol to estimate the prevalence of dementia; (2) identify the risk factors associated with Alzheimer’s disease; (3) examine patterns of care for Canadians with dementia; and (4) develop a uniform data base for future longitudinal studies.

Focus On Discovery 16.1: The Nun Study: Unlocking the Secrets of Alzheimer’s? © Wiley Canada

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The Nun Study is a remarkable investigation involving 678 Catholic nuns who consented to keep diaries, undergo cognitive testing and allow autopsies of their brains. For example, low linguistic ability was found in 90% of those who developed Alzheimer’s disease and in only 13% of those who didn’t (Snowden et al., 1996).

Delirium One of the most frequent organic mental disorders in older adults, delirium is defined as a clouded state of consciousness, involving trouble concentrating, restlessness, disorientation, and swings in activity and mood. Accurate diagnosis is critical to the welfare of older persons although it is frequently misdiagnosed.

The causes of delirium include drug intoxication, nutritional imbalance, infection, neurological disorders, and stress. It may also occur following major surgery, during psychoactive substance withdrawal, and following head trauma or seizures. Complete recovery is possible if the underlying cause is identified and treated. If untreated, brain damage and mortality can result. Primary prevention strategies are effective in reducing the rates of delirium and decreasing the duration of episodes.

Old Age and Psychological Disorders

Most psychopathology found in the elderly is not directly linked to the physiological processes of aging.

Overall Prevalence of Mental Disorders in Late Life Current prevalence rates indicate that persons over 65 have the lowest overall rates of mental disorders of all age groups when the disorders are grouped together. The majority of people aged 65 and older are free from serious psychopathology; however, between 10 and 20% have problems that require professional help.

Depression Mood disorders are less common in older than in younger adults, but account for nearly half the admissions of older adults for acute psychiatric care. Symptoms of depression have been found to differ in older vs. younger adults. Greater prevalence of depression in older people is associated with gender (women are more prone towards depression) the presence of dementia and physical health problems.

The depletion syndrome is a subtype of depression more commonly found in older adults and includes loss of pleasure, vitality, and appetite as well as hopelessness and somatic symptoms. Older people will most certainly experience loss of loved ones. While bereavement may cause depression, it is no longer included in the DSM-5. There is, however, a diagnostic category, persistent complex bereavement disorder that has been listed as a condition for further study.

Behavioural, cognitive, and brief psychodynamic therapies have been found to be equally effective in treating depression in the elderly. Older adults seem to be less likely than younger people to recover without treatment. Interpersonal therapy has also been used successfully and may be more effective than cognitive-behavioral approaches. Reminiscence therapy is a form of intervention in which the elderly reflect on past negative events and attempt to resolve any remaining conflicts; they also strive to place their lives with a context that allows self-acceptance. Evidence to date suggests that this type of life review can be beneficial; however, it is important to avoid obsessive rumination of past short-comings or problems.

Antidepressants have been found useful. Finally, electroconvulsive therapy is used when other treatments have not been effective.

Anxiety Disorders © Wiley Canada

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Among elderly adults, anxiety disorders are more common than depression. Disorders of anxiety are less prevalent than among younger adults. Anxiety is nevertheless quite common in the elderly and symptoms of anxiety appear to manifest themselves differently in the elderly. Not surprisingly, the elderly report more worries about health and less about work than younger adults. In addition, the elderly appear to place less emphasis on guilt and blame. Finally, the elderly focus more on the somatic aspects of anxiety rather that the cognitive aspects. Causes include life stressors, medical problems, medication effects, and confusion related to delirium. Trauma-related disorders are also found in older patients. While research on treatments is scant, the same approaches used with younger adults appear to be helpful.

Substance-Related Disorders Alcoholism was generally believed to be less prevalent in the elderly, More recent evidence, however, suggests that alcohol abuse may be more common than previously thought. Tolerance for alcohol diminishes with age, and older people metabolize alcohol more slowly.

Misuse of prescription and over-the-counter medications is a greater problem than drug or alcohol abuse in the elderly – such misuse may be deliberate or the result of misinformation. Older adults tend to use tranquilizers, anti-depressants and sleep aids that may have been prescribed years earlier.

Sleep Disorders A frequent complaint among the elder is insomnia. Insomnia can affect 1 in 5 people aged 65 and older. The most common sleep problems among older adults are difficult in falling asleep, frequent awakening in the night, early morning awakenings and daytime fatigue. Other causes of sleep problems include medications, illness, pain, stress, depression, and lack of activity.

Sleep apnea is a respiratory disorder in which breathing ceases repeatedly throughout the night.

Both snoring and sleep apnea increase as people age.

Pharmacotherapy is the most common treatment for sleep disorders for people of all ages but particularly for the elderly. Sleeping medications quickly lose their effectiveness and may create additional problems such as drug-dependent insomnia, drug hangovers and increases in respiratory difficulties.

Recent research demonstrated that cognitive-behavioural treatment for sleep difficulties in older populations may be superior to drug therapy (see Canadian Contributions 16.1).

Canadian Contributions 16.1: Charles Morin and the Treatment of Insomnia in Older Adults For the past 15 years Charles Morin and his colleagues have been engaged in a comprehensive program of research on all aspects of sleep disorders. In fact, much of what we know about insomnia in the elderly is due to efforts of Morin and his colleagues. He is also the president of the Canadian Sleep Society (www.canadiansleepsociety.ca).

Suicide Suicide rates for people over 70 are higher than for other age groups in most regions. Rates for men increase sharply and continue to increase in old age. Elderly people are more likely to be successful in their suicide attempts, and they are less likely than younger people to communicate their intentions. Several factors contribute to suicide in the elderly: Older adults have fewer resources; and are more isolated (and therefore less likely to be rescued from death). It may also be the case that suicides among the elderly are more planned and less impulsive than suicides among younger people.

Treatment and Care of Older Adults

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Treatment of Older Adults While clinicians in general are often pessimistic regarding the chances of success when treating older adults; however, the data does not show that psychotherapy is less effective for the elderly.

Nursing and Home Care Improving the quality of nursing home care is particularly important, as the nursing home environment itself has been shown to have adverse effects on mental and physical health.

Canadian Perspectives 16.2 Home Care in Canada In Canada, each province has its own approach to home care and its delivery. Recent studies by CAG and CARP, have suggested that Canadian health care is suffering from a federal policy on the provision of home care, chronic under-funding, a decreasing commitment on the part of several key provinces to providing universal health care. For the moment, women are more likely to receive home care than men; those living alone are provided home care more often than those living with another person; home care increases with age. The Health Council of Canada (2012) concluded that many seniors with complex needs were not receiving the home care to the extent that they needed it.

Alternative Living Settings In recent years, both Canada and the U.S. have seen dramatic increases in assisted living or retirement home availability. The philosophy of assisted living stresses autonomy, independence, dignity and privacy.

Issues Specific to Therapy with Older Adults In treating the elderly, it is important to recognize their special needs. The American Psychological Association provides Guidelines for Psychological Practice with Older Adults.

Content of Therapy Several therapy issues are specific to working with older adults. Content issues include recognition that emotional distress may be a realistic reaction to problems in living, considering their social contexts and need for more selective social contacts, addressing feelings about death and practical concerns about planning for death, and philosophical or religious examination of one's life.

Process of Therapy Regarding process, many clinicians suggest that therapy with the aged should be more active and directive, and may need to proceed more slowly. Therapists need to be aware of the problem of dependency on therapists and caregivers, and of the importance of accurate interpretation of the complex and subtle emotions of older adults. The potential for error is greater when the therapist is considerably younger than the client.

Canadian Perspectives 16.3: PRISMA—An Integrated Preventive Project for the Frail Elderly at Risk of Functional Decline PRISMA (Program of Research to Integrate the Services For The Maintenance of Autonomy) is based on an integrated service delivery model. PRISMA is comprised of four integrated care mechanisms and two assessment tools. The four care mechanisms are: (1) co-ordination between decision managers at the regional and local levels; (2) a single entry point for accessing the services; (3) a case management process; © Wiley Canada

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and (4) individualized service plans. The initial results from the PRISMA project are quite promising, in contrast to an earlier attempt by Hébert and associates that was somewhat less successful.

STUDENTS SHOULD KNOW Key Points 1.

Students should understand the concepts of age effects, cohort effects, and time-of-measurement effects, how these effects make interpretation of studies of aging difficult, and how cross-sectional and longitudinal studies are conducted.

2.

Dementia is a gradual deterioration of intellectual abilities to the point that social and occupational functioning are impaired; memory symptoms are most prominent. Alzheimer's-type disease involves wasting of cortical cells.

3.

Delirium is a clouded state of consciousness characterized by difficulty in concentrating, restlessness, and fluctuations in mood and functioning.

4.

Delirium is usually caused by an underlying problem such as stress, medication, or drug intoxication, and complete recovery is possible if these problems are recognized and treated.

4a.

The elderly have a wide range of problems that are directly related to the aging process.

5.

Despite assumptions to the contrary, psychological problems such as depression, anxiety, and substance abuse, are not more prevalent in older adults. Still, the unique situation of the older adult needs to be considered in understanding and treating each of these disorders. Sleep disorders, particularly insomnia, are more common among the elderly.

6.

Individuals over age 65 are three times more likely to commit suicide than are younger adults.

7.

Most older adults maintain sexual interest and enjoy sexual activity. A general slowing of the sexual response cycle does occur with age, and the intensity of sexual arousal may be less.

8.

Nursing home placement can have a detrimental effect on the mental and physical health of older adults. Community care seeks to maintain continuity of care to allow the elderly to remain at home.

The insurgence of assisted living in Canada and the U.S. provides an alternative to hospitals and nursing homes.

9.

Modifications in the content and process of therapy make traditional psychotherapy approaches appropriate and effective with older adults.

Key Terms age effects (p. 498)

ageism (p. 496) © Wiley Canada

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Alzheimer’s disease (p. 501) cognitive reserve hypothesis (p. 504) cohort effects (p. 498) cross-sectional studies (p. 499) delirium (p. 507) dementia (p. 501) longitudinal studies (p. 499) neurofibrillary tangles (p. 502)

paraphrenia (p. 501) plaques (p. 502) selective mortality (p. 500) sleep apnea (p. 515) subjective age bias (p. 496) time-of-measurement effects (p. 498)

New Names None.

LECTURE LAUNCHERS 1. The Canadian Study of Health and Aging See below under Some Ideas for Utilizing the Internet for descriptions of this research project and abstract of some of their reports. This is a good example of a large study design and points out the importance of baseline data in any research project. This was not just a questionnaire or correlational study, but rather, it involved direct observation and empirical measures of memory, judgement and other cognitive variables.

The results point out some of the inevitable trends in an aging society, such as an increase in the rate of cases of dementia and the rising cost of providing medical care for a population within this demographic.

This makes the study of aging and the work of psychologists who provide counselling and neuropsychological testing and remedial services of great importance to Canadians. It also helps to explain the current political and economic struggles in Canadian society. Groups on the left are trying to maintain universal health care coverage through moneys collected from wage earners and businesses. Groups on the right are trying to reduce the percentage of these costs paid by the wealthy, and increase the cost to individuals who require health care, through user fees and privatized health care. You may wish to refer your students directly to the Canadian Study of Health and Aging web site: www.csha.ca/

2. Aging in Canada Most students could use a bit of general background on the demographics of the Canadian population.

Statistics Canada provides an overview of this topic: http://www.statcan.gc.ca/dailyquotidien/150929/dq150929b-eng.htm, noting that as of 2015, Canadians over aged 65 outnumbered children aged 0 to 14 for the first time. The profound change in the country's demographics will affect every part of Canadian life including health care, the services that we need to provide, the nature of retirement and the jobs to which these students will have access as psychologists or psychiatrists.

3. What Leads to Successful Aging?

A prospective longitudinal study conducted by Vaillant and Vaillant (1990, American Journal of Psychiatry, 147, 31-37) involved assessment of a sample of white men at the age of 65; the men had been followed since age 18 using questionnaires, interviews, questionnaires completed by wives, and demographic information.

The sample was originally selected in college for their good physical health and high academic achievement. © Wiley Canada

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Psychosocial adjustment measures were developed based on compilations of measures covering the areas of "ability to work" (continued employment and sustained job success), "ability to play" (job/retirement satisfaction and taking 3+ weeks of vacation), and "ability to love" (marital satisfaction and recreation with others), as well as global measures of psychosocial adjustment, physical health, observer-rated life satisfaction, and subject-rated life satisfaction. In addition, physical health at age 65 was rated by an internist, based on a physical examination.

The results? The most significant predictor of both physical and mental ill health at age 65 was psychoactive substance use (usually tranquilizers) before age 50. Presence of childhood strengths, including the cohesiveness of the home, positive relationships with mother and father, and closeness to siblings, were related to physical health at age 65. Of the men who remained in excellent physical health at age 65, the following variables were usually present: warmth of childhood, longevity of ancestors, low blood pressure in college, or regular exercise in college. Interestingly, childhood socioeconomic status, childhood emotional problems, and college scholastic aptitude were not related to older adult outcome, either physical or psychosocial. "Maturity of ego defences" rated before age 50 was related strongly to later psychosocial adjustment.

4. Detecting Dementia Early Many family members ignore early signs of dementia in their spouses or parents, perhaps because they prefer not to hear a definitive (and depressing) diagnosis. The Discussion Stimulator below explores the issue of telling vs. not telling patients a diagnosis of Alzheimer's. However, physicians and psychologists find cause for alarm in the recent finding that one in five family members did not recognize symptoms of dementia in a relative, and of those who did, half did not seek medical evaluation (Ross et al.; 1997, Journal of the American Medical Association).

The study looked at 191 Japanese-American men, ages 71 to 93 in a larger research project called the Honolulu-Asia Aging Study. Family members were interviewed before the diagnosis of dementia; many apparently assume nothing can be done for dementia, and so avoid pursuing a diagnosis and medical assessment.

In fact, as readers of the text should know, many causes of dementia are reversible or preventable.

Even in cases such as Alzheimer's, early recognition can help families prepare for the future, understand their family member's difficulties, and create a safe environment for care.

In light of this information, students might be interested in knowing early signs of dementia: -

repeating comments misplacing items difficulty finding names for familiar objects getting lost on familiar routes personality changes becoming physically passive losing interest in activities once enjoyed inability to recall recent events

5. Mnemonic Training to Improve Memory Can normal older adults learn to improve their memory through training in mnemonic strategies? A metaanalytic study suggests that they can (1992, Verhaeghen, Marcoen, & Goossens; Psychology and Aging, 7, 242-251). Studies were included which used normal healthy subjects, aged 60 or over, without organic pathology. Analyzing the results of 33 studies, the authors conclude: (1) the mere fact of testing the elderly twice improves their performance and (2) training the elderly in the use of mnemonics (most studies used imagery techniques) improves their performance further. The most successful training program included younger subjects, group training sessions, brief sessions (e.g., around 20 minutes), and pretraining. © Wiley Canada

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Educational differences were not related to improvements following training. Students might enjoy being exposed to mnemonic strategies themselves (suggestions available in Belezza, F.S., 1983, “Mnemonicdevice instruction with adults”, in M. Pressley & J. R. Levin, Eds., Cognitive Strategy Research: Psychological foundations (pp.51-73). New York: Springer-Verlag).

6. Hot Flashes Cooled by Cognitive-Behaviour Therapy Fifty-two menopausal women experiencing frequent hot flashes were treated with an 8-week treatment of either cognitive-behaviour therapy, hormone replacement therapy, or a no-treatment control (Hunter & Liao; 1996. British Journal of Health Psychology, 1, 113-125). While both hormones and CBT reduced hot flashes, CBT had the added benefit of reductions in anxiety and depressed mood and perceptions of hot flashes as less problematic in everyday life. Self-ratings of overall improvement occurred in 90% of the CBT group and only 50% of the hormone group.

7. Mortality and Bereavement The expression "to die of a broken heart" is more popular among writers than scientists, but research shows that it may indeed hold a certain truth. One of the best studies of mortality subsequent to bereavement is that of Rees and Lutkins (1967, British Medical Journal, 4, 13-16). They studied a small Welsh town whose 2,350 people were all served by the same doctor for many years. First, a list was compiled from county records of the names of all town residents who had died in a six-year period, and each of the deceased was matched with a living resident of the same age, sex, and marital status. Then, using that register and a nurse's memory, lists of all close relatives (spouses, parents, children, siblings) of both groups were compiled.

Mortality rates between the two groups of relatives after the date of the deceased's death constitute the data of the study.

In the five years following the date of death, 2–3% of the control families each year experienced the death of a close member, whereas among the bereaved families, almost 12% experienced another death in the first year, 5% in the second year, and 3%, 2%, and .1% in the third, fourth, and fifth years respectively.

Statistical tests showed that the spouses, children, and siblings of the bereaved were all significantly more likely to die in the first year following bereavement than were control relatives. The increased risk was most clearly elevated for widows.

It has been suggested that relatives may die in quick succession for reasons other than the emotional impact of the loss. For instance, a husband and wife may be infected by the same disease or may have lived the same unhealthy lifestyle. Contrary to this prediction, Rees and Lutkins found that of families where the deceased died at home, 7.1% experienced another death within the year. In contrast, in families where the deceased died suddenly when away from home, 37.6% experienced another death that year. In this sample, all such deaths were unexpected, thus they likely were more traumatic for the survivors.

Finally, it should be noted that death following bereavement was largely confined to the elderly.

The youngest relative to die within a year of bereavement was 44; most were over 70.

8. Memory “Biotech firms are tantalizingly close to unravelling the mysteries of memory. On the way are drugs to help fading minds remember and let haunted ones forget.” http://www.forbes.com/global/2002/0204/060.html This source discusses recent advances in understanding the nature or memory and that offer the possibility of producing chemicals that can enhance memory.

If you ask a class of students who would be interested in such a drug I believe you’ll find it in excess of 75% or more. This can lead to a discussion of possible side effects; reference to © Wiley Canada

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“Flowers for Algernon” (either the book or the movie, Charlie – Flowers for Algernon) and the nature of enhanced performance drugs for sports. Are enhanced performance drugs for school or science any different?

DISCUSSION STIMULATORS Ageism Consider the following scenes: * A 60-year-old man is asked his age as he registers at a hotel, so that he may receive the proper deference by hotel staff. * A dress shop has clothing arranged according to age groups, with clothing appropriate for older people grouped together. * A 55-year-old employee of a large company is asked to retire. * The eldest son and his wife are expected to care for the elderly father, while the youngest son bears no responsibility.

These situations describe typical treatment of the elderly in Japan, a country we associate with respectful and positive views of old age. Do they represent ageism?

Kimmel (1988, American Psychologist, 43, 175-178) says yes. But what is wrong with treating people differently based on their age? Kimmel asserts that both positive and negative stereotypes about the elderly have powerful effects on older persons' views of themselves, and on public policy. One study found that elderly nursing home residents had ageist beliefs themselves; when given plausible alternative explanations for their behaviour and symptoms (floors are slippery because they must be kept clean, and even young people slip on them) instead of attributions about aging or personal failure, the residents improved in their participation and sociability. In public policy, ageism is evident in mandatory retirement at a specific age, and in entitlement programs based solely on age.

You might ask students to debate whether "ageism," defined as discrimination of individuals based on age, is always wrong. What do they think of mandatory retirement? Of senior citizen discounts? Of special deference for the aged in Japan?

Disclosing the Diagnosis of Alzheimer's: To Tell or Not to Tell?

Many families who bring their relatives for evaluation of Alzheimer's disease plead with professionals not to disclose the diagnosis to the patient. Unlike in the area of cancer, where consensus is strong that patients should be told their diagnosis, the case is less clear for Alzheimer's. Students might be asked to debate the two sides of the issue; a “Sounding Board” piece in the New England Journal of Medicine (April, 1992, Drickamer, M.A., & Lachs, M.S.) presents arguments for and against disclosure.

The Case for Not Telling: -

The diagnosis of Alzheimer's disease cannot be made with certainty prior to autopsy.

The prognosis of the disease course and life expectancy of patients is quite variable.

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-

-

Patients with Alzheimer's have deteriorating cognitive functions; it can be difficult to find a time to disclose the diagnosis when the diagnosis can be made reliably, but the patient is still well enough to understand it.

Diagnostic labelling may lead to stigmatization by insurers, health professionals, and others in society.

Stress (such as learning one's diagnosis) may exacerbate the symptoms of Alzheimer's and lead to depression.

Little evidence exists to determine whether patients with Alzheimer's would want to know their diagnosis.

The Case for Telling: -

-

-

Our culture believes that medical decision-making should maximize patient autonomy.

Patients cannot make informed choices about whether to accept or forego treatments without knowing the truth.

Persons with a progressive illness should be given the opportunity to make decisions about their future while they are still competent to make these decisions. For example, knowing one's diagnosis might lead to having a voice in subsequent care decisions (by making one's wishes known to the person who will make decisions after the patient is incompetent), being able to do advance planning in the areas of financial arrangements, seeking other medical advice, personal plans, etc.

Uninformed patients cannot make decisions regarding whether or not to participate in research projects related to the disease.

Patients may prefer to express their thoughts and fears before they are unable to.

Differential Diagnosis: Dementia vs. Delirium The successful differentiation of dementia and delirium is an extremely important task for those working with the elderly. Since delirium is very often reversible, while dementia is often not, it is essential to recognize the difference between the two. For example, it is not uncommon for factors such as malnutrition, unintentional overmedication, or surgery involving general anaesthesia to create a state of delirium in an older person that may be misinterpreted as dementia by family members who then believe there is nothing they can do to correct the symptoms. Present the following cases to your class for practice in distinguishing the two problems: Dementia vs. Delirium CASE A: Fred White is a 72-year-old man who was brought to the clinic accompanied by his wife and children. While Fred denied having any memory problems, his wife reported that he had been forgetting where he put things around the house, and then would accuse the housekeeper of taking them. He also could not remember social engagements, and recently at a party failed to recognize a couple of friends. His wife Lilly reported that these problems had been occurring for some time, perhaps as long as two years. At that time she noticed he was having trouble finding his keys, but she did not think anything was wrong since he had always misplaced a few things around the house. When he started accusing the housekeeper of stealing items, which happened about one year ago, she started to think something was wrong, especially since he had always liked the housekeeper.

Fred made five errors on the Kahn mental status test. He did not know the name of the clinic or its address. He did not know the date or month, and could not remember the president before Reagan. Fred denied feeling depressed and was not overly concerned when he made errors on the mental status test.

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CASE B: June West is a 79-year-old woman who was brought to the clinic by her neighbour, who noted a sudden change in June's behaviour. According to the neighbour, Sam Spade, June had always dressed immaculately and had been fairly reserved and polite. In the last week, however, she had begun appearing somewhat dishevelled, and also made some overt sexual overtures to Sam (e.g., "Hey big boy, looking for some action?"). While she had previously walked her dog only during the daytime, Sam now observed that June went out walking with the dog at random hours, including late at night. June's apartment, which had always been immaculate, was now in disarray, and Sam had noted that there was no food in the refrigerator.

When asked how she was doing, June denied having any problems or having made any overtures to Sam. June made 4 errors on the mental status test. She incorrectly identified the clinic as a hotel, and giggled when she said it. She did not know the date or month or the President before Reagan (she said "Kennedy").

She also thought she knew the interviewer from a nightclub and thought he might be the maitre d'. She denied feeling depressed and appeared to be in good spirits.

The following factors are among those that should be considered in distinguishing dementia from delirium: - Onset: The onset of dementia is usually gradual and insidious, whereas that of delirium is usually abrupt and obvious.

- Symptoms: Early symptoms of dementia include failing attention, memory loss, and declining mathematical ability; the person may also make errors of judgement, show irritability, personality changes, or loss of a sense of humour. Symptoms of delirium include restlessness, fluctuating alertness, confusion, decrease in amount of sleep with day-night reversal, and sexual acting-out. Both dementia and delirium patients may deny their symptoms.

- Responses to test questions: While both patients with dementia and those with delirium may make the same errors on a mental status exam, the quality of their responses is likely to be different: those with dementia commonly make denotative errors, whereas delirium patients often give connotative, symbolic responses.

After presenting this information, it should be easy for students to identify Case A as dementia, and Case B as delirium.

Aging in Literature There are many well-written and absorbing novels that provide excellent windows into the life of the elderly. You might refer your students to these books as a means of helping them understand and consider the issues involved in growing older. May Sarton's As We Are Now tells the story of a 76-year-old woman who has suffered a heart attack and been committed to an old people's home. The first-person account offers a searing insight into the hope, despair, anger, and compassion of her experiences there. The Diary of a Good Neighbour, by Doris Lessing, depicts the developing relationship between a fashionable, successful middle-aged woman and a fierce, vulnerable 80-year-old woman after they meet by chance in the local pharmacy. Lessing's Child of Violence series begins with Martha Quest (book of the same title) as a young woman in Rhodesia and ends with her as a very old woman living in London in The Four Gated City. The book, Still Alice, by Lisa Genova depicts a 50-year-old psychology professor who is diagnosed with earlyonset Alzheimer’s disease. Students will be even more likely to be familiar with the 2014 movie of the same name, starring Julianne Moore (who won an Oscar for the role) as Alice.

Elder Abuse in Canada Most students will have not have had much contact with this problem. It is something they can imagine, however, and an Internet search of relevant topics will net a good deal of information. A discussion around just the definition is quite interesting. Does just failing to visit aged parents amount to "abuse" or does it take more active wrongdoing. See the “Elder Abuse in Canada” web resources below for some starting points.

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Sex and Aging One way to make the elderly seem human is to make it salient that many people of considerably advanced age are still sexually interested and sexually active. After looking at some of these resources students may be asked to consider the implications of an aging population, drugs such as Viagra, health for many well into their 80s, etc. This is an on-going issue for care facilities that often don't really know how to address the issue of sexually active residents. For information on this topic: www.nia.nih.gov/health/publication/sexuality-later-life

Health Canada Division of Aging and Seniors www.hc-sc.gc.ca/hl-vs/iyh-vsv/seniors-aines-eng.php The Division of Aging and Seniors, Health Canada, provides federal leadership in areas pertaining to aging and seniors. The Division serves as a focal point for information and centre of expertise.

Activities include: - providing advice and supporting policy development; - conducting and supporting research and education activities; - encouraging innovative means of improving the health of seniors in situations of risk and in preventing situations of risk from developing; - working and consulting with partners, including the provinces, territories, seniors organizations and other sectors; and - encouraging communication and disseminating information.

- providing operational support to the National Advisory Council on Aging; This a basic starting point for information about issues of aging in Canada. A number of exercises can be designed that ask students to search for information, policy proposal, etc.

NIMH Aging and Mental Health www.nimh.nih.gov/health/topics/older-adults-and-mental-health/index.shtml This is another good starting point for information about aging. This one is from the US National Institute of Mental Health and focus on mental health issues.

Stem Cell Research The use of embryonic stem cells for therapeutic research is quite controversial and often of interest to students. With the 2004 announcement by Harvard that they will of offer free stem cell lines to researchers, the controversy has escalated. The CBC has a clear summary of the issue and links to articles and editorials in the New England Journal of Medicine. archives.cbc.ca/science_technology/biotechnology/clips/17507/ The CBC’s Science and Health site is a good starting point of information in general. www.cbc.ca/health/

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Students can be asked to research this issue and report on their findings about how stem research works, what diseases it is used in, etc.

SOME IDEAS FOR UTILIZING THE INTERNET Public Health Agency of Canada The Public Health Agency of Canada website is excellent and contains a wealth of information on issues about aging, including age-friendly communities: http://www.phac-aspc.gc.ca/seniors-aines/index-eng.php

Ideas from other Countries Have students research what other countries are doing for the elderly. Is assistance privately or publicly funded? Is there legislation around care homes? For example, here is a website describing elderly care in Sweden. https://sweden.se/society/elderly-care-in-sweden/

Canadian Study of Health and Aging This important study may be looked at in some detail below.

CSHA Home Page: www.csha.ca/ Summary of results: csha.ca/r_study_results.asp

Commission on the Future of Health Care in Canada This is one of the most important commissions ever established in Canada. www.hc-sc.gc.ca/hcs-sss/com/fed/romanow/index-eng.php

Aging Links Statistics Canada: Population by sex and age group across the country http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/demo31a-eng.htm Administration for Community Living: Administration on Aging This agency of the U.S. Department of Health and Human Services offers information, statistics, and program results on topics related to aging and older Americans. http://aoa.acl.gov/

Elder Abuse in Canada: It’s time to face the reality Government of Canada information about elder abuse: http://www.seniors.gc.ca/eng/pie/eaa/elderabuse.shtml

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Health Canada www.phac-aspc.gc.ca/ncfv-cnivf/familyviolence/age_e.html Students may be asked to consider the variety of ways that seniors can, and are abused in Canada and consider social policies that could help to prevent what is bound to be a growing problem.

Alcohol Abuse and the Elderly www.agingincanada.ca/Seniors%20Alcohol/1g3ciii.htm There is evidence that using the mind on a regular basis can not only be used as a remedial measure, but actually prevent certain diseases of aging or lessen their severity. I would ask students to look at some mnemonic method and use it for several weeks. You may tie it to material that will appear on a test and demonstrate to them some immediate value in practising this one mental activity.

Alzheimer's Society of Canada Basic information on the nature and attempts to prevent and cure a disease whose incidence is growing and will continue to grow as the population ages. http://www.alzheimer.ca/en

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CHAPTER 17 OUTCOMES AND ISSUES IN PSYCHOLOGICAL INTERVENTION

CHAPTER SYNOPSIS In this chapter, the effectiveness of various therapies is evaluated, as well as issues common to therapies in general, such as the roles of client personality and expectancies. Contemporary developments, such as the use of technology in psychotherapy, are discussed.

Client, Therapist and Client-Therapist Factors that Influence Therapy Outcome While types of therapies and issues of diagnosis affect the outcome of psychotherapy a number of client, therapist, and factors involving the client-therapist relationship are also important.

Client Factors that Influence Therapy Outcomes The demoralization hypothesis suggests that clients will seek help because they feel demoralized. Therapy is viewed as giving hope to clients, and hope can lead to positive expectations in therapy.

Client Personality Previous chapters have mentioned that personality variables may have an impact on the severity of symptoms. At least one author has suggested that personality may account for as much as 40% of outcomes in therapy. Attachment style is also related to outcomes.

Goals and the Motivation to Change Unsurprisingly, motivation to change has been identified as one of the most important factors in treatment outcome (see Focus on Discovery 17.1).

Type and Severity of Dysfunction Clients with more extreme levels of dysfunction typically show significant clinical improvement However, treatment outcomes can be complicated by comorbidity.

Focus on Discovery 17.1: Motivational Interviewing Even though some clients may be experiencing great distress and engaging in self-defeating behaviour, they still resist change and focus on the benefits of their dysfunctional behaviours. Motivational Interviewing (MI) is a type of dialogue between therapist and client that attempts to get the client to understand the selfdefeating nature of this process.

Therapists Factors that Influence Therapy Outcomes

Instructor’s Manual to accompany Abnormal Psychology, Sixth Canadian Edition by Flett et al.

Two therapist factors that are seen to be important in treatment are: (1) the personal qualities of the therapist; and (2) therapist experience training and competence. The personal qualities of the therapist can often be traced to the personality traits and styles of the therapist. The experience of the therapist also appears to have a positive impact on successful therapy. More experienced therapists will have the necessary core competencies (the ability to enter into a therapeutic relationship and be an effective communicator).

Client-Therapist Relationship Factors that Influence Therapy Outcomes There are several aspects of the client-therapist relationship that are important. For example, as in any relationship, the client and therapists can "hit it off" or they can be at odds with one another. The terms therapeutic or working alliance refers to the degree of rapport and trust that is developed between the client and the therapist. Therapists and clients tend to differ in their evaluations of the therapeutic alliance, and positive treatment outcomes are better predicted by the client’s view of the working alliance than the therapist’s view.

General Issues in Evaluating Psychotherapy Research Therapy as Researched vs. Therapy as Practiced Recently, there has been an increased insistence on the use of evidence-based treatments. In an effort to promote evidence-based treatments, the use of therapy manuals has become the norm in psychotherapy research. There has been some criticism of treatment manuals as being unwieldy for actual practice and that such manuals generate rule-governed treatments that may not be appropriate in all cases. Treatment manuals have resulted in increased internal validity but external validity remains a concern.

Focus on Discovery 17.2: Research vs. Practice in PTSD: Why a Gap Exists and How It Is Being Addressed When knowledge is not put into practice, it is the clients who suffer. In the treatment of PSTD, exposure based treatments have been shown to be effective. For a variety of reasons these treatments are frequently not used by therapists working for the U.S. Department of Veterans Affairs.

Treatment Efficacy vs. Treatment Effectiveness Treatment efficacy refers to the results obtained in controlled research settings. Effectiveness refers to what is offered and received by clients in the real world. The efficacy of some treatments is well established; however, evidence of its effectiveness often lags behind. Factors that impact negatively on effectiveness include lack of therapist training, failure to use treatment manuals, and a lack of ongoing monitoring during treatment. A 1995 Consumer Reports effectiveness study confirmed the dodo bird effect – that is, various therapies were similarly effective.

Focus on Discovery 17.3: Consensus Beliefs Involving Psychotherapy Research An international group comprised of leading psychotherapy researchers was given a survey that asked each researcher to indicate their degree of agreement with 20 statements about psychotherapy, based on existing research. The experts strongly agreed with seven of these claims.

Focus on Discovery 17.4: Stepped Care Models and the Treatment Process: Can We Do More With Less?

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The concept of stepped care involves the notion that clinicians should match the level of treatment required to the seriousness of the adjustment problem involved, but less involved and less costly interventions are the starting point, with more complex interventions following if the initial interventions are not successful.

The Challenge of Managed Care Managed Care in Canada is administered via our universal health care system. This system requires that service providers use empirically supported therapies (ESTs). The American Psychological Association maintains a list of ESTs for various disorders, whereas the Canadian Psychological Association promotes evidence-based practice, which requires psychologists to stay up to date on the literature and apply it appropriately in diagnosis and treatment.

Review of Behavioural and Cognitive Therapies Both behaviour therapy and cognitive therapy attempt to change abnormal behaviour, thoughts, and feelings by drawing on the methods used and the discoveries made by experimental psychologists.

Evaluation of Counterconditioning and Exposure Methods In counterconditioning, the response to a given stimulus is eliminated by eliciting different behaviour in the presence of that stimulus. Joseph Wolpe's systematic desensitization involves having a deeply relaxed person imagine a graded series of anxiety-provoking situations; the relaxation inhibits the anxiety that would otherwise be elicited. The technique is used in conjunction with other approaches in the treatment of a variety of anxiety-related problems. Evidence from numerous studies has supported the effectiveness of the procedure in treating specific phobias, obsessive-compulsive disorder, post-traumatic stress disorder, panic disorder and agoraphobia.

Evaluation of Operant Methods Operant treatments involve efforts to shape behaviour through rewards and extinction. A wide range of childhood problems have been treated with success using operant conditioning, including bed-wetting, hyperactivity, social withdrawal, aggression, and self-mutilation. The techniques are effective in training children with intellectual disabilities and autism as well.

Behaviour therapists have developed a number of procedures for improving generalization and maintenance of treatment gains. These procedures include intermittent and naturalistic reinforcement, environmental modification, eliminating secondary gain, and relapse prevention. An important part of treatment maintenance is attributing gains to the patient rather than to the therapist. Cognitive and behavioural therapists aim to make the professional helper superfluous by motivating the patient to continue practicing skills and meeting new challenges.

Evaluation of Cognitive-Behaviour Therapy Cognitive restructuring refers to changing a pattern of thought that is presumed to be causing a disturbed emotion or behaviour. Ellis's rational-emotive behaviour therapy (REBT) asserts that sustained emotional reactions are caused by non-verbalized assumptions and demands people impose on themselves and others.

Therapy aims to change these cognitions by rationally evaluating them. REBT has been found to be most effective in reducing self-reports of anxiety. It may also be useful in treating anger, depression, and in combination with behavioural techniques, for treating sexual dysfunction. Rational-emotive education has been used with children to improve self-concept and reduce test anxiety. Questions have been raised about how to define irrationality and about whether irrational thinking is necessarily unhealthy.

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Beck's cognitive therapy (CT) seeks to provide clients with experiences that will disconfirm their negative schemata. Beck's cognitive therapy asks patients to look for objective evidence regarding their cognitive biases. CT has been shown to be an effective treatment for depression and anxiety disorders.

While Beck's and Ellis's approaches share many similarities, there is an important difference. Beck's approach is inductive whereas Ellis's is deductive. In addition, Beck is more likely to work to promote rapport with clients and acknowledge their frame of reference, whereas Ellis's approach is more didactic and forceful. Both approaches have in common the idea that people can change by thinking differently. Schemafocused therapy introduced by Jeffery Young takes Beck’s and Ellis’s approaches one-step further by considering thoughts and beliefs at a deeper level, i.e., schemas.

Review of Psychoanalytic Therapies Basic Concepts and Techniques in Classical Psychoanalysis vs. Contemporary Psychodynamic Treatment The focus of classical psychoanalysis is on lifting repression of unconscious conflicts existing in the psyche from childhood. Psychoanalytic techniques include free association, dream analysis, and interpretation. One of the more important techniques, transference, relies upon the notion that the patient will transfer their unconscious attitudes to their relationship with the therapist.

Brief therapies are characterized by a planned number of sessions, concrete goals, interpretations directed toward current life circumstances, and on not encouraging a transference neurosis.

There are a number of elements that distinguish between short-term psychodynamic therapy and cognitive behavioral therapy, e.g., a focus on affect and emotions, an emphasis on past experiences and how they affect current experiences, an emphasis on the therapy relationship, etc.

Evaluation of Psychodynamic Psychotherapy Outcomes in Research Traditional psychoanalysis is difficult to evaluate scientifically and, and basic tenets such as the unconscious and the nature of insight have been questioned. Evidence is conflicting about whether its outcome is better than what would occur with the passage of time. However, evidence concerning brief psychodynamic therapy is more encouraging.

Review of Client-Centred Therapy Basic Concepts and Techniques Rogers’s client-centered therapy is based on the premise that people can understand themselves in terms of their immediate experience of themselves and their world and that mental health problems arise when people fail to be attentive to their inner nature. The therapist’s role is to create conditions of acceptance in a nonjudgemental manner.

Evaluation of Client-Centred Therapy Much of the outcome research in client-centred therapies is focused on relating outcome to personal qualities of the therapist. Such research has not been consistent in demonstrating that qualities of warmth, genuineness, and empathy are sufficient to help clients change. Rogerian therapy has been criticized for its reliance on subjective reports in treatment outcome research, questions about how a therapist can truly understand a client's phenomenology, the lack of specification about self-actualization, and doubts about the basic assumption that humans are innately good.

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Extension of Client-Centred Therapy: Compassion Focused Therapy Compassion focused therapy was developed specifically for people who are highly critical of themselves and do not have the capacity for self-acceptance. The process involves the therapists acting as a role model for empathy and displaying a compassionate role both toward him or herself and the client.

Review of Couples Therapy The problems facing individuals in therapy are often complicated because the individual is also involved in a dysfunctional relationship. Marital conflict can have a negative impact on all family members.

The normality of conflict Conflict seems inevitable in any long-term relationship and how couples deal with conflicts often determines the quality and duration of their relationship. Recent research showed that although relationship satisfaction decreased over the first four years of a marriage, marital problems were quite stable.

The Approaches to Couples Therapy “Couples” therapy does not consist of a set of therapeutic procedures. There is great variety within couples therapy; techniques are consistent with the theoretical orientation of the therapist.

Couples and family therapy appear to have begun in the 1950s at the Mental Research Institute in California. Initial efforts placed the emphasis on communication skills, uneasy relationships and inflexibility. Other approaches include cognitive-behavioral therapy (emphasis is placed on communication and increased efforts to please the other member of the couple), integrative behavioral couples therapy (a combination of cognitive-behavioral techniques and a Rogerian notion of emotional acceptance) and emotion focused therapy (which contains both psychodynamic and humanistic elements – see Canadian Perspectives 17.1). Some of the general features of all couples therapy include communication skills, empathic listening, completion of homework assignments and practice of newly acquired skills.

Ethical Issues and Special Considerations Both the severity and nature of marital dysfunction vary considerably. Such therapy can be further complicated by the presence of abuse (e.g.., physical, sexual, emotional or other). Ethical considerations can also arise when one member of the couple divulges a secret while the other member of the couple is not present. A split alliance occurs when the therapist has a stronger alliance with one member of the couple than with the other.

Evaluation of Couples Therapy Outcome research has demonstrated the couples therapy is beneficial for many problems. It is typically less effective for couples with more severe relationship distress. Couples therapy can be helpful even for individual psychopathology, such as for problem gamblers. Couples therapy can also be effective when one partner has a substance abuse problem or depression. Improvement effect sizes tend to be larger in efficacy studies than in effectiveness studies. There is a need for greater diversity in couples therapy research.

Canadian Perspectives 17.1: Emotion-Focused Couples Therapy Emotion-focused couples therapy (EFT) was developed by Les Greenberg of York University and Susan Johnson, now at the University of Ottawa. This model suggests that distress in relationships occurs when mutual attachment needs are not being met and improvement can occur when members of a relationship learn to express their emotional needs and agree to attend to the other member(s) of the relationship.

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Psychotherapy Integration Recent reviews suggest that the cognitive-behavioral orientation is dominating clinical models in today’s training programs. Such an approach may not be in the best interests of either clients or the field of clinical psychology.

Eclectisims and Theoretical Integration in Psychotherapy A rapprochement is increasingly developing between the various theoretical paradigms.

Therapists of different approaches are increasingly using techniques outside of their particular orientation.

Four Types of Psychotherapy Integration Three modes of psychotherapy integration have been proposed: technical eclecticism (exemplified by Lazarus’s multimodal therapy; common factorism (identifying common components of all effective therapies), theoretical integration (synthesizing not only technique but theory as well), and assimilative integration (staying primarily within one orientation, but assimilated concepts and techniques from other orientations).

Contemporary Developments in Treatment and Intervention It seems apparent that the need for service in the general population exceeds the services that are available or that can be delivered. Innovation and perhaps the development of psychotecnnologies in service delivery will be needed as we move forward. Some examples of the use of new technologies include Skype, Facebook, Twitter, Internet bases service delivery and video conferencing (see Student Perspectives 17.1).

Student Perspectives 17.1: Computerized CBT for Depressed and Anxious Students In a recent study, university students were offered treatment for either depression or anxiety using a computerized Cognitive Behavior Treatment program (cCBT). The program showed mixed results but users reported moderate to high satisfaction. The importance of this study is that it demonstrated the feasibility of this form of psychotherapy.

STUDENTS SHOULD KNOW Key Points 1.

The evaluation of the effects of psychotherapy has grown in significance as the demand for accountability increases.

2.

Client factors that have an influence on therapy outcomes are client expectations, client personality, the client’s motivation to change and the severity of the dysfunction.

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3.

Therapist factors that have an influence on therapy outcomes are the personal qualities of the therapist and their experience, training and competence.

4.

A working alliance between the client and therapists is also considered an important influence on therapy outcome.

5.

Increased use of treatment manuals improves internal validity but does not necessarily address concerns over external validity.

6.

A distinction should be made between treatment efficacy and treatment effectiveness.

7.

Cognitive and behaviour therapies draw on the methods and discoveries of experimental psychologists in an attempt to change abnormal behaviour.

8.

Evidence demonstrates the effectiveness of counterconditioning, exposure, operant, and cognitivebehavioural interventions in alleviating a wide range of disorders.

9.

Cognitive restructuring involves changing a pattern of thought presumed to underlie maladaptive feelings and behaviours. Examples of this approach include rational-emotive behaviour therapy, Beck's cognitive therapy, and social problem solving.

10.

Behaviour therapists have developed a number of procedures for promoting the generalization and maintenance of treatment effects.

11.

In classical psychoanalysis, childhood repressions are the focus while brief psychodynamic therapy puts more emphasis on the patient's ability to achieve control over the environment.

12.

Carl Rogers argued that the client should direct therapy, and that the therapist's major goal is to demonstrate genuineness, unconditional positive regard, and empathy.

13.

Couples or marital therapists focus on helping partners reward each other, increasing acceptance, and enhancing communication.

14.

A rapprochement may be developing between most therapeutic schools of thought. Increasingly, therapists report using techniques that fall outside of their particular theoretical orientation.

15. Several modes of psychotherapy integration have been proposed, including technical eclecticism, common factors, and theoretical integration, and lively debate continues as to the value and feasibility of each.

16. There is a growing trend toward psychotechnologies or the use of computer technology (Internet, etc.) to help in the delivery of service.

Key Terms assimilative integration (p. 555) common factorism (p. 555) compassion-focused therapy (p. 546)

core competencies (p. 530) demoralization hypothesis (p. 526) dodo bird effect (p. 535) © Wiley Canada

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effectiveness (p. 534) efficacy (p. 534) empirically informed therapies (p. 538) empirically supported therapies (ESTs) (p. 536) evidence-based practice (p. 538) psychotechnologies (p. 556)

split alliance (p. 551) stepped care (p. 537) technical eclecticism (p. 555) theoretical integration (p. 555) therapeutic (working) alliance (p. 531)

New Names Les Greenberg.

LECTURE LAUNCHERS 1. Emotion-Focused Couples Therapy This eclectic brand of therapy was developed in Canada by Les Greenberg of York University and Susan Johnson of the University of Ottawa. One of its unique attributes is that it is a therapy that utilizes theoretical concepts derived from attachment theory. (See information on Mary Ainsworth in Chapter 15).

Attachment theory has advanced into adult development and suggests that attachment styles experienced by children when developing are carried into adulthood and form the foundation of adult and family relations.

The language of EMT even uses attachment theory terminology such as "secure base." It is an interesting attempt to adapt a very successful development theory into a set of therapeutic methods. The empirical evidence over the next several years will tell if this attempt is a significant improvement over existing therapeutic strategies and models. This is also a therapy that is open to empirical investigation. Papers, Les Greenberg's work, is a good starting point. This issue of whether a therapy can or should be open to empirical investigation is also an interesting lecture. For decades psychoanalytic therapists managed to avoid empirical evaluation of their work. Greenberg has also done studies that compare the effectiveness of several methods including psychoanalysis, and looked at what actually transpires between patient and therapist in effective therapeutic encounters. cf. Greenberg, L. (1999). “Ideal psychotherapy research: A study of significant change processes”, Journal of Clinical Psychology, 55, 1467-1480 and Greenberg, L. and Mateu Marques, C. (1998). “Emotions in couples systems”, Journal of Systemic Therapies, 17, 93-107.

2. Do Therapists Matter?

A special issue of Clinical Psychology: Research and Practice (1997; 4, 40-89) was devoted to "the therapist as a neglected variable in psychotherapy research." Garfield argues that therapy research assumes that all therapists in a given theoretical orientation perform equally well, ignoring variables that may discriminate clinical competence. Larry Beutler focuses on therapist experience and training as important variables to consider in the design of outcome studies. In a comparison of outcomes across therapists, Luborsky et al. found that three variables predicted outcome: peer ratings of therapist efficacy, patient ratings of the helping alliance, and therapists' adherence to their treatment manuals. In contrast, Strupp and Anderson found that in their study of time-limited dynamic psychotherapy, self-controlling and self-blaming therapists adhered most closely to the treatment, yet had the worst treatment outcomes. Therapeutic alliance was addressed by Lambert and Okiishi.

3. The Dodo Bird Revisited Students may have enjoyed reading about the Dodo Bird Effect in the chapter – that is, the finding that when it comes to psychotherapy, “everyone wins” and the different therapies perform quite equivalently. In The © Wiley Canada

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Dodo Bird verdict: Status in 2014 (The Behavior Therapist, 37, 91-95) Lilienfeld argues that there is much evidence that some therapies have better outcomes than others. Lilienfeld suggests that the dodo bird effect has been falsified and that “it is high time to consign it to the dustbin of paleontology once and for all.” This might be a good opportunity to have students discuss the common factors that are important in psychotherapy (e.g., therapist-client relationship, hope) versus specific ingredients of various therapies (e.g., cognitive restructuring versus psychodynamic insight).

4. Carl Rogers (1902-1987) Carl Rogers died suddenly in 1987 at the age of 85, following surgery for a broken hip. Obituaries from the Los Angeles Times (February 6, 1987) and the American Psychologist (1988, 43, 127-128) offer a glimpse into the life of this influential champion of the humanistic paradigm. Rogers was born Jan. 8, 1902, in Oak Park, Illinois. He received his doctorate from Columbia University Teachers College in 1931. Rogers founded the Center for the Study of the Person in La Jolla, California in the 1960s, where he remained active until his death. Those who knew Rogers describe him as a quiet but intent listener, who was able to convey his real interest in and empathy for the phenomenological world of the individual. While caring deeply about individual persons, he doubted authority, institutions, credentials, and diagnosis. Accused in the 1940s of "destroying the unity of psychoanalysis," Rogers successfully pioneered the new method of nondirective, client-centred therapy, turning the tables on the authority of analysts.

One of Rogers' most important contributions was his concern with conducting research in psychotherapy. He was one of the first to assert that therapists should demonstrate that their methods work; he even went so far as to tape therapy sessions at a time when the analytic relationship was considered almost sacred. Friends report that on his 80th birthday, Rogers announced that he would devote the rest of his life to working toward world peace, and to that end travelled to the Soviet Union in 1986 and led workshops in Hungary, Brazil, and South Africa.

5. The Future of Psychodynamic Psychotherapy In a special issue of Psychotherapy (1992, 29), clinicians from various theoretical orientations were asked to describe the changes they anticipated in their paradigm. Hans Strupp, writing on "The future of psychodynamic psychotherapy" (pp. 21-27), notes that psychodynamic thinking continues to be based in the notion of unconscious conflict, while paying greater attention to incorporating issues related to interpersonal experiences and emphasizing the client's subjective experience. Strupp identified the following trends in psychodynamic therapy: 1) Increasing attention to disturbances and arrests in infancy and early childhood (in contrast to Freud's emphasis on the Oedipal period).

2) Focus on treatment of personality disorders and "difficult" patients, as opposed to the "classical" neurotic conditions that Freud viewed as the primary focus of analysis.

3) Focus on the dyadic character of the therapeutic relationship, resulting in re-definition of the concepts of transference and countertransference.

4) Recognition of the importance of the patient-therapist relationship or alliance that is more collaborative and "human" than the detached "blank screen" of classical analysts.

5) Utilization of the advances made in neuroscience and pharmacotherapy, in combination with psychotherapy.

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7) Renewed emphasis on briefer forms of psychotherapy, largely in response to societal pressures.

8) Attempts to devise specific treatments for specific disorders, partly due to developments in the area of managed care and the investigative model of clinical trials for testing the efficacy of new drugs.

9) Development of treatment manuals.

10) Continued search for the mechanisms of change in psychotherapy.

Strupp sees these developments as "[infusing] psychodynamic psychotherapy with renewed vitality and vigor" (p. 25).

6. Briefest of the Brief: Single-Session Therapies Attention has recently been focused on an occurrence that in the past would have been considered a failure—dropout, and premature termination. The reality is that many therapeutic relationships last for just a single session. While certainly many of these therapeutic encounters are cut short for less than ideal reasons, clinicians are beginning to recognize the possible value in planning for and implementing single session therapy (Rosenbaum and Talmon, 1995; in “Brief Therapy and Managed Care: Readings for Contemporary Practice”). The following are some examples of heuristics that facilitate therapeutic change in a single session: -

Expect change. "Not only is change inevitable, but in fact it is already happening, though the client may not have noticed yet" (p. 115). Before coming in the door, the client has begun a change process. At the end of the session, the client should be left with the feeling that change will continue to occur.

-

View each encounter as a whole, complete in itself. This stance encourages the therapist to be open, creative, and ready to learn about the client.

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Don't rush or try to be brilliant. Sometimes what clients need is a dose of reassurance, catharsis, and problem solving. Most of the work is done by the client.

-

Emphasize abilities and strengths rather than pathology.

-

Recognize that life, not therapy, is the great teacher.

In this context, students may be encouraged to ponder whether they have had any defining conversations in their lives that changed things for them.

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7. HANDOUT Rational-Emotive Therapy and Education for Children Though he works almost exclusively with adults, Ellis has been interested for some years in extending RET to problems of childhood and especially to education. Recently, several reports have appeared that attempt to apply the principles of rational-emotive therapy to children and adolescents (Ellis and Bernard, 1983).

Although there is not yet enough evidence that children can understand and accept the tenets of RET or that the sometimes complex intellectual discussion with an RET therapist can be adapted to a level appropriate for a youngster, a number of preliminary studies suggest that the enterprise holds some promise.

In their review of RET, Haaga and Davison (1989) distinguish between RET applied to normal children and RET employed with clinically disordered children. With normals, workers have experimented with what is called Rational-Emotive Education. REE consists of classroom lectures, typically conducted by specially trained teachers that explain the general cognitive rationale that people's thoughts influence their feelings and behaviour. Students are taught that certain kinds of thoughts are irrational and that troublesome interpersonal situations like being teased can be made less so by altering one's way of thinking about them (one is reminded of the old childhood refrain about sticks and stones breaking bones but names not being able to harm one). The teacher conducts classroom discussions and tells stories to bring the concepts to life.

Specially designed cartoon materials and colouring books are also sometimes used. The overall rationale for REE is that it might be preventive in its effects, that is, that children given such education may later in life be spared some of the emotional distress that burdens many adults. In this respect REE can be considered a form of primary prevention within the framework of community psychology.

What are the results of studies of Rational-Emotive Education? Cangelosi, Gressard, and Mines (1980) showed that a twenty-four session "rational-thinking group" intervention improved self-concept among high school volunteer subjects more than did loosely structured group discussions or no treatment at all. Unfortunately there was no long-term follow-up to assess the possible preventive benefits of REE. In a study with sixth graders, Knaus and Bokor (1975) found superior reductions in test anxiety and increases in self-esteem from an REE program consisting of 85 ten to thirty-minute sessions as compared to a non-RETbased self-concept enhancement program and a no-treatment control. It is also encouraging that the REE sessions were conducted by regular classroom teachers after only three hours of training; this suggests excellent disseminability of the REE treatment. Other studies (e.g., Jasnow, 1982) support the belief that REE can have positive effects on nonclinical samples of children and adolescents, but as yet follow-up measures, to assess its preventive impact, are lacking.

REE has been applied as well to some clinical problems in children. Von Pohl (1982) employed REE in a residential and day treatment facility with six disturbed children, focusing mostly on "acting out" problems (extreme misbehaviour). The study suggested beneficial effects on behaviours such as talking out of turn, complaining, and being out of seat. A twenty-four session REE class improved levels of aspiration and anxiety in a group of learning disabled children in a study by Omizo, Cubberly, and Omizo (1985). Both studies, however, have methodological flaws that warrant considerable caution in viewing the results as strongly supportive for REE. Cangelosi, A. Gressard, C.F., & Mines, R.A. (1980). “The Effects of a Rational-Thinking Group on SelfConcepts in Adolescents”; The School Counselor, 27, 357-361.

Ellis, A. & Bernard, M.E. (1983). “An Overview of Rational-Emotive Approaches to the Problems of Childhood”. In A. Ellis & M.E. Bernard (Eds.) Rational-Emotive Approaches to the Problems of Childhood, New York: Plenum.

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Haaga, D.A. & Davison, G.C. (1989). “Outcome Studies of Rational-Emotive Therapy”, In M.E. Bernard & R. DiGiuseppe (Eds.), Inside Rational-Emotive Therapy, New York: Academic Press.

Jasnow, N. (1982). “Effects of Relaxation Training and Rational-Emotive Therapy on Anxiety Reduction in Sixth Grade Children”. Unpublished doctoral dissertation, Hofstra University.

Knaus, W. & Bokor, S. (1975). The Effect of Rational-Emotive Education Lessons on Anxiety and SelfConcept in Sixth Grade Students, Rational Living, 10, 7-10.

Omizo, M.M., Cubberly, W.E., & Omizo, S.A. (1985). “The Effects of Rational-Emotive Education Groups on Self-Concept and Locus of Control Among Learning Disabled Children”, The Exceptional Child, 32, 1319.

Von Pohl, R. (1982). “A Study to Assess the Effects of Rational-Emotive Therapy with a Selected Group of Emotionally Disturbed Children in Day and Residential Treatment”, Unpublished doctoral dissertation, University of Alabama.

8. Prescriptive Authority for Psychologists The Canadian Psychological Association formed a task force to evaluate whether the association should advocate for prescriptive authority. Information about the rationale and mandate of the task force can be found here http://www.cpa.ca/aboutcpa/committees/professionalaffairs/prescriptiveauthoritytaskforce/ where there is also a report to the committee’s 2010 final report, which is also available here: http://www.cpa.ca/docs/File/Task_Forces/CPA_RxPTaskForce_FinalReport_Dec2010_RevJ17.pdf Students will be interested in the pros, cons, and training issues associated with psychologists having prescriptive authority. Note that the task force concluded basic psychopharmacology should be a mandatory part of clinical training programs and required for accreditation. The task force did not, however, may any specific recommendation around whether the association should advocate for prescriptive privileges or not.

DISCUSSION STIMULATORS How Does a Therapist Differ From a Friend?

A good way to begin a discussion about psychotherapy is to ask students to consider how a therapist differs from a friend. You could write their suggestions on the board and add some of your own; this usually encourages students to air their views on the value of therapy. A possible list of differences: 1) Advantages of getting help from a therapist rather than from a friend: -

Expert opinion (a therapist presumably has expertise and training in helping people)

-

Knowledge of resources (a therapist will be able to refer you to appropriate resources which you may need)

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Understanding of serious problems (a therapist is trained to recognize and handle more serious problems)

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Confidentiality (a friend might disclose what you say, whereas a therapist is bound not to)

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Objectivity (a friend may be too intimately involved with you to have an objective perspective on your problem)

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Separation from personal life (you can disclose personal material to a therapist knowing that you will not be facing that person later at a social occasion)

2) Advantages of getting help from a friend rather than a therapist: -

Cost (a friend will not charge you!)

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Less stigma (sharing your problem with a friend does not expose you to the stigma of having "mental problems")

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Convenience (your friend may be more available, particularly on short notice)

-

Intimate knowledge (your friend may know you better, over a longer period of time and in more varied situations, and may also know the significant others in your life)

Pre-Test on Views Related to Psychotherapy The following survey could be passed out before beginning the class sessions on intervention, to give students an opportunity to consider their views related to psychotherapy. (You may want to have students fill out the same survey again at the end of the course, to see how their opinions have changed.)

Survey of Views Related to Psychotherapy 1. What is the purpose of therapy?

2. Who should select the goals of therapy: the client, the therapist, or both? Explain your answer.

3. Should therapists give specific advice to clients?

4. What is the most important feature of effective therapy?

5. Is therapy generally helpful? Why or why not?

Issues in the Use of Control Groups in Therapy Outcome Studies One area of considerable debate in psychotherapy outcome research concerns what percentage of patients improve over time without treatment. Eysenck suggested that the figure is about two out of three, the same as the number who improve in psychotherapy. Bergin agreed that two out of three people improve in psychotherapy, but he argued that only one out of three improve over time. Some of the problems that come up in attempting to address this question include: Is it ethical to put someone on a "waiting list" when they request treatment, in order to study the natural process of change? Will someone on a waiting list in fact wait or will they seek help from relatives, friends, or other professionals? If we were to find that therapy does not help more people than does the mere passage of time, but that therapy hastens the process of recovery, is this justification for the treatment? Should the appropriate control group be people who ask for © Wiley Canada

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therapy and are given a sham treatment designed to maximize their expectations of being helped ("placebo" control)? What are the ethics of this alternative? Exactly what is "improvement" in psychotherapy and how is it to be measured?

Note: Ethical concerns can be avoided by comparing experimental treatment to a control group who receives traditional treatment.

Exercise in Types of Therapeutic Communication To help students get a flavour for the actual interchange of therapy, it is helpful to give them a chance to talk with each other in purposeful ways and observe the different effects. One method is to conduct the following exercise using different "response modes" which are commonly used in therapy.

1) Questions: For the first exercise, have students sit in a circle (or several smaller circles if you have a large class).

A. Closed-ended questions. Have students go around the circle, asking the person next to them a closed-ended question (can be yes–no, specific, or multiple choice). That person replies, and then asks the next person a closed question. Continue this for a few minutes or until everyone has had a turn.

B. Open-ended questions. Go around the circle again, but this time, only open-ended questions may be asked. (Spend some time explaining what an open-ended question is and give a few examples yourself.)

Discuss students' experiences with this exercise, including the following questions: * What differences did you observe in the types of responses generated to the two types of questions?

(Closed-ended questions usually yield briefer answers and a narrower range of responses; open-ended questions allow for a broader range of responses, longer answers, and usually have a longer latency, as the responder needs more time to think.) * From the point of view of the answerer, how did it feel to be asked the two types of questions? (Most people find answering closed-ended questions more frustrating, as they are constricted in how they are allowed to answer.) * From the point of view of the questioner, how did it feel to be asked the two types of questions? (Most people find open-ended questions more difficult to think of.) * In the context of therapy, which type of question would be used for what purpose? (Closed-ended questions might be useful in assessment, where a large amount of information needs to be collected; openended are usually preferable for building rapport, encouraging the client to give his or her own perspective, etc.)

2) Silence.

A. "Silence is poison." For this exercise, the group has to keep talking for 5 minutes and avoid any silence at all costs. They should be encouraged to interrupt and overtalk. Briefly discuss their reactions afterward.

B. "Silence is golden." Now, have another 5-minute discussion, but this time there must be at least 5 seconds silence between speakers (advise them not to count out the seconds, though).

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less, and quieter students usually feel frustrated. "Golden" allows the talker more time and thought, and also provokes more anxiety. You might spend some time talking about how silence is used in psychotherapy.

3) Reflection. While empathic reflection is one of the hallmarks of Rogerian therapy, all therapists use reflections to some extent in order to build rapport and help the client to feel understood. For this exercise, first review what a reflection is and demonstrate some reflective statements. Then have the students' pair up.

One person talks about a topic of their choice, and the other person responds using only reflections (no questions!). After five minutes, the partners switch roles. Alternatively, you might have the students remain in a group; you make statements that a client might make, and ask the students to take turns reflecting.

Students might be encouraged to try using reflections when talking to friends outside of class; first warn them to pick a time when they are prepared to listen, since this way of responding encourages people to continue talking! You could then discuss their experiences in a later class.

4) Interpretation. When giving an interpretation, the therapist speaks from another frame of reference, pulls in related pieces of information, and makes connections for the client. You might pass out a case description and have the class come up with interpretations of the behaviour or personality described.

5) Advisement. Advice giving is a controversial aspect of therapy, and interesting to discuss with students.

In some forms of therapy, such as behavioural, "advice" might be common in the form of specific suggestions for behaviour change. In other forms of therapy, such as client centred, advice would never be given. You might try an exercise similar to that used for reflections, but this time only advice can be given.

Discuss with students what it feels like to be on the receiving end of advice, when advisement might be appropriate, etc.

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HANDOUT Identifying Irrational Beliefs Ellis originally presented eleven irrational beliefs that are thought to underlie emotional distress. More recently, Dryden (1999, Rational Emotive Behavior Therapy: A Training Manual, NY: Springer Publishing Company) proposes that these beliefs fall into four basic types listed below. After discussing students' views on these beliefs—whether they are in fact irrational, what specific beliefs might fit under each type, etc.— present them with some case material and have them identify the irrational beliefs underlying a person's statements, behaviour, or feelings.

For example, consider the following individuals: A college student insists that her boyfriend call her whenever he is leaving his room for any reason, so that in case she tries to call and he is not in, she will know where he is. She became angry and jealous when her boyfriend did not answer the phone and had not called to tell her he was going out; it turned out that he had been in the shower and had not hear the phone ring. What irrational belief(s) does this woman hold? An example may be "I must be loved." What irrational belief(s) does her boyfriend hold that keeps him in the relationship and makes him follow her restrictions?

Examples may include "I must be dependent on others" or "I must be loved."

Another college student found it very upsetting to get a B rather than an A in any course. He was so afraid of "failing" (which to him meant getting a B) that he continually dropped out of his classes before the term was finished. What irrational belief(s) does this student hold? An example may be "I must be perfect."

Irrational beliefs are irrational because they are rigid, not consistent with reality, illogical, or detrimental to an individual's pursuit of goals. Look at the four basic types of irrational beliefs listed below and see if you can determine what makes them irrational.

Musts: According to REBT, dogmatic musts or demands are the core of much psychological disturbance.

Musts are often based upon wise preferences—i.e. "I really want to do well on the Abnormal psychology final" is a sound, rational belief that becomes distorted into "because I really want to do well, I absolutely must."

Awfulizing: When we fail to get what we believe we must have, there is a tendency to believe that it is awful.

Although not getting what we want may be unpleasant, is it really awful? Not doing well on the Abnormal psychology final is certainly undesirable, and probably unpleasant, but is it truly awful? How bad is it compared to losing a loved one? To a nuclear disaster? By believing that consequences are worse than they actually are, we become more distressed than is necessary.

Low Frustration Tolerance: When we do not get what we believe we must have, there is a tendency to conclude that the situation is intolerable and that we can't stand it. According to REBT, a situation that is truly intolerable can result in only two outcomes (1) the person will disintegrate, or (2) the person will never be happy again if the dreaded event occurs. This takes the form of "If I don't do well on the Abnormal psychology final I won't be able to stand it." By believing that we cannot stand frustration, we avoid challenges. How many events can you recall that you were not able to stand? What were the consequences?

Self downing/Other downing: When we do not get what we believe we must have and we can attribute this ourselves or to someone else, there is a tendency to dislike not only the behaviour that interfered with out wants, but also the person responsible for that behaviour. By self/other downing, we are discouraged from focusing on effective ways of dealing with the problem. "If I don't do well on the final, I'm a miserable failure." or "If I don’t do well on the final, it is the professor’s (or the book’s) fault"

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Adapted from Dryden, W. (1999). Rational Emotive Behavior Therapy: A Training Manual. NY: Springer Publishing Company.

How important is the use of Evidence-Based Treatment?

Forman, Gaudiano, and Herbert (2016, Pragmatic recommendations to address challenges in disseminating evidence-based treatment guidelines, Canadian Psychology, 57, 160-171) discuss strategies to better support clinicians in selecting appropriate treatments for various disorders. These authors argue that treatment guidelines have had a limited impact on the care clients receive. Students could discuss whether it is important that clinicians use evidence-based treatments (after an introduction to the pros and cons of efficacy studies). How would they support clinicians in maintaining an evidence-based practice? What would they say to psychologists who trust their own clinical judgment over research, thus continuing to use a therapy that has not been supported by research?

Students' Choice After reading this chapter, the students have been exposed to a number of different approaches to therapy. If they were seeking therapy for themselves or for a friend, what type of therapist would they choose? What are their reasons for that choice?

SOME IDEAS FOR UTILIZING THE INTERNET

Emotionally Focused Therapy This is a truly Canadian therapy, developed by Les Greenberg and Susan Johnson, based, in part, on the theories of Canadian born Mary D. Salter Ainsworth. These sites should give a clear overview of the theory behind this system.

Susan Johnson's Home page www.iceeft.com/ A list of references www.iceeft.com/index.php/resources Students could be asked to get an overview of either the theory or methods of emotionally focused therapy and then contrast them with one other method with which they are familiar. This is a good opportunity to focus on the relationship between theory and practice.

Canadian Psychological Association http://www.cpa.ca/ The Canadian Psychological Association website has many resources that students may be interested in as well as a section entirely devoted to resources for students: © Wiley Canada

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http://www.cpa.ca/students/ Students will find lists of potential careers for psychology majors, accredited clinical psychology programs in Canada, and links for provincial and territorial licensing requirements. Student affiliate memberships to CPA are relatively inexpensive (currently $75/year) and provide discounted rates for the annual convention.

APA Division 12 Society of Clinical Psychology www.apa.org/divisions/div12/homepage.html This site provides a clear overview of the field of clinical psychology and the various sub-fields within it.

Students can have a look around the Division 12 site and consider the goals Larry Beutlers set for the task force. What can students find about what is generally considered to be effective practice in psychotherapy across a variety of schools and methods?

The Scientific Review of Mental Health Practice www.srmhp.org/ “The Scientific Review of Mental Health Practice (SRMHP) is the only peer-reviewed journal devoted exclusively to distinguishing scientifically-supported claims from scientifically-unsupported claims in clinical psychology, psychiatry, social work, and allied disciplines. It applies the best tools of science and reason to objectively evaluate novel, controversial, and untested mental health claims. Our purview includes claims regarding the efficacy of psychotherapies and self-enhancement methods, the validity of assessment instruments, and the scientific evidence for psychiatric diagnoses.”

This journal and the scientists who publish in it are creating quite a debate in clinical psychology.

By following the link, students will find that many of the examples are available with no subscription.

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CHAPTER 18 LEGAL AND ETHICAL ISSUES

CHAPTER SYNOPSIS The legal and mental health systems collaborate continually, though often subtly, to deny a substantial proportion of our population their basic civil rights. The mentally ill who have broken the law can be committed to a prison hospital through criminal commitment proceedings. Civil commitment is a set of procedures by which a person who has not broken a law can be incarcerated in a mental hospital.

Criminal Commitment The mental condition of a person committing a crime has been taken into account in judging culpability for hundreds of years, and in modern times mental health professionals assist judges in their decisions about how to handle mentally ill criminals. Canadian law has looked to two sources for historical precedent regarding the idea that under certain circumstances an individual, due to some alteration in their mental capacities beyond their control, can neither control themselves nor comprehend the wrongfulness of their actions. These two sources are English common law and Napoleonic law. In the former the concepts of mens rea or "guilty mind" and "No crime without an evil intent" were present in law by the early Middle Ages and the idea that mental illness or insanity could prevent them by the 1200s.

The Not Criminally Responsible Defence The defence of not criminally responsible is the legal argument that a defendant should not be held responsible for an illegal act if a mental illness (mental disorder) interferes with the accused's ability to understand the wrongfulness of their action or renders them incapable of controlling their actions. In Canada the insanity defence is seldom used and, when used, seldom successful. Individuals who are found "not criminally responsible" are almost always detained in mental health facilities for long periods. The Canadian Charter of Rights and Freedoms does apply to individuals under these circumstances and the government must provide evidence that an individual is still a danger to society if they attempt to keep them in a mental health facility.

Several landmark Canadian cases have shaped the nature of this defence. All countries that have evolved legal concepts from British common law refer to the famous Rex vs. M'Naghten of 1843. This case established the basis for the modern "insanity defence" and set the precedent of treating individuals differently if something about their condition at the time of the offence made it impossible for them to understand the quality or nature of their actions. Regina vs. Swain 1991 established certain rights for individuals found not guilty by reason of insanity. It lead to bill C-30 which incorporated the Canadian Charter of Rights into law, established provincial review boards to balance the rights of individuals found not guilty but mentally ill vs. the danger posed to the community and even changed terminology to "not criminally responsible." Winko vs. BC put the burden of proof on the government such that an individual found not criminally responsible may be incarcerated in a mental health facility only so long as proof exists that they are still a potential danger to society.

Instructor’s Manual to accompany Abnormal Psychology, Sixth Canadian Edition by Flett et al.

Focus on Discovery 18.1: The Stigma of Mental Illness and Employment Discrimination Several recent legal decisions in Canada have focused attention on the issue of civil rights for individuals diagnosed with a mental illness. The Canadian Human Rights Commission reports many cases each year.

The Canadian Mental Health Association is active in promoting the civil rights of people diagnosed with mental illness.

Fitness to Stand Trial The insanity defence concerns the accused's mental state at the time of the crime. A second issue, whether the person is competent to stand trial, concerns the defendant's mental condition at the time of his or her trial. Far greater numbers of people are committed to prison hospitals after being judged incompetent to stand trial than are found not guilty by reason of insanity.

When judged incompetent, bail is denied, a commitment for a pre-trial evaluation is invoked, and, in some cases, very long periods can elapse before the individual is judged competent. Some have argued that even dramatically psychotic people should be allowed to stand trial, since the disadvantage of the confusion may be less than the disadvantage of a lengthy period of commitment without trial. Focus 18.1 presents the challenge posed to the courts by dissociative identity disorder as an insanity defence.

Canadian Perspectives 18.1: Louis Riel and the Issue of Fitness to Stand Trial A case could be made that Louis Riel was either "not criminally responsible" or "unfit to stand trial" by contemporary standards.

Civil Commitment Civil commitment affects far greater numbers of people than criminal commitment. In all provinces and territories individuals can be committed to a mental hospital against their will if they are judged to be suffering from a mental disorder and a danger to self or others. Civil commitment is governed by the Canadian Mental Health Act, which is similar, but with slightly different provisions, in each province and territory. There are differences in the definition of mental disorder, and what constitutes danger to self and others. Table 18.2 summarizes the differences across the provinces and territories.

Community Commitment: Community Treatment Orders Community treatment orders were introduced in Saskatchewan in 1995 and they are now used throughout Canada, except in New Brunswick and the three territories. In general, these are a set of conditions that an individual must adhere to as a condition of release from a mental health facility. They are most often applied to people with schizophrenia. Several groups suggest that these provisions are an infringement of rights guaranteed under the Charter of Rights and Freedoms as these individuals have not been found guilty of a crime.

Preventive Detention and Problems in Risk Assessment It is frequently believed that the mentally ill are violent; this belief is largely unfounded. However, mental illness combined with substance abuse can increase the probability of violence. In the absence of substance abuse, the mentally ill are no more violent than the general population.

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Studies concerning the prediction of violence have generally found that mental health professionals are poor at making a judgement about who will be violent and who will not. One approach which has been shown to increase the accuracy in predicting violence is the use of actuarial models of prediction. There are also a number of conditions under which prediction of violence is improved: (1) if a person was repeatedly violent in the past; (2) if the person’s past includes a single but very serious act – repeated violence can be expected if the condition under which the original acts occurred have not changed; and (3) if violence appears imminent – the individual is pointing a loaded gun in the direction of other people.

Canadian Contributions 18.1: Marnie Rice and Actuarial Risk Assessment Marnie Rice and her colleagues at the Oak Ridge Mental Health Centre in Penetanguishene, Ontario have developed the Violence Risk Appraisal Guide (VRAG) which is a series of measures and observations designed to predict recidivism rates for offenders eligible for parole. The two best predictors are the Psychopathy Checklist designed by Robert Hare of UBC, and a measure of elementary school maladjustment.

Focus on Discovery 18.2: The Tarasoff Case—The Duty to Warn and to Protect There was some indication that university student, Prosenjit Poddar might harm Tatianna Tarasoff. – a woman for whom he had an unrequited romantic interest. Poddar confided in a psychologist that he intended to buy a gun. The psychologist notified the campus police that Poddar might pose a serious danger to Tarasoff. Later Poddar killed Tarasoff. A court determined that although the psychologist had correctly notified the police, he also had a duty to warn Tarasoff – something that he did not do. The Tarasoff decision has generated considerable debate with respect duty and responsibility of mental health.

Trends toward Greater Protection Recent trends have established more safeguards in commitment proceedings—the trial must be timely, evidence must be "clear and convincing," and the danger posed must be "imminent." Court rulings have established that the "least restrictive alternative" to freedom is to be provided when treating disturbed people. A right to treatment has also been established to insure that people cannot be committed involuntarily without providing minimal standards of care. Further, the patient's status must be reviewed periodically to determine if the grounds for commitment still exist. Involuntary patients have the right to refuse certain treatments, but physicians can override this refusal in emergency situations. Subtle pressures influence even voluntary patients to accept the treatment recommendations of professional staff, and value judgements necessarily arise in treatment decisions. Paul and Lentz have proposed that patients should not be allowed to refuse treatments that have minimal goals, such as self-care, but should be able to refuse treatments with optimal goals designed to enhance adequate functioning.

A new approach, advance directives, helps to protect the patient's rights by legalizing their wishes as to how they wish to be treated in the event they are no longer competent.

Canadian Perspective 18.2: “A Beautiful Mind in Canada?”: Scott Starson and The Right to Refuse Treatment In some respects Scott Starson is similar to John Nash, who was the subject of a book entitled "A Beautiful Mind" by Sylvia Nasar and a subsequent movie starring Russell Crow. Starson, who prefers being called Professor Starson has authored scientific articles (in spite of having no formal training in physics and not being a professor). Starson was diagnosed as having schizoaffective disorder. After making death threats to colleagues, Starson was found not criminally responsible on account of a mental disorder and has been detained in psychiatric hospitals in Penetanguishene and Ottawa. Starson has fought for his right to refuse treatment, and finally won at the Supreme Court level. Treatment can still be forced on patients who are shown to lack the capacity to make such a decision. © Wiley Canada

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Deinstitutionalization, Civil Liberties, and Mental Health The policy of deinstitutionalization, fueled by the goal of treating mentally ill patients in the community rather than in hospitals, has led to a great reduction in the number of individuals institutionalized in psychiatric hospitals. Unfortunately, community facilities are sometimes unprepared to handle patients' needs. Many of the discharged patients are homeless and may not receive any social services or financial assistance. Further, many of those discharged are apparently ending up in jails, nursing homes, and other institutions ill-suited to meet their needs.

Canadian Perspective 18.3: Solutions for Mentally Ill People in Canada Canadian investigative journalists have played a major role in suggesting changes that need to be made in Canada with respect care for the mentally ill. These changes include; modifications to the Mental Health Act, increases in supportive housing, expanded home care, community mental health centres, the development of risk assessment tools, etc.

Ethical Dilemmas in Therapy and Research Some of the issues facing mental health professions include ethical considerations in research and greater attention to the concept of informed consent.

Ethical Restraints on Research The training of scientists equips them to pose interesting and important question. However, these scientists are not always specifically trained to determine the ethical constraints involved in answering these questions. Those participating in scientific experiments must be protected from harm, risk, humiliation and invasion of privacy. In Canada, medical research is governed by four documents: The Nuremberg Code, the Declaration of Helsinki, the Medical Research Council of Canada’s Guidelines in Research Involving Human Subject, and the Tri-Council Working Group’s Ethical Conduct for Research Involving Humans.

Today, universities and hospitals have Ethics Committees (formed by members not involved in the research project) who review all research proposals.

Informed Consent The concept of informed consent requires investigators to provide people with enough information to allow them to decide whether they want to accept any risks that may be inherent in their participation. Participants must be of a legal age to give consent. There must be no deception included in the experimental design and participants must be able to withdraw from the experiment at any time.

Confidentiality and privileged communication Confidentiality means that nothing will be revealed to a third party except other health professionals who are actively involved in providing treatment. Privileged communication means that communication between the mental health professional and the patient is protected by law. There are, however, several limits to privileged communication (for one example see Focus on Discovery 18.2).

Who is the client and patient?

Although it should be, it is not always clear who is the client and who is the patient. For example, a psychologist who is given a court mandate to assess an individual’s competency to stand trial has a responsibility not only to the patient but also to the state. In the practice of clinical psychology, there are a

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number of potential situations in which the mental health professional assesses or treats a patient at the request of a client (not the patient) who pays.

Choice of Goals Ideally, it is the patient who sets the goals of therapy. However, it is evident that in a variety of settings the goals of therapy may go against the wishes of the client. Some examples of these setting would be prisons, schools and mental health hospitals.

STUDENTS SHOULD KNOW Key Points 1.

Criminal commitment is the process by which mentally ill individuals who have broken the law can be committed to a prison psychiatric hospital.

2.

The insanity defence refers to the inability of the individual to distinguish right from wrong. Several Canadian court rulings have further delineated the concept of "not criminally responsible."

3.

Section 16 of the Criminal Code of Canada spells out the conditions that must be met in order for an individual to be found "not criminally responsible" (not guilty) of a crime. Basically the individual must be suffering from a mental disorder that either makes it impossible for them to understand the meaning of their act or incapable of controlling their actions.

4.

A mentally disturbed individual can be transferred to a mental health facility if they are judged incompetent to stand trial.

5.

Civil commitment is a set of procedures by which a person who has not broken the law can be involuntarily detained in a mental hospital; commitment can occur if a person is mentally ill and judged to be a danger to himself or others. The rules and procedures for this are slightly different for each province or territory and are covered by the Canadian Mental Health Act.

6.

A number of recent legal developments have increased protections for those people committed through criminal and civil proceedings. These include care in the least restrictive setting, the right to treatment, and the right to refuse certain treatments.

7.

Regulations have been formulated to protect the rights of subjects in psychological research. Subjects must be informed of the risks involved in the research and be free to withdraw at any time.

8.

Although the prediction of dangerousness is a difficult task for mental health professionals, actuarial models of prediction can be of considerable use.

9.

The ethical codes of various mental health professions dictate that, with certain exceptions, the communication between patient and therapist must be kept confidential. A privileged communication refers to a confidential communication protected by statutory law.

10.

Both the right to treatment and the right to refuse treatment have generated much debate.

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11.

Therapists face additional ethical dilemmas in determining the client to whom they owe their allegiances, what the goals for treatment should be, and what techniques should be used to achieve those goals.

Key Terms actuarial prediction (p. 575) civil commitment (p. 563) community commitment (p. 571) community treatment order (p. 571) confidentiality (p. 589) criminal commitment (p. 563) informed consent (p. 588)

insanity defence (p. 563) M’Naghten Rules (p. 566) neurolaw (p. 567) not criminally responsible (p. 563) prior capable wish (p. 582) privileged communication (p. 578)

New Names Daniel M'Naghten, Tarasoff case

LECTURE LAUNCHERS 1. "Not criminally responsible" Section 16 of the Criminal Code of Canada and some recent court decisions defining the types of mental disorders that can invoke section 16 make for an interesting lecture.

Canadian Supreme Court decisions may be found, and searched, here: www.scc-csc.gc.ca/ Judgements are found here: http://scc-csc.lexum.com/scc-csc/en/nav.do If, for example, you just search decisions for “section 16” (note the quotation marks) you will find many relevant decisions. Another useful search is “criminally responsible”.

Having students read decisions and see the logic of the application of section 16 can be quite enlightening for them.

2. Diminished Responsibility When the insanity defence is used, the facts of the crime are generally not in dispute. It is acknowledged that the defendant committed an act against the law, so what is at issue is whether the defendant should be held responsible for his or her behaviour. The insanity plea pits two extreme views of the defendant in opposition: either he is sane, hence blameworthy and guilty, or insane, and innocent. Some scholars and lawyers have tried to chart a middle course by allowing that certain circumstances may mitigate

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blameworthiness without altogether eliminating guilt. What this means operationally is that the charge and sentence for a given act would vary according to circumstances. What circumstances is a matter of debate.

The least radical and best-known version of what is known as the doctrine of diminished responsibility takes into account the context of the crime. Common examples of such mitigating circumstances are those where the person acted in self-defence, in response to provocation, in the heat of passion, or while intoxicated. As formulated in the model penal code, the issue is whether the act was "committed under the influence of an extreme mental or emotional disturbance for which there is reasonable excuse." Whether there is reasonable excuse for the disturbance must be judged by how a normal person "in the [defendant's] situation under the circumstances as he believed them to be" would have felt. In essence, the relevant factors are situation, as opposed to person variables; what matters is not how the defendant actually felt, but how the situation would have made most people feel. It is common for such factors to influence both the charge and the sentence for an illegal act.

A second, more radical version of diminished responsibility takes into account person variables which relate to the "capacity of the accused to form the specific intent essential to constitute a crime" (People v. Wells, cited in Stone, 1975, Mental health and law: A system in transition. Rockville, Md.: National Institute of Mental Health). For instance, first degree murder may be defined as a deliberate, premeditated killing; if it could be shown that the defendant lacked the intellectual capacity to plan the murder, or was so lacking in impulse control that premeditation was very unlikely, how others would respond to the circumstances of the crime is less important than how the defendant, by virtue of his or her capacities, could respond to it.

The third version of diminished responsibility proposes that the crime be judged in the complete context of the defendant's life, person, and circumstances. Responsibility would be reduced if the person was predisposed by upbringing in a deviant family or subculture to commit criminal acts, or if the person was generally unable to control his behaviour or recognize the wrongfulness of his acts, or if the situation was a provocative one, etc. This highly flexible standard is not currently in use. If pursued to its logical extreme it seems to present the dilemma of why, given a determinist position, should anyone be held blameworthy for their acts? This may explain why the courts shied away from the notion of diminished responsibility. As Stone notes, the free will premise of the legal system is most viable if the exceptions to the rule are clearly defined.

3. Joint Statement of the American Medical Association and the American Psychiatric Association Regarding the Insanity Defence Below are excerpts from a joint statement on the insanity defence adopted by the American Medical Association and the American Psychiatric Association in April 1985. As is made clear in the first paragraph, the two organizations adopted differing policies in regard to the defence, thus necessitating the statement.

The complete statement and a commentary on it can be found in American Journal of Psychiatry, 1985, 142, 1135-1136.

"In the past two years the American Medical Association and the American Psychiatric Association have adopted position statements on the insanity defence. The APA took the position that the defence should be maintained but restricted to cognitive (as distinguished from volitional) matters that affect a defendant's behaviour. The AMA, by contrast, urged that the defence be abolished and that the issue of a defendant's mental status be relevant only to the issue of criminal intent, which is that element of all major crimes referred to in legal terms of mens rea, and to the questions of appropriate disposition following trial. This difference in approach has led to considerable discussion and constructive debate within and outside of both associations . . ."

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" . . . It is the firm belief of the representatives of both the AMA and the APA who met to discuss these matters that further information is likely to lead to a consensus on whether there should be an insanity defence and, if so, how it should be structured."

"This belief is buttressed by the fact that the motivating concern and basic judgements of both associations in this area essentially are the same. Both start from the proposition that, as a matter of sound public policy, the criminal justice system must seek to assure a reasonable balance between the public's legitimate interest in protection from potentially violent offenders, and the mentally disordered defendant's entitlement to fair and humane treatment. Thus, both associations agree that mental impairment should exonerate criminal behaviour in only a narrow class of cases, and that defendants so exculpated should not suffer punishment or hardship as a result. Beyond that paramount concern, there are two other matters directly affected by the insanity defence that are of special importance to the medical profession: 1) assurance of proper medical and psychiatric treatment to disordered criminal offenders; and 2) establishment of an appropriate role for physicians who testify in legal proceedings."

"The first concern has been an active one for both the AMA and the APA. There are many criminal offenders who, whether or not they successfully plead the insanity defence, are simply not receiving adequate psychiatric treatment . . . While there is no established correlation between mental illness and crime, the persistence of mental illness in a convicted offender can only impede the effective reduction of future criminal behaviour by that offender."

"There is also a shared concern on the part of the AMA and the APA over the role of medical testimony in the legal system. While this concern is by no means limited to the use of psychiatric testimony in criminal trials, that use is nevertheless one of high public visibility. In general, the adversary system does not facilitate lay comprehension of reasoned medical judgement. To the contrary, the adversary system, by its nature, tends to polarize expressions of medical opinion and to highlight the differences even when a large degree of agreement is present . . . It is especially important that the law not seek to mask basic policy decisions in the guise of medical expertise. To be sure, medical knowledge is often critical to effective policy analysis, but the need for clear lines as to where medical expertise ends and value judgements begin is essential."

"This admonition is equally applicable to physicians who are called upon or choose to testify. While it is perhaps understandable that some physicians may become caught up in the combat of litigation, it is necessary that they not stretch their medical opinions beyond legitimate, established scientific and clinical knowledge. When physicians do overreach, they may make it easier for the side that they support in a case, but they bring disrepute on themselves and their profession. Society will not, and in our view should not, tolerate the misuse of medical expertise to serve unrelated legal ends.”

4. Ethical Abuses in Private Psychiatric Hospitals Charges of serious ethical abuses, driven by concerns for falling profits, have recently been made against several large chains of for-profit mental hospitals in the United States (Moffat, S., February 2, 1992.

“Healing patients, or profits?” Los Angeles Times, A1, A24, A25). A woman, feeling very depressed one night, called an 800 number shown on a television ad offering free counselling. Given an address to go to, she arrived at a private psychiatric hospital where, after it was determined that her insurance coverage would pay for psychiatric hospitalization, she was dragged away by some attendants and committed against her will—without even seeing a mental health professional. It took frenzied phone calls to her lawyer to get her released the following day, but not until she had spent a night against her will on a locked ward, for which she received a bill for $1700 (which included a fee for a doctor she did not see)!

Other hustles are made to the parents of teenagers who are untidy, get drunk from time to time, and are disobedient. Some ads portray such behaviours as signs of serious mental illness and encourage parents © Wiley Canada

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to commit their adolescents for treatment. Highly skilled salespeople working for some private hospitals sell inpatient stays to potential consumers—all of whom have private insurance. A parent in upstate New York saw an ad with an 800 number encouraging worried parents to call. He phoned because he wanted to get his children away from stormy divorce proceedings and was told, on the basis of a short phone conversation with a salesperson, that his children could be enrolled in a "youth program" in California, which would include such things as trips to Disneyland and shopping malls. They would even buy plane tickets for his two children. Unknown to him or to his youngsters until they arrived in California, he had agreed to commit them to a mental hospital. It took him two weeks to get them released, and he claimed that during that time, they were not even seen by a professional for evaluation.

These horror stories are different from the accounts of what Pinel saw in La Bicetre, different from the snake pit portrayed in the movie Amadeus, and different still from Ken Kesey's One Flew Over the Cuckoo's Nest. A key dissimilarity is that the earlier abuses took place in public hospitals, in which financial expense to either the patient or family was not an issue. What is happening in some private hospitals today is that empty beds have to be filled to make ends meet and that most private insurance carriers cover inpatient treatment—sometimes more completely than less expensive outpatient care. At stake is an $8 billion dollar a year industry, where the pursuit of available yet shrinking private insurance dollars leads some hospitals not only to egregious abuses like the above but also to more subtle perversions like making diagnoses on the basis of what insurance will cover rather than on informed professional judgement. Other abuses include providing unnecessary treatments and extending hospital stays longer than actually needed. All this is happening at a time when tens of thousands of uninsured individuals, many of them living on the streets, do not have access to proper care.

5. Predicting Violence with the Psychopathy Checklist The Psychopathy Checklist, discussed in Chapter 13 has recently shown promise as a measure for predicting violence. Salekkin, Rogers, and Sewell (1996; Clinical Psychology: Science and Practice, 3, 203-215) conducted a meta-analysis of 18 studies using the Hare Psychopathy Checklist. The meta-analysis revealed that 72% of individuals classified as likely offenders went on to commit violent crimes; 59% of those judged unlikely to offend remained nonviolent. However, as with other methods for predicting violence, a substantial proportion of subjects (41%) were wrongly classified as violent.

In a study of 81 paroled offenders followed for an average of 30 months, Serin (1996; Law and Human Behavior, 20, 207-217) found that the Psychopathy Checklist-Revised was a better predictor of violent recidivism than predictions based on a history of violent crime or three actuarial risk scales. The PCL-R predicted violent recidivism 50% better than chance classification.

6. Who is Likely to Molest Again?

A published study of 251 sex offenders followed for 25 years yielded important information about the characteristics of those child molesters who are most likely to reoffend (Prentky, Knight, and Lee, 1997.

Journal of Consulting and Clinical Psychology, 65, 141-149). The following variables, based on archival data, predicted which molesters committed a sexual offence again: - a strong sexual preoccupation with children, both in fantasy and in the amount of time they spent around them - prior sexual offences - unusual sexual behaviours such as fetishism, exhibitionism, and transvestism.

7. Ethical Issues in Psychotherapy Research Conducting research on psychotherapy raises difficult ethical issues that differ from those issues common to all research with human subjects. In a thought-provoking article, Imber and colleagues (1986, American Psychologist, 41, 137-146) discusses these issues in the context of the NIMH Treatment of Depression © Wiley Canada

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Collaborative Research Program's handling of ethical dilemmas. The NIMH depression study is described in Chapter 10 of the text. Because students will be familiar with the project, they might be asked first to identify ethical issues which may arise in the project and ways to resolve those issues, before the following material from the Imber et al. article is presented.

In determining whether a patient was admitted to or withdrawn from the study, the research investigator, rather than the patient's therapist, had ultimate authority in this study. Does this policy provide the best care to the patient? The study addressed this issue by basing guidelines for eligibility and withdrawal on clinical care considerations as well as on research purposes, weighing the patient's preference and therapist's recommendations heavily, and preserving patients' right to drop out unilaterally.

In a controlled trial such as this one, treatment regimens were standardized rather than based on the flexible clinical judgement that is used more often in non-research psychotherapy settings. This issue was addressed by standardizing broad guidelines and suggestions for treatment rather than rigid directives.

Treatment assignments were made randomly, rather than being based on patient preferences or evaluation findings about the patient. Do patients adequately understand the random nature of treatment assignment, and feel they would have access to alternative treatment if they refused the research protocol?

To address this issue, the NIMH project instructed researchers not to exert pressure on potential candidates, to provide adequate referrals if the research protocol was refused, and to allow patients to drop out if they preferred an alternative treatment to the one they were assigned (which 10% of patients did).

One of the treatment conditions in this study was a pill-placebo control. Should patients be assigned to an inactive treatment when effective interventions are available? Safeguards implemented to address this problem included screening out subjects who were imminently suicidal, providing regular contact with a pharmacotherapist, periodic independent evaluations, and a clear mechanism for patient withdrawal and referral to appropriate treatment.

Long delays may occur (in this study about 3 weeks) between the time a potential subject requests treatment, and the time treatment actually begins, due to screening procedures and scheduling problems. Are patients in acute distress put at unnecessary risk by this waiting period? In this study, the waiting period was used for several clinically relevant tasks, such as evaluating the patient condition and "washing-out" drugs which would interact adversely with imipramine. When immediate treatment was deemed compelling, patients were withdrawn from the study and treatment was arranged elsewhere.

Following treatment, informing patients of the treatment condition they were in and referring for further care where indicated, while good ethical practice, may confound the results of the follow-up assessments. To balance research purposes with patient care, this study referred patients who had not improved for further treatment, but asked those who had improved to put off further treatment; the latter were seen later for an appointment to re-evaluate their request for a referral. For ethical reasons, patients on pill-placebo were told of their treatment status at termination, despite the fact that this might contaminate their follow-up evaluations.

In any psychotherapy study, some patients will withdraw from treatment, despite considerable energy having been expended in their care. Will the resulting frustration for researchers preclude their following up these patients who may remain at risk? In the NIMH study, careful efforts were made to maintain contact with dropouts for the duration of the study and refer them for appropriate treatment.

DISCUSSION STIMULATORS Should Right to Die Legislation Apply to People with Mental Disorders?

In June, 2016, legislation permitting medically assisted suicide became law. Although many individuals have already taken advantage of the new law, people with severe and treatment resistant mental disorders are not entitled to physician-assisted suicide. Already, many individuals with mental disorders have spoken out about this inequity, and a constitutional challenge, spearheaded by the British Columbia Civil Liberties © Wiley Canada

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Association, is in the works. One individual who is fighting for access to medically assisted dying is 26year-old Adam Maier-Clayton of Ontario. The idea of a physically healthy young man fighting for the right to medically assisted suicide should make the issue quite complex for students, and there will likely be strong arguments on both sides.

Community Protection vs. Civil Rights: Megan’s Law Named "Megan’s Law" after the 7-year-old New Jersey girl who was sexually assaulted and murdered, community notification laws require child molesters on probation to register and be made known to the communities they live in. The idea is to protect people from neighbours who are known sex offenders.

Critics contend that the laws don't prevent a convicted child molester from going to another community to offend again; in fact, that is what many molesters do. Further, ex-convicts who are trying to make a good faith effort at rehabilitation are stigmatized and ostracized.

Ethics Role-Play: Confidentiality This role-play exercise will help students grapple with the ethical issues involved in providing mental health services. There are four roles to be assigned; the rest of the class can observe the debate and give their opinions about the issues afterward. The following information might be photocopied and distributed to the class before asking for volunteers for the parts.

When the role-play is complete, you may tell students that the law in many U.S. states now allows minors to seek therapy for certain reasons (including drug use and sexuality/pregnancy decisions) without parental consent.

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HANDOUT Ethics Role-Play A walk-in clinic for teenagers within a large children's hospital in Edmonton has been providing counselling for adolescents who walk in on their own asking for help with various medical and psychological problems.

Some of these adolescents are "street children" who do not have contact with their parents; others are adolescents who live at home but, for various reasons, choose to seek therapy on their own. The clinic has had a policy of keeping information about such issues as drug use and teenage sexual behaviour confidential; they assure their clients that discussions about these issues will not be disclosed to parents or juvenile justice personnel. Recently, some parents and juvenile justice system workers (probation officers) have criticized the clinic for keeping this information confidential. You are meeting to discuss the issues and determine whether the clinic should be limiting their assurances of confidentiality to their clients.

ROLES: Dr. Clout: You are a psychologist who runs the clinic in question. You strongly believe that therapy can only be effective if the client knows that everything she/he says during therapy will be kept in the strictest of confidence. Without this guarantee, the client will be unable to trust the therapist and unable to disclose his/her innermost fears and secrets. Furthermore, you are certain that most of the clients the clinic serves would not come to the clinic if they knew that their illicit behaviour would be reported to their parents or to the probation officers. Therefore, if confidentiality was limited, the important services being provided by the clinic (such as information about safe sex, drug abuse counselling, referrals to human service resources) would not reach the community most in need.

Mr./Ms. Wright: You are a parent working for a parents rights group, and are also involved in a Tough Love program for keeping kids off drugs. You represent a group of parents who are seriously concerned about the clinic's policy of keeping information confidential which could harm children. Recently, an adolescent girl who had been seen at the clinic was found dead of a drug overdose in Edmonton. Her parents feel that if the clinic had notified them of her drug use, they might have been able to prevent this tragedy. Furthermore, you feel that since the clients of the clinic are minors, their parents should be asked for consent before they are offered treatment of any kind.

Mr./Ms. Strict: You are a juvenile justice worker who is frustrated by your inability to significantly limit the gang activity and drug use in the community. You feel that the clinic, which has contact with many of the adolescents you are concerned about controlling, should be working with the juvenile justice system to help monitor and limit drug use.

Mr./Ms. Young: You are a teenager who has been a client at the clinic and have volunteered to offer your opinion about this matter. You have consulted with other clients at the centre in order to better represent their position. You feel strongly that the clinic should be allowed to keep information about drug use and sexual behaviour confidential. In fact, you are certain that most if not all of the adolescents who use the clinic would never set foot in the door again if their secrets were going to be exposed. In fact, since this inquiry has begun, the number of clients using the clinic has dropped dramatically.

Confidentiality and HIV Diagnosis In Focus on Discovery 18.2, a recent issue regarding confidentiality vs. Tarasoff duties has arisen in the area of HIV diagnosis. Present the following vignette for class discussion: You are a counsellor working in an HIV/AIDS clinic. The clinic offers confidential testing for HIV, and your job is to present the results of HIV tests to clients and discuss their reactions to the diagnosis. One day, © Wiley Canada

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a couple comes to the clinic to hear the results of their HIV tests. You are to meet with the man to go over his results, and another counsellor will be meeting with his girlfriend.

It turns out that the man (your client) is HIV positive. When you meet with the man and disclose his diagnosis, you discuss the modes of transmission of the virus and the importance of safe sex. You also encourage him to disclose the diagnosis to any former and current sexual partners, and he assures you that he will do so.

As the man leaves your office, you observe him greeting his girlfriend in the waiting room. His girlfriend hugs him and says, "Thank God, I'm negative." Your client responds, "That's great; so am I!" They walk off arm in arm.

Discussion could involve what the counsellor should do, and whether the man's confidentiality is more important than the duty to warn the girlfriend that she may be in danger. Most of your class will undoubtedly identify with the girlfriend and feel that the counsellor should break confidentiality. To counter this stance, the following arguments might be offered: * If people are not guaranteed confidentiality, they will not get tested for HIV, and this will increase the risk of transmission and delay treatment. * Given that information about safe sex is widely available, people involved in sexual relationships have a responsibility to protect themselves regardless of their knowledge of a person's HIV status.

Ethics in Marital Therapy The text raises the important question: Who is the client in marital therapy? What if one partner's goals are at odds with those of the other? Margolin (1982, American Psychologist, 37, 788-801) raises several other ethical issues related to marital therapy that might be discussed in class. One of particular interest involves confidentiality. Imagine that Mr. and Mrs. Crack are being seen in marital therapy, and Mr. Crack requests an individual appointment with the therapist. During this session, he discloses that he is having an affair, and asks the therapist to keep this information confidential. What should the therapist do? Should the information be disclosed? Should the therapist have granted an individual interview? Should the therapist have implied that she would keep information from the spouse? These questions are hotly debated by marital therapists, who reach very different conclusions. Some therapists will not see the spouses individually. Others will consent to individual appointments, but inform the couple in advance that information disclosed there might not be kept confidential (thus giving the client the chance to decide whether to share the information or not). Other therapists agree to keep disclosures confidential, and may even encourage the sharing of "secrets." To make the issue even more complicated, what if marital therapy is initiated after a client has been seen in individual therapy? Information obtained during the earlier individual sessions cannot ethically be disclosed to the spouse without the client's permission. If the client gives permission for confidentiality to be broken, does she actually remember all that she has disclosed individually? Would she have responded differently if she knew before the fact that the information might be disclosed to her spouse? While a consensus has not been reached on these issues, an overriding ethical principle is to inform clients of the limits of confidentiality, so that they know before disclosing information whether or not the therapist has promised to keep it private.

Ethical Dilemmas: Should vs. Would Not surprisingly, mental health practitioners report that they have more rigorous standards for what they should do in ethical situations than for what they feel they would do in handling a particular dilemma (Smith, McGuire, Abbott, and Blau, 1991. Professional Psychology: Research and Practice, 22, 235-239).

While clinicians apparently use codified ethical and legal guidelines in deciding what they should do, they cite other factors, including personal values (e.g., it feels right; upholding personal morals/standards) and practical considerations (e.g., fear of verbal/social reprisal by supervisor, colleague, or client; financial need) © Wiley Canada

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when deciding what they would do. To understand the complex issues involved, students might be asked to consider what they "should" and "would" do in handling the following ethical dilemmas.

Ethical Dilemmas Child Abuse? To Report or Not to Report You are seeing a 9-year-old girl, "Sherri," diagnosed with Oppositional Disorder, in individual therapy.

After 6 months of treatment and a number of parent sessions, your impression of her mother is that she is a caring, thoughtful parent. A primary focus of therapy has been helping Sherri's mother learn to set appropriate, firm limits, rather than letting her daughter avoid consequences for misbehaviour. Today, you meet with her mother first, and she reports that she has been trying hard to stick to her decision to not allow her daughter to watch T.V. for the week, as a consequence for Sherri's lying about her homework. She says that Sherri has been very upset about this consequence, and has been yelling at her mother, crying, and threatening to run away to her best friend's house.

When you meet with Sherri alone, she reports that her mother has been mean to her all week by not letting her watch T.V. She asks you what would happen if she told you that her mother had hit her. In particular, she wonders if children are taken away from their parents for this, and if she might be sent to live with her best friend, whose mother she feels is more understanding. She then tells you that her mother hit her with a belt several days before, and it left a bruise and red marks. You ask to see the place on her leg where she was hit, and she shows it to you; there is no mark there now.

Knowing the law that mental health practitioners are mandated to report suspected child abuse, what should you do in this situation? Would you file a report? Why or why not?

Ambiguous Diagnosis You are a psychologist working at a private psychiatric hospital. Most of your work involves referrals from psychiatrists for psychological evaluations, including your opinion regarding diagnosis of the patients. A psychiatrist, Dr. Bard, has referred a number of patients to you in the past, and you find him to be a competent and caring mental health professional. He is also one of two primary referral sources in your private practice, and a personal friend. He refers you a patient, Todd, a 15-year-old boy who was recently hospitalized for psychiatric treatment. Dr. Bard tells you that the boy is depressed, and his diagnosis is listed in the chart as "Atypical Depression." In your assessment of Todd, you find that his symptoms most closely fit the diagnosis of Conduct Disorder. While he does show some symptoms of Major Depression (irritable mood, anhedonia, and difficulty concentrating), he does not meet all the criteria for the disorder. You know that his insurance company will not pay for psychiatric hospitalization for Conduct Disorder, but they will pay for treatment of depression.

What should you write in your evaluation? What would you do in this situation? Explain your reasoning.

Ethics in Research Students likely have participated in various psychological experiments in your psychology department.

What were they told about the experiments, and what sort of informed consent procedure did they go through? Did they retain a copy of the consent form? Did they feel free to withdraw at any time? Do they know who to contact if they believe their rights were violated? Perhaps you could review your department's human subjects guidelines with the class.

Canadian Code of Ethics for Psychologists www.cpa.ca/aboutcpa/committees/ethics/codeofethics

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Students can be asked to design a study, perhaps a comparison of drug vs. psychotherapy for depression.

They can be asked to look for guidance on ethical issues in the Canadian Code of Ethics for Psychologists (above). They could also be asked to compare this code of ethics with that available from the American Psychological Association.

See: Five Principles for Research Ethics: www.apa.org/monitor/jan03/principles.html

Ethical Principles of Psychologists and Code of Conduct www.apa.org/ethics/code/index.aspx

Milgram's Research Milgram's famous obedience to authority studies created considerable controversy regarding the protection of human subjects in psychological experimentation. The film of these studies, Obedience, is certain to provoke reactions from the students regarding this issue.

For more on Milgran’s study, including audio clips: www.simplypsychology.org/milgram.html

LSD Research Montreal Democracy Now story on Professor McCoy Exposes the History of CIA Interrogation, From the Cold War to the War on Terror. www.democracynow.org/2006/2/17/professor_mccoy_exposes_the_history_of Students can be asked to sit on a panel in which this research design has been presented and rule on whether or not the procedure meets current ethical guidelines of either the Canadian Psychological Association or the Tri-Council guidelines of the Social Sciences and Humanities Research Council of Canada. See links to both codes of ethics above under “Canadian Codes of Ethics for Psychologists.”

SOME IDEAS FOR UTILIZING THE INTERNET Criminal Code of Canada Potential health care workers should have some familiarity with the criminal code and know where to find it: laws.justice.gc.ca/en/C-46/ Click on Part I, then section 16: "Defence of Mental Disorder."

TCPS 2 Certification © Wiley Canada

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Students could be asked to complete the TCPS2 tutorial and earn the associated certificate for bonus credit.

Students could be informed that faculty and student researchers at many institutions are required to complete the certificate as part of their Research Ethics Board application. The tutorial and materials are quite interesting and students should be encouraged not to rush through it. http://www.pre.ethics.gc.ca/eng/education/tutorial-didacticiel/

Civil Liberties in Canada Most provinces have a civil liberties association. The rights of current and former mental patients and of individuals found "not criminally responsible" under section 16 of the criminal code are certainly their concern. There is also a Canadian organization: ccla.org/ This site has links to the provincial organizations.

I often ask students to visit this site, get a sense of the position of civil libertarians, and then ask them to consider which civil rights should or should not apply to someone with a mental disorder or someone who has committed a major crime due to a mental disorder.

M'Naghten Ruling www.pbs.org/wgbh/pages/frontline/shows/crime/trial/history.html A PBS Frontline documentary on the insanity plea.

Canadian Court System There is a good deal of overlap between mental health professionals and the law. Psychologists and psychiatrists testify in courts, consult with legal bodies, are governed by legislation, etc. A familiarity with court rulings and a sense of how to find them would be useful to any psychology student.

Supreme Court of Canada www.scc-csc.gc.ca/ This site is searchable. Search for "section 16," "mental disorder", or the specific name of a disorder such as "schizophrenia." You can also search for a specific relevant case such as "Regina vs. Rogers."

Ask students to find one recent case that involves a mental disorder and summarize the issue and ruling.

For more information about provincial and territorial courts: https://www.cjc-ccm.gc.ca/english/resource_en.asp?selMenu=resource_courtsystem_en.asp#ptc .

Provincial “supreme” courts have a different name in some provinces. With the correct term a student can then search for and find the Internet site for the "supreme" court in their province or territory and search for provincial or territorial rulings involving mental disorders.

The Canadian Legal Information Institute also has a list of legal resources across Canada: © Wiley Canada

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www.canlii.org/

Canadian Mental Health Act The mental health act is similar, but different, in each province. Here are some sample interpretations and actual acts from some provinces.

Ontario: Interpretation www.med.uottawa.ca/sim/data/Mental_Health_Act_Ontario_e.htm New Brunswick: The Act www.gnb.ca/acts/acts/m-10.htm British Columbia: Guide to the Mental Health Act www.health.gov.bc.ca/mhd/mentalhealthact.html Manitoba: The Act web2.gov.mb.ca/laws/statutes/ccsm/m110e.php Prince Edward Island: The Act www.gov.pe.ca/law/statutes/pdf/m-06_1.pdf CMHA The BC Mental Health Act in Plain English www.cmha-bc.org/content/resources/cmhapubs/mha_plain.pdf Students can be asked to consider a situation in which someone they know has developed a condition (e.g., paranoid delusions) that make the student think that the individual is about to hurt someone. Students can then be asked to find out how to get this person admitted to a mental health facility. What does it take? How long will the person be held? Will they ever get out?

Not Sick Enough: The Insanity Defence Public Radio Works A series of radio programs on the topic of the insanity defence: americanradioworks.publicradio.org/features/mentally_ill/stories/notsick1.html The insanity defence tends to get attention in sensational, high-profile cases: the Unabomber, Lorena Bobbitt, and most notoriously, John Hinckley. Surveys show Americans worry that too many criminals escape punishment by saying they're insane. But, in fact, successful use of the insanity defence is rare—even for defendants with profound mental illness. American RadioWorks Correspondent John Biewen examines one case that illustrates the difficulties of claiming legal insanity: the story of Kyle Zwack.

For more controversial defendants, the students could search for the cases of Andrea Yates (Texas woman initially convicted of killing her five children, then later found not guilty by reason of insanity) or in Canada,

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Vincent Li, who beheaded a fellow passenger on a Greyhound Bus. Students could evaluate whether they would qualify as Not Criminally Responsible on Account of Mental Disorder under Canadian law.

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