Abnormal Psychology, 7E Thomas F Oltmanns Solution Manuals

Instructor’s Resource Manual

Abnormal Psychology Eighth Edition

THOMAS F. OLTMANNS Washington University in St. Louis

ROBERT E. EMERY University of Virginia

CONTENTS Preface

iv

Sample Syllabus

vi

Chapter 1

Examples and Definitions of Abnormal Behavior

1

Chapter 2

Causes of Abnormal Behavior

14

Chapter 3

Treatment of Psychological Disorders

37

Chapter 4

Classification and Assessment of Abnormal Behavior

55

Chapter 5

Mood Disorders and Suicide

73

Chapter 6

Anxiety Disorders and Obsessive-Compulsive Disorder

94

Chapter 7

Acute and Posttraumatic Stress Disorders, Dissociative Disorders, and Somatic Symptom Disorders

111

Chapter 8

Stress and Physical Health

133

Chapter 9

Personality Disorders

148

Chapter 10

Feeding and Eating Disorders

167

Chapter 11

Substance-Related and Addictive Disorders

184

Chapter 12

Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria 204

Chapter 13

Schizophrenia Spectrum and Other Psychotic Disorders

222

Chapter 14

Neurocognitive Disorders

240

Chapter 15

Intellectual Disabilities and Autistic Spectrum Disorders

256

Chapter 16

Psychological Disorders of Childhood

274

Chapter 17

Adjustment Disorders and Life-Cycle Transitions

291

Chapter 18

Mental Health and the Law

306

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A SAMPLE SYLLABUS PSYCHOLOGY 266 –ABNORMAL PSYCHOLOGY COURSE SYLLABUS Section: 00000 Room: 00000 Mondays/Wednesdays 5:00 PM to 6:15 PM Instructor: Your Name Here Session: Fall 2014 Office Hours: I would be happy to meet with students anytime by appointment. I will also generally be available before and after class each week.

Email: Your E-mail Here REQUIRED TEXT: Oltmanns & Emery, Abnormal Psychology (Eighth Edition, 2015).

COURSE DESCRIPTION: This course distinguishes between normal behavior and psychological disorders.

Subjects may include stress disorders, problems with anxiety and depression, unusual and abnormal sexual behavior, schizophrenia and addictive behaviors.

Diagnosis, causes, and treatments of psychological problems and disorders are discussed. Information offered is updated to the DSM-5 Manual.

Prerequisites: PSY 101 with a grade of C or better or permission of the instructor.

COURSE COMPETENCIES: 1. Describe how abnormal behavior is defined and comprehend the difference between normal and abnormal behavior.

2. Define the models of abnormal behavior and understand the advantages to the biopsychosocial approach.

3. Gain an understanding of the different major forms of psychotherapy as well as their relative effectiveness.

4. Describe defining characteristics of the current DSM-5 nomenclature in the classification of abnormal behavior.

5. Describe and understand the major diagnostic criteria, theories, and treatment of depression and other affective (mood) disorders.

6. Define the terms and issues associated with the major diagnostic criteria, theories, and treatment of anxiety and obsessive-compulsive disorders.

7. Describe the major diagnostic criteria, theories, and treatment of stress disorders, dissociative and somatic symptom disorders.

8. Understand the roles of stress and coping in physical health.

9. Describe the major diagnostic criteria, theories, and treatment of personality disorders.

10. Identify the major diagnostic criteria, theories, and treatment of feeding and eating disorders.

11. Define the major diagnostic criteria, theories, and treatment of substancerelated and addictive disorders. vi C.

12. Describe the major diagnostic criteria, theories, and treatment associated with sexual dysfunctions, paraphilic disorders, and gender dysphoria.

13. Describe the major diagnostic criteria, theories, and treatment of schizophrenia spectrum and other psychotic disorders.

14. Describe the major diagnostic criteria, theories, and treatment of dementia, delirium, and other neurocognitive disorders.

15. Identify the major diagnostic criteria, theories, and treatment of intellectual disabilities and autism spectrum disorders.

16. Describe the major diagnostic criteria, theories, and treatment of attentiondeficit-hyperactivity-disorder and other psychological disorders of childhood.

17. Understand the significance of adjustment disorders and life cycle transitions on psychological well-being.

18. Understand the intersection of mental health and the law as well as the practical implication of the law on the practice of mental health treatment.

GRADING and EVALUATION: 1. Class participation and attendance is MANDATORY, unless you have extreme circumstances see syllabi under absences.

2. There will be 100 points possible for Case Study Assignment completed in this course.

3. There will be 200 points possible for Assignments given (Analysis Papers: Memoir = 100 points, and Psychological Autopsy = 100 points).

4. There will be 400 points possible for Tests completed in this course.

5. There will be 50 points possible for two In-Class activities/ presentations, at 25 points each (Formal Debate & Re-creation of a famous insanity defense trial).

Extra Credit: There will be no extra credit given in this course.

Total points possible: 750 The final grade is calculated by dividing the total number of points the student achieves by the total possible points available. The result is the percentage earned by the student.

Percentage A=100–90 B=89–80 C=79–70 D=69–60 F=59–00

Points 750–677 676–604 603–531 530–458 457–000 vii C.

NOTE TO THE STUDENTS: Success in this course depends on: 1. Reading the text chapters prior to discussing them in class. This will allow you to interact in class about the content and any questions that may arise.

2. Completing your Learning Objectives prior to each class.

3. Completing your Key Terms prior to each class.

4. Participating in each of the In-class exercises.

5. Attending all class meeting dates.

6. Asking questions.

7. Taking notes.

8. Reviewing the course material.

The instructor reserves the right to alter the items in this syllabus via verbal instruction in class. The student is responsible for taking notes of any such change(s) and acting accordingly.

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SAMPLE ASSIGNMENTS ANALYSIS PAPERS: Students are required to complete two assignments:

1.

“The psychological autopsy”: The purpose of the psychological autopsy is to:

(a) Provide the victim’s family with information about the death. (b) Enable the professional organization, or society, to develop future prevention programs and lessons learned so that those experiencing SI and family members are better served.

After selecting a famous individual that has committed suicide, use the Internet as your guide for answering the following questions about the victim of suicide.

1. Did this person have a history of mental illness diagnoses prior to committing suicide? a. If so, describe this history. b. If so, does this appear to be related to the suicide? c. If so, what treatments did this individual seek or receive prior to suicide? d. If not, does this person’s behavior prior to suicide suggest that they may be qualified for a DSM-5 diagnosis?

2. Did this individual display any classic warning signs of suicide prior to the act? a. If so, what were these signs?

3. Was the use of substances involved in the events leading up to the suicide? a. If so, how?

4. Describe some of the major life stressors or stress events that may have contributed to the suicide?

5. Does this individual have a family history of suicide or mental illness?

Disclaimer: This demonstration is strictly for educational purposes and is entirely fictional; the person named in the psychological autopsy or anyone related to them was never actually evaluated, and the report author conducting this psychological autopsy is not qualified to conduct psychological autopsies. Due: [Date]; Points: 100 2.

For the second written assignment, you will be writing journal entries weekly on the subject matter for each class based on the readings, PowerPoint ix C.

presentation, speakers, in-class discussion, activities, videos, etc. I want you to keep these together in a journal (i.e. spiral-ring notebook or something of your choosing). Toward the end of the semester, I want you to turn this into your own “Personal Memoir of Being in An Abnormal Psychology Class.” I want you to organize entries by looking at themes: did your perception of abnormality change, what particularly you found interesting or not interesting, did you find you wished you had the opportunity to explore something else in detail, etc. This is where you can use your creativity. Then I want you to design your own journal cover, dedication page, title page, table of contents, abstract, the text body of your memoir, and then you may include an appendix with pictures or actual journal entries. Again, this is where you can use your own personal style and creativity. Due:[Date]; Points: 100 Both of these assignments must be typed, double-spaced with no larger than 12-point font Times New Roman, summary of each assignment is required.

Case Study Assignment: Due: [Date]; Points: 100 This process will require the student to: 1. Read the case study given by the professor based on a fictional patient describing the medical history.

2. Assess symptoms.

3. Assess other potential problematic areas of the person’s life such as social, spiritual, emotional, cognitive, work/education level, physical.

4. Diagnostic criteria based on DSM-5.

5. Identify stressors.

6. Recommendations for treatment.

7. Describe the case from each.

8. Assessment of prognosis.

9. Summarize results in a written statement.

Format Outline: Written statement, 3–4 typed pages, double-spaced, no larger than 12-point font Times New Roman. Points will be taken off if you DO NOT meet the minimum page requirements.

In-Class Activities/Presentations: Each worth 25 points. The student will be actively conducting research, reviewing current and past insanity defense verdicts, legal statutes regarding mental health, and learning about a variety of different concepts related to psychology and the law. Each student will be an active participant in each of these two activities. There is NO MAKE-UP of these. For these two In-Class Oral presentations, the students are to do the following: x C.

1. Re-creation of one of the famous cases regarding the insanity defense This activity is designed to allow students to use their creativity and work as a group to analyze criminal commitment, the insanity defense, not guilty by reason of insanity, M’Naghten Rule, incompetent to stand trial, and guilty but mentally ill.

Have the students select a case that they find most interesting that has used the insanity defense, such as Jeffrey Dahmer, Susan Smith, John Du Pont, Andrew Goldstein, Kenneth Bianca “The Hillside Strangler,” John Hinckley, John Wayne Gacy “Clown Killer,” David Berkowitz “Son of Sam,” Albert Fish “Brooklyn Vampire.”

Let students do some research if there is another case they want to trial. Due: [Date], [Date], & [Date]; Points: 25 2. Debate: Should psychologists be able to date former patients?

Debates are a great way to stimulate critical thinking and student participation. In addition, this provides a method of applying learned material from the textbook to “real-world” application. Elliot (1993) added that debates can also produce an environment conducive to “active learning” and “cooperative learning”; she found that 50% percent of her student evaluations “emphasized how debates illuminated class readings” (pp. 36-37). Due: [Date]; Points: 25

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COURSE OUTLINE ABNORMAL PSYCHOLOGY-PSY 266

Date

Topic

Readings

8/23-Syllabus, 8/25,

Intro, Syllabus

Chapter 1 handouts

8/30

Examples and Definitions of Abnormal Behavior

Chapter 1

9/1, 9/8, 9/6 NO CLASS LABOR DAY

Models of Abnormal Behavior

Chapter 2 handouts

9/13, 9/15

Treatment of Psychological Disorders

Chapter 3

9/20, 9/22

Classification and Assessment of Abnormal Behavior

Chapter 4

9/27, 9/29

Mood Disorders and Suicide

Chapter 5

10/4, 10/6 Guest Speaker TBD

Anxiety and Obsessive Compulsive Disorders

Chapter 6 handouts

10/11, 10/13,

Acute and Posttraumatic Stress Disorders, Dissociative Disorders, and Somatoform Disorders

Chapter 7 handouts

Test 2 (10/13)

10/18, 10/20,

Stress and Physical Health

Chapter 8 handouts

Psychological Autopsy Assignment due (10/20)

10/25, 10/27

Personality Disorders

Chapter 9 handouts

Case Study Assignment due (10/27)

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Assignments (Due on day listed)

Test 1(9/22)

Date

Topic

Readings

11/1

Eating and Feeding Disorders

Chapter 10

11/3

Substance Abuse and Addiction Disorders

Chapter 11

Test 3 (11/3)

11/8, 11/10

Sexual dysfunctions, paraphilic disorders, and gender dysphoria

Chapter 12

Oral Presentations/ In-Class Activity

11/15, 11/17

Schizophrenia Spectrum and Related Psychotic Disorders

Chapter 13

11/22

Dementia, Delirium, and Neurocognitive Disorders

Chapter 14

11/29 11/24 NO CLASS or Discussion post

Intellectual Disabilities and Autistic Spectrum Disorders

Chapter 15

12/1

Psychological Disorders of Childhood

Chapter 16

Oral Presentations/ In-class Re-creation of court trial

12/6-Finish court trial verdict if needed,

Adjustment Disorders and Life-Cycle Transitions

Chapter 17

Oral Presentations/ In-class Re-creation of court trial

xiii C.

Assignments (Due on day listed)

Re-creation of court trial Analysis paper 2: Personal Memoir due (11/17)

Date

Topic

Readings

Assignments (Due on day listed)

12/8-Debate

Mental Health and the Law

Chapter 18

DEBATE Activity: Should psychologists be able to date former patients? Due: [Date] Test 4

12/13-12/17 FINAL EXAMS

This syllabus is tentative. You are responsible for knowing any changes that are announced in class via verbal or written communication.

xiv C.

Chapter 1 Examples and Definitions of Abnormal Behavior Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview : p.2 Recognizing the Presence of a Disorder: p. 4

Lectures: Popularity of Abnormal Psychology

Defining Abnormal Behavior: p. 5

Lectures: Causality

Harmful Dysfunction Mental Health vs. Absence of Disorder Culture and Diagnostic Practice

Discussion Ideas: Diagnostic criteria Classroom: The Use of Popular Media

Who Experiences Abnormal Behavior? p. 10

Discussion Ideas: Sex differences

Frequency in and Impact on Community Populations Comorbidity and Disease Burden Cross-Cultural Comparisons The Mental Health Professions: p. 14

Discussion Ideas: Graduate school in psychology myths

Psychiatry Clinical Psychology Social Work

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PROFESSOR NOTES

Psychopathology in Historical Context: p. 15

Discussion Ideas: Personality disorders

The Greek Tradition in Medicine Classroom: The Creation of the Asylum Historical approaches Worcester Lunatic Hospital: A Model Institution Lessons from the History of Psychopathology

Methods for the Scientific Study of Mental Discussion: Who must provide Disorders: p. 18 scientific evidence?

The Use and Limitations of Case Studies Clinical Research Methods Classroom: Getting to know different research methods.

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CHAPTER OUTLINE

I.

II.

Overview A.

Psychopathology (pathology of the mind): the symptoms and signs of mental disorders including such phenomena as depressed mood, panic attacks, and bizarre beliefs

B.

Abnormal psychology is defined as the application of psychological science to the study of mental disorders.

C.

Mental disorders are defined by a set of features (symptoms).

D.

Terms: psychosis, delusion, insanity, nervous breakdown, syndrome

Defining abnormal behavior A.

Personal distress—subjective experience of suffering; this defintion misses cases in which an individual does not identify own thoughts/behaviors as problematic

B.

Statistical norms—how common or rare it is in the general population

C.

1.

By definition, people with usually high levels of anxiety or depression would be considered to be abnormal because their experience deviates from the expected norms.

2.

Another weakness of the statistical approach is that it does not distinguish between deviations that are harmful and those that are not.

Maladaptiveness—Wakefield’s harmful dysfunction concept 1.

The condition results from an inability of some internal mechanism on the part of the person

2.

The condition causes harm to the person.

3.

Mental illness is defined as harmful dysfunction in terms of a product of disruptions of thought, feeling, communication, perception, and motivation.

4.

The harmful dysfunction view of mental disorder recognizes that every type of dysfunction does not lead to a disorder; only dysfunctions that result in significant harm to the person are considered to be disorders.

3 C.

D.

DSM-5 (APA, 2013) defines mental disorders associated with (any or all) 1. A syndrome (groups of associated features) that is characterized by disturbance of a person’s cognition, emotion regulation, or behavior 2. The consequences of which are clinically significant distress or disability in social, occupational, or other important activities

E.

F.

III.

3.

The syndrome reflects a dysfunction in the psychological, biological, or developmental processes that are associated with mental functioning.

4.

Must not be merely an expectable response to common stressors and losses, or a culturally sanctioned response to a particular event (e.g., trance states in religious rituals)

5.

Not primarily a result of social deviance or conflicts with society

Mental health means more than the absence of mental illness.

1.

Healthy people can be described as ‘flourishing.’

2.

Flourishing people have more positive emotions, are calm and peaceful, have positive attitudes, and possess a sense of meaning and purpose.

Culture and diagnostic practice: DSM-5 defines pathologies in terms of our particular culture and cultural values.

1.

Culture is defined in terms of the values, beliefs, and practices that are shared by a specific community or group of people.

2.

Cultural values influence the opinions regarding normal and abnormal behavior

Epidemiology A.

The scientific study of the frequency and distribution of disorders within a population

B.

Incidence—number of new cases of a disorder that appear in a population during a specific period of time

C.

Prevalence—total number of active cases that are present in a population during a specific period of time (lifetime prevalence—proportion of people in a given population affected by the disorder at some point during their lives) 4 C.

D.

Gender differences are found in many but not all mental disorders; most prominent differences include anxiety disorders and depression (more common in women), and substance abuse and antisocial personality disorder (more common in men).

E.

Comorbidity and Disease Burden 1. Comorbidity is the presence of more than one condition within the same period of time.

2. Disease burden is measured by combining two factors: mortality and disability

IV.

F.

Global Burden of Disease Study (Sponsored by World Health Organization, WHO)—assessed impact of conditions; mental disorders are responsible for 1percent of death but 47percent of disability in the U.S. and developed nations, and 28 percent of all disability worldwide

G.

Cross-Cultural Comparisons: 90 percent of individuals with bulimia nervosa are women, usually university students, in the Western society

H.

Draguns and Tanaka-Matsumi (2003) reported that mental disorders are shaped by culture, that no mental disorder is caused entirely due to cultural factors, that psychotic disorders are less influenced by culture, and that the symptoms of disorders vary across cultures

Mental health professions A.

Psychiatry is the branch of medicine that is concerned with the study and treatment of mental disorders.

Psychiatrists are physicians (medical doctors) who specialize in treating mental disorders ; they often prescribe medication.

B.

Clinical psychology is concerned with the application of psychological science to the assessment and treatment of mental disorders. Clinical Psychologists complete a Ph.D. or a Psy.D. (about 4 years plus internship) and are trained in assessment, psychotherapy, and applying scientific principles to the study of abnormal psychology

C.

Social Work is another profession that is concerned with helping people achieve an effective level of psychosocial functioning. Social workers generally hold an M.S.W. and are committed to action that may be socially based or individually based.

D.

Masters-level professional counselors, marriage and family therapists, and psychiatric nurses also provide individual and family psychotherapy; non-graduate trained staff often provide psychosocial 5 C.

rehabilitation.

V.

E.

Currently, dramatic changes in the provision of mental health care services are being driven by managed care companies, which place emphasis on cost containment.

F.

Individuals receive treatment in many different types of settings and from a variety of professionals; only 40 percent of those who receive treatment receive it from a specialized mental health professional such as the ones above listed.

G.

However, 34 percent of individuals receive treatment for psychiatric problems from their primary care physicians who do not have specialized training.

Psychopathology in historical context A.

The Greek tradition: Hippocrates 1.

Assumed mental disorders had natural causes, not demonological sources

2.

Believed health depended on maintaining a balance of four bodily fluids: blood, phlegm, black bile, and yellow bile

B. The Creation of the asylum: Middle Ages

C.

1.

Established to house the mentally disturbed

2.

Moral treatment emphasized support and respect for human dignity

3.

Dorothea Dix was a prominent and effective advocate for humane treatment of the mentally ill in hospitals.

4.

Profession of psychiatry emerged from the development of large institutions

5.

Woodward’s Worcester Hospital (mid-1800s in U.S.) as a “model institution” employing moral and physical treatment approaches—based on protestant values; reported recovery rates from 82 to 91 percent between 1833 and 1845

6.

Created to serve heavily populated cities and to assume responsibilities that had previously been performed by individual families

Lessons from the history of psychopathology 6 C.

VI.

1.

Cultural bias often, perhaps always, influences current thinking and treatment approaches.

2.

Scientific research is crucial to identify and understand effective treatment.

Methods for the scientific study of mental disorders

A.

B.

Basis is the “open-minded skepticism” of the scientific method 1.

Formulation of hypotheses

2.

Collection and analysis of empirical data

3.

Refinement of hypotheses based on findings

Case studies can provide a wealth of information about a particular pathology and can help generate research questions and hypotheses, but they are limited because they can be interpreted in many ways and may not be reliable or generalizable.

1. Important sources of information 2. Case studies can be viewed from many different perspectives.

3. Risky to draw conclusions

C.

Clinical research methods 1. It is pivotal to understand how it is important to conduct research related to each disorder.

7 C.

LEARNING OBJECTIVES LO 1.1 Is there an obvious line that divides normal from abnormal behavior?

LO 1.2 Who decides what’s abnormal and what isn’t?

LO 1.3 What are the most common mental disorders?

LO 1.4 Can people with mental disorders function in everyday life?

LO 1.5 What can I do if I’m worried about someone’s mental health?

LECTURE SUGGESTIONS Bias and labeling: It may be helpful to introduce the students to the concepts of bias and labeling as they begin the course. There are many ways to start the discussion. For example, a discussion of the labels that students used in high school to describe other groups of students and those labels that were used by other groups to describe them may be a good lecture starter. Ask students to think back to high school and remember the different groups or ‘clics’ that were present. Ask them if they felt comfortable with the labels that others attached to them. Did any of them feel limited by the labels others used to describe them? Then discuss why labels are important in diagnoses of mental disorders so that therapists and other professionals can discuss similar symptoms and come to agreement on potentially helpful treatment options. However, it is important to remember that each person labeled with a mental disorder is, first and foremost, an indvidual. Remind them that they may have felt limited by their label in high school and that they should think about how much more limiting a label of mental illness could be.

Causality: Biological reductionism assumes that biological factors cause abnormalities. For example, some mental health professionals and others suggest that “chemical imbalances” are the source of the emotional and behavioral problems. This suggestion assumes that because certain biological states are associated with psychological disorders, the biological state causes the disorder. However, causality can move in the opposite direction. Use the following argument to illustrate this point: If a teacher insults a student, the student is likely to feel some powerful emotion, perhaps anger or embarrassment. If he/she does feel this emotion, some physiological changes will therefore occur. For example, if the student becomes angry, norepinephrine will be released into the bloodstream.

Does this mean that the cause of the student’s anger is the flow of norepinephrine? Not at all; we would still say that the cause of the student’s anger (and accompanying physiological changes) is feeling insulted. Similarly, the cause of a person’s depression is probably not simply a chemical imbalance, although a chemical imbalance may occur when a person is depressed. This does not mean that the biological approach is not important or valuable. Balance the lecture with an emphasis on the value of the biological approach to psychopathology.

8 C.

Popularity of abnormal psychology: Research has shown that, on average, students are exposed to at least five different psychiatric diagnoses among their friends and family. Starting class by exploring the different reasons for registering for the course may be an opportunity to address the stereotypes, stigma, and labels associated with mental illness. It is important to find a balanced teaching style for this course. The diagnostic approach offers real-life application of the assessment of signs and syptoms as they pertain to a particular diagnosis. Most students do not plan to become clinicians, so a strictly ‘diagnosis-centered’ teaching style may be too applied for many students. A teaching style utilizing anecdotes and examples to describe various conditions can be very interesting to students, but there are two risks in this approach: students may get lost in the stories and miss the diagnostic message, and if lecturers use real-life examples, it may breach client confidentiality. A third risk, which is problematic using any teaching style for a course in abnormal psychology, is that students will, with little knowledge and no experience, start diagnosing everyone from their family and friends to their bosses (or psychology instructors!). It may be helpful in the first lecture to discuss these risks to minimize the effect of each. For instance, it may be beneficial to explain that it is quite common for students in an abnormal psychology course to start ‘diagnosing’ people they know and to have them make a pledge not to do so for the remainder of the course. It may be helpful to tie this into the concept of the wide range, in which ‘normal’ behaviors occur, and to discuss the difficulty in diagnosing what is ‘abnormal’.

DISCUSSION IDEAS Diagnostic criteria: Use the following case study to illustrate the weaknesses involved in using the statistical rarity criteria for abnormality: A resident in a dormitory is the only one of 80 students in the dorm to not attend the first home college football game. When asked to explain this, he states simply, “I don’t particularly like football; I’d rather play this computer game.”

Ask the class whether this student is therefore abnormal. Most will agree that the student is statistically rare, but not deviant. Then explain how utilizing the DSM-5 defining characteristics—(1) present distress, (2) disability, and (3) increased risk of suffering death, pain, disability, or a loss of freedom—provide a more suitable definition of mental illness. Discussion question: Is statistical rarity a useful criterion to utilize for the detection of mental illness?

One can argue that noticing unusual behavior is an important "beginning point" in detecting and, eventually, treating mental illness but not in labeling one as abnormal.

Sex differences: As will be discussed later, there are wide prevalence differences for males and females for many disorders, 9 C.

including those who develop the disorder and those who seek treatment. These differences are found in numerous domains, including depression, anxiety, substance abuse, autism spectrum disorders, certain personality disorders, and hyperactivity. Although specific mechanisms will be elucidated later in the term, it may be interesting for students to explore their ideas about why these differences may occur, including biology, social expectations and roles, perceptions of others regarding the meaning of behaviors, or other factors.

Graduate school in psychology myths: Many students have beliefs about graduate school in psychology that are not based on fact and can cause them to be misdirected in terms of their career goals. Present this list ‘beliefs about graduate school’ and ask the class to dispel each of them as myth.

(1) A Clinical Psychology Ph.D program is the only graduate training for practicing psychologists.

(2) The psychotherapy training of a psychiatrist is more complete than that of a psychologist or social worker.

(3) Clinical Psychology programs are devoted to training students for clinical practice.

(4) It is easier to get accepted to a Clinical Psychology program than to a medical school.

(5) Master’s programs—because they are shorter—are less expensive than doctoral programs.

(6) Social workers cannot actually conduct psychotherapy—only psychologists and psychiatrists are trained to work directly with clients/patients.

(7) School psychologists cannot practice independently in a private practice.

(8) Counseling psychologists are ‘guidance counselors’ who work in a school setting only.

Personality and personality disorders: A continuing controversy in the field has been the classification of personality disorders. Should a “difficult person” be classified as having a mental disorder? Ask the students to think of their most “difficult” friends or acquaintances. Then ask them whether they consider whether these people should be diagnosed with mental disorders. You can then ask them to expand on their impressions and provide an opportunity to discuss the impact of labeling, the meaning of the term psychopathology, and the distinction between conditions that are ego-dystonic and ego-syntonic.

CLASSROOM ACTIVITIES Effects of labeling: The effects of labeling can be illustrated in the following demonstration. Ask for six volunteers to participate in a discussion, explaining that each participant will be labeled. Take a roll of masking tape and write the following labels on strips of tape: (1) Abnormal (2) Normal (3) Suffering (4) Deviant (5) Mentally ill, and (6) Psychopath.

Place the tape on each volunteer’s forehead and ask them to carry on a conversation about a mundane topic they consider unrelated to mental health. Ask volunteers to not look at their own label and to treat the others in terms of 10 C.

their labels. After a few conversations (change the topic after about 5 minutes), it will become clear that the negative labels lead to adverse treatment of the students with labels suggesting abnormality or deviance.

Historical approaches: Present students with a well-known criminal case, such as that of Jeffrey Dahmer. Then assign them to small groups and instruct each group to develop a particular “historical” view of the case. For example, one group would be asked to provide a "demonological" view, another a “Hippocratic” view (blood was equated with cheerfulness and activity, phlegm with apathy and sluggishness, black bile with melancholy, and yellow bile with irritability and excitability), and others with “modern” (biological, psychological, and social) views of the case. Give them about 10 minutes to do this work and then ask the class to reconvene and present their views.

Wanted: A job in the mental health field: Sometimes students are unsure of the different types of professionals that are available in the mental health field. Divide the class into small groups and hand each group a different profession, such as psychiatrist, clinical psychologist, social worker, marriage and family therapist, psychiatric nurse, counselor, and any other professional you may want to add, such as an addictionologist (MD), art therapist, dance movement therapist, etc. Then ask the students to work together in their small groups to come up with a job announcement that defines: (a) the education and degree requirements, (b) typical setting where you will find this individual working, and (c) the job tasks and description. After you have given the students five to seven minutes to work on this, have them share and present the information to the class. This is also an opportunity where you can break down the different clinical specialty areas as they relate to psychology. For example: child and adolescent psychology, forensic psychology, neuropsychology, health psychology, counseling psychology, social psychology, and industrial/organizational psychology. Another variation of this activity is that the students can put together a brochure describing the profession, or they can role-play an interview with a student playing the specific professional and another student interviewing them about the profession.

Abnormal or normal: You decide: Ask the students to stand up. Tell them that you will be reading a series of statements, and they will have to decide whether the statement is “abnormal” or “normal.” Make sure to let the students know that there is no fence-sitting, so they must each decide if the statement is more likely to represent something that is “normal” or “abnormal.” Feel free to also add your own statements or make modifications to the ones given.

1.

2.

3.

4.

5.

Speeding on the freeway Taking more than 20 items in the grocery line that simply states 20 items or less Running a red light Drinking alcohol Using drugs 11 C.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Talking to yourself Making to-do lists Cheating on a significant other Having test anxiety Being nervous on a first date Suffering from depression Hearing voices Experiencing rapid shifts in your mood Having suicidal or homicidal thoughts Refusing to take care of your hygiene and grooming needs

The use of popular media: Some celebrities are very influential in defining what is considered “normal” or “abnormal.” Many popular figures in pop culture today defy what society defines as ‘social norms’ through racy outfits, outlandish behavior, and constantly changing hairstyles. It may spark some interesting class discussion to show a few current music videos or mention some current celebrities, to discuss the stigma, labels, stereotypes, prejudicial views, the process of acceptance, etc., as it relates to the definition of abnormal behavior and to those who are diagnosed with a mental disorder.

Why study abnormal psychology: From A to Z: This activity can be done individually or in small groups. Ask students to write down, for each letter of the alphabet, a topic that is related to the field of abnormal psychology. This can be done by using the textbook, Internet, personal experience and opinions, and the media, or you can decide which you would prefer the students to use. After giving the students time to complete their lists, allow time for students to share different topics for each letter of the alphabet.

VIDEO RESOURCES http://visual.pearsoncmg.com/mypsychlab/episode17/index.html?clip=4&tab=tab0 Special Topics: Diagnosing Mental Disorders (7:01) The Diagnostic and Statistical Manual of Mental Disorders, or DSM, has had a long and often controversial history.

In this video, psychologists David Barlow of Boston University and Scott Lilienfeld of Emory University explain how the DSM’s development and refinement over the years has led it to become the most important, albeit still controversial, guideline for psychologists to use in diagnosing and treating psychological disorders today.

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http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Current_Diagnostic_ Models_Sue_Mineka.html Current Diagnostic Models: Sue Mineka (3:06) In this video, Psychologist Sue Mineka describes the various diagnostic perspectives and how they often work together.

http://media.pearsoncmg.com/ab/ab_lefton_psychology_8/media/sim19/sim19.html Doing Simple Statistics Practice calculating simple statistics and graphing data.

http://media.pearsoncmg.com/ab/PH_Ciccarelli_2/flashpoint/MPL_history/index.html Closer Look: A History of Psychology This dynamic, multi-level simulation takes students on a tour through the history of psychology and introduces them to psychology's founding fathers and groundbreaking concepts. Students may follow their interest forwards and backwards through this simulation, connecting with the content at their own pace.

http://media.pearsoncmg.com/ab/ab_lefton_psychology_8/media/timeline/index.html History of Psychology Timeline Explore this interactive timeline of developments in the field of psychology in the larger historical context.

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Chapter 2 Causes of Abnormal Behavior Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: p. 25 Brief Historical Perspective: p.26 The Biological Paradigm The Psychodynamic Paradigm The Cognitive Behavioral Paradigm The Humanistic Paradigm The Problem with Paradigms Systems Theory: p. 31

Lectures: Challenging reductionism

Holism Reductionism Levels of Analysis Causality Equifinality and Multifinality The Diathesis-Stress Model Reciprocal Causality Development Psychopathology Biological Factors: p. 34 The Neuron and Neurotransmitters Neurotransmitters and Psychopathology Cerebral Hemispheres Major Brain Structures and Psychopathology Psychophysiology Endocrine System

Discussion Ideas: Causation vs. causality Classroom: Systems approach to causation Creating your own theory

Lectures: Oliver Sacks Discussion Ideas: Behavior genetics and the nonshared environment

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PROFESSOR NOTES

Psychological Factors: p. 42 Human Nature Evolutionary Psychology Attachment Theory Dominance Temperament Emotions Learning and Cognition The Sense of Self Stages of Development Social Factors p. 48

Discussion Ideas: Evolutionary psychology Object relations and attachment theory, Jerome Kagan

Discussion Ideas: Gender differences

Close Relationships Marital Status and Psychopathology Social Relationships Gender and Gender Roles Prejudice, Poverty, and Society

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CHAPTER OUTLINE

I.

II.

Overview A.

The cause or etiology of abnormal behavior remains a mystery.

B.

Psychologists have argued for biological, psychodynamic, cognitive-behavioral, and humanistic paradigms as best explaining normal and abnormal psychology.

C.

The biopsychosocial model is an approach that integrates evidence from across biological, psychological, and social dimensions of behavior.

D.

Paradigm is a set of shared assumptions that includes both the substance of a theory and beliefs about how scientists should collect data and test the theory.

Brief historical perspective A.

Early cultures explained abnormal behavior through reference to demonology, witchcraft, and some less-than-scientific descriptive accounts.

B.

Scientific approach to understanding causes of abnormal behavior was aided by three breakthroughs of the nineteenth and early twentieth century: 1. The discovery that general paresis followed syphilis infection showed that apparently psychological symptoms (e.g., delusions of grandeur) could be caused by a physical disease.

2. Freud's development of psychoanalytic theory a. Importance of early childhood experiences and unconscious influences b. Structures of the psyche (id, ego, superego) and defense mechanisms 3. A new academic discipline, psychology, emerges with the work of Wundt, Pavlov, Skinner, and Watson. a. b. c.

Classical and operant conditioning (Pavlov, Skinner) Scientific focus on observable behavior (Skinner) Wilhelm Wundt introduced the scientific study of psychological phenomena: learning

C. The biological paradigm The discovery of the cause of general paresis (general paralysis) is a remarkable and historically important example of the biological paradigm, which looks for biological abnormalities that 16 C.

cause abnormal behavior, for example, brain diseases, brain injuries, or genetic disorders.

General paresis is caused by syphilis, a sexually transmitted disease. We know this as a result of over a century of research—some good and some bad.

III.

D.

The psychodynamic paradigm The psychodynamic paradigm, an outgrowth of Sigmund Freud’s (1856–1939) theories, asserts that abnormal behavior is caused by unconscious mental conflicts that have roots in early childhood experience.

E.

The cognitive-behavioral paradigm Like the biological and psychodynamic paradigms, the foundations of the cognitive-behavioral paradigm, which views abnormal behavior as a product of learning, can be traced to the nineteenth century, specifically to 1879, when Wilhelm Wundt (1832–1920) began the science of psychology at the University of Leipzig. Wundt made a profound contribution by introducing the scientific study of psychological phenomena, especially learning. Two prominent early scientists who made lasting substantive contributions to learning theory and research were the Russian physiologist Ivan Pavlov (1849–1936) and the U.S. psychologist B. F. Skinner (1904–1990).

F.

The humanistic paradigm Humanistic psychology opposes the biological, psychoanalytic, and behavioral explanations, emphasizes free will, views human nature as inherently good, and posits a natural movement towards self-actualization.

G.

The problem with paradigms Paradigms can both direct and misdirect scientists.

Systems theory A. Systems theory is an integrative approach to science that embraces multiple influences on behavior, including the best elements of the four paradigms. Think of systems as a synonym for the biopsychosocial model.

B. Systems approach to etiology 1.

Holism assumes that the whole is more than the sum of the parts.

2.

Reductionism (the opposite of holism) assumes the whole is the sum of its parts and can be understood by examining its smaller components.

3.

Levels of analysis: a focus on different subsystems leads to differing perceptions of 17 C.

causality such as the biological, psychological, and social views of abnormal behavior; can be explained as the use a different “lens”: one is a microscope, another a magnifying glass, and the third a telescope, but remember no specific lens is the only way to view abnormality 4.

Causality: when you evaluate the cause of mental disorders according to a combination of factors, not by a single, manageable problem.

5.

Equifinality: a psychological disorder may have multiple causes; there are many routes to the same destination; multiple pathways=equifinality

6.

Multifinality: the same event can lead to different outcomes (e.g. abuse can lead to very different outcomes in different children)

7.

Diathesis-stress model a.

Diathesis is a predisposition to develop a disorder (usually, but not necessarily, a heredity factor)

b.

Stress is a difficult life experience (usually, but not necessarily, a psychologically-based experience)

c.

Risk factors are circumstances that are correlated with an increased likelihood of a disorder and may contribute to causing it.

8.

Reciprocal causality: the direction of causality can be in both directions simultaneously (e.g., children affect parents just as parents influence children)

9.

Developmental psychopathology—emphasizes the importance of understanding developmental norms for a particular behavior in order to consider whether that behavior is abnormal (age-dependent judgments are necessary) a.

Premorbid History is a pattern of behavior that precedes the onset of the disorder.

b.

Prognosis is a predictable course of a disorder.

IV. The basic approaches A. Biological factors 1.

The neuron and neurotransmitters 18 C.

2.

a.

Soma—the cell body

b.

Neurons—billions of tiny nerve cells that form the basic building blocks of the brain

c.

Dendrites-- branches that receive messages from other neurons

d.

Axon—trunk of the neuron; messages are sent through the axon to other neurons

e.

Axon terminals-- buds on the end of the axon from which messages are sent to other neurons

f.

Synapses-- small gaps that separate neurons

g.

Neurotransmitters-- substances released by the terminal buttons into the synapse; some reach other receptors, while some are taken up by the neuron itself in the process called reuptake

h.

Receptors—receive the neurotransmitters once they are released into the synapse

i.

Neuromodulators-- chemicals that may be released from neurons or from endocrine glands (e.g., endorphins) that affect neurotransmitter function

j.

Mental disorders have been linked to neurotransmitters; having more or less of various neurotransmitters is hypothesized to be related to several syndromes.

Neurotransmitters and psychopathology a.

Scientists have reported that dysfunction related to the neurotransmitters is common in some individuals with mental disorders, whether it be an oversupply or undersupply.

b.

Additionally, the density and sensitivity of the receptors also play a role in the development of abnormal behavior.

c.

Schizophrenia treatment targets the neurotransmitter dopamine by blocking these receptors.

d.

Depression specifically targets the reuptake of serotonin and links to a depletion of serotonin, which is responsible for mood, as a cause of this disorder.

e.

However, keep in mind that a biochemical difference does not mean that these problems are caused by a chemical imbalance in the brain.

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3.

Major brain structures a.

b.

c.

Hindbrain consists of medulla, pons, and cerebellum, which regulate basic bodily functions—generally not related to abnormal behavior 1.)

Medulla—regulates heart rate, blood pressure, and respiration, thus those bodily functions involved in sustaining life

2.)

Pons—regulates sleep stages

3.)

Cerebellum—involved in physical coordination

Midbrain—involved in control of some motor activities, especially those related to fighting and sex 1.)

Reticular activating system regulates sleeping and waking

2.)

Damage here can result in disturbances in sexual behavior, aggressiveness, and sleep—usually due to brain traumas or tumors

Forebrain—more recently evolved—location of most sensory, emotional, and cognitive processes; largest brain region 1.)

d.

Limbic system—central to the regulation of emotion and learning as well as responsible for linking the midbrain with the hindbrain a.)

Thalamus—receives and integrates sensory information from sense organs and higher brain structures

b.)

Hypothalamus—controls basic biological urges such as eating, drinking, and sexual activity; much of what we do related to the autonomic nervous system is controlled by this part

Cerebral hemispheres: Most of forebrain, composed of the two cerebral hemispheres; many brain functions are lateralized 1)

Left hemisphere-- regulates language function; right hemisphere regulates spatial organization and analysis

2)

Corpus callosum-- connects the two hemispheres and is involved in coordinating 20 C.

the functions of each side

4.

5.

3)

Ventricles-- chambers in the forebrain that are filled with cerebrospinal fluid.

4)

Cortex-- consists of frontal, occipital, parietal, and temporal lobes

5)

Cerebral cortex-- the uneven surface of the forebrain that lies underneath the skull; controls sophisticated memory, sensory, and motor functions; divided into four lobes (i.e., frontal, parietal, temporal, and occipital) a)

Frontal lobe-- located behind the forehead and is responsible for higher mental processes, such as reasoning, planning, emotion, speech, and movement

b)

Parietal lobe-- located on the top back portion of the head, receives and integrates sensory information and is related to spatial reasoning

c)

Temporal lobe-- located beneath the frontal and parietal lobes, processes smell and sounds, regulates emotions, and is involved in learning, memory, and language

d)

Occipital lobe-- located behind the temporal lobe at the back lower portion of the head and is responsible for vision and visual processing

Major brain structures and psychopathology a.

Only the most severe mental disorders have been associated with extensive brain damage.

b.

Stroke causes the blood vessels in the brain to rupture, which cuts off the oxygen supply to the brain and kills the brain tissue in the surrounding areas.

c.

Alzheimer’s disease causes tangles of neurons in the brain, which are usually found during autopsies.

d.

Schizophrenia impacts the ventricles of the brain, which are enlarged.

Psychophysiology— study of changes in the functioning of the body resulting from psychological experiences a.

Endocrine system— collection of glands that produce psychophysiological responses 21 C.

by the release of hormones into the bloodstream; activated by stress b.

Hormones— chemical substances that are released by the glands into the bloodstream that impact functioning

c.

Nervous system—central and peripheral

d.

6.

1.)

Central—brain and spinal cord

2.)

Peripheral—connections leading from the brain to the muscles, sensory systems, bodily organs, including voluntary nervous system and involuntary or autonomic nervous system

3.)

Autonomic nervous system-- made up of sympathetic and parasympathetic systems

Psychopathology and psychophysiology 1.)

Autonomic overactivity, hypothesized to be responsible for excessive anxiety

2.)

Chronic underarousal, may be related to antisocial personality disorder

Behavior genetics—the study of genetic influences on normal and abnormal behavior a.

Genotype—individual’s actual genetic structure

b.

Phenotype—expression of a given genotype; influenced by experience

c.

Dominant/recessive inheritance-- when a trait is caused by a single gene that has only two alleles.

d.

Most forms of behavioral abnormality, if related to genetics, are polygenic—caused by more than one gene; multiple genes are probably responsible for nearly all disorders and behavioral disorders should be viewed as on a continuum.

e.

Family Incidence Studies 1.)

Identify normal and ill probands and review the incidence of a disorder within the same family

2.)

Higher incidence of a disorder in families of ill probands may indicate the 22 C.

influence of a genetic factor; however, since family members share the same environment, it may also indicate an environmental etiology. f.

Twin studies 1.)

Monozygotic twins-- produced from a single egg; share 100 percent of genetic make-up

2.)

Dizygotic twins-- produced from separate eggs; share 50 percent of genetic make-up

3.)

Key question: Are MZs more similar than DZs for a particular disorder?

Concordance rates for MZs vs. DZs are compared; if MZ rate is greater, there is a genetic component for that trait or disorder, assuming equal environmental effects

4.)

High concordance for both suggests influence of shared environment

5.)

Low concordance rates for both MZ and DZ points to the influence of the nonshared environment—experiences that are unique to one twin, for example

g.

Adoption studies 1.)

Basic design is to compare those who were adopted as infants with their biological vs. adoptive relatives

2.)

If concordance rate with biological parents is higher than concordance rate with adoptive parents, a biological factor is assumed; if more similar to adoptive parents, then an environmental factor is assumed

h.

i.

Potential misinterpretations of behavior genetics findings: 1.)

If there is a genetic influence, a disorder is inevitable.

2.)

If a characteristic is genetically influenced, it cannot be modified.

3.)

If there is a genetic influence, a particular gene must be directly responsible for the behavior.

Gene-environment interaction -- a kind of diathesis-stress model in which both the genetic make-up and environmental influences affect the development of a disorder 23 C.

j.

Gene-environment correlation-- the connection between the genetic make up of the person and her experiences; experience is not random

B. Psychological factors 1.

2.

We can organize many psychological factors affecting mental health into six categories: (1) human nature, (2) temperament, (3) emotion, (4) learning and cognition, (5) our sense of self, and (6) human development a.

Basic psychological functions are hypothesized by evolutionary psychologists to have their origins in natural selection and to have adaptive or evolutionary value.

b.

Natural selection-- the process in which successful, inherited adaptations to environmental problems become more common over successive generations.

c.

Inclusive fitness-- the reproductive success of those who have the adaptation to their offspring

d.

Sexual selection-- improves inclusive fitness through increased access to mates and mating

e.

Bowlby's attachment theory states that the critical factor in development is the quality of attachment formed between infant and parent; attachment theory has strong empirical support.

f.

Dominance relations have been proposed to be crucial in human as well as animal groups.

g.

Temperament—characteristic styles of relating to the world; five basic temperaments have been identified: extraversion, agreeableness, neuroticism, conscientiousness, and openness to experience. Temperament is particularly important in personality disorders.

h.

Emotions may be the motivating factor behind social behavior and may be more basic than cognition.

1.)

The six basic emotions are love, joy, surprise, anger, sadness, and fear.

2.)

It is useful to think of emotional systems, which are physiologically and psychologically linked

Learning and cognition 24 C.

3.

4.

a.

Modeling—learning by observing/imitating others

b.

Motivations, temperament, and emotions can be changed through learning.

c.

Social cognition—how humans process information about themselves and others; including how attributions are made

d.

Attributions– related to the perceived causes or people’s beliefs about the cause and effect relationship

e.

Causes of psychopathology 1.)

Fears and anxieties can be classically or operantly conditioned

2.)

Depression may be caused by learned helplessness (attribution of negative events to internal, global, stable causes) or cognitive distortions

Sense of self a.

Identity may be unitary, or people may have multiple identities/roles, also known as an integrated view of self

b.

Lack of positive self-esteem, self-concept, self-efficacy may play a role in development of psychopathology

c.

Relational self-- the unique actions and identities associated with significant relationships one may have with others

d.

Self-control-- a process of intrinsic things within an individual that provide rules for appropriate behaviors

e.

Self-esteem -- often the controversial aspect of our sense of self that values one’s abilities in life

Stages of development a.

Freud's psychosexual model emphasizes sexuality in development through adolescence.

b.

Erikson's psychosocial model emphasizes social interactional tasks through the life span.

25 C.

c.

Psychopathology can occur during stressful developmental transitions.

d.

Developmental stages—periods of time marked by age and/or social tasks during which children or adults face common social and emotional challenges

e.

Developmental transitions—mark the accomplishment of one developmental stage and the beginning of the next developmental stage

C. Social factors 1. The broadest perspective with numerous potential sources of influence 2. Social roles and expectations are seen as causes of abnormal behavior.

3. Labeling theory states that people’s actions conform to the labels or “self-fulfilling prophesy.”

4. Social influences on abnormal behavior include interpersonal relationships, social institutions, and cultural values.

5. Close relationships and psychopathology: strong correlations are found between troubled relationships and psychopathology; question is direction of causality a.

Marital difficulties and psychopathology are correlated.

b.

Social support from peers or others outside the family can buffer the impact of troubled family relationships.

6. Gender and gender roles a.

Women seem to have more depression, while men are diagnosed more with substance abuse.

b.

Gender roles influence the development, expression, or consequences of psychopathology.

c.

Social expectations may foster women to become depressed when faced with adversity, while men’s roles dictate to “carry on.”

d.

Androgyny—the possession of both male and female gender role characteristics, associated with being overly “feminine” or overly “masculine” 26 C.

e.

It is important to address the impact of gender roles when assessing the prevalence of various disorders.

7. Prejudice, poverty and society: It is difficult to entangle the separate effects of each since they are so highly correlated with each other (and with marital status). a.

In 2009, 9.3 percent of White families were living below the poverty level compared to 22.7 percent of Black families, and 22.7 percent of Latino families.

b.

36.7 percent of single Black mothers are living in poverty, compared to 27.3 percent of single White mothers and 38.8 percent of single Hispanic mothers living in poverty

c.

Poverty impacts more African Americans than Whites, but the experience of poverty is different.

d.

Prejudice and poverty is associated with an increased risk for mental disorders.

e.

Poverty increases the exposure to toxins that can damage the central nervous system.

8. Abnormal behavior must be considered in the context of a society’s values, which may influence its development and expression.

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LEARNING OBJECTIVES LO 2.1: What is the biopsychosocial model and why do we need it?

LO 2.2: What does “correlation does not mean causation” mean?

LO 2.3: How is “mental illness caused by a chemical imbalance in the brain” an example of reductionism?

LO 2.4: Are scientists likely to discover a gene that causes mental disorders?

LO 2.5: How do social and psychological factors contribute to emotional problems?

LO 2.6: Is abnormal behavior really all about labeling and role-playing?

LECTURE SUGGESTIONS Challenging reductionism: Miller and Keller’s model—Current directions APS reader (2E, p.5) Miller and Keller offer an insightful look at the issue of biological reductionism and the broader question of how neurobiological theories relate to psychological ones. After the “decade of the brain” (1990s), it has become common to describe a psychopathology as simply a “chemical imbalance,” for example. But Miller and Keller warn against viewing the biological level as primary: “Biological data provides valuable information that may not be obtainable with self-report or overt behavior measures, but biological information is not inherently more fundamental, more accurate, more representative, or even more objective." They also criticize the attempt to view psychological and biological data as interactive, preferring the concept of "implementation" when viewing the way in which biological reality impacts upon the psychological—and vice-versa. This language allows for the concept that "a given neural circuit might implement different psychological functions at different times or in different individuals.”

The important point of the Miller/Keller article is that syndromes should not be looked at as caused by underlying biological mechanisms, such as depression caused by a lack of available serotonin in the brain. Instead, the psychological and biological are more like simultaneous systems that impact upon each other; psychological phenomena alter the brain, and existing biological conditions implement or play a role in how the psychological will manifest. The systems approach advocated in this text can easily be reconciled with the Miller/Keller hypothesis; biological, social, and psychological systems can be viewed as interacting in both causal directions.

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An interesting trend in current clinical practice is also challenged by the authors of this article, which is to treat "biological disorders" with "biological treatments" and psychological disorders with psychologically-based treatments. They provide compelling arguments to dispute this trend; often an apparently psychological disorder can be effectively treated with medication, and the reverse is also true.

Cases of so-called "biological depression" can, in some cases, be treated effectively with psychological (e.g. cognitive) treatments.

Oliver Sacks: Use any of Oliver Sacks' cases from The Man Who Mistook His Wife for a Hat to illustrate the way in which brain injuries can affect the psychological functioning of an individual. The title chapter is a good one; the patient actually could not distinguish his wife from his hat!

Sacks, O. (1985). The Man Who Mistook His Wife for a Hat and Other Clinical Tales. New York: Summit Books.

Evolutionary psychology: The evolutionary model is here to stay and becoming more widely accepted every day, especially in psychology. In order to embrace this model, however, we must first accept the connection between other animals and humans. If we look into the animal kingdom, we can find many examples of chimpanzees and other animals behaving in very “human” ways. For example, chimps develop political alliances, display a great deal of "empathy" for those in distress, and reconcile with opponents after battling, often with a kiss and embrace.

The evolutionary model, however, has been weakened by exaggerations, misperceptions, and poor theoretical conceptualization.

What evolutionary theory provides that other psychological theories fall short of offering is ultimate explanations. For example, rather than focusing only on immediate, proximate reasons for particular tendencies, the evolutionary approach attempts to provide deeper reasons for why we choose certain types of mates, why we tend to avoid incest, and why we favor our own kin. A more complex model of evolutionary theory will allow more insight into these larger human tendencies, but only if we can overcome the human/other animal dualism, which has been pervasive in the field of psychology thus far.

Object relations and attachment theories: Give a brief summary of object relations theory, and discuss its similarity to Attachment Theory. The basic assumptions of this model are as follows: (a)

Human beings are inherently relational by nature.

29 C.

(b)

The course of development is determined by the nature of early relationships with primary caregivers.

(c)

Healthy identity and sense of self is possible only through supportive relationships.

(d)

Psychotherapy consists of developing constructive client-therapist relations, allowing the client to reconstruct (or even construct) a healthy sense of self.

You may also wish to describe the concept of splitting, in which the person is unable to maintain a coherent internal concept of an important other. This ego splitting is thought to be a determining factor in narcissistic and borderline personality disorders.

Jerome Kagan: Describe Kagan's research on temperament. Kagan is a particularly interesting researcher as his early career was spent as an advocate for a social-learning perspective, whereas he subsequently argued that genetics play a more powerful role in personality/temperament. Kagan's research suggests that about 20 percent of the population from birth will be overly sensitive, difficult, and irritable. About half of these infants will become shy adults who have difficulty with social relations.

Kagan, J. (1994). Galen's Prophesy: Temperament in Human Nature. New York: Basic Books.

Thought of the day: As a way to stimulate some discussion related to the lecture material, begin the class with a question (e.g., What do you believe causes abnormal behavior, or mental disorders?). Give the students three to five minutes to write down their answers. Answers can come from a combination of the chapter readings, media, personal experience, opinions, etc. This can be a perfect time to discuss the “labels” and “stigma” associated with mental illness, as well as the different paradigms to consider.

Quick summary: Before beginning the lecture of the day, ask students to select one concept, such as a key term, important figure/theorist, a specific disorder, treatment method, etc., outlined in the chapter (e.g., The Diathesis-Stress Model). After the students have selected the topic of their choice, they can draw a logo, symbol, or bumper sticker, write a poem or a song lyric, or come up with a toast or eulogy to capture the essence of the term selected.

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Psychoneuroimmunology: The mind-body connection:

Lorentz (2006) reported that stress is an “unconscious response to a demand,” and stress becomes problematic when the “demand exceeds an individual’s ability to respond or cope effectively” (p. 5).

Therefore, we can see that stress has both benefits and consequences with repeated exposure. Some researchers would state that most of all disorders, from the common cold to major depression, have emotional roots as the underlying cause. Even Freud claimed that anxiety was the root of all pathology. At what point do you believe the demand of the stressor would overcome an individual’s ability to cope? This can be a starter for the lecture on mind-body dualism and the contributions of the ancient philosopher, Descartes. In addition, you can ask for students to brainstorm ways that their own thoughts, emotions, and behaviors have impacted either their physical or psychological well-being. Another lecture starter would be to ask students to write down either individually or in a small group a list of positive and negative coping mechanisms, as well as stressors for each letter of the alphabet. For example, for the letter A, some examples of coping mechanisms would be alcoholism and archery, with academics being a stressor. You may also select specific letters of the alphabet as a different modification of this activity.

Lorentz, M. (2006). Stress and psychoneuroimmunology revisited: Using mind-body interventions to reduce stress. Alternative Journal of Nursing, (11), 1-11. Retrieved from http://www.altjn.com/perspectives/stress.pdf on May 24, 2011.

DISCUSSION IDEAS Correlation vs. causality: Present an example of two correlated variables that appear to be causally connected but are explained by a third variable, and ask the students to explain the relationship. Then ask students what the connection is between smoking cigarettes and cancer. Is this just a correlation, or is there a "causal" connection? How does one establish causality? Three factors should eventually emerge in the discussion: (1) a temporal succession between smoking and the onset of cancer should be identified, (2) a mechanism that explains how cigarettes affect the lungs should be described, and (3) a linear relationship (the more one smokes, the greater the chances for developing cancer) should exist between the two. In this case, all of these are present, thus leading to a justified "causal model." Then ask students about other supposed "causal connections"— between the use of marijuana and the use of harder drugs; between lowered levels of serotonin and norepinephrine and depression; between depression and suicidal ideation. Are causal models justified in those cases? Apply the criteria and discuss. This will help students clarify the difference between correlation and causality.

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Behavior genetics and the nonshared environment: Current directions APS reader (1E, p.17): The Turkheimer article provides a brief background in behavior genetics, nicely condensed in the three laws expressed on pg. 17: (1) All human behavioral traits are inheritable, (2) The effect of being raised in the same family is smaller than the effect of genes, and (3) A substantial portion of the variation in complex human behavioral traits is not accounted for by the effects of genes or families. The "gloomy prospect" referred to repeatedly in this article appears to focus on the rather mysterious nonshared environmental factor which behavioral geneticists have been attempting to understand for the last several years.

Ask the class about this nonshared environmental factor, which appears to account for a large percentage of the variance in individual differences. Begin by focusing on the question raised by Turkheimer: why are siblings so unlike one another when they share both genetics and environment?

Then ask students to consider which aspects of the environment are shared and which are unshared by siblings. Probe them to think about an even larger question of whether we can confidently state that, when we experience the “same event,” it really is the “same event”? To what extent do individual differences in readiness, perception, and personality lead to each of us experiencing a great deal of "uniqueness" in our daily life?

Gender differences: Introduce Carol Gilligan’s theory that women are more relationship-focused and men are more achievement-oriented. Then ask what factors might cause these differences. This provides a good opportunity to illustrate the systems approach in that biological, psychological, and social factors probably all contribute to these differences (if, indeed, they do exist). Excerpts from Gilligan’s In a Different Voice (1982) or Deborah Tannen’s You Just Don’t Understand (1991) could provide a good starting point.

Gender and gender roles: The Housekeeping Monthly (1955) article defined what stipulates a “good wife.” You can access this article from the link below and either display it on an overhead projector or make copies of the article to distribute to your students. Ask the students to read the article and assess some of the social factors, such as relationships, marriage, gender roles, and societal norms, as it relates to abnormal behavior. Students can write down which of the statements they think are more relevant to the information discussed in the chapter, as well as discuss their reactions to the article. Some key questions you may want to ask can include the following: Did you ever witness any of these norms in your home growing up? How have things changed since the 50s? What would it have been like to live during these years with these gender roles? Would you look for any of these traits in a potential partner, why or why not? What if the gender roles were reversed in the article? What would this look like?

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The article can be retrieved from the following link: http://www.j-walk.com/other/goodwife/images/goodwifeguide.gif

CLASSROOM ACTIVITIES Systems approach to causation: Divide the class into three groups: (a) psychological, (b) social, and (c) biological. Present the class with the following situation: "A college freshman, in his first month of school, is experiencing a very disturbing repetitive nightmare. In the nightmare, he is constantly being chased. He runs and runs and then asks a very official-looking person for directions home, but the person does not seem to speak his language. The student is so anxious about this repetitive nightmare that he seeks counseling at the Student Counseling Center (he had been in psychotherapy for anxiety in high school before, after he switched high schools when his father was transferred)."

Ask the students to provide a causal explanation and treatment plan based on their given approach.

Then discuss their explanations, and address how the systems approach would treat these seemingly different explanations. This allows you to demonstrate the way in which psychological, social, and biological approaches do not necessarily contradict each other.

Creating your own theory: Ask students, either individually or in groups, to generate their own theories to explain the development of psychopathology. You may wish to ask students to do this exercise before reading this chapter and again afterward. This is also a nice exercise to repeat at the end of the semester to see how their explanations change as a function of completing the course. You can read some of them or ask volunteers to present them.

Use of social media: Use a popular medium such as YouTube, Facebook, MySpace, Twitter, etc., to portray a course concept (e.g., Bowlby’s Attachment theory related to the bond between a mother and child or Bandura’s concept of modeling). Ask the students to then describe the concept portrayed or to discuss with peers in small groups.

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Debate: Which paradigm is the “fairest of them all”: Divide the class into these four sections: biological paradigm, psychodynamic paradigm, cognitivebehavioral paradigm, and biopsychosocial paradigm. Tell the students it is up to them using their textbooks, notes, personal knowledge, Internet, and the assistance of their peers to support why their selected paradigm is the “fairest” when assessing the causes, symptoms, and treatment of psychiatric disorders. Ask for each of the groups to share the information gathered with the class to spark a discussion about the pros and cons of each paradigm.

Caught in the act of a “defense mechanism”: Using Table 2.1, Some Freudian Defense Mechanisms, in the textbook, write the defense mechanisms listed on strips of paper, and hand these out to students or ask the students to turn to page 29 to review the defense mechanisms in the textbook. Then you can either show short clips from popular movies or YouTube videos, or ask the students to think of a time when they witnessed a celebrity or famous individual engaging in one of these defense mechanisms.

Evaluation of the id, ego, and superego: The id, which could be viewed as the “demanding child,” is ruled by the pleasure principle. The id involves the desire for instant gratification of one’s desires. The ego is based out of the reality principle and is the more adult part of the personality that focuses on stability to deal with reality; the ego could be viewed as the “traffic cop.” The ego weighs out the pros and cons of situations before making a decision.

Lastly, we have the superego, which is one’s sense of right or wrong; also known as the conscience, this could be defined as the “judge.” The superego focuses on the rules and the sense of accomplishment if you follow them versus the negative consequences such as punishment if you do not follow these standards for behavior.

This activity can be done several different ways. You can break the classroom into small groups and ask the students to evaluate popular cartoon characters based on what part of the mind, according to Freud, the character primarily functions from. Another way this can be done is to use newspaper clippings of cartoons or display some images of popular cartoon characters on an overhead projector. For example, Tigger from Winnie the Pooh would be an example of the id; Jiminy Cricket from Pinocchio would illustrate the superego, and Rabbit from Winnie the Pooh would be an example of the ego. Additionally, you could ask students to create, using their own inspiration, a cartoon character that would function primarily from one of the parts of the mind based on the Psychoanalytic theory.

Fact or fiction: At the end of lecture, this is a way that, as the professor, you can incorporate some critical thinking related to the chapter material. On small sheets of paper, write down two facts that were discussed in the 34 C.

lecture material or readings and one piece of information that is fiction. For example, (a) In Freud’s Psychoanalytic theory, the mind is comprised of three parts: the id, subego, and ego, (b) The cognitivebehavioral paradigm focuses on learning when evaluating abnormal behavior, and (c) If you are a child or an adult of a divorced or never-married family, there tends to be more psychological problems. The ‘facts’ are letters (b) and (c). Then ask the students to identify the two facts and the fiction. Another way that this can be done is to ask the students to recap the information discussed in lecture by writing down two facts and one fiction on a piece of paper. After the students have completed this, ask them to share with peers sitting next to them to see if their peers can guess the facts. This could also be used as a potential study guide or as test or quiz questions if you decide to take these up after the lecture.

Sunshine and cloud: At the end of the class, have students write down in one to two minutes a recap of what they learned from lecture that day. First, have them write down their “sunshine” (e.g., the concept they most enjoyed learning about that day or an activity that was fun) and then write down the “cloud” (e.g., the concept the student found to be the most unclear or was not as enjoyable). This activity can provide an assessment of the student’s comprehension as well as the presentation of the lecture material, highlighting where changes could be made.

VIDEO RESOURCES http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/APS2010/ShinobuKitayama. html Shinobu Kitayama: Can you talk about the relationship between biology and culture? (1:52) Watch this video about how biology, evolution, and culture are related.

http://media.pearsoncmg.com/ab/psychtutor/PsychTutor_Correlation_vs_Causation.html Correlation vs. Causation Explore the differences between correlation and causation.

http://media.pearsoncmg.com/ab/ab_lefton_psychology_8/media/lbp8e_11395/lbp8e_11395.html Physiological, Evolutionary, and Cognitive Theories of Emotion 35 C.

Explore this presentation on the differences between physiological, evolutionary, and cognitive theories of human emotional responses and the scientists associated with each theory.

http://media.pearsoncmg.com/ab/ab_lefton_psychology_8/media/lbp8e_16602/lbp8e_16602.html Drugs Commonly Used to Treat Psychiatric Disorders Explore different drug types and match them to the corresponding disorder types they are designed to treat.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/APS2010/JoshuaAronson6. html Joshua Aronson: What is the relationship between evolutionary theory and psychology today? (3:32) Watch this video on the relationship between psychology and evolutionary theory.

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Chapter 3 Treatment of Psychological Disorders Chapter-at- a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: p. 53 Four Views of Frances Biological Treatments: p. 55 Psychopharmacology Electroconvulsive Therapy Psychosurgery

Lectures: Electroconvulsive therapy

Psychodynamic Psychotherapies: p. 58 Freudian Psychoanalysis Ego Analysis Psychodynamic Psychotherapy

Lectures: Critiques of psychotherapy

Cognitive Behavior Therapy: p. 60

Lectures: Feedback interventions

Systematic Desensitization Other Exposure Therapies Aversion Therapy Contingency Management Social Skills Training Cognitive Techniques Beck’s Cognitive Therapy Rational-Emotive Therapy “Third-Wave” CBT

Video Case: Hypochondriasis, Henry

Humanistic Therapies: p. 64

Classroom: Debate on the role of insight

Discussion Ideas: Computer-based psychotherapy

Client-Centered Therapy A Means, Not an End?

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PROFESSOR NOTES

Research on Psychotherapy: p. 65

Discussion Ideas: Psychotherapy as empathy

Does Psychotherapy Work?

Psychotherapy Process Research Common Factors Therapy as Social Support Therapy as Social Influence Pain Relief?

Classroom: Practicing techniques,

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CHAPTER OUTLINE I.

II.

III.

Overview A.

There are many available treatments for psychological disorders, including biological treatments and psychotherapy.

B.

Only a small percentage of those diagnosed as having a mental disorder actually receive treatment.

C.

The many approaches to psychotherapy can generally be grouped into the four major paradigms.

D.

The authors favor using different treatments and approaches for different disorders because different therapies are most effective for different problems; this is called eclectic therapy.

Theoretical orientations in psychotherapy A.

Biological—mental illness is understood as physical illness;agents that promote biological change (e.g., medication) are the primary treatment modality

B.

Psychodynamic—promotes insight into unconscious motivations and defenses and insight into the influences of the past on the present

C.

Cognitive-behavioral—teaches new ways of thinking and acting to produce more adaptive functioning

C.

Humanistic—goal is to increase emotional awareness and genuine emotional expression and to help people take responsibility for their own life choices

Treatments A.

Biological treatments can be traced back to the discovery of the cause and cure for general paresis. They often alleviate symptoms rather than cure disorders, however.

1.

Psychopharmacology—the study of the use of medications to treat psychological disturbances; psychotropic medications are generally safe and effective but typically do not provide a cure (only symptom relief); may have unpleasant side effects, and are often taken for long periods of time a. Some psychotropic medications help produce changes in thinking, mood, and behavior. b. 11 percent of American women are prescribed antidepressants, while 5 percent of American men are prescribed antidepressants. c. Most psychotropic medications are prescribed by a primary care physician instead of a psychiatrist who is trained in prescribing these medications for mental disorders. d. Americans seem to be searching for a magic pill.

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2.

Electroconvulsive therapy (ECT)—deliberate induction of a seizure by passing electricity through the brain a. Though controversial, ECT is effective and currently used to treat severe depression. b. Bilateral ECT—a current is passed through both sides of the brain c. Unilateral ECT—a current is passed through one side of the brain (safer, more common, and with less memory loss); less side effects but also less effective d. Developed by Ugo Cerletti and Lucio Bini, both Italian physicians in 1938, seeking a treatment for schizophrenia

3.

Psychosurgery—surgical destruction of specific regions of the brain a. Prefrontal lobotomy severs frontal lobes—limited in effectiveness and associated with frequent and severe side effects, including a high mortality rate b. A very circumscribed version (cingulotomy) is rarely used in serious conditions as a last resort for obsessive-compulsive disorder. c. Used to treat severe obsessive compulsive disorder

B.

Psychodynamic psychotherapies 1.

Freudian psychoanalysis a. Free association, dream interpretation, and slips of the tongue provide information about the unconscious. b. Insight is the goal and is promoted by interpretation. c.

Therapeutic neutrality encourages free association and transference.

d. Goals are to replace maladaptive defenses with adaptive defenses and help the patient find socially and psychologically appropriate outlets for needs and drives. e. Current status of Freudian psychoanalysis 1.) Requires considerable time, expense, and a desire for self-exploration 2.) Most accessible to well-functioning, introspective, and financially secure people 3.) Utilized for "neurotic" disorders, including anxiety; those without psychoses benefit the most 4.) Current psychodynamic approaches are more engaged, directive, and less protracted than psychoanalysis 40 C.

2.

Ego analysis—emphasizes the patient’s coping with the external (past/present relationships), as well as the internal (unconscious) world a. Sullivan saw personality functioning as related to dominance and affiliation. b. Horney believed people have competing needs for closeness, dominance, and autonomy (moving toward, against, and away from others). c. Erikson's psychosocial stage theory emphasized social, rather than sexual, aspects of development. d. Attachment theory—Bowlby believed a primary human characteristic is to form attachments to caregivers; healthy attachments are necessary for healthy development.

3.

Psychodynamic psychotherapy a. Psychotherapists are more actively engaged with their clients; they direct patients’ recollections, focus on current life circumstances, offer interpretations more quickly and directly, and provide emotional support. b. Short-term psychodynamic psychotherapy uses psychoanalytic techniques (particularly analysis of transference), but focuses on specific emotional issues.

C.

Cognitive-behavior therapy 1.

Focuses on behavior change in the present rather than understanding of the past or alteration of the dynamics of personality

2.

Encourages a collaborative therapist-client relationship to focus on the present, with direct efforts to change problems through the use of empirically supported treatments

3.

Historical roots include Watson's principle that all behavior is learned and could be unlearned, Pavlov's classical conditioning studies, and Skinnerian operant conditioning principles

4.

Outcome-oriented rather than theoretical

5.

Classical conditioning techniques—derived from Pavlov’s work, use exposure and counterconditioning to alter existing responses by pairing new responses with old stimuli a. Systematic desensitization developed by Wolpe to treat phobias 1.) Relaxation training 2.) Constructing a hierarchy of fears 3.) Gradually pairing the feared stimulus (in imagination) with relaxation 41 C.

4.) Effective for fears and phobias but unclear exactly why; may be factors other than counterconditioning; other possibilities include the removal of reinforcement for avoidance, the extinction of the fear, an increased self-efficacy, or support from therapist b. In vivo desensitization—gradual exposure (in real life) to feared stimulus while maintaining relaxed state c. Flooding—exposure to feared stimulus at full intensity while preventing avoidance until the conditioned response is extinguished d. Aversion therapy 1.) Creates, rather than eliminates, an unpleasant response (e.g., nausea) to an undesirable behavior (e.g., smoking) 2.) Controversial because it involves creating distress 3.) Often successful in the short-term but has high relapse rates 6.

Contingency management techniques use the operant conditioning principle that behaviors that are reinforced will increase, and those that are punished will diminish. a. Contingency management—controlling the rewards and punishments for behaviors of interest; most effective when the therapist has control over the patient’s environment (e.g., token economy in a hospital setting) b. Effective in those “controlled” settings, but results often do not generalize

7.

Social skills training—teaching desirable ways of behaving that are rewarded in the everyday world a. Assertiveness training teaches clients to be direct about their feelings and wishes, often uses role-playing b. Social problem solving is a step-by-step approach to dealing with social problems.

8.

Cognitive techniques a. Attribution retraining encourages clients to be more scientific and less intuitive in their attributions about causes. b. Self-instruction training is a series of structured steps designed to teach impulsive children internal controls. c. Cognitive therapy, developed by Beck for treatment of depression, advocates collaborative active challenging of distorted beliefs and cognitions. d. Rational emotive therapy (RET) challenges a client's irrational beliefs. In contrast to cognitive therapy, clients are directly challenged through disputation in the therapy session.

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9.

“Third-wave” CBT refers to treatment approaches which focus on acceptance, mindfulness, values, and relationships. a. Dialectical behavior therapy emphasizes mindfulness—increased awareness of feelings, thoughts, and motivations

b. Acceptance and commitment therapy encourages accepting oneself and making a commitment to appropriate changes.

10. Cognitive-behavioral approaches are diverse but united in their empiricism.

D.

Humanistic therapies—developed as an alternative to psychodynamic and behavioral approaches 1.

Conceptualizes distress as resulting from the frustrations of human existence and alienation of the self from others

2.

Therapy involves helping the individual make life choices and increasing his/her emotional awareness, not treating “problems”; the therapist is not an “expert”

3.

A genuine, warm relationship between client and therapist is the central means for producing therapeutic change, rather than simply a method for delivering the treatment.

4.

Client-centered therapy developed by Carl Rogers a. Empathy and a warm, genuine relationship are crucial. b. Self-disclosure by the therapist is encouraged to facilitate the relationship. c. Unconditional positive regard must be demonstrated toward the client. d. Nondirective; clients, not therapists, control sessions e. It’s more about the relationship built between the client and therapist than the tools or techniques utilized in session.

5.

IV.

Little systematic research to support humanistic psychotherapy; empathy, however, has been found to play a positive and central role in the psychotherapy process

Research on psychotherapy A.

Does psychotherapy work? General conclusions: yes, it does work, at least in the short term

B.

Outcome research—evaluation of effectiveness of psychotherapy 1.

Meta-analysis studies aggregate the results of many studies. a. The average client receiving psychotherapy is better off than 80 percent of those who are untreated.

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b. The average gain produced by many accepted medical treatments is much smaller. c. Two-thirds of clients improve significantly in therapy; one-third of those who do not seek treatment improve over time.

2.

Improvement without treatment a. Skeptics such as Eysenck have asserted that psychotherapy does virtually nothing; however, he asserted that two-thirds of people would improve even without treatment. b. Treatment can be difficult to define, since most of those who are distressed seek advice/counsel of friends or family members. c. One-half of those seeking psychotherapy improve as a result of having unstructured conversations with a professional.

3.

Placebo effect a. Across health care disciplines, substantial treatment gains are a function of placebo—apparently inert aspects of treatment b. Patients’ belief in a treatment and expectation of improvement play important roles. e. Placebo control groups can help identify treatments that promote benefits beyond those of placebo alone. d. Double-blind studies are necessary to experimentally evaluate but impossible to conduct, since therapists must know what type of therapy they're conducting.

4.

Efficacy and effectiveness a. Efficacy: can specific treatments work?

1.) Studies are tightly controlled.

2.) Treatment and no-treatment conditions are utilized.

3.) Strong internal validity but uncertain external validity b. Effectiveness: does treatment work in the real world?

1.) Studies are correlational.

2.) Generally eclectic therapy examined 3.) Cannot inform us about cause and effect but provide valuable descriptive information c. The Consumer Reports study (1995) 1.) Effectiveness study surveying readers who had seen a mental health professional 44 C.

in the past 3 years (about 3000 respondents) 2.) Concluded that therapy helped; 87 percent of those who felt "very poor" at beginning of treatment felt at least "so-so" (or "good" or "very good") when surveyed 3.) Psychologists, social workers, and psychiatrists were equally effective; marriage counselors were less effective.

4.) Medication added little to psychotherapy; people who received psychotherapy alone had similar improvement to those who received psychotherapy plus medication.

5.) Study may be limited (e.g., by selectivity in participation or by correlational nature) but generally confirms the conclusion that psychotherapy is effective.

5.

Other factors influencing improvement a. Nature of client's problems: diagnosis b. If psychotherapy is going to be effective, it generally works rather quickly; after six months to a year, the rate of improvement drops off; patients tend to drop out of therapy at a high rate; average number of sessions is five c. YAVIS clients (young, attractive, verbal, intelligent, successful) are more likely to succeed in therapy

C.

Psychotherapy process research—studying qualities of therapist-client relationship that predict success regardless of theoretical orientation 1.

Common factors a. Research indicates little difference in outcome between major treatment modalities; the term “common factors” arose to indicate the common aspects between all approaches that make a difference in the therapeutic process (e.g., a good clienttherapist relationship) b. Well-controlled study conducted by Sloane (1975); compared behavioral and psychodynamic therapies, found the following: 1.) Psychodynamic and behavior therapy were generally equally effective, and superior to no treatment.

2.) Success of therapy depended most on the personal relationship between the client and therapist.

3.) Motivational interviewing is a contemporary example of the importance of the common factors that were developed as a placebo to compare the treatment of alcohol abuse.

2.

Therapist supportiveness, warmth, and empathy is related to positive outcomes across different approaches to treatment.

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3.

Frank's comparison of modern psychotherapy and primitive healing suggests some "common ingredients" in all therapeutic relationships. a. A trained healer in whom the sufferer believes and from whom s/he seeks treatment b. A structured set of interactions between healer and sufferer in which change occurs as a consequence of words, acts, or rituals c. Therapy as social support - a positive therapist-client relationship predicts the successful outcomes across approaches in treatment d. Therapy as social influence - Jerome Frank (1909–2005), an American trained in psychology and psychiatry, argued that, in fact, psychotherapy is a process of persuasion; therapy persuades clients to make beneficial changes in their emotional life

V.

Couple, family, and group therapy A.

B.

C.

Couples therapy—seeing couples who are involved in an intimate relationship together 1.

Goal is to improve the relationship, not treat the individuals

2.

Focus is on resolving conflicts and promoting mutual satisfaction by improving communication, negotiation, and conflict resolution skills

3.

Couples therapy can improve marital satisfaction, but questions remain about long-term Effects.

Family therapy—two or more family members in a session, generally including children 1.

Goals may include improving family relationships, improving problem-solving skills, and helping the family cope with the psychopathology of a family member.

2.

Many family therapists utilize a systems approach, emphasizing family members’ interdependence and alliances.

Group therapy—may involve a few or many members 1.

Psychoeducational groups are designed to teach group members specific skills or information relevant to psychological well-being.

2.

Experiential group therapy—interpersonal interaction and relationships among group members form the primary component of treatment

3.

Self-help groups—people who share a common problem share information and experiences

4.

There is limited research evaluating the effectiveness of experiential group therapy.

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D.

VI.

Prevention - community psychology attempts to improve individual well-being by promoting social change 1.

Primary prevention—attempts to improve the environment to promote health and prevent psychopathology

2.

Secondary prevention—involves early detection of emotional problems in order to treat them more effectively

3.

Tertiary prevention—intervention after the illness has been identified, including treatment and other assistance

Specific treatments for specific disorders A.

Some evidence indicates that different approaches are more effective for particular disorders.

B.

There is a need for more research to establish which problems are treated most effectively with which treatments.

C.

The authors assert that 1.

The client’s problem, rather than the therapist's orientation, should determine the approach used.

2.

Clients should be informed about research evidence and treatment alternatives.

3.

Psychotherapists should approach therapy as both scientists and practitioners.

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LEARNING OBJECTIVES LO 3.1: What do treatments for psychological problems look like?

LO 3.2: How did Freud influence psychotherapy?

LO 3.3: What is cognitive-behavior therapy?

LO 3.4: Does psychotherapy work?

LO 3.5: What is the placebo effect? How do placebos work?

LO 3.6: Is it important to “click” with your therapist?

LECTURE SUGGESTIONS Electroconvulsive therapy: ECT has always been, and probably will continue to be, a controversial treatment. However, is it an effective treatment? In 1977, Turek and Hanlon argued that most studies of ECT have major flaws; number of treatments, types of illness, and measurements of outcome are rarely well-controlled. The psychiatrist Peter Breggin (1979) has argued that ECT is not only a "poor experiment," but it is a dangerous one. Some studies conclude that ECT is effective in helping as many as 72 percent of patients, compared with 23 percent who receive placebos (Wechsler, Grosser, & Greenblatt, 1965). The number of deaths reported from ECT is similar to that reported for general anesthesia: about 3 in 10,000. The frequency of side effects has significantly declined with the use of unilateral ECT and muscle relaxants, which prevent injury during the procedure.

How does ECT work? Keltner and Boschini summarize the ‘mechanism of action’ findings as pointing to four routes by which ECT provides improvement: (1) Slowing down brain waves may work in much the same manner that ‘rebooting a computer’ works; (2) The rebalancing of neurotransmitters; (3) The rebalancing of hormones; and (4) The brain-strengthening effect of induced seizures, which is somewhat akin to the increased muscular development produced by lifting weights. Due to the nature of the procedure, its history of abuse, the controversies surrounding the underlying mechanisms involved in its effects, and the question of its effectiveness, perhaps ECT will continue to be one of the most controversial treatments within the mental health field.

Brogan, P.R. (1979). Electroshock: Its brain-disabling effects. New York: Springer.

Keltner, N.L.; Boschini, D.J. (2009). Electroconvulsive therapy, Perspectives in Psychiatric Care, 45(1), 66–70.

Turek, I.S. & Hanlon, T.P. (1977). The effectiveness and safety of electroconvulsive therapy (ECT). Journal of Nervous and Mental Diseases, 16, 419–431.

Wechsler, H., Grosser, G.H., & Greenblatt, M. (1965). Research evaluating antidepressant medications on hospitalized mental patients: A survey of published reports during a five-year period. Journal of Nervous and Mental Diseases, 141, 231–239.

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Critiques of psychotherapy: Despite the psychotherapy outcome research that indicates that it is effective, some very scathing critiques of psychotherapy have emerged over the past twenty years. James Hillman has argued that, by turning the psychotherapy client "inward," we have ignored the larger social and political problems in our modern world. In his book, We've Had a Hundred Years of Psychotherapy—and the World's Getting Worse, he argues that psychotherapy is often too shallow and too narrow, and that psychotherapy clients often are not encouraged to really reflect on the whole picture. Instead, they emerge with very shallow understandings like "I have poor self-esteem" or "I am a victim of abuse" rather than penetrating the depth of the issue.

R.D. Rosen popularized the term psychobabble in the late 1970s to denote the vague language and catchy terms used by psychotherapists and psychotherapy clients. The danger of psychobabble, according to Rosen, is that it implies that we can reach well-being rather easily, as soon as we recognize our problems. For example, simply admitting "I'm uptight" or "hung up on my mother" allows us to feel that we've made progress or even have solved our problems.

What is the effect of psychotherapy on society at large? How is the world different as a result of the popularity of psychotherapy? Is it better or worse? Describing these critiques can raise some interesting questions for discussion.

Hillman, J., & Ventura, M. (1992). We've Had a Hundred Years of Psychotherapy—and the World's Getting Worse.

San Francisco: Harper Collins.

Rosen, R.D. (1977). Psychobabble. New York: Avon Books.

Feedback interventions: Current directions APS reader (1E, p.30): Much of psychotherapy is based on providing effective feedback to the client, feedback which will presumably improve their functioning in the domains in which they seek improvement. Kluger and DeNisi, however, begin their article by pointing out that a meta-analysis of studies of feedback interventions yielded mixed results. Some feedback seems to help improve performance, whereas in approximately one third of the cases, feedback results in reductions in effectiveness for those receiving the feedback.

Many issues regarding the effectiveness of feedback need to be examined before conclusive determinations can be made. Kluger and DeNisi, however, provide a framework for understanding some of the key issues involved in the question of when, how, and where feedback will be effective. One very striking point that the authors make, for example, is that feedback can serve to shift the focus of attention from the task to the self. In fact, both positive and negative feedback carry this potential, which tends to lead to either no improvement in performance or performance decrements. If the task is particularly complex, this effect may be more pronounced. The shift in attention to the self, which valence-driven feedback often inspires, can deplete the attentional resources needed to improve one’s performance. Kluger and DeNisi also point out that feedback that is given in a situation where goals have been well established and arise from the performer tends to be more effective.

What is the clinical relevance of this work on feedback-based interventions? One point that becomes rather obvious here is that providing feedback for a client is not universally helpful. Feedback is most effective when it is preceded by the establishment of client goals. Moreover, if a client is working on specific aspects of her performance—for example, improving social skills—feedback should be directed to those specific aspects. It should be task-focused and not person-focused. Of course, we also know from other research that feedback that is delivered in a kind and gentle way is more effective than feedback given in a harsh, judgmental manner. Instructors 49 C.

might be interested in asking students to compare the process of providing feedback in a therapy context to that of an educational context.

DISCUSSION IDEAS Computer-based psychotherapy: Current directions APS reader (1E, p.39) The use of the computer as an aid in the world of clinical psychology has continued to grow in the last couple of decades. For example, it has become increasingly common for clients to complete assessment scales, such as the MMPI-II on a computer. The advantages of such practice are obvious: it reduces the contact time required of trained therapists (cost-effective), it provides detailed scoring in a timely fashion, and it may even allow for more openness and self-revealing on the part of the client. In fact, Taylor and Luce cite sources that testify to the fact that more symptoms are typically reported on computer-assisted assessments than on human-delivered assessments.

But can the computer be used for actual treatment? Can the computer replace the therapist to provide more effective treatment? The Taylor/Luce article suggests several ways that this may take place; some preliminary data, moreover, lends support to the concept of computer-assisted psychotherapy. Thus far, computer programs have been used most effectively, it seems, for “specific” problems such as OCD, panic disorder, and simple phobias.

Clients benefit from the information the program can provide, and direct suggestions can be useful in dealing with situations that these disorders involve. Response prevention programs for OCD, for example, can simulate the states that lead to compulsive behaviors and then encourage the client to resist performing the ritual. Internet support groups have become increasingly popular and allow for clients to both learn more about their issues/illnesses and to receive some support from others.

For more “general” kinds of problems like self-esteem issues, relationship issues, or even depression, the situation is somewhat different. Can the computer provide the kind of specific feedback clients need? Even more challenging for computer-assisted therapy programs, though, is the question of the importance of the relationship between client and therapist: can the computer simulate the healing qualities of this relationship? Ask students to consider these questions and use their imagination in thinking about the future of psychotherapy on the computer.

You might also ask the students whether they think the Taylor/Luce article overgeneralized the positive results of just a few studies to support their positive claim that computer- generated psychotherapy is as effective as human interactive therapy. What are the limitations of computer-assisted therapy?

Psychotherapy as empathy: If we examine some of the findings of psychotherapy process research, we see that a warm relationship between therapist and client may be the most important factor in successful therapy. If this is the case, must psychotherapists be so highly trained, having master’s or doctoral degrees ? Why not test people on an empathy scale, and then provide some limited training and allow them to practice, regardless of their knowledge of human behavior? Most students will be quite reluctant to accept this position, but they will perhaps be hard-pressed to justify the length and nature of the current education of clinical psychologists. You may wish to point out that the findings referred to here are generally from studies in which the therapists had received adequate professional training; we cannot determine whether these results would hold up with untrained therapists. Also, many aspects of conducting therapy clearly do require knowledge of human behavior and training—assessment, diagnostic judgments about hospitalization—and there is research suggesting that some applied techniques that are effective (e.g., systematic desensitization) do require some training.

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In search of the magical pill: Antidepressant medications are among the most psychotropic medications prescribed to Americans. Barber (2008) reported, as outlined in the textbook, that around 11 percent of women and 5 percent of men are currently taking an antidepressant. It is also common for an individual to seek an appointment with a primary care physician (e.g., PCP) to prescribe medication for mental health issues instead of making an appointment to see a psychiatrist.

Why do you think most individuals would rather go to their PCPs for psychotropic medication when this individual has not been specifically trained to prescribe these medications like a psychiatrist has been trained? Is there a fear or stigma associated with going to the psychiatrist’s office as compared to going to a regular family care practice? Why or why not? If you could create a “magical pill,” what would this medication look like, what would the side effects be, to whom would it usually be prescribed, and what issues would it address? What happens to individuals when they cannot find a “pill” to fix their problems?

Token economy debate: should patients really receive rewards for treatment?

Contingency management is a way to make the connection with one’s actions and the consequences of those actions. This is done through the use of rewards and punishments. An example of this would be called “token economy.” Token economy is frequently used in residential treatment settings, such as state hospitals, other psychiatric hospitals, and residential treatment facilities, such as group homes within the community. The patients would receive some form of “token,” or something of monetary value, for participating in treatment, for following guidelines, and for participating in outings from the facility, etc. They would also receive some form of punishment, such as having privileges revoked, for being noncompliant with treatment and facility expectations. Would you say that patients may only be following the treatment guidelines to receive a treat or some form of token; why or why not? What are the benefits and consequences of this type of system? Do you have personal experience with the concept of token economy, such as from being in a school setting or at home with your parents’ guidelines? If so, did this work for you? What messages, if any, may be sent through the use of this CBT technique to both staff and/or patients?

CLASSROOM ACTIVITIES Debate on role of insight: Is insight necessary for long-lasting behavior change? Select two groups to present alternate arguments with the following assumptions: The "behaviorists" will contend that understanding the original cause of the problem is difficult and, even more importantly, irrelevant to changing behavior. The “psychodynamic psychotherapists” argue that if the patient doesn't grasp the source of the problem, then you are simply treating the symptoms and allowing for symptom substitution to occur. It may be helpful to present a case and ask each side to develop and describe a treatment plan.

Practicing techniques: Several of the techniques described in this chapter can be demonstrated in the classroom, but doing so with student volunteers may be anxiety provoking. One way around this is to ask for a student to serve as the voice of the “client” with other students calling out prompts, or to have students take turns jumping in and playing the role of “client,” while you serve as “therapist” and model techniques. In this way, no one student is asked to provide much of his or her own personal material. An alternative is to ask for a volunteer to role-play a client with a set of preprinted instructions for specific “symptoms.” Techniques students may find particularly interesting are

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Analysis of transference—A focus on the client-therapist relationship, with specific emphasis on the client’s assumptions and distortions, and the insight they may provide regarding the client’s models of relationships, internal experience, and defenses Systematic desensitization—students describe a specific fear while the therapist helps the client construct a "fear hierarchy" in which they rank the order of at least 8–10 situations in which the fear tends to emerge.

Gestalt "empty chair" technique—the client must present a conflict within herself, and the therapist asks the client to put one side of herself in the empty chair and carry on a conversation between the two parts, attempting to reconcile the situation.

Rational-emotive therapy—Ellis’ challenging style involving active disputation of illogical or faulty cognitions is likely to provoke strong responses. A discussion of the degree of empathy required for successful psychotherapy may be an interesting follow-up.

Name the appropriate treatment: Provide students with a series of treatment presentations and ask them to name the most appropriate treatment for each scenario. This can be done in small groups to allow for more student discussion. Possible scenarios may resemble any of the following: (1) A mother presents with severe depression after a history of bouts with unipolar depression. She is now considering suicide and feels unable to care for her two young children. (2) A student is concerned about her relationship with an abusive boyfriend. She wishes to understand why she continues to enter into abusive relationships despite the fact that she was never abused as a child. (3) A marital couple is considering divorce. There are charges of infidelity, concerns about commitment, and a great deal of overt conflict.

Student groups should be asked to suggest an appropriate treatment and to justify those choices based on the strengths and weaknesses of the treatment modalities and the nature of the presenting patients.

Can social skills training help in the dating world?

We have become a society were technology is so valued that it is more convenient to send a lengthy text message by cellular phone, or an instant message via the computer, instead of picking up the telephone to talk to someone directly or, better yet, to talk face-to-face. Are we a society that can be connected by multiple forms of media and technology at any minute, or have we become a society of disconnection? Ask the students to list all of the many ways that they communicate with friends, family, or significant others such as MySpace, Facebook, Twitter, text message, IM (instant messaging), e-mail, etc. This can be listed on the white board, or a chalkboard, in class or within small groups. Then after the students have had time to list the different ways in which they communicate, ask the following questions to the class: How do you think the importance and expansion of technology has impacted the development of social skills for individuals of all age groups (i.e., children, adolescents, young adults, middle and older adults)? All humans have an instinctual need to be in relationships with others. Has technology ever been in the way of healthy communication, acting as a barrier for your significant relationships? Can technology cause others to misperceive your intentions of what you were trying to convey, due to the mode you used to transmit the message? How so? What can we do to address this?

Debate: To meet or not to meet a partner online, that’s the question: Debates are a great way to spark discussion and a way to apply one’s knowledge of the course information to real-life situations. Divide the class in half and randomly select which half will defend either “to meet a partner online” or “not to meet a partner online.” Ask the students to work together using the information from lectures, textbook readings, media, and personal experience as a way to defend their side of the argument. Then add in the question about whether or not couple therapy should be mandatory for individuals entering a serious relationship. It 52 C.

was previously discussed that one’s relationship status, specifically being unmarried or divorced, is strongly correlated with one’s mental health. The goal of couple therapy is to improve the overall quality of the relationship, but not to treat the individual. Couple therapy has shown to improve satisfaction rates in relationships, but long-term effectiveness is left to be discovered. With the high percentage of divorce rates here in the United States, should “couple therapy” be a requirement before you enter a marriage or a partnership? Why or why not? What would these rules look like for individuals interested in entering a serious relationship? Would the rules be different for those who meet online than they would be for those who meet in person, such as at work or in school? What are the pros and cons of meeting a significant other online through the use of a dating site like Match.com or eHarmony? Do you believe there is a higher risk for the relationship to dissolve if the couple first meets through the Internet than if the couple had first met in person?

Participation in group therapy: Give the students either a list of open groups that are available in the community, such as a support group, a grief group, Narcotics Anonymous, Alcoholics Anonymous, or a self-help group, just to name a few, or ask them to conduct their own research of available group therapy sessions within the community. Ask the students to attend at least two of these “open” groups that are available to the general public. Then have the students write down what they learned, or their thoughts on being part of a group therapy session, to share with the class. If this is not a feasible option, bring in a guest speaker from the community who facilitates group therapy as a treatment modality for a question and answer session for the students.

Create a prevention plan: Primary, secondary, or tertiary: Break the students into small groups and pass out small sheets of paper with one of the following levels of prevention (e.g., primary, secondary, or tertiary). Then ask the students to use their creativity, understanding from the lectures and the textbook, and the help of their peers to come up with a prevention plan for a population decided by the group. Allow the students ten to fifteen minutes to complete this activity. The students can create a brochure, adapt a skit to display the plan, or simply write down their thoughts on paper to share with the class. This will also provide some assessment of the comprehension and application of the concepts discussed in the lecture to real-life situations.

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VIDEO RESOURCES http://media.pearsoncmg.com/ab/ab_lefton_psychology_8/media/lbp8e_12432/lbp8e_12432.html Psychodynamic, Behavioral, Trait and Type, Humanistic and Cognitive Approaches to Personality Explore this table comparing different approaches to personality. http://media.pearsoncmg.com/ab/ab_video_players_1/psych/audioPlayer.html?fileId=freud_psych_persp_186 Freud's View of the Human Mind (3:06) Listen to an overview of unconscious factors affecting personality http://visual.pearsoncmg.com/mypsychlab/episode17/index.html?clip=6&tab=tab0 In the Real World: Cognitive Behavioral Therapy (5:42) Watch this video in which psychologist Heather Murray of Boston University gives an in-depth explanation for how cognitive behavioral therapy works, specifically how it is used to treat patients with anxiety disorders. http://visual.pearsoncmg.com/mypsychlab/episode02/index.html?clip=2&tab=tab0 The Basics: Scientific Research Methods (6:43) This video defines independent/dependent variables and control/ experimental groups, and explains how experiments are designed and conducted. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Research_Methods.html Research Methods (4:57) Watch this video in which different research methods, including correlation and experimental, are discussed.

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Chapter 4 Classification and Assessment of Abnormal Behavior Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: p.78 Basic Issues in Classification: p. 80 Categories versus Dimensions From Description to Theory Classifying Abnormal Behavior: p. 81

Discussion Ideas: Culture-bound syndromes

Brief Historical Perspective The DSM-5 System Culture and Classification Evaluating Classification Systems: p. 85 Discussion Ideas: The Barnum Effect Reliability Validity Unresolved Questions Problems and Limitations of the DSM-5 System Basic Issues in Assessment: p. 90 Lectures: Consistency in personality: A new Purposes of Clinical Assessment approach to assessment Assumptions About Consistency of Behavior Classroom: Evaluating the Usefulness of Assessment Planning an assessment Procedures The value of diagnosis Psychological Assessment Procedures: p. 92 Interviews Observational Procedures Personality Tests and Self-Report Inventories Projective Personality Tests

Lectures: The Thematic Apperception Test Self-monitoring in assessment Video Case: Depression/Deliberate Self-Harm, Sarah

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PROFESSOR NOTES

Biological Assessment Procedures: p. 100 Brain Imaging Techniques Psychophysiological Assessment

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CHAPTER OUTLINE I.

II.

Basic issues in classification A.

Diagnosis is important because it enables the clinician to refer to the knowledge base of a particular set of problems.

B.

Diagnosis does not necessarily provide any information about cause.

C.

One important question is at what level (e.g., individual or family) should a problem be conceptualized

D.

Categories versus dimensions 1.

Categorical approach—distinctions are qualitative; either in a category or not

2.

Dimensional approach—attributes seen as falling on a continuum and continuous

3.

The DSM is a categorical classification system, but abnormal behavior can also be conceptualized as dimensional.

Classifying abnormal behavior A.

Brief historical perspective 1.

There are two widely used classification systems. a. International Classification of Diseases (ICD), published by the World Health Organization; currently ICD-10 b. Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association; currently DSM-5

B.

The DSM-5 system 1.

Basic characteristics a. Disorders are grouped under broad headings (e.g., Anxiety Disorders). b. Disorders are defined by inclusion and exclusion criteria as well as duration. c. Contains diagnoses for over 200 disorders 57 C.

C.

Culture and classification 1.

DSM-5 recognizes that cultural norms may influence the experience and expression of emotional distress.

2.

DSM-5 recognizes culture-bound syndromes: sets of symptoms seen in people of non-western cultures

3.

DSM-5 encourages clinicians to consider the influence of cultural factors in both the expression and recognition of symptoms of mental disorders by including discussions of cultural concepts of distress. a. Culture-bound syndromes— patterns of erratic or unusual thinking and behavior that have been identified in diverse societies around the world and do not fit easily into the other diagnostic categories b. Ataques de nervios—inability to interrupt the dramatic sequence of emotion and behavior; ataques are provoked by situations that disrupt the person’s social world c. Bulimia nervosa is thought to be a culture-bound syndrome for Western societies.

III. Evaluating classification systems--DSM-5 A.

B.

Reliability—the consistency of a measurement (including diagnosis) 1.

Interrater reliability—refers to agreement of raters (in this case, clinicians) about observations (diagnosis)

2.

Test-retest reliability—refers to the consistency with which a patient displays the diagnosable symptoms between assessments

Validity—the usefulness, meaning, or importance of a measurement (diagnosis) 1.

Etiological validity—concerned with factors that contribute to the onset of the disorder

2.

Concurrent validity—concerned with current correlations between the disorder and other symptoms or behaviors

3.

Predictive validity—concerned with the course and stability of the disorder over time

4.

Validity is not all or none; there are degrees of usefulness.

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C.

D.

IV.

Problems and limitations of the DSM-5 system 1.

Optimal thresholds for diagnoses (e.g., of level of distress or impairment, number of symptoms); existing thresholds between abnormal and normal behavior have been critisized as being too vauge

2.

The DSM-5 is categorical; however, many disorders appear dimensional.

3.

Additional questions center around whether the DSM-5 organization is optimal for designing treatments or research.

4.

The failure to make better use of information regarding the course of disorders over time

5.

The absence of a specific definition of social impairment is a practical issue.

6.

DSM-5 does not classify clinical problems into syndromes in the simplest and most beneficial way.

The problem of comorbidity 1.

Defined as the simultaneous appearance of two or more disorders in the same person

2.

56 percent of those who met criteria for one disorder also meet criteria for at least one other Disorder.

3.

When comorbidity is high, the validity (meaningfulness) of the diagnosis is weaker.

4.

Frequent comorbidity also highlights unanswered questions regarding the longitudinal course of symptoms of one or more diagnoses.

Basic issues in assessment A.

Purposes of clinical assessment 1.

Collecting and interpreting information that will be used to understand a person and make a diagnosis.

2.

Primary goals are making predictions, planning interventions, and evaluating interventions

3.

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B.

C.

Assumptions about consistency of behavior 1.

Consistency—behavior is consistent over time and across situations

2.

Levels of analysis (biological, psychological, or social) determine the type of assessment used; assessment can focus on individual or social systems.

3.

Clinicians want to know if they can generalize the samples of behavior obtained during assessment to natural settings.

Evaluating the usefulness of assessment procedures 1.

Reliability (consistency) a. Test-retest reliability measures the consistency of an assessment procedure over time. b. Split-half reliability measures the internal consistency of the items within a test.

2.

Validity (meaningfulness) a. Addresses question of the meaning of a particular score on a test b. Measures degree to which a scale accurately predicts future behavior c. Cultural differences can make assessment procedures that are valid in one group invalid in others.

V.

Psychological assessment procedures A.

Psychological assessment procedures 1.

Interviews a. Most frequently used assessment procedure b. Allows direct gathering of information about client’s subjective experience c. Allows observation of appearance and important nonverbal behaviors d. Other than when making decisions related to intellectual disability, the use of psychological or biological tests are not required to use DSM-5 diagnostic categories.

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e. Structured interviews begin with an overview of the current episode with open-ended questions; then they procede by imposing more structure, creating a systematic framework for collecting information. f.

Advantages: interviewer can control interview, observe nonverbal behavior, and cover a great deal in short time

g. Limitations: some people are unable or unwilling to provide information; clients are influenced by social desirability; subjectivity and bias can enter in from the client and/or the interviewer 2.

Observational procedures a. Informal observations provide information from the natural environment or controlled settings. b. Rating scales allow an observer to make judgments and rate behavior on a scale. c. Behavioral coding systems or formal observational schedules 1.) Focus on frequency of specific, targeted behavioral events 2.) Can include self-monitoring in which the client observes and records his/her own behavior d. Advantages: a more direct source of information; does not rely on self-report e. Limitations: may be time-consuming and expensive; bias can still influence ratings; behavior may be altered during observation, and observations do not necessarily generalize to other situations

3.

Personality tests and self-report inventories a. Data is collected in a standardized setting; underlying traits or abilities are assessed. b. Personality inventories are "objective tests" containing clear statements that the person endorses or rejects (“objective” refers to the scoring) c. Minnesota Multiphasic Personality Inventory (MMPI-2) is the most widely used psychological test 1.) 500+ statements rated by the test-taker as true or false for him/herself 61 C.

2.) Includes validity scales to check whether the person is avoiding frank and honest responses, being overly defensive, careless, or exaggerating problems 3.) Test interpretation is based on explicit rules derived from empirical research.

4.) Advantages: information concerning the client's test-taking attitude is obtained; assesses a wide range of problems quickly in an objective manner, and actuarial scoring provides comparisons with other patients 5.) Limitations: not sensitive to some forms of psychopathology; dependent on the ability of a client to be able to complete a long and difficult test; data is not available on all profiles, and profile types are not stable over time, which may reflect a reliability problem or the test’s sensitivity to change 4.

Projective personality tests a. The person is presented with ambiguous stimuli (e.g., a picture or inkblots) and asked to generate a response (a story or description) b. Assumes responses will contain meaningful clinical information (i.e., the subject is projecting hidden desires or conflicts) ; based on psychoanalytic theory c. Intuitive scoring looks for recurrent themes; Exner created a more objective, quantitative scoring system for the Rorschach, focusing primarily on the form of responses rather than the content. d. Advantages: they may provide useful information that may not be obtained by other methods, they may reveal aspects of the person's view of the world and possibly unconscious motives, and they may supplement information learned with other assessment measures e. Limitations: projective tests tend to have poor reliability and validity, lack standardization in scoring and administration, have limited normative data associated with them, and may be time-consuming f.

Hermann Rorschach (1884–1922) developed the Rorschach test in 1921, which consists of a series of 10 inkblots used to assess personality characteristics and psychopathology.

g. Thematic Apperception Test (TAT) consists of a series of drawings that depict human figures in various ambiguous situations.

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VI.

Biological assessment procedures 1.

Brain imaging techniques—examining the brain through X-ray type procedures a. Static brain imaging—detailed pictures of the brain; magnetic resonance imaging (MRI)—provides clearer images, which can be more easily transformed into three dimensions b. Dynamic brain imaging—PET and fMRI (functional MRI) images highlight brain functioning as it is occurring 1.) Positron emission tomography scanning (PET)—very expensive but provides detailed images of the brain and reflects changes in activity of the brain regions 2.) Computed tomography (CT) can provide a static image of specific brain structures; usually the MRI has replaced the use of this technique in most research facilities.

3.) Functional MRI (fMRI)-- rapid images of changes in brain activity obtained through the measurement of oxygen flow; can measure momentary changes in brain activity c. Advantages: provides detailed information regarding brain structure and activity, which may, in the future, have diagnostic or research value d. Limitations: procedures are expensive; adequate norms have not yet been established for these measures; very limited clinical utility; relationship between brain activity and specific cognitive/emotional processes is not clear

2.

Psychophysiological assessment uses autonomic nervous system responses (e.g., heart rate, perspiration, skin conductance) as a measure of psychological state a. Results may be inconsistent with each other and with subjective reports b. Anxiety responses and associated physiological reactivity have been measured using this method. c. Relationship characteristics in married couples can be identified using physiological measures. For example, some husbands show a pattern of high physiological response but little verbal expression of the arousal; this pattern is 63 C.

associated with dissatisfaction with marriage and, ultimately, divorce. d. Advantages: reduces or eliminates subjectivity or bias on the part of the interviewer and client; measures can be taken while patients are doing other activities such as sleeping e. Limitations: equipment is expensive and can be intimidating; validity and reliability of any one physiological measure is questionable

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LEARNING OBJECTIVES LO 4.1: Why do we need a system to classify abnormal behavior?

LO 4.2: Should disorders that are unique to our own culture be considered cultural concepts of distress?

LO 4.3: What is the difference between reliability and validity?

LO 4.4: How could the DSM-5 classification system be improved?

LO 4.5: Why do clinical interviews sometimes provide limited or distorted results?

LO 4.6: Why is the MMPI-2 sometimes called an objective personality test?

LO 4.7: Why are brain imaging procedures not used for the diagnosis of mental disorders?

LECTURE SUGGESTIONS Consistency in personality: A new approach to assessment: Current directions APS reader (1E, p.24) Walter Mischel and colleagues suggest a new approach to assessment in a clever effort to describe consistency in a more effective manner. For years, personologists have viewed personality consistency in terms of trait-consistency behavior across different situations. An extrovert, for example, should be socially active in many situations. This approach, however, was short-sighted and led to a large degree of “error,” which resulted in low consistency scores for personality across situations.

The new approach that is suggested here examines consistency within situations for each individual. For example, a person might be consistently friendly when greeting new people in one situation, yet consistently rebellious in relation to authority figures in another situation. This results in what Mischel calls the "if-then" approach to personality. Specific cues within each situation may activate specific aspects of one’s personality, which lead to a consistent response, what is referred to here as a “stable activation network."

This approach is quite relevant to the assessment of pathology. Often, we expect—as personologists did—that people diagnosed with a mental illness will be consistently pathological in all situations. This type of consistency is a myth. For example, a person with antisocial personality disorder might be violent and destructive only in situations where he is dealing with authorities. If we do not view him within this context, we might miss a very consistent and important aspect of his personality. More broadly, Mischel’s work implores us to "take the situation seriously" in considering who the person that we are assessing really is.

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Thematic Apperception Test (TAT): In the TAT, the examiner presents a series of ambiguous pictures and asks the subject to generate stories for each that tell who the people in the picture are, what they are thinking and feeling, what is occurring, and what will happen next. Students can experience this personality test from the standpoint of the clinical patient. However, it will be important to emphasize that in order to obtain truly interpretable data, it would be necessary to have a series of stories and to interpret recurrent themes rather than simply compelling themes or images from one story. For the purposes of demonstration, an actual TAT stimulus card should not be used, but a facsimile can be found in almost any picture that offers some degree of ambiguity. Ask students to write their stories on paper, then raise the following points for interpretation: 1. What are the moods of the characters? Are they consistent with the action?

2. Is there interpersonal interaction? What is its character?

3. Are any of the following themes present, and if so, in what manner? a. motivation/achievement b. conflict c. success/failure d. nurturing e. rejection f. independence 4. Do interpersonal or other problems arise? If so, how are they resolved?

5. Are parent-child relationships portrayed? If so, how?

6. Are any themes repeated in the story?

Remind students that projective assessment techniques have low interrater reliability, and may reflect the projections of the test interpreter rather than those of the test-taker. However, many clinicians continue to use projective assessment techniques and feel that they are rich sources of information. Few clinicians would, however, rely exclusively on one projective measure but would use a battery of assessment tools and information that is consistent across many sources.

Self-monitoring in assessment: One procedure that is similar to but distinct from self-report inventories is the self-monitoring procedure.

Subjects are asked to observe themselves, recording particular behaviors, emotions, or cognitions as they occur in their everyday lives. They record the environment in which the feeling, thought, or behavior took place. For example, if a pedophile was asked to keep track of his sexual urges for children, he might note that he felt an urge as he drove past a school yard. An alcoholic would keep track of when he felt a need for a drink. The frequency of these feelings, thoughts, or behaviors would also be recorded. The information produced from self-monitoring can then be utilized by the therapist in treatment.

Self-monitoring often provides useful information that cannot be obtained from personality inventories. It is especially useful for identifying the environmental reinforcers for problematic behavior. From the research 66 C.

standpoint, however, the results produced from the self-monitoring procedure have questionable validity (Nelson, 1977). Clients’ motivations to record their observations vary greatly, and the instructions given to clients are often not well standardized or controlled.

One interesting side effect that may be positive from the standpoint of treatment, but problematic for research, is the tendency for reactivity. The smoker employing self-monitoring techniques is likely to smoke less; the drinker tends to cut back on drinking. This is similar to the "Hawthorne effect," a finding in social psychology, in which observation affects performance.

Bornstein, P.H., Hamilton, S.B., & Bornstein, M.T. (1986). Self-monitoring procedures. In A.R. Ciminero, K.S. Calhoun, & H.E. Adams (Eds.), Handbook of behavioral assessment (2nd edition). New York: Wiley.

Nelson, R.O. (1977). Assessment and therapeutic functions of self-monitoring. In M. Hersen, R.M. Eisler, & P.M. Miller (Eds.), Progress in behavior modification. New York: Academic Press.

DISCUSSION IDEAS Culture-bound syndromes: The DSM-5 recognizes that a number of distinct syndromes are culture-specific. Discussion of the specific manifestations of behavioral disorders across cultures and the ways that abnormal behavior can be syndromal (as opposed to simply haphazard) is illustrated in a fascinating manner by this section of the DSM. What do students make of disorders such as Koro, Amok, Ghost Sickness, and other culture- specific disorders? What does their existence say about the nature of abnormal psychology? Hsia and Barlow comment, in a 2001 article, about the differences and similarities between the panic disorder kyol goeu (literally, ‘wind overload’) that is reported amongst Khmer refugees and the Puerto Rican ataques de nervios (literally, ‘attack of nerves’). Many of the same anxiety-based symptoms are described for each. Hsia and Barlow also describe other culture-bound syndromes such as ghost sickness, falling out, brain fag, hwa-byung, shenjing shuairou, shenkui, and shin-byung. Do students think that, given the large discrepancies in typologies but similarities in many of the symptoms of such disorders, this means that diagnosis is inherently culture-bound and socially constructed? What hope is there for a ‘universal’ diagnostic system that could be agreed upon by all human cultures? Also in a Westernized society, bulimia nervosa is viewed as a culture-bound syndrome. What are your thoughts on this: agree or disagree?

Hsia, C. & Barlow, D. (2001). On the nature of culturally bound syndromes in the nosology of mental disorders.

Transcultural Psychiatry, 38(4), 474–476.

The stigma of mental illness: Page 82 of the textbook describes how being labeled as having a mental illness changes not only the way a person is viewed by other people, but the way a person views herself. Discuss what labeling theory is and how the principles of labeling theory apply to mental illness diagnoses. What is the role of social status and the social 67 C.

distance between the patient and the mental health professional in the likilhood of being labeled, and what does that label look like? What might be the impact of a mental illness label on a person searching for a job or housing? What impact might there be of a label on someone’s social, family, and romantic relationships? How might the effects of these labels be different for people of different social status? How might people of greater social status be able to reduce the negative effects of labels?

CLASSROOM ACTIVITIES Planning an assessment: Have students break into small groups and plan a comprehensive assessment for a particular case. Suppose, for example, a 32-year-old recently widowed woman, living at home, came for therapy because she "doesn't get along with her mother at all." Her husband, a policeman, was killed on the job two years ago, and the client has not returned to work since. She complains: "Life is simply not worth living. I only hang around to help Mom and Dad, but they don't even appreciate it anyway." The task of the student groups is to utilize many types of assessment tools in an overall "assessment plan." For example, students should include a structured interview, self-report measures, personality tests (objective and projective), and social system assessment devices. Given the constraints of time and money, what are the key tests that they would suggest administering? What do they expect to find out from each assessment tool? Compare the assessment programs of different groups, and discuss the strengths and weaknesses of each group's approach.

The value of diagnosis: Divide the class into groups and ask groups to discuss and prepare a presentation of the benefits and drawbacks, respectively, of having a diagnostic system for mental/behavioral disorders. Issues that should be brought out, if students do not spontaneously identify them, include that classification facilitates communication between mental health professionals and others, informs research, aids in the development of specific treatment approaches for recognizable syndromes, enables a third party reimbursement system, and can help people feel understood and assuage anxiety. At the same time, our classification system is obviously inadequate for many people and conditions, subject to political and other nonscientific influences, and can be stigmatizing. Given these competing outcomes, what do students think about whether we should diagnose and, if at all, under what circumstances and by whom should diagnoses be made?

Conducting a naturalistic observation: Ask the students to select a partner in the class with whom they can complete the following activity. Then write the following questions below on the board or pass them out to the students as a handout. Ask the students to mutually select a place on campus to go complete the observation. Students will need to document everything they are observing without sharing their observations while in the field. Allow ten minutes for the observation, and after the students return to class, ask them to (a) share their observations, (b) look for similarities and differences, and (c) categorize the data as specified below.

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1. List your name and your partner’s name 2. Place of observation on campus 3. Two to three words to describe the environment, such as “peaceful, calm” 4. Share observations 5. Categorize the data with at least three different categories with two examples under each, for example: Gender Male Female

Ethnicity White Hispanic African American Asian American

Shoes Tennis shoes Sandals High heels

The pig personality profile: This assessment tool is not scientifically based, but it is a good discussion starter, especially about the validity of measurement and assessment tools. There are many variations of this activity that involve drawing such things as a pig or a mountain, etc. You can access a detailed description of the “Pig personality profile” at http://www.uri.edu/volunteer/PDF/Pig_personality.pdf. This activity gives some information about personality characteristics based on how the student draws a pig. After completing the activity, ask for the students’ thoughts on the assessment as it relates to perceived views of one’s personality, relationships, interpersonal skills, and communication style.

Cotton, G. (2011). The pig personality profile. Retrieved from http://www.uri.edu/volunteer/PDF/Pig_personality.pdf on May 30, 2011.

The Barnum effect According to the text, many people accept psychologist’s assessments uncritically, even though they are prone to error like everyone else’s. Moreover, people have a tendency to overestimate the degree to which the results of a psychological assessment are a meaningful and unique comment about themselves. On page 92 of the text, the authors describe one reason for this acceptance: the psychological assessments are sometimes quite vague or superficial thus appearing to tell special information about the individual while actually applying to most people in general. This is referred to as the Barnum effect. Demonstrate the Barnum effect to students by asking them general questions and then making vague and superficial statements that likely apply to them because of the vagueness of your assertions. Next, divide students into small groups and have students attempt to do this on other members of the group. Use this exercise as a springboard to a discussion on the importance of critically evaluating psychological information. Additionally, students should discuss the dangers of the Barnum effect within psychological assessments and what can be done to alleviate these dangers.

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Measurements that come to life: Likert scales are commonly used in research. Have five very large pieces of paper taped on the board or the wall of the classroom with each stating the following range: Strongly disagree (1), disagree (2), neutral (3), agree (4), and strongly agree (5). Then ask the students a series of statements that you create, or you can modify the statements you use from these examples listed below. The students will be asked to literally move under, or move close to, the response that would best answer where they figuratively stand in regard to an issue or statement.

1. It is better to be labeled “different” than to be labeled “abnormal.”

2. It is more acceptable to visit a psychologist than it is to visit a psychiatrist.

3. I would much rather suffer from an anxiety disorder than from a substance abuse disorder.

4. Stigma exists for individuals diagnosed with a mental disorder.

5. Children should not be prescribed psychotropic medications.

6. I would rather be diagnosed with a mental disorder in childhood than to be diagnosed later in adulthood.

7. I would prefer medicine over psychotherapy.

8. Society is looking for a magical pill to cure all.

9. Media causes eating disorders.

10. Marijuana should be prescribed for medicinal purposes.

Have students create an assessment tool: Have the students divide into small groups, then pass out different issues, such as disorders like major depression, anorexia nervosa, or generalized anxiety disorder, or topics like test anxiety, relationships, communication, career counseling, etc. Tell the students that each small group will be creating an assessment tool to cover the topic given.

Ask the students to first outline key issues related to the topic, but to also address the issues of reliability and validity related to the measurement. Once the students have completed the activity, allow time for sharing the tool with the class for questions and feedback. This topic can assist in covering the lecture topics of the importance of assessment tools in the field of psychology while taking into account the factors of reliability and validity when selecting a measurement to use with clients.

VIDEO CASE: Sarah—Depression/Deliberate Self-Harm (15:37) Sarah is a high school senior who has suffered with depression and a tendency to cut herself when under stress. She mentions she dealt with continual abuse as a child, which led to her isolating herself, crying and hiding. Ultimately, this led to cutting herself as a means of ‘getting relief.’ She also describes dissociating; she does not remember aspects of the self-injury process. She feels that she has made a great deal of progress with regards to self-control but is still very fearful and says “Cutting is always in the back of my mind still today.”

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Discussion questions: 1. What would you like to know more about with regard to this client? The interviewer did not address the nature of the abuse that Sarah mentioned; would it be important to know more about this? What about her family history would you like to know?

2. Why would a person ( like Sarah) find relief following cutting herself?

3. How can you combat the tendency to “isolate” that we see prominently in Sarah’s case? What could a clinician do to help her overcome this tendency?

VIDEO RESOURCES http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/Cider/Cultural_Influences_ on_Abnormality_and_Psychology.html Psychology in the News: Cultural Influences on Abnormality and Psychology (2:50) Listen to this examination of cultural differences and their possible impact on psychological disorders.

http://media.pearsoncmg.com/ab/ab_lefton_psychology_8/media/methods/index.html Overview of Clinical Assessment Tools This video reviews the various clinical assessment tools, such as structured interviews, projective tests, and MRI. It uses actors to actively demonstrate methods in action.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/APS2010/TomWidiger6.html Tom Widiger: Could you briefly describe how the DSM evolved? (1:07) Watch this video in which clinical psychologist Thomas Widiger of the University of Kentucky defines the DSM. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/APS2010/JohnCacioppo2. html John Cacioppo: How did you first put biological and social science together? (2:08) Watch this interview with social neuroscientist John Cacioppo of the University of Chicago on bridging the gap between biological and social perspectives on human behavior.

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http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Current_Diagnostic_ Models_Sue_Mineka.html Current Diagnostic Models: Sue Mineka (3:06) In this video, psychologist Sue Mineka describes the various diagnostic perspectives and how they often work together.

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Chapter 5 Mood Disorders and Suicide Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: 106 Symptoms: p. 109

Lectures: Cognitive distortions Mood and emotion in depression

Emotional Symptoms Cognitive Symptoms Somatic Symptoms Behavioral Symptoms Other Problems Commonly Associated with Depression Diagnosis: p. 111

Video Case: Bipolar Disorder with Psychotic Features, Ann

Depressive Disorders Bipolar Disorders Future Descriptions and Subtype Course and Outcome: p. 116

Lectures: Bipolar disorder in children

Depressive Disorders Bipolar Disorders

Frequency: p. 117

Lectures: Gender differences in depression

Incidence and Prevalence Risk for Mood Disorders Across Life Span Gender Differences Cross-Cultural Differences

Video Case: Major Depression, Everett Video Case: Major Depression, Helen

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PROFESSOR NOTES

Causes: p. 119

Lectures: Suicidal ideation

Social Factors Psychological Factors Biological Factors Interaction of Social, Psychological, and Biological Factors

Treatment: p. 128

Classroom: Explanatory style

Discussion Ideas: Treatability of depression

Depressive Disorders Cognitive Therapy Bipolar Disorders Electroconvulsive Therapy Seasonal Mood Disorders

Suicide: p. 132 Classification of Suicide Frequency of Suicide Causes of Suicide Treatment of Suicidal People

Discussion Ideas: The clustering and contagion of suicide Intolerance of depressed people

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CHAPTER OUTLINE I. Overview A. Emotion—a state of arousal defined by subjective feeling states

II.

B.

Affect—pattern of observable behaviors associated with emotion

C.

Mood—pervasive and sustained emotional state

D.

Depression should be distinguished from clinical depression; depression is a mood, whereas clinical depression refers to a clinical syndrome—symptoms such as depressed mood, fatigue, loss of energy, sleeping difficulties, appetite changes, cognitive and behavioral changes, etc. Depressed mood includes disappointment and despair.

E.

Mania involves a disturbance in mood in which a person feels predominantly euphoric; symptoms include exaggerated feelings of physical and emotional well-being, inflated self- esteem, pressured speech, and racing thoughts; euphoria is an exaggerated feeling of physical and emotional well-being.

F.

Mood disorders should be thought of as episodic in that people generally experience depression (or mania) during relatively discrete periods of time.

1.

Depressive disorders-- the individual experiences only episodes of depression

2.

Bipolar disorder (previously manic-depression)—the person experiences episodes of mania or hypomania as well as depression

Symptoms A.

B.

Emotional symptoms 1.

Depression—dysphoric mood—feeling gloomy, dejected, despondent, despairing

2.

Manic emotions include feeling elated, optimistic and cheerful, even euphoric, but also commonly irritable; easily provoked to anger

Cognitive symptoms 1.

Depression a. Thinking slowed down; poor concentration is common b. Guilt and worthlessness are common. c. Beck’s depressive triad—focusing on negative aspects of the self, the environment, and the future d. Suicidal thoughts and actions

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2.

C.

People with mania experience racing thoughts, high distractibility, grandiosity, and inflated self-esteem.

Somatic symptoms 1.

Depression a. Fatigue, lethargy, aches and pains b. Changes in appetite and sleep patterns—usually loss of weight/disturbed sleep c. Anhedonia, the inability to experience pleasure, is also common. d. Loss of sexual desire

2.

Mania a. Reduced need for sleep b. Dramatically increased energy

D.

E.

III.

Behavioral symptoms 1.

Depression—psychomotor retardation—slowing down of motor responses

2.

Mania—gregariousness, high energy and activity levels, impulsivity, flirtatious and provocative behavior

Other problems commonly associated with depression 1.

Comorbidity—the simultaneous manifestation of more than one disorder

2.

60 percent of depressed patients experience anxiety

3.

Alcoholism—40 percent of alcohol-dependent people experience clinical depression; order of onset varies

4.

Eating disorders, alcoholism, and anxiety disorders are also more common among first-degree relatives of depressed people.

Diagnosis A.

B.

Two important issues 1.

Should mood disorders be narrowly or broadly defined?

2.

Are features of mood disorders (e.g., presence of environmental stressors) related to different types of disorders, or simply alternate expressions of the same underlying disorder?

Contemporary classification 1.

Depressive disorders 76 C.

2.

3.

a.

Major depressive disorder—the experience of at least one major depressive episode (at least two weeks duration) without any manic episodes; often multiple discrete episodes

b.

Persistent depressive disorder (Dysthymia)—less severe symptoms but predominantly depressed mood for at least two years; most individuals experience two or more of the following: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness

c.

Often, both sets of symptoms are seen in the same person; they are two aspects of the same disorder.

Bipolar disorders a.

Bipolar I disorder—the person has experienced at least one manic episode

b.

Bipolar II disorder (hypomania) —the person has experienced at least one major depressive episode, at least one hypomanic episode, and no full-blown manic episodes. Hypomania is the experience of a less severe period of increased energy, which is generally a shorter duration and weaker in intensity than full-blown manic episodes

c.

Cyclothymia—chronic but less severe mood swings; at least two years in which the person experiences numerous hypomanic episodes and numerous periods of depression but no major depressive or manic episodes

Further descriptions and subtype a.

Melancholia—a particularly severe form of depression with symptoms including loss of pleasure, loss of interest, loss of appetite, early morning awakenings, and excessive guilt; tends to respond well to biological treatments

b.

The presence of psychotic features 1.

Can be mood congruent or mood incongruent

2.

More likely to require hospitalization and biological treatments

c.

Postpartum onset refers to an episode specifier that denotes a major depressive or manic episode beginning within four weeks after childbirth

d.

Bipolar disorder may be rapid cycling—having at least four episodes of mania, hypomania, or depression within a year

e.

Seasonal affective disorder—a mood disorder in which the onset of episodes is associated with changes in seasons 1.

Somatic symptoms are common.

2.

Most meet criteria for unipolar disorder; some bipolar II, few bipolar I

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IV.

Course and Outcome A.

Course and outcome 1.

Depressive disorders a. Average age of onset is early thirties; 32 is the actual average b. Minimum duration is two weeks by definition, but can be much longer c. Most will have at least two depressive episodes. d. Frequently, a chronic and recurrent condition; mean number of lifetime incidents for people suffering with unipolar depression is 5–6 e. One half recover within six months; the longer the remission period, the lower the risk of relapse. f.

Remission—when a person’s symptoms are diminished or improved

g. Relapse—a return of active symptoms in a person who has recovered from a previous episode 2.

Bipolar disorder a.

Onset usually between ages 18–22

b.

Average manic episode is 2–3 months

c.

Long-term course 1.) Most will have more than one episode.

2.) Length of intervals between episodes varies and is difficult to predict.

3.) Half of bipolar patients are able to achieve a sustained recovery.

V.

Frequency A.

Incidence and prevalence 1.

Lifetime risks from National Comorbidity Survey (NCS-R) a.

Major depressive disorder: 16 percent

b.

Dysthymia: 3 percent

c.

Bipolar I and II combined: 4 percent

2.

Unipolar: bipolar ratio is 5:1

3.

More than 20 percent of those with a mood disorder receive adequate treatment during the past year.

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B.

Risk for mood disorders across the life span 1.

Researchers previously thought that depression occurred more frequently among the elderly.

2.

Clinical depression and bipolar disorder are less common among elderly people than they are among younger adults.

3.

Successively younger generations appear to be at greater risk for depression.

C.

Gender differences: women are two to three times more likely to experience depression than are men; the difference is not simply due to the fact that women are more likely to seek treatment than are men; the difference is not observed in bipolar I disorder

D.

Cross-cultural differences: vocabulary and social differences make this difficult to investigate; symptoms are interpreted differently and emotions have different expressions. Most studies indicate, however, that clinical depression is a universal phenomenon, although symptoms may vary considerably from culture to culture

VI. Causes A.

B.

Social factors 1.

Loss (of significant others, of social role, of self-esteem, etc.) plays an important role in the onset of depression.

2.

Stressful life events and depression—causality can go both ways; stressful life events do often precede onset of depression, and "severe events" play a significant role in development of depression. Stress generation is when depressed individuals create life circumstance that increase stress.

3.

Stressful life events may also play a role in precipitating the onset of manic episodes and in the probability of relapse; the stresses may involve clearly negative experiences but neutral or even positive life disruptions.

4.

Gender differences in the frequency and nature of stressful events may explain some of the gender difference in the prevalence of major depression.

5.

Bipolar: mania can be induced by positive events or achievements; aversive patterns of emotional expression and communication within the family (e.g., hostility and criticism) can play a role in the recurrence of mania

Psychological factors 1.

Interpretations of life events affect their impact. Cognitive theory suggests that distortions such as overly negative views of the self, environment and future, and assigning global, personal meaning to failures play important roles

2.

Hopelessness theory—causal attributions of bad events to internal, stable, and global causes and perception of lack of control seen as primary 79 C.

3.

Interpersonal factors: depressed people’s behavior influences their environments and can create additional stressors including decreased social support

4.

Rumination—a ruminative response style (as opposed to a distracting style) is associated with more severe depressive episodes; more common in females

5.

The interaction of cognitive and interpersonal factors contributes to the vulnerability, onset, and maintenance of depressive symptoms.

6.

Maladaptive schemas-- general patterns of thought that guide the way depressed people perceive and interpret the world

7. The vulnerability to depression is influenced by early life experiences, and the onset of depression is often triggered by life events and circumstances.

C.

Biological factors 1.

Genetics—family studies and twin studies suggest a mild genetic influence for unipolar depression, and a stronger one for bipolar depression a.

Twin studies: One study found .69 and .19 concordance rates for monozygotic and dizygotic twins for bipolar depression. The concordance rates for unipolar depression were .54 and .24, respectively. The heritability estimate for bipolar is about 80 percent; for unipolar, it is about 52 percent.

b.

Kendler's research on the interaction of severe life stress and genetics 1.) Severe life events increase the probability of depression even among those at low genetic risk.

2.) The magnitude of the effect of stress is much greater for the genetically predisposed.

c. Most researchers believe the transmission of mood disorders is polygenic. There is not strong evidence of a single gene responsible for mood disorders; however, some newer research provides evidence for a specific genetic marker for bipolar disorder (chromosome 18). d. The serotonin transporter (5-HTT) gene has been studied because several drugs used to treat depression have a direct impact on this particular neurotransmitter.

2.

Neuroendocrine system—dysfunction in the hypothalamic-pituitary-adrenal (HPA) axis may also play a role in the development and maintenance of depression

3.

Brain imaging studies the differences in structure and activity in people with depression, noting some areas of the pre-frontal cortex (PFC) becoming less active than normal, while other areas of the PFC show abnormally elevated activity.

4.

Neurotransmitters—serotonin appears particularly important, as levels are related to mood, hopefulness, sleep, and appetite. However, many neurotransmitters are likely to be involved

5.

Combined influences of social, psychological, and biological factors, as opposed to any one domain exclusively, are probably responsible for mood disorders.

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VII. Treatment A.

Interventions for depressive disorders 1.

Cognitive therapy—focuses on recognizing, challenging, and overcoming cognitive distortions and errors in logic; patients are encouraged to replace self-defeating cognitions with more rational self-statements

2.

Interpersonal therapy—focuses on interpersonal factors in current relationships that cause and maintain depression; treatment focuses on building communication and problem-solving skills

3.

Antidepressant medications

4.

B.

a.

Selective serotonin reuptake inhibitors—synthesized in a laboratory to inhibit the reuptake of serotonin without affecting other neurotransmitters; fewer side effects for patients while remaining as effective as other antidepressants; by far the most commonly prescribed antidepressant

b.

Tricyclics—block the uptake of neurotransmitters (especially norepinephrine) from the synapse; not as widely used today because of the side effects (blurred vision, drowsiness, blood pressure drops)

c.

Monoamine oxidase inhibitors—not as widely used because of the dietary restrictions necessary for patients, but effective; also used in some anxiety disorders

Medication and psychotherapy a.

Both are effective; neither clearly more than the other

b.

In practice, medication and psychotherapy are often combined; recent evidence suggests that quicker remission of symptoms is likely when medication and therapy are combined.

Treatment of bipolar disorders 1.

2.

Lithium carbonate for bipolar disorder a.

Very effective for treating bipolar patients in a manic or depressive phase

b.

Reduces relapse in patients who continue taking lithium between episodes

c.

40 percent do not respond to lithium, especially rapid cycling patients and those who show schizophrenic features

d.

Negative side effects (e.g., nausea, weight gain, memory problems) contribute to a poor compliance rate ; approximately 50 percent do not take as prescribed

Anticonvulsant medications a.

Patients who do not respond well to lithium are often prescribed valproate or carbamazepine.

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3.

b.

50 percent of bipolar patients respond positively to the anticonvulsants

c.

Side effects include GI distress and sedation.

Psychotherapy for bipolar disorder a.

Can be an effective supplement to medication

b.

Interpersonal and cognitive therapies focus on stress and the onset of symptoms, the regulation of sleep, relationships, and work patterns.

c. Little research to support the value of psychotherapy; preliminary data suggest that medication and psychotherapy together are more effective than medication alone.

C.

Electroconvulsive therapy for unipolar or bipolar disorder 1.

Most patients receive two or three treatments/week, totaling 6–8 sessions.

2.

The mechanism of action is unknown, but ECT is effective for those with severe depression.

3. Also an appropriate treatment for those with rapid cycling bipolar disorder and depression with psychotic features D.

Seasonal mood disorders 1.

Light therapy is often used; exposure to broad-spectrum bright light used for one-two hours per day

2.

Improvement is often found within two-five days; light therapy plus cognitive therapy may be particularly helpful.

3.

Unclear what the mechanism is that explains improvement, but may be tied to hormonal secretion

VIII. Suicide A.

B.

Basic facts 1.

50 percent of all suicides occur in the context of a mood disorder.

2.

15–20 percent of all patients with mood disorders will eventually kill themselves.

3.

The highest rate of suicide in the U.S. is found in white males over the age of 50, specifically men who have been occupationally successful are more likely to commit suicide.

Classification of suicide 1.

DSM-5 lists suicide ideation as a symptom of mood disorders. In contrast to the principles that were followed in creating DSM-5, classification systems for suicide are based on causal theories rather than descriptive factors.

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2.

Durkheim (1858–1917) developed a sociological classification system based on etiology. a.

Egoistic suicide occurs when people become alienated from society, depressed, and apathetic.

b.

Altruistic suicide occurs when people sacrifice their lives for the sake of others.

c.

Anomic suicide occurs following the breakdown of social order.

d.

Fatalistic suicide occurs when the circumstances of a person’s life become unbearable.

e.

Nonsuicidal self-injury—some people deliberately harm themselves without trying to end their lives; the most frequent forms of nonsuicidal self-injurious behaviors involve cutting, burning, or scratching the skin.

3. Self-harm is a reflection of frustration and anger; it may be a way to punish the self, to combat extended periods of emptiness, or to regulate one’s negative emotional states.

C.

Frequency of suicide 1.

12 people for every 100,000 complete suicide in U.S. and Canada each year. a. Rates among middle age people have increased by 30 percent in the recent past. b. Rates are generally highest among young people (15-24) and the elderly (particualrly in white males)

2.

35,000 people in U.S. kill themselves each year. a. In 2010, more people died from suicide than from car accidents

3.

Rate of adolescent suicide has increased dramatically; for people within the ages of 15–24, suicide is the third leading cause of death; suicide is the eighth leading cause of death for the general population.

4.

Attempts versus completed suicides

5.

a.

10:1 in general population

b.

100:1 in adolescents

c.

Females 15–19 make three times as many attempts as males; suicide rates (completion rates) are four times higher among males, however.

d.

Men use more destructive, successful means (guns, hanging), whereas women tend to use drugs.

Rates are highest for older people, especially white males; the proportion of attempts that end in fatality is particularly high among the elderly. a. Although suicide attempts are more common in younger people, completion rates are higher in older adults.

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6.

D.

Causes of suicide 1.

Psychological factors: interpersonal psychological theory points to experience of intense distress, hopelessness, and frustration of psychological needs leading to shame, guilt, anger, or grief; both the desire to die and the ability to inflict lethal harm to the self are necessary for suicidality

2.

Biological factors

3.

E.

Rates among U.S. service members have increased dramatically after more than a decade of combat in Iraq and Aganistan. In 2012, the number of U.S. service members who committed suicide exceeded those killed in combat.

a.

Reduced levels of serotonin associated with attempted and completed suicide

b.

Impulsivity may be an important personality trait in predicting suicide; may be genetic

c.

Genetic predisposition to psychopathology, coupled with a tendency towards impulsivity may be a lethal combination in terms of suicidal behavior.

Social factors a.

Connection to supportive social structures (e.g., religious affiliation) is associated with reduced risk for suicide.

b.

Social policies related to access to firearms also play a role.

c.

“Contagious suicide” can occur as a result of media coverage of a previous suicide.

Treatment of suicidal people 1.

Crisis centers and hotlines provide immediate support and referral for treatment. Research has not demonstrated their effectiveness in reducing suicide rates.

2.

Psychotherapy—goals are to first reduce lethality, negotiate agreements, provide support, and help broaden the perspective of the suicidal patient

3.

Medication--treating the underlying problem (e.g., depression, schizophrenia) is important. SSRIs are often used, but their effectiveness varies; some cases have been reported in which new suicidal ideation occurs after SSRIs are used, so caution is advised here

4.

Involuntary or voluntary hospitalization is often used to provide intensive monitoring and limit access to methods of self-harm

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LEARNING OBJECTIVES LO 5.1: What is the difference between clinical depression and a low mood?

LO 5.2: Are there different kinds of depression?

LO 5.3: How do depressive and bipolar disorders differ?

LO 5.4: Are we more likely to experience depression as we get older?

LO 5.5: Why do some people become depressed after stressful life events while others do not?

LO 5.6: Is psychological treatment as effective as medication in treating depression?

LO 5.7: Why do some people want to end their own lives?

LECTURE SUGGESTIONS Cognitive distortions: Describe some of Beck's cognitive distortions. Ask the class whether they've engaged in any of these errors and if they feel that there's a connection between these types of logical errors and depression. Some of the distortions, with Beck's examples, are •

arbitrary inference—e.g., an intern became quite discouraged when he received an announcement that all patients seen first by interns should be subsequently also examined by resident physicians. He thought, "The chief doesn't have faith in my work."

•

selective abstraction—e.g., a patient was praised by her employer about many aspects of her work.

Among the many comments the employer made, she asked the patient to no longer make copies of her letters. The patient's immediate thought was, "She is dissatisfied with my work."

•

Dichotomous thinking—e.g., a person viewed their boss as either the greatest boss in the world or an absolute tyrant who was terribly unreasonable.

Beck, A.T. (1967). Depression: Clinical, experimental, and theoretical aspects. Philadelphia: University of Pennsylvania Press.

Mood and emotion in major depression: Current directions APS reader (2E, p.162): Jonathan Rottenberg presents both a theory and a set of research findings that challenge some of the most commonly held beliefs about depressed people—that they respond more strongly to negative events because they expect negative experiences and are primed for greater emotionality. In fact, Rottenberg’s work indicates that, for the most part, depressed people are less emotionally responsive following frustrating or challenging experiences.

His model suggests that depression should be viewed as a ‘shutting down’ of emotional responsiveness, and that it 85 C.

may be adaptive in some circumstances. He believes that, whereas mild depression may facilitate some kinds of emotional responses, clinical depression does not; it impedes emotionality instead.

Bipolar disorder in children: Bipolar disorder is one of the easier psychological disorders to reliably identify if mania is a component (i.e., Bipolar I disorder) due to the easily recognizable nature of manic symptoms and the fact that the simple presence of mania indicates that a person has the disorder. However, bipolar disorder is increasingly being diagnosed in children, despite the fact that obvious manic symptoms are generally not present. Rather, the disorder’s presence is inferred from a variety of factors, including the early presence of significant mood lability, a high level of irritability and emotional reactivity as components of an early onset mood disorder, lack of response to antidepressant therapy, concurrent diagnoses of hyperactivity without response to stimulants, or other at times poorly defined criteria.

Given that this view of bipolar disorder is of relatively recent origin, there have not been sufficient longitudinal studies tracking such cases over time to establish the validity of such an approach to classification. However, some children and adolescents so diagnosed respond well to mood stabilizers. This is an interesting example of clinical practice moving faster than empirical validation of diagnosis or treatment approaches, but there is apparent efficacy of the treatment in at least some cases. A tension exists between the ethics of providing unproven treatment versus withholding treatment that may be effective. This is particularly relevant to the treatment of children with psychotropic medication, as many medicines are not adequately researched for use with children.

Gender differences in depression: Current directions APS reader (1E, p.49): Susan Nolen-Hoeksema, a noted depression researcher, describes some of the research focused on the prominent gender differences in the incidence of depression in adults. Generally, about twice as many women are diagnosed with clinical depression than men among adults. Interestingly, Nolen-Hoeksema points out that “Girls are no more likely than boys to evidence depression in childhood, but by about age 13, girls’ rates of depression begin to increase sharply, whereas boys’ rates of depression remain low.” The adult differences in incidence of depression, however, between men and women are very robust, even cross-culturally.

Several factors, according to Nolen-Hoeksema, account for these differences. First, women experience more traumas—notably, sexual abuse—than men. Because they have less power and status, they also experience more everyday strains and stresses. These psychological and social factors then interact with some biological differences.

Women are more sensitive to stress in general; Nolen- Hoeksema hypothesizes that this may be due to a dysregulation of the hypothalamic-pituitary-adrenal axis. She also points out that girls’ tendencies to have lower self-concepts, be more interpersonally oriented, and ruminate following stress and distress make them more vulnerable to depression.

Suicidal ideation: Suicidal ideation ranges in severity from fleeting thoughts about one's death to the formulation of specific plans to end one's life. Ideas of suicide are much more common than actual suicidal behavior. Occasional thoughts about suicide are surprisingly common among adolescents in the general population. In one study, 24 percent of high school girls and 15 percent of high school boys indicated that they had experienced serious suicidal thinking at some point during their lives (Lewinsohn, Rohde, & Seeley, 1996). This data was collected as part of a longitudinal study of depression among 1,709 adolescents. The investigators found that 314 (18 percent) of these students met the diagnostic criteria for major depressive disorder. In the context of a structured diagnostic interview, each student was asked a series of questions about thoughts of death and suicide. Their responses to some of these questions are listed in the following table. Although the frequency of suicidal thoughts was alarmingly high in the total sample, note that such thoughts were particularly prominent among depressed adolescents; almost half the students who met diagnostic criteria for major depressive disorder reported serious thoughts about death or dying, compared to only 9 percent of the students who were not depressed. Similarly, suicide attempts were much more common among the depressed students (22 percent) than among the students who were not depressed (3.7 percent).

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Lifetime Frequency of Suicidal Thoughts and Attempts in One Large Community Sample of Adolescents

LEVEL OF SUICIDAL INTENT (Questions from the Interview)

TOTAL SAMPLE (n=1709)

DEPRESSED SUBSET (n=314)

THOSE NOT DEPRESSED (n=1395)

1.

Thoughts of death: Have you ever felt so bad that you thought about death or dying? A lot?

16.3%

48.6%

9.1%

2.

Suicidal thoughts: Have you thought about hurting (or killing) yourself?

12.9%

41.2%

6.5%

3 Suicide plan: If you were going to kill yourself, do you know how you would do it?

8.3%

27.5%

4.0%

4.

Suicide attempt: Have you ever tried to kill yourself or done anything that could have killed you?

7.1%

22.0%

3.7%

Lewinsohn, P.M., Rohde, P. and Seeley, J.R. (1996). Adolescent suicidal ideation and attempts: Prevalence, risk factors, and clinical implications. Clinical Psychology: Science and Practice, 3, 25–46.

College students and suicide: Suicide has been found to be the second leading cause of death for college students (Suicide.org, 2011). The number one cause of committing suicide is the missed diagnosis of depression. When college students leave for college, they are faced with a transition from being dependent on their parents or caregivers to being more autonomous, which can create anxiety, stress, and confusion for some college students. They have newly found expectations and responsibilities not only from their parents, professors, and peers, but also expectations they place on themselves to achieve success while being independent. A study conducted by Professor David Drum from the University of Texas at Austin found that over half of college students have considered suicide at some point in their college careers (Johnson, MSNBC, 2008). What can universities do to encourage college students to receive the help and treatment for mood disorders? Would health fairs or free screenings for depression help; why or why not?

Why do you think that suicide is so high for college students? What factors do you think increases the suicide risk for a college student versus someone in the general population? You could also continue this discussion as a classroom activity by asking the students to break into small groups to come up with a suicide prevention plan that would be targeted to college students that could be used on college campuses.

Johnson, A. (2008). Half of college students consider suicide: Mental health on msnbc.com. Retrieved from http://www.msnbc.msn.com/id/26272639/ on May 30, 2011.

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Suicide.org (2011). College student suicide. Retrieved from http://www.suicide.org/college-student-suicide.html on May 30, 2011.

DISCUSSION IDEAS

Treatability of depression: Research on treatment of depression demonstrates that many approaches are effective—cognitive therapy, behavioral, interpersonal, antidepressants, and other approaches all work quite well. Why are so many approaches successful in treating depression? Remind students that, for problems like schizophrenia and severe personality disorders, treatments are much less effective. The treatability of depression may be due to many things: (a) it tends to be time-limited (though often recurs), (b) many systems are interconnected, so if one can intervene in any one system, a positive, rather than negative, pattern can be instituted, and (c) we know more about depression than we do about most psychological disorders. Also, ask students why they think, given the treatability of depression, so few people actually seek treatment. This is one of the great ironies about mood disorders; they are very treatable, yet so often people do not seek treatment.

The clustering and contagion of suicide: Current directions APS reader (1E, p.56) Thomas Joiner explores the concept of suicide contagion by first distinguishing between mass clusters and point clusters. Mass clusters are media related and induced, whereas point clusters are locally induced. The evidence for mass clusters is quite minimal, but the evidence for point clusters is, though mostly anecdotal, fairly convincing. But can the phenomenon of one suicide following another be correctly thought of as “contagion”?

Joiner argues that most cases of point clustering can be accounted for by a number of more mundane factors, rather than resorting to a kind of mystical concept of contagion.

Often, both the initial suicide victim and the follow-up victim are suffering from some common severe life event or events. Of course, once a friend commits suicide, this already constitutes a severe life event for the follow-up suicide candidate. Often good social support is lacking in these situations, and personality factors play a prominent role; the victims usually are already suffering from depression and/or other mental illnesses prior to the first suicide. Finally, people choose friends assortatively—that is, they tend to have similar qualities and problems.

Although Joiner unpacks the concept of contagion by elucidating several processes that may be at work in the clustering of suicides, he does not doubt the danger of one suicide leading to another. Given the knowledge of these processes, how can we deal with the prospect of suicide clustering? What can be done to avoid subsequent suicides once one has occurred, for example, on a college campus? Should we keep quiet about the suicide, or have discussion groups or "rap sessions" to deal with the increased stress and distress that a college suicide incurs?

Intolerance of depressed people: Coyne has shown that depressed people are not as socially attractive as nondepressed people. They are not fun to be with, and therefore, we tend to avoid or even reject them. First, ask the students if they agree with that characterization. Coyne has also found that the common practice of attempting to "cheer up" the depressed person tends to make him feel worse. Why are we so intolerant of depressed people in our society? What is a "good way" to treat depressed people or friends? Why does "cheering up" generally not work? Perhaps it doesn't work because it makes the depressed person feel that he’s requiring special attention, he’s not pleasing others (so that he needs to be "cheered up"), and he feels that he’s disappointed his friends by not being able to be "cheered up."

Coyne, J.C. (1976). Toward an interactional description of depression. Psychiatry. (39) 28–40 88 C.

Exercise vs. antidepressants: James A. Blumenthal and his colleagues out of Duke University (1999) found that engaging in 30 minutes of exercise at least three times a week is an effective way to treat depression. It seems as though Americans are constantly searching for a magical pill that is the cure-all for any disease or illness. What are your views of the pros and cons of the use of antidepressants to treat major depression versus an exercise plan? Why do you think most Americans would rather take a pill every day than exercise routinely? What would happen to the big pharmaceutical companies if there were an increase in adopting the treatment of exercise versus taking medication? What are the health benefits of exercise versus the side effects of taking an antidepressant? Does one outweigh the other? How would you react if you were prescribed an exercise regime as your treatment instead of being given a prescription to fill for medication?

Blumenthal, J., Babyak, M., Moore, K., Craighead, W., Herman, S., Khatri, P., Waugh, R., Napolitano, M., Forman, L., Appelbaum, M., Doraiswamy, P., and Krishnan, K. (1999). Effects of exercise training on older adults with major depression. Archives of Internal Medicine, 159(19), 2349-2356.

CLASSROOM ACTIVITIES Explanatory style: Have students respond to a few situations on the Attributional Style Questionnaire. Then explain that research (Peterson & Seligman, 1984) has found that people who make internal, stable, and global attributions to bad events have a tendency to either be depressed or become depressed. The basic form of the questionnaire is this: Please try to vividly imagine yourself in the situations that follow.

SITUATION Write down the one major cause ____________________ Is the cause due to something about you or something about other people or circumstances? totally due to me

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totally due to other people or circumstances

In the future in this situation, would this cause again be present? will never again be present

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will always be present

Is the cause something that just influences this situation or does it also influence other areas of your life? influences just this situation

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all situations in my life

Some situations on the ASQ include the following: (1) Your friend rejects you. (2) You are unable to complete your work within a deadline. (3) A friend asks you for help with a math problem and you don't try to help.

Peterson, C., & Seligman, M.E.P. (1984). Causal explanations as a risk factor for depression: Theory and evidence.

Psychological Review, 91, 347–374.

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Peterson, C., Semmel, A., von Bayer, C., Abramson, L.Y., Metalsky, G.I. & Seligman, M.E.P. (1982). The attributional style questionnaire. Cognitive Therapy and Research, 6, 287–300.

Using the internet and other forms of media to conduct a psychological autopsy: Have each student select a popular figure in society, such as a politician, celebrity, author, actor, comedian, etc., that has committed suicide. Then, by using class time or assinging the exercise as an outside homework assignment, ask the students to use as many resources (i.e., Internet, books, magazines, etc.) to find out as much information on the individual who committed suicide. Ask the students to either write down the information or to type the information to share with the class. Some examples of the information you would want the student to search for are as follows: The applicable behaviors listed by the DSM-5 as outlined criteria for depression, which include changes in eating and sleeping habits, behavioral agitation, loss of interest, loss of energy, diminished ability to concentrate, feelings of worthlessness, withdrawal from family and friends, and drastic mood changes. Did the individual talk about suicide, give away possessions, have an obsession with death, make plans to commit suicide, or buy a gun?

What information can you find on the individual’s family life, relationships, level of education, alcohol and substance use history, quality of social support systems, past problems or stressors? Was there a family history of mental illness or prior hospitalizations or suicide attempts? What did the physical autopsy reveal, such as the date, time, location, method used, details of discovery, and cause of death? Once the students have found as much information as they can, have them write up a summary of the findings to turn in or share with the class.

Case study: 1. Jill was a freshman at a very large university in the Northeast where it was easy to blend in as just another student. Most of Jill’s classes had anywhere from 200 to 300 students, so the professor could not take attendance.

Friends would be the only people to notice if you were not in class, that is, if you had friends in the class. Jill was very quiet and mostly kept to herself, but she did have a few friends she met in orientation. She lived in the all-girls freshman dorm where the resident assistants (RAs) were college juniors, seniors, or graduate students. The RAs did not regularly check up on every student that lived in the dorm. Jill started to miss more of her classes and become more isolative with her friends. Jill’s roommate noticed she would often sleep in and would be in her pajamas until the afternoon. Jill would only care for grooming and hygiene needs after her roommate or other friends would say something to her. Her roommate noticed that Jill stashed a bottle of pills under her bed one day when she was taking the sheets to the laundry mat on campus. When Jill’s roommate confronted her, Jill became very defensive and told her to stay out of her business. Jill’s friends decided it was best to just let her deal with her own problems. The next week, Jill attempted to overdose on medication.

2. Tom came from a family of physicians and was very excited to attend the same university where his father completed medical school. Tom studied in the library every day, both before and after class. He was preparing to apply to medical school and wanted his grades to be perfect. One day he was up so late studying for his biology exam that he overslept and missed his exam. Tom was so distraught he felt his chances of going on to medical school were over, and he said, “There is no reason to live.” His friends noticed he started to withdraw and had stopped attending all of his classes. Tom refused to tell any anyone what had happened with the course. One night, Tom’s roommate found a website up on his computer that described in detail ways to commit suicide in which it would look like an accident.

For each of the above cases, ask students to come up with a plan of action.

Debate: Should doctor-assisted suicide be legal or illegal?

Randomly number the students off as either number one or two, or you can simply divide the class in half.

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After you have separated the class, assign each half of the class a side of the argument to defend: Doctor- assisted Suicide should be Legal, or Doctor-assisted Suicide should be Illegal. Allow the students time to gather information in support of their side of the argument, and then allow the debate to begin. As the professor, you can be the facilitator and mediate between the two sides if needed.

VIDEO CASES IN ABNORMAL PSYCHOLOGY: Everett—Major Depression (23:36) Everett is a 71-year-old man who claims that his depression may have begun as early as age 2. He describes his primary feelings when he is depressed as “very alone and very worthless.” Interestingly, his depression was not diagnosed formally until age 48. He also talks about the process of self- medicating (using alcohol) to deal with his depressed feelings. The low point in his life was his attempted suicide—“I had no hope for the future.” He finally found a psychiatrist with whom he could work and began the process of understanding and healing.

Discussion questions: 1.

Why was Everett not diagnosed until age 48? Why are so many people undiagnosed with regard to mental illness? How does this differ from physical illnesses?

2.

What does the term “self-medicating” mean, and why is self-medicating so common among mental health patients?

3.

Is Everett’s suicide attempt a typical or an atypical attempt? Were his cognitions at the time of his suicide attempt typical or atypical of suicidal people?

4.

Do you feel that Everett, at age 71, is finally cured of his depression?

Ann—Bipolar Disorder with Psychotic Features: (15:37) Ann is a middle-aged woman who developed bipolar disorder at age 33. She experienced very strong paranoid thoughts along with grandiose thinking. As a result of her manic and psychotic symptoms, she went through a divorce, lost her job, and lost most of her friends. She has had only one major depressive episode, where she found it hard to get out of bed and was listless. In order to maintain productivity and creativity, she “runs light” on her bipolar medications so that she is able to function at a high level in the business world.

Discussion questions: 1.

What is the connection between bipolar disorder and psychotic thinking?

2.

Ann’s paranoid thinking accompanied her grandiosity. Is this common? How are paranoid and grandiose thoughts related?

3.

The loss of her marriage, her job, and her friends was very traumatic. What allowed Ann to overcome these losses and manage to "rebuild" her life?

Helen--Major Depression, age 83 (14:05) Helen is an 83-year-old woman who has been married for the past 60 years. She remembers being depressed 91 C.

ever since childhood and currently keeps a lethal supply of sleeping capsules on hand. She has received ECT, insulin shock therapy, and anti-depressant medications. Her symptoms include reduced energy, loss of interest in activities, and suicidal ideation.

Discussion questions: 1.

It is not uncommon for the typical person to feel depressed on occasion. Compare and contrast Helen's depression to that of a typical person.

2.

Suicidal thoughts are a common symptom for a depressed person. Brainstorm ways of helping this type of person.

VIDEO RESOURCES

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Everette_Major_ Depression.html Everette: Major Depression (2:04) Watch this interview in which a man describes how it feels to experience major depression.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/mypsychlab/joorman_j.html Jutta Joormann: Impact of Mood and Emotion on Social Behavior (1:09) Watch this video on how individual differences affect mood disorders.

http://media.pearsoncmg.com/ab/ab_lefton_psychology_8/media/lbp8e_15547/lbp8e_15547.html Bipolar Disorder Quiz Explore this true/false quiz about bipolar disorder.

http://abavtooldev.pearsoncmg.com/mydevelopmentlab/index.php?interview=346 Depression, Reward Regions, and the Brain: Erika Forbes Watch this video about depression in young people.

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http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/Lifespan/Grieving_ Part_1.html Grieving a Loss Part 1: Bob, 81 Years Old (6:44) Watch this video on how an elderly man is dealing with bereavement.

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Chapter 6 Anxiety Disorders Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: p.144 Symptoms of Anxiety Disorders: p. 145 Anxiety Excessive Worry Panic Attacks Phobias

Lectures: Primitive fear of snakes The Rat Man Embarrassment Classroom: Fear vs. anxiety Fears and phobias Video Case: Social Phobia, Steve Video Case: Panic Disorder, Jerry, age 58

Diagnosis of Anxiety Disorders: p. 147

Classroom: Number of phobias

Specific Phobia Social Anxiety Disorder Agoraphobia Panic Disorder Generalized Anxiety Disorder Course and Outcome

Frequency of Anxiety Disorders: p. 151 Prevalence Comorbidity Gender Differences Anxiety Disorders Across the Life Span Cross-Cultural Comparisons

Discussion Ideas: Gender differences Childhood abuse Video Case: Obsessive-Compulsive, Ed, age 44

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PROFESSOR NOTES

Causes of Anxiety Disorders: p. 152

Discussion Ideas Nosophobia

Adaptive and Maladaptive Fears Social Factors Psychological Factors Biological Factors

Treatment of Anxiety Disorders: p. 158

Classroom: Constructing a behavioral hierarchy

Psychological Interventions Biological Interventions

Obsessive-Compulsive and Related Disorders: p. 162 Symptoms of OCD Diagnosis of OCD and Related Disorders Course and Outcome of OCD Frequency of OCD and Related Disorders Causes of OCD Treatment of OCD

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CHAPTER OUTLINE I.

Symptoms of anxiety disorders A.

People with anxiety disorders are preoccupied with, and/or persistently avoidant of , thoughts or situations that provoke fear or anxiety.

B.

In contrast with fear, which is in response to a real, immediate danger, anxiety is more diffuse and general, out of proportion to threats from the environment; adaptive at low levels, but maladaptive when excessive, and associated with pessimism and negative self-evaluation at higher levels (Barlow’s "anxious apprehension"); anxiety involves a more general or diffuse emotional reaction, and fear is experienced in the face of real, immediate danger

C.

Excessive worry is common in anxiety; worry is defined as a relatively uncontrollable sequence of negative, emotional thoughts and images anticipating future threats or danger.

D.

Panic attacks—sudden, overwhelming experiences of terror or fright; can be distinguished from anxiety in four major ways: more focused, less diffuse, more intense, and sudden onset

E.

1.

Physical symptoms are dizziness, heart palpitations, sweating, and nausea.

2.

Cognitive symptoms include sense of loss of control or the belief that one is going to die, go crazy, or have a heart attack.

Phobias—persistent and irrational fears associated with specific objects or situations leading to avoidance 1.

II.

Specific phobia—fear of specific objects or situations; e.g., acrophobia is the fear of heights, zoophobia is the fear of small animals, and agoraphobia is the fear of being in places where escape might be difficult

Diagnosis of anxiety disorders A.

DSM-5 anxiety disorders 1.

Specific diagnoses a.

b.

Panic disorder—recurrent unexpected panic attacks, one of which is followed by a period of one month or more in which the patient continues to have problems related to the attack, such as worry, anxiety, or avoidance Agoraphobia—with or without panic attacks—is anxiety about being in situations from which escape might be either difficult or embarrassing.

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III.

c.

Specific phobia—fear that is excessive or unreasonable, related to a specific object or situation

d.

Social anxiety disorder (social phobia)—similar to specific phobia, but performance or interactions in social situations are the focus of fear

e.

Generalized anxiety disorder (GAD)—excessive anxiety and worry about a number of distinct events or activities that are debilitating over a period of at least six months; the worry should not be focused on a fear of panic attacks or being embarressed

2.

Although anxiety disorders are seen as distinct, some experts (lumpers) argue that anxiety is a general condition with multiple manifestations; other experts (splitters) argue that all of the anxiety disorders are separate disorders.

3.

The course of anxiety disorders varies: some people recover fully, while others have persisting problems.

Frequency of anxiety disorders A.

Prevalence 1.

Anxiety disorders are more common than any other mental disorder.

2.

One-year prevalence rates: specific phobias, 9 percent; social phobias, 7 percent; GAD, 3 percent; panic disorder, 3 percent; ; agoraphobia , 1 percent

3.

Only 25 percent of people with diagnosable anxiety disorder ever seek treatment.

B.

Comorbidity is very high; 50 percent with anxiety disorder also have another anxiety disorder or mood disorder, with highest comorbidity rates for GAD, and severe cases of panic disorder with agoraphobia (lowest rates for simple phobias); substance abuse disorders are also common in those with anxiety disorders

C.

Gender differences: women are three times as likely as men to experience specific phobias; they are also twice as likely to experience agoraphobia and panic disorder, yet social phobia is only slightly more common in women

D.

Anxiety across the life span: the elderly show lower prevalence rates for anxiety disorders; stressful life events do not seem to lead to anxiety as commonly in the elderly; older people with anxiety disorders have generally had symptoms for years; new data indicate, however, that prevalence rates may go up as people reach their late 70s and 80s 97 C.

E.

IV.

Cross-cultural comparisons show that different cultures express anxiety in different ways; people in Westernized society experience anxiety in relation to their work performance, while people in other countries are more concerned with family issues or religious experiences.

Causes of anxiety disorders A.

Evolutionary theories view anxiety as part of an adaptive system; anxiety disorders may represent problems in the regulation of that system; however, the important question for clinical psychologists is not only why we experience anxiety, but why it occasionally becomes maladaptive.

B.

Social factors

C.

1.

Stressful life events: an intuitive connection exists between stress and anxiety; research shows that women with anxiety symptoms were more likely to have experienced danger; the depressed were more likely to have experienced loss; and serious interpersonal conflicts are common just prior to the onset of agoraphobia.

2.

Childhood adversity: women with anxiety disorders were more likely to recall parental indifference and physical abuse during childhood or adolescence; similar childhood events are reported by anxious and depressed people.

3.

Attachment relationships and separation anxiety: Ainsworth and Bowlby’s attachment theory suggests that anxiety has its roots in separation anxiety; anxiety disorders may be related to insecure attachments to caregivers developed early in life.

Psychological factors 1.

Learning processes: a.

Classical conditioning-- pairing a conditioned stimulus with an unconditioned stimulus to yield a conditioned response; responsible for some phobias, fears

b.

Preparedness model suggests we are biologically prepared to develop phobias selectively to certain stimuli because doing so has evolutionary value.

1.) Once conditioned, responses to fear-relevant stimuli (e.g., spiders, snakes) are more resistant to extinction than those to fear-irrelevant stimuli (e.g., flowers).

2.) Preparedness may also explain social phobias: we may be prepared to fear faces that are critical, angry, or rejecting.

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c.

2.

D.

Observational learning plays an important role in learning anxiety, especially for fear-relevant stimuli, which further supports preparedness theory.

Cognitive factors a.

Perception of lack of control: people who feel less able to control events are more likely to be anxious and develop specific anxiety disorders, including panic disorder, social phobia, and GAD.

b.

Catastrophic misinterpretation of bodily sensations or perceived threat can lead to panic (e.g., increased heart rate can be misperceived as evidence of having a heart attack) and behaviors that are counterproductive.

c.

Attention to threat and shifts in attention: heightened sensitivity to signs of potential danger contributes to worry, which may lead to anxiety; attentional mechanisms also are involved in social phobias (negative affect leads to self-focused attention, leading to decrements in performance)

d.

Thought suppression: attempting to avoid certain thoughts can make the thoughts more intrusive and increase the distressing emotions associated with the unwanted thoughts.

Biological factors 1.

Genetic factors a.

Twin studies 1.) Concordance rates for MZ significantly higher than DZ twins for anxiety disorders

b.

2.)

Heritability estimates are 20–30 percent for GAD

3.)

Greatest genetic influence found for agoraphobia; least for specific phobias

Genetic and environmental factors: Kendler and Prescott’s 2006 study conclusions regarding anxiety disorders 1.) Genetic risk factors are not highly specific (different genes affect each disorder) nor highly nonspecific (one common set of genes causes all of the disorders) 2.) Two genetic factors found: one for GAD, panic disorder, and agoraphobia; the other with specific phobias 99 C.

3.) Unique (specific to the individual) environmental factors play a role in all of the anxiety disorders 2.

Neurobiology a.

Lab studies of animals have identified brain pathways associated with fear and anxiety.

1.) One circuit involves rapid communication that bypasses the cortical areas and generates a rapid behavioral (e.g., fight-or-flight) response.

2.) A second circuit involves the cortex and generates slower but more organized responses.

3.) Relevant brain regions are also associated with other sets of non-anxious responses, and other brain regions are also involved in anxiety.

V.

b.

Serotonin and GABA are inhibitory neurotransmitters that serve to dampen stress responses; when these neurotransmitter levels are reduced, increased fear and anxiety may result.

c.

The amygdala stores unconscious, emotional memories – the kind that are generated through learning.

Treatment of anxiety disorders A.

Psychological interventions 1.

3.

Exposure: desensitization and flooding a.

Systematic desensitization for fears involves teaching relaxation, then presenting items of a fear hierarchy while the patient is in relaxed state; some evidence that direct (in vivo) exposures work better than imaginal ones.

b.

Flooding involves exposure to the most frightening stimuli rather than working from least to most frightening; success rates have been excellent using this method.

c.

Exposure as a treatment for panic disorder 1.)

Situational exposure—repeatedly confronting previously avoided situations

2.)

Interoceptive exposure—actions that induce the physical sensations that occur in actual panic attacks

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(practice in slow breathing) can be helpful in the treatment of panic disorder.

4.

B.

a.

Relaxation training usually involves teaching the client alternately to tense and relax specific muscle groups while breathing slowly and deeply.

b.

Breathing retraining is a procedure that involves education about the physiological effects of hyperventilation and practice in slow breathing techniques.

Cognitive therapy is useful for anxiety disorders; generally accompanied by a behavioral approach a.

Recognizing faulty logic

b.

Considering worst case scenarios helps to identify exaggerated worry (decatastrophisizing)

c.

Recognizing the relation between these thoughts and maladaptive emotional responses

d.

Examining the evidence that supports or contradicts the beliefs

e.

Teaching clients more useful ways of interpreting events in their environments

Biological interventions 1.

2.

Anti-anxiety medications are the most frequently used types of minor tranquilizers. a.

Benzodiazepines reduce vigilance and somatic symptoms, but are less effective for worry and rumination; effective for GAD and social phobias, but not for specific phobias

b.

Many patients with either panic disorder or agoraphobia tend to relapse when medication is discontinued.

c.

Addiction/withdrawal symptoms are a serious problem for benzodiazepines; 40 percent of people who use the medication for more than six months will have withdrawal symptoms.

d.

Diazepam (Valium) and Alprazolam (Xanax) reduce many symptoms especially vigilance and subjective somatic sensations, such as increased muscle tension, palpitations, increased perspiration, and gastrointestinal distress.

e.

Benzodiazepines bind to specific receptor sites in the brain that are ordinarily associated with a neurotransmitter known as GABA; these drugs enhance the activity of GABA

SSRIs have now become the first line treatment for many anxiety disorders, as they have similar therapeutic benefits as more traditional forms of antidepressants, but they have fewer side effects.

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3.

VI

Tricyclic antidepressants a.

Imipramine: effective for agoraphobia with panic attacks; has a decreased risk of dependency, but relapse possible when discontinued

b.

Uncomfortable side effects (weight gain, dry mouth, overstimulation—sometimes palpitations, sweating, light-headedness) associated with the tricyclics can lead to discontinuing the medication.

Obsessive-compulsive and related disorders A. Overview 1. One of the most debilitating mental illnesses in the world 2.

B.

DSM-5 lists obsessive-compulsive disorder (OCD) in a separate chapter than other anxiety disorders.

Symptoms of OCD 1. Obsessions are repetitive, unwarranted, intrusive cognitive events in the form of thoughts, images, or urges and are often nonsensical and involve something socially unacceptable or horrific.

2. Compulsions are repetitive behaviors or mental acts done to reduce anxiety.

C.

Diagnosis of OCD and related disorders 1. DSM-5 defines OCD in terms of the presence of obsessions and compulsions. The person must attempt to ignore, suppress, or neutralize the obsessions in a time-consuming way (more than one hour per day).

2. With regard to the obsessions, a person may be or may not be aware that the obsessions are not rational. A person may be classified as having one of three levels of insight about obsessions: a. b. c.

Good or fair insight (understands that obsessions are either not true or probably not true) Poor insight (person thinks OCD beliefs are probably true) Absent insight/delusional insight (person is completely convinced the OCD beliefs are true).

3. Hoarding disorder was added as a distinct disorder to the DSM-5 and involves persistent difficulties in getting rid of possessions regardless of their real value.

D.

Course and outcome of OCD 102 C.

1. A 40-year longitudinal study with 5 and 40-year follow-ups resulted in the following data: a. b.

E.

30 percent were recovered at first follow up, 50 percent at 40-year follow-up 80 percent of patients showed improved functioning

Frequency of OCD and related disorders 1.

Two percent of U.S. adult population meets the criteria at some point in their lives.

2.

12-month prevalence is 1.2 percent.

3. Hoarding is much more common.

F.

Causes of OCD 1. The cognitive model places emphasis on the role of attentional processes. OCD may be the result of the maladaptive consequences of trying to suppress unwanted or threatening thoughts that a person has learned to see as dangerous or forbidden.

2.

G.

Obsessions and compulsions are related to several brain regions including the basil ganglia, the orbital prefrontal cortex, and the anterior cingulate cortex. These areas are more active in people with OCD.

Treatment of OCD 1. Exposure and response prevention uses prolonged exposure to the situation that increases a person’s anxiety while preventing a compulsive response. This is the most effective treatment.

2. Biological treatments: medications such as selective serotonin reuptake inhibitors (SSRI’s) are often chosen because they have fewer side effects than do other medications. However, tricyclic antidepressants, such as clomipramine, may also be used.

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LEARNING OBJECTIVES LO 6.1: Why is a panic attack sometimes called a “false alarm?”

LO 6.2: What is the expected long-term outcome for people with anxiety disorders?

LO 6.3: Is there a unique causal pathway for each type of anxiety disorder?

LO 6.4: If phobias are learned quickly and easily, why are they so hard to extinguish?

LO 6.5: Do psychological treatments have any advantages over medication for treatment of anxiety?

LO 6.6: What is the difference between obsessions and normal intrusive thoughts?

LO 6.7: Why is response prevention coupled with exposure in the treatment of OCD?

LECTURE SUGGESTIONS Primitive fear of snakes: Current directions APS reader (2E, p. 123) Authors Ohman and Mineka make a strong case for the special properties of snakes as feared stimuli for both humans and primates. Snake fear is particularly strong and prevalent in humans; 38 percent of females and 12 percent of males nominated it as one of their chief fears. It is, moreover, easier to induce fear of snakes and harder to extinguish this fear than it is the fear of other, more mundane objects (flowers or mushrooms, for example). In fact, we seem to develop the fear of snakes even when we cannot consciously perceive the snake—as in the backward masking technique that the authors describe. Snakes draw our attention and become the focus of attention quite easily.

All of these findings are cited in an effort to establish that the fear of snakes is a “primitive fear” that does not require higher cortical function. The fear of snakes has probably been established through evolutionary processes early in our development, in fact. Ohman and Mineka then argue for a special "fear module" that would function independently of conscious thought but allow us to respond to snakes as stimuli without higher cognitive processing. Perhaps one clinical implication of this article is that we should certainly respect and understand the depths of the fear of snakes that some clients present and consider treatments which view the fear as below the level of conscious thought. Mere “talking about it” will very likely not touch the depth and primitiveness of an evolutionarily ancient fear such as the fear of snakes.

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The Rat Man (Freud): In one of his famous cases, The Rat Man, Freud, vividly describes an obsessive-compulsive episode: "On the day of her departure he knocked his foot against a stone lying in the road, and was obliged to put it out of the way by the side of the road, because the idea struck him that her carriage would be driving along the same road in a few hours' time and might come to grief against this stone. But a few minutes later it occurred to him that this was absurd, and he was obliged to go back and replace the stone in its original position in the middle of the road."

Freud, S. (1909). Notes upon a case of obsessional neurosis ("rat man") and process notes for the case history.

Standard Edition, 7:3-122.

The key concept is that obsessions are ego-dystonic, unwanted, and appear to come from outside the control of the person suffering them. Students will, generally, be able to relate to this episode to some extent; it will then be possible to discuss the relationship between superstitious behavior and obsessive-compulsive behavior. Point out to students that the thoughts and behavior of people with OCD generally differ primarily from others in their intensity rather than the nature of the thoughts and behaviors themselves. Ask students to nominate some of their own obsessive thoughts or even behaviors (e.g., checking behaviors). Then discuss the range of possible dysfunctions that these thoughts and behaviors can cause.

Embarrassment: People with social phobia fear embarrassment. Embarrassment, though, is a common, but painful, experience for most of us. It is also one that begins early in our development, and may even be hard- wired. About 20 percent of 3-year-olds and 50 percent of 5-year-olds show signs of embarrassment, according to parents (Buss, 1980), and several different things occur when embarrassment strikes. First, there is the awareness that we are blushing. This is perhaps the most exasperating thing about embarrassment. We can often hide anxiety and other feelings, but no matter how much we disclaim feeling embarrassed, a red face is a dead giveaway. Why we blush is not known.

Charles Darwin wrote what is still considered the most complete essay on blushing, and he concluded that only people experience this. Other species turn red in the face sometimes, but that is from rage, not embarrassment. Since self-consciousness is considered uniquely human ,and blushing is associated with self-consciousness, perhaps this explains how blushing (out of embarrassment) is uniquely human.

Second, the embarrassing feelings cause a temporary drop in self-esteem. We feel clumsy, incompetent, and foolish. It is not surprising, then, that a third part of embarrassment is often an attempt to escape the situation. We may change the subject or actually leave the situation physically; we certainly try to shift the attention away from ourselves.

Is the embarrassment of the social phobic on a continuum with "everyday embarrassment" or completely different in structure? How can we help the social phobic deal with embarrassment? Ask students about their own experience with embarrassment and how they suggest helping people with social phobia deal with embarrassment.

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Ask students to grapple with the following: Embarrassment is an aversive experience. It is difficult to identify benefits from being embarrassed (pain, for example, is aversive, but is clearly beneficial as a signal of potential injury). Yet this response, like other forms of anxiety, presumably developed because it has (or had) evolutionary value. What might this value be?

Buss, A.R. (1980). Self-Consciousness and Social Anxiety. San Francisco: Freeman

DISCUSSION IDEAS Gender differences: How can we best explain the gender differences in the prevalence rates of anxiety disorders? Women are three times as likely as men to have specific phobias and twice as likely to suffer from agoraphobia and panic disorder. Is it due to socialization, in which women are expected to be less capable and confident in dealing with danger? Are women secondarily reinforced for being frightened or anxious? Within the discussion, it may be important to keep in mind that most of these anxiety disorders are at least partly genetically determined. Does that mean that women are hard-wired to experience more anxiety? If so, why would that be?

Childhood abuse: What is the connection between childhood abuse and anxiety disorders? Stein and his colleagues (Stein et. al., 1996) present data that suggests an important link between anxiety disorders and childhood physical and sexual abuse. In a sample of 125 patients diagnosed with anxiety disorders, the incidence of physical abuse was higher among both men and women than in a matched sample of community residents. Women in the sample, moreover, reported more sexual abuse than did controls, and those with panic disorder reported a particularly high level of sexual abuse. (Note that much research does link child abuse to PTSD, an anxiety disorder that is grouped with dissociative disorders in the next chapter.)

After describing this research, ask students for their responses. Why would those suffering from panic attacks report a particularly high incidence of sexual abuse? What is the connection? Remind students of the nature of this research—it is a retrospective study. What other explanations can be offered as alternatives to the causal model that assumes that childhood abuse causes anxiety disorders? This can lead to both a discussion about the importance of childhood abuse and the nature of retrospective research (especially its limitations) and the difference between correlation and causality. Then ask students: what would be a better methodology if one wanted to establish causality?

Stein, M.B., Walker, J.R., Anderson, G., Hazen, A.L. (1996). Childhood physical and sexual abuse in patients with anxiety disorders and in a community sample. American Journal of Psychiatry, 153, 275–277.

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Nosophobia: One type of simple phobia that is particularly debilitating is nosophobia, a fear of illness. There have been reports of people asking for as many as 100 AIDS tests. Many people are so afraid of developing other infections that they take extreme precautions (e.g., using artificial supplies of oxygen) to avoid illness. After describing these symptoms, ask the class what type of treatment might be effective in treating such a phobia. Cognitive and behavioral treatment methods, those involving insight-oriented or interpersonal approaches, and use of medication can then be discussed and the benefits and drawbacks identified.

CLASSROOM ACTIVITIES Fear vs. anxiety: Suggest that students conduct a "thought experiment." Pretend that a lion just walked into the classroom and appeared threatening. Give them a few minutes to consider the emotional, cognitive, and behavioral responses they might have in this situation. Then ask them to imagine themselves taking the final exam in this class. Again, allow a few minutes for them to "experience" this event. Use the blackboard to tabulate their responses, using the three categories of emotional, cognitive, and behavioral responses. Then use these examples to illustrate some of the similarities and differences between the fear response and anxiety.

Fears and phobias: Ask students to anonymously write down their three biggest fears or phobias. Then ask them to include a description of how each of these fears affects their lives. After these papers are submitted, you can read some of them aloud, and the class can discuss whether the fears should be classified as phobias. The exercise will also make it clear that fears and even phobias are not uncommon; however, the degree to which they interfere with activities varies.

Number of phobias: Ask students to nominate as many different phobias as they can recall. Give preference to the technical terms but also accept their ‘lay language’ in describing fears of snakes, spiders, etc. Then compare the list generated by the class to the rather exhaustive medical terminology list given on the following website: http://www.designedthinking.com/Fear/Phobias/Medical/medical.html.

This exercise can also be modified by asking the students to find a list of phobias for each letter of the alphabet from A to Z. Constructing a behavioral hierarchy: Have the class pair off into dyads and describe a fear- or anxiety-provoking situation to their partners. Within each pair, one student will present fears while the other plays the role of the therapist. Assign the students the task of 107 C.

constructing a hierarchy in which they list the most frightening (to be labeled 10) through the least frightening (to be labeled as 1) situations associated with a presented fear. For example, if they are discussing a fear of heights, standing on the Empire State Building and looking down might be at the top of the list. Looking at a picture of a tall building might be at the bottom of the list. Students should try to identify at least ten situations. Then ask them to switch roles, from playing the role of therapist to being the one who presents the fears. Stress the fact that constructing a good hierarchy is crucial in the implementation of effective systematic desensitization.

Progressive relaxation or guided imagery exercise: This exercise offers an opportunity for the students to experience the real-life application of this cognitive-behavioral therapy technique. Ask the students to get comfortable in their chairs or move to a more comfortable place in the room. Then you can use a meditation guided recording on CD, or an example to walk you through the exercise like the ones listed in Davis, Eshelman, and McKay’s guide, The Relaxation & Stress Reduction Workbook (2000).

Davis, M., Eshelman, E., & McKay, M. (2000). The Relaxation & Stress Reduction Workbook (5th edition).

Oakland, CA: New Harbinger Publications.

Coulrophobia: why are so many people afraid of clowns?

Coulrophobia is the intense fear of clowns that is experienced not only by children but also by adults.

Hollywood and popular media have played off of this phobia related to clowns. Dunnell (2009) reported that popular culture, such as in the film Batman with the “clown-like appearance of the Joker” as well as in Stephen King’s It, with “Pennywise,” may have helped reinforce this intense fear of clowns. To spark the discussion, you could show a short clip of both of the above listed characters as a visual aid. Dunnell (2009) asked the following question: “… can negative childhood experiences combined with media imagery really explain such a common and often acute fear of clowns? Or is there something more deep-rooted in human psychology that can explain coulrophobia?” He continued on to discuss the impact of Jaws and how even today individuals refuse to go into the water, have a fear that they will be attacked by the great white shark, or simply have a fear of water (Dunnell, 2009).

Can you think of another popular movie character that may have created the same types of fear as “Pennywise” or “The Joker”? How did this character impact you as a child? Does this character still impact you today?

Dunnell, T. (2009). Coulrophobia: The fear of clowns. Retrieved from http://www.suite101.com/content/coulrophobia-the-fear-of-clowns-a149243 on June 1, 2011

VIDEO CASES IN ABNORMAL PSYCHOLOGY: Steve—Social Phobia, age 54 108 C .

Steve, a 54-year-old man, describes himself as suffering from a social anxiety disorder. He says that he was a school phobic as a student, feeling like every day was a “performance” that frightened him. “High school was one of the most painful experiences of my life,” he proclaims, and he is not interested in reunions, which would stir up those memories. He now finds himself clamming up in dining situations when others are close, feeling that others are watching him. There are some clear signs of paranoid ideation in Steve—the hypervigilance and fear of being watched. But his primary fear is that others will see him as ignorant or stupid. He began his academic work as a philosophy student and was a successful teacher but the fear of a dissertation committee’s judgment and his obsessive concern with whether his teaching was acceptable drove him out of the academic arena for his work.

Discussion questions: 1.

What is the connection between anxiety and paranoia? Does Steve suffer from paranoia or anxiety?

2.

Is Steve’s fear of appearing ignorant or stupid typical of a social phobic? Why would he have such a fear when he appears to be quite professional, composed, and engaging?

3.

Would you advise Steve to try to face up to his fears and continue to pursue his career as a teacher or avoid such difficult situations and find “easier” ways of making a living?

Ed, Obsessive-Compulsive, age 44 (11:25) Ed is an electronic technician who has had obsessive-compulsive disorder for the past 20 years. His disorder is characterized by disturbing thoughts that lead to horrific behavior, which includes the typical checking and hand-washing rituals of obsessive-compulsive people. His therapy includes medication, psychotherapy, and participation in a self-help group.

Discussion questions: 1.

Ed describes his most distressing thought as revolving around God and the church. Why is this thought so disturbing to Ed?

2.

Many of us have an obsessive-compulsive component to our personalities. Think of one instance in which you or someone you know has engaged in a behavior that could be classified as somewhat obsessive-compulsive. Then have them compare that behavior to what Ed experiences.

Jerry, Panic Disorder, age 58 (11:05) Jerry is a 58-year-old man who experienced his first panic attack within the past year. His symptoms include shortness of breath, heart palpitations, sweating, nausea, faintness, fear of dying and fear of going crazy. His episodes occur erratically, sometimes two to three times a day and lasting about three to four minutes: he compares them to a heart attack.

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Discussion questions: 1.

Jerry describes two particular situations during which his panic attacks occur frequently. How has the occurrence of these panic attacks modified his lifestyle?

2.

At times all of us panic or feel some of the symptoms described as being part of panic disorder.

Describe a situation in which you feel similar to Jerry, then explain how your behavior is different from one suffering from panic disorder.

VIDEO RESOURCES http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/WoodIt/Anxiety_Disorders. html Anxiety Disorders (2:00) Listen to this explanation on the distinction between normal, everyday feelings and psychological disorder. http://visual.pearsoncmg.com/mypsychlab/episode07/web_index.html?clip=4&tab=tab0 Special Topics: Learning to Overcome Phobias (6:50) Watch this video on phobias, conditioning, and counter-conditioning. http://wps.prenhall.com/wps/media/objects/803/822654/simulations/unch_11.swf Biomedical Therapies Try this drag and drop exercise to match drug treatments with psychological disorders. http://media.pearsoncmg.com/ab/ab_lefton_psychology_8/media/obsessive_compulsive/swf/launch.html The Obsessive-Compulsive Test Try this test for measuring obsessive thoughts. http://visual.pearsoncmg.com/mypsychlababnormalDSM5/episode2/web_index.html?clip=1&tab=tab0 Dave: Obsessive-Compulsive Disorder (OCD) (1:09) Watch this description of living with obsessive-compulsive disorder.

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Chapter 7 Acute and Posttraumatic Stress Disorders, Dissociative Disorders, and Somatic Symptom Disorders Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: p. 175 Lectures: Acute and Posttraumatic Stress Disorders: Psychogenic amnesia p. 175 Child sexual abuse I Child sexual abuse II Symptoms of ASD and PTSD Rape trauma syndrome Diagnosis of ASD and PTSD Acute Stress Disorder Discussion Ideas: What Defines Trauma Recovering memories of trauma Frequency of Trauma, PTSD, and ASD Impact of 9-11 Causes of PTSD and ASD Biological Factors Video Case: PTSD, Bonnie Prevention and Treatment of ASD and Video Case: PTSD, Sara PTSD

Dissociative Disorders: p. 186 Hysteria and the Unconscious Hypnosis: Altered State or Social Role Symptoms of Dissociative Disorders Diagnosis of Dissociative Disorders Frequency of Dissociative Disorders Causes of Dissociative Disorders Treatment of Dissociative Disorders

Somatic Symptom Disorders: p. 196

Lectures: Hypnotic amnesia Discussion Ideas: Dissociative identity disorder Classroom: Hypnosis

Classroom: Illness Anxiety Disorder

Symptoms of Somatic Symptom Disorders Diagnosis of Somatic Symptom Disorders Frequency of Somatic Symptom Disorders Causes of Somatic Symptom Disorders Treatment of Somatic Symptom Disorders

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PROFESSOR NOTES

CHAPTER OUTLINE I.

II.

Overview A.

Traumatic stress: redefined as both the experience of an event involving actual or threatened injury or death and the response of intense fear, helplessness, or horror in reaction to that event

B.

Dissociation is defined as the disruption of the normally integrated mental processes involved in memory, consciousness, identity, or perception.

Acute and posttraumatic stress disorder A.

Posttraumatic stress disorder (PTSD) is defined by symptoms of re-experiencing a traumatic event, avoidance, and increased autonomic arousal or anxiety, with symptoms lasting more than one month.

B.

Acute stress disorder (ASD) occurs within the first four weeks after exposure to trauma and includes symptoms similar to PTSD and dissociative symptoms.

C.

Dissociative disorders are characterized by persistent, maladaptive disruptions in the integration of memory, consciousness, or identity.

D.

Somatic symptom disorders are characterized by unusual physical symptoms that occur in the absence of a known physical illness.

E.

Symptoms

F.

1.

Re-experiencing the trauma—distressing thoughts or images, nightmares, or flashbacks; in its most extreme form, this symptom can involve a dissociative state in which the person believes the event is occurring in the present

2.

Avoidance—avoiding stimuli associated with the trauma, including thoughts or feelings related to the event; can also involve numbing of responsiveness

3.

Arousal or anxiety—restlessness, agitation, exaggerated startle response, irritability, and sleeplessness are common

4.

Dissociative symptoms—feeling dazed, out of touch with reality, not integrating an experience or set of experiences a.

Depersonalization—feeling cut off from oneself or one’s environment

b.

Derealization—feeling a sense of unreality about oneself or the world

c.

Dissociative amnesia—inability to recall important aspects of a traumatic experience

Classification 1.

Initial focus on "combat neurosis" experienced by soldiers

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G.

Diagnosis of ASD and PTSD 1.

PTSD a. Exposure to actual or threatened death, serious injury, or sexual violence, either by experiencing the event, witnessing the event, learning of the event, or repeated exposure to aversive details of event b.

Presence of one or more intrusive, recurrent symptoms: involuntary memories; distressing dreams; dissociative reactions; intense or prolonged exposure to internal or external cues that resemble an aspect of the event; marked physiological reactions to internal or external cues that either symbolize or represent the event

c. Persistent avoidance of stimuli associated with traumatic event d. Negative alterations in mood or cognitions associated with the traumatic event e. Marked changes in arousal and reactivity associated with the event f.

Disturbance persists for more than one month.

g. Disturbance causes clinical levels of distress or impairment h. Not attributable to the effects of a substance such as alcohol or drugs and is not caused by another medical condition.

2.

ASD a. Exposure to actual or threatened death, serious injury, or sexual violence, either by experiencing the event, witnessing the event, learning of the event, or repeated exposure to aversive details of event b. Presence of nine or more of the following symptoms: 1.

Intrusion symptoms a. Distressing , involuntary memories of event b. Recurrent distressing dreams c. Dissociative reactions d. Intense or prolonged psychological distress or marked physiological reactions

2.

Negative mood a. Persistent inability to experience positive emotions

3.

Dissociative symptoms 113 C.

a. Altered sense of one’s surroundings b. Inability to remember important details of event 4.

Avoidance symptoms a. Efforts to avoid distressing memories, thoughts, or feelings associated with event b. Efforts to avoid external reminders of event

5.

Arousal symptoms a. Sleep problems b. Irritable behavior c. Hypervigilance d. Concentration problems e. Exaggerated startle response

c. Duration 3 days to 1 month d. Causes clinical levels of distress and/or impairment e. Not attributable to other causes such as drugs, alcohol, or medical conditions H.

Frequency 1.

A study in the Detroit area found that 90 percent of people living in that area have experienced at least one traumatic event with about 9 percent leading to the development of PTSD; similar rates have also been reported for individuals living in Mexico.

2.

Women are more likely to develop PTSD following rape, as compared to the risk factor among men who are exposed to combat.

3.

Children have a 20-40 percent chance of developing PTSD.

4.

Minority groups are more likely to experience PTSD because of their more difficult living conditions; in addition, if we look at people with less education, they are more likely to live in dangerous environments and be exposed to more trauma.

5.

PTSD is common among crime victims.

6.

The most common cause of PTSD is the sudden unexpected death of loved ones.

7.

Trauma exposure increases if someone engages in risky behavior; men, young people in their late teens and early 20s, people with a history of conduct disorders, and extroverts are more 114 C.

likely to experience trauma.

8.

People with a family history of mental illness, particularly anxiety disorders, are also at an increased risk.

9.

PTSD can persist a long time. Among WWII former prisoners of war, 40 years after the war, only 30 percent of POWs who had suffered from PTSD were fully recovered.

10. The course of trauma exposure means that individuals who suffer from ASD are more likely to develop PTSD based on primarily three symptoms: numbing, depersonalization, and a sense of reliving the experience.

I.

Causes 1.

Social factors a. Greater trauma intensity, exposure, and life threat associated with increased risk. b. Social support after the trauma is associated with better outcome.

2.

Biological factors a. Genetic factors appear to contribute to PTSD, particularly to arousal/anxiety 1. Monozygotic twins show higher concordance rates for PTSD following trauma than do dizygotic twins. b. Biological consequences of PTSD include functional and perhaps structural changes; these are often associated with sympathetic nervous system arousal; hard to determine if some of these symptoms are simply correlative or caused by the trauma c. Genes contributed most strongly to arousal/anxiety symptoms and least strongly to reexperiencing.

3.

Psychological factors involved in PTSD a. Dissociation may be an unconscious defense mechanism that helps victims to cope with trauma. b. Preparedness, purpose, and the absence of blame can aid coping with trauma. However, victims must be careful not to assign self-blame as this increases risks for PTSD. c. Emotional processing: acknowledging and addressing emotions associated with the trauma, organizing and expressing experiences and integrating them into a new worldview (meaning-making); may be important aspect of adaptive coping

4.

J.

The above factors interact: pre-trauma characteristics, the trauma itself, and post-trauma support and coping all play a role.

Prevention and treatment of ASD and PTSD 115 C.

III.

1.

Prevention through early intervention: individual counseling and/or group counseling/discussions ASAP—social support believed to be crucial

2.

Critical incident stress debriefing (CISD): a one- to five-hour group meeting in which people share experiences and reactions and in which group leaders offer education, assessment, and referral; widely used, immediate response, though no empirical evidence supporting its effectiveness at reducing PTSD

3.

Psychotropic medication is often used, particularly antidepressants.

4.

Psychotherapy involves helping the client re-experience the trauma and his/her responses and helping the client alter resulting maladaptive thoughts.

5.

Cognitive-behavioral approaches (e.g., prolonged exposure) are empirically supported; imagery rehersal therapy, confronting feared situations in one’s imagination, successfully reduces nightmares.

6.

Eye movement desensitization and reprocessing involves rapid back-and-forth eye movements while reliving the trauma; has not been empirically demonstrated to be effective beyond the effect of exposure itself

7.

Antidepressant medications have become commonly used, partly because of the high comorbidity between PTSD and depression and partly because of their overall effectiveness

Dissociative disorders A.

Dissociation—persistent, maladaptive disruptions in the integration of memory, consciousness, or identity

B.

Hysteria and the unconscious 1.

Both somatic symptom and dissociative disorders seen as expressions of hysteria; literally, “wandering uterus” (Greek), caused by frustrated sexual desires

2.

Charcot (1859–1947)—used hypnosis to treat and induce hysteria; influenced Freud and Janet

3.

Janet viewed dissociation as an abnormal process; Freud veiwed it as normal and similar to repression.

4.

Dissociative disorders are characterized by persistent, maladaptive disruptions in the integration of memory, consciousness, identity, or perception; verges on the unbelievable

5.

Psychologists generally agree that unconscious processes do exist and play a role in both normal and abnormal emotion and cognition.

6.

Implicit memory (memory without awareness) is empirically supported and illustrates that unconscious processes exist, while explicit memory is a conscious recollection.

7.

The rational system uses abstract, logical knowledge to solve complex problems over time, and the experiential system uses intuitive knowledge to respond to problems immediately without the 116 C.

delay of thought.

8.

C.

Hypnosis—subjects experience loss of control over their actions in response to suggestions from the hypnotist

Symptoms of dissociative disorders 1.

Trauma often plays a role in dissociation and dissociative disorders. a. Fugue and amnesia usually follow a traumatic event; depersonalization is a less dramatic symptom where people feel detached from their bodies; derealization is a related symptom and involves a feeling of detachment from one’s surroundings. b. Dissociative identity disorder-- hypothesized to be related to past trauma (such as chronic physical and sexual child abuse); this disorder was formerly referred to as multiple personality disorder, where two or more personalities coexist within a single individual

2.

D.

Recovered memories: the question of the validity of recovered memories has been debated for a number of years; recent research indicates that memories recovered outside of the scope of therapy are likely to be more veridical

Diagnosis of dissociative disorders 1.

Dissociative amnesia—sudden inability to remember extensive and important personal information; response to trauma or extreme stress (not a result of substance abuse, head trauma, or an organic disorder); generally related to a traumatic experience

2.

Dissociative fugue—a subtype of dissociative amnesia; sudden, unplanned (but purposeful) travel away from home; inability to recall the past, confusion about identity, or the assumption of a new one

3.

Depersonalization/derealization disorder—persistent and severe feelings of being detached from oneself or social/physical environment; usually follows a new or disturbing event a. Limited splitting between conscious and unconscious mental processes; no memory loss occurs b. Occasional depersonalization experiences are normal and experienced by about half the population.

4.

E.

Dissociative identity disorder (DID) (formerly multiple personality disorder)—two or more distinct personality states in an individual that take control over behavior with some memory loss occurring between personalities

Frequency of dissociative disorders 1.

Increase in diagnosis of multiple personality disorder has been observed in conjunction with the recognition of the high prevalence of child sexual abuse, which is said to play a role in the etiology of many dissociative disorders 117 C.

a. Prior to 1980, about 200 case histories of multiple personality disorder were reported for the entire world; in a 1986 report, about 6,000 cases were reported in North America b. Some professionals argue that most clinicians overlook dissociative disorders; patients are misdiagnosed as having schizophrenia, borderline personality disorder, depression, panic disorder, and substance abuse.

2.

The majority of mental health professionals are skeptical about reports of high prevalence of dissociative disorders; some argue that they were created by the power of suggestion and are essentially role-playing.

3.

Influence of Sybil (e.g., movie and book): caused new cases to skyrocket to 40,000

4.

One study claimed that over 10 percent of the general adult population suffers from dissociative disorder, with 3 percent suffering specifically from DID.

5.

Most cases of dissociative disorders are diagnosed by advocates of the disorder.

6.

40 percent of hospitalized psychiatric patients met the DSM criteria for the diagnosis of a dissociative disorder.

7.

Dissociative disorders are rarely diagnosed outside of the U.S. and Canada.

8.

The DSM-5 includes an estimated prevalence of DID at 1.5 percent, although this is based on a small study.

9.

The number of personalities in DID can range from two to hundreds.

10. Some experts, such as Nicholas Spanos, argue that DID is not real; they argue it is caused by patients acting out roles driven by their own and their therapists’ expectations. Spanos and his colleagues were able to replicate the symptoms of DID through role-playing and hypnosis with randomly assigned volunteers.

F.

Causes of dissociative disorders 1.

Research is very limited.

2.

Psychological factors a. Trauma plays a role in dissociative fugue, dissociative amnesia, and perhaps dissociative identity disorder. b. Much information comes from retrospective reports—evaluations of the past from the vantage point of the present; validity is of concern, since memories can be selectively recalled, distorted, or created to conform with subsequent experiences c. State-dependent learning 1.

C.

Learning that occurs in one cognitive/emotional state is best recalled in the same state.

118

2.

3.

Has been used to explain DID—according to this view, repeated experience of trauma, dissociation, and state-dependent learning leads to independent personalities

Biological factors—not yet systematically studied a. Preliminary evidence indicates no genetic contribution. b. Some biological factors can cause dissociation-like impairments, but little specific research demonstrating dissociation disorders links to biological factors.

4.

G.

IV.

Social factors: some argue that dissociative disorders are produced by iatrogenesis—the manufacturing of dissociative disorders by their treatment; patients develop multiple personalities in response to the leading questions of their therapists, not as a result of defense mechanisms

Treatment of dissociative disorders 1.

Since dissociation is hypothesized to occur as a response to overwhelming trauma that is not integrated, treatment involves uncovering and expressing past traumas.

2.

Hypnosis and abreaction: the emotional reliving of past traumatic experiences is thought to allow integration of the trauma into conscious experience

3.

In DID, treatment is to reintegrate the different personalities into a whole and not have one personality dominate the others.

4.

Medications (antianxiety, antidepressant, and antipsychotic) are used to reduce distress, but do not cure the disorder.

5.

There is no research available to support any treatment for dissociative disorders.

Somatic symptom disorders A.

B.

Typical symptoms and associated features 1.

Involves physical symptoms that cannot be explained by an organic impairment; there is nothing physically wrong with the patient, but the symptoms are not feigned

2.

“Physical symptoms” can involve substantial impairment of a somatic system, multiple physical symptoms, preoccupation with a particular part of the body, or fears about a particular illness (despite negative medical tests)

Unnecessary medical treatment 1.

People with somatic symptom disorders typically consult their physicians, not mental health professionals.

2.

Many times physicians perform unnecessary medical procedures because they do not recognize 119 C.

the nature of the patient's problems.

3.

C.

A substantial percentage of patients consult physicians for which no organic cause can be found; this fact highlights the fact that substantial use of the physical health care system may be related to psychological factors.

Diagnosis of somatic symptom disorders 1.

Conversion disorder— psychological conflicts are converted into physical symptoms, often mimicking those found in neurological diseases or disorders, e.g., hysterical blindness or paralysis; may make no anatomical sense

2.

Somatic symptom disorder—at least one severe somatic symptom complaint accompanied by excessive worry about symptoms. a. May present their symptoms in histrionic manner b. Patients may exhibit la belle indifference—a flippant lack of concern about the physical symptoms c. In contrast to stereotypes, it is not more comon in older adults; sometimes called Briquet’s syndrome, after French physician Pierre Briquet.

3.

Illness anxiety disorder (formerly hypochondriasis) —persistent, intense, and disturbing fear or belief that one is suffering from a physical illness

4.

Body dysmorphic disorder—preoccupation with an imagined defect in physical appearance; typically focuses on a facial feature, such as the nose or mouth; may lead to repeated visits to a plastic surgeon

5.

Malingering and factitious disorder a. Malingering is pretending to have a disorder to achieve a tangible benefit b. Factitious disorder is a feigned condition that is motivated by a desire to assume the sick role; one prominent example is Munchausen syndrome.

6.

D.

Measurement and detection of these disorders may be difficult because they involve unconscious processes that cannot be observed directly.

Frequency of somatic symptom disorders 1.

Conversion disorders may have been common during the time of Charcot, Janet, and Freud, but are rare today; lifetime prevalence of conversion disorder is 50 cases per 100,000 population, and 0.7 percent prevalence for individuals with BDD; other somatic symptom disorders are more common. DSM-5 estimates 5-7 percent of the population suffers from illness anxiety disorder.

2.

Gender differences a. Hypochondriasis is equally common among men and women.

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b. All other forms of somatic symptom disorder are much more common among women.

3.

Somatic symptom disorders are more common among lower socioeconomic groups, people who have less than a high school education, African Americans, and people who have lost a spouse (through divorce, separation, or death) and are considerably more common in Puerto Rico than on the U.S. mainland.

4.

Cultural norms about the expression of emotion may play a large role in the development of somatization disorder. a. Latin cultures have greater prevalence rates; may be due to their negative views on the expression of emotion. b. The Korean syndrome of hwa-byung, which is characterized by symptoms of fatigue, insomnia, indigestion, and aches/pains may be another example of cultural influence; Koreans have norms against expressing negative emotions.

5.

Comorbidity a. People who suffer from somatic symptom disorders frequently have comorbid depression and anxiety. b. Antisocial personality disorder is often seen in family members of people with somatization disorder.

E.

Causes of somatic symptom disorders 1.

Biological factors a. Misdiagnosis can be critical; there are obvious risks if a true physical disorder is untreated; in one study, 25 percent of patients diagnosed with a conversion disorder were later identified to have a neurological disease. b. Diagnosis by exclusion—complaint is assumed to be a part of a somatic symptom disorder only when various known physical causes are ruled out c.

2.

Medically unexplained syndromes are sometimes used to describe somatic symptom disorders.

Psychological factors a. Janet and Freud assumed that conversion disorder was a consequence of traumatic experiences overwhelming coping abilities; Freud later viewed the trauma as fantasized and viewed dissociation as a defense against unacceptable sexual impulses. He described the following: 1.

Primary gain—symptoms may serve the function of protecting the conscious mind by expressing the psychological conflict unconsciously

2.

Secondary gain—symptoms may help a patient to avoid work or responsibility or gain 121

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attention b.

3.

Cognitive behaviorists focus on 1.)

Positive and negative reinforcement

2.)

Learned assumption of the sick role

3.)

Tendency to amplify somatic symptoms

4.)

Alexithymia—a deficit in the capacity to recognize and express emotions that are signaled by physiological arousal

5.)

Misattribution of normal somatic symptoms

Social factors a. People may be fearful, sad, or uncertain about their lives but express these emotional concerns physically because of limited insight or social intolerance of psychological complaints. b. More common in non-industrialized countries and among less-educated people in the U.S., perhaps because people with less education do not have the opportunity to learn to describe their inner turmoil in psychological terms.

F.

Treatment of somatic symptom disorders 1.

Virtually no systematic research conducted on any treatment for somatic symptom disorders, except cognitive-behavior therapy; some evidence suggests that it is an effective treatment for illness anxiety disorder and body dysmorphic disorder a. Operant approach—rewards successful coping and life adaptation instead of rewarding "pain behavior" and the sick role b. Cognitive behavior therapy—incorporates operant techniques and cognitive restructuring to address the emotional and cognitive components of pain c. Antidepressants and SSRIs may be effective in treating these disorders. A combination of medical and cognitive treatments appear to have the best results.

2.

One difficulty in treating somatic symptom disorders is that patients typically consult primary care physicians about their ailments and refuse referrals to mental health professionals.

3.

Recommendations for physicians treating patients with somatic symptom disorders: a. A strong and consistent physician-patient relationship is important; physicians are urged to schedule routine appointments, conduct brief medical exams, and offer consistent emotional support and medical reassurance.

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b. Physicians should convey a sense of concern; patients who do not receive this empathy are likely to ignore physicians's advice and/or change doctors c. Refer patients to mental health professionals with sensitivity

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LEARNING OBJECTIVES LO 7.1: How does DSM-5 define trauma?

LO 7.2: Does trauma always lead to PTSD? LO 7.3: Can the unconscious mind cause mental disorders?

LO 7.4: What are recovered memories?

LO 7.5: Is multiple personality disorder real?

LO 7.6: Were conversion disorders common in Freud’s time?

LECTURE SUGGESTIONS Psychogenic amnesia: Current directions APS reader (69-75) Arrigo and Pezdek attempt to broaden the discussion of memory repression by reviewing some of the literature on forgetting or repressing aspects of trauma that do not concern childhood sexual abuse. They argue that the debate about recovering memories of sexual abuse has become so politically charged that the question of whether memories can be repressed or recovered as a scientific question has been largely lost. A number of domains are then explored, including memories involved in disasters, war combat, attempted suicides, violent deaths of parents, and adult rape experiences. In each case, some credible evidence appears to exist in which amnesia took place. In some cases, such as in war combat amnesia, there is even evidence of long-delay recovery of forgotten memories.

The article concludes, “Across a range of types of traumatic events, implicit memory for the traumatic event has been documented despite the absence of explicit (conscious) memory for it.”

Although Arrigo and Pezdek provide a context in which to view the “repressed memory of sexual abuse” debate, the research they present does not offer a solution to the more extreme and controversial aspects of that debate. The question that Loftus and others have raised concerns the spontaneous or forced recovery of memories from very long ago for which no implicit memories had existed prior to a therapist’s work. The research presented here does broaden the context in which to view the question of amnesia for traumatic events, but it does not provide convincing evidence of the kind that would resolve the very controversial repressed memory issue.

Child sexual abuse I: How prevalent is child sexual abuse? How relevant is it in the development of somatization disorder and multiple personality disorder? These are questions that are difficult to answer for two reason: the first, because it is difficult to obtain accurate statistics, and the second, because research on this area is only in its youth. There is, however, increasing documentation of childhood sexual abuse, and especially in the lives of those who suffer from somatization disorder and dissociative disorders. It has been estimated that one out of every four or five girls and one out of every nine or ten boys are sexually abused before the age of 18, although estimates vary widely depending on definition and methodology. One study (Morrison, 1989) compared women who suffered from a mood disorder to women with somatization disorder. Somatization disorder patients were significantly more likely to report childhood sexual abuse (despite reporting a similar level of childhood sexual experiences) than were 124 C.

women with a mood disorder. About 50 percent of those with somatization disorder, as compared to 17 percent of those with mood disorders, reported having been sexually abused as children. One of the difficulties involved in such studies is that patients with dissociative and somatic symptom disorders may not be considered reliable sources when they report their own experiences. It may be useful to ask the students how they would attempt to overcome this problem in an investigation of the connection between childhood sexual abuse and these disorders.

Morrison (1989), American Journal of Psychiatry, 146, 239–241.

Child sexual abuse II: A popular misperception is that people who were abused as children are likely to abuse their own children.

Since it is likely that some of your students were themselves abused as children, exposing this myth might provide some personal relief, as well as have educational value. The belief is based on the common error made when the direction of prediction is not taken into consideration, a mistake sometimes made in the study of traumatic experiences and their sequelae. It is true that people who abuse their children are more likely to have been abused as children. It is also true that people who were abused as children are slightly more likely to abuse their own children than people who were not themselves abused. However, it is still unlikely that a person who was abused as a child will abuse his or her own child. Describe the reason for this: just because prediction is possible in one direction does not mean it necessarily is possible in the opposite direction. This fact has implications for the retrospective research on trauma and emotional disorders. Because people with certain disorders have a frequent occurrence of an historical event (such as child abuse), it does not follow that people who have that experience are likely to develop the disorder.

Rape trauma syndrome: Describe the rape trauma syndrome in some detail, using the Burgess & Holmstrom model: Immediate phase: a variety of reactions are possible. Fear and anxiety are the most common emotions.

Some may be angry; others may be passive and depressed. Many will have difficulty sleeping. Disturbed appetite or somatic complaints are common. The rape incident itself will often haunt the victim, with memories flashing before them without their control. Some may feel guilt, shame, or regret that they were unable to prevent the incident; the most powerful and universal emotion, however, is fear.

Long-term phase: After an initially very powerful emotional reaction, rape victims often begin a long-term process of coping with the effects of the incident. Often they will attempt to change their life-routines in some way.

They may change residences or transfer colleges, or they may change some aspect of their appearance (e.g., hair style). Many of these changes can be seen as a function of a need for control, even if that control is illusory to a large extent. Nightmares as well as sleep disturbances will often continue. Specific fears/phobias may develop—of going out, of being in crowds, of being in situations similar to the one in which the incident occurred.

Burgess, A.W. & Holmstrom, L.L. (1974). Rape: Victims of crisis. Bowie, M.D: Brady.

Hypnotic amnesia: The connection between hypnosis and dissociation is intriguing. More specifically, hypnotic amnesia, in which a subject is asked to forget certain memories—and dissociation, in which a person loses access to aspects of memory—are strikingly similar. In both cases, the person forgets certain memories and is later able to recall them (not always, however, in the case of dissociative disorders). The forgetting in hypnotic amnesia and dissociation occurs without any insight into why they forget or any sense that they have forgotten. Also, events are more readily 125 C.

forgotten in hypnosis (Kihlstrom, 1980) than basic knowledge; this is true in dissociation as well. These parallels have led some thinkers (Bliss, 1980) to suggest that multiple personality and other dissociative disorders can be explained by a process of self-hypnosis. Bliss concludes that the cause of the "syndrome of multiple personalities seems to be the patient's unrecognized abuse of self-hypnosis" (1980, p. 1395) to forget unpleasant events.

Unpleasant events are forgotten or delegated to a separate personality with the aid of a hypnotic state. This hypothesis is intriguing, although it hinges on the acceptance of hypnosis as an altered state, which itself is controversial.

Bliss, E.L. (1980). Multiple personality, allied disorders and hypnosis. New York: Oxford University.

Kihlstrom, J. (1980). Posthypnotic amnesia for recently learned material: Interactions with "episodic" and "semantic" memory. Cognitive Psychology, 12, 227–251.

The many faces of ourselves: DID Popular culture can provide a safe way to spark some discussion or debate on lecture material. The Breakfast Club, a 1985 film by John Hughes, or the SHOWTIME series, United States of Tara, executively produced by Steven Spielberg and created by Diablo Cody, would be ideal candidates to use. After showing a small clip of either production, ask the students to think about the different sides of their personalities. Do you wear certain masks based on who’s around, what the setting is, or what the expectation are of others, etc.? What do the many faces that incorporate into who you are look like? You can ask students to draw a picture of what these different faces look like, or they can simply put the information into a narrative form. This activity can create an opportunity to move into the lecture on dissociative identity disorder. You can further ask the students the following questions: What are your thoughts on dissociative identity disorder; are there pros and cons? How would it be to live with this disorder?

Cody, D. (Writer) and Spielberg, S. (Executive Producer) (2001). United States of Tara [Television Series]. U.S.: Showtime Networks Inc. A CBS Company.

Hughes, J. (Writer and Producer) (1985). The Breakfast Club [Motion Picture]. U.S.: Universal Studios.

DISCUSSION IDEAS Recovering memories of trauma: Current directions APS reader (76-82) Richard McNally’s article summarizes the laboratory results of subjects who are grouped according to their standing on the repressed memory issue. The groups are constituted by the following criterion: (1) the repressed memory group—consisting of people who suspect they had been sexually abused as children but who have no explicit memories of abuse, (2) the recovered memory group—consisting of people who report having remembered their abuse after long periods of not having thought about it, (3) the continuous memory group—consisting of people who were abused and never forgot about it, and (4) the control group—consisting of people who report that they never were abused. The repressed memory group of subjects reported the most psychiatric symptoms, with the recovered memory group reporting the second largest number of depressive and PTSD symptomatology. Both the repressed memory group and the recovered memory group scored higher on a measure of fantasy-proneness than did the two other groups.

Perhaps most disturbing was McNally’s findings regarding tendencies towards memory distortion and the 126 C.

creation of false memories in the laboratory. “Recovered-memory subjects exhibited greater proness to this false memory effect than did subjects reporting either repressed memories of CSA (childhood sexual abuse), continuous memories of CSA, or no abuse.” Ask students to interpret these results, which can easily fuel skepticism regarding the veridicality of repressed memory recovery. McNally does an excellent job of leading the reader to a conclusion without stating it. If those who claim to have recovered memories of abuse after a long time period are prone to fantasy and able to create false memories easily, doesn’t that make us question whether the memories they report having recalled are really accurate? The goal of such a discussion should be to arrive at a healthy skepticism about the most extreme of repressed memory claims, when long-lost memories are believed to be recalled with minimal implicit signs, after significant “therapeutic work” in which the goal was the recall of repressed memories.

Impact of 9/11/01: Reactions to the terrorist attacks of 9/11/01 in the United States illustrate the dramatic impact of traumatic stressors on a societal level, as well as on an individual level. Individuals responded with fear, shock, numbness, depression, hypervigilance, and emotional withdrawal. As a society, we collectively exhibited many of the same responses. A discussion of response styles and their associated outcomes can illustrate tendencies to cope with potentially overwhelming events by (a) denying the impact, pushing emotions away, and avoiding reminders (consciously or unconsciously), or (b) focusing on the event and the emotional, cognitive, and behavioral responses it evokes. Students will likely vary in their belief about what type of response is most adaptive. Discussions of the paradoxical effects of thought suppression (Wegner et al., 1987) may be informative.

Wegner, D.M., Schneider, D.J., Carter, S.R. III, & White, T.L. (1987). Paradoxical effects of thought suppression.

Journal of Personality and Social Psychology, 52, 5–13.

Wenzlaff, R.M., Wegner, D.M., & Roper, D.W., (1988). Depression and mental control: The resurgence of negative unwanted thoughts. Journal of Personality and Social Psychology, 55, 882–92.

Dissociative identity disorder: The rise in reported cases of dissociative identity disorder is astounding. Prior to 1980, only about 200 cases were reported worldwide; now thousands are reported annually. What could account for this change? Explain to the class that a change of this dramatic proportion could not be explained by one factor alone. Then ask for suggestions: changes in attitude among clinicians, societal acceptance, increases in childhood abuse, and more accurate assessment tools all may be considered important. Will this rise in reported cases continue to grow or will incidences of dissociative identity disorder diminish, making it a kind of "fad" of the 1980s and 1990s?

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CLASSROOM ACTIVITIES Hypnosis: Have someone skilled in hypnosis conduct a class demonstration to determine how susceptible to hypnosis your students are. You might point out that some research suggests that people with dissociative identity disorder tend to be quite susceptible to self-hypnosis. One theory of the etiology of multiple personality disorder focuses on the role of self-hypnosis in coping with childhood trauma. On the more adaptive side, hypnosis has been helpful in many other domains—pain control, enhancing relaxation, and behavioral change (e.g., weight loss and smoking cessation programs).

Illness anxiety disorder: Many students will be able to relate to illness anxiety disorder, and wonder whether they, in fact, satisfy the criteria for this disorder. Have students write as many physical problems that they thought they might have at some point in time. Then ask them to circle the ones they actually did have. Ask students to share these "records" anonymously, or request permission to read some of them out loud. This exercise will clarify the fact that most people have lots of concern about physical problems that they anticipate the possibility of getting, or feel they may have, based on some symptoms they do have. Use this to then clarify the difference between "concern about physical problems" and a clinically diagnosable somatic symptom disorder. Also clarify differences between general use of the term “hypochondriac” and illness anxiety disorder. The factors that mental health professionals would be looking for to make such distinctions would be (1) longevity, (2) frequency of complaint, and (3) interference in daily functioning.

What’s your best excuse?

The textbook defines malingering as faking physical symptoms or illness for some type of external gain, and factitious disorder is defined as feigning illness for the desire to take on the sick role in order to be cared for rather than to receive external gain. Have students brainstorm about some of the creative excuses they have used to remove themselves from a particular situation or as a way to avoid something unpleasant. For example, prompt them for an excuse for skipping class, avoiding going to work, missing a date with someone, avoiding a family function, etc. The students can work on this activity individually or in small groups. After the students have brainstormed some ideas, have them discuss these with peers and come up with a “top” excuse from each small group to be voted on as the “best excuse.” The students will turn in the selected excuse per table on a small sheet of paper to be read out loud for peers to vote on as the “best excuse.” This can be a way to use humor and lighten the mood when discussing the concepts of somatic symptom disorders.

Create an assessment tool for acute stress disorder, posttraumatic disorder, dissociative disorders, or somatic symptom disorders: Divide the class into small groups to work on developing an assessment tool that the university could use to evaluate if a student is experiencing the assigned disorder. On several small pieces of construction paper, write down the different disorders from each of the above categories and pass one disorder out per small group. Then ask the group members to work together using their notes, the textbook, the Internet if available, their knowledge of the disorder, and their creativity to come up with a simple assessment tool that could be used to identify whether or not a student is experiencing the signs and symptoms of the assigned disorder. After the students have had time to create their assessment tool, allow time for sharing with the class.

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Both sides of the story: In this activity, you will be able to assess the students’ comprehension of the topics covered in the lecture, the readings, their notes, etc. You will give the students a statement and ask them to write down, in two to five minutes, information to support “both sides of the story” (i.e., information to support the agree side and information to support the disagree side of the statement). For example, you could state any of the following: 1.

Body dysmorphic disorder is similar to eating disorders.

2.

Dissociative identity disorder is not a believable psychiatric disorder.

3.

If you are exposed to a traumatic event, you will develop ASD or PTSD.

4.

Hypnosis can be an effective treatment modality.

5.

The best treatment for individuals suffering from somatic symptom disorders is through their primary care physicians.

Body consciousness: Individuals diagnosed with illness anxiety disorder are more sensitive to normal bodily sensations and to see these signs as a serious illness. Ask the students to write down how they are consciously aware of their bodily sensations as it relates to pain and illness. Ask the students to keep a body-conscious diary, or journal, to keep a daily record of when they experience pain, aches, itches, dryness, dizziness, fatigue, nausea, etc. In addition to recording the bodily sensations, ask the students to also record the location and what may have triggered the sensation. It will be helpful to ask the students to additionally record any images, thoughts, and feelings experienced at the same time as the bodily sensations. This activity can provide further discussion about the diagnosis of illness anxiety disorder, treatment options, etc.

Guest speaker: Have someone from the community who specializes in working with children come into the classroom to present on how ASD and PTSD signs and symptoms (i.e., avoidance, reexperiencing, flashbacks, arousal, anxiety, and dissociative symptoms) present in children. The guest speaker can also talk about the use of play therapy as a treatment modality for providing care for youth. A play therapy demonstration or video may also be helpful for the practitioner to bring in.

VIDEO CASES IN ABNORMAL PSYCHOLOGY: Bonnie—Posttraumatic Stress Disorder Bonnie, an EMT in her early 40s, describes herself as basically ‘normal’ prior to the trauma she experienced on 9-11-01. She says, “It was horrific” and tells of seeing body parts, cars on fire, and dead bodies as she tried to perform her medical duties at the scene of 9-11. She still sees some of those scenes on her ‘bad days.’ Immediately after the trauma, she began to experience classic PTSD symptoms: trouble sleeping, increased startle response, and avoidance behaviors. She also describes visual hallucinations related to the incident. It appears as if therapy (and, perhaps, time) has been very helpful, and she is able to cope and live in a functional manner at this point. At her worst, however, Bonnie removed herself from her social world, was afraid of everything, and avoided even leaving 129 C.

the house for periods of time.

Discussion questions: 1.

In some ways, Bonnie’s case of PTSD is even more dramatic than most—because of the degree and magnitude of the 9-11 experience. In what ways are her symptoms typical of PTSD? How are they unusual or atypical?

2.

Bonnie seems to describe ‘going into a shell’ after 9-11. She didn’t see friends or family and says that her partner was severely affected as well. How could Bonnie have handled the situation better? Were her symptoms and problems ‘inevitable’ given her experience on 9-11?

3.

It is clear that Bonnie’s mental health has improved dramatically through therapy. We don’t hear much about the therapy. What kind of therapy do you think Bonnie probably received? What therapeutic techniques and approaches have been demonstrated to be effective in working with patients like Bonnie?

Sara—Posttraumatic Stress Disorder Sara, a middle-aged woman who has been traumatized by an abusive relationship, describes her most prominent symptoms as manifesting themselves at night. She has a great deal of trouble falling asleep and also says that, “I would wake up 37 times a night.” Most of the trauma she experienced with her abusive spouse occurred at night. Even after she is free of the relationship, she continues to relive some of the trauma. She says that she intellectually knows that she is safe, but emotionally feels that she is vulnerable to another attack from her abusive husband. Medication and psychotherapy seem to have helped quite a bit.

Discussion questions: 1.

Sara’s symptoms occur mostly at night. What kinds of coping mechanisms could be helpful for her after 9 p.m., when her anxious feelings tend to begin to trouble her?

2.

Sara says that medication and therapy have helped her. What types of medications might be useful for a PTSD patient such as her, and what therapeutic approaches might be most effectively utilized?

3.

Compare Sara’s symptoms and responses to those of Bonnie—both are diagnosed as having PTSD. Note that Bonnie’s symptoms occurred in response to one ‘horrific’ day, whereas Sara’s came as the result of years of consistent abuse. How does that difference in traumatic experience affect the nature of each of their symptoms? Which has a better prognosis for treatment?

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VIDEO RESOURCES

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/mypsychlab/foa_c4.html Edna Foa: Research on Post-Traumatic Stress Disorder (PTSD) (1:56) Watch this video to learn about research into PTSD and what that research has determined.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Discovering_Optimism _and_Resilience_Renee_Firestone.html Discovering Optimism and Resilience: Renee Firestone (5:00) Watch this video about resilient personalities involving survivors of difficult events. It discusses Erikson's stage of generativity versus stagnation.

http://pet.pearsoncmg.com/e/iat-prejudice Implicit Association Test: Prejudice Explore this simulation about the implicit association test for prejudice. Determine what you think about this test.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/mypsychlab/loftus_f.html Elizabeth Loftus: Role of Misinformation in Memory Distortion (0:59) Watch this video about how misinformation can distort memory and how it affects those involved with the event.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Dissociative_Identity_ Disorder_The_Three_Faces_of_Eve.html Dissociative Identity Disorder: The Three Faces of Eve (4:39) Watch this classic footage of a psychiatrist interviewing “Eve,” the subject of the famous movie, The Three Faces of Eve. The Three Faces of Eve is a 1957 American film adaptation based on a book written by two psychiatrists and 131 C.

was based on their case of Chris Costner Sizemore, also known as Eve White. She was believed to be suffering from multiple personality disorder.

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Chapter 8 Stress and Physical Health Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: p. 207 Defining Stress: p. 208

Classroom: General Measures of Stress

Stress as a Life Event Stress as Appraisal of Life Events Symptoms of Stress: p. 210 Psychophysiological Responses to Stress Coping Health Behavior Illness as a Cause of Stress

Diagnosis of Stress and Physical Illness: p. 217

Lectures: Stress, positive emotion, and coping Psychobiology of stress Alcohol use and stress Responses to rejection

Discussion Ideas: Mind-body connection

Brief Historical Perspective Contemporary Approaches Psychological Factors in Some Familiar Illnesses: p. 218

Video Case: Adjustment Disorder, Julia

Cancer Acquired Immune Deficiency Syndrome (AIDS) Pain Disorder Sleep-Wake Disorders

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PROFESSOR NOTES

Cardiovascular Disease: p. 221 Symptoms of CVD Diagnosis of CVD Frequency of CVD Causes of CVD Prevention and Treatment of CVD

Discussion Ideas: Hostility and coronary heart disease Classroom: Coronary heart disease

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CHAPTER OUTLINE I.

II.

Overview A.

Stress is defined as a challenging event that creates physiological or psychological strain; stress also requires adaptation for the individual.Traumatic stress involves exposure to actual or threatened death.

B.

The distinction between physical and psychological illness is increasingly seen as a false dichotomy: there is no psychosomatic disorders listed in DSM-5.

C.

Behavioral medicine—a multidisciplinary field including medical and mental health professionals focusing on the role of psychological factors in physical illness; the new field is called health psychology

Defining stress A.

B.

Stress as a life event.

1.

Stress rating scales (e.g., Holmes and Rahe's Social Readjustment Rating Scale (SSRS), 1967) list various troublesome life events and assign stress values to each life event.

2.

Criticisms of stress rating scales include reliance on retrospective reports, failure to distinguish between positive and negative events, and lack of consideration of individual differences in the impact of specific stressors.

3.

A problem in quantifying the impact of stressors is that they vary greatly in their effects on different individuals.

Stress as apprasial of life events 1.

From this perspective, the important aspect of stress is the individual's cognitive appraisal of the "stressful event."

2.

Primary appraisal is the cognitive evaluation of the challenge, threat, or harm posed by a particular event; an event is a stressor only when it is appraised as such by the individual.

3.

Secondary appraisal—the assessment of one's abilities and resources for coping with a difficult event

4.

The appraisal definition runs the risk of being a tautalogy, a redundant statement that means nothing, by defining a stress event as one that causes us to feel threatened and overwhelmed and by defining that which causes us to feel overwhelmed and threatened as stress.

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III.

Symptoms of stress A.

B.

Physiological responses to stress 1.

The fight-or-flight response includes the arousal of the sympathetic nervous system: adrenaline is released, heart and respiration rates increase, blood pressure rises, pupils dilate, and blood sugar levels go up.

2.

This response has clear survival value in physically dangerous situations, but in many stressful situations in the modern world, this response is not adaptive.

3.

Physiologically, when a threat is perceived, the amygdala responds by secreting corticotrophin-releasing factor (CRF), which activates the sympathetic nervous system; adrenal glands then release epinephrine, cortisol, and adrenal hormones, which promote immediate healing, but in excess, can produce long-term problems.

4.

Psychoneuroimmunology (PNI)—the study of the relationship between stress and the immune system; stress has a direct impact on immune system functioning

5.

Cannon and Selye argued that intense or chronic stress can lead to physical illness. a.

According to Cannon, prolonged sympathetic arousal overwhelms the body’s homeostasis, a term he coined.

b.

Selye’s general adaptation syndrome involves three stages: alarm, resistance, and exhaustion.

c.

Direct impact may also be due to the fact that, analogous to a car running out of gas, stress is so taxing on the body that we can no longer perform even routine functions when overstressed.

Coping with stressors 1.

Problem-focused coping is externally oriented and involves changing the stressor.

2.

Emotion-focused coping is an attempt to alter the internal processes associated with stress (e.g., attempting to relax).

3.

Americans tend to prefer change over acceptance. Eastern cultures emphasize acceptance.

4.

Predictability and control are important in coping with stress; even the illusion of control can alleviate stress in humans.

5.

Finding a physical outlet for frustration, such as exercise, can be helpful in coping with stress.

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IV.

V.

6.

People who repress unpleasant emotions appear to be at greater risk for developing stress-related physical illnesses; repression is a generally maladaptive form of emotion-focused coping (Cramer, 2000; Somerfield & McCrae, 2000).

7.

Optimism is a factor in successful coping when individuals see the positive, while pessimism is when individuals give up and focus on the negative.

8.

Religion and philosophical beliefs play an important role in the coping process. Forgiveness can also be healthful, as well as finding another source of meaning in life outside of religion.

C.

Health behaviors (e.g., eating a balanced diet, regular sleeping, exercising) and avoiding unhealthy behaviors (e.g., cigarette smoking, drug use, excessive alcohol consumption) reduce stress; social support can buffer the impact of stressors, as can following medical advice.

D.

Social support is also associated with increased health behaviors, decreased immunosuppression, and better general physical functioning; a good marriage can provide a strong buffer, whereas a conflicted marriage can reduce immune system functioning considerably.

E.

Illness can also be the cause of stress.

F.

Medical advice—93 percent of people fail to follow medical advice; for example, patients that have high blood pressure, patients who discontinue medication, and people with diabetes adhering to strict diets

G.

Illness behavior, behaving as if you are sick, is also stress related; increased stress is correlated with such illness behaviors as making more frequent office visits to physicians or allowing chronic pain to interfere with everyday activities (Taylor, 1990).

H.

Social support not only encourages better health behavior but also has direct health benefits. This effect has even been found in monkeys.

1.

Cultures vary in their forms of social support.

2.

A good marriage appears to be a critical source of social support.

Diagnosing stress and physical illness A.

Early theorists believed in the specificity hypothesis—that specific personality types caused specific psychosomatic diseases; research does not support this hypothesis.

B.

Stress and illness are important components of the DSM-5.

1.

When emotions or behaviors affect physical health, DSM-5 diagnoses them as Psychological Factors Affecting Other Medical Conditions.

2.

This diagnosis is part of the DSM-5’s new category, called Somatic Symptom and Other Disorders.

Psychological factors and some familiar illnesses A.

Cancer 137 C.

1.

Second leading cause of mortality in the U.S., causing 23 percent of all deaths

2.

While cancer appears a purely biological illness, psychological factors are important.

3.

a.

Relevant to the development of cancer—health behaviors influence onset (e.g., cigarette smoking, exercise)

b.

Relevant indirectly to course: anxiety and depression can lead to more negative health behaviors, decreased positive health behaviors, and decreased compliance with medical treatments.

c.

Relevant directly to course: weakening of the immune system caused by stress appears to decrease the ability to fight cancerous tumors (at least in rats).

d.

Structured self-help groups can lead to improved quality of life, beneficial physical effects, and greater longevity.

e.

Cancer patients are often anxious or depressed, and commonly suffer “cancer-related fatigue,” which is a condition attributable to both the emotional factors and the physical side effects of cancer, like chemotherapy.

Cancer is the source of a great deal of stress to its victims, as well as to their loved ones.

B. Acquired immune deficiency syndrome (AIDS) 1.

High-risk behaviors are direct causes of HIV infection.

2.

Increased stress and decreased social support appear to be associated with a more rapid progression of physical symptoms.

3.

Social support is extremely important to the AIDS patient's psychological well-being.

4.

Some individuals develop AIDS within months of contracting the virus; some remain symptom free for ten years or more.

5.

Advances of medical science have improved the prognosis of AIDS; AIDS is no longer listed within the top 15 causes of death in the United States.

C. Pain disorders 1.

Recurrent acute pain (e.g., headaches) and chronic pain (e.g., back problems) are extremely common, expensive, and interfere with work performance.

2.

Pain tends to be linked with depression and anxiety, but the direction of causality is not clear; pain is subjective, making it difficult to evaluate.

3.

The goal of pain management is to minimize the impact of pain on people's lives, and programs generally include education about pain and its consequences, pain control techniques, like relaxation or exercise, attempts to change expectations about pain, and social interventions with 138 C.

families or support groups.

4.

Patients of pain management treatment report greater life satisfaction, improved employment status, less reliance on medication, and less pain.

D. Sleep-wake disorders 1.

VI.

The DSM-5 includes a variety of sleep-wake disorders, which are disorders where sleep is the primary complaint. There are 10 specific categories of sleep-wake disorders in the DSM-5: a.

Insomnia disorder: problems in sleep quantity or quality

b.

Hypersomnolence disorder: excessive sleepiness despite getting seven or more hours of sleep

c.

Breathing related sleep disorders

d.

Circadian rhythm sleep disorder: a mismatch between the patient's 24-hour sleep pattern and the 24- hour life demands

e.

Non-rapid eye movement arousal disorders: incomplete awakening and either sleepwalking or sleep terrors, as well as recurrent episodes of screaming or other signs of fear

f.

Nightmare disorder: frequent and awakening frightening dreams

g.

Rapid eye movement sleep behavior disorder: involves vocalization or complex motor behavior, but the patient awakes easily (unlike sleepwalking)

h.

Restless leg syndrome: involves an urge to move the legs that disturbs sleep at least three times per week and causes clinical levels of distress

i.

Substance/medication-induced sleep disorder

Cardiovascular disease (CVD) A.

Hypertension and coronary heart disease (CHD) are the most important of the cardiovascular diseases; myocardial infarction (heart attack) is the most deadly form of coronary heart disease.

B.

The most common symptom of CHD is pain in the middle of the chest, often extending down the left arm.

C.

1.

Systolic blood pressure is the highest pressure that the blood exerts against the arteries— occurs when the heart is pumping blood

2.

Diastolic blood pressure is the lowest amount of pressure that the blood creates against the arteries—occurs between heartbeats

3.

Hypertension: defined by a systolic reading above 140 or a diastolic reading above 90

Two major forms of CHD are angina pectoris and myocardial infarction (MI).

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D.

1.

Angina involves chest pain, usually brought on by exertion; it does not damage the heart but may signify greater risk for MI, which does cause damage.

2.

Hypertension has two forms: in primary (essential) hypertension, high blood pressure is the main problem; in secondary hypertension, the cause is a kidney or endocrine disorder.

Risk factors for CHD include gender (males are twice as likely to have CHD than women), age (risk increases with age), social factors (low-income groups show higher incidence of CHD), and family history of CHD 1.

Health behaviors are important; smoking, diet, cholesterol levels, alcohol consumption, and lack of exercise increase risk for CHD.

2.

Some aspects of Type A behavior also appear related to CHD.

E.

Risk factors for hypertension include genetic factors, a high-salt diet, health behavior, and lifestyle factors; hypertension is also more common in industrialized countries.

F.

CHD is caused by oxygen deprivation to the heart. Oxygen deprivation may be caused by atherosclerosis—a thickening of the coronary artery wall that occurs as a result of the accumulation of blood lipids (fats) with age.

G.

Psychological influences on CVD include health behavior, immediate and more chronic stress, personality, depression, and anxiety.

H.

Positive health behaviors, such as exercising regularly and not smoking, are associated with reduced risk of coronary heart disease.

I.

Chronic or intense stress can contribute to cardiovascular disease.

J.

1.

Cardiovascular reactivity has been found to predict coronary problems.

2.

Job strain—high psychological demands paired with reduced control-- elevates the risk for CVD.

3.

Type A behavior—a style of response that is competitive, hostile, urgent, impatient, and achievement-striving—has been linked with CHD. a.

Research initially suggested that Type A behavior predicted CHD, but this theory has not received continued support.

b.

Hostility is associated with heart disease.

c.

Heart disease is a lifestyle illness; obesity, lack of exercise, and a fatty diet all are risk factors for CHD.

New research has found that depression is three times more common in people with CHD than it is in people without CHD. The presence of depression is associated with greater risk for future CHD as depresion doubles the risk for future cardiac events. Anxiety also appears to be related to increased risk for sudden cardiac death.

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VII.

K.

Social support and economic resources are associated with better outcomes for those with CHD.

L.

Cultural norms regarding health behaviors and competition are associated with CVD.

M.

The study of risk factors for CHD provides an excellent example of the value of the systems approach—psychological, social, genetic, and economic factors all play a role and should all be considered in prevention and treatment

Causes of CVD A.

Biological factors—deprivation of oxygen to the heart muscle; atherosclerosis, which is the thickening of the coronary artery wall; coronary occlusion; and a positive family history for hypertension and CHD

B.

Psychological factors— health behaviors that have been well documented in association with heart disease include avoiding or quitting smoking, maintaining a proper weight, following a low-cholesterol diet, exercising frequently, monitoring blood pressure regularly, and taking antihypertensive medication as prescribed

C.

Psychological factors continued—stress also contributes to CVD by taxing the cardiovascular system and increasing heart rate and blood pressure; high-demand and high-stress jobs increase risk for CVD/CHD, as does Type A behavior, which is a competitive, hostile, time urgent, impatient and achievement-striving style of responding to challenge; depression is three times more common among patients with CHD and doubles the risk for future cardiac events; and anxiety seems to be associated with CHD and a sudden cardiac death

D.

Social factors—friends and family can encourage a healthy or unhealthy lifestyle, interpersonal conflict can create anger and hostility, and societal and cultural values and accepted norms can also impact the risk for CVD. In fact, a spouse’s confidence in coping predicts a patient’s increased survival over four years.

E.

Integration and alternative pathways—CVD is an excellent example of the value of the systems approach; CVD is caused by a combination of genetic makeup, an occasional structural defect, maintenance in the form of health behavior, and how hard the heart is driven by stress, depression, coping, and societal standards

VIII. Prevention and treatment of cardiovascular disease A.

Antihypertensives reduce high blood pressure; beta-blockers reduce risk of myocardial infarction or sudden coronary death following a cardiac episode.

B.

Primary prevention can involve promoting positive health behaviors (quitting smoking, eating less fatty and salty foods, and exercising).

C.

Secondary prevention includes stress management and improving positive health behavior .

1.

Healthy behavior has been proven to reduce high blood pressure, often eliminating the need for medication.

2.

Relaxation training and biofeedback can help patients control autonomic nervous system 141 C.

responses; however, they do not appear to be as effective as medications.

3.

D.

Weight loss appears to be the primary factor associated with controlling CHD.

Tertiary prevention includes increasing positive health behaviors, altering Type A behavior (through role-playing or cognitive therapy). Also, it focuses on some of the possible effects of CHD, including depression, anxiety, and family distress.

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LEARNING OBJECTIVES LO 8.1: How can stress make you physically ill?

LO 8.2: What are some good ways of coping with stress?

LO 8.3: What does it mean to say people are resilient?

LO 8.4: Does stress really play a role in diseases like cancer and AIDS? LO 8.5: What is a “lifestyle disease”?

LO 8.6: What is “Type A” behavior? Can it really cause heart attacks?

LECTURE SUGGESTIONS Stress, positive emotion, and coping: Current directions APS reader (1E, p.83) Folkman and Moskowitz discuss the importance and utility of positive emotions in the process of coping with stress. In a 1980 article, Folkman and colleagues argue that positive emotions allow sustained coping efforts, provide a temporary “breather” for people coping with severe stress, and restore depleted resources. Caregivers and partners for AIDS patients who were dying reported many instances of positive emotions, which seemed to serve these functions. In this article, the authors argue that positive reappraisal, problem-focused coping, and the creation of positive events also play a role in the successful coping process.

Those copers who can find the positive side of a bad situation (e.g., “This is allowing me to grow as a person.”) have successfully reappraised in a positive direction. Setting up a “to-do list” and systematically executing it is an example given of problem-focused coping. Creating a "psychological time-out" by doing something enjoyable in the midst of a stressful situation is also helpful for those undergoing a great deal of stress.

Although Folkman and Moskowitz have identified some important ways that positive emotions aid in the coping process, they acknowledge that there are many unanswered questions regarding this work. They wonder whether it is the intensity or the frequency of the positive emotion that is efficacious for the person coping with stress. Also, which positive emotions are most adaptive? What types of stressful situations—acute or chronic, for example—benefit from positive emotions most? Most importantly, however, they pose the question of whether the use of positive emotions can be learned or taught—or whether this process of using positive emotions to cope with stress is personality-based.

Psychobiology of stress: Current directions APS reader (2E: p. 87) Margaret Kemeny provides a good summary of the ways in which stress can impact upon physiological structures and affect behavior and even psychopathology. Three systems are largely affected by stressful life events: the autonomic nervous system, the hypothalamic-pituitary-adrenal axis, and the immune system. For example, depression can result from the effects of immune cell products on the brain.

The integrated specificity model disputes the widely held belief that stress acts in a general manner upon the physiological system. The new model, which is supported by recent research, argues that specific stressful 143 C.

conditions, along with the particular manner of response (e.g., coping style) elicits qualitatively different emotional and physiological responses. We can no longer assume a unified stress response; individual differences must be taken into account.

Alcohol use and stress: The tension-reduction hypothesis of alcohol consumption states that alcohol reduces tension and individuals drink in order to experience relief from tension. The empirical support for this hypothesis has been mixed, leading to skepticism regarding its basic premise. Cooper suggests that an important mediating factor in the connection between stress and alcohol use is the type of coping style employed by the individual. Cooper and colleagues examined the effect of stress on alcohol use in adult men and women. Stressors were highly predictive of both alcohol use and drinking problems among men who relied on avoidant forms of emotion coping. Stressors were negatively related to alcohol use among men who were low in avoidant emotion coping and were unrelated to alcohol use among women. This study suggests that the tension-reduction theory may, in fact, hold, but only for men and only for those who engage in these types of avoidant strategies for coping with stress. Men may be particularly vulnerable to this pattern of response, due to their social conditioning about the use of alcohol (e.g., drinking is a way of dealing with stress). Would identifying those who are vulnerable to this pattern be helpful in preventing severe drinking problems before they develop?

Cooper, M.L., Russell, M., Skinner, J.B., Frone, M.R., & Mudar, P. (1992). Stress and alcohol use: Moderating effects of gender, coping, and alcohol expectancies. Journal of Abnormal Psychology, 101, 139–152.

Responses to rejection: Which types of people are most vulnerable to emotional responses as a result of social rejection? The construct sociotropy may be useful in this regard; Beck used the word to describe a social dependency that can be thought of as a relatively stable individual difference variable. Nicholas Allen and his colleagues (1996) hypothesized that those high on sociotropy would be particularly vulnerable to develop depression when they perceive a loss or rejection in social relationships. This is relevant to the study of stress, since a social rejection can, according to this hypothesis, be more stressful for some people than for others.

In Allen and his colleagues’s study, subjects were asked to perform a series of imagery trials depicting neutral and stressful (social rejection and achievement failure) scenes. Individuals who were high on sociotropy responded more emotionally (in self-report and physiologically) to the social rejection scenes. Thes responses suggest that those who are socially dependent may be more vulnerable to the kind of stress associated with social rejection. The study can be criticized for having weak external validity; immediate responses in a laboratory to imaginary scenes are unlike the experiences of actual social rejection.

Allen, B.N., Horne, D.J de L., & Trinder, J. (1996). Sociotropy, autonomy, and dysphoric Emotional responses to specific classes of stress: A psychophysiological evaluation. Journal of Abnormal Psychology, 105, 25–33.

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DISCUSSION IDEAS Mind-body connection: What is the connection between the mind and body, and between psychology and physiology? Are some mental disorders purely psychological? Purely biological? How does biology influence psychology? How can psychology affect biology? A discussion of these issues can highlight the frequent and misleading dichotomizing that occurs in popular, and even professional, discussions of such issues, including “the nature-nurture debate” over the causes of psychological disorders. Students themselves may have a tendency to become polarized in their arguments, particularly as they respond to others with opposing views. Pointing this behavior out is a valuable way to highlight the need for an awareness of the unreasonable nature of propositions that disorders (mental or physical) are purely psychological or purely physiological.

Hostility and coronary heart disease: Why is hostility the most powerful emotional predictor of coronary heart disease? What are some of the causes of high levels of hostility? How can high levels of hostility be dealt with effectively? What kinds of factors might maintain an individual’s hostile stance?

Debate: Is obesity a choice?

According to the Centers for Disease Control (2011), 67 percent of Americans who are 20 years of age and older are considered either obese or overweight. Binge eating disorder has already been discussed as a way to potentially view obesity as a psychiatric disorder. Ask students to brainstorm why they think 67 percent of Americans fall into the obese or overweight category. Then ask students to think of some creative ways that would increase health awareness and personal accountability as it relates to health issues. What factors may contribute to obesity and being classified as overweight for college students?

Centers for Disease Control (CDC) (2011). Obesity and overweight: Faststats. Retrieved from http://www.cdc.gov/nchs/fastats/overwt.htm on June 10, 2011.

CLASSROOM ACTIVITIES General measures of stress: Pass out the Holmes-Rahe Social Readjustment Rating Scale and have the students fill it out. Then ask them to discuss (a) the validity of the scale, (b) whether they could add any life events to those on the scale, and (c) any suggestions for better ways to measure stress. This is a widely used but rather flawed measurement device in that many factors (e.g., coping styles and culture) are ignored.

Coronary heart disease: Divide the class into small student groups, and ask students to describe a case of coronary heart disease. Some will undoubtedly know of a case and be willing to talk about it. Ask the students to discuss the ways in which stress may have played a role in the situations they describe and to make lists of relevant stressors. Then bring the class back into one group and have the students share some of their most interesting cases and compare stressor lists. Ask students whether all cases of CHD involve stress, or whether some are simply biologically and/or genetically based.

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Stressors: From A to Z: Ask the students to break into small groups and select a group member to be the scribe. Then you can either give each small group specific letters of the alphabet, or you can ask the entire group, while working together with their peers, to come up with one list using every letter of the alphabet. You can ask them to (1) create a list of stressors from A to Z, and then to (2) create a coping list from A to Z using every letter of the alphabet.

Yoga or meditation demonstration: You can ask for a volunteer in the community that is a certified yoga instructor or someone who practices meditation regularly to come into the classroom for an in-class demonstration. Students can ask questions as well as participate in the live demonstration. The instructor could also educate the students on the health benefits of practicing yoga or meditation as well as proper breathing methods and techniques.

Biofeedback demonstration: Bring in a mental health professional who is trained and certified in biofeedback and who uses this as a treatment modality in a practice or facility. Ask for student volunteers who would like to participate in advance.

Prepare a consent form explaining that the participation is only for educational purposes and is not to be used as treatment for clinical symptomology.

Create a health promotion plan: Ask students to use their own creativity to come up with some ideas that could be incorporated into their local community or on campus to either provide education on health awareness, to provide a process for screening for health issues, or to provide information on health risk factors. The students can be broken into small groups to work on this plan together or individually. Some ideas may include creating a health blog, a health website for students with FAQs, a brochure of resources, or health fair ideas, etc.

VIDEO CASE IN ABNORMAL PSYCHOLOGY: Julia—Adjustment Disorder (18:49) Julia has been positively diagnosed with HIV. Her symptoms began with a cold that lasted about a month and just would not go away. She was, at that time, a drug addict who was primarily using crack cocaine. She has since become sober. In response to her illness, she has been forced to develop a very “organized life” in which she schedules doctor appointments, medications, and other health-related activities carefully in order to provide herself the best opportunity to maintain good health. She also describes the ways in which having HIV has influenced her social life; she has had to adjust her behavior dramatically because of the response that others have to her illness.

One interesting aspect to her development of the illness is that it seems to have brought her extended family closer together. She says they just had their first family gathering in 25 years.

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Discussion questions: 1.

Julia appears to be a very "high energy" person (possibly even manic); how do you think this personality style affects how she adjusts to her illness?

2.

What kinds of emotions did Julia go through in response to finding out about her diagnosis? Are these common responses, or are these responses unique to Julia?

3.

What are the benefits of having a coherent and connected family structure for Julia? Does having an illness tend to “bring families together” or break them apart?

VIDEO RESOURCES

http://visual.pearsoncmg.com/mypsychlab/episode13/index.html?clip=6&tab=tab0 What's In It For Me?: How Resilient Are You? (4:42) Watch this video discussing how psychologically resilient people react to negative situations. http://media.pearsoncmg.com/ph/hss/livepsych/media/interface/stress_and_the_immune_system.html Stress and the Immune System Try this narrated, interactive examination of the impact of stress on the immune and sympathetic nervous systems. http://media.pearsoncmg.com/ab/ab_lefton_psychology_8/media/healthy_behavior/index.html Healthy Versus Unhealthy Behaviors and Brain Functioning Explore different types of behaviors, such as alcohol use or exercise, and watch how it affects the brain. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/mypsychlab/figures/E15_S02_stress.html Stress Pathways of the Body (1:31) View this animation about stress pathways in the body. http://media.pearsoncmg.com/ab/ab_lefton_psychology_8/media/lbp8e_14512/lbp8e_14512.html Explore this drag-and-drop exercise categorizing coping strategies and their effects.

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Chapter 9 Personality Disorders Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: p. 232 Symptoms: p. 234

Lectures: Personality disorders and alcoholism

Social Motivation Cognitive Perspectives Regarding Self and Others Temperament and Personality Traits Context and Personality

Discussion Ideas: Dangerous assumptions

Diagnosis: p. 237

Lectures: Self-esteem, narcissism, and aggression

Classroom: Acting out Personality Disorders

Cluster A: Paranoid, Schizoid, and Schizotypal Personality Disorders Video Case: Borderline Personality Cluster B: Antisocial, Borderline, Disorder, Liz Histrionic, and Narcissistic Personality Disorders Cluster C: Avoidant and Obsessive-Compulsive Personality Disorders A Dimensional Perspective on Personality Disorders

Frequency: p. 245

Lectures: The dimensional nature of personality

Prevalence in Community and Clinical Samples Gender Differences Stability of Personality Disorders over Time Culture and Personality

Discussion Ideas: Ethical Considerations Psychopathy and criminal responsibility

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PROFESSOR NOTES

Schizotypal Personality Disorder (SPD): p. 249 Symptoms Causes Treatment

Borderline Personality Disorder (BPD): p. 251

Lectures: Dialectical Behavior Therapy for Borderline Personality Disorder

Symptoms Causes Treatment

Video Case: Compulsive Gambling, Ed

Antisocial Personality Disorder (APD): p. 255

Video Case: Antisocial personality, Paul, age 28

Symptoms Causes Treatment

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CHAPTER OUTLINE I.

Overview A.

II.

Defining characteristics of personality disorders (PDs) 1.

Evident in two (or more) ways: cognition, such as ways of thinking about self and other people, and emotional responses dealing with interpersonal functioning or impulse control

2.

Emphasizes the duration of the pattern and the social impairment associated with the traits in question

3.

Inflexible and pervasive across a broad range of personal and social situations

4.

Source of clinically significant distress or impairment

5.

Stable and long duration with onset in adolescence to early adulthood

B.

PDs are a controversial category; they are not highly reliable and have poorly understood etiology.

C.

Nevertheless, PDs are important, as they are associated with problems in multiple domains, such as significant social and occupational impairments, disruption within interpersonal relationships, marital discord, violence, and with an increased risk for other psychological disorders.

D.

PDs, unlike other disorders, involve ego-syntonic patterns of behavior: people with PDs do not view their thoughts and behaviors as unacceptable or abnormal. This lack of insight results in limitations in the usefulness of self-report measures. Self-report measures are more useful with most other mental disorders, which are ego-dystonic, meaning they are distressed by their symptoms.

Symptoms A.

Social motivation: two central motives are affiliation and power; deficient or exaggerated motivation may be seen in PDs and described as maladaptive variations with regard to the needs for affiliation and power.

B.

Cognitive perspectives regarding self and others: pervasive distortions or misperceptions of self or others are often central in PDs because our social world depends on mental processes that determine knowledge of ourselves and other people. Many of our social interactions depend on our ability to judge the nature of our relationships with other people and respond in appropriate ways; PDs can disrupt these judgements.

C.

Temperament and personality traits 1.

Temperament—a characteristic style of relating to the world; often evident in the first year of life

2.

The five-factor model (five factors, each with six facets) is a prominent theory of temperament; the five factors are extroversion, neuroticism, openness, conscientiousness, and agreeableness.

3.

Personality disorders can be viewed as maladaptive variations on these traits in either direction (e.g., antisocial PD have too little anxiety and fear).

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III.

D.

Even though PDs involve relatively inflexible and problematic behavior and expressions of experience, PD features may not be expressed in all situations, and the adaptive value of traits varies across contexts.

E.

Social circumstances frequently determine whether a specific pattern of behavior will be assigned a positive or negative meaning by other people.

Diagnosis A.

B.

The DSM-5 includes two different approaches to classifying personality disorders: 1.

Categorical definition of personality disorders—where a patient must meet a specific threshold to be placed in one of 10 specific diagnoses; these catagories are organized into clusters

2.

Dimensional definition of personality disorders—describes abnormal personality on a set of 29 dimensional scales

Cluster A (the schizophrenia spectrum disorders): includes people who appear odd or eccentric 1.

2.

3.

C.

Paranoid personality disorder a.

Inappropriate suspiciousness of others' motives

b.

Take extraordinary precautions to avoid being exploited or injured

c.

Overly reactive to minor slights or insults

d.

May create self-fulfilling prophecies— their behaviors cause others to become annoyed and cautious towards them, thus apparently confirming their suspicions

Schizoid personality disorder a.

Pervasive pattern of indifference to others

b.

Diminished range of emotional experience and expression

c.

Prefer social isolation

Schizotypal personality disorder a.

Peculiar patterns of behavior

b.

Perceptual and cognitive disturbances

c.

Unusual speech—vague or disjointed

d.

Unusual but not actively psychotic or out of touch with reality

Cluster B: includes people who appear excessively dramatic, emotional, or erratic 1.

Antisocial personality disorder 151 C.

2.

3.

4.

D.

a.

Irresponsible and antisocial behavior beginning by childhood or adolescence and continuing into the adult years

b.

Disregard for, and violation of, others' rights

c.

Irritable, impulsive, aggressive, reckless, and irresponsible; frequently involved in fights

Borderline personality disorder a.

Pervasive pattern of instability in mood and interpersonal relationships

b.

Intense unstable relationships with other people and are often seen as manipulative

c.

Rapid, inexplicable mood changes, sometimes shifting from feelings of depression to feelings of anger and then to feelings of anxiety over a pattern of several hours

d.

Identity disturbance—difficulty maintaining an integrated, coherent sense of self; many clinicians see this as the hallmark of borderline personality disorder.

Histrionic personality disorder a.

Pervasive pattern of excessive emotionality and attention-seeking behavior

b.

Self-centered, demanding, vain, dramatic; constantly seeking approval

c.

Emotions are shallow and easily aroused, often reacting to situations with inappropriate exaggeration

Narcissistic personality disorder a.

Pervasive pattern of grandiosity

b.

Exaggerated sense of self-importance

c.

Preoccupation with own achievements

d.

Unable to empathize with others

e.

Overlaps substantially with borderline personality disorder; both types feel that other people should recognize their needs and do special favors for them

Cluster C: includes people who appear anxious, dependent, and fearful, and obsessive-compulsive personality disorders.

1.

Avoidant personality disorder a.

Pervasive pattern of social discomfort, fear of negative evaluation, timidity

b.

Tendency towards social isolation, although desire to be liked

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c.

2.

3.

E.

Dependent personality disorder a.

Pervasive pattern of submissive and clinging behavior

b.

Anxious and helpless when alone; need others for advice and support; usually find one person to latch onto for help, support, and connections

c.

Easily hurt by criticism

Obsessive-compulsive personality disorder (OCPD) a.

Pervasive pattern of orderliness, perfectionism, at the expense of flexibility, openness and efficiency, and need for mental/interpersonal control

b.

Set overly ambitious, unobtainable standards for their own performance

c.

Preoccupied with details and rules; often lose sight of the main point of an activity or project

d.

Emotionally restricted, excessively conscientious, moralistic, judgmental, intolerant of others' emotionality and imperfection

e.

Not the same as obsessive-compulsive disorder; OCPD is a risk factor for many anxiety disorders, including OCD. Most closely aligned with OCD; involved with checking rituals rather than cleaning rituals

Dimensional perspective on personality disorders 1.

There is considerable overlap of symptoms between categories: PDs have a high comorbidity with other PDs, and many people do not display a clear pattern of any specific DSM-5 PD

2.

The workgroup charged with revising the DSM proposed a diagnostic technique based on many personality dimensions. a.

3.

IV.

Very sensitive to criticism; therefore avoid contact with others, often indistinguishable from generalized social phobia

Diagnosis would involve two steps: first, the clinician must make judgments about the patients level of interpersonal functioning based on the way they view themselves and others; second, the clinician must describe which personality problem the patient has based on a five-factor model approach

Many experts believe that the dimensional approach will eventually replace the categorical approach once it is better studied.

Frequency A.

Prevalence—community and clinical samples 1.

In community samples: lifetime prevalence of PDs is 10 percent

2.

In community samples: obsessive-compulsive (highest at about 4 percent), avoidant (3–4 percent), 153 C.

and antisocial (about 3 percent) have the highest prevalence rates; narcissistic is the least prevalent, with less than 1 percent, but this low rate may be due to the limitations of self-report approaches for assessing narcissistic personality disorder

B.

3.

High comorbidity among the personality disorders (50 percent)

4.

Personality disorders are very prevalent among clinical samples; 75 percent of people with a PD also have another mental illness.

Gender differences 1.

Overall, an equal number of men and women have personality disorders; antisocial disorder is much more common in men (about 5 percent) than among women (approximately 2 percent)

2.

Gender bias a.

Critics claim that definitions of some categories may be based on female sex roles and stereotypes that are arbitrarily labeled as maladaptive.

b.

Clinicians, however, may be more willing to diagnose women as borderline or dependent, even when men have the same clinical presentation.

C.

Temporal stability over time is a basic assumption and one of the most important considerations. Other than antisocial traits, PDs do not, however, appear to be highly stable from adolescence and persist to adulthood. Indeed, one longitudinal study found similar charactersitics more than 20 years after the initial observation.

D.

Culture and personality 1.

Culture plays a large role in defining what behaviors are appropriate or acceptable. a.

People across cultures differ in the degree to which they express emotion.

b.

People across cultures also differ in the degree to which they value individualism versus Collectivism.

2.

It is not clear whether DSM-5 personality disorders are relevant to other cultures.

3.

In order to describe personality disorders as cross-cultural, two particularly important questions must be addressed: a.

In other cultures, what are the personality traits that lead to social and occupational impairment?

b.

Are the DSM-5 diagnostic criteria meaningful in other cultures?

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V.

Schizotypal personality disorder A.

Schizotypal personality disorder 1.

Symptoms of schizotypal PD represent manifestations of the predisposition to develop schizophrenia; in fact, the phrase was originally an abreviation for schizophrenic phenotype.

2.

Many family members of people with schizophrenia show signs of schizotypal PD

3.

Criteria: a pervasive pattern of social and interpersoanl deficits starting in early adulthood and indicated by five (or more) of the following (as well as not better attributable to another mental disorder or exlusively associated with another diagnosed disorder):

4.

5.

a.

Ideas of reference

b.

Odd beliefs or magical thinking

c.

Unusual bodily perceptions

d.

Odd thinking and speech

e.

Suspiciousness or paranoid ideation

f.

Innappropriate or restricted affect

g.

Odd behavior or appearance

h.

Lack of close friends

i.

Excessive social anxiety does not diminish with familiarity

Causes a.

Evidence from family, twin, and adoptions studies indicates a significant genetic contribution.

b.

Odd thinking and speech, inappropriate or constricted affect, and excessive social anxiety are significantly more common among the relatives of the schizophrenic patients than among the relatives of the depressed patients.

c.

Increased prevalence of schizotypal personality disorder among the relatives of schizophrenic patients

d.

These personality disorders are not more prevalent among the relatives of people with mood disorders.

e.

These patients do not respond well to insight-oriented psychotherapy because they do not see themselves as having psychological problems.

Treatment 155 C.

VI.

a.

Difficult to study because most people with personality disorders do not seek or remain in treatment and many have comorbid diagnoses, as well as a relatively high percentage of premature termination (drop out of treatment).

b.

Antipsychotic medications, and perhaps antidepressants, have modest benefits.

c.

Controlled studies of psychotherapy are absent, but these approaches do not appear particularly effective.

d.

Pure forms of personality disorders are rare.

Borderline personality disorder A.

Historical perspective 1.

Kernberg’s psychodynamic theory: borderline personality disorder is a set of features found in a variety of disorders a.

Has a basis in deficient ego development

b.

Splitting—the tendency to see people and events alternately as entirely good or entirely bad

B.

Borderline personality disorder overlaps with many other personality disorders (schizoid and cyclothymic personality disorders), especially with depression, impulse control disorders, and substance use disorders.

C.

Symptoms—frantic efforts to avoid abandonment; unstable and intense relationships; identity disturbances; impulsiveness; recurrent suicidal behavior; affective instability; chronic feelings of emptiness; anger control problems; paranoid ideation or dissociative symptoms; depression. The overriding characteristic of boarderline personality disorder is a pervasive pattern of instability in self-image, interpersonal relationships, and mood.

D.

Causes 1.

Genetic factors have not been demonstrated to play a central role.

2.

Parental loss, neglect, or mistreatment during childhood hypothesized to be important

3.

Other parenting problems also common (i.e., neglect, abuse, and domestic violence). These relationships are correlational and do not empirically demonstrate cause; a longitudinal study suggests the following:

4.

a.

Physical abuse is associated with increased risk for antisocial PD.

b.

Sexual abuse is associated with increased risk for borderline PD.

c.

Neglect is associated with increased risk for Cluster B PDs: antisocial, avoidant, narcissistic, and borderline.

Adolescent girls with BPD report pervasive lack of supervision, frequent witnessing of domestic 156 C.

violence, and being subjected to inappropriate behavior by their parents and other adults.

F.

E.

Treatment

1.

Psychodynamic psychotherapists use transference to help patients develop more integrated and realistic identities and relationships; this psychotherapy is based on the transference relationship, which is the way in which the patient behaves toward the therapist and is thought to reflect early primary relationships.

2.

Dialectical behavior therapy utilizes supportive, behavioral, and cognitive strategies focusing on interpersonal relationships, tolerance of distress, and regulation of emotional response; dialectics involves placing opposite or contradictory ideas side-by-side.

3.

Treatment is difficult; people with borderline personality disorder have difficulty maintaining an appropriately close relationship with the therapist; however, some controled studies suggest that dialectical behavioral therapy is an effective treatment for this PD.

4.

A variety of psychotropic medications targeting specific symptoms are often employed, but they are not clearly effective.

5.

Between one-half to two-thirds of all patients with BPD discontinue treatment against their therapists’ advice.

6.

Dialectical behavior therapy (DBT), developed by Marsha Linehan, refers to strategies that are employed by a therapist to help the person appreciate and balance apparently contradictory needs to accept things as they are.

Impulse control disorders 1.

VII.

Characterized by a failure to control harmful impulses; relatively little is known about them a.

Intermittent explosive disorder—aggressive behavior resulting in assaultive acts or destruction of property; level of aggression not proportional to stressor

b.

Kleptomania—stealing object not for personal use or value; theft not motivated by anger or vengeance.

c.

Pyromania—deliberate and purposeful fire setting accompanied with a fascination with fire and things related to fire

Antisocial personality disorder A.

Overview 1.

Cleckley's theory of psychopathy emphasizes emotional deficits (absence of anxiety, shame, and guilt) and personality traits (impulsivity and self-focus); he described the psychopath as intelligent and superficially charming, but chronically deceitful, unreliable, and incapable of learning from experience.

2.

Robins' view emphasizes observable behaviors and repeated conflict with authorities.

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3.

DSM-5 combines a focus on observable behavior with elements of Cleckley’s psychopathy (e.g., lack of remorse).

4.

Psychopathy Checklist (PCL) is based on Cleckley's original description of the disorder and is a fairly reliable measure of the psychopathy construct for the assessment of psychopathy.

B.

Symptoms: failure to conform to social norms (i.e., unlawful behavior); deceitfulness, impulsivity, irritability and aggressiveness; reckless disregard for safety of self/others; irresponsibility (i.e., with work or finances); lack of remorse; must be 18 years old, and diagnosis requires evidence of conduct disorder prior to age 15.

C.

Antisocial behavior across the life span 1.

2.

D.

Moffitt (1993, 2007) proposed a distinction between a

Adolescence-limited antisocial behavior, which is more common, may be adaptive and is short-lived

b

Life-course persistent antisocial behavior, in which antisocial behavior continues in varied forms across the life span

Older psychopaths are less likely to engage in impulsive or criminal behaviors but may well continue to exhibit antisocial personality traits; some evidence that psychopaths tend to ‘burn out’ by the age of 40–45

Causes 1.

Biological factors: several twin studies suggest there is a genetic contribution to antisocial behavior; however, the results from adoption studies suggest genes and adverse environmental circumstances interact to create risk

2.

Social factors: family conflict, inconsistent or absent discipline, and fathers with antisocial tendencies are associated with increased risk. Children with difficult temperaments may elicit negative parenting behaviors. Thus the interaction of child and environment can lead to antisocial tendencies. Lack of learned social skills and the consequences of prior choices can perpetuate that pattern.

3.

Psychological factors: avoidance learning and disinhibition; psychopaths may be less sensitive to punishment or less able to consider negative consequences a. Psychopaths may be emotionally impovershed; experience less anxiety and fear (e.g., decreased startle responses); also more impulsivity b. Diminished ability to suspend activities or shift attention to consider that their behavior might lead to negative consequences

E.

Treatment 1.

Outcomes have been difficult to assess because of low rates of seeking treatment, high rates of substance abuse, and low compliance with prescribed treatment; moreover, research on the effectiveness of treatments is very limited.

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a. Treatment is generally ineffective, yet behavior therapy approaches can change behaviors.

2.

Is often measured in terms of frequency of repeated criminal offenses rather than in terms of changes in behavior

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LEARNING OBJECTIVES LO 9.1: What is the difference between being eccentric and having a personality disorder?

LO 9.2: In what ways are borderline and narcissistic personality disorders similar?

LO 9.3: What are the advantages of a dimensional approach that would describe personality problems as variations on maladaptive personality traits?

LO 9.4: Which personality disorders are least likely to change as a person gets older?

LO 9.5: Why are personality disorders so difficult to treat?

LO 9.6: What is the difference between antisocial personality disorder and psychopathy?

LECTURE SUGGESTIONS Personality disorders and alcoholism: What is the comorbidity of personality disorders with alcoholism? What role does having a personality disorder play in the course and outcome of alcoholism? Which are the most common personality disorders among alcoholics? Jon Morgenstern at the Mount Sinai School of Medicine has examined these questions in a recently published study of 366 patients in alcohol treatment programs. The findings are useful to both our understanding of personality disorders and of alcoholism. Morgenstern and his colleagues’findings include the following: (1) There were high levels of comorbidity among personality disorders, with 2.3 as the average number of personality disorders among those who met the criteria for at least one, and 35 percent had 3 or more. (2) A majority of the alcoholics had at least one personality disorder. (3) The most prevalent personality disorder was antisocial personality disorder; and (4) significant gender differences emerged, with women showing a greater tendency towards borderline personality disorder and with men towards antisocial personality disorder. Perhaps the most important finding, however, was that having a personality disorder was linked to more severe symptomatology of alcoholism as well as other clinical problems. The presence of a personality disorder, then, appears to worsen the situation for an alcoholic. Possibly the reverse could also be said—that alcohol abuse worsens personality disorders—but research would be needed to establish that. As for the interpretation of the gender differences found, the tendency for men to be more aggressive and for women towards affective instability could lead to antisocial personality disorder in male alcoholics and borderline personality in female alcoholics. This study, of course, is correlational in nature and so caution should be exercised when attempting to find causal connections between any of the variables.

Morgenstern, J., Langenbucher, J., Labouvie, E., & Miller, K.J. (1997). The comorbidity of alcoholism and personality disorders in a clinical population: prevalence rate and relation to alcohol typology variables.

Journal of Abnormal Psychology, 106, 74–84.

Self-esteem, narcissism, and aggression: Current directions APS reader (1E, p. 91): Roy Baumeister and colleagues state that the prevailing theory that aggressive people are lacking in 160 C.

self-esteem is really unsupported. Aggressive people, according to most research, tend to have higher than average self-esteem and, when threatened, lash out at their critics or their opponents. In fact, the concept of narcissism is more precise than that of self-esteem for purposes of identifying important determinants of violent behavior; threatened narcissism or egotism, then, becomes a useful way of talking about individuals who are likely to become violent. The argument is further supported by studies that show that bipolars tend to be more aggressive in their manic phase than in their depressed phase.

Baumeister’s own lab has produced a number of studies that support the theory of threatened narcissism.

Narcissism itself is linked to high but unstable self-esteem, suggesting that the narcissist’s esteem can be raised or lowered by circumstances. In the laboratory studies, narcissistic participants who were insulted demonstrated a tendency to display aggression (sounding an aversive blast of loud noise) when given the opportunity. Field studies conducted with inmates also revealed higher levels of narcissism. A favorable self-view—when disputed or undermined by others—can therefore be treated as a risk factor for aggressive behavior. Further research is needed in which the relationship between narcissism, sensitivity to criticism, and aggression is more thoroughly examined.

The dimensional nature of personality: The question of categorical versus dimensional classification is particularly relevant to personality disorders.

People with PDs adopt rigid personality traits, but these traits are generally not qualitatively different than those seen in the rest of the population. The difference is quantitative and lies in the extreme and inflexible nature of those with PDs. Can the personality disorders be described as something like ‘personality styles’ in a way that would demonstrate the similarities between ‘normals’ and those with personality disorders? David Shapiro's classic book, Neurotic Styles (1965), provides some very vivid descriptions of maladaptive personality styles. He also describes differences in personality styles that characterize the different personality disorders. For example, he says the hysteric views the world in terms of impressions, while the obsessive-compulsive personality style is detail-oriented. Shapiro's point is that each of us has elements of these neurotic styles to some degree, and abnormality should properly be viewed as ‘on a continuum’ rather than as an aberration from normality.

Psychopathology arises when the person's style is unable to handle the stress and changes that the person encounters in his or her life. Ask students to consider their own personality styles, their characteristic ways of seeing the world and relationships, and what form of personality disorders they would have if their styles became more extreme or rigid due to stress, failure, or overwhelming change. This can lead to an interesting discussion of the continuum between ‘normality’ and ‘disorder.’

Shapiro, D. (1965). Neurotic styles. New York: Basic Books.

Dialectical behavior therapy for borderline personality disorder: One of the most challenging tasks for therapists is presented by borderline personality disorders. Most therapists find them to be very ‘labor-intensive’ and require a great deal of resources in many ways. Linehan’s Dialectical Behavior Therapy (DBT) has provided a new model that has, literally, revolutionized the treatment of BPDs. In fact, data indicate that DBT is more effective than nearly any other treatment approach utilized for treatment of BPD. The approach utilizes emotion regulation, interpersonal skill-development, and some cognitive-behavioral aspects.

Linehan suggests that patients need to learn to regulate their own emotions and behaviors while also working on acceptance and mindfulness. She borrows some of her ideas from Eastern philosophy and religion; more specifically, some of her treatment is based on the teachings of Zen Buddhism. Patients who are able to increase their mindfulness and acceptance, and who develop better social skills tend to reduce the level of conflict and stress in their lives, as well. This approach is being utilized in hospitals and in mental health centers, and in both group and individual modalities.

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Linehan, M. & Dexter-Mazz, E. (2008). Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed.) in Barlow, David H. (Ed); pp. 365–420. New York, NY: Guilford Press.

DISCUSSION IDEAS Dangerous assumptions: By labeling some people as having personality disorders, we are making a number of assumptions including (a) that people have stable, enduring characteristics, and (b) that some people's personalities are inflexible and inherently maladaptive. Does this mean we are foreclosing on the possibility of self-change? Should the concept of personality disorder be changed to consider the possibility of change either through developmental progress or therapeutic intervention? Note that aside from ASPD, personality disorders may be diagnosed in adolescents, even though many clinicians are reluctant to do so, and there is not good evidence of continuity of PD features from adolescence into adulthood.

Ethical considerations: Many people with antisocial personality disorder are extremely dangerous. Biological researchers are getting closer to identifying genetic markers or mechanisms that may be causally related to the disorder. If a gene can be isolated that determines the development of psychopathy, what should be done about this? A range of possibilities can be considered, from aborting all children with this genetic marker, to mandatory psychotherapy, to no special consideration. If there is a "criminal personality type," what would the practical value be of identifying genetic markers for it?

Psychopathy and criminal responsibility: Antisocial personality disorder is clearly different in many important ways from other psychological disorders and involves behaviors and characteristics most people would judge unfavorably from a moral perspective. However, ASPD may have a strong genetic or biological component, and therefore, the characteristic behaviors, though volitional, may not be simply a matter of free choice. Ask students to consider the implications of research that would demonstrate clear biological substrates to this disorder in terms of moral or criminal responsibility for antisocial behaviors. In particular, they may wish to consider whether biological markers of psychopathy should be considered as a partially or completely mitigating criminal responsibility, and the implications of responses in either direction.

Does the media influence the development of personality disorders?

When we look at the influence of popular movies and the actors and actresses that play in these movies, is there a chance that that show biz business fosters the development of personality disorders? If you were to look at an advertisement for someone who is very theatrical, has an exaggerated expression of emotion, is easily influenced by others, is shallow, needs to be the center of attention, acts inappropriately seductive, and is concerned with physical attractiveness, do these characterisitcs seem to describe the personalities we see on television and in popular films?

If, in films, actors and actresses are forced to play these major roles that conform to these personalities characteristics, do you think that they may adopt some of these traits in their normal ways of interacting with others, in ways of expressing emotions, or just as ways of being? What other personality disorders do you believe media may contribute to the development of and what examples can you think of that have been portrayed in popular films?

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Gender and personality disorders?

As mentioned in the textbook, personality disorders are seen equally in both men and women; however, there are higher rates of certain personality disorders for men versus women. Antisocial personality disorder is more common in men with rates of 5 percent of men, as compared with 1 percent of women meeting the diagnostic criteria. Borderline personality disorder and dependent personality disorder are thought to be more common in women, but some critics suggest this prevalence is due to the sex roles and stereotypes of women versus those of men. It has also been mentioned that paranoid personality disorder and obsessive-compulsive personality disorder are more prevalent in men than in women. Feminine versus masculine traits can be viewed in how the personality disorders are categorized with dependent, histrionic, and borderline personality disorders viewed as feminine and antisocial, paranoid, and obsessive-compulsive personality disorders viewed as masculine. If the criteria is based on stereotypical sex roles or the obedience to these roles, how might that cause bias or an increase in both men and women being diagnosed with a personality disorder? Is this a way of pathologizing how men or women interact in relationships or express their emotions?

Borderline personality disorder: self-injury, a suicide attempt, or a cry for help?

When describing BPD to students, the metaphor that these individuals are equivalent to ‘emotional burn victims’ can be illuminating. Whereas a burn victim’s skin would be sensitive to touch, an individual with BPD is sensitive to emotions, to self-identity, to abandonment, aand to relationships, and he may engage in certain behaviors because of the influence of relationships with others. One of the diagnostic criterion for BPD is recurrent suicidal behavior, gestures, threats, or self-mutilating behavior. Why do you think there is a high incidence of individuals who engage in self injury? Do you believe it is a suicidal attempt and a way to cope with problems or merely a cry for help and a cry to be heard?

CLASSROOM ACTIVITIES Acting out personality disorders: List the various personality disorders on slips of paper in a hat and ask for volunteers to act out a scene. Then explain to the volunteers that they are to pick a slip and play the role of a person who has that disorder. Some scenes that work well are scenes in which top executives are talking about marketing a new soft drink or psychology faculty are planning a new research project that involves students in introductory psychology classes. Ask observing students to try to guess the personality disorders that are being acted out in the scenes. After acting out the scenes, actors and observers can then discuss the accuracy of the portrayal of each of the disorders.

Personality disorders at a party: Ask for student volunteers and then, once you have ten volunteers, pass out descriptions of the different personality disorders to the volunteers. Allow time for the students to plan out how they will portray their selected personality disorders. Explain to the students that they will each be attending a party during which they will need to act out their personality disorders. It may be helpful to bring in some props like shot glasses, cups, martini shakers, table cloth, table and chairs, and to play some music to assist the students in acting out being at a party. Give the students seven to ten minutes to act out the scene at a party; after that, ask the rest of the class to guess which personality disorder each student was portraying throughout the skit.

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Assessment of popular cartoon characters or T.V./film personalities: This activity can be modified several ways. You can show, on the overhead projector, several images of popular cartoon characters and T.V. personalities to the class and ask the students, either individually or in a small group setting, to assess the characters for the diagnostic criterion of each of the personality disorders. Or you can pass out a picture of one cartoon character or T.V. personality per table for a small group to evaluate one character for the one of the personality disorders. Lastly, you could assign this exercise as a homework assignment, and ask the students to evaluate one of their favorite cartoon characters or T.V./film personalities for a personality disorder.

Then they can share their findings with the class. It may be helpful to give an example to the students first by using the cartoon character,“The Joker” from Batman, who clearly exhibits characteristics of antisocial personality disorder.

Personality disorders worksheet: John Suler, Ph.D., a professor at Rider University, has provided an accessible worksheet online that can be used by students to assess their knowledge and understanding of personality disorder using different vignettes. The worksheet can be accessed as a pdf file online at http://users.rider.edu/~suler/perdis.html. The suggested answers are also provided, but the worksheet can also be used to spark some discussion related to the diagnostic criterion for the different personality disorders.

Suler, J. (2011). Teaching clinical psychology: In-class exercises. Retrieved from http://users.rider.edu/~suler/perdis.html on June 28, 2011.

Personality disorder excursion: game This activity can be used as an introduction to the various personality disorders, used as a way to assess comprehension of personality disorders, or used as a review of the chapter before an examination or quiz. Type up the description of each of the different personality disorders without the specific personality disorder names on the PowerPoint slides and print off the slides one per page. Then tape the large PowerPoint slides around the room, or on to different desks around the room. Divide the class into small groups and ask them to travel around the room as a team and to write down the correct personality disorder for each of the descriptions. This is an activity for which you could give extra credit points if all of the descriptions are answered correctly. It may also increase the competiveness to only give students ten to fifteen minutes to complete the activity. When the students show the completed list for checking, it will be more challenging to say two disorders are wrong than telling them the specific numbers that are incorrect.

VIDEO CASES IN ABNORMAL PSYCHOLOGY: Liz—Borderline personality disorder (18:04) Liz submits that she has many of the symptoms associated with borderline personality disorder. She is an impulsive and compulsive shopper, has anger management problems, has made suicide attempts, has difficulties with relationships, complains of an intense fear of abandonment, and experiences extreme loneliness. Her suicide attempt occurred after the end of a six-year relationship, and, indeed, she claims that her relative good mental health today is due to having a secure relationship. She was an only child and describes herself as always having been extremely sensitive, especially to abandonment. She also has a tendency to blame others for any negativity in her life, and she states that she can “talk people under the table” and be very "manipulative."

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Discussion questions: 1.

Do you think Liz’s relatively positive mental state is stable and long-lasting, or is it completely dependent upon having this stable relationship?

2.

What are some of the difficulties in treating a person like Liz, who is an admitted “externalizer,” and who blames any problems on others?

3.

How do you think that being an only child played a role in the development of Liz’s mental health issues?

4.

Liz describes many personality weaknesses and difficulties that she has; what are some of the strengths that you see in Liz? Ed—Compulsive Gambling Ed, a compulsive gambler who has been in recovery for 30 years, describes his early gambling as ‘fun.’ He says that his self-esteem as a student and as an athlete was low and he found a kind of identity as a gambler. He enjoyed the feeling of ‘being right’ when he won and found that, at the racetrack, others viewed him very positively.

Over time, he began to lose virtually everything that he cherished—money, relationships, self-esteem, etc. His recovery has been aided by Gamblers Anonymous, and he has now been able to contribute to other people’s recovery and development.

Discussion questions: 1.

How is Ed’s case typical of that of an impulse control disorder? What features do you look for in distinguishing a ‘social’ or ‘casual’ gambler from someone who has a serious problem?

2.

Ed states that most people with ‘compulsive personalities’ hope to recover quickly once they make the decision to finally quit their compulsive behavior. Why is it not so easy? What steps need to be taken before one can fully recover from this disorder?

3.

There is no obvious ‘mental problem’ that can be detected in Ed. How does that make it even more difficult for someone like him to recognize the problem and begin treatment? Consider his description of the way others viewed him at the racetrack. How could that contribute to his denial?

Paul, Antisocial Personality, age 28 (11:15) Paul is a 28-year-old homeless, divorced man with one child. He engages in aggressive and reckless behavior, which, combined with his violent temper, makes him a danger to others. He has been in jail on numerous occasions and resents authority figures. He is proud of his capacity to survive on the streets.

Discussion questions: 1.

At one point during his interview, Paul stated, "What I want to do, I do it...I never let anyone tell me how to live. I don't live by society's rules." Discuss a few instances in which Paul adheres to his statement. How does this attitude reflect developmental deficits?

2.

One typical symptom of antisocial personality disorder is a resentment of authority figures. Comment on Paul's attitude towards authority figures, specifically the criminal justice system.

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VIDEO RESOURCES http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Josh_Schizoaffective_ Disorder.html Josh: Schizoaffective Disorder (3:40) Watch this video as a patient describes living with paranoia and schizoaffective disorder. http://media.pearsoncmg.com/ab/ab_lefton_psychology_8/media/lbp8e_16577/lbp8e_16577.html Psychotherapy Practitioners and Their Activities Explore this drag-and-drop exercise to match the titles of various psychotherapy practitioners with their job descriptions. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/WoodIt/Conscience.html Conscience (3:00) Listen to this commentary on killers without a conscience. http://visual.pearsoncmg.com/mypsychlababnormalDSM5/episode1/web_index.html?clip=5&tab=tab0 Steve: Social Anxiety Disorder (Social Phobia) (3:00) View this video in which Steve discusses his social phobia and how it affects his daily life and choices. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Janna_Borderline_ Personality_Disorder.html Janna: Borderline Personality Disorder (2:05) In this video, Janna talks about dealing with conflicting feelings with a diagnosis of borderline personality disorder.

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Chapter 10 Feeding and Eating Disorders Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: p. 263 Symptoms of Anorexia: p. 265

Video Case: Anorexia Nervosa, Natasha

Significantly Low Weight Fear of Gaining Weight Disturbances in Experiencing Weight or Shape Amenorrhea Medical Complications Struggle for Control Comorbid Psychological Disorders Symptoms of Bulimia: p. 267 Binge Eating Inappropriate Compensatory Behavior Excessive Emphasis on Weight and Shape Comorbid Psychological Disorders Medical Complications

Lectures: Perfectionism and bulimia Video Case: Anorexia Nervosa: Binge-Eating/Purging Type, Jessica

Diagnosis of Feeding and Eating Disorders: p. 269

Lectures: Beauty through time

Contemporary Classification

Discussion Ideas: Evaluating common diets

Frequency of Anorexia and Bulimia: p. 271

Lectures: Thin-ideal internalization

Standards of Beauty Age of Onset

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PROFESSOR NOTES

Causes of Eating Disorders: p. 274 Social Factors Psychological Factors Biological Factors Integration and Alternative Pathways

Lectures: Genetic Studies of Eating Disorders Discussion Ideas: Role of food in a family Classroom: Etiology debate Body Image

Treatment of Anorexia : p. 278 Course and Outcome of Anorexia Nervosa Treatment of Bulimia : p. 279 Cognitive Behavior Therapy Antidepressant Medications Interpersonal Psychotherapy Course and Outcome of Bulimia Nervosa

Discussion Ideas: Treatment of eating disorders

Video Case: Bulimia, Ann, age 46

Prevention of Eating Disorders: p. 280

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CHAPTER OUTLINE I.

Overview A.

Feeding and eating disorders—severe disturbances in eating behavior that result from an individual's obsessive fear of gaining weight 1.

B.

C.

II.

The DSM-5 identifies six subtypes of feeding and eating disorders with the two most extensively studied being anorexia nervosa and bulimia nervosa.

Two major subtypes 1.

Anorexia nervosa—extreme emaciation, or the refusal to maintain a minimally normal body weight; people with anorexia nervosa are hungry, yet starve themselves

2.

Bulimia nervosa—involves repeated episodes of binge eating followed by inappropriate compensatory behaviors such as self-induced vomiting, misuse of laxatives, or excessive exercise

Both are about 10 times more common among females than they are among males. They usually develop in teens and young adults.

Symptoms of anorexia nervosa A.

Refusal to maintain a normal weight; below roughly 85 percent of expected body weight; the average victim of anorexia nervosa loses 25-30 percent of normal body weight; DSM-5 does not contain a specific criteria for “too thin” but suggests that a body mass index (BMI) of under 18.5 is useful in adults.

B.

High morbidity risk: 5 percent of those with anorexia admitted to university hospitals die of starvation, suicide, or medical complications

C.

Disturbance in evaluating weight or shape 1.

Many people with anorexia deny having problems with weight.

2.

Distorted body image—inaccurate perception of body size and shape

3.

People with anorexia are unduly influenced by their body weight or shape in self-evaluation.

D.

Fear of becoming fat; fear of losing control; fear of gaining weight

E.

Other symptoms 1.

Amenorrhea—absence of at least three consecutive menstrual cycles; necessary for diagnosis in women a. Is a reaction to the loss of body fat and does not precede anorexia b. Some experts recommend dropping this as a criteria because the presence or absence of amenorrhea is not a distinguishing feature of anorexia; some bulimics also have amenorrhea.

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Indeed, the latest version of the DSM (DSM-5) does not require this.

2.

F.

III.

Many anorexic individuals lose interest in sex; the presence or absence of menstruation does not differentiate between women who meet other diagnostic criteria for anorexia nervosa, and menstrual irregularities are common in bulimia nervosa; DSM-5 dropped this diagnostic criterion because amenorrhea does not differentiate between women who meet other criteria for anorexia.

Medical complications—can be serious and lead to death 1.

Constipation, abdominal pain, intolerance to cold, and lethargy are common complaints.

2.

Blood pressure and body temperature may fall below normal.

3.

Dermatological problems—dry or cracked skin; lanugo, fine downy hair on face or body

4.

Anemia, impaired kidney functioning, cardiovascular difficulties, dental erosion, bone loss

5.

Electrolyte imbalance—disturbances in levels of potassium, sodium, calcium, etc.,; can lead to cardiac arrest, kidney failure

G.

Struggle for control—people with anorexia are more likely to exhibit excessive conformity, struggle to maintain self-control, and take pride in their ability to restrict; however, clinical accounts and some research suggest that more are conforming and controlling

H.

Comorbid psychological disorders 1.

Obsessive-compulsive disorder, obsessive-compulsive personality disorder, and depression are associated with anorexia nervosa. They may play a role in the development of anorexia, but they can also be reactions to starvation.

2.

Symptoms of anorexia often, but not always, co-occur with bulimia nervosa symptoms, such as binge eating and purging.

3.

People with anorexia seem obsessed with food; however, a study on volunteers who underwent semi-starvation during World War II suggests that this obsession may be the effect of starvation, rather than the cause of anorexia.

Symptoms of bulimia A.

Binge eating—eating a substantially greater amount of food in a fixed period of time (e.g., less than 2 hours); more than most people would eat under similar circumstances; many inappropriate eating behaviors border on being statistically normal in American society. Indeed over 35 percent of people report occasional binge eating.

1.

Binges may be planned in advance or may begin spontaneously.

2.

Most individuals with bulimia tend to be ashamed of their eating problems and keep binges secret.

3.

During a binge, the individual usually eats rapidly, until uncomfortably full. There is an associated sense of lack of control over eating.

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4.

B.

Inappropriate compensatory behavior 1.

2.

Purging—eliminating the consumed food from the body a.

Self-induced vomiting—the most common form of purging, occuring in 90 percent of bulimics; it brings immediate physical relief and reduces fears of weight gain

b.

Laxatives, diuretics (which increase frequency of urination), and enemas—less common forms of purging

c.

None of the above forms of purging are clearly effective in compensating for excessive intake.

Excessive exercise and rigid fasting are alternative behaviors to purging; they are compensatory behaviors but are not considered purging.

C.

Self-esteem and much of daily routine center on weight, diet, and appearance; people with bulimia are very sensitive to others’ comments about their weight or appearance; the patients’ self-evaluations are unduly influenced by their weight and shape.

D.

Comorbid psychological disorders

E.

IV.

Binges are often triggered by unhappy moods and may be temporarily comforting; may begin with an interpersonal conflict, self criticism about weight or appearance, or intense hunger following a period of fasting

1.

Depression is the most common, and may precede or follow (as a reaction to) bulimic symptoms

2.

Anxiety disorders, personality disorders (especially borderline), and substance abuse (mostly alcohol and stimulants) also may co-occur with bulimia.

Medical complications 1.

Dental enamel erosion and excess gag reflex from repeated vomiting; can lead to rumination—regurgitating and rechewing food

2.

Enlargement of the salivary glands

3.

Electrolyte imbalances with associated serious medical consequences

4.

Ruptures of esophagus or stomach occasionally occur and, in rare cases, lead to death.

5.

Repeated vomiting can also produce a gag reflex that is triggered too easily and perhaps unintentionally.

Diagnosis of feeding and eating disorders A.

Contemporary classification 1.

The DSM-5 identifies six types of feeding and eating disorders: a. Pica—eating nonnutritive substances such as dirt or paper 171 C.

b. Rumination disorder—repeated regurgitation of food c. Avoidant/restrictive food intake disorder—appears most often in infants and involves a complete lack of interest in food d. Binge-eating disorder—episodes of binge eating without the purging behavior e. Anorexia nervosa; two subtypes: restricting type and binge eating/purging type. f. Bulimia nervosa V.

Frequency of anorexia and bulimia A.

The prevalence of eating disorder has increased substantially in recent years.

B.

The 12-month prevalence of anorexia is approximately .5 to .9 among females.

C.

Bulimia rates, which suggest a cohort effect for females are about 1.5 percent among females and .5 percent among males; binge eating disorder has a lifetime prevalence rate of 3.5 percent.

D.

1.

Overlap: about 50 percent of anorexics engage in episodes of binge eating and purging; many cases of bulimia have a history of anorexia

2.

Binge eating disorder and occasional binge eating are even more common. With respective lifetime prevalences of 3.5 percent and 4.9 percent in women, and 2 percent and 4 percent in men.

Standards of beauty—scientists believe that gender roles and standards of beauty attribute to the incidence of eating disorders in women 1.

Both anorexia and bulimia are much more common in females, which is thought to reflect a greater societal emphasis on looks and thinness in females.

2.

Beauty has become increasingly equated with thinness in our culture; models have become thinner over time. a. 69 percent of Playboy centerfolds and 60 percent of Miss America contestants weigh 15 percent below the expected weight for their height.

E.

3.

Eating disorders are more common in North America, Western Europe, and industrialized Asian nations.

4.

In third world countries where food is scarce, wealth is positively correlated with body weight; in these countries, being larger is a symbol of beauty.

Age of onset—anorexia and bulimia typically begin in late adolescence/early adulthood. Hormonal changes, autonomy struggles, problems with sexuality, and reactions to normal changes in body weight and shape may all play some role.

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VI.

Causes of anorexia and bulimia A.

B.

Social factors 1.

Much more common in females; single biggest risk factor for an eating disorder is being female.

2.

More common in fields that emphasize weight and appearance, e.g., models, ballet dancers, gymnasts

3.

More common in females who report greater exposure to popular media and who endorse more gender role stereotypes

4.

More common in middle- and upper-class whites, but increasing in African Americans of higher SES

5.

Higher prevalence in Arab and Asian women living in Western countries than the women living in their native countries

6.

Troubled family relations a.

Bulimia—greater family conflict and rejection that may also contribute to depression

b.

Anorexia—nonconflictual, but enmeshed (overly involved in one another's lives)

c.

Sexual abuse—many women with eating disorders report a history of childhood sexual abuse, but it is not more common than in women with other psychological problems

d.

Parents may influence the development of eating disorders by being preoccupied with diet and thinness themselves and may encourage their children to be thin

7.

Basic influence is the individual’s internalization of the ideal of thinness

8.

Young people with anorexia nervosa are obsessed with controlling their eating because eating is the only thing that they can control in their intrusive families.

9.

More common in young women than middle or older aged and much more common in countries with a thin ideal in the popular media and culture.

Psychological factors 1.

Struggle for control; Hilde Bruch’s (1904-1984) approach a.

"Good girls"—eager to please, conforming, perfectionistic

b.

Efforts to control eating reflect attempts to assert one’s own control

c.

Poor interoceptive awareness—recognition of internal cues, including emotional states and hunger

d.

Perfectionists set unrealistically high standards, are self-critical, and demand nearly flawless performance from themselves.

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2.

3.

4.

C.

Depression, low self-esteem, and dysphoria a.

There is an increased prevalence of depression in women with eating disorders and their family members, and antidepressents can reduce some of the symptoms of bulimia nervosa.

However, depression is most often secondary rather than a cause.

b.

Many women with eating disorders are preoccupied with their social selves—how they present themselves to others and how others perceive and evaluate them.

c.

Negative mood states commonly trigger episodes of binge eating in people with bulimia and in people with the binge-eating/purging subtype of anorexia.

Negative body image—a critical evaluation of one's weight and shape a.

Current research now focuses on dissatisfaction since distorted body image is not a necessary component to an eating disorder.

b.

One way to assess a negative body image is to compare people’s ratings of their “current” and “ideal.”

c.

Current longitudinal studies have found that negative evaluations of weight, shape, and appearance predict development of disordered eating.

Dietary restraint—direct consequences of overly restrictive eating or inappropriate efforts to control eating including binge eating, preoccupation with food, and perhaps out-of-control feelings of hunger a.

Weight suppression, defined as highest weight minus current weight, predicts maintenance of bulimia.

b.

An overly restrictive diet increases hunger frustration and a lack of attention to internal cues, all of which make binge eating more likely.

Biological factors 1.

The body’s response to dieting: people have weight set points—fixed weights or small ranges of weight that the body tends to maintain. When food intake is reduced, there is a slowing in metabolic rate, the rate at which the body expends energy as it tries to compensate for the reduction of food.

2.

Genetic mechanisms—concordance rates of 23 percent for MZ twins and 9 percent for DZ twins have been found for bulimia, suggesting some heritability, possibly through the transmission of personality characteristics, including childhood anxiety, that increase risk for bulimia; recent evidence suggests that genetic factors influence eating pathology after puberty.

3.

Neurophysiological measures—elevations in endogenous opioids, low levels of serotonin, and diminished neuroendocrine functioning are associated with eating disorders. These appear to be effects rather than causes.

4.

Eating disorders have been linked to hormonal disturbances or lesions in the hypothalamus.

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D.

Cause is best understood through a systems approach—social, psychological, and biological factors interact in the development of eating disorders. The specific causal pathway may vary substantially from person to person.

VII. Treatment of anorexia A.

B.

Two goals for treatment 1.

Weight gain, including use of inpatient settings with coercive methods if necessary (e.g., forced feeding or intravenous feeding, strict behavior therapy programs)

2.

Address the difficulties that cause or maintain the problems, commonly through individual and family therapy

3.

The Maudsley method requires that parents take complete control of their child’s eating for a while; later, the patient can reassert self-determination as eating improves; age appropriate autonomy is returned to the teenager as eating and weight improve.

4.

Three other approaches are currently utilized: Bruch’s psychodynamic therapy to increase interoceptive awareness and correct distorted perceptions of self; cognitive behavioral approaches to alter beliefs about the importance of weight and shape; and feminist therapies that encourage women to pursue their own values rather than following prescribed social roles. There is no evidence to support or dispute the effectiveness of any of these approaches.

5.

Hospitalization may also prevent suicide, address depression, medical complications, or remove a patient from a dysfunctional social circumstance.

Course and outcome 1.

Treatments are not very effective. At 10- and 20-year follow-ups, only about half of patients have weights within the normal range. Follow-up treatment studies show normal weight in 50 percent; 20 percent significantly below weight; up to 5 percent may die; the majority remain preoccupied with diet, weight, and shape.

2.

Positive prognostic indicators include early onset, conflict-free parent-child relationships, early treatment, less weight loss, and absence of binge eating and purging.

VIII. Treatment of bulimia A.

Cognitive behavior therapy (CBT)—significantly reduces binge eating and purging 1.

Individual, self-help formats, or group approaches effective

2.

Education and behavioral strategies to normalize eating patterns

3.

Challenging dysfunctional beliefs about self, appearance, and dieting

4.

Preparing strategies for coping with expected relapses

5.

CBT leads to a 70–80 percent reduction in binge eating and purging; one-third to one-half are able 175 C.

to cease the bulimic pattern completely; majority maintain these gains up to 1 year

IX.

B.

Interpersonal psychotherapy—focuses on difficulties in close relationships; appears to require more time, but long-term benefits are at least equal to those of cognitive behavior therapy. Indeed, a 12 month study found that patients treated this way continued to improve following the cessation of treatment.

C.

Antidepressant medication—somewhat effective, but does not supplement psychotherapy as the treatment of choice

D.

Course and outcome—current evidence shows treatments are more effective for bulimia than anorexia.

Following diagnosis, about 70 percent are free of all symptoms, 20 percent continue to meet diagnostic criteria and 10 percent are chronically ill; comorbid psychological disorders also appear to improve when bulimic symptoms end, and one in ten are chronically ill

Prevention of eating disorders A.

B.

Recent research reveals some interesting trends in prevention work; successful programs: 1.

Attack the thinness ideal indirectly; focus on promoting healthy eating patterns

2.

Dissonance interventions were previously common—where patients complete tasks in which being obsessed with one’s eating is dissonant (e.g., giving speeches to young women about the importance of overcoming overconcerns about one’s body weight and appearance)

3.

Results show that a more direct, positive focus on healthy patterns of behavior seems to be more effective than a dissonance-based approach.

Prevention research appears to be moving in the right direction.

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LEARNING OBJECTIVES LO 10.1: How can you tell if someone has an eating disorder?

LO 10.2: How do images of women in the media contribute to eating disorders?

LO 10.3: Do men suffer from eating disorders?

LO 10.4: What is binge-eating disorder?

LO 10.5: Why do some girls and women develop eating disorders when others do not?

LO 10.6: What treatments work for anorexia and bulimia?

LO 10.7: Can eating disorders be prevented?

LECTURE SUGGESTIONS Perfectionism and bulimia: In a paper published in the Journal of Abnormal Psychology, Joiner and colleagues discuss the role of perfectionism, perceived weight, and actual weight in producing bulimic symptoms. Using two samples totaling 890 women (undergraduate students), they tested a diathesis-stress model in which perfectionism was viewed as a risk factor in the development of bulimia for women who perceive themselves as overweight. Both studies confirmed their hypothesis, suggesting that those women who perceive their weight in a negative light (as overweight) and are perfectionistic are more likely to develop bulimic symptoms in college. Actual weight was not a significant predictor of bulimic symptoms, though the correlation between actual weight and perceived weight was fairly high.

Joiner and his colleagues’ study serves as an excellent example of a diathesis-stress model and also as a good example of an interactive model. The statistical analyses revealed a significant interaction, with perfectionism and perceived weight interacting to influence the prevalence of bulimic symptoms.

Joiner, T.E., Heatherton, T.F., Rudd, M. D., & Schmidt, N.B. (1997). Perfectionism, perceived weight status, and bulimic symptoms: Two studies testing a diathesis-stress model. Journal of Abnormal Psychology, 106, 145–153.

Beauty through time: April Fallon (1990) describes the change in perceptions of attractiveness in the book, Body Images: Development, Deviance, and Change. She writes of the latter Middle Ages that “the ‘reproductive figure’ was the ideal—corpulent, with emphasis on the stomach's ‘fullness’ as a symbol of fertility. Between 1400 and 1700, fat was considered both erotic and fashionable.” Regarding the nineteenth century, Fallon writes, “At its height in the 1880s, young women in the United States worried about being too thin... Doctors encouraged a plump shape as a sign of health.” This contrasts with our present near-obsession with thinness and provides a perspective that emphasizes the societal factors that may be involved in eating disorders. Similarly, the differences in prevalence in Western, industrialized nations and less developed societies should clearly indicate the social influence on eating disorders. Challenge students to consider what this means. Are eating disorders solely a product of society?

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Fallon, A. (1990). Culture in the mirror: Sociocultural determinants of body image. In T.F. Cash & T. Pruzinsky (Eds.), Body Images: Development, Deviance, and Change. Guilford Press: New York.

Thin-ideal internalization: Current directions APS reader (1E, p. 97) Is an intense concern with thinness a risk factor for an eating disorder? Thompson and Stice provide compelling evidence that confirms what most of us already believe, that some eating disorders can be traced back to the internalization of the ideal of thinness. “Thin-ideal internalization refers to the extent to which an individual cognitively ‘buys into’ socially-defined ideals of attractiveness and engages in behaviors designed to produce an approximation of these ideals” (Thompson et al., 1999). The Thompson and Stice model, then, states that this internalization leads directly to body dissatisfaction, which, in turn, leads to dieting. Research has established that dieting can then lead to either anorexia or bulimia (binging as a result of caloric deprivation).

Indeed, evidence of such a process is mounting; those who have internalized this thin-ideal have been found to be more likely to diet, experience more negative affect, have body dissatisfaction, and begin to show bulimic symptoms. Perhaps more heartening is that Thompson and colleagues have begun to demonstrate that challenging this thin-ideal internalization in a variety of ways can lead to less body-image dissatisfaction and less eating disorder pathology. In one study, participants were asked to "argue against" the idealization of thinness, in writing or verbally, and this led to a reduction in their own internalization of the ideal. It would be interesting to find out how early this internalization of a thin-ideal occurs in our society, as the prevalence of dieting, body dissatisfaction, and even eating disorder pathology seems to be manifest at younger and younger ages.

Genetic studies of eating disorders: Current directions APS reader (2E, p. 170) Klump and Culbert examine the association studies that have looked for a genetic basis in eating disorders. Twin studies suggest that there may be a much larger impact of genetics than was previously thought; as much as 83 percent of the variation in risk for eating disorders may be accounted for by genetics. Most genetic research in this area has focused on neurotransmitters, neuropeptides, and hormones that may be responsible for food intake and/or mood states known to be affected by eating disorders (e.g., anxiety).

There is fairly strong evidence for a link to anxiety in the genetic basis for eating disorders. In other words, candidate systems that are known to play an important role in the development of anxiety also seem to be at play in eating disorders. They suggest a kind of diathesis-stress model in which a genetic predisposition may interact with life events and behaviors to influence the development of eating disorders. The authors argue that dieting alone could not be a strong cause of eating disorders because many women diet, but few develop the disorder. In conjunction with a genetic risk for eating pathology, however, dieting may provide the stress that would lead to the development of an eating disorder.

DISCUSSION IDEAS Evaluating common diets: Ask students to discuss the strengths and weaknesses of various popular diet strategies and programs (e.g., the Atkins diet, Weight Watchers). Are they healthy nutritional programs or "quick fixes" that lead to fast weight loss but almost certain relapse? Is dieting a viable option, given the percentage of people who regain the weight and the connection between dieting and eating disorders? What kinds of weight-loss programs, if any, would students recommend and why? Do they really work, or have we just "bought into" a myth that thin equals happiness, and will simply finding the right diet will to thinness?

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Role of food in a family: Discuss the role of food in students' families. Was food used as a reward? Were children "forced" or encouraged to finish everything on their plates? If the child refused to finish food or eat certain foods, was punishment utilized? What is the consequence of these various approaches to food that a family may adopt? Are any approaches influential in the development of eating disorders? This can be done either with the whole class or in small groups, with a return to the whole class for a discussion of group impressions.

Treatment of eating disorders: Why is bulimia so much more "treatable" than anorexia? Compare the course and outcome rates for each, and ask students to speculate on the reasons for the discrepancies. Is bulimia a "less serious" disorder? Should bulimia be conceptualized as more of a "passing phase" in adolescent women's lives and less as a mental health disorder?

Stress the fact that there is a great range in severity of bulimic symptoms, and the possible course and outcome of the disorder varies greatly among patients.

Bulimia nervosa: A culture-bound syndrome: Why is bulimia considered more of a culture-bound syndrome than anorexia? Bulimia is thought of as the ‘invisible’ eating disorder because someone with the disorder could be normal weight or overweight. How does society promote the development of eating disorders, specifically bulimia? Are there things that society could put into place to decrease the prevalence of bulimia? If so, would it differentiate between whether you lived in a rural or urban area or if you were a college woman?

Fashion industry: A cause or validation of eating disorders?

We are bombarded by different forms of media expressing the importance to be thin to be considered attractive. If we look at Marilyn Monroe, who was a fashion icon, today’s standards of beauty may represent her as being overweight and not making the cut for a high-fashion model. How influential do you think the fashion industry may be in the onset of eating disorders? Do you think eating disorders are common and accepted in this industry; why or why not? Ana Carolina Reston died in 2006 as a result of anorexia nervosa, and we have been able to witness many other celebrities come forward with eating disorders to share their own struggles. Is there something that the fashion industry could have done to prevent the death of Ana? What could be done to prevent the development of eating disorders and educate current models of the signs and risks to be aware of as it relates to eating disorders? Crystal Renn is an example of a plus-sized model. How will her role impact women and their perceived body image or the development of eating disorders?

CLASSROOM ACTIVITIES Etiology debate: Ask groups of students to develop arguments regarding the etiology of eating disorders. The following statement can serve as the focal point of a debate: Men are responsible for the prevalence of eating disorders among women in this culture. Men demand thinness and reject women who have anything but the perfect figure. Men control rewards in this country, and men reward women for thinness. This leads to self-esteem being tied to thinness, and hence, an obsession with weight.

This, in turn, is bound to lead to a high prevalence of eating disorders. We should concentrate our efforts on changing men's attitudes, not on simply treating the women who suffer from eating disorders.

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Body image: Most surveys find that a great majority of people, especially women, are unhappy with their bodies. Ask the students to fill out a quick anonymous survey asking them about their body image. Then discuss the results. You may wish to use the following items: Generally, I am happy with my body.

1 2 strongly disagree

3

4

5 strongly agree

I wish my body were _____________. (circle one) 1 much thinner

2 3 somewhat the same thinner as it is

4 5 somewhat much heavier heavier

The part of my body I'm least happy with is my ____________.

The part of my body I'm most happy with is my ____________.

Ask the students to indicate their gender on the survey; most studies find that women are much less content with their bodies than are men; see if this holds true in your class.

Promia versus proana websites: Ask the students to research the different websites attributed to “promia,” sites for the development of bulimia nervosa, and “proana,” sites for the development and acceptance of anorexia nervosa. After the students have been able to locate a website on the Internet for each, ask the students to write a short description of the information offered on the sites, the pictures or images provided, opinions by participants on the sites, and the overall perception of the sites. Then ask the students to share their findings with the class.

Food and exercise journal: Provide the students with a copy of a food diary or ask them to just record, for a week, everything they eat for each meal and if they were able to exercise. Then ask the students to share their findings of what types of food the students are eating, what times they eat, and whether or not they engage in exercise. This can provide insight into proper nutrition, diet, and the importance of exercise.

Guess the secret ingredient: Black bean brownies: As the professor, you can discuss how you can make changes to your diet and substitute some ingredients for healthier versions. Before class, purchase a box of brownie mix, and instead of adding the oil and eggs, substitute a can of black beans that are pureed. Then follow the normal baking instructions listed on the box. Have some portions of the baked brownies in small cups to be handed out to the students to taste. Then divide the students into smaller groups to work as teams to brainstorm what the secret ingredient is in the brownies. Tell the students that two ingredients were removed and one was added as a healthier alternative. You may decide to offer extra credit if a team guesses correctly.

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Design a treatment center: This activity can be done individually or in a small group setting. Tell the students that they have just been awarded a grant to design a treatment facility for eating disorders. Let them know that there is an abundance of monetary funds, and they can design their facility however they would like. Ask the students to answer the following questions: (a) Where would the treatment facility be located? (b) How would the treatment facility be designed? (c) What treatment options will be provided? (d) What types of professionals will be employed at the agency? (e) What are the fees, or do you accept insurance? (f) What is the name and website of the agency? Add anything else that may be relevant. After the students have had ample time to create a full description of the facility, ask them to either share in a small group format or with the class.

VIDEO CASES IN ABNORMAL PSYCHOLOGY: Natasha—Anorexia Nervosa Natasha is a young woman who is very concerned with social comparison. She says that she always compared herself with the skinniest people and worried that she did not measure up to the highest standards. If she discovered any signs of ‘excess’, she would punish herself by not eating for a period of time. Through this fasting, she gained a sense of control and power. She also felt power as she exercised—and did so to excess. When she recognized that she had some of the tell-tale signs of anorexia, she relished this and celebrated her status as anorexic. Over time, however, Natasha realized that the illness was destroying her; she states, “Anorexia took everything away from my life.” She lost all of her friends, with the exception of her boyfriend. She has, since, began her recovery and, despite some relapses and slips, is doing fairly well today. She has developed a more positive attitude towards food and is allowing her body to develop in a more natural way.

Discussion questions: 1.

Natasha describes using laxatives and exercising to excess. These are classic symptoms of bulimia. Why is she not considered a bulimic?

2.

A strong interest in control and feelings of power in exercising control are common symptoms of anorexia.

How do they serve to reinforce the person’s unhealthy behaviors?

3.

Natasha has not been recovered or ‘well’ for very long. What are her chances of relapsing? What are some hopeful signs that would lead to an optimistic prognosis for her?

Jessica—Anorexia Nervosa: Binge-Eating/Purging Type, Part I (13:55) and Part II (15:32) Jessica discusses her experience with anorexia in a very open and frank manner throughout this interview.

She focuses on her body image, weight loss, and perfectionistic tendencies in Part 1, and on the purging behaviors (vomiting, excessive exercise, diet pills, and use of laxatives) in Part 2, but the two sections are really just parts of one complete interview.

In Part 1, Jessica describes the beginnings of her anorexic symptoms. When she was 19, and six months into her freshman year, she started dieting as a means of losing weight and gaining control of some aspect of her life—her eating. She admits to being hypercritical of her body and having a distorted perspective: “No matter how thin I was, it wasn’t thin enough.” She is both a perfectionist and a people pleaser, and, in order to compete in Theatre School in NYC, she felt she had to be thinner. She also received mostly positive feedback from teachers in 181 C.

the school regarding her weight loss. Her restricting behavior, though, became extreme; she describes going through phases where all she’d eat was sugar-free Jello for breakfast, lunch, and dinner. She began this period at about 130–140 pounds and reached a low weight of around 100. A key factor is her hypercritical attitude towards her body and the statement, “I felt that I didn’t deserve to eat.”

Discussion questions: 1.

What role did Jessica’s perfectionism play in the development of her eating disorder?

2.

Is Jessica’s focus on “one food” (e.g. sugar-free Jello) typical of an anorexic’s diet? What about her distinction between ‘safe” and “unsafe” foods?

3.

Do you think Jessica would have had eating disorder problems if she had not been involved in a theatre program? How does a program in which thinness is stressed affect the development of eating disorders?

In Part 2, Jessica describes her purging behaviors. She says, “When I ate normally, I’d get really panicky,” and this led to her vomiting. At first, the purging provided relief of tension but, later, she describes the shame and disgust she felt in relation to her vomiting. She would also go to the gym "no matter what, and referred to it as "punishing exercise." She says she never enjoyed the exercise, and it was only to negate calories. Jessica also abused diet pills and laxatives, often taking more than the prescribed or suggested amounts. At times, she suffered from depression; she describes feeling that she never lived up to her own and others’ expectations and feeling unable to deal with her own emotions. Therapy, for her, allowed her to express herself and accept herself.

Discussion questions: 1.

What suggestions would you make to help a person avoid purging when, after eating a normal or large meal, that person begins to “feel panicky” about the calories just ingested?

2.

One symptom that Jessica did not describe is binging. If she does not binge at all, would she still be diagnosed with “anorexia, the binge/purging type” or would she be correctly diagnosed with “anorexia, the restricting type”?

(The answer is, of course, the former; you do not have to binge in order to be classified within the binge/purging type). Do you think Jessica does binge-eat at times?

3.

How did therapy help Jessica? Do you think inpatient therapy would be necessary or desirable in a case such as this?

Ann, Bulimia, age 46 (9:25) Ann is a 46-year-old pre-school teacher suffering from bulimia. She is showing many of the typical symptoms, such as being overly concerned with weight, body size, and eating. Rather than vomiting or using laxatives, however, she exercises excessively. She comments that will power and her ablity to regulate and suppress emotions, not diet, are the main issues in her eating disorder.

Discussion questions: 1.

During her interview, Ann compared her disorder to that of an alcoholic. In what ways are bulimics similar to alcoholics? How are they different?

2.

Ann appeared to be a "normal" woman during her interview; she did not look sick. Is this characteristic of eating disorders or, more specifically, of bulimia? What problems does this cause for diagnosis or assessment?

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VIDEO RESOURCES http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Eating_Disorders.html Eating Disorders (1:20) Watch this video as a pathologist expresses his concern for teens with eating disorders. http://visual.pearsoncmg.com/mypsychlababnormalDSM5/episode8/web_index.html?clip=1&tab=tab0 Natasha: Anorexia (1:15) Watch Natasha discuss how looking at thin people affected her eating disorder.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MDL_CoeVideos/Body_ Image_and_Eating_Disorders.html Body Image and Eating Disorders (3:44) Watch this video discussion of body image and eating disorders.

http://visual.pearsoncmg.com/mypsychlababnormalDSM5/episode8/web_index.html?clip=4&tab=tab0 Stacy: Living with Binge Eating Disorder (7:01) Watch this video of Stacy, who has binge eating disorder.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/College_Students_and_ Eating_Disorders.html College Students and Eating Disorders (3:15) Watch this video interview with a nutritional therapist discussing eating disorders.

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Chapter 11 Substance Use Disorders Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: p. 285 Symptoms: p. 287

Lectures: Heroin deaths

The Concept of Substance Dependence Alcohol Tobacco Amphetamine and Cocaine Opiates Sedatives, Hypnotics, and Anxiolytics Cannabis Hallucinogens and Related Drugs

Video Case: Alcoholism, Chris

Diagnosis: p. 295

Lectures: Marital problems and alcohol abuse Brief History of Legal and Illegal Substances DSM-5 Course and Outcome Other Disorders Commonly Associated with Addictions Frequency: p. 298

Lectures: High-achieving drug addicts

Prevalence of Alcohol Use Disorder Prevalence of Drug and Nicotine DependenceDiscussion Ideas: Risk for Addiction Across the Life Span Gender differences Causes: p. 302

Lectures: Behavior genetics Alcohol and aggression

Social Factors Biological Factors Psychological Factors Integrated Systems

Discussion Ideas: Disease theory

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PROFESSOR NOTES

Treatment: p. 308

Classroom: Drug alternatives Detoxification How would you approach a friend Medications During Remission who you believe has an alcohol Self-Help Groups: Alcoholics Anonymous problem?

Cognitive Behavior Therapy Outcome Results and General Conclusions Gambling Disorder: p. 312 Symptoms Diagnosis Frequency

185 C.

CHAPTER OUTLINE I.

II.

Overview A.

Costs of substance abuse are enormous and include monetary (health-related costs) and emotional costs (individual and family); according to the World Health Organization, alcohol use was responsible for 5 percent of the total burden of disease and disability worldwide in 2004.

B.

Substance use disorder—the maladaptive pattern of behaviors that are related to the continued use of drugs despite the significant distress they cause

C.

Substance dependence—describes substance use disorders of at least moderate intensity

D.

Addiction—older term often used to describe problems such as alcoholism, now replaced by substance dependence; often used to describe alcoholism

E.

Drug of abuse—a chemical substance that alters mood, perception, and brain functioning, also called a psychoactive substance 1.

Central nervous system depressants—alcohol, hypnotics, sedatives

2.

Central nervous system stimulants—nicotine, caffeine, amphetamine, cocaine

3.

Opiates (narcotic analgesics)—decrease pain

4.

Cannabis (marijuana)—produces euphoria and an altered sense of time

5.

Hallucinogens—perceptual changes

6.

Polysubstance abuse—people with substance abuse disorders frequently abuse more than one drug

Symptoms A.

The concept of substance use disorders 1.

Two general areas of difference between those with disorder and those without: (1) patterns of pathological consumption and (2) consequences of prolonged patterns of abuse

2.

Craving and psychological dependence are two terms often used to describe dependence; people take the drug to control how they feel, to relieve negative mood states and/or to prepare for certain activities, e.g., public speaking. The amount of time spent planning to take the drug may be a good index of dependence.

3.

Diminished control is a way of describing the increasing dependence associated with abuse; when a person has less "freedom of choice" about using the drug

4. Tolerance and withdrawal a.

Considered to be evidence of physiological dependence 186 C.

b.

Tolerance—nervous system becomes less sensitive to the effects of alcohol or any other substance; increased quantities are necessary to achieve the same effect; metabolic tolerance occurs when the liver adjusts it production of enzymes in expectation of the drug 1.

Pharmacodynamic tolerance occurs when brain receptors adapt to the drug. a.

c.

B.

Down regulation—when the nueron reduces the number of receptors senestive to the substances in the drug

Withdrawal—symptoms experienced when a dependent person stops using a drug 1.

Alcohol withdrawal symptoms include hand tremors, sweating, nausea, anxiety, and insomnia—sometimes alcohol withdrawal delirium (commonly known as delirium tremens or DTs)

2.

Withdrawal symptoms are most severe for alcohol, opioids, and the class of sedatives/hypnotics.

3.

Refers to the symptoms experienced when a person stops using a drug

Alcohol 1.

Affects virtually every organ and system in the body

2.

Absorbed through stomach, small intestine, and colon; absorption rates affected by the concentration of alcohol in the beverage, volume and rate of consumption, and presence of food in the digestive system

3.

Average rate of metabolism is 1 oz. of 90 proof liquor or 12 oz. of beer per hour

4.

Short-term effects—rate of intoxication varies from person to person; slowed reaction time and interference with tasks including driving may occur at well below legal limits for driving a.

5.

Blood alcohol levels—the amount of alcohol per unit of blood 1.

Strong correlation between blood alcohol level and central nervous system effect

2.

Symptoms of alcohol intoxication: slurred speech, uncoordination, unsteady gait, nystagmus (involuntary eye movements), impaired attention and memory, stupor or coma

3.

A drink is considered to be 12 ounces of beer, 4 ounces of wine, or 1 ounce of 86-proof whiskey.

Long-term consequences a.

Interpersonal relationships with family and friends are disrupted; takes a toll on marriage

b.

Harm to fetus may occur if abuser is pregnant 187 C.

C.

D.

c.

Blackouts—abusers may continue to function without passing out, but be unable to remember their behavior

d.

Interference with job performance and financial difficulties

e.

Legal problems (DUI, domestic and child abuse, and other violence)

f.

Health problems 1.

Impairs functioning of liver, pancreas, gastrointestinal system, cardiovascular system, and endocrine system

2.

Increased risk of cirrhosis of the liver, heart problems, cancer, memory impairment

3.

Nutritional deficiencies

Tobacco 1.

Nicotine is the active ingredient in tobacco, which is its only natural source.

2.

Nicotine toxic in its pure form; unpleasant effects in high doses

3.

Short-term effects include increased heart rate and blood pressure—nicotine stimulates the release of norepinephrine, dopamine, and serotonin—possibly simulating the effects of antidepressant drugs; relaxation may be explained by the higher dosage level (which seems to relax, as compared with small doses, which seem to stimulate) or the reduction of withdrawal symptoms

4.

Long-term consequences—extremely harmful and addicting a.

Tolerance and withdrawal symptoms (drowsiness, lightheadedness, headaches, muscle tremors, and nausea)

b.

Psychologically, it is as difficult to withdraw from nicotine as it is to withdraw from heroin.

c.

Increases the likelihood of developing heart disease, lung disease, and cancer

d.

Women who smoke have increased risk of fertility problems; if pregnant, increased risk of low birth weight and birth defects

e.

More than 3.5 million people in the world die prematurely each year as a result of tobacco. 80 percent of all deaths caused by lung cancer can be attributed to smoking tobacco.

Amphetamines and cocaine 1.

Psychomotor stimulants simulate the actions of epinephrine, norepinephrine, dopamine, and serotonin.

2.

Cocaine is a naturally occurring stimulant drug that is extracted from the leaf of a small tree that grows at high elevations, as in the Andes mountains; amphetamines are synthetically produced; both can be taken orally, inhaled, or injected.

188 C.

E.

3.

Short-term effects include an increase in heart rate and blood pressure, suppression of appetite and decrease in need for sleep. It can also lead to dizziness, confusion, panic states; generally induces a positive mood state in which people feel more confident, friendly, and energetic, followed (several hours later) by a mildly depressed or irritable mood; overdoses can result in irregular heartbeat, convulsions, coma, and even death.

4.

Long-term consequences a.

Can lead to the onset of psychosis (with high doses and repeated exposure; usually disappears a few days after the drug has been cleared) and the possibility of increasing the severity of symptoms among people who have already developed a psychotic condition

b.

Disrupted relationships, impairment in occupational functioning, and financial ruin

c.

Prolonged use is linked to an increase in criminal and violent behavior, but it is not clear whether this phenomenon is due to the drug itself or due to the lifestyles with which it is frequently associated.

d.

Withdrawal consists mainly of a depressed state, sometimes even clinical depression.

Opiates 1.

Include opium (a poppy with a white flower), morphine, codeine, and heroin; can be taken orally, injected, or inhaled; opiods are a synthetic version of opium and are often used to reduce pain

2.

Heroin is a synthetic opiate made by modifying the morphine molecule.

3.

Short-term effects include a sense of dreamlike euphoria, sometimes accompanied by increased sensitivity in hearing and vision, a "rush" (brief, intense feeling of pleasure). After continued use, negative changes in mood and emotion occur, relieved only by the intake of the drug; high doses can lead to a comatose state, severely depressed breathing, and convulsions; these unpleasant symptoms are relieved for 30-60 minutes after each new injection a.

4.

F.

Some people mix together cocaine and opiates; this is called a speedball.

Long-term consequences include chronic lethargy, preoccupation with finding or using the drug, rapid tolerance; many of the difficulties are associated with the opiate user's lifestyle: needing to constantly obtain large amounts of an expensive, illegal substance, increased likelihood of AIDS, violence, and suicide

Sedatives, hypnotics, and anxiolytics 1.

Tranquilizers—used to decrease anxiety or agitation

2.

Hypnotics—help people sleep

3.

Sedatives—general term for drugs that calm people or reduce excitement

4.

Barbiturates—wide variety of uses, including the treatment of chronic anxiety 189 C.

G.

5.

Benzodiazepines—synthetic drugs that have replaced barbiturates; used in the treatment of anxiety disorders

6.

Short-term effects include a state of intoxication similar to that associated with alcohol: impaired judgment, slowness of speech, lack of coordination, a narrowed range of attention, a disinhibition of sexual and aggressive impulses, and sometimes, increased hostile behavior (referred to as a “rage reaction”)

7.

Long-term consequences—when discontinued, worsening of original anxiety symptoms, irritability, paranoia, sleep disturbance, agitation, muscle tension, restlessness, and perceptual disturbances; discontinuance syndrome is when people abruptly stop taking high doses of benzodiazepines

Cannabis 1.

The active ingredient in marijuana is THC; hashish refers to the dried resin from the top of the female cannabis plant. a.

H.

Marijuana—the dried leaves and flowers of cannabis that can be smoked as a cigarette or in a pipe; can also be ingested orally

2.

Short-term effects include a sense of well-being and happiness, although some people become anxious and paranoid; temporal disintegration, or difficulty retaining and organizing information, lapses in attention and concentration

3.

Long-term effects do not appear to include tolerance or withdrawal except when high doses of THC have been taken for long periods. Heavy, continuous use may lead to certain types of deficits on neuropsychological tests involving sustained attention, learning, and decision making (these deficits may reflect residual drug effects, cognitive withdrawal symptoms, or toxic brain effects); tolerance effects in humans remain ambiguous

4.

Some people actually report that they become more sensitive to the effects of marijuana after repeated use; this increased sensitivity is called reverse tolerance.

Hallucinogens and related drugs 1.

Molecular structure resembles that of neurotransmitters, such as serotonin and norepinephrine

2.

LSD acts by blocking serotonin receptors in the brain.

3.

Psilocybin is found in some mushrooms, and mescaline is found in peyote. Known as angel dust, phencyclidine (PCP) is a synthetic drug that has different properties from the other hallucinogens; at lower doses, it leads to relaxation, warmth, and numbness, whereas at higher doses it can induce psychotic behavior, delusional thinking, and sudden mood changes.

4.

MDMA (Ecstasy) has characteristics of hallucinogens and stimulants; use leads to changes in sensory experiences and mood state, known as the club drug

5.

PCP was originally developed as a painkiller.

6.

Short-term effects include vivid, powerful visual images which may change rapidly; these 190 C.

experiences are usually pleasant but can be frightening ("bad trips"); most haluccinogens are not toxic. However, some, such as PCP and MDMA, are very toxic.

7.

8.

Long-term consequences a.

LSD, psilocybin, and mescaline: tolerance develops quickly; withdrawal symptoms do not typically occur

b.

Flashbacks—brief visual aftereffects that occur at unpredictable intervals

Small doses lead to relaxation, warmth, and numbness, and higher doses induce psychotic behavior, including delusional thinking, catatonic motor behavior, manic excitement, and sudden mood changes.

III. Diagnosis A.

Public attitudes regarding alcohol consumption have changed dramatically during the course of U.S. history.

B.

DSM-5 classifications are divided into two main categories: substance use and substance-induced disorders.

1.

Substance use disorders: refer to the kinds of problems that come to mind when most of us think about someone being addicted to a drug

2.

Substance-induced disorders: include primarily the immediate impact of taking a drug

3.

Alcohol use disorder: substance abuse related to alcohol that includes the following:

4.

C.

a.

A problematic pattern of alcohol use leading to clinically significant distress or impairment

b.

Tolerance

c.

Withdrawal

DSM-5 emphasizes the terms recurrent and maladaptive pattern for this purpose.

Course and outcome 1.

Course, age of onset, and time progression vary widely.

2.

However, periods of heavy use tend to alternate with periods of relative abstinence.

3.

Vaillant's study of 456 inner-city adolescents from Boston and 268 undergraduates from Harvard a.

21 percent of the college group and 35 percent of the city group met diagnostic criteria for alcohol abuse at some point.

b.

Mortality rate is higher among abusers; heart disease and cancer are twice as common (perhaps related to higher smoking rates among abusers) 191 C.

D.

c.

Members of the city group began using alcohol earlier, but they were more likely to achieve stable abstinence.

d.

Proportion of men who continued to abuse alcohol went down after the age of 40; the longer a man remained abstinent, the greater the probability that he would continue to be abstinent

Other disorders commonly associated with addictions: antisocial personality disorder, mood disorders, anxiety disorders, and conduct disorder (in adolescence)

IV. Frequency A.

Drug-use related problems are found in most countries; opium is used most heavily in Southeast Asia and some Middle Eastern countries; cocaine is used in South America, and imported into North America; cannabis is widespread around the world; and in Japan, amphetamines are heavily used.

B.

Most people who use alcohol or drugs do not become dependent.

C.

The age of initial use is a risk factor; the incidence of alcoholism for males who began drinking at age 14 is double that of those who began at age 18; the same pattern is true for females.

D.

Prevalence studies of alcohol use, abuse, and dependence show that two-thirds of Western males drink regularly; less than 25 percent abstain.

E.

F.

1.

Among all men and women who will ever use alcohol, roughly 20 percent will develop serious alcohol-related problems at some point during their lives.

2.

National Epidemiology Survey on Alcohol and Related Conditions (NESARC) study found a lifetime prevalence rate of 30 percent for alcohol use disorder, 18 percent for abuse, and 20 percent for dependence.

3.

Most alcohol use disorders are untreated; in the NESARC study of 43,000 adults, only 24 percent of those deemed alcohol-dependent had ever received treatment.

Gender differences 1.

Approximately 60 percent of women in the U.S. drink alcohol occasionally.

2.

NESARC reported the lifetime prevalence for abuse of or dependence on any type of controlled substance was 10.3 percent; this is approximately one-third the rate for alcohol abuse.

3.

Social disapproval probably explains why women are more likely than men to drink in the privacy of their own homes, either alone or with another person; a single standard dose of alcohol will produce a higher peak blood alcohol level in women than it will in men.

Prevalence of drug and nicotine use disorders 1.

The lifetime prevalence for abuse of or dependence on any kind of controlled substance is 10.3 percent.

192 C.

G.

V.

2.

Lifetime rate for nicotine dependence is 24 percent

3.

The percentage of U.S. adults who smoke has decreased since 1964; however, rates increased during the 1990s for people between the ages of 18 and 25.

Risk for addiction across the life span 1.

Older people drink less than younger people drink; both problem and non-problem rates are lower

2.

The elderly use fewer illegal drugs but more prescription and over-the-counter medications than do younger people; their use of multiple drugs increases their risk for dependence.

3.

The proportion of people who abstain from drinking alcohol is only 22 percent for people in their 30s; increases to 47 percent for people in their 60s, and is approximately 80 percent for people over 80 years of age

4.

One estimate suggested is that 25 percent of people over the age of 55 use psychoactive drugs.

Causes A.

Etiology of alcoholism best viewed within a developmental framework that views the problem in terms of various stages: initiation and continuation, escalation and transition to abuse, and development of tolerance and withdrawal

B.

Social factors 1.

Cultural or religious customs and attitudes influence patterns of alcohol and substance use.

2.

Initial experimentation with drugs is most likely to occur among those who are rebellious, extroverted, and whose parents and peers model or encourage use. a.

Parents appear to have greater influence over their children’s alcohol use, whereas peers more strongly influence drug use.

1.

C.

The circumstances in which an adolescent is first introduced to alcohol can influence a person’s later drinking behavior. For example, drinking small amounts with meals or during religious ceremonies may be less likely to lead to alcohol dependence.

b.

An unpleasant emotional climate and reduced parental monitoring increases the probability that an adolescent will affiliate with peers who use drugs.

c.

Levels of negative affect tend to be high in families of alcoholic parents.

Biological factors 1.

Millions of people are unable to tolerate even small amounts of alcohol; this response is particularly common in those of Asian ancestry.

2.

Genetics of alcoholism 193 C.

3.

a.

Patterns of alcohol consumption, social, and psychological problems related to alcohol often run in families.

b.

Twin studies show both genetic and environmental factors influence the quantity and frequency of drinking.

c.

Adoption studies support both genetic and environmental influences for both females and males, and they support a relationship between alcohol abuse and antisocial personality traits.

d.

Genes that influence the development of alcohol dependence are involved in the metabolism of alcohol (ADH and ALDH) and are involved in personality traits that relate with alcohol use (e.g., sensation seeking).

Neuroanatomy and neurochemistry a.

Reward pathways in the brain appear to be stimulated by many drugs of abuse, though less clearly by alcohol use; dopamine may play an important role in these pathways.

b. Endorphins – the endogenous opioid system may be more highly activated in some people in response to alcohol 4.

5.

D.

Dopamine and reward pathways a.

The medial forebrain bundle seems to be related to brain reward mechanisms.

b.

Natural rewards such as food or sex increase dopamine levels in certain sections of the reward pathways. This is known as the mesolimbic dopamine pathway.

c.

Substances can abuse these pathways to create addiction.

Endogenous opioid peptides, or endorphins, represent an exciting area of research. Some theorists associate alcoholism with an exaggerated activation of the endogenous opioid system.

Psychological factors 1.

Expectations greatly influence alcohol (and other drug) use (Nicolai et al., 2010). a.

People believe that alcohol can enhance pleasurable experiences and improve their moods, increase their assertiveness, and decrease their tension.

b.

Adolescents just beginning to experiment with alcohol and who initially have the most positive expectations about the effects of alcohol go on to consume greater amounts of alcoholic beverages.

c.

Parental/peer attitudes/portrayal of alcohol in the media may influence these expectations.

d.

Positive expectancies about alcohol are likely to encourage people to drink; negative expectancies diminish use but are not as powerful.

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2.

E.

VI.

Alcohol transforms experiences in a positive way, enhances social and physical pleasure, enhances sexual performance and experience, increases power and aggression, increases social assertiveness, and reduces tension.

Integrated systems approach 1.

Social, psychological, and biological factors all influence the person's behavior at each stage in the cycle from initial use of the drug through the onset of tolerance, withdrawal, or other symptoms of dependence.

2.

Initial experimentation is influenced by the person's family and peers, and by expectations about drug effects.

3.

Short-term positive effects reinforce continued consumption.

4.

Genetic factors influence the development of alcoholism in interaction with environmental factors.

5.

Serotonin deficiencies and insensitivities to the adverse effects of alcohol may influence the development of more serious abuse and dependence.

6.

Physiological responses (e.g., tolerance and withdrawal) then play a role in continued and more serious abuse.

Treatment A.

Treatment is complicated by the lack of acknowledgement of problems on the part of many substance abusers and, generally, high levels of treatment noncompliance.

B.

Some clinicians argue that abstinence is the only reasonable treatment goal, while others suggest that moderate use (of legal drugs) is acceptable.

C.

Treatment approaches 1.

Detoxification a.

Removal of the drug on which a person is dependent often involves withdrawal symptoms and may last 3–6 weeks.

b.

Medication is sometimes given to minimize withdrawal symptoms.

c.

Disulfiram (Antabuse)—blocks the breakdown of alcohol; a person on antabuse will become extremely sick after drinking alcohol; research is inconsistent regarding disulfiram’s effectiveness

d.

Naltrexone (Revia) is used to decrease the endogenous opioid system’s response to alcohol; research has indicated that it is an effective treatment, particularly when combined with psychotherapy.

e.

Acamprosate (Campral) has been used in Europe and appears to facilitate both decreased alcohol intake and abstinence; appears to reduce symptoms of withdrawal 195 C.

f.

D.

E.

F.

SSRIs, such as fluoxetine, can also be helpful when people have dual diagnoses of alcoholism and depression.

Self-help groups: Alcoholics Anonymous 1.

Recoverers follow a 12-step spiritually-focused program and attend regular meetings.

2.

Dropout rates are high, as are sobriety rates for those who remain in AA

3.

Social factors may be most important in explaining positive outcomes.

4.

Available in virtually all communities in the United States and Europe; seen as the first line of attack against alcohol abuse

Cognitive-behavior therapy (CBT) 1.

Coping-skills training focuses on the identification of situations that lead to drinking and on finding healthier alternatives.

2.

Relapse prevention focuses on self-efficacy, adaptive coping responses, and teaches interpreting lapses as temporary rather than permanent, diminishing self-blame and guilt. The guilt and perceived loss of control that the person feels whenever the person finds himself using the subtance he is trying to avoid is called the abstinence violation effect.

3.

Short-term motivational therapy is designed to increase individuals’ awareness of substance-abuse problems by gently helping them recognize inconsistencies between their behavior and goals; useful for people who are in beginning stages of abuse

4.

CBT teaches people to identify and respond more appropriately to circumstances that regularly precipitate drug abuse (Finney & Moos, 2002).

Outcome results and general conclusions 1.

People who enter treatment tend to show improvement for several months, but relapse is also common.

2.

No other form of treatment (individual, outpatient or inpatient) has been proven superior.

3.

There is no consistent evidence that specific treatment approaches are best suited to specific types of people.

4.

More treatment and greater treatment compliance are associated with more positive outcomes.

5.

Those who are successful in treatment find improvements in their overall health, and in their social and occupational functioning.

6.

Long-term outcome for the treatment of alcoholism is best predicted by the person’s coping resources (e.g., social skills and problem solving abilities).

196 C.

VII. Gambling disorder A.

The history of treating gambling as a disorder is confusing and complex.

B.

Symptoms

C.

D.

1.

Central features involve impaired control, social impairment, and continuation despite harmful consequences.

2.

Often involves chasing losses, which refers to trying desperately to win back what has been lost by gambling

3.

Experiences of tolerance and withdrawal are similar to other forms of dependence.

Diagnosis 1.

Diagnosis is based on nine categories of symptoms, many of which are similar to substance use disorders.

2.

Individuals increase their gambling to experience the same level of stimulation.

3.

Agitated or emotional distress when they try to stop

4.

Chasing losses—gambling more to recover gambling losses

5.

Illegal activity not required (different from earlier editions of DSM)

Frequency—data regarding frequency has become increasingly available in recent years; lifetime prevalence is about 2 percent

197 C.

LEARNING OBJECTIVES LO 11.1: What evidence is needed to show that a drug is addictive?

LO 11.2: What are the long-term consequences of abusing psychomotor stimulants?

LO 11.3: Where is the boundary between substance use disorders and recreational drug use?

LO 11.4: In what ways are drug problems different among the elderly?

LO 11.5: What are the most important risk factors for alcoholism?

LO 11.6: How does AA differ from other approaches to treating alcoholism?

LO 11.7: What factors predict better long-term outcome for treatment of alcoholism?

LECTURE SUGGESTIONS Heroin deaths: Why is it that so many people die of unintentional heroin overdoses? Often, the specific cause of death in a heroin-related death is something of a mystery (Brecher, 1972). Medical examinations sometimes indicate that the level of heroin in the victim's body would not have been sufficient to cause the person to die. If the heroin itself did not kill the person, why did he or she die? Several alternative explanations have been suggested. One possibility is that the person used heroin in combination with another drug, like alcohol, which could boost the effects of an ordinary dose of heroin to lethal proportions. Another involves the fact that heroin is sometimes mixed (or diluted) with quinine before being sold on the street. Quinine can be lethal if it is injected.

Marital problems and alcohol abuse: A recent article examined the long-term effects of alcohol use on marital disputes and marital aggression.

They found that the two factors interacted in that alcohol use predicted more marital disputes (at a later time point) and that marital problems also tended to lead to more use of alcohol in an effort to cope with the marital problems.

Substance abuse in husbands was particularly injurious to marriages, leading to more aggression on the part of the wives. This is an important study in that it was able to demonstrate that even if substance abuse is not currently impacting upon a couple’s marital happiness, it is likely to have a long-term effect down the road.

Instructors can ask students whether they would consider dating or marrying a partner who has a substance dependence disorder. Nearly all will say that they would never choose such a partner. You can, then, ask why so many people, in fact, do marry people who have such problems! One answer is that the partner with the problem may conceal the extent of his problem. Also, the partner who marries the alcoholic may, herself, be in denial about the severity of the partner’s pattern of use.

Keller, P., El-Sheikh, M., Keiley, M., & Liao, Pei-Ju (2009). Longitudinal relations between marital aggression and alcohol problems, Psychology of Addictive Behaviors, 23, 2–13.

198 C.

High-achieving drug addicts: The remarkable career of William Steward Halstead, one of the physicians who founded Johns Hopkins Medical School, provides a fascinating example of a person who was able to make enormous contributions to society in spite of reportedly being secretly addicted to morphine throughout most of his brilliant career (Brecher, 1972). Halstead is known as the "father of modern surgery." He was, of course, personally troubled by his addiction.

He tried valiantly and quite unsuccessfully to stop using morphine on several occasions. Nevertheless, his addiction only interfered with his ability to work when he tried to quit and began to experience symptoms of withdrawal.

Jerry Garcia, the deceased lead guitarist of the Grateful Dead, is known to have been a heroin addict for much of his adult life, using a form of heroin that is smoked. His addiction, however, did not prevent him from becoming one of the most accomplished rock musicians of all time. He performed over 500 different songs, wrote more than 80 songs, and played thousands of concerts over a 30-year career with the Dead, but was apparently not able to control his addiction to heroin. Garcia died in 1995 of a heart attack while in a treatment facility for his addiction.

Behavior genetics: Current directions APS reader (1E, p. 102) Danielle Dick and Richard Rose provide a review of some of the current findings and "hot issues" in the field of behavior genetics. This article is quite challenging, and instructors should not expect students to be able to understand all of the material covered here. There are a couple of findings and some underlying issues, however, that are quite relevant, especially in the domain of substance abuse, and that are worth considering. For example, in the study of Finnish twins from which the authors draw most, they report that, “The genetic contributions to individual differences in drinking frequency increased over time, accounting for only a third of the variation at age 16, but half of it just 30 months later” (Rose, Dick, Viken, & Kaprio, 2001). This finding challenges a common assumption that the importance of genes always is greatest at birth and diminishes over time. Genetic factors, in fact, continue to play a vital role in behavior throughout the life cycle, and sometimes play a larger role during certain "critical periods," like adolescence, for substance use or abuse.

Another interesting point emerged from the discussion of the interaction between genetics and the environment. Some environments allow for a greater genetic contribution to behavior. For example, in terms of alcohol use, genetic effects explained a great deal of the variance in drinking among twins reared in nonreligious households as compared to those reared in religious households. Genetics also played a large role in urban drinking but played a smaller role in alcohol use in rural environments. Dick and Rose state that, “The influence of genetic dispositions can be altered dramatically by environmental variation across communities.” This type of interaction between the genetic and environmental factors is very important for students and researchers to understand because it tells us that, once again, our behavior is not a function of nature or nurture but that both are inexorably interwoven.

Alcohol and aggression: What is the connection between alcohol and aggression? Does alcohol affect aggressive behavior? Lau, Pihl, and Peterson (1995) investigated the effects of provocation, alcohol intoxication, and frontal lobe dysfunction on aggression. In this study, aggression was measured by the shock intensity delivered to a sham opponent. Half of the all-male subjects completed the study while intoxicated; the other half while sober.

All three of the independent variables influenced shock intensity; in other words, provocation, intoxication, and lower cognitive functioning all led to more aggression. Additionally, a cognitive functioning by provocation interaction emerged; individuals in the lower cognitive performance quartile responded to increased provocation with heightened aggression. The study provides a good model from which to understand the effect of alcohol use on aggression.

199 C.

Lau, M.A., Pihl, R.O., & Peterson, J.B. (1995). Provocation, acute alcohol intoxication, cognitive performance, and aggression. Journal of Abnormal Psychology, 104, 150–155.

DISCUSSION IDEAS Gender differences: Why are there such strong gender differences in alcohol use/abuse? Research suggests that women who are better educated and earn a higher income are more likely to drink; this would suggest that gender differences in alcohol consumption may begin to fade. If we become more tolerant of women drinking, moreover, more women may be willing to drink and, thus, the alcohol problem will become even more substantial. Is there any reason to doubt these trends? Will there always be a gender difference in alcohol use?

Disease theory: Is alcoholism a disease? This is a highly controversial topic; those who believe that alcohol is more of a biological problem (strongly genetic and basically a medical problem) argue that alcoholism is a disease. Many psychologists do not regard alcoholism as a disease, but rather a set of problematic and injurious behaviors.

Students who have some familiarity with AA may tend to favor the disease model, but this position can be challenged by arguing these two points: 1) it is certainly an unusual disease, if it is one, since it is behavior-dependent, and 2) willpower alone has been known to have "cured" many sufferers from this "disease.” It may also be helpful to ask students to define “disease.” Another interesting question is why are many people so strongly motivated to view alcoholism as a disease. This topic can lead to a discussion of personal responsibility and volitional activity in relation to mental illness.

What if caffeine became illegal?

Caffeine is one of the most accepted and widely used drugs in the world. It may also be helpful to ask students to come up with a list of their favorite caffeinated drinks, hot or cold. Then follow with the rest of the discussion points. Often people tend to forget that caffeine is indeed a drug that you can become dependent on and from which you can experience withdrawals. What would happen if caffeine became an illicit drug (i.e., illegal)? What would happen, and how would our society function? If caffeine was illegal, do you think people would increasingly start using another stimulant drug, and if so, which one? What would happen to giants like Starbucks and other coffee companies? Also, we cannot forget sodas such as Coke and Pepsi or energy drinks such as Red Bull or Rockstar.

Considering that we also have one of the highest percentages of obesity in both children and adults, would making all forms of caffeine illegal have a positive outcome on the health of children and adults here in the U.S.?

Valium: Mother’s little helper: In 1966, The Rolling Stones released a song called, “Mother’s Little Helper.” The song was about a suburban housewife who abuses drugs to “get her through the day.” This image is quite different than the stay-at-home mother image we see that is responsible for homemaking duties, such as cleaning, cooking, and caring for the family. A study by Bardhi, Sifaneck, Johnson, and Dunlap (2005) found that patterns of pill use and misuse were most often found in college-educated, upper-middle to upper-socioeconomic class women from White and Asian backgrounds. Why do you think it is mostly this population who is most likely to use, abuse, and potentially become dependent on prescription pills?

College students and binge drinking: The risks and dangers The website collegedrinkingprevention.gov (2011) listed an assortment of risks and dangers to which binge 200 C.

drinking contributes, such as death, injury, assault, sexual abuse, unsafe sex, academic problems, suicide attempts, health problems, drunk driving, vandalism, property damage, police involvement, and alcohol abuse and dependence. What can be done to prevent these different risks from occurring, both before a student enters college, at the university level, and then beyond? Are there certain extracurricular activities, organizations, athletics, or clubs that may put a student at an increased risk for binge drinking?

Why? What about spring break? Are there even more risks associated with this week of partying? What are some good tips and precautions to ensure your friends are safe when they go out?

CLASSROOM ACTIVITIES Drug alternatives: Break the class up into small groups and ask the groups to attempt to develop the longest possible list of enjoyable alternatives to drugs. They will undoubtedly list things that fall into the category of "relaxation experiences" (e.g., meditation, massage, music) or "sensation magnifying experiences" (e.g., canoeing, skydiving).

The subsequent discussion can then be oriented around (1) which activities would be good alternatives for which drugs, and (2) why people tend to prefer drug-taking over many of these activities. One explanation is that these activities require at least initial effort, some learning, and often some degree of concentration—all of which we tend to avoid when dealing with leisure activity. (Think of the number one leisure activity—TV!) How would you approach a friend who you believe has an alcohol problem?

Given the information presented in this chapter and the multiple factors contributing to substance abuse, ask students to describe an approach they might choose if they were trying to change a friend’s maladaptive alcohol use.

Would they address the problem directly? Which treatment approaches, if any, would they recommend? How responsible would they feel to try to help the friend, and to what extent does their view of alcoholism affect their approach? Broadening the discussion, to what extent do they feel society should intervene to “help” people with alcoholism by encouraging or enforcing treatment? How do they balance individual rights and society’s responsibility to protect its members, and do they see this in a different light than the treatment of serious mental health disorders?

The big 3: Most widely used drugs by college students: Ask students to write down anonymously the top three drugs (e.g., illicit or licit) that they believe college students most frequently use. Then ask for a couple of student volunteers to tally up the results and write the top three drugs most commonly used by college students on the board. This activity can foster a discussion as to why college students use drugs, and a discussion of the risks, the different categories of drug use, or the different types of drugs.

Debate: Should marijuana be legalized?

Debates are always an interesting way to increase participation and an outlet for students to share their thoughts and opinions. Randomly divide the class in half and then assign one half of the class a side of the argument as to whether or not marijuana should be legalized. Act as the mediator between the two sides to make sure each has an equal opportunity to share their side of the argument. Encourage the students to also use information in their textbook, the Internet, etc.

Create a risk assessment for college students: Divide the students into small groups and ask each group to create a risk assessment for drug abuse or 201 C.

dependence. You can modify this activity by giving each group of students a different drug category. The risk assessment could be something used by Resident Advisors (RAs), the campus health center, the campus counseling center, etc. After the students have had about ten minutes to complete the assessment tool, ask for the groups to share their ideas with the class.

Create a skit or infomercial on the negative effects of drugs: Ways of preventing drug use and intervention methods have usually been in trends from scare tactics to providing more education of the risks involved with drug and alcohol use. Ask the students to form small groups and either pass out specific categories of drugs to each small group or allow the small groups to select the drug they plan to work on. Ask the students to use their creativity to come up with a skit or an infomercial to act out the risks and negative effects of the drug or drugs they selected for this activity.

Design a tattoo to explain substance abuse versus substance dependence: This activity can be done at the beginning of class to get an idea of the students’ comprehension of the terms of substance abuse and substance dependence. Provide the students with sheets of paper and crayons, markers, or colored pencils. Then ask the students to create or design a tattoo that would reflect an accurate picture of the terms substance abuse and substance dependence. After the students have had ten minutes to create the tattoos, ask for volunteers to share their designs.

VIDEO CASE IN ABNORMAL PSYCHOLOGY: Chris—Alcoholism (15:32) Chris is a 27-year-old man who presents as a classic young alcoholic. His drinking started at age 12 and consisted of mostly beer drinking, but in strikingly large quantities (as much as 30 beers a day at its peak!). He explained that his drinking led to the use of other drugs, especially marijuana and cocaine. At one point, he was spending as much as $1000 a week on cocaine. He has now been sober for two years, after an eight-month stay in a residential facility. At one point, Chris mentions that he was a sexual abuse victim and that he is the product of a family for whom alcohol abuse is very prevalent.

As a consequence of his substance abuse, Chris experienced problems in college; he was “kicked out.” He also got into a lot of fights when intoxicated. His argument is that his drinking also led to infidelity, and therefore, to trouble in his marriage. Chris views his affair as a direct result of his “drinking and drugging.” He claims that he never let his drinking interfere with his work, however. He appears to have "bought into" the AA model and has been successful in abstinence, although he occasionally thinks about "having a beer."

Discussion questions: 1.

What role do you think genetics played in Chris’ alcoholism?

2.

To what extent do you believe Chris’ statement that “drinking caused me to do things that I wouldn’t normally do,” like having an affair?

3.

Compare Chris to a friend or acquaintance in college. Are similar people currently attending this school? Can we be certain that they do or do not have serious alcohol problems? How can we make proper assessments?

4.

Do you think that Chris will remain sober? What do you think would happen if he indulges his interest in "having a beer"?

202 C.

VIDEO RESOURCES http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Alcohol_Withdrawal. html Alcohol Withdrawal (1:44) Watch this video on the effects alcohol withdrawal has on the brain. http://media.pearsoncmg.com/ab/Virtual_Brain/vb/reward/ Visual Brain: Drug Addiction and Brain Reward Circuits Explore this virtual brain model examining how pleasure centers, brain reward circuits, and dopamine play a role in drug addiction. http://media.pearsoncmg.com/ab/ab_video_players_1/psych/audioPlayer.html?fileId=a01drugeffects_40 The Effects of Drugs and Alcohol (0:40) Listen to this overview of the synapse's role in processing drugs and alcohol. http://visual.pearsoncmg.com/mypsychlababnormalDSM5/episode10/web_index.html?clip=1&tab=tab0 Chris: Alcohol Use Disorder (1:38) Watch this video in which Chris talks about the difficulty of admitting he had a problem with drugs and alcohol.

Without admitting the problem exists, treatment cannot effectively begin. http://media.pearsoncmg.com/ab/ab_lefton_psychology_8/media/lbp8e_06212/lbp8e_06212.html Behavioral Effects Associated with Various Blood Alcohol Levels Explore this drag and drop exercise that matches blood alcohol levels with behavioral effects.

203 C.

Chapter 12 Sexual and Gender Identity Disorders Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: p. 319

Lectures: Gender differences in sexuality

Brief Historical Perspective Sexual Dysfunctions: p. 321 Symptoms Diagnosis Frequency Causes Treatment

Lectures: Animal sexual behavior: The Coolidge Effect Childhood sexual abuse Performance anxiety Discussion Ideas: Most common sexual disorders

Paraphilic Disorders: p. 332 Symptoms Diagnosis Frequency Causes Treatment

Discussion Ideas: Recidivism in sex offenders Classroom: Treatment of sex offenders Societal responses to sex offenders

Gender Dysphoria : p. 343 Symptoms Frequency Causes Treatment

Lectures: Longitudinal study of girls with gender identity disorder Video Case: Patients as Educators, Transsexual, Denise, age 24

204 C.

PROFESSOR NOTES

CHAPTER OUTLINE I.

Overview A.

William Masters (1915–2001) and Virginia Johnson (1925–2013) described the human sexual response cycle in terms of three phases: excitement, orgasm, and resolution.

B.

Sexual excitement is associated with vasocongestion (engorgement of the blood vessels, especially in the genitals); genitals become swollen, reddened, and warmed while muscular tension, heart rate, and respiration rate increase.

C.

Orgasm is usually distinct from the gradual build up of sexual excitement that precedes it; involves a sudden release of tension that is intensely pleasurable; for women, it involves three stages ("sensation of suspension or stoppage," a feeling of warmth spreading throughout the pelvic region, and sensations of throbbing/pulsating); for men, it involves two stages (first, a sensation of ejaculatory inevitability, triggered by the movement of seminal fluid toward the urethra, and, second, contractions that propel semen through the urethra)

D.

Resolution, which can last 30 minutes or longer, is the phase in which the person's body returns to its resting state; men are generally unresponsive to further sexual stimulation for a period of time known as the refractory period; women may be able to respond to further stimulation almost immediately.

E.

Brief historical perspective 1.

II.

Work of Alfred Kinsey (1894-1956) a.

Took a behavioral approach in studying sexual behavior of men and women

b.

Conducted first scientific surveys of sexual behaviors, interviewing 18,000 men and women between 1938 and 1956

c.

Argued that differences among people in sexual behavior are quantitative, not qualitative

d.

He was a biologist that focused specifically on those experiences that resulted in orgasm.

Sexual dysfunctions A.

Sexual dysfunctions are inhibitions of sexual desire and interference with the physiological responses leading to orgasm.

B.

Symptoms

C.

Normal sexual activity patterns 1.

Sexual activity is common: 95 percent of men and 97 percent of women report having had sexual intercourse; oral sex is also common, though not as common

2.

29 percent of women and 75 percent of men reported that they always have an orgasm with their partner (and 44 percent of men reported that their partners always had orgasms during sex).

205 C.

D.

3.

Relationships may be considered intimate and even satisfying regardless of orgasm; 41 percent of women reported they were extremely physically satisfied with their partners.

4.

Strong negative emotions (anger, fear, and resentment) are often associated with sexual dissatisfaction; sometimes these emotions are primary and causative, and sometimes they are secondary effects of sexual difficulties.

5.

However, a large proportion of men and women report being extremely satisfied with their partners both emotionally and physically. Indeed, a relationship may be considered intimate and satisfying simply because there is sexual activity, regardless of whether both partners experience orgasm.

Diagnosis 1.

2.

3.

4.

Diagnosis of a sexual dysfunction is somewhat subjective, as it must consider the person’s age and circumstances. Thus, diagnoses may have poorer reliability than other DSM-5 diagnoses.

However, there are two diagnostic criteria common to all forms of sexual dysfunctions in the DSM-5: a.

The symptoms have persisted for at least six months.

b.

The symptoms lead to marked distress in the person who experiences them.

Male hypoactive sexual desire disorder a.

Sexual desire is the person’s willingness to approach or engage in those experiences that will lead to sexual arousal; hypoactive sexual desire is defined in terms of subjective experiences, such as the lack of sexual fantasies and lack of interest in sexual experiences.

b.

Fluctuations in sexual desire are normal; lack of interest in sex must be both persistent and pervasive to be considered a clinical problem; interest in sexual experiences, not frequency, is of importance.

c.

Patients with hypoactive sexual desire have a high frequency of sexual dysfunctions and mood disorders.

d.

Defined as subjective experiences such as the lack of sexual fantasies and lack ofinterest in sexual experiences

Erectile disorder a.

Erectile dysfunction—difficulty in achieving or maintaining an erection

b.

Many men experience it at some time; only a problem when chronic and distressing

c.

Was previously called impotence; this term has been dropped due to negative associations

Female sexual interest/arousal disorder—inhibited sexual arousal a.

Inability to achieve genital responses (lubrication and swelling) necessary for intercourse

b.

Sexual desire is present; physiological responses are inhibited 206 C.

c.

5.

Female orgasmic disorder—failure of women with uninhibited sexual arousal to reach orgasm; may be generalized (they have never experienced orgasm) or situational (able to reach orgasm in some situations but not in others); however, it is difficult to define in relation to inhibited sexual arousal because the various components are difficult to measure

6.

Premature (early) ejaculation

7.

8.

E.

This problem is often seen as decreased subjective arousal.

a.

Problems with the control of ejaculation; inability to inhibit ejaculation long enough to complete intercourse

b.

May be defined by timing of ejaculation (before or shortly after insertion) or by the couple’s satisfaction; 90 percent of men who suffer lifelong premature ejaculation ejaculate within one minute of penetration

c.

Many experts prefer the term early ejaculation to premature ejaculation because it is less pejorative.

d.

DSM-5 focuses on a person’s subjective control (routinely ejaculating before he wishes) rather than on a fixed amount of time.

Delayed ejaculation a.

Also called male orgasmic disorder and ejaculatory inhibition; characterized by a marked delay in ejaculation or inability to ejaculate

b.

It must be experienced in most sexual encounters (75 percent) and must not be the result of the man attempting to delay ejaculation.

Genito-pelvic pain/penetration disorder a.

Dyspareunia—genital pain during or after sexual intercourse; more common in women; often associated with other sexual dysfunction

b.

Vaginismus—involuntary spasm of muscles surrounding the vagina preventing penetration; often fear of intercourse and vaginal penetration is involved; the DSM-5 version of this disorder is more broadly defined than in previous editions

Frequency 1.

Survey data indicate that sexual dysfunctions are fairly common.

2.

Survey data reveal significant gender differences in the prevalence of all types of problems; premature ejaculation affects one-third of adult men; one-third of women said they lacked interest in sex, and almost one-fourth said they experienced a period of several months during which they were unable to reach orgasm.

3.

Sexual behavior across the lifespan 207 C.

F.

a.

Many adults remain sexually active throughout the life span.

b.

Gender differences become marked in the late fifties with rates of inactivity rising quickly for women.

c.

Sexual differences between older and younger people are primarily a matter of degree.

d.

Some prominent gender differences occur in later life; 65 percent of men between ages 70 and 74 are still sexually active, whereas only 30 percent of women within the same age range report being sexually active.

e.

Cultural and ethnic differences have been reported for sexual practices, beliefs about sexuality, and patterns of sexual decision making; however, people seek treatment for sexual disorders worldwide, suggesting this is not a culture-bound problem.

f.

Inhibited orgasm in both men and women is sometimes caused by the abuse of alcohol and other drugs.

Causes 1.

2.

Biological factors a.

Male sex hormones, especially testosterone, influence sexual desire; low levels of testosterone are associated with decreased sexual desire; the reduction of male sex hormones over the life span may explain the decline in sexual desire among elderly males.

b.

Erectile dysfunction is often at least in part biologically based; vascular, neurologic, and hormonal impairment problems often contribute to impaired erectile responsiveness.

c.

Smoking and using drugs like alcohol and marijuana may have negative effects on arousal and function; SSRIs can produce, as a side effect, delayed ejaculation and orgasmic dysfunction.

d.

Neurological disorder, pelvic disease, and hormonal dysfunction can interfere with vaginal swelling and lubrication.

Psychological factors a.

Sexual desire and arousal may be determined by mental scripts that we learn throughout childhood and adolescence; the perceived social meaning of an event is important.

b.

Arousal can also be influenced by relationship factors and culturally-determined attitudes toward sexuality.

c.

Female sexual dysfunction is associated with a lack of assertiveness and a lack of comfort talking about sexual activities; anorgasmic women are more uncomfortable talking to their partners about sexual activities, hold more negative attitudes toward masturbation, and feel greater guilt about sex.

d.

Relationship problems including communication problems, power conflicts, and an absence 208 C.

of intimacy and trust can lead to sexual problems.

G.

e.

Previous harmful or traumatic experiences, including childhood sexual abuse, can affect interest and arousal.

f.

Performance anxiety or fear of failure can inhibit sexual arousal and disrupt sexual performance; Barlow's studies showed that men who experience erectile failure are less easily sexually aroused, less aware of their level of arousal, and have more negative responses to erotic stimuli

Treatment 1.

Sensate focus (Masters & Johnson)—couples spend quiet, relaxed time learning to touch each other and focus on physical intimacy and communication regarding what feels good

2.

Scheduling time for sexual activity provides quiet, relaxed, private time for intimacy.

3.

Cognitive restructuring and education—changing the way people think about sex a.

Correcting myths (e.g., that foreplay is unimportant)

b.

Provide information about sexual behaviors/dysfunctions in the general population

4.

Communication training—many people with sexual dysfunctions have difficulty talking with their partner about sex, especially what they find arousing

5.

Available research indicates that psychological treatments for sexual dysfunction are successful; cross-cultural research, however, raises questions about the use of some Western techniques in other cultures; beliefs about masturbation and communication regarding sexuality may differ dramatically as a function of culture.

6.

Psychologically-based treatments must be tailored to the specific culture in order to be effective.

7.

Biological treatments a.

Medications can also be useful;Viagra is the first oral medication (1998) for treatment of erectile dysfunction. There is also Cialis and Levitra. These medications facilitate blood flow to the penis and are effective in approximately 50 percent of cases. For many, however, psychological treatments continue to be beneficial; pharmaceutical companies are currently developing and evaluating medications to treat sexual dysfunction in women, such as Intrinsa, a patch that delivers testosterone though the skin to increase sexual desire.

b.

Severe forms of erectile disorder can be treated with the surgical implanting of a penile prosthesis that can be used to make the penis rigid during intercourse.

209 C.

III. Paraphilic disorders A.

B.

Overview 1.

Sexual arousal associated with atypical stimuli; literally “love beyond the usual”

2.

Persistent sexual urges are associated with nonhuman objects, with the suffering or humiliation of oneself or one's partner, or with children or other nonconsenting persons.

3.

DSM-5 makes an important distinciton between paraphilias (any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with a phenotypically normal, physically mature, consenting human partner) and paraphilic disorders, which describe paraphilias that either lead to subjective distress or social impairment for the person or harm or threaten to harm other people.

Symptoms 1.

Over 100 years ago, anything other than heterosexual intercourse was considered pathological.

Sexual fantasies are quite common, and a large percentage of men and women engage in sexual fantasies and mutually consentual behavior, such as oral sex.

2.

The central problem with these disorders is that sexual arousal is dependent on images that are detached from reciprocal, loving relationships with another adult; hostility and violence are common to these fantasies.

3.

Compulsion and lack of flexibility are also important features of paraphilic behaviors. a.

C.

D.

Individuals with these disorders may report feeling compelled to act in an illegal or immoral way. In this sense, these disorders are similar to addictions.

Diagnosis 1.

DSM-5 requires that erotic preoccupation must have persisted for at least 6 months and must cause clinically significant distress or impairment.

2.

Several diagnoses only need the person to experience the very distressing compulsions, but other diagnoses require the person to actually act on those urges.

3.

Although listed as distinct disorders, it may be useful to think of paraphilic disorders as one diagnostic category with specific subtypes.

Fetishistic disorder 1.

Sexual arousal associated with nonliving objects

2.

Often involves women's underwear, shoes and boots, or products made out of rubber or leather

3.

Typically, the person masturbates while holding, rubbing, or smelling the fetish object.

210 C.

4.

E.

F.

G.

H.

Sexual interst in nonliving objects in itself is unusual; however, in the case of a disorder, sexual interest is focused exclusively on the object.

Transvestic disorder 1.

Defined as cross-dressing for purpose of sexual arousal

2.

Occurs almost exclusively among heterosexual males; should not be confused with the behavior of some gay men known as “drag queens”

3.

Person masturbates while cross-dressed, often imagining himself to be the male as well as the female object of his own sexual fantasy

4.

Those who cross-dress and are uncomfortable or unhappy with their gender would be diagnosed as transvestic fetishism with gender dysphoria, also known as gender identity disorder (GID).

Sexual masochism disorder 1.

Recurrent, intense sexually arousing fantasies, urges, or impulses involving being humiliated, beaten, bound, or otherwise made to suffer

2.

Arousal often involves pain or feelings of shame and disgrace (e.g., being forced to display one's naked body to others)

3.

Goal is orgasm or sexual fulfillment, not actually injury or severe pain

4.

Disproportionately represented by privileged groups in society

Sexual sadism disorder 1.

Sexual sadism involves intense, sexually arousing fantasies, urges, or behaviors that involve the psychological or physical suffering of a victim.

2.

Often involves asserting dominance and experiencing power and control; sometimes the severity of the behaviors escalates over time

Exhibitionism 1.

Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving exposure of one's genitals to an unsuspecting stranger over a period of at least six months; moreover, the individual has acted on these urges with an unconsenting person

2.

Almost exclusively a male disorder

3.

About 50 percent of men have erections while exposing themselves, and some masturbate at the time; others masturbate shortly after the experience while fantasizing about the victim's reaction.

4.

They generally hope to shock their victims, but they may also hope that the victim will become sexually aroused.

211 C.

5.

I.

J.

K.

L.

This is seldom an isolated disorder; men who engage in this behavior often do it more than once.

Voyeuristic disorder 1.

Observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity for the purpose of sexual arousal

2.

The process of observing is, itself, arousing for voyeurs.

3.

Voyeurs masturbate during observation, or later while remembering what they saw.

4.

The person may fantasize about having a sexual relationship with the observed people, but direct contact is seldom sought.

Frotteuristic disorder 1.

A person who is fully clothed becomes sexually aroused by touching or rubbing his genitals against other nonconsenting people

2.

Generally chooses crowded places; rubs genitals against a victim's thighs and buttocks or fondles her genitalia or breasts

3.

High-frequency form of paraphilia; frotteurs may engage in hundreds of such acts

4.

Frotteurs seek to escape as quickly as possible after touching or rubbing their victims.

Pedophilic disorder 1.

Entails recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with prepubescent children (generally 13 or younger); the perpetrator must be at least 16 and at least five years older than the children involved

2.

Child molestation is a legal term and not the same as pedophilia; a pedophile diagnosis can be made simply from the presence of fantasies.

3.

Most pedophiles are heterosexual; most victims are girls; sexual contact typically involves caressing and genital fondling; child often knows the perpetrator; more than half of the incidents take place in the home of either the child or the offender

4.

Incestuous relationships are ones in which sexual activity between close blood relatives occurs, but this definition can be expanded to include stepchildren and their stepparents.

5.

Perhaps half of the men who commit incest have also engaged in sexual activity with children outside their own families; these pedophiles may be the most harmful and difficult to treat.

Rape and sexual assault 1.

Nonconsensual sexual penetration by physical force, by threat of bodily harm, or when the victim is incapable of giving consent by virtue of mental illness, mental retardation, or intoxication

2.

Somewhere between 14 and 30 percent of adult women have been raped, depending on the survey 212 C.

and definition of rape. Actual prevalence is probably near 20 percent.

M.

N.

3.

Most female victims know the person who raped them (called acquiantance rape); approximately 4 percent of forced rapes are committed by strangers.

4.

Rape is motivated by varied factors including aggression and sexual arousal involving the suffering of nonconsenting persons.

5.

Knight’s classification of rapists divide them into those who are primarily interested in sexuality and those primarily interested in aggression. a.

Sadistic rapists’ behavior is determined by a combination of sexual and aggressive impulses

b.

Nonsadistic rapists are preoccupied with sexual fantasies but are not interested in violence and aggression.

c.

Vindictive rapists are intent on violence and are not erotically motivated.

d.

Opportunistic rapists are very impulsive and often are psychopaths.

Frequency 1.

Very little research on unconventional sexual behavior, especially for victimless forms of paraphilia

2.

People who exhibit one paraphilia often exhibit others.

3.

Most paraphiliacs are men, around 95 percent

Causes 1.

2.

Biological factors a.

Some evidence of elevated levels of testosterone in convicted sexually violent offenders, but this may be due to prolonged substance abuse

b.

The four F’s--feeding, fighting, fleeing, and [fornication]--are controlled by structures in the temporal lobes, especially the amygdala and the hippocampus.

c.

Some men with pedophilia and exhibitionism show subtle forms of left temporal lobe dysfunction; most temporal lobe damage victims, however, experience a reduction in sexual interest or activity, so these results should be viewed cautiously.

Social factors a.

Voyeurism, exhibitionism, and frotteurism may represent aberrant versions of normal evolutionary mating processes for men. Location and appraisal of potential partners, exchange of signals of interest, and tactile interactions usually set the stage for intercourse.

b.

Background factors associated with atypical sexual behaviors include (1) early crossing of normative sexual boundaries (e.g. early abuse), (2) lack of appropriately-modeled sexual 213 C.

behavior and values, (3) low self-esteem, or lack of confidence and ability in social interactions, and (4) ignorance and poor understanding of human sexuality.

3.

c.

Failure to achieve intimacy and poor interpersonal skills may be at the core of most forms of paraphilia.

d.

Paraphilic behavior is reinforced by the momentary pleasure associated with orgasm.

e.

Paraphilias are associated with early crossing of normative sexual boundaries, such as sexual abuse, lack of consistent parental environment, lack of self-esteem, lack of confidence and ability in social interaction, and ignorance and poor understanding of human sexuality.

Psychological factors a.

O.

Lovemap—mental picture representing a person's ideal sexual relationship, learned in childhood and adolescence; may be distorted, leading to difficulty uniting love and lust in a relationship

Treatment 1.

Aversion therapy had traditionally been the most common treatment form—the stimulus (e.g., child disrobing) that elicits the inappropriate response (sexual arousal) is paired with an aversive stimulus (e.g., shock); research supporting the efficacy of this approach has been equivocal.

2.

Cognitive-behavioral treatment—cognitive restructuring and education, social skills training, and stress management procedures; results of outcome studies do not indicate that such treatment is highly effective

3.

Hormones and medication—drugs that reduce levels of testosterone are sometimes used and may be effective; other medications, such as antidepressants or antianxiety drugs, are also used, perhaps reducing social anxiety, leading to less deviant sexual behaviors

4.

Legal issues—Community notification laws provide information to the general public regarding convicted sex offenders’ past behavior; the first includes community notification laws such as Megan’s Law, which require the distribution of information to the public regarding the presence of child molesters; sexual predator laws allow indefinite enforced psychiatric hospitalization after completion of prison terms based on presumed risk of reoffending

IV. Gender dysphoria A.

B.

Gender identity vs. sex roles 1.

Gender identity—sense of oneself as being either male or female

2.

Sex roles—characteristics, behaviors, and skills that are defined within a specific culture as being either masculine or feminine

Symptoms 1.

Gender dysphoria—sense of discomfort with one’s anatomical sex (also called transsexualism) 214 C.

C.

D.

E.

2.

Transsexuals report they were aware of these feelings very early in childhood; feelings intensify during adolescence.

3.

Distinguish from transvestic fetishism, which is a paraphilia in which the person dresses in opposite sex clothing for a sexually erotic experience; also distinct from homosexuality, in which there is no gender dysphoria

Frequency 1.

Approximately one out of every 12,000 males and 30,000 females are transsexuals.

2.

Mild forms of cross-gender behavior are relatively common in preschoolers, but deeply ingrained cross-gender behaviors and attitudes are rare.

Causes 1.

Gender identity disorder is poorly understood; may be strongly influenced by sex hormones (particularly during prenatal period)

2.

Pseudohermaphroditism—genetically male but born with ambiguous genitalia—often raised as girls, but when testosterone takes effect in adolescence, boys generally adopt a masculine gender identity with ease, providing evidence for the influence of prenatal hormonal effects

Treatment 1.

Changing gender identity through psychotherapy has been largely unsuccessful; treatment has focused on changing anatomy to reflect gender identity.

2.

Sex-reassignment surgery—artificial male or female genitalia can be constructed, though the artificial penis is not capable of becoming erect in response to sexual stimulation. a.

Stringent selection criteria; patients required to live as opposite sex for several months prior to being accepted for surgery

b.

Patients are generally satisfied with the results, believe they have no trouble passing for their new gender, and studies reveal reduced anxiety and depression

215 C.

LEARNING OBJECTIVES LO 12.1: Should sexual problems be defined primarily in terms of difficulty reaching orgasm?

LO 12.2: What role do mental scripts play in sexual arousal?

LO 12.3: What are the primary targets of psychological approaches to treating sexual dysfunctions?

LO 12.4: How have changing attitudes toward sexuality influenced the definition of paraphilias?

LO 12.5: Should excessive sexual behavior be considered a disorder in its own right?

LO 12.6: Does deviant sexual arousal ever play a role in sexual assaults?

LECTURE SUGGESTIONS Gender differences in sexuality: Current directions APS reader (1E, p. 109) Letitia Peplau, a professor at UCLA, outlines four of the most prominent gender differences in sexuality and reviews the relevant literature for each of these differences. Men show greater sexual desire overall. Both heterosexual and homosexual men report more sexual fantasies, are interested in sex more often, spend more money on sexual products and videos, and masturbate more often than women do. “Women tend to emphasize committed relationships as a context for sexuality more than men do” (pg. 110). This second difference is focused on the role that relationships play in sexuality; men’s fantasies are more likely to involve strangers, anonymous partners, and focus on specific sex acts and sexual organs. Women’s sexuality is generally linked to a close relationship. Men’s sexuality is more tied to aggression. They are more likely to view their own sexuality within an aggressive context, focusing on power, experience, and domination. Women’s sexuality rarely involves physical force and violence in any way. Finally, men are less likely to change their sexuality; if a relationship ends, for example, they tend to substitute another sexual relationship or masturbate to maintain the same level of sexuality. Women demonstrate more plasticity in their sexuality; in a committed relationship, they may have frequent sex, but if that relationship ends, they might suspend sexuality for several months until another relationship begins. Women are also more likely to change their sexual orientation. College, for example, led to a larger increase of women becoming lesbian or bisexual (women, .4 percent beginning college to 3.6 percent as graduates; men, 1.7 percent, beginning college, to 3.3 percent as graduates) than the percentage increase of men becoming gay or bisexual.

The author, then, suggests that recognizing these key differences in sexuality between men and women is very important in both diagnosis and treatment of sexual disorders and sexual problems. For example, she argues that we have often made the mistake of "lumping" all homosexuals—men and women—together in our conceptualizations. The prominent gender differences discussed here should lead us to view a lesbian and gay male more in terms of their biological sex than as members of a cross-gender homosexual group. Women’s sexuality has some consistent features regardless of sexual orientation, for example. Peplau also claims that DSM tends to be male-oriented and does not take into account women’s issues or approaches to sexuality in a complete sense, but the professor does not provide examples to illustrate this point. Do we need a different diagnostic scheme to take into account these gender differences, or is it sufficient to take into account these differences within the current scheme?

216 C.

Animal sexual behavior: The Coolidge effect The study of animal sexual behavior can shed light on human sexual behavior patterns and the influence of physiology on male-female sex differences. An interesting example is the “Coolidge effect,” named after U.S. president Calvin Coolidge. The story (which may or may not be true; Carlson, [1986]) is that the president and his wife were visiting a farm, and the first lady discovered that just one rooster was responsible for a great deal of sexual activity and productivity among the flock of hens. She commented, “You might point that out to Mr. Coolidge.”

Upon his discovery that the rooster’s activity was with a different hen each time, the president responded, “You might point that out to Mrs. Coolidge.”

Males have an increasingly longer refractory period after each ejaculation. The so-called Coolidge effect refers to the fact that males will have a much briefer refractory period when presented with a new female than with the female with whom they have completed sexual activity (this effect is particularly strong for rams). This response pattern may suggest that biologically-driven gender differences in sexual behavior could explain some sexual behaviors considered social in origin.

Beamer, W., Bermant, G., & Clegg, M. (1969). Copulatory behavior of the ram, Ovus Aries. II. Factors affecting copulatory satiety. Animal Behavior, 17, 706–711.

Childhood sexual abuse: What is the connection between childhood sexual abuse and adult sexual disorders? An Austrian study examined the effect of single-incident sexual abuse and multiple-incident sexual abuse on adult sexual disorders in 202 female university students. Victims of multiple childhood sexual abuse more frequently reported sexual desire disorders and orgasm disorders than did single-incident victims and nonvictims. In fact, single-incident victims did not differ from nonvictims in their sexual dysfunction. Negative family experiences were significantly related to all types of sexual disorders, suggesting that family dysfunction or family problems play a major role in the development of sexual problems. This study suggests that it may be continual sexual abuse and general family difficulties that most strongly influence sexual problems. Of course, this finding does not mean that a single traumatic incident in childhood is unimportant and not worthy of clinical attention.

Kinzl, J.F., Traweger, C., & Biebl, W. (1995). Sexual dysfunctions: Relationship to childhood sexual abuse and early family experiences in a nonclinical sample. Child Abuse and Neglect, 19, 785–792.

Performance anxiety: Some recent studies by Barlow (described briefly in the text) seem to provide some insight into the role of performance anxiety in sexual function disorders for men. "Normal" subjects and subjects who had reported difficulty achieving erection were asked to watch sexually arousing films. In one condition, they were instructed to "achieve the best erection you can," while in the other condition they were not given performance demands. Normal subjects did, in fact, achieve their best erections in the performance condition, whereas those subjects who experienced sexual dysfunction difficulties produced their best erections in the absence of a performance demand.

This study offers very clear evidence that performance anxiety can play an important role in male erectile failure. It also raises a question about the role of voluntary control in sexual arousal. Those normal subjects who achieved their best erections under instructions to do so demonstrated a voluntary control that is somewhat surprising. Would this generalize to women? To what extent is "performance anxiety" limited to men?

Barlow, D.H. (1986). Causes of sexual dysfunction: The role of anxiety and cognitive interference. Journal of 217 C.

Consulting and Clinical Psychology, 54, 140–148.

Longitudinal study of girls with gender identity disorder: This study followed 25 young girls who expressed symptoms of gender identity disorder when they were quite young (average age of 9 years old) and, then about 14 years later (average age now 23). At time point, 60 percent of the subjects met the diagnostic criteria for GID, whereas 40 percent had symptoms but were subclinical.

Fourteen years later, only 3 of the girls were diagnosed as having GID or gender dysphoria. Many of the participants displayed signs of sexual activity that were not conventional, heterosexual activity. Eight participants (32 percent) reported bisexual and homosexual fantasies and 6 (24 percent) were classified as bisexual/homosexual in behavior.

Perhaps the most significant finding in this study is the drop in reports of gender identity disorders—at least in the form of a full-blown, diagnosable form. Only 12 percent continued to show clinical symptomatology. Other longitudinal studies had found that nearly 70 percent continue to have gender identity problems at follow-up. The current study has its own limitations; most prominently, its sample size is quite limited.

Drummond, K.D., Bradley, S.J., Peterson-Badali, M., & Zucker, K.J. (2008). A follow-up study of girls with gender identity disorder, Developmental Psychology, 44, 34–45.

DISCUSSION IDEAS Most common sexual disorders: The most common sexual disorders are male erectile disorder for men and inhibited orgasm for women. Why would these be the most common disorders for each gender? Ask students to consider physiological, psychological, and cultural factors in their responses. What societal factors might be addressed if a goal was to reduce the prevalence of these disorders? What societal factors might be expected to give rise to other sexual dysfunctions?

Recidivism in sex offenders: Current directions, APS reader (1E, p. 116) R. Karl Hanson presents some interesting data on the recidivism of sex offenders that can lead to an interesting discussion about treatment and policy regarding sex offenders. He argues that (1) the myth that sex offenders continue to commit sexual crimes frequently is not as accurate as is commonly believed, and (2) we must take into account empirically demonstrated predictors in order to improve our accuracy for predicting recidivism for sex offenders. The most valid predictors of recidivism are demographic and offense-history variables: marital status, any stranger victims, any male victims, any unrelated victims, age less than 25, any noncontact sex offense, total number of prior sexual offenses, any violent offense, and total number of prior offenses. A meta-analytic review involving close to 24,000 sex offenders found that about 13.4 percent committed a new sex offense within a four- to five-year span.

Is this a high number or a low number? Should we be more favorable towards sex offenders and allow them more freedom in the form of release from prison or hospital treatment programs on the basis of this data? Hanson argues that it is difficult to determine if a sex offender has changed because we cannot mimic the “sexual offense situation” in an institutional setting. How, then, do we decide if the offender is ready for release? He also argues that self-esteem is not a useful measure because studies show that even when self-esteem of the perpetrator is increased, the rate of recidivism does not change. Students may have a “knee-jerk” immediate reaction that we should never release a sex offender, but this, of course, is unrealistic. The question is: how do we deal with this very dangerous phenomena in a way that is humanistic in protecting the perpetrator/patient and also effective in protecting society?

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Reasons why people cheat: After dividing the class into small groups of students, ask them to create the top five reasons why men and women cheat on their significant others. The students can make two separate lists, one for men and one for women, if that is what the small group decides. After the students have created their list of the top five reasons, ask them to conduct some research online to compare the group’s list with the findings from the Internet. This can also be a good activity to spark a debate as to the differences in men and women, the importance of relationships and intimacy, and how life changes, such as having a new baby, may cause conflict in the home and relationship.

Autoerotica: As a cause of death Cooke, Cadden, and Margolius (1994) described four cases of individuals who died as a result of autoerotica.

The article can be accessed at http://www.hawaii.edu/hivandaids/Autoerotic_Deaths_Four_Cases.pdf. Ask the students to read the different cases and evaluate each of the different cases. Then have a discussion of the different fetishes and paraphilias described in the textbook. This may also create an opportunity for students to search the Internet for deaths determined to be caused by autoerotica by coroners across the country or globe.

Cooke, C., Cadden, G., & Margolius, K. (1994). Autoerotic deaths: Four cases. Retrieved by http://www.hawaii.edu/hivandaids/Autoerotic_Deaths__Four_Cases.pdf on July 1, 2011.

CLASSROOM ACTIVITIES Treatment of sex offenders: Divide the class into small groups and ask them to consider the following statements raising issues concerning the treatment of sexual offenders: (1) Ordinary "talk-therapy" is generally not successful in treating these disorders. (2) Sex offenders are an increasing danger in our communities. (3) Sex offenders will usually not consent to very uncomfortable forms of aversive conditioning, psychosurgery, or castration. Should the state have the right to employ these techniques (if they are successful) without the consent of (a) a first offender and/or (b) a repeat sex offender? Ask the groups to present their opinions and conclusions in the larger group.

Societal responses to sex offenders: Given that no approaches to treating paraphilias are demonstrably very effective and that many sex offenders recidivate, how should society balance individual rights of those convicted of sexual offenses with the need for protection of others? Notification laws and sexually violent predator laws infringe on liberties offered to other society members (even those with nonsexual violent crime convictions), with the goal of decreasing future sexual offending. Ask the class to consider this issue given what we do and do not know about paraphilic disorders. For example, we consider them forms of psychopathology, have some evidence for biological contribution to the behaviors, and seek to “treat” those with the disorders. At the same time, we have no proven treatments and view paraphilic behaviors as volitional. In a classroom or small-group format, have students separate out and weigh the different components in this complex issue (e.g., desire for retribution, protection of potential victims, real versus illusory control, balancing individual and societal rights).

Guest speaker: Gender identity disorder Ask for volunteers in the community or actively contact a local agency or an organization to ask for a presenter to come speak about gender identity disorder and to offer a personal testimonial of living with the disorder. Ask students to anonymously write down two or three questions that they would like the guest to answer 219 C.

so that you are able to type the questions beforehand to pass them on to the speaker. Allow time for other free-thought questions, and you could also include a homework assignment for the students to complete a journal entry on what they learned, found interesting, and how they would advocate and educate others who are unfamiliar with gender identity disorder.

Sexual and gender identity trivia game: Use the key bolded terms throughout the chapter to create a review game. Use large index cards to break the categories into Sexual History, Sexual Functioning, Sexual Dysfunction in Women, Sexual Dysfunction in Men, Paraphilias, and Gender Identity Disorder. Then have note cards with the respective questions under each category worth a point value of 100, 200, 300, 400, and 500. Divide the class into small teams for the trivia game. This can be an opportunity to review for the exam and potentially offer extra credit points to the students.

Paraphilias: Personal thoughts Before class, prepare, on separate large pieces of white printer paper, the individual names of each paraphilia.

Post each sheet of paper in various places around the classroom. Then ask the students to roam around the room writing down their first initial thoughts, pictures, or symbols after they read each term. Allow ten minutes for the students to post their responses. Then ask for student volunteers to read out loud the feedback for each definition.

This can begin the discussion of the various paraphilias or evaluate the current level of knowledge and understanding of the course readings and lectures.

Men’s sexuality versus women’s sexuality: Write both the concepts of ‘men’s sexuality’ and ‘women’s sexuality’ on the board in the classroom. Divide the class into small groups and ask them to discuss the difference between men and women when it comes to sexuality and the expression of this. Ask the students to define and differentiate between men’s sexuality and women’s sexuality. The students can write words, draw pictures, or use symbols for their respective lists. After the students have had five to seven minutes to come up with a list for both men’s and women’s sexuality, ask each group to contribute information from their list to the board.

Sexual and gender identity disorder: Scavenger hunt Have several sticky notes with the key terms from the chapter written on them. Then place a sticky note on each of the students’ backs. Allow ten minutes for the students to roam around the room to ask questions of their peers related to the concepts covered in the chapter. Students can only answer yes or no as responses (e.g., is my sexual disorder related to men or to women? Do I violate the rights of others? Do I receive pleasure from harming others?).

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VIDEO CASE IN ABNORMAL PSYCHOLOGY Denise--Transsexual, age 24 (21:36) Denise is a 24-year-old biological male who has been living as a female for the past two years. Ever since she was four years old, she felt like she should be a female and is now receiving hormone therapy and saving for sex-reassignment surgery. Denise experiences the typical symptoms of a transsexual, feeling her assigned sex is inappropriate and her genitals are repugnant.

Discussion question: Denise makes the distinction between a transsexual and a transvestite. Give a brief definition and describe the typical behavior of each. Which one does Denise feel is looked upon most favorably by society?

VIDEO RESOURCES http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Sexual_Disorders.html Sexual Disorders (1:13) Watch this video about different types of sexual dysfunction.

http://pet.pearsoncmg.com/e/iat-sexuality Implicit Association Test: Sexuality Try this simulation on the Implicit Association Test of sexuality.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/mydevelopmentlab/HumanSexualityVideoSeries /ABWCarroll.html Dr. Richard Carroll, Sex Therapist (1:13) Watch this short video of sex therapist Dr. Richard Carroll.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Anonymous_ Pedophilia. html Anonymous: Pedophilia (1:49) Watch this video about a pedophile from the viewpoint of an unidentified pedophile.

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Chapter 13 Schizophrenic Disorders Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: p. 349 Symptoms: p. 351

Lectures: Positive and negative symptoms

Positive Symptoms Negative Symptoms Disorganization

Classroom: Myths about schizophrenia Video Case: Schizophrenia, Larry

Diagnosis: p. 355

Discussion Ideas: Objectifying schizophrenia

Brief Historical Perspective DSM-5 Subtypes Related Psychotic Disorders Course and Outcome

Classroom: Focusing through the voices Video Case: Schizoaffective Disorder, Josh

Frequency: p. 359 Gender Differences Cross-Cultural Comparisons Causes: p. 360 Biological Factors Social Factors Psychological Factors Interaction of Biological and Environmental Factors The Search for Markers of Vulnerability

Lectures: Schizophrenia: A neurodevelopmental approach Labeling theory Discussion Ideas: Cognition in schizophrenia Implications for vulnerability

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PROFESSOR NOTES

Treatment: p. 372

Video Case: Schizophrenia, Georgianna, age 33

Antipsychotic Medication Psychosocial Treatment

CHAPTER OUTLINE I. Overview A.

Symptoms of schizophrenia involve deterioration of basic functions affecting individuals’ thoughts and perceptions

B.

Symptoms must occur in the absence of other disorders (mood disorders, delirium, dementia, substance abuse disorders); among mental disorders, it is the second leading cause of disease burden, and the financial costs for the U.S. are around $63 billion

C.

Phases of schizophrenia

D.

II.

1.

Prodromal phase—obvious deterioration in functioning, change in personality with characteristics similar to schizotypal personality disorder, including peculiar behaviors and perceptual experiences

2.

Active phase—symptoms such as hallucinations, delusions, and disorganized speech are present

3.

Residual phase—signs and symptoms similar to that of the prodromal phase—positive symptoms may improve, but negative symptoms and impairment often continue

The most common symptoms of schizophrenia include changes in the way a person thinks, feels, and relates to other people and the outside environment.

Symptoms A.

B.

There is no specific set of symptoms characteristic of all schizophrenic patients, but classes of symptoms include the following: 1.

Positive (psychotic) symptoms—presence of abnormal functioning—e.g., hallucinations, delusions

2.

Negative symptoms—absence of normal functioning—e.g., social withdrawal, lack of initiative, and deficits in emotional responding

3.

Disorganization—verbal communication problems and bizarre behavior

Positive symptoms—characterized by the presence of an abberant response 1.

Hallucinations—sensory experiences not caused by actual external stimuli 223 C.

2.

C.

a.

Usually auditory (hearing voices)

b.

Often include voices commenting on patient’s behavior or giving instructions

c.

Do not imply that these symptoms are beneficial or adaptive, but rather suggests that they are characterized by the presence of an aberrant response

Delusional beliefs—idiosyncratic beliefs that are rigidly held despite their illogical and unreasonable nature a.

Defended even when shown contradictory evidence; false beliefs are based on incorrect inferences about reality

b.

Person is preoccupied with these irrational beliefs and unable to understand another person’s perspective with regard to the belief

c.

Common delusions include the belief that thoughts are being inserted into the person’s head, the belief that others can read his/her thoughts, and grandiose or paranoid delusions.

d.

In clinical practice, delusions are often complex and difficult to define. The content can be very bizarre and confusing.

e.

The subjective experiences of people with this disorder serve as a valuable resource for knowledge about delusions.

Negative symptoms—defined in terms of the absence or reduction of responses or functions that should be present 1.

Affective and emotional disturbances a.

Diminished emotional expression (also called blunted affect)—failure to exhibit signs of emotion or feelings

b.

Anhedonia—inability to experience pleasure, emotional deficit

2. Avolition and alogia

D.

a.

avolition—indecisiveness, ambivalence, loss of will power, a lack of volition or will

b.

alogia—impoverished thinking and poverty of speech, along with thought blocking; patients have little to say, cannot maintain a train of thought; speechlessness

Disorganization 1.

Thinking disturbances a.

Disorganized speech—saying things that don't make sense, also called a thought disorder

b.

Loose associations— derailment or abruptly shifting topics 224 C.

c.

Tangentiality—irrelevant responses

d.

Perseveration—saying things over and over, repeating the same word or phrase over and over again

2.

III.

Abnormal motor behavior a.

Catatonic behavior —involves obvious reductions in reactivity to stimuli; immobility and muscular rigidity, or excitement and overactivity often associated with a stuporous state or generally reduced responsiveness

b.

Inappropriate affect—incongruity between emotional state and behavior or the lack of adaptability in emotional expression

Diagnosis A.

B.

History 1.

Eugen Bleuler (1911) suggested the name schizophrenia to refer to "splitting of mental associations.”

2.

One unfortunate consequence of this description has been its confusion with dissociative identity disorder.

DSM-5—contains 6 criteria for schizophrenia: 1.

Two (or more) of the following for a significant poriton of time during a 1-month period. At least one of these must be a, b, or c. a.

Delusions

b.

Hallucinations

c.

Disorganized speech

d.

Grossly disorganized or catatonic behaivor

e.

Negative symptoms

2.

Functioning in a major area of life must suffer for a meaningful portion of time since the onset of symptoms.

3.

Continuous signs of disturbance for at least a 6-month period

4.

Schizoaffective and depressive or bipolar disorder must have been ruled out.

5.

Symptoms not attributable to the effects of a substance

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6.

C.

Subtypes 1.

D.

If there is a history of autism spectrum disorders, the diagnosis of schizophrenia may only be made if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month.

Earlier versions of the DSM (tracing back to the DSM-I) divided schizophrenia into subtypes, which included the catatonic, disorganized, paranoid, residual, and undifferentiated subtypes.

However, the most recent version (DSM-5) has done away with these distincitons.

Related psychotic disorders 1.

Delusional disorder— individual does not meet the full symptomatic criteria for schizophrenia; exhibits preoccupation with nonbizarre delusions; the presence of hallucinations, disorganized speech, or grossly disorganized or catatonic behavior rules out this diagnosis

2.

Brief psychotic disorder—individual exhibits psychotic symptoms for at least one day but no longer than one month, often following a markedly stressful event a.

3.

E.

IV.

Schizophreniform disorder—same diagnostic criteria as schizophrenia but for a reduced duration.

Schizoaffective disorder—is an ambiguous and somewhat controversial category; symptoms of schizophrenic disturbance overlap with a depressive or manic episode, but psychotic symptoms are present at some point without mood disorder symptoms

Course and outcome 1.

Typically begins during adolescence and early adulthood and typically has a poor outcome

2.

Has historically been seen as severe and progressive, but some people with schizophrenia have more positive outcomes

3.

Best predictor of symptom severity at follow-up is severity of psychotic symptoms at initial assessment

4.

Recent evidence indicates that while some patients do have positive outcomes, relatively few are able to achieve successful aging.

5.

Manfred Bleuler studied 208 schizophrenic patients who had been admited to Swiss hospitals during 1942 and 1943. After 23 years, 53 percent of patients were recovered or significantly improved.

Frequency A.

Lifetime morbidity risk is approximately 1 percent; one out of every 100 people will experience or display symptoms of schizophrenia at some time during their lives.

B.

Gender differences in onset and course 226 C.

C.

1.

Men are about 30 to 40 percent more likely to develop schizophrenia than are women.

2.

Early onset affects men more often than it affects women, while later onset affects women more than it affects men.

3.

Males are more likely to experience negative symptoms.

4.

Some theorists argue that there are two different types of schizophrenia: one version that has an earlier onset and affects men and another that occurs later and affects women.

Cross-cultural comparisons 1.

Although observed in virtually every culture, frequencies vary from 8 to 43 cases for every 100,000 people.

2.

Higher incidence occurs in urban than in rural areas, but socioeconomic status does not appear to play a substantial role in frequency.

3.

Substantial cross-cultural differences have been uncovered regarding the course of schizophrenia. a.

V.

Clinical and social outcomes better in developed countries than in less developed countries

Causes A.

Biological factors 1.

Strong support for a genetic influence a.

Genetics—the role of genetics has been studied more extensively with schizophrenia than with any other mental disorder. The evidence suggests an important genetic component.

b.

Family studies—as genetic similarity increases between two people, the risk for schizophrenia increases; for example, siblings have a 50 percent chance, and nieces, nephews, and cousins have a 25 percent chance

c.

Twin studies—higher concordance rates among schizophrenics for monozygotic (48 percent) than for dizygotic twins (17 percent)

d.

Adoption studies—children of schizophrenic parents who are adopted by nonschizophrenic parents are as likely to be diagnosed with schizophrenia as they would be if their schizophrenic parent had raised them. One study of children who had been removed from their schizophrenic mothers before three days old (and not given contact with their mothers or the mothers’ families) still found a 16.6 percent lifetime morbidity risk of schizophrenia.

e.

Linkage studies 1.

Theoretically, genetic influence could be due to a single gene or a number of genes; polygenic influence is most likely.

2.

Research has not been able to specify a gene(s) responsible for schizophrenia, but specific regions of chromosomes have been implicated.

227 C.

3.

The enzyme, catechol-O-methyltransferase (COMT), involved in breaking down dopamine, may play an important role in schizophrenia; the COMT gene is on chromosome 22.

f.

Spectrum of schizophrenic disorders—the overall pattern of results suggests that vulnerability to schizophrenia is sometimes expressed as schizophrenia-like personality traits and other types of psychoses

g.

Molecular genetics 1.

The mode of transmission has not been well identified.

2.

Although research suggests a genetic component, no specific genes related to schizophrenia have been identified conclusively. a.

2.

The COMT gene has attracted special interest as it is associated with a small but consistent increase in schizophrenia likelihood.

h.

Pregnancy and birth complications—mothers of people who develop schizophrenia were more likely to have experienced problems before and during birth; it is possible that pre- and perinatal problems interact with genetic factors

i.

Viral infections—people with schizophrenia are more likely to have been born during the winter months; it is possible that they had more viral infections during winter months, but this hypothesis has not received direct support

Neuropathology—identifying differences in the structure of the brain a.

Structural brain imaging—magnetic resonance imaging (MRI) has found smaller total brain tissue volume, enlarged ventricles, and smaller size of limbic system structures in people with schizophrenia 1.

It is unclear if these differences are a sign of generalized brain deterioration.

2.

It is unclear if these differences are associated with specific types of schizophrenia.

b.

Functional brain imaging—positron emission tomography (PET) suggests dysfunction in frontal cortex and temporal lobes of people with schizophrenia and mood disorders

c.

Conclusions on neuropathology 1.

Schizophrenia is associated with diffuse patterns of neuropathology.

2.

Many patients with other psychiatric and neurological disorders show similar patterns of brain dysfunction and structure, which include some regions of the prefrontal cortex and several regions in the temporal lobes.

3.

Brain imaging techniques identify group, not individual, differences in schizophrenia and are not useful diagnostic tools.

228 C.

3.

Neurochemistry a.

b.

c.

B.

1.

Developed while trying to understand how antipsychotic drugs called neuroleptics decrease symptoms of schizophrenia.

2.

It is unclear if people with schizophrenia show differences in dopaminergic activity and D2 receptors prior to taking antipsychotic medication.

3.

Dopamine hypothesis focuses on the function of specific dopamine pathways in the limbic area of the brain.

The dopamine hypothesis is overly simplistic.

1.

Some patients do not respond to drugs that block dopamine.

2.

With antipsychotics, dopamine blockage is immediate, but symptoms do not remit for days to weeks.

3.

New antipsychotic drugs act primarily on other neurotransmitters, but they are also effective.

4.

Schizophrenia may involve a complex interaction between dopamine and serotonin receptors.

Current theories focus on other neurotransmitters, including serotonin, glutamate, and GABA.

Social factors—environmental events play an important role 1.

C.

Dopamine hypothesis

Social class—an inverse relationship exists between social class and schizophrenia a.

Social causation hypothesis—social class hardships cause schizophrenia

b.

Social selection hypothesis—people with schizophrenia gradually fall into the lower social classes

2.

Research has supported both hypotheses to some extent.

3.

Higher risk has been reported among social immigrants (people who have moved to a new country); may be paritally due to the fact that migrants tend to settle in cities where they may face greater exposure to discrimination

4.

In general, the results of studies on socioeconomic status suggest that schiophrenia may be at least partially influenced by social factors.

Psychological factors 1.

Family interactions— previously, it had been hypothesized that communication and behavior 229 C.

within families was a causal factor; this is not the case, however (most of these initial studies lacked control groups)

D.

VI.

2.

For people with schizophrenia, relapse is associated with family patterns of interaction characterized by high levels of expressed emotion (EE)—negative or intrusive attitudes and behavior toward the patient

3.

High EE also predicts relapse for other disorders.

4.

Cross-cultural studies reveal that high expressed emotion tends to be more prominent in Western countries, possibly serving to explain the more severe course/outcome of the disorder in the West.

5.

Patients with mood disorders, eating disorders, panic disorder with agoraphobia, and obsessive-compulsive disorder are also more likely to relapse following discharge if they are living with a high EE relative.

Interaction between genetics and environment provides the most sensible model to explain schizophrenia.

The search for markers of vulnerability A.

The workgroup for DSM-5 considered including attenuated psychosis syndrome, which would involve the prodromal symptoms of schizophrenia, but it was ultimately placed in section III (Conditions for Further Research).

B.

A promising option might be to identify the endophenotype, a component or trait that lies somewhere on the pathway between the genotype, which lays the foundation for the disorder, and full-blown symptoms of the disorder.

C

Ideally, any markers will meet the following criteria:

D.

1.

Able to distinguish between those who have developed schizophrenia and those who have not

2.

Stable characteristic over time

3.

Able to identify biological relatives of people with schizophrenia

4.

Able to predict who will develop schizophrenia

5.

Vulnerability markers have been called endophenotypes

Possible markers include the following: 1.

Working memory impairment a.

People with schizophrenia show deficits on the n-back task, in which subjects are asked to identify which symbols they have seen previously.

b.

Working memory problems are stable for schizophrenia patients and are also found within unaffected first-degree relatives of schizophrenic persons.

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c.

2.

VII.

Many people with schizophrenia also show deficits with central executive functioning or the manipulation of data that are held in storage buffers.

Eye-tracking dysfunction a.

People with schizophrenia exhibit rapid eye movements instead of smooth-pursuit tracking, specifically while tracking the motion of a pendulum or a similarly oscillating stimulus.

b.

Eye-tracking deficits may identify people with a particular form of schizophrenia.

c.

Approximately 50 percent of the first-degree relatives of schizophrenic persons show similar smooth-pursuit impairments.

Treatment A.

Antipsychotic medication 1.

Use of medications with people with schizophrenia began in 1950 with phenothiazines (e.g., Thorazine), which had a calming effect and allowed for deinstitutionalization.

2.

Antipsychotic drugs reduce the severity of and sometimes eliminate psychotic symptoms.

3.

B.

a.

About half of patients show significant improvement within four to six weeks; some show only mild improvement (30–40 percent); about a quarter show no improvement

b.

Continued maintenance medication after the acute phase may reduce relapse rate from 65–70 percent to about 40 percent.

c.

Unfortunately, 25 percent do not improve on antipsychotic drugs.

Motor side effects a.

Extrapyramidal symptoms (EPS)—muscular rigidity, tremors, restless agitation, involuntary postures, and motor inertia are quite common; may diminish after three to four months; other medications can minimize the severity of EPS

b.

Tardive dyskinesia (TD)—involuntary movements of the mouth and face, spasmodic movements of the trunk and body; sometimes it is irreversible; approximately 20 percent of patients develop TD after long-term neuroleptic use

Second-generation antipsychotics—introduced in the U.S. in the 1990s 1.

As effective in treating positive symptoms as traditional antipsychotics; less likely to produce tardive dyskinesia

2.

Are no more effective in reducing negative symptoms than are traditonal antipsychotics, although, this is contrary to early expectations and reports; also, many serious side effects are common for the second-generation antipsychotics: weight gain and risk for medical conditions, such as diabetes, hypertension, and coronary artery disease

3.

They produce a broader range of neurochemical actions in the brain than do the first-generation 231 C.

C.

antipsychotic drugs, acting on both serotonin receptors and dopamine receptors, leading to more success with reduction of positive symptoms and, perhaps, less risk of motor symptom development.

Psychosocial treatment—long-term strategies 1.

2.

3.

4.

5.

Family-oriented aftercare involves an education component to improve coping skills of family members. a.

Goals are to eliminate unrealistic expectations and improve communication.

b.

Reduces relapse rates only if available on an ongoing basis

c.

Experts currently call for research into more efficient family-oriented treatment programs.

Social skills training (SST) a.

Involves modeling, role-playing, and reinforcement of positive behaviors

b.

Seems to improve social adjustment but may not reduce relapse rates

Cognitive therapy a.

Interventions may focus on cognitive procedures that evaluate, test, and correct distorted ways of thinking about self and environment; some cognitive approaches are specific to deficits often found in schizophrenic patients.

b.

Cognitive enhancement therapy aims to improve cognitive capacities; both cold cognitive functions (e.g. working memory) and social cognitive skills are targeted.

Assertive community treatment (ACT) a.

Focus is on providing an array of psychological interventions and medication on a regular and continuous basis in the community

b.

Studies suggest it is effective in reducing inpatient hospital days and, despite its expense, it is cost-effective.

c.

Psychosocial intervention that is delivered by an interdisciplinary team of clinicians

Institutional programs a.

Hospitalization (at least two to three weeks) is often needed for acute psychosis.

b.

Social learning programs: behaviorally-based (e.g., using a token economy system); effective for increasing adaptive behaviors and decreasing problem behaviors

c.

Institutionalization with social learning programs has been shown to lead to positive long-term outcomes.

232 C.

LEARNING OBJECTIVES LO 13.1: Why do clinical scientists say that schizophrenia is a “heterogeneous” disorder?

LO 13.2: How should long-term outcome be measured in schizophrenia?

LO 13.3: Why are some personality disorders considered to be schizophrenia spectrum disorders?

LO 13.4: Why can’t we use brain imaging to diagnose schizophrenia?

LO 13.5: What characteristics would define a useful marker of vulnerability to schizophrenia?

LO 13.6: What aspects of schizophrenia are addressed most directly by psychosocial treatments?

LECTURE SUGGESTIONS Positive and negative symptoms Students generally have a difficult time distinguishing between positive and negative symptoms of schizophrenia. As with positive and negative reinforcement, they often consider the terms “positive” and “negative” to refer to “good” and “bad” rather than “present” and “absent.” Therefore, it may be helpful to devote some additional time to this method of classifying symptoms. Remind students that positive symptoms are symptoms that are present that should not be present, that negative symptoms refer to aspects of behavior and relating that should be there but are absent, and that these terms have nothing to do with “good” or “bad” aspects of the disorder.

Positive symptoms of schizophrenia are the aspects of the disorder that people most clearly equate with “craziness,” such as hearing voices, having delusional beliefs, and exhibiting odd behaviors. However, the negative symptoms are in some ways more disabling, as they represent the loss of core aspects of the ability to socially relate. Negative symptoms are also the more difficult to treat and associated with the poorest prognosis.

Schizophrenia: A neurodevelopmental perspective: Current directions APS reader (1E, p. 122) Conklin and Iacono present some of the current biologically-based schizophrenia research. One of the most prominent hypotheses is that schizophrenia “results from a disruption in forebrain development during the perinatal period” (pg. 122). The symptoms are then triggered or manifest in adolescence as the brain reaches full maturity. Of course, we have long suspected that schizophrenia is a "biologically-based" disease, mostly because of the strong evidence from family, twin, and adoption studies. Specific genetic linkage studies, however, have not yet identified an actual link, but a promising development has occurred in examination of chromosome 1 (Brzustowics et al., 2000). Still another recent line of research has looked at the risk of hypoxia-associated obstetric complications (that result in oxygen deprivations) with some evidence that schizophrenia may result from a combination of a genetic predisposition coupled with obstetric complications. For many years, we have also suspected that in utero, viral exposure may play a role in the development of schizophrenia because of the high number of winter births among schizophrenia patients and the increase in viral epidemics in the fall that may have influenced pregnancies.

Enlarged ventricles (fluid-filled spaces in the brain) have been identified in schizophrenia patients as a 233 C.

causative factor or simply a correlate of the disease. Imaging studies also reveal blood-flow abnormalities in the medial-temporal and frontal lobes of schizophrenia patients. It is possible that temporal lobe dysfunction contributes to positive symptoms (e.g. hallucinations and delusions), whereas frontal lobe dysfunction may contribute to negative symptoms (e.g., impoverished thought and social withdrawal). Memory functions are also impaired in schizophrenia and research continues to grow suggesting that cognitive impairments can be clearly identified, which is consistent with brain imaging research results. The dopamine hypothesis, "has been revised to suggest a dysregulation of dopamine resulting in an excess of dopamine in temporal areas and a depletion of dopamine in frontal areas” (pg. 124).

Conklin and Iacono also discuss some early indicators that are being examined, which could lead to earlier identification of schizophrenic tendencies. In a British study by Jones and colleagues (1994), preschizophrenic children exhibited delayed motor development, lower test scores at ages 8,11, and 15, preferred solitary play at ages 4 and 6, and were rated as more anxious in social situations at age 15. Eye movement dysfunction continues to be an area of investigation because we find abnormalities not only in schizophrenic patients themselves but also in relatives of the patients, suggesting a genetic basis. Finally, the connection between schizophrenia and velocardiofacial syndrome (VCFS) presents some fascinating and promising opportunities for understanding the origins of schizophrenia. The rate of schizophrenia among people afflicted with this congenital syndrome is about 25 times higher than the overall incidence rate of schizophrenia in the population. Children with VCFS and preschizophrenic children show “strikingly similar developmental characteristics” (pg. 126). This article does an excellent job of summarizing recent developments in schizophrenia research and does so in a very readable manner.

Labeling theory: Many sociocultural theorists have argued that schizophrenic symptoms may be caused by the diagnosis itself.

They use "labeling theory" to explain at least some of the etiology of schizophrenia. The logic is as follows: once a patient is diagnosed as "out of touch with reality," he or she is more likely to conform to the diagnosis. They may even be positively reinforced for "schizophrenic behavior," since the diagnostician wishes to confirm his/her diagnosis. Rosenhan’s (1973) study provides a graphic illustration of the tendency for people to see what they expect based on a label. Volunteers presented themselves to psychiatrists with the manufactured “symptom” of hearing voices that said “empty,” “hollow,” and “thud.” They were hospitalized and continued to be viewed as having schizophrenia despite the fact that they were, and were behaving as, normal people. Many current theorists grant that labeling can be dangerous and can have a deleterious effect on psychiatric patients. Few, however, agree that schizophrenia is "created by society" or is the result of a self-fulfilling prophecy due to labeling. The cross-cultural, biological, and genetic evidence is simply too powerful.

Rosenhan, D.L. (1973). On being sane in insane places. Science, 179, 250–258.

Szasz, T.S. (1977). Psychiatric Slavery. New York: Free Press.

DISCUSSION IDEAS Objectifying schizophrenia: We may refer to a person who suffers from schizophrenia as "schizophrenic," and we say that such a person “is a schizophrenic” rather than saying that they “have schizophrenia.” This tends to imply that once people exhibit the symptoms of schizophrenia, they will always suffer from those symptoms. Perhaps more importantly, labeling in this manner defines the person by his or her disorder and may be seen as suggesting that the disorder is the most salient, or the defining aspect of the person. Should we continue to use this language? Does it make sense to assume that people with schizophrenia will always have the disorder, or should we view them as victims of a temporary 234 C.

illness, like we view people with depression, phobias, and anxiety disorders? Remind the students that many people who have episodes of schizophrenia do not have subsequent symptoms (about one-third). Should we use the term “schizophrenic” at all? (We don’t refer to people with leukemia as “leukemics.”)

Cognition in schizophrenia: Current directions APS reader (1E, p. 130) Deanna Barch’s article on cognitive deficits in schizophrenia provides a good summary of some of the recent literature on cognitive impairments involved in schizophrenia. The discussion of cognitive problems schizophrenic patients experience, especially with working memory, can easily lead to a reflection on causative versus correlative factors. Are these cognitive impairments the cause of schizophrenia or simply byproducts of the disease? Describe some of the deficits that are apparent in schizophrenic patients and then ask students to consider some of the factors that have been identified as tied to schizophrenia: prenatal and perinatal disturbances, dopamine dysregulation, dysfunctional family systems with overly critical parental behavior, working memory deficits, eye movement abnormalities, temporal and frontal lobe blood flow irregularities. From these factors, ask students to decide which are potential causes and which are correlatives.

Implications of vulnerability: If linkage studies are able to determine more clear genetic markers, and/or brain imaging techniques can identify abnormalities in the brain of infants predisposed to schizophrenia, what would students recommend to reduce the probability of mental illness in the young child who is at risk of developing symptoms? Ask students to (a) consider what is known about the influence of environmental factors on the development and maintenance of schizophrenia in particular, to (b) consider known and hypothesized effects of specific stressors, to (c) differentiate between factors that may reduce the development of problems and those that may compensate for their presence, and to (d) develop a plan that they might suggest for parents of children determined to be at high risk for the development of schizophrenia.

CLASSROOM ACTIVITIES Myths about schizophrenia: Break the class into small groups of students and ask the groups to respond to the following commonly-held beliefs about schizophrenia: (1) People with schizophrenia have a split personalities.

(2) People with schizophrenia are dangerous.

(3) People with schizophrenia cannot be cured.

(4) People with schizophrenia cannot live independently or care for themselves.

(5) People with schizophrenia come from dysfunctional families.

Ask the groups to rewrite each of these "myths" to properly qualify each statement: e.g., people with schizophrenia are believed to have a split between their thoughts and their feelings. Groups should then tackle the question of how and why these myths have been propagated and how they can be challenged and overcome.

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Focusing through the voices: Ask students to speculate on what it would be like to live with auditory hallucinations common to schizophrenia. It is often difficult to truly empathize with the challenge of this experience. The following exercise offers a small glimpse into the challenge of focusing one’s attention within the context of auditory hallucinations.

Exercise: Ask for six volunteers from the class. Without telling the rest of the class, tell the volunteers that they will each represent a ‘voice’ in the mind of someone with schizophrenia. Ask them each to pick a topic they will discuss in front of the class. It works best if one or two students choose to make a noise or say a word repeatedly, (e.g., ‘boom”) while one tries to give a running dialogue on everything he/she sees happening in the classroom, and another makes random comments about ancillary events, such as the weather. Instruct them that they will stand in front of the class and begin to talk simultaneously and get louder over time as if fighting to be heard.

Ask students to try and keep notes on what the volunteers are saying. Let this continue for approximately one minute.

After the activity is completed, have students reflect on the experience. Were they frustrated? Did they notice physical and emotional responses to the experience and their frustration? What would it be like to live with auditory hallucinations most of the time?

A song to capture the essence of schizophrenia: Divide the class into small groups and ask them to reflect on the lecture, class discussion, and the readings for this activity related to the chapter on schizophrenia. Then ask the students to select a popular song that would best illustrate the diagnosis of schizophrenia, perception, or treatment of schizophrenia and be able to give an explanation as to why they selected that particular song. Allow five to seven minutes for the students to brainstorm and come up with a song idea, then ask the groups to share with the class.

Pictionary: Schizophrenia Put on cards the bolded terms in the textbook chapter, such as positive symptoms, negative symptoms, etc.

This activity can be done by the whole class, in small groups or in small groups paired with other small groups to create a team A and a team B. Provide some blank paper and writing utensils for the students, such as markers, colored pencils, or crayons. Decide who will go first in the game. Selecting from the cards you created and using them as prompts, the students then will go one by one, drawing for their team to guess the concept or definition they have selected. The students will take turns from their respective teams.

Case Study: For this activity, you can have the same case study or a variety of case studies related to the chapter on schizophrenia and psychotic disorders for the students to assess. After dividing the class into small groups, pass out a case study to each small group. Ask the students to work within their groups to identify the following: (1) Diagnosis—evaluate the signs and symptoms evident within the case study (2) Evaluate the multiaxial of the DSM Axis I–Axis V (3) If the individual in the case study does not meet criteria for schizophrenia, might he qualify for a related psychotic disorder and why?

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(4) What would be the best treatment methods?

(5) What is the prognosis for this individual?

VIDEO CASES IN ABNORMAL PSYCHOLOGY: Larry—Schizophrenia (16:54) Larry has been given a diagnosis of paranoid schizophrenia. He admits to hearing occasional voices, stating that he has “all kinds of companions.” He describes having created fictional baseball players as a child. Symptoms began in the seventh grade but fully surfaced in his senior year of high school when he suffered from a “nervous breakdown.” By the time he reached his junior year of college, he says he had difficulties even making it to classes.

He also describes having “lost all contact with reality” and that, without medication, he tends to “lose all contact with reality.”

Larry’s descriptions of his paranoid thoughts are typically not very well articulated. There is an edge in his voice in response to questions, which may be an indicator of his difficulties with trust. He says that he has never “acted physically” on any of his hallucinations or in response to any of his negative voices. He maintains two clerical volunteer positions, lives alone, and seems to be coping relatively well with his disease. He regrets, however, not being able to have a son, not having a more free life, and not having been able to pursue some of his grandiose dreams, such as becoming a professor of Political Science at Harvard.

Discussion questions: 1.

Do you think Larry’s creation of "fictional baseball players" could have been viewed as an early indicator of his pathology?

2.

Larry says he is basically pretty happy with his life as it is now. Do you believe him? Do you think he suffers more than we are able to observe in this interview?

3.

How do you think Larry would present himself if he were not on his medications or was having an acute episode?

4.

Does Larry have primarily positive symptoms or negative symptoms? Describe aspects of each of them.

Josh—Schizoaffective Disorder (20:23) Josh suffers from obsessive thoughts that often have paranoid content. He says that, currently, medications control his psychotic symptoms, but, when not medicated, he is likely to have powerful hallucinations and delusions. He believed the mafia was after him, and he also believed he was in the middle of a war. He has also had grandiose thoughts of winning the Nobel Prize and of running in the Boston Marathon. His symptoms began as a freshman in high school. He describes reading a book about the Beatles and finding that the book was telling him what people in his class were saying. He also states that he began abusing alcohol in eighth grade, which may have contributed to his symptoms. At 19, he was brought to a mental hospital in handcuffs. He says he was suffering from “paranoia and panic to the max” at that time.

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Currently, Josh suffers from cycles of mood changes, which are fairly classic bipolar fluctuations. He describes feeling “really high and manic” at times, and then, at other times, suffering from feeling “really low, can’t get out of bed, don’t shower, don’t shave.” He says that he is still “too paranoid to be close to anyone” but has maintained a steady job for about nine years. At present, he still has hopes to have a wife but acknowledges that he will probably never have a family and says of his illness, “It is not fun at all—it’s not funny at all.”

Discussion questions: 1.

What do you think the impact of alcohol use was on Josh’s symptoms? What about his discussion of the use of marijuana? Do you think this worsened his condition?

2.

How are Josh’s symptoms different from those who suffer from simply a mood disorder or from schizophrenia? What does schizoaffective disorder mean, and how does this case exemplify this diagnosis?

3.

Do you think it is realistic for Josh to consider a romantic relationship with a woman? Is he capable of having a successful relationship?

Georgianna--Schizophrenia, age 33 (12:35) Georgianna is a 33-year-old woman with schizophrenia who first knew something was wrong at the age of fourteen. She has experienced delusions, hallucinations, and catatonic episodes; now she controls her episodes by medication.

Discussion questions : 1.

Georgianna describes her schizophrenia as developing in order for her to escape from reality. Describe specific situations in which a schizophrenic episode allowed her to do so.

2.

Describe the role Georgianna's family played in her schizophrenia; note both positive and negative influences.

VIDEO RESOURCES http://media.pearsoncmg.com/ab/ab_lefton_psychology_8/media/schizophrenia/index.html Schizophrenia Overview Try this narrated overview of schizophrenia including an interactive video-based simulation.

http://wps.prenhall.com/wps/media/objects/803/822654/simulations/unch_11.swf Biomedical Therapies Try this drag and drop exercise to match drug treatments with psychological disorders.

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http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Josh_Schizoaffective_ Disorder.html Josh: Schizoaffective Disorder (3:40) Watch this video of Josh discussing his personal experiences with schizoaffective disorder.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Brain_Imaging_2.html Brain Imaging (Alternate) (1:38) Watch this video about ways to scan the brain with information about the available scanning options.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/APS2010/RandallEngle2. html Randall Engle: What Is Working Memory? (3:04) Watch psychologist Randall Engle explain how working memory manifests.

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Chapter 14 Dementia, Delirium, and Amnestic Disorders Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: p.380 Symptoms: p. 383

Discussion Ideas: Alzheimer’s symptoms

Delirium Major Neurocognitive Disorder Diagnosis Brief Historical Perspective Specific Disorders Associated with Dementia

Classroom Activities: Dealing with cognitive deficits Video Case: Dementia, Alvin Discussion Ideas: Assessment of dementia

Frequency of Delirium and Major Neurocognitive Disorders: p. 394 Prevalence of Neurocognitive Disorders Prevalence by Subtypes of Neurocognitive Disorders Cross-Cultural Comparisons Causes: p. 396 Delirium Neurocognitive Disorder

Lectures: Cognitive activity and Alzheimer’s disease Discussion Ideas: The future of aging

Lectures: Engaged lifestyle as a buffer against dementia Effects of a stroke,

Treatment and Management: p. 399 Medication Environmental and Behavioral Management Support for Caregivers

Lectures: Treatment for Alzheimer’s disease Classroom Activity: Visit a nursing home Speaking Out Videos: Video Case: Wife of patient with Alzheimer’s Disease, Sarah, 240

C.

PROFESSOR NOTES

CHAPTER OUTLINE I.

II.

Overview A.

Dementia—gradual loss of memory and impairment in cognitive functions, such as language, reasoning, and decision making

B.

Delirium—a short-term confused state associated with agitation and hyperactivity, disorganized thinking, and reduced ability to maintain and shift attention

C.

Amnestic disorders—limited memory impairments; loss of ability to learn new information or recall previously learned information

D.

Diagnosis and treatment generally provided by neurologists; neuropsychologists have expertise in assessing cognitive impairments associated with these disorders

Symptoms A.

B.

Delirium 1.

Primary symptom is clouding of consciousness in association with reduced ability to maintain and shift attention; memory deficits are probably a result of attention problems; fleeting perceptual disturbances (e.g., visual hallucinations) are also common

2.

Symptoms have a rapid onset (from a few hours to a few days) and usually fluctuate throughout the day, with symptoms generally worse at night.

3.

The delirious person is likely to be disoriented with relation to time or place, but generally the person does not experience identity confusion; the sleep-wake cycle is also often disrupted.

4.

Distinguished from dementia in its rapid onset, brief duration, lack of alertness and responsiveness, confused speech, and positive immediate prognosis

Major neurocognitive disorder (NCD)—a new DSM-5 diagnosis previously called dementia but now somewhat more broad as it also contains individuals whose cognitve decline is domain specific 1.

2.

Neurocognitive symptoms a.

Dementia can affect people who previously displayed high levels of intelligence.

b.

The early stages of dementia are difficult to identify because they resemble normal aging.

Memory and learning—memory loss is the central feature of major NCD a.

Retrograde amnesia—loss of memory for events prior to onset of an illness or the experience of a traumatic event

b.

Anterograde amnesia—inability to learn or recall new material after a particular time; most obvious problem in the early stages of major NCD 241 C.

3.

4.

Verbal communication a.

Aphasia—loss or impairment in language caused by brain damage; includes trouble finding words, naming objects, or comprehending instructions

b.

Apraxia—difficulty performing purposeful movement in response to verbal commands; individual has sufficient strength and comprehension but cannot translate the various components into meaningful action

Perception a.

Agnosia—difficulty identifying stimuli in the environment; it is associated with visual, auditory, or tactile sensations; it can be relatively specific or more generalized, e.g., visual agnosia is the inability to recognize certain objects or faces

b.

Can be associated with brain dysfunction; site of lesion determines type of agnosia

5.

Loss of capacity for abstract thinking—overly concrete interpretations; difficulty interpreting words with more than one meaning or explaining how two things are alike

6.

Judgment and social behavior—failure in social judgment and problem-solving skills, resulting in impulsive and careless behavior; the disruption of short-term memory, perceptual skills, and higher-level cognitive abilities

7.

Assessment of neurocognitive impairment

8.

a.

Mini-Mental State Examination—measures a person’s level of cognitive impairment; assesses orientation to time and place, anterograde amnesia, agnosia, aphasia, and apraxia

b.

Neuropsychological assessment 1.

Can be used as a more precise index of cognitive impairment

2.

Psychological tests that evaluate sensorimotor, perceptual, and speech functions

Personality and emotion a.

Emotion 1.

Emotional responses may appear to be apathetic or emotionally flat.

2.

Hallucinations and delusions occur in at least 20 percent of the cases; more common in later stage najor NCD; common themes are phantom houseguests and personal persecution

3.

Depression is common, often in response to awareness of one’s situation; it is not surprising that individuals tend to become depressed upon realizing that they are losing much of their cognitive faculty

4.

Emotional reactions may become exaggerated and less predictable.

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b.

C.

1.

Increased agitation may be present with pacing restlessly or wandering away from familiar surroundings.

2.

Seizures may occur, which consist of involuntary, rapidly alternating movements of the arms and legs.

3.

In the later stages of the disorder, patients may develop problems in the control of the muscles by the central nervous system.

Dementia versus depression 1.

There is much overlap between dementia and depression; approximately 25 percent of patients with dementia also exhibit signs of depression.

2.

There are five major symptom-based differences between depression and dementia:

3.

D.

Motor behavior

a.

Depression has uneven progression over weeks, whereas dementia has even progression over months and years.

b.

Depressed patients complain of memory loss, whereas dementia patients try to hide this.

c.

Depression is often worse in the morning, whereas dementia is worse later in the day.

d.

People with depression are often aware and exaggerate their disability, whereas people with dementia are unaware and try to minimize the disability.

e.

Depressed pateints may abuse substances, whereas this is uncomon in dementia patients.

Pseudodementia—may be used to describe people displaying some of the signs of dementia but are likely experiencing them as a consequence of major depression not as a result of dementia.

Diagnosis 1.

Historical perspective a. Alois Alzheimer and Emil Kraepelin discovered that a form of major NCD was associated with bundles of neurofibrillary tangles and amyloid plaques in the brain. b. Kraepelin, who first referred to this form as Alzheimer’s disease, distinguished between early and late onset of the disorder, but others have questioned the validity of this distinction.

2.

Early versions of the DSM classified the various forms of dementia as organic mental disorders. a.

Disorders associated with major NCD vary based on onset and course only.

b. Major NCD includes what was previously dementia as well those forms previously known as amnesic disorders. In order to qualify for major NCD, the patient must experience cognitive 243 C.

decline in one or more domains, and those declines must interfere with the person’s independence in everyday activities. c. Mild NCD is used to recognize less severe forms of the disorder.

3.

Specific cognitive disorders a.

Neurocognitive disorder due to Alzheimer's disease 1.

Onset is gradual and cognitive deterioration is progressive.

2.

Diagnosis is made by ruling out other conditions, such as vascular disease, Huntington’s disease, Parkinson’s disease, or chronic substance abuse.

3.

Definitive diagnosis made upon a brain exam during autopsy that identifies neurofibrillary tangles (in cerebral cortex and hippocampus), which have also been found in adults with Down syndrome and patients with Parkinson’s disease, and amyloid plaques (in cerebral cortex), which consist of a central core of homogenous protein material called beta-amyloid surrounded by clumps of debris left over from destroyed neurons.

4.

Researchers have developed a method for identifying amyloid plaques using positron emmsion tomography (PET). The hope is that this may one day replace post-mortum autopsies. b.

Frontotemporal neurocognitive disorder 1.

Associated with atrophy of frontal and temporal lobes of the brain

2.

Memory and language deficits, personality changes, impulsive actions similar to Alzheimer’s 3.

Early personality changes that precede the onset of cognitive impairment are more common.

4.

Impaired reasoning and judgment are more prominent than anterograde amnesia

5.

In comparison to Alzheimer’s patients, patients with frontotemporal NCD are also more likely to engage in impulsive sexual actions, roaming, aimless exploration, and other types of disinhibited behaviors. c.

Major neurocognitive disorder with Lewy bodies (NCD with Lewy bodies) 1.

A relatively new diagnostic category that has unclear boundaries and overlaps with other forms of major NCD; many experts agree that NCD with Lewy bodies may be second most common form of major NCD after Alzheimer’s disease 2.

Initial symptoms are memory deficits followed by global major NCD

3.

Episodic nature of symptoms resembles delirium 244 C.

4.

Other symptoms include visual hallucinations, muscular rigidity

5.

Lewy bodies, also called intracytoplasmic inclusions, are rounded deposits found in nerve cells.

6.

Named after F.H. Lewy, who first described them in 1912; found in the brain stem nuclei of patients with Parkinson’s disease 7.

30 percent of people who meet diagnostic criteria for Alzheimer’s disease also have Lewy bodies in cortical neurons. d.

Vascular neurocognitive disorder 1.

One cause of major NCD is vascular or blood vessel disease, which affects the arteries responsible for bringing oxygen and sugar to the brain.

2.

Onset may be sudden; signs or symptoms of a stroke must be present

3.

A stroke is the severe interruption of blood flow to the brain.

4.

The area of dead tissue produced by a stroke is an infarct; behavioral effects of a stroke are obvious and distinguished from major NCD, since they appear suddenly, affect voluntary movements, gross speech, and intellectual abilities, and result in unilateral impairments, such as paralysis of only one side of the body.

5.

When these small strokes occur over a period of time, and if their sites are scattered in different areas of the brain, this produces cognitive impairment, which is referred to as vascular NCD. e.

Neurocogntive disorder due to traumatic brain injury 1. Traumatic brain injury (TBI) results from the head being involved in a collision, resultng in the displacement of the brain in the skull. a.

Often consciousness is lost

b. Individuals who experienced TBI are more likely to experience dementia later in life.

2. Popular media have begun covering these occurrences. f.

Huntington's disease 1.

Differentiated major NCD—patients exhibit chorea, unusual involuntary muscle movements; subtle at first but become uncontrollable as the disorder progresses 2.

Personality changes occur, along with the onset of depression and anxiety

3.

Movement disorder and cognitive deficits caused by neuronal degeneration in basal ganglia 245 C.

4.

Diagnosis depends on a positive family history for the disorder; one gene from either parent makes one vulnerable 5.

Major NCD is most evident in recent memory and learning; higher level cognitive functions are typically not affected g.

Parkinson's disease 1.

Motor system disorder caused by degeneration of substantia nigra and loss of dopamine, which is produced by cells in this area 2.

Symptoms: tremors, rigidity, postural abnormalities, decreased voluntary movements; only 20 percent become demented

III.

Frequency of delerium and major neurocognitive disorders A.

B.

C.

A pressing health care issue 1.

15 percent of elderly hospitalized medical patients show symptoms of delirium; can appear in people as young as 40 to 45

2.

As the population ages, the incidence of major NCD will increase dramatically.

Major NCD can be difficult to diagnose.

1.

Early or mild symptoms can be hard to distinguish from the forgetfulness of normal aging.

2.

Definitive diagnosis requires autopsy of the brain after the person’s death

3.

By the year 2030, more than 9 million people in the U.S. will be affected by Alzheimer’s disease.

Prevalence of major neurocognitive disorder 1.

Increases dramatically with age a.

1 percent for ages 65–69

b.

6 percent for ages 75–79

c.

40 percent for ages over 90

2.

Survival rate is reduced in those with dementia; there is much variability, with some patients living 20 years

3.

No gender differences for overall prevalence, although specific types may vary by sex; it seems to be that major NCD in men is associated with vascular disease or is secondary to other medical conditions like alcohol abuse; the incidence of vascular NCD is generally lower in women than in men at all age groups 246 C.

4.

D.

IV.

Prevalence by subtypes of neurocognitive disorder: Alzheimer's type major NCD appears to be the most common, followed by NCD with Lewy bodies and vascular NCD, Pick's disease, and Huntington's disease, which is quite rare and affects only 1 person in every 20,000.

Cross-cultural influences 1.

Difficult to assess because of the role of education in cognitive functioning

2.

Some differences exist and are likely a function of genetic, dietary, and other environmental factors

3.

Alzheimer’s disease may be more common in North America and Europe, whereas vascular NCD is more common in Japan and China.

Causes A.

B.

Delirium 1.

Medication side effects are common cause; includes psychiatric drugs, painkillers, stimulants (including caffeine) and cardiac medications

2.

Can develop in conjunction with medical illnesses, such as pulmonary, cardiovascular and endocrine diseases, and infections, most commonly with urinary tract infections

Neurocognitive disorder 1.

Genetics a.

Major NCD runs in families.

b.

Twin studies confirm that genetic factors play a role in major NCD. One study of Sweedish twins found a 50 percent concordance rate among monozygotic twins, more than double the dizygotic rate.

c.

Linkage studies have found specific genes related to different forms of Alzheimer’s as well as to increased risk for Alzheimer’s

d.

2.

1.

Mutations on chromosome 14 and chromosome 1 have been found to be associaed with early onset Alzheimer’s.

2.

The APP and APOE genes are also associated with dementia.

Although genetic research is exciting, a word of caution is necessary as most people who develop these disorders do not have one of the specified genes.

Neurotransmitters—chemical transmission of messages in the brain is disrupted a.

Parkinson's disease—degeneration of the dopamine pathways in the brain stem

b.

Huntington's disease—gamma amino butyric acid (GABA) deficiencies

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c.

V.

Alzheimer's disease—acetylcholine (ACh) deficiencies

3.

Viral infections—major NCD may be the product of slow viral infections, with susceptibility to the virus being genetically predisposed

4.

Immune system dysfunction—the immune system breaks down; therefore the brain tissue is left susceptible to deterioration; the presence of beta-amyloid at the core of amyloid plaques is one important clue to the possible involvement of immune system dysfunction

5.

Environmental factors a.

Head injury with loss of consciousness in adulthood is associated with increased risk for Alzheimer’s

b.

Higher levels of education associated with reduced risk of developing Alzheimer's.

c.

Increased “brain work” leads to facilitation of neuronal activation, increased cerebral blood flow, and higher levels of glucose and oxygen consumption in the brain.

Treatment and management A.

B.

C.

Accurate diagnosis 1.

Delirium can be effectively treated when detected early enough for the underlying medical condition to be treated.

2.

Secondary NCD (e.g., as a result of depression) can be treated successfully with antidepressants or other treatments for the primary condition.

3.

A return to previous levels of cognitive function is generally not possible for people with NCD, especially those with Alzheimers disease.

Medication 1.

Some drugs do improve cognitive symptoms by boosting acetylcholine (ACh), a neurotransmitter that is involved in memory action, but the effect is temporary and of questionable clinical significance.

2.

New drug treatments in development will target neuron destruction.

3.

Neuroleptic medications are used to treat psychotic symptoms in demented patients.

4.

One drug that has been approved for use with Alzheimer’s patients, donepezil (Aricept), increases ACh activity.

Environmental and behavioral interventions 1.

Providing structure and predictability—e.g., familiar surroundings

2.

Labeling environment, making important areas accessible, and making sure the area is safe 248 C.

3.

D.

Helping the person remain physically active and involved in activities

Support for caregivers 1.

Family members care for 80 percent of people suffering from NCD.

2.

Emotional and physical burdens are often overwhelming for caregivers; they frequently feel lonely, sad, guilty, depressed, and frustrated.

3.

Caregivers benefit from flexible, comprehensive programs, such as support groups, informal consulting, and ad hoc consultation services.

4.

Results from randomized controlled trials suggest that support for caregivers can improve quality of life and well-being for both the patient and the caregiver.

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LEARNING OBJECTIVES LO 14.1: What is the difference between cognitive problems in anxiety and those seen in major neurocognitive disorders?

LO 14.2: In what ways is delirium different from dementia?

LO 14.3: Is memory impairment the only indication that a person is developing a major neurocognitive disorder?

LO 14.4: Why is depression in an elderly person sometimes confused with dementia?

LO 14.5: How could education help to reduce a person’s risk for major neurocognitive disorder?

LO 14.6: What are the most difficult problems faced by people caring for a person with a major neurocognitive disorder?

LECTURE SUGGESTIONS Cognitive activity and Alzheimer’s disease: Current directions APS reader (1E, p. 137) Wilson and Bennett review the literature that explores the connection between the level of cognitive activity and incidence of Alzheimer’s disease. In the last decade, it has become clear that the incidence of Alzheimer’s disease is related to the level of education and occupation, and this common, but mostly untested assumption, has formed by noting a greater level and frequency of cognitive activity among the highly educated elderly . Indeed, in one study of older Catholic clergy members, "Persons reporting frequent participation in cognitively stimulating activities had only half the risk of developing Alzheimer’s disease” (Wilson et. al., 2002).

The causative mechanism that links cognitive activity to Alzheimer’s disease, however, is not clear. One current theory is that the more educated (and cognitively active) begin their old age at a higher level of cognitive function, and therefore they need to "lose more" capacity before being finally diagnosed as having Alzheimer’s.

There is evidence, also, of a slower loss of cognitive function among those more cognitively skilled. In fact, researchers have noticed that processing skills like perceptual speed and working memory do not decline as rapidly within those who are more cognitively active. It is also possible that the impact of Alzheimer’s disease pathology is simply not as strong in persons with more education, suggesting that those who are more cognitively active are more capable of “tolerating” Alzheimer’s disease pathology.

One of the natural assumptions in response to this research is to recommend that older people remain as “cognitively active” as they can. Indeed, this makes perfect sense given the research. Wilson and Bennett, however, are quick to point out that, “It is uncertain to what extent cognitive stimulation in late life, as opposed to early life or adulthood, is critical.” More research would be needed to examine the effects of “cognitive training programs” for the elderly. It certainly appears as if the brain functions similarly to other parts of the body; if you don’t use it, you’re more likely to “lose it.”

Engaged lifestyle as a buffer against neurocognitive disorder: A recent study provides hope for the effects of an ‘engaged lifestyle’ on symptoms of neurocognitive disorder and, possibly, on the symptoms of Alzheimer’s disease. Participants were assigned to either a control group or an 250 C.

experimental group in which they were challenged with cognitive tasks in a group setting. This was, indeed, an intensive procedure; the groups met 20 times per week and worked on problems related to speed of processing, memory, and reasoning. The experimental group scored higher on a number of cognitive dimensions—including speed, inductive reasoning, and divergent thinking (fluency). There were no differences, however, in need for cognition, mindfulness, or memory self-efficacy. This kind of immersion in cognitive activities has been advocated for several years now—as a buffer against cognitive deterioration—but this study indicates that there may be some evidence of the value of staying engaged and active cognitively through one’s adult years.

Stine-Morrow, E.A.L., Parisi, J.M., Morrow, D.G., & Park, D.C. (2008). The effects of an engaged lifestyle on cognitive vitality: A field experiment. Psychology and Aging, 23, 778–786.

Effects of a stroke: The effects of a stroke, discussed briefly in this chapter, vary considerably from patient to patient. Perhaps the most crucial factor in determining the effects of a stroke is the area of the brain in which the rupture occurs. The left hemisphere is associated with positive emotions, while the right has been found to be associated with negative emotions. Damage to the left hemisphere, then, should be more apt to promote depression (a reduction in happy emotional responses). Right hemispheric damage may actually lead to more positive emotional states (or at least less negative ones). One study by Sackeim and colleagues (Archives of Neurology, 1982, 39, 210–218) supports this hypothesis. Individuals who cried uncontrollably had suffered damage to the left hemisphere, while those who laughed uncontrollably had typically suffered right hemispheric damage.

Treatment for Alzheimer's disease: Behavioral treatment for Alzheimer's disease has been found to be at least mildly beneficial, especially when the disease is detected early enough. Behaviorists attempt to identify behaviors performed by the patient that are problematic for the him and/or his family: e.g., wandering and demanding attention. They also try to identify particular behaviors that the family would like to increase.

The family can then be taught to apply simple operant conditioning principles that can be used with the Alzheimer's patient. If the patient suffers from depression, the behavior therapist can help the patient and caregiver develop a list of activities that the patient finds pleasurable. They can then work to make those activities a regular part of each day. Over time, these behavioral strategies tend to be helpful in relieving depression and enhancing the life of the family as a whole.

Fisher, J.E. & Carstensen, L.L. (1990). Behavior management of the dementias. Clinical Psychology Review, 10, 611–629.

Teri, L. & Logsdon, R. (1991). Identifying pleasant activities for Alzheimer's disease patients.

DISCUSSION IDEAS Alzheimer's symptoms: Ask students if any of their grandparents have experienced symptoms of Alzheimer's disease or other forms of major neurocognitive disorder. Some questions that may elicit descriptive information include the following: (1) What were the first signs of a problem?

(2) Is there evidence of anterograde and/or retrograde amnesia?

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(3) How has the illness progressed over time?

(4) What kinds of interventions have been used?

Assessment of major neurocognitive disorder: Ask a hypothetical question that may help students think about the impact of major neurocognitive disorder (NCD). "If a test could be developed that would accurately predict at your current age future incidence of major NCD, would you be interested in taking that test?" Ask students who would wish for such information how they might use this knowledge to best prepare for the later onset of such a disease.

The future of aging: By the year 2050, it is estimated that there will be more old people than children or adolescents. Medical science and other factors will, particularly, swell the ranks of those over 65, in whom the greatest risk of major neurocognitive disorder lies. More people will live beyond 80 and even 90 years of age. What effect will this have on society? On nursing homes? On caregivers? On the fields of psychology and neurology?

Successful aging: We see the influence of aging in today’s society with the concept of ageism and its portrayal in the media.

What does successful aging look like? Is this picture different for men than it is for women? What factors can contribute to successful aging? How is Hollywood influencing the concept of aging?

Popular children’s films and the concept of aging: Show a couple of clips from Disney children’s films that you can access online through YouTube. Ask the students to evaluate how older adults are portrayed in the film, looking at personality characteristics, emotions, appearance, interactions with others, how the character is portrayed in the film, etc. Then ask the students to think about how this portrayal would influence children’s views of older adults or the concept of aging. It may also be helpful to ask about students’ personal experience with older adults when they were children and how those expereinces were shaped.

CLASSROOM ACTIVITIES Dealing with cognitive deficits: Break the class into small groups and ask them to discuss (1) how their family has dealt with or might deal with major neurocognitive disorder or other such disturbances in their own family, and (2) positive strategies that might improve the functioning of the sufferer as well as the coping process for the caregivers. Groups can then present their thoughts to the class. Some solutions may involve choosing to ignore cognitive difficulties in the elderly. Ask the class what the effects of ignoring or denying these kinds of problems might be.

Visit a nursing home: Suggest that students who wish to do so visit a local nursing home. Ask the students to share their experiences with the class. Ask the students to focus specifically on residents who appeared to be suffering from cognitive deficits and to consider possible diagnoses. If the student has already been informed of the diagnosis, you may ask 252 C.

the student to not reveal the nature of that diagnosis in his/ her presentation to the class so that other students can still attempt a diagnosis. Consider specific symptoms, course, and other relevant factors.

Guest speaker: Geropsychology Invite a guest speaker to come to the class and talk about working in the field of geropsychology, including in the discussion such notes as the typical diagnoses seen, the treatment and intervention options, the special considerations for working with this population, job availability, the typical psychological issues associated with aging, etc.

Chapter key word bingo: Identify all of the key words and definitions from the chapter and then create Bingo cards with the different terms and a bingo free space. Ask the students to create BINGO chips out of small slips of paper. Read out the definitions from the chapter randomly, creating a BINGO style review game to cover the chapter material. It may increase the competiveness to offer extra credit points that can be used towards their scores in a future exam.

Future predictions: How will life be in older adulthood?

Ask students to envision what “entering late adulthood” will look like. How will you dress, what will your interests be, how will you view yourself, others, the world, etc.? What will you want the younger generation to know and how will you like to be treated? How do you think the world will be: the same or different once you are 65 years or older?

VIDEO CASES IN ABNORMAL PSYCHOLOGY Alvin—Major Neurocognitive Disorder: Alvin is an aging art professor who is suffering with the beginning symptoms of Alzheimer’s disease. He is still working but has found himself lost and also confused on many occasions. His wife says that he has a great deal of trouble ‘staying on target’ and that his mind tends to wander. We see some indications of this in the interview. He also gets increasingly frustrated and even agitated as he is unable to complete tasks in an efficient manner. He has trouble processing temporal information and also geographic information.

Discussion questions: 1.

What are some signs of denial that you see in Alvin as he talks about his illness and difficulties? Is this healthy or unhealthy—a sign of hope and determination or avoidance and denial?

2.

Alvin has continued to work despite his cognitive deterioration. In what ways is his continued work helpful for him? How is it a liability or a danger?

3.

What is the prognosis for Alvin? What might we expect to see in three or four years, as his disease progresses? What are some positive ‘buffers’ that might work in his favor as he struggles with this illness?

Sarah—Wife of Patient with Alzheimer’s Disease: Sarah, the wife of Wilburn Johnson, describes the difficulties of living with a person with Alzheimer’s disease. She says that when he first began to show serious symptoms, she was angry and felt that fate had mistreated her. “It felt like he had left me.” She now has to help get him dressed, assist him in the bathroom, and take care of 253 C.

him almost completely. The stress of coping with Alzheimer’s is clear when she compares her own experience with cancer to living with her husband’s condition. She states that, “You kind of have hope when you have cancer… but, with Alzheimer’s, you die just a little each day.”

Discussion questions: 1.

In what ways do the caretakers of Alzheimer’s patients suffer more than the patients themselves?

2.

Sarah says that living with her husband’s condition is even worse than going through her own experience with cancer. Why do you think this is?

3.

How do you think supportive therapy may be able to help Sarah cope with her current situation?

VIDEO RESOURCES http://abavtooldev.pearsoncmg.com/sbx_videoplayer_v2/simpleviewer.php?projectID=MPL_ABC2009&clipID= memory_boost.flv&ui=2 Memory Boost: Mild Cognitive Impairment (2:09) Watch this video as World News Tonight looks at mild cognitive impairment and the drugs that are being developed to help aging sufferers. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Dementia_Judy.html Dementia: Judy (2:00) Watch this video as a middle-aged woman describes early-onset dementia. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/DSM_In_Context/Alvin_ Dementia_3.html Alvin: Dementia (Alzheimer’s Type) (2:58) Watch this video discussion of the social difficulties and impairments of an Alzheimer's patient. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Celexa_and_the _Elderly.html Celexa and the Elderly (1:49) Elderly people suffering from depression face a number of difficulties with quality of life, slow healing from physical illnesses, and side effects from various antidepressant medications on the market. The drug Celexa, now 254 C.

reported to be the best drug for this elderly population, is improving their depression without significant side effects. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Cultural_Influences_ Robert_Sternberg.html Cultural Influences on Intelligence: Robert Sternberg (2:31) In this video, psychologist Robert Sternberg discusses how cultural surroundings affect intelligence and how different continents and countries have different concepts of what intelligence is.

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Chapter 15 Intellectual Disabilities and Autistic Spectrum Disorders Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: p. 405 Intellectual Disabilities: p. 405

Discussion Ideas: Labeling Intellectual Disability

Symptoms of Intellectual Disabilities Diagnosis of Intellectual Disabilities Frequency of Intellectual Disabilities Causes of Intellectual Disabilities Treatment: Prevention and Normalization

Classroom: Guest speaker on intellectual disabilities, Debate on “mainstreaming” Optimizing treatment of intellectual disability,

Autistic Spectrum Disorders: p. 419

Lectures: Training parents Delay vs. difference controversy

Symptoms of ASD Diagnosis of ASD Frequency of ASD Causes of ASD Treatment of ASD

Discussion Ideas: Behavioral approaches to autism Discussing Rain Man Video Case: Asperger’s Disorder, David Video Case: Autism, Billy, age 3 Video Case: Free From Silence

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PROFESSOR NOTES

CHAPTER OUTLINE I.

Intellectual disabilities A.

Overview 1.

Autism is the most familiar condition of autism spectrum disorders (ASD). a.

2.

Most people with autism also have intellectual disabilities. a.

3.

B.

DSM-5 uses ASD to refer to a broad range of conditions including autism and Asperger’s disorder (high functioning autism).

Children with severe autism cannot communicate.

Academic struggles are typically the focus of intervention with intellectual disabilities.

Symptoms of intellectual disabilities 1.

2.

General diagnostic criteria for intellectual disability a.

Significantly subaverage IQ; IQ of 70 or below

b.

Significant limitations in adaptive behavior

c.

Onset before age 18

Measuring intelligence a.

Early definitions focused on mental age, which was determined by comparing an individual’s test results with the average obtained for various age groups.

b.

Current definition based on intelligence quotient IQ, which is a test’s rating of an individual’s intellectual ability.

1.

Most IQ tests have a normal distribution: they are scored to have a mean of 100 and a standard deviation of 15; still, defining intelligence has been a controversial topic. a.

In children, IQ is sometimes measured as a ratio of mental age to chronological age.

2.

About two-thirds of the population has an IQ within one standard deviation of the mean, which inclues scores ranging between 85–115; the cut-off score for intellectual disability is 70, although DSM-5 marks the cut-off score between 65-75. About 2 percent of the population falls below two standard deviations of the mean, with IQ scores below 70.

3.

By school age, IQ scores are relatively stable and good predictors of future functioning.

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4.

Some controversy has arisen over the Flynn effect, which is the marked trend of rising IQ scores during the past few decades. IQ score averages are constantly being updated to reflect this trend, so older people’s IQ scores fall relative to this rising mean. The implications are that some individuals (who score about 70 on IQ tests) may be identified as having an intellectual disability when, previously, they would not have been identified with this disability.

5.

DSM-5 uses IQ scores below approximately 65-70 to indicate intellectual disability.

6.

Controversies have arisen about the degree to which IQ tests are culturally fair.

7.

C.

a.

This has lead to the creation of culture-fair tests that contain material that is equally familiar to people regardless of their cultural background.

b.

Biases in testing are often cited as reasons why minorities and the poor tend to score lower on IQ tests than Caucasians and upper class individuals in the United States.

Intelligence tests are good predictors of school achievement but not of other forms of intelligence.

Measuring adaptive skills 1.

Focus is on skills necessary to live successful independent lives a.

Conceptual skills—self-sufficiency and functional abilities

b.

Social skills—ability to understand how to conduct oneself socially

c.

Practical skills—ability to manage the ordinary activities of daily living, including self-care, health, and work

2.

Deficits need to be in only one area for diagnosis

3.

Adaptive skills are more variable over time than intelligence

D.

Onset before age 18—excludes people whose deficits began later in life as a result of brain injury or disease; people with intellectual disabilities have not lost skills they previously had

E.

Diagnosis of intellectual disabilities 1.

Early efforts a.

In 1866, Langdon Down described the faces of children who had been identified with intellectual disabilities as being reminiscient of those of Mongolians; the condition later became known as Down syndrome.

b.

IQ tests were developed to identify children with special educational needs; Simon, Terman, 258 C.

and Wechsler’s developmental work is crucial here. c.

2.

The identification of a specific cutoff point on cognitive test scores has been controversial because any choice is necessarily arbitrary 1.

At one point, the American Association on Intellectual and Developmental Disabilities (AAIDD) included all people one stadard deviation below the mean in their definition, but this created the undesired consequences of including many well-functioning people and distracting from many others in need of assistance.

2.

AAIDD now uses the cut-off score of 70.

Contemporary diagnosis—AAIDD uses a multiaxial diagnosis and considers etiology, level of support needed, and other factors to provide individual assessments; the AAIDD rates “intensity of needed support” across many areas of life. DSM-5 bases classification on conceptual, social, and practical level of impairment, not IQ score)and still uses the following categories: mild, moderate, severe, and profound. The authors of the textbook belive the traditional system is reliable, straigtforward, and supported by much research and thus still provide a descriptions of its categories: a.

b.

c.

Mild intellectual disability—(traditional system IQ range: 50–55 to 70) 1.

85 percent of people with intellectual disability

2.

Few physical impairments

3.

Generally reach approximately the sixth-grade level academically

4.

Can develop vocational skills

5.

Usually live in the community

Moderate intellectual disability—(traditional system IQ range: 35–40 to 50–55) 1.

10 percent of people with intellectual disability

2.

Often have obvious physical abnormalities

3.

Academic achievement is second-grade level

4.

Close supervision needed for both work and living situations

Severe intellectual disability—(traditional system IQ range: 20–25 to 35–40) 1.

3–4 percent of people with intellectual disability

2.

Abnormal motor development

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d.

3.

3.

Communicative speech limited

4.

Close supervision needed for community living

Profound intellectual disability—(traditional system IQ range: below 20–25) 1.

1–2 percent of people with intellectual disability

2.

Motor skills, communication, self-care very limited

3.

Constant supervision needed

4.

Often institutionalized

Given that the Supreme Court has ruled that the death penalty is cruel and unusual punishment for a person with intellectual disabilities, accurate diagnosis becomes even more important than ever.

F.

Frequency of intellectual disabilities 1.

Best estimate is that about 2.3 percent of general population have IQs of 70 or below and could be diagnosed with an intellectual disability; however, it is thought that only 1 percent have intellectual disabilities when considering the following factors:

2.

a.

IQ cannot be adequately assessed in very young children.

b.

Many people with low IQs have good adaptive skills.

c.

Life expectancy is much shorter for many individuals with intellectual disabilities.

More common among the poor and certain ethnic groups for non-biologically-based subtypes; no difference in prevalence rates for biologically-determined intellectual disability based on socioeconomic status.

G.

Causes of intellectual disability 1.

Biological factors—half of all cases caused by known biological abnormalities; these tend to be among the more severe cases a.

Chromosomal disorders 1.

Most common known biological cause is Down syndrome (trisomy 21); incidence increases with maternal age (1 in 100 after age 40); generally function in the moderate to severe range; have diminished life expectancy—usually develop brain pathology similar to Alzheimer’s in their 30s and die in mid-adult life

2.

Most common known genetic cause is fragile-X syndrome— a weakening or break on one arm of the X chromosome; occurs in about 1 out of 4000 males and in 1 out of 6,000 260 C.

girls; not all have intellectual disabilities; some are simply learning disabled—distinctive facial appearance (elongated face, high forehead, large jaw, and large, underdeveloped ears)

b.

3.

Klinefelter syndrome—found in 1 in 1000 live male births; characterized by the presence of one or more extra X chromosomes in males; low normal intellectual functioning to mild intellectual disability

4.

XYY syndrome is linked with about a 10-point lowered IQ; occurs in 1or 2 out of every 2,000 male births.

5.

Turner syndrome—XO configuration in females—tends to result in small, sexually undeveloped girls with normal IQ; found in 1 out of every 2,200 live female births

Genetic disorders 1.

PKU (phenylketonuria)—recessive gene pairing which occurs in 1 out of 15,000 births; children are born with normal intelligence, but the build-up of phenylalanine produces brain damage, which leads to severe to profound intellectual disability if not detected and if the child is not placed on low phenylalanine diet; 1 in every 54 normal people carries a recessive gene for PKU

2.

Tay-Sachs disease, Hurler syndrome, and Lesch-Nyhan syndrome are other rare recessive-gene disorders that can result in intellectual disability.

c.

Infectious diseases—infections during pregnancy, at birth, or in infancy to early childhood can result in intellectual disability—cytomegalovirus, toxoplasmosis, rubella, AIDS/HIV, syphilis, genital herpes, encephalitis (after birth), and meningitis (after birth) are some diseases which, untreated, can cause severe intellectual disabilities or death in some cases

d.

Fetal alcohol syndrome can produce mild intellectual disability and physical abnormalities.

e.

Exposure to environmental toxins—e.g., mercury poisoning, lead poisoning, or drugs-- can produce intellectual disabilities; despite attempts to control lead in the environment, children who live in old, dilapidated housing are at risk for eating lead chips.

f.

Other biological abnormalities can also result in intellectual disabilities in children.

1.

Rh incompatibility—Rh-negative mother develops antibodies that attack the blood cells of the Rh-positive fetus, which can result in intellectual disabilities

2.

Premature birth—before 38 weeks of gestation or birth weight of less than 5 pounds

3.

Anoxia—oxygen deprivation during delivery

4.

Severe malnutrition

5.

Epilepsy 261 C.

g.

Normal genetic variation—cultural familial retardation is a term used for intellectual disabilities of unknown etiology 1.

There is considerable controversy over the role of genetics in intelligence; runs in families and is linked with poverty; is caused by genes or by psychosocial disadvantages

2.

Research suggests that genetics determines a range of intelligence and that environment determines where in that range an individual falls; this is reffered to as reaction range.

2.

Psychological factors—abuse, deprivation, and isolation can cause abnormalities in intelligence.

3.

Social factors—impoverished environments and lack of stimulation and responsiveness are associated with limited development of intelligence; studies of adopted children suggest positive effects of stimulating and responsive environments. Children who were adopted away from adverse circumstances scored 12 points higher on IQ tests than their mothers scored.

H.

Treatment: prevention and normalization 1.

Primary prevention—good prenatal care and nutrition, treatment of infectious diseases like syphilis, avoidance of harmful drugs, and vaccinations; amniocentesis can be used prenatally to identify syndromes associated with intellectual disability, and in the future, gene therapy may also offer the opportunity for treatment

2.

a.

It is now possible to screen for Down syndrome using an ultrasound machine.

b.

It is hoped that in the future, gene therapy may offer opportunities for treating a developing fetus.

Secondary prevention—early social and educational intervention programs; e.g. Head Start can produce short-term gains in IQ (5–10 points) and longer-term gains in adaptive functioning such as being less likely to repeat a grade; unfortunately, the IQ gains from headstart are much diminished or have disappeared within a few years.

3.

Tertiary prevention—early detection and promotion of good parent-child relationships, basic self-care and life-survival skills training, comprehensive medical care, and sometimes, use of medication for aggressive behavior

4.

Normalization—facilitating integration into social activities, including mainstreaming children into regular classrooms when possible and keeping them out of institutional care a.

The deinstitutionalization movement began in the 1960s 1.

Of those living in instiutions today, 55.5 percent have profound intellectual disability

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II.

Autistic spectrum disorders (ASD) A.

DSM-5 criteria for ASD are far more broadly defined than in previous editions of the DSM. As a result, symptoms include far less severe impairments, prognosis is better, comorbidity is lower, and incidence rates are higher.

B.

Symptoms of autism begin early; significant impairments in relationships, communication, and behaviors, absorption in one’s own mental activity; in 40 percent of cases, the baby develops normally for a time but either stops learning new skills or loses the skills acquired earlier 1.

2.

3.

4.

Deficits in social communication and interaction a.

Deficits in speech and language, 54 percent remain mute and 35 percent with other ASDs

b.

Apparent lack of interest in communication

c.

Limited or no use of gestures or other forms of nonverbal communication

d.

Dysprosody (abnormal speech rate, rhythm, and intonation), echolalia (rote repetition of phrases), and pronoun reversal (e.g., “you” for “I”) are common; children with autism fail to individuate

e.

Autism is characterized by profound indifference to social relationships, odd, stereotypical behaviors, and severely impaired or nonexistent communication.

Impaired social interaction a.

Inability to relate to others is perhaps the central feature of autism.

b.

Lack a "theory of mind"; in other words, are unable to recognize others’ perspectives; this is demonstrated by a fialure to correctly solve the “Sally-Ann test” of theory of mind.

c.

Lack of interest in forming attachments—uncomfortable with physical touching

Restricted, repetitive interests and activities a.

DSM-5 allows for a broad range of possible symptoms; individuals with high-functioning autism may show unusual fascination with some activity, while those with more severe cases may spend most of the day flapping a string in front of their eyes.

b.

Spinning and hand/arm flapping as well as other behaivors that serve no function other than self-stimulation are common.

c.

Rigid adherence to routine

d.

Self-stimulatory behaviors appear to provide escape and relaxation.

Unusual sensory stimulation—unusual responses to sensory input despite physically normal 263 C.

sensory apparatus; e.g., strong response to loud noises or appearing deaf or displaying apparent sensory deficit 5.

Self-injurious behavior—e.g., head banging, biting the fingers and wrists—appears to be a form of self-stimulation

6.

Savant performance—rare; exceptional ability in a highly specialized area of functioning, e.g., music, art, or mathematics; not associated with superior intelligence; does not suggest that people with classic autism are actually normal or superior in intelligence.

7.

Past research showed 1.4 percent of children have IQs below 55; 50 percent between 55 and 70, and 25 percent have IQs over 70

C.

Diagnosis of autistic spectrum disorders 1.

Historical—Kanner and Asperger (1940s) both identified similar syndromes, but Asperger's patients were of higher intelligence; Asperger's disorder is now considered a subtype of autistic spectrum disorder in which a person has no language deficits

2.

Contemporary—pervasive developmental disorders encompassed a.

In a controversial change, DSM-5 adopted a broad spectrum approach to diagnosing ASD with the following main categories of symptoms: 1.

Persistent deficits in social communication and social interaction across many contexts including the following: a.

Deficits in social-emotional reciprocity

b.

Deficits in non-verbal communication used for social interaction

c.

Deficits in developing, maintaining, and understanding social relationships

2.

Restricted, repetitive patterns of behavior, interest, or activities, involving at least two of the following: stereotyped or repetitive motor movement; insistence on sameness; highly restricted interests; hyper- or hyporeactivity to sensory input

3.

Symptoms must be present in the early developmental period

4.

Symptoms must cause clinically significant impairment or distress

5.

Symptoms must not be better explained by intellectual disability of global developmental delay; stereotyped behaviors may manifest following a period of at least two years of normal development 264 C.

a.

D.

Rett’s disorder—at least five months of normal development followed by decelerated head growth and symptoms similar to those seen in autism; found almost exclusively in girls

Frequency of autism and pervasive developmental disorders 1.

For a long time, it was thought that only 4 in 10,000 have autism; now it is believed that as many as 200 in10,000 may have the disorder.

2.

E.

Several theories have been proposed about why the explosion of autism has occurred. a.

Environmental factors like the measles/mumps/rubella vaccination have been implicated; research does not support this theory, however.

b.

Experts believe that the increased prevalence estimates are likely due to increased awareness and broadened diagnostic criteria.

c.

Three to four times as common in boys than girls; more common among siblings of a child with autism (gender-linked etiology and biologically-based disorder)

Causes of autism 1.

Psychological and social factors: historically, autism was believed to be caused by cold “refrigerator parents;” evidence does not support this hypothesis.

2.

Biological factors—evidence of a biologic contribution a.

Fragile-X syndrome, Rett’s disorder, and a handful of other known causes of intellectual disability are known to be causes of different autisms.

b.

Twin studies and family incidence studies suggest a strong genetic factor, yet much is still unknown about the linkage and why DZ twins’ rates are so low; concordance rates were 60 percent for MZ twins and 0 percent for DZ; recent research identified a “hotspot” on chromosome 16 that is linked with 1 percent of cases

c.

Brains of children with autism are larger than average; brain development appears to be arrested at age 2 to3, and the cerebral and cerebellar brain volume are smaller than normal at later ages

d.

Limbic system, cerebellum, and frontal lobe may all be involved in the development and maintenance of autistic disorders

e.

Research on mirror neurons—neurons that fire both when one performs an action and when one observes others performing the same action—is promising; autistic children may not be able to effectively utilize mirror neurons

f.

Neurophysiology 1.

Some evidence exists that endorphin levels are elevated in people with autism; people 265 C.

with autism are like addicts high on heroin; they lack interest in others because their excessive internal rewards reduce the value of the external rewards offered by relationships.

2.

F.

Recent research suggests neuropeptide deficits may also play a role, especially oxytocin and vasopressin, which affect attachment and social affiliation.

Treatment of ASD 1.

Course and outcome—there is no “cure”; very few people with autism ever function in the normal range; those with Asperger's disorder have a more positive prognosis, although this has not been established empirically. Only 20 percent achieve a good outcome; 50 percent have a poor outcome.

2.

a.

More autistic children are now cared for in their own homes, and some better outcomes seem to have been reflected in recent studies

b.

The development of language capacities at age 5 and 6 and higher IQs are associated with the best outcomes.

c.

Joint attention—coordinating attention with another through gestures, social responding, or social initiation—predicts language development from preschool age to age 9

d.

One quarter of autistic children develop seizure disorders as teenagers; some also develop affective disorders in adult life.

Medication—many classes of drugs are used, from antipsychotics to opiate agonists. A few help with some symptoms (e.g., of stereotyped behaviors) but none provide a cure

3.

a.

Chelation therapy-- administering agents that remove heavy metals from the body; this is not advised by the National Institutes of Health and can be very dangerous

b.

Certain antipsychotics, particularly risperidone, help in behavior management; medication used for OCD (SSRIs) helps with stereotyped behavior.

Psychotherapy—applied behavior analysis (ABA) a.

Identify specific target behaviors (e.g., use of sign language, self-care, social responsiveness) 1.

b.

c.

Attempt to teach the use of both instrumental and expressive gestures.

Use positive reinforcement and punishment to increase positive behaviors and to control problematic ones 1.

Difficult because these children do not find social approval reinforcing

2.

Immediate reinforcement with primary reinforcers, e.g., food, often required

Some success in teaching self-care skills, reducing self-injury; less success in developing genuine social responsiveness 266 C.

d.

Overall, applied behavior analysis (e.g., 40 hours per week for two plus years) is effective when compared to control groups of limited or no treatment—but very costly

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LEARNING OBJECTIVES LO15.1: How are IQ scores like “grading on the curve”?

LO15.2: Did the United States really support human breeding (eugenics)?

LO15.3: How can intellectual disabilities be prevented?

LO15.4: Is there an “epidemic of autism”?

LO15.5: Are children exceptionally intelligent underneath their autism?

LO15.6: What is wrong with psychological theories of the cause of autism?

LECTURE SUGGESTIONS Training parents: One treatment approach for autistic children involves the training of parents. The parents would be given lectures, readings, demonstrations, practice role-playing, and also receive home visits and consistent telephone contact from professionals. One of the first skills a parent would be taught is the simple reinforcement of eye contact on the part of the child. Later, parents can become involved in teaching more sophisticated communication skills.

For example, parents can teach their autistic child to identify words such as "belt" by pointing at the child's belt while saying the word, and they can teach the concept of ownership by pointing to the child and saying, "your belt" and then pointing to themselves and saying, "my belt." Are these programs effective? Koegel (1982) and his colleagues compared a parent-training program with a typical outpatient clinic program. Both programs improved social behavior, play, and speech and decreased tantrums and echolalia. The behavior of children whose treatment took place in the clinic, however, did not generalize well to the home environment, whereas those in the parent-training group showed noticeable improvement in their children’s behavior at home. Howlin and Rutter (1987) found similar benefits to home training in a study conducted with British autistic boys. They conclude that the improvements in children whose parents received training from professionals suggest that parent training should become a permanent part of the treatment of autism.

Howlin, P.A. & Rutter, M. (1987). Treatment of autistic children. New York: Wiley.

Koegel, R.L., Schreibman, L. Britten, K.R., Burke, J., & O'Neill, R.E. (1982). A comparison of parent training to direct child treatment. In R.L. Koegel, A. Rincover, & A.L. Egel (Eds.), Educating and understanding autistic children. San Diego: College Hill Press.

Delay versus difference controversy: One controversy that has emerged in the study of developmental problems is whether those that are classified as having developmental disorders are simply delayed in their development, as compared to the development of other children, or if they are qualitatively different from other, normal children. The controversy has continued with evidence supporting both views, but recently, the weight of the evidence seems to be on the side of the "difference" theory, especially when it comes to autism. In a study conducted by Shulman and colleagues (1995), autistic children demonstrated cognitive impairments in tasks that require higher operational thought, such as free-sorting representational objects and class-inclusion tasks. They conclude that autistic children have difficulty with tasks 268 C.

that necessitate internal manipulation of information. Autistic children showed deficits (in Shulman's study) that separated them not only from normal children but also from intellectually disabled children. Research conducted by Jacob Burack (1994) also suggests a cognitive difficulty for autistic children; Burack's work suggests that autistic children may have an inefficient attentional lens. Both of these lines of research suggest that autistic children demonstrate cognitive deficits that are distinctive, contributing to evidence of the genetic factor as well as the "difference" theory regarding autism.

Burack, J.A. (1994). Selective attention deficits in persons with autism: Preliminary evidence of an inefficient attentional lens. Journal of Abnormal Psychology, 103, 535–543.

Shulman, C., Yirmiya, N., & Greenbaum, C.W. (1995). From categorization to classification: A comparison among individuals with autism, mental retardation, and normal development. Journal of Abnormal Psychology, 104, 601–609.

DISCUSSION IDEAS Labeling intellectual disability: The term “mentally retarded” has aquired a stigma that goes well beyond its factual meaning. Ask students to free associate to the term “retarded” and see what images and thoughts come to mind. Because of this stigma, the DSM-5 no longer uses the label “mental-retardation.” Clearly, describing a child as “mentaly retarded” on the basis of intelligence testing alone is not warranted. What are some of the stereotypes and stigmas associated with the label “mental retardation”?

Where do these stereotypes and stigmas arise from? Has this stigma become stronger in recent years, or has society become less stigmatizing of people with intellectual disabilities? Ask students to describe what they believe can be done to change the general public’s perception of people with intellectual disabilities. Do you believe that the new DSM-5 label of “intellectual diability” will help to change the way these people are viewed and treated?

Behavioral approaches for autistic spectrum disorders: Why are behavioral approaches to autism the most effective ones? No other treatment approach has yielded results nearly as favorable. Behavioral approaches are based, largely, on operant conditioning methods in which rewards and punishments are systematically applied to increase the child’s ability to attend to others, play with other children, develop academic skills, and eliminate self-mutilating behavior. It is important for students to recognize that autism will not simply respond to a ‘talking cure’; behavior techniques are necessary in order to effect change in the social deficits that autism presents.

Discussing Rain Man: Show the film Rain Man and discuss its portrayal of autism. Does the main character have the three major characteristics of autistic individuals (impaired social interaction, impaired communication, and stereotyped behavior, interests, and activities)? Given the rarity of savant performance, do the media present an unbalanced view of disorders like autism by focusing on the unique abilities of a character like Raymond?

269 C.

CLASSROOM ACTIVITIES Guest speaker on intellectual disabilities: Contact a local treatment agency that provides care for individuals with intellectual disabilities and ask a counselor to come to class to discuss treatment strategies and programs utilized at the counselor’s agency. Many students currently work as summer counselors with this population, so they should be able to actively participate in such a discussion.

Debate on "mainstreaming": Much controversy has arisen over the question of whether children who are mentally retarded should be "mainstreamed" into regular classes or be separated and placed in special education classes. Ask the class to participate in a debate on this topic. Some students can take the position that retarded children should be mainstreamed, while others can argue that special classes are more effective for educating them overall. Stress to the class that there are no right answers here; leading experts in school psychology do not agree on this issue. A central issue is the degree to which separation enables greater gains through specialized educational approaches versus the stigma of being separated and the benefits of being a part of the general academic community.

Optimizing treatment of intellectual disability: Divide the class into four groups according to the four levels of intellectual disability and ask them each to consider the kinds of treatment programs that would be appropriate if they were working with that level of clinical population. Then reconvene, allowing each group to report on the types of settings, tasks, treatments, and prognoses that they might expect among the individuals classified within the level of intellectaul disbility assigned. What will become clear is that each level of intellectual disability requires a treatment program and approach that is tailored to the individual's needs.

Cultural-familial retardation: As mentioned in the textbook, some individuals develop intellectual disabilities as a result of poverty, genes, or psychosocial advantages. Ask students to create a list of potential risk factors for the development of cultural-familial retardation. Then have the students create a list of factors that act as protective factors against the development of cultural-familial retardation. After the students have created both lists, then ask the students to create prevention and intervention strategies that could be implemented for at-risk populations.

VIDEO CASES IN ABNORMAL PSYCHOLOGY: David—Asperger’s disorder David was diagnosed with Asperger’s disorder six years ago after displaying unusual, quirky characteristics that nobody in his social environment recognized as part of a disorder until that point. He says that his disorder affects all aspects of his life—primarily work and social relationships. He says that, “You don’t see a lot of things coming,” meaning that he doesn’t recognize and interpret social cues the way others are able to. He is now aware that his asking so many questions and his need for everything to be ‘spelled out’ for him makes him difficult for others to deal with. With his treatment and the recognition of his basic tendencies, David has worked hard to overcome his disability. He says, “I’ve installed a filter into myself” so that he does not respond instinctively with too much anxiety or too directly with others. He seems to be highly functional, maintaining a job and a number of long-term friendships as well as a good relationship with his parents. On the other hand, romantic relationships have been very difficult for him, and he has to work extremely hard to maintain his level of functionality.

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Discussion questions: 1.

David did not classify himself as abnormal for much of his life. How has classifying himself as an Asperger’s sufferer helped him to cope with his difficulties? How has it hurt him?

2.

What work has David done to improve his functioning? How has he had to adapt to a world which is foreign to him?

3.

David’s parents did not seek treatment for him—even though he was slow to walk and talk as a child. He was, in fact, not diagnosed until he was already an adult. What benefits do you think would have been derived from early treatment in his case?

Billy-- Autism, age 3 1/2 (12:25) Billy is a 3 1/2-year-old autistic child who displays some common symptoms of autism such as lack of appropriate eye contact, hyperactivity, not playing with toys, and inability to communicate. His parents have arranged for 42 hours of therapy a week to help build social and communication skills.

Discussion question: Having a handicapped child puts a tremendous amount of strain on the parents of the child. Describe some of the daily stressors of Billy's parents. What other stressors might the family of a handicapped child encounter that were not mentioned in the video segment? Also, describe ways of dealing with the stressors.

Free from Silence (Prime Time Live, 1/23/92, 17:45) Facilitated communication with autistic children is examined. Apparently autistic children have greater capacities for language than we previously believed. Using a keyboard and a facilitator to help "guide" the child, autistic children have been able to "write" messages. Advocates of facilitated communication claim that there is a 90 percent success rate for autistic children being able to communicate through the keyboard. The technique, however, is highly controversial; cynics believe that it is the facilitator who is guiding the process; thus, the facilitator is communicating, not the autistic child.

Discussion questions: 1.

Many people do not believe facilitated communication is effective; they do not believe the child is actually communicating. In fact, most research suggests that the facilitator is doing the communicating, but this is currently being investigated more carefully. If the child is not doing the communicating, and the facilitator is, are there any reasons to continue to use facilitative communication?

2.

It is difficult to believe that autistic children are typing grammatically correct passages without ever having learned correct grammar. Explain some other reasons why people are hesitant to believe facilitative communication works. Why were professionals so willing to believe that it does work?

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VIDEO RESOURCES

http://visual.pearsoncmg.com/mypsychlab/episode11/index.html?clip=3&tab=tab0 Special Topics: Intelligence Testing, Then and Now (5:37) Psychologists have been interested in studying intelligence for some time. This video shows how intelligence tests have developed and evolved. The video considers the purpose of intelligence tests and discusses some of their strengths and weaknesses. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Are_Intelligence_Tests _Valid_Robert_Guthrie.html Are Intelligence Tests Valid: Robert Guthrie (1:50) This video provides a critical analysis of the accuracy of intelligence tests. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/mydevelopmentlab/glover_e. html Is There A Link Between Prenatal Exposure to Stress and Developmental Disorders in Children? (1:38) Professor Glover's research examines the long-term effects of early stress on children's emotional, behavioral, and cognitive development. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/Cider/Difficulty_of_Autism_ Research.html Psychology in the News: Difficulty of Autism Research (2:39) This video presents an overview of autism and the difficulties in researching it.

272 C.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL_ABC2009/Against_ Odds_Children_with_Autism.html Against Odds: Children with Autism (2:47) Parents describe the difficulty in watching not one, but all three of their children develop autism.

273 C.

Chapter 16 Psychological Disorders of Childhood Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: p. 436 Externalizing Disorders: p. 437

Lectures: Risk taking in adolescence

Symptoms of Externalizing Disorders Diagnosis of Externalizing Disorders Frequency of Externalizing Disorders Causes of Externalizing Disorders Treatment of Externalizing Disorders

Discussion Ideas: Attention deficit hyperactivity disorder in adults Classroom: ADHD treatment Video Case: ADHD, Jimmy

Internalizing and Other Disorders: p. 454 Symptoms of Internalizing Disorders Diagnosis of Internalizing and Other Childhood Disorders Frequency of Internalizing Disorders Causes of Internalizing Disorders Treatment of Internalizing Disorders

Lectures: Physical and sexual abuse Discussion Ideas: Childhood depression Nature/nurture A “sick society?”

Classroom: Dealing with separation/loss

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PROFESSOR NOTES

CHAPTER OUTLINE I.

II.

Overview A.

Developmental psychopathology: children’s behavioral and emotional problems must be considered in the context of developmental norms because children change rapidly during the first 20 or so years of life and norms of behavior fluctuate during development. Psycholgisits only become worried if a child’s behavior deviates substantially from developmental norms.

B.

Externalizing disorders—the most commonly diagnosed childhood disorders; characterized by failure to control behavior according to the expectations of others

C.

Internalizing disorders—involve the child's internal world and are associated with subjective distress (e.g., anxiety, sadness)

D.

DSM-5 has disorders common in children scattered throughout the manual; the authors of the textbook see this as a mistake.

Externalizing Disorders A.

Externalizing symptoms are characterized by rule violations, anger and aggression, disobeying parents or teachers, annoying peers, impulsivity, and deficits in attention.

B.

Rule violations

C.

1.

Some misconduct is normal; more serious or chronic rule violations are not; children’s age is also important to consider in relation to the timing of rule violation.

2.

Children with externalizing problems violate rules at an earlier age than is developmentally normal.

3.

Behavior problems that begin in childhood are more likely to persist into adulthood than those beginning in adolescence, since rule violations are more normative in the teen years.

4.

25.9 percent of arrests for violent offenses—major crimes including murder, rape, and robbery—were of people under the age of 21 in 2011.

5.

Children of different ages are likely to violate very different rules. For example, a preschooler with an exernalizing problem may be disobedient to parents or aggressive with other children, whereas a school-aged child may be disruptive in the classroom.

6.

Adolescent-limited externalizing behavior ends along with the teen years.

7.

Life-course-persistent antisocial behavior continues into adult life; antisocial behavior of children whose problems begin before the age of 12 is more likely to continue if they have fewer social bonds, less involved families, and troubled peer relationships.

Negativity, anger, and aggression—the intent of the child and the degree of remorse felt are essential for placing the behavior in context 275 C.

III.

1.

We tend to punsh children if their intent is selfish and they show little remorse

2.

Relational aggression—actions meant to hurt others in more subtle ways, such as gossip

D.

Impulsivity—tendency to act before thinking; distinct from intentional misbehavior; impulsive children struggle with executive functioning, which is the internal direction of behavior

E.

Hyperactivity and attention deficit 1.

Hyperactivity—squirming, fidgeting, or restless behavior, most noticeable in structured settings

2.

Attention deficit—distractibility, frequent shifts from one uncompleted activity to another, careless mistakes, poor organization/effort, and general "spaciness" a.

Problems with sustained attention or ability to "stay on task" are a key element.

b.

The continuous performance test is commonly used to measure sustained attention; distinguishes children with and without attention-deficit/hyperactivity disorder (ADHD)

Diagnosis of externalizing disorders A.

DSM-5 has externalizing disorders listed in different places in the manual; this is one of the authors’ objections to the manual. Some disorders, such as ADHD, have undergone many revisions since earlier editions of the DSM.

B.

Contemporary 1.

Attention-deficit/hyperactivity disorder (ADHD)—characterized by hyperactivity, inattention, impulsivity; according to DSM-5, at least some symptoms must be present before the age of 12, persist for at least 6 months, and be consistent across situations a.

Historically, views about whether hyperactivity or inattention is prominent have changed.

b.

Hyperactivity and inattention are now viewed as independent symptoms; children may have either or both.

c.

DSM-5 views ADHD as a dimensional disorder, even though it is diagnosed categorically.

2.

Oppositional defiant disorder (ODD)—a pattern of hostile, negativistic, and defiant behavior

3.

ADHD vs. ODD—currently viewed as separate but overlapping disorders (50 percent of children with one have the other) and 25 percent of children with each problem have a learning disability

4.

Controversial issue of whether to use subtypes for ADHD—predominantly inattentive, predominantly hyperactive-impulsive, or combined types; less support for the predominantly hyperactive-impulsive subtype as distinct from the combined type with a pattern of serious rule violations

276 C.

5.

IV.

V.

Conduct disorder(CD)—defined by a pattern of behavior (e.g., stealing or assault) that is illegal and antisocial; juvenile delinquency is a legal classification. a.

Most of the symptoms invole index offenses—crimes that are illegal at any age—as well as status offenses—acts that are only illegal for minors.

b.

DSM-5 places CD and ODD in a new diagnostic category: “Disruptive, Impulse-Control, and Conduct Disorders”

Frequency of externalizing A.

At least 19 percent of adolescents have an externalizing disorder (Merikangas et al., 2010).

B.

ADHD— 9.5 percent of children have ADHD; after the first few years of life, two to ten times as many boys as girls have externalizing problems.

C.

Family risk factors 1.

Family adversity index (Rutter, 1989): low income, overcrowding in the home, maternal depression, paternal antisocial behavior, conflict between the parents, and removal of the child from the home

2.

Risk increases dramatically when at least two of these risk factors are present.

Causes of externalizing A.

Biological factors 1.

Temperament—child's innate basic behavioral characteristics including activity level, emotionality, and sociability a.

Thomas and Chess's model distinguishes between three temperament types: 1.

Easy children—quickly form social relationships and follow discipline

2.

Difficult children—challenge parental authority

3.

Slow-to-warm-up children—tend to be shy and withdrawn

2.

Neuropsychological abnormalities in ADHD: hard signs of brain damage are rare and appear in 5 percent of cases of ADHD; soft signs are more frequent in people with ADHD, as are other physical abnormalities, but no characteristic markers have been found; some evidence indicates impaired executive functioning in ADHD children and their relatives; minor anomalies in physical appearance, delays in reaching developmental milestones, maternal smoking and alcohol consumption, and pregnancy and birth complications are common among children with ADHD

3.

Genetics and ADHD a.

A recent large study (Levy et al, 1997) found concordance rates for ADHD of 80 percent and 40 percent, respectively for MZ and DZ twins.

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B.

b.

Research supports a dimensional rather than categorical approach to the classification of ADHD.

c.

Genes also contribute to ODD , but to a lesser extent than ADHD

d.

Interaction between genetic predisposition and the environment probably accounts for a great deal of the variance in ADHD; boys genetically predisposed to low MAOA activity (monoamine oxidase activity), in interaction with a difficult environment (maltreatment) led to more conduct problems

Social factors—socialization is the process of shaping a child’s behavior and attitudes so to fit societal standards 1.

Parenting styles—the dimensions of warmth and control a.

Authoritative—loving, with firm discipline—most effective, children tend to be well-adjusted

b.

Authoritarian—lacks warmth; strict and harsh discipline—children often compliant but anxious

c.

Indulgent—affectionate, but weak discipline—often related to impulsivity and noncompliance

d.

Neglectful—unconcerned with emotional or discipline needs—often related to serious conduct problems

2.

Coercion—when unwitting parents positively reinforce children's misbehavior by giving in to their demands, and the parents themselves are negatively reinforced by the children ending their misbehavior when the parent gives in

3.

The importance of parental love a.

Children who feel loved and secure tend to be more compliant

b.

Some children engage in problematic behaviors to obtain parental attention for them; any attention is better than being ignored; this is reffered to as negative attention

4.

Conflict and inconsistent discipline—frequent changes in standards of discipline within one parent, between two parents, between actions and words—correlated with externalizing problems

5.

Peers, neighborhoods, television, and society are also important determinants of children's social behavior—violence is modeled; peer groups may teach antisocial behavior; poverty, inadequate schooling, and violence in communities play a major role in children's development

6.

Differences seen in parenting of children with ADHD may simply be a function of the difficulties inherent in parenting children with ADHD, who present difficulties to parents.

7.

Social factors in ADHD—mothers of children with ADHD are more critical, controlling, and demanding; this seems, however, to be primarily a reaction to the child’s problems. Nevertheless, family and social adversity do contribute to ODD and are comorbid with ADHD. 278 C.

C.

Psychological factors 1.

2.

D.

VI.

Self-control and externalizing disorders a.

These children have deficits in the ability to delay gratification—the ability to defer small, immediate rewards for larger long-term benefits

b.

Tend to overinterpret the aggressive intentions of peers and may attempt to “get you before you get me”

c.

Ironically, children with ADHD tend to overestimate rather than underestimate their competence, suggesting that low self-esteem is not a major factor.

Children with externalizing disorders may also have deficits in moral reasoning.

Integration and alternative pathways 1.

Childhood disorders have multiple causes, and there are many pathways to the same disorder.

2.

Biological, psychological, and social factors interact in causing children's psychological disorders.

Treatment of externalizing disorders A.

Psychostimulants for ADHD 1.

Lead to at least some improvement in at least 75 percent of cases

2.

Work by increasing arousal and alertness

3.

Small dosages lead to improved attention and decreases in motor activity in all children; however, psychostimulant abuse can lead to restless even frantic behavior, which once appeared as a paradoxical effect until research found that the psychostimulants affected normal children, and even adults, in the same way.

4.

Often taken through adolescence and into adulthood; ADHD is not "outgrown"

5.

They help control behavior, but they do not have substantial benefits for learning and academic performance.

6.

Treatment study of preschoolers with ADHD (PATS) revealed that children who remain on psychostimulants improve over a 10-month period, but about 1/3 of the preschoolers discontinue medication.

7.

Side effects may include decreased appetite, increased heart rate, sleeping difficulties, and slowing of physical growth (although growth can be made up during non-medicated periods); new PATS data indicates that deceleration in growth may be more significant than had been previously thought.

8.

Most common prescribed psychostimulant medication: Ritalin, Dexedrine, Cylert, and Adderall 279 C.

9.

DSM-5 formally recognized the diagnosis of adult ADHD.

10. Numerous double-blind studies have demonstated the efficacy of psychostimulants 11. Currently, 2.7 million children in the United States—4.8 percent of school-aged population—are treated with psychostimulants; the rate of psychostimulant use in children increased from somwhere between 300 and 700 percent between 1987 and 2008.

12. Some have argued that psychostimulants may be overused in the United States.

B.

C.

Other medications for ADHD 1.

Antidepressants—a second-line treatment that may work for reasons that are currently unclear

2.

Strattera, the only nonstimulant medication approved for treatment of ADHD, has less potential for abuse but is less effective than psychostimulants and can have serious side effects, including increased suicidality.

3.

Clonidine may be used in combination with psychostimulants—research on effectiveness is controversial; there are even some reports of sudden death among treated children

4.

Other side effects are more serious, such as an increase in motor tics in a small percentage of cases.

Behavioral family therapy (BFT) teaches parents and teachers to use operant conditioning. It is used for ODD mostly. Specific behavior problems are identified, preferred alternatives are listed, and consequences set. Goals include a focus on rewards rather than punishment, firm but not angry punishment when necessary, and increased warmth; BFT typically beings with parent training for how to identify and deal with the child’s bad behavior.

1.

One of the main goals of BFT is to teach authoritative parenting.

2.

Research suggests that BFT is a good short-term solution, but there is a lack of research investigating the long-term effectivness of this treatment.

D.

Child-focused problem-solving skills training (PSST) is designed to help children develop more reasoned and well-planned solutions to problems.

E.

Treatment of conduct disorders 1.

Very resistant to treatment, especially in adolescents

2.

Behavioral family therapy and using negotiation can be helpful.

3.

Multisystemic therapy (MST), combining family treatment with interventions in child's peer group, school, and neighborhood appears to be effective. a.

4.

A 13-year study found signicantly lower recidivism, or repeat offending among troubled youths treated with MST.

Residential programs are effective while adolescents reside there, but they do not prevent recidivism once the adolescent leaves the residential placement.

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5.

Juvenile court is designed to rehabilitate but may lead to more behavioral problems; diversion—keeping problem youths out of the juvenile justice system—is associated with better outcomes a.

F.

The juvnile justice system is based on the concept of the state as a parent for incarcerated youths.

Course and outcome 1.

2.

3.

ADHD a.

Hyperactivity symptoms decline with age during adolescence; impulsivity and attention deficits more likely to persist, is measured by higher levels of motor vehicle accidents

b.

Prognosis dependent on whether ODD or CD are comorbid; when both ADHD and ODD or CD are present, youth are more likely to develop problems with substance abuse, criminality, and other antisocial behaviors

ODD and CD a.

About 50 percent exhibit antisocial behavior into adulthood

b.

Antisocial behavior that begins during adolescence has a better prognosis than antisocial behavior that begins during childhood.

The continuity of externalizing disorders highlights the importance of prevention.

VII. Internalizing and other disorders A.

B.

C.

Special factors to consider about children's internalizing symptoms 1.

Children can experience different symptoms of mood and anxiety disorders than adults experience; e.g., "irritable mood" can replace "depressed mood" in major depressive episodes.

2.

DSM-5 contains no separate category for internalizing disorders.

Depressive symptoms 1.

Normal emotional development is difficult to assess because children are neither reliable nor valid informants.

2.

Some studies have found no correlation between parent and child reports of incidence of depression; multiple informants should therefore be used for research and clinical practice.

3.

Parents may systematically underreport depressive symptoms in their children.

Children's fears in developmental perspective—frequency of children's fears declines with age; different fears develop at different ages; some fears are common and apparently stable across different ages of childhood 1.

Anxiety is a general and diffuse emotional reaction that is often linked with anticipation about the 281 C.

future.

D.

E.

Separation anxiety 1.

A normal fear; distress upon separation from attachment figures that typically lasts from about 8 to 15 months old; toddlers and preschoolers typically continue to experience distress with separation

2.

Separation anxiety disorder—excessive separation fears that persist for at least four weeks; must exhibit three or more of these symptoms and interfere with functioning: persistent and excessive worry for the safety of an attachment figure, fears of getting lost or being kidnapped, nightmares with separation themes, and refusal to be alone

3.

School refusal (school phobia)—extreme reluctance to go to school; often traced to separation anxiety disorder; accompanied by various symptoms of anxiety, such as stomach aches and headaches

Other symptoms of childhood disorders 1.

2.

Troubled peer relationships—children who are aggressive and disobedient or shy and withdrawn tend not to be well-liked by their peers, creating additional problems a.

Peer sociometric methods assess relationships by asking children to indicate their level of liking for their peers, and children are classified according to their peers’ report: popular children, average children, neglected children, rejected children, and controversial children

b.

Rejected children are more likely to have externalizing problems; neglected children are more likely to have internalizing problems.

Many problems of childhood can be conceptualized as developmental deviations—departures from age-appropriate norms

VIII. Diagnosis of internalizing disorders A.

DSM-5 defines depressive and anxiety disorders the same for children and adults. The authors of the textbook are not happy with this approach because not only do children show sadness in different ways at different ages, but their cognitive capacities also change in important ways across development.

B.

Anxiety and depressive disorders

C.

1.

Selective mutism involves the consistent failure to speak in certain social situations; uncommon, found in less than 1 percent of children with mental illness

2.

Mood dysregulation disorder is a controversial, new diagnosis that applies to children but is listed with depressive disorders.

Other neurodevelopmental disorders 1.

Specific learning disorder—a diagnosis for children who perform far below their age group in a specific learning area

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D.

IX.

2.

Tic disorder—includes Tourette’s disorder and is characterized by repeated motor and verbal tics.

3.

Developmental coordination disorder—slowness and inaccuracy of performance of motor skills

Trauma- and stressor-related disorders 1.

Reactive attachment disorder—is characterized by withdrawn behavior among very young children around adult caregivers

2.

Disinhibited social engagement disorder—very young children are indiscriminant toward caregivers

E.

Elimination disorders—encopresis and enuresis refer, respectively, to inappropriately controlled defecation and urination. This may be considered abnormal at age 5 and is often treated through the use of biofeedback equipment, such as the bell and pad, which is about 75 percent effective.

F.

Children’s behavior is closely tied to their relationships with family, school, and peer contexts; some have suggested that children should not be individually diagnosed but described in the context of their relationships, mostly, in the context of their family relationships.

Frequency of internalizing disorders A.

Prevalence of externalizing behavior declines with age (except during adolescence), but internalizing problems increase with age.

B.

Precise prevalence estimates are difficult to obtain, but as many as 35 percent of young women and 19 percent of younger boys have more externalizing disorders, while older girls have more internalizing problems that lead to a distinctive pattern in child treatment referrals; 31.9 percent of adolescents have anxiety disorders.

C.

Because younger children are more likely to be referred for treatment by adults, and boys have more externalizing disorders, more boys under 12 are referred for psychological treatment; by early adulthood (when clients self-refer), more women than men seek treatment.

D.

Suicide—third leading cause of death among teens; rates have tripled since the 1960s; suicide attempts in adolescents tend to be impulsive, related to family conflict, and often motivated by anger

E.

Cluster suicides can occur among teenagers; when one teenager commits suicide, his or her peers are at an increased risk.

283 C.

X.

Causes of internalizing disorders A.

B.

Biological factors 1.

Kagan and his colleagues identified a temperament called inhibited to the unfamiliar.

2.

Infants with this temperamental style cry easily, are fearful in response to novel stimuli, and are at increased risk for anxiety disorders.

Social factors 1.

2.

C.

XI.

Attachment relationships—attachment theory (Bowlby, Ainsworth)—stresses the importance of the relationships between infants and their caregivers; psychopathology occurs due to troubled attachments a.

Attachment can be secure (facilitating both closeness and exploration) or insecure (linked with problems in one or both areas)

b.

Insecure attachments consist of anxious-avoidant, anxious-resistant, and disorganized.

c.

Insecure attachments predict later internalizing and externalizing problems (though not specific disorders) and social difficulties.

Separation and loss can play important roles in the development of internalizing disorders.

Psychological factors 1.

Emotion regulation and internalizing behavior—children learn to identify, evaluate, and control their feelings based on the reactions, attitudes, and advice of parents and others

2.

Zahn-Waxler suggests that children of depressed mothers tend to take on a parenting role rather than being parented, feel excessive guilt, and are at increased risk for depression themselves.

Treatment of internalizing disorders A.

Internalizing disorders 1.

Few treatments for internalizing disorders have been developed or studied.

2.

Antidepressants are commonly prescribed, but there is a lack of research into their effectiveness in children; only fluoxetine (Prozac) has proven to be effective for children’s depression.

3.

New data from the Treatment for Adolescents with Depression Study (TADS) indicates that medication combined with CBT (cognitive-behavior therapy) is superior to other treatment groups (medication alone, or CBT alone) and to controls

4.

Evidence from the TADS data and other studies suggesting that use of antidepressants may impact upon suicidality has led to a decrease in prescriptions for adolescents, but the frequency of suicides has gone up during the past several years.

5.

Overall, antidepressant medications seem to be effective enough to warrant continued use, despite 284 C.

concerns about the increase in suicidality; of course, suicidal behavior should be monitored closely in all adolescents who are depressed and, especially, in those who are receiving antidepressant medications.

B.

6.

For anxiety, evidence shows that CBT is effective—benefits extending to 6–7 years after treatment; family and individual CBT are equally effective; Imipramine and Luvox may also be effective medications

7.

Clomipramine and SSRIs are also effective in treatment children with OCD, but exposure and response prevention would still be the treatment of choice for both children and adults with OCD.

8.

Adult treatments often have been used without evidence that they will work specifically for children.

Course and outcome 1.

Until recently, the view that internalizing disorders resolved quickly on their own prevailed.

2.

While specific fears do tend to be short-lived, other problems, such as depression and anxiety disorders, tend to persist into adulthood.

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LEARNING OBJECTIVES LO 16.1: Are children’s psychological disorders different from adults’?

LO 16.2: Is ADHD different from just being a “bad kid”?

LO 16.3: Are children’s psychological problems a sign of family problems?

LO 16.4: Can medication help children behave—and do better in school?

LO 16.5: Can young children be depressed?

LO 16.6: Do antidepressants cause teen suicide?

LECTURE SUGGESTIONS Risk taking in adolescence: Current directions APS reader (2E, p.181) Laurence Steinberg explores the question of why adolescents tend to engage in so many risky behaviors. He argues that adolescents’ risk-taking is not fully explained by cognitive views that have emphasized their irrationality, their beliefs in their own invulnerability, or their ignorance regarding base-rates and consequences for such behaviors. Instead, Steinberg takes a developmental neuroscientific perspective through which he argues that the socioemotional system is largely developed by adolescence, whereas the cognitive control network continues to develop throughout adulthood. Significant increases in reward salience characterize the puberty period (in both humans and in rodents), leading to greater interest in risk-taking that promises to result in rewards.

Steinberg claims that this perspective on adolescent behavior helps to explain why cognitive interventions designed to ‘change the thinking’ of adolescents have largely failed. He argues that interventions designed to alter the environment—enforcing laws against the use of alcohol, increasing the cost of cigarettes, and raising the driving age—would be more likely to reduce adolescent fatalities and injuries that are due to engaging in risky behaviors.

Students will be likely to want to dispute Steinberg’s conclusions, even if they agree with the research and logic of his arguments.

Physical and sexual abuse: Physical and sexual abuse often are associated with negative emotional and behavioral outcomes. It makes intuitive sense that being the victim of abuse, particularly by a parent, could lead to significant distress and emotional or behavioral difficulties. Retrospective research seems to confirm this impression. Large percentages of people with mental disorders report that they were physically or sexually abused as children. However, this research can lead one to make assumptions not actually supported by the available data. Point out to students the true meaning of retrospective research of this nature, and identify for them (or help them identify) its limits: Because many people with emotional disorders self-report abusive histories, we cannot assume that most people who are abused develop emotional disorders. We need to know the population base rates of abuse, and we would need prospective data to make such inferences. Another potential problem is the fact that self-reported abuse is not synonymous with abuse.

While it may be unlikely that people would incorrectly identify themselves as abused when they were not, many people who were abused may not acknowledge that fact.

This information does not, of course, imply that physical and sexual abuse are not significant stressors, and research has demonstrated their link with the risk for subsequent emotional and behavioral difficulties. However, 286 C.

retrospective research must be interpreted accurately. It is generally easier to obtain retrospective data, and there is a tendency for many people (lay and scientific) to overinterpret retrospective data.

DISCUSSION IDEAS Attention deficit hyperactivity disorder in adults: Current directions APS reader (1E, p.145) Given the high incidence of ADHD in childhood (3–5 percent), it would seem that ADHD in adulthood would be a lot more prominent. Stephen Faraone’s article highlights the ways in which diagnostic criteria, since it is different for adult ADHD than for childhood ADHD, can determine the outcome of research findings. The correlation between childhood ADHD and adulthood ADHD ranges dramatically in research studies (11 percent to 70 percent), but according to Faraone, this is largely due to the way in which DSM diagnoses childhood and adult ADHD. Ask students whether they think ADHD is prominent among adults. Of course, this is just anecdotal, but you can have them anonymously nominate some candidates they have encountered and even ask them to describe some of them. Then discuss what factors allow some of the adults who have ADHD to function at a high level. Type of occupation, level of social support, and severity of case will likely be prime predictive factors.

Childhood depression: Ask students to recall the key elements of depression and describe a typical depressed individual. Then ask them how a depressed child might differ in his/her external presentation. They will likely have stated that a depressed person looks and feels sad. Point out that in its colloquial use, the term “depressed” is synonymous with “sad” or “down.” Depressed children and adolescents, however, often do not look sad or down; instead, their predominant affect is often irritability, and they may appear primarily angry and oppositional. Additionally, children often do not show the same continuity of affective states as do adults, and thus, may appear euthymic or even happy and playful at times, yet they may still have an underlying depression. (You may wish to ask students to speculate as to the reasons for this—responsiveness to demand characteristics, lack of psychological sophistication, context-dependence, etc.) Given these differences, depressed children may easily elicit responses that are angry, rejecting, and that exacerbate their problems, highlighting the importance of careful and accurate assessment and diagnosis.

Nature/nurture: The text provides some evidence for a biological (nature) basis for childhood disorders and some evidence of the effects of ineffective parenting (nurture) on children. Ask students to comment on the nature/nurture issue with regard to disorders of childhood. Is there such a thing as a "difficult child?” How important are the parents in the etiology of conduct disorders? ADHD? Eating disorders? If students (correctly, of course) state that there is an interaction between nature and nurture, ask them to speculate about how this interaction might operate.

A "sick society"?

One way of interpreting the statistic that at least 12 percent of children suffer from a mental disorder is to argue that "something is wrong with our society." If there is something wrong, what is it? Ineffective parenting?

Insufficient research support for effective treatments? Apathy? After identifying some of the societal problems leading to mental disorders of childhood, you can ask about solutions. Should parenting classes be required? Should more money be spent on research? Should children be monitored by the government more closely, e.g., mandatory psychological testing?

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Are children over prescribed psychotropic medication?

We see the statistics of how many children and adolescents will be diagnosed with an externalizing or an internalizing disorder. Medication is usually the first treatment method used. Do you think that children are overmedicated today? What diagnoses do you think are more prevalent in boys than in girls? How does this change once one enters adolescence? What other types of treatment methods should be considered? How do you think medication will affect children once they become adults?

CLASSROOM ACTIVITIES ADHD treatment: Although most psychiatrists and many psychologists emphasize the use of stimulant medication as the first-line treatment for ADHD, it is known that stimulants do not “cure” ADHD; they treat the symptoms for as long as the person takes the medication. Psychotherapy is generally recommended as well to help the child develop more effective impulse control and to enhance the parent-child relationship. However, many parents are reluctant to use medication or even engage in psychotherapy. One comment often made is a variant of “It’s called ADHD now, but it used to be just a lack of discipline. When I was a kid, you did what you were told or got smacked, and that worked just fine.” Comments like these reflect a belief that the symptoms of ADHD are volitional and that a child simply needs to decide to behave appropriately. However, children with ADHD do in fact seem to have deficits in their ability to conform their behavior to situational expectations. At the same time, the focus of behavior therapy is to increase their ability to do so, suggesting that they do not lack the ability.

Ask students for their input into this debate. Is ADHD a “real” disorder, or do kids with ADHD simply need to decide to behave? Why are there more cases of ADHD diagnosed now? Does this increase reflect changes in behavioral standards, changes in personal accountability, or increased awareness of a true disorder?

Dealing with separation/loss: If Bowlby and Ainsworth are correct, early attachments predict adult responses to a wide variety of situations, especially responses to separations of various sorts. Suggest that the class create a paper-and-pencil test of "responses to separations" that might be related to the nature of early attachments. The items on the questionnaire might include how one deals with good-byes, with leaving home (e.g., for college), with break-ups of romances, etc.

Ask students to discuss different ways that internal working models of attachment relationships might be expressed.

Guest speaker on play therapy: Find a mental health professional that is a registered play therapist through the Association for Play Therapy website at www.4apt.org. Have this guest speaker come to talk about the field of play therapy: the education requirements for working in the field, the necessary licensure and clinical supervision, play therapy-specific training, what play therapy is, examples of this type of treatment, etc.

Mean Girls, movie clip: Relational aggression You can access a clip from the movie Mean Girls from YouTube. It is an excellent example of how girls display conduct disorder in a more covert way. Give some examples of relational aggression (RA), such as teasing, rolling the eyes, gossiping, etc., and of how primarily girls engage in this behavior. Then discuss the psychological impact of RA: for example, the difficulty with trust, hopelessness, suicide, eating disorders, self-injury, depression, etc. Ask students if they have witnessed RA or have been a victim of this type of behavior. Since we see the big 288 C.

movement in the school systems to try to abolish the impact of bullying, ask the students to create a plan that could be implemented to target relational aggression.

VIDEO CASES IN ABNORMAL PSYCHOLOGY: Jimmy—Attention Deficit Hyperactivity Disorder (17:21) Jimmy is an 11-year-old boy who has been diagnosed as ADHD. He articulates some of the reasons for his diagnosis early on in the interview. “I come into conversations out of nowhere….I’m only connected to my own mind.” The most striking feature that is immediately present in Jimmy is how fast he talks, which makes it very hard to understand what he is saying. He appears to be socially normal in the sense that he makes and keeps friends and does not have the common ADHD physical hyperactivity, although he keeps his hands and feet moving. Still, he can sit in a chair for long periods of time.

One of the problems Jimmy experiences is with transitions. He says once he "gets into something" it is difficult for him to switch to another activity. His mother says that it also is often difficult to establish a “getting ready for school” routine that is effective. She intimates that he has missed the bus because of not being organized and prepared. He now takes medication (presumably, a stimulant like Ritalin) during the week to help him focus his attention during school. His mother does not seem confident that it is helping, however. He also claims that he has difficulty initiating new ideas for his school projects. His mother seems to spend many hours helping him organize and complete his school assignments. As his mother is talking to the interviewer, Jimmy appears to drift off and is whistling to himself at times.

Discussion questions: 1.

Why does Jimmy have trouble with "transitions" in activity? Is this common or unusual for children with ADHD?

2.

One of Jimmy’s most obvious features is his "fast talking." How would you work on this to make him speak in a manner that is understandable to others?

3.

Jimmy’s mother provides a great deal of support and aid. Would you suggest that she cut back on her helping and allow Jimmy to be more independent, especially in school assignments? Why or why not?

4.

Jimmy appears to "zone out" of the conversation and starts whistling to himself when the interviewer and his mother are talking. Is this indicative of his ADHD or simply a function of being an 11-year-old boy who cannot enter into an adult conversation?

VIDEO RESOURCES http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/mydevelopmentlab/gentile_i. html Violence and Video Games: Douglas Gentile (3:28) This video asks if there are traits or other risk factors that make some children susceptible to becoming aggressive.

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http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/DSM_In_Context/Jimmy_ ADHD_1.html Jimmy: Attention-Deficit/Hyperactivity Disorder (ADHD) (1:26) Watch this video interview with Jimmy, a boy with ADHD, talking about his impulsive behaviors.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Divorce_and_Adolesce nce.html Divorce and Adolescence (1:03) In this video, a teenager discusses the impact of his parents' divorce on him.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Medicating_Kids_with _ADD.html Medicating Kids with ADD (1:33) Watch this video about Ritalin helping kids with ADHD and about problems with overmedicating.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/mydevelopmentlab/forbes_d. html Depression, Reward Regions, and the Brain: Erika Forbes (1:15) Professor Forbes's research includes the development of depression in young people and, in particular, the roles of positive affect and neural systems of reward. Here, she explores what issues arise when studying depression in adults versus depression in children and adolescents.

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Chapter 17 Adjustment Disorders and Life-Cycle Transitions Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: p. 466 Symptoms: p. 467 Diagnosis

The Transition to Adulthood: p. 469 Symptoms of the Adult Transition Diagnosis of Identity Conflicts Frequency of Identity Conflicts Causes of Identity Conflicts Treatment During the Transition to Adult Life Family Transitions: p. 472 Symptoms of Family Transitions Diagnosis of Troubled Family Relationships Frequency of Family Transitions Causes of Difficulty in Family Transitions Treatment During Family Transitions Couples Therapy and Family Therapy

Discussion Ideas: Gender differences Classroom: Resolving the identity crisis

Lectures: Marital conflict Marital quality and internalizing disorders Structural family therapy Discussion Ideas: Perceived equity in relationships Classroom: Family communication

The Transition to Later Life: p. 480 Symptoms Diagnosis of Aging Frequency of Aging Causes of Psychological Problems in Later Life Treatment of Psychological Problems in Later Life

Lectures: Stage models of bereavement Discussion Ideas: Aging, positive emotions, and technological support Ageism

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PROFESSOR NOTES

CHAPTER OUTLINE I.

Overview A.

Many people seek psychological treatment despite not having a mental disorder; these people are usually seeking help with psychological pain.

B.

Psychologists are interested in the study of the struggles in moving from one stage of adult development into a new one; adult development consists of fairly predictable challenges that occur during adult life in relationships, work, life goals, and personal identity.

C.

Life-cycle transitions—challenges arise when moving from one social or psychological stage of adult development into a new one

D.

1.

The transition to adult life raises issues related to identity, career, and relationships in the late teens and early twenties.

2.

Family transitions during the middle years involve major changes in life and in relationships and may include happy events (e.g., birth of a child) or unhappy ones (e.g., divorce)

3.

The transition to later life includes major changes in life roles (retirement, grief over the death of loved ones) and more abstract issues involved in aging and mortality

Symptoms and diagnosis of life-cycle transitions 1.

E.

Life cycle transitions are varied, and while different people respond to the same event in various ways, Erikson noted conflict as a common theme; he termed this conflict as a “crisis of the healthy personality.” a.

May be a consequence of change, but also a catalyst for needed change

b.

Interpersonal conflicts often increase during life-cycle transitions, especially those involving close relationships.

c.

Psychological pain is often referred to as another common symptom of life-cycle transitions; research shows that the same brain systems are involved in both physical and psychological pain.

Diagnosis 1.

DSM-5 employs a list called “Other conditions that may be of a focus of clinical attention.”

2.

Adjustment disorders—development of clinically significant symptoms in response to stress that are not severe enough to warrant classification as another mental disorder

3.

Unfortunately, DSM-5 only briefly describes adjustment disorders.

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4.

F.

Erikson’s stages of adult psychosocial development 1.

2.

II.

Adjustment disorders are grouped with acute stress disorders (ASD) and post-traumatic stress disorder (PTSD).

Erikson's eight stages of psychosocial development include four stages of adult development: a.

Identity versus role confusion—resolution of the identity crisis; this period of basic uncertainty about self provides the first complete answer to the question, “Who am I?”; the major challenge of adolescence and young adulthood, the young person’s goal is to integrate various role identifies into a global sense of self

b.

Intimacy versus self-absorption—achieving a balance between closeness with others and independence; one life goal is to form an intimate relationship in early adulthood

c.

Generativity versus stagnation—highlights the importance of family and career accomplishments in mid-life; people who stagnate may have a family and a job, but they live life without a sense of purpose or direction

d.

Integrity versus despair—looking back on life may involve satisfaction or wishes to change what occurred; integrity comes from “the acceptance of one’s one and only life cycle as something that had to be and that by necessity, permitted of no substitutions”

Models of adult development, such as Levinson's, attempt to identify social tasks and transitions that occur consistently at various stages of development, such as the early adult transitions, midlife transition, and the late-adult transition.

The transition to adulthood A.

Symptoms of the adult transition 1.

Psychosocial moratorium—a time of uncertainty about identity and goals and a period in which one experiments with roles and discovers a niche

2.

Identity crisis—defining one’s identity is the central task of adolescence a.

It may be good for young people to have a moratorium, a period of uncertainty about themselves and their goals.

3.

Changes in roles and relationships also occur at this time; conflicts in relationships with parents and peers increase; Horney identified needs to move toward, away from, and against others as competing strategies in early adult development.

4.

Emotional turmoil—anxiety and depression may increase because of uncertainty about relationships; emotional struggles stem both from competing feelings and from the intensity of these emotions

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B.

C.

Diagnosis of identity conflicts: Marcia's (1966) identity categories 1.

Identity diffusion—young people questioning childhood identities but not actively searching for new adult roles

2.

Identity foreclosure—young adults who never question themselves or their goals but follow the predetermined course of their childhood commitments

3.

Identity moratorium—people who are in the middle of an identity crisis while actively searching for adult roles

4.

Identity achievement—young people who have successfully decided on long-term goals after going through all of the other stages (questioning, etc.)

Frequency of identity conflicts 1.

Everyone makes life-cycle transitions; there is little empirical data on who or how many people have significant problems. a.

D.

2.

During the 1960s, some young people developed an alienated identity achievement in which their definition of self was at odds with many values help by the larger society.

3.

With few attractive career opportunities, delays in making commitments to work and family can also result from limited opportunities available to some members of society.

Causes of identity conflicts 1.

2.

E.

Popular books refer to the struggles of transitioning to adulthood as the quarter-life crisis.

Family influences—a balance of support/supervision and allowing independence is associated with best outcomes a.

Industrialized societies' affluence, education, and availability of alternative roles may increase the conflict around identity.

b.

In less developed countries, parental authority or economic necessity are more likely to dictate life course.

Gender roles influence the resolution of the identity crisis and the formation of identity. a.

Women may be more likely to form identities based on family relationships and not based on careers.

b.

Men may form identity before entering lasting relationships.

Treatment of transition to adult life 1.

Little research conducted on people seeking treatment for distress during this transition

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III.

2.

Validating the young person’s distress and helping him/her understand and clarify life choices is key; normalizing the experience of identity conflict may also be helpful.

3.

Supportive, non-directive therapy is generally advised.

Family transitions A.

Some contemporary researchers use the concept of family life cycles, which involves the developmental course of family relationships throughout life.

B.

Symptoms of family transitions 1.

Conflict in family has a variety of sources but is often tied to life transitions and is a common consequence of changing family relationships. a.

Marital satisfaction often declines following the birth of the first child and rises once children leave.

b.

Power struggles are attempts to change dominance relations within the family.

c.

Intimacy struggles are attempts to alter the degree of closeness in a relationship.

d.

Uncertain interpersonal boundaries increase conflict.

e.

Families with happy relationships reciprocate positive actions and overlook negative behavior, while troubled families reciprocate negative feelings and tend to ignore the positive.

f.

The demand and withdrawal pattern is where one partner becomes increasingly demanding and the other withdraws further and further.

2.

Fighting can cause emotional distress for all family members; unresolved conflicts can lead to more serious emotional problems; anger is often an “emotional cover-up” masking deeper hurts, including loneliness, pain, longing, and grief.

3.

Cognitive conflicts include family transitions and can also set off new identity conflicts that confront people with a fundamental conflict between acceptance and change.

C.

Diagnosis of troubled family relationships: some argue that all individual diagnoses should be replaced under a relationship-based classification system; DSM-5 uses straightforward if not limited groupings, such as “partner relational problem” and “parenting problem”

D.

Frequency of family transitions 1.

Over 90 percent of adults in the U.S. will get married.

2.

Age at first marriage has increased from early 20s to late 20s (about 5 years later), about 26 for women and about 28 for men

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3.

Almost half of all people who get married in the U.S. live together prior to marriage.

4.

Five out of six married women have children; increasing numbers of single women are having children; in 2005, 40 percent of births were to unmarried mothers, including 69.9 percent of African American mothers, 48 percent of Hispanic, and 25.3 percent of white mothers.

5.

There is marital discord in at least 31 percent of couples. a.

6.

E.

Although “happily ever after” is not realistic, at any given point in time, most married couples report being happy with their marriage.

About 40 percent of marriages will end in divorce: half occur within the first seven years; divorce is likely to be followed by remarriage. The rate of divorce has declined since 1980.

Causes of difficulty in family transitions 1.

Psychological factors a.

Gottman's (1994) four basic communication troubles 1.

Criticism—attacking someone's personality rather than his or her actions

2.

Contempt—an insult motivated by anger intended to hurt the other person

3. Defensiveness—a self-justification, such as denying responsibility, blaming the other person, or "yes-but”-ing 4.

2.

Stonewalling—isolation and withdrawal that precludes communication

Social factors a.

Family roles contribute to distressed family relationships.

1.

In traditional roles where the married couple is unhappy, women feel unsupported and men feel disengaged.

2.

In nontraditional roles, the couple must define their own roles rather than assume traditional social roles; there is some evidence that androgynous couples have happier marriages.

b.

Poverty, unemployment, poor living conditions, and lack of social support can all contribute to family problems.

c.

Teenage pregnancy, nonmarital childbirth, divorce, and family violence are social issues as well as psychological ones.

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3.

F.

Biological factors a.

Individual psychopathology and individual problems are, in part, biologically determined, and they are both causes of family distress.

b.

Research indicates a genetic contribution to divorce; people with emotional disorders may be less likely to get or stay married.

c.

The gene-environment correlation is demonstrated by the finding that growing up with an unrelated male leads to earlier menarche. The reason, argues Jane Mendle, is that the mothers of daughters with an unrelated male in the household probably had early menarche.

Treatment during family transitions 1.

2.

Premarital Relationship Enhancement Program (PREP) a.

Prevention program where couples discuss expectations about marriage and learn communication and problem-solving skills

b.

PREP couples maintained marital satisfaction three years later, while control couples' satisfaction declined.

c.

The results of PREP are optimistic, but systematic research on the topic is still lacking.

Couple therapy and family therapy attempt to change relationships, not individuals. a.

b.

IV.

Cognitive behavioral couple therapy (CBCT) focuses on interactions, particularly the exchange of positive and negative behaviors communication styles, and strategies for solving problems.

1.

Leads to significant short-term improvements in marital satisfaction in half of couples

2.

Recurrence of problems is common; relapse at follow-up is also common.

Can also be used to treat psychological disorders as an alternative to individual therapy

Transition to later life A.

Middle-aged men and women become increasingly aware of their aging bodies, but both men and women may be more concerned with husbands' health, since men have an approximately seven-year-shorter life expectancy.

B.

Chronic diseases, such as hypertension, become more common, sensory systems decline in acuity, and some cognitive abilities diminish; these changes accelerate around the age of 75.

C.

Social transitions include retirement and redefinition of family roles from life-long occupations, while children find themselves increasingly caring for them; also we must face our own death and specific fears about a painful prolonged death.

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D.

Ageism—stereotypes about older people can lead to a form of social prejudice called ageism—mostly based on misconceptions, including that older people are stubborn, irritable, bossy, and complaining; in fact, personality is generally consistent through the life cycle

E.

Symptoms 1.

Physical functioning and health decline with age, but not as rapidly as is commonly believed a.

Menopause—the cessation of menstruation is an important physical focus for middle-aged women, typically occurs at around age 50—sometimes involves hot flashes and emotional swings; hormone replacement therapy alleviates many symptoms of menopause and decreases risk for heart and bone diseases, but increases cancer risk 1.

2.

3.

Menopause is a rather sudden event compared to the other, gradual processes of aging.

b.

Functioning of all sensory systems declines, sensitivity to taste, smell, and touch decreases, muscle strength declines, and diseases develop more frequently

c.

Osteoporosis—a condition in which bones become honeycombed and can be broken easily

Life satisfaction and job satisfaction tend to be higher in older than younger people, but sense of purpose may be diminished a.

Little research has been conducted on Erikson’s concept of integrity vs. despair; assumption is that older people are examining their lives in a retrospective way and that their judgments have an effect on the quality of their lives.

b.

Older people are more selective in their relationships, but the quality and importance of their relationships increase.

c.

A foreshortened time sense encourages focus on the positive.

d.

Despite common stereotypes, older people tend to remain sexually active; in fact, about a quarter of the oldest age group report having sex once per week or more.

Grief and bereavement—grieving in response to the death of a loved one—becomes more common a.

Kubler-Ross's (1969) stage model for coping with terminally ill patients includes denial, anger, bargaining, depression, and acceptance.

b.

Research shows that the sequence of emotions and "coping style" is much more individual and less stage-like than Kubler-Ross's model would indicate.

c.

A DSM-5 diagnostic category called “Complicated grief” was proposed and rejected.

d.

Mood, anxiety, and cognitive disorders are the most common emotional problems for elderly.

e.

Possibly 10–15 percent of bereaved people experience prolonged grief.

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4.

F.

G.

H.

Mental disorders are less common among adults 65 years and older, but depression, when present, tends to be more severe. a.

Suicide rates are highest among the elderly over 65 (particularly white males).

b.

Suicide is one of the top 10 causes of death among older adults.

c.

Suicide can be the result of chronic pain, physical disease, or the prospect of a long terminal illness; some refer to such choices as “rational suicide,” a controversial term for the decision some severely ill older adults make in ending their lives.

d.

Assisted suicide—a hotly debated topic where medical professionals help terminally ill patients to end their lives comfortably; it is currently legal in three states. The patients are predominantly white.

Diagnosis of aging 1.

Young-old—adults in good health, active members of their communities—roughly between the ages of 65 and 75

2.

Old-old—suffer from physical, psychological, or social problems; roughly 75 to 85 years old and require some assistance in living; 6 percent live in nursing homes

3.

Oldest-old—adults 85 years old or older; some need constant assistance, and some still maintain their vigor; 15 percent live in nursing homes

4.

Gerontology—the multidisciplinary study of aging

Frequency of aging 1.

The proportion and number of older Americans is expected to increase dramatically through the middle of the twenty-first century, especially in the "oldest-old" category.

2.

By 2030, one-fifth will be 65 years old or older; by 2050, the oldest-old (85 and up) may comprise one-quarter of the U.S. population.

3.

72 percent of older men are married; 42 percent of older women live alone.

Causes of psychological problems in later life 1.

Health a.

Poor health is the most common contributor to a negative quality of life.

b.

Health behavior—increased vigor and good health are associated with proper diet, exercise, weight control, and the avoidance of cigarette smoking and excessive alcohol.

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2.

3.

I.

Relationships a.

Men over 70 list relationships with spouses, friends, and children as positive contributions to quality of life.

b.

Since many women over 70 are widowed, they mention relationships with spouses less frequently than do men, but they list friends, children, and general socializing as most important to them.

Social factors, such as recreation, religion, and integration into a community, are thought to influence the well-being of the elderly.

Treatment of psychological problems in later life 1.

Geropsychology is a new subdiscipline of health psychology and behavioral medicine; it was developed for studying and treating the behavioral components of health and illness in the elderly.

2.

Living wills—legal documents that direct health care professionals not to perform certain procedures in order to keep a severely disabled or terminally ill person alive; can be important in humanizing the process of dying

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LEARNING OBJECTIVES LO 17.1: What problems in living cause some people to seek psychological help?

LO 17.2: How does DSM-5 classify emotional problems that are not disorders?

LO 17.3: Is the “midlife crisis” a myth?

LO 17.4: Is an identity crisis necessary for healthy adult development?

LO 17.5: How are family relationships critical to psychological well-being?

LO 17.6: Is it depressing to grow older?

LECTURE SUGGESTIONS Marital conflict: Current directions APS reader (2E, p. 55) Frank Fincham of the University at Buffalo discusses the stature of “marital conflict” in the world of current marital research. This was the hot research topic for marital researches for a number of years, but Fincham makes a compelling argument that we should begin to look at other aspects of marriage besides conflict. We have learned from the research on marital conflict that conflict within a marriage leads to a number of negative outcomes or consequences. “Marital conflict has been linked to the onset of depressive symptoms, eating disorders, male alcoholism, episodic drinking, binge drinking, and out-of-home drinking” (pg. 152). Distressed couples, moreover, behave worse during conflicts, have more predictable interactions, and often follow a "demand-withdrawal" pattern of interaction in which one partner demands and the other then withdraws.

This research focused on marital conflict, however, has ignored some important variables that also play a part in marital success or failure. Specifically, Fincham argues that there are a number of promising "variables" to examine in order to better understand marriage: (1) the context in which the conflict is taking place, (2) individual characteristics of the marital partners, and (3) the larger context in which the marriage is embedded (society).

Conflict, for example, that occurs in the context of an impoverished family would probably be experienced differently and lead to different outcomes than in the context of a middle class family.

Marital quality and internalizing disorders: South and Krueger investigated the connection between the quality of a marriage and the presence of symptoms of internalizing disorders. They looked at depression, generalized anxiety disorder, panic attacks, and neuroticism in 379 twin pairs. Overlap was found between genetic influences on both marital quality and the internalizing spectrum. Their results suggest that people with a genetic predisposition to internalizing disorders are more likely to express these symptoms in the context of a marriage that has a good deal of conflict/discord in it. This is an excellent example of a diathesis-stress model—wherein the stress of a difficult marriage may cause symptoms and, indeed, the emergence of a syndrome or disorder like depression or anxiety.

South, S.C. & Krueger, R.F. (2008). Marital quality moderates genetic and environmental influences on the internalizing spectrum, Journal of Abnormal Psychology, 117, 826–837

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Structural family therapy: How can the power struggles within the family be altered? One family systems approach, "structural family therapy," focuses particularly on the family power structure. One of the leading figures in this approach is Salvatore Minuchin, a family therapist in Philadelphia. Minuchin's approach reframes the individual's problems in terms of family problems. Usually, the family presents a problem with one member, e.g., the child is "acting out at school."

Minuchin refers to this member of the family as the "I.P." (identified patient). He finds that, generally, the family has exerted some power over the I.P. that has resulted in the development of these symptoms. In order to change the power structure in the family, Minuchin will then proceed to align himself with this weaker member, allowing a more balanced power structure to emerge (homeostasis). The family will, naturally, resist this change, but with the help of the power of the therapist, the identified patient will begin to develop greater self-esteem; the other family members will need to adapt, and the therapist can help them to develop a homeostasis that does not require one member to develop symptoms.

Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Minuchin, S. (1987). My many voices. In J.K. Zeig (Ed.), The evolution of psychotherapy. New York: Brunner/Mazel.

Stage models of bereavement: Since the popularity of Kubler-Ross's theory on stages of bereavement, many professionals working with patients who have lost a loved one or are terminally ill attempt to move these patients through the stages, assuming that patients who are angry are in the beginning stages of coping, patients who do not wish to face their problems are in a very primitive denial phase, etc. Kubler-Ross's theory, however, has received little empirical support and, in fact, people often respond in different sequences or with different emotions than those Kubler-Ross proposes. As you can imagine, problems emerge when clinicians strictly interpret a theory like Kubler-Ross's model, assuming it is both normative to cope with loss/death in this fixed, sequential way and unhealthy to cope otherwise. Patients who deviate from this sequence may, for example, be viewed as "denying" or "not really facing the problem." In fact, some research suggests that those patients who show milder responses in their grieving are better adjusted in the long run. This is a good example of how an intuitively attractive theory or model can be misused by mental health professionals.

DISCUSSION IDEAS Gender differences: Are there gender differences in the formation of an identity? Traditionally, women define themselves in terms of relationships. Men tend to define themselves in terms of their careers. Why has this been the case? Is it still true?

Will it continue to be true in the future as gender roles continue to change?

Perceived equity in relationships: Perceived equity is an important dimension in interpersonal relationships. Perceived equity can be defined as the perception that there is an equal contribution given by each partner, as well as equal responsibilities assumed by each partner in the relationship. Perceived equity does not simply refer to behavioral reinforcement, but is considered a "cognitive" factor since it involves a good deal of interpretation on the part of the person. Marital problems often arise because one person perceives that the other is not assuming as many responsibilities as they are. How important is perceived equity in relationships? Ask students to consider the equity issue in a variety of relationships and to discuss the importance of equity in each of these: (1) roommates, (2) romantic relationships, (3) 302 C.

parent-child relationships, and (4) teacher-student relationships. How often are failures in these relationships due to perceived inequities?

Aging, positive emotions, and technological support: Current directions APS reader (1E, p. 160) The Carstensen and Turk Charles article, on the emotional well-being of the aging, and the Fisk and Rogers article, on the use of technology in the aging, both raise some interesting questions about the role of the aging in our population. Carstensen and Turk Charles point out that, although we think of the aging as people suffering from more physical and mental problems, one underexamined strength that aging people have is their regulation of emotion. Older people are able to view social interactions in a time-limited context, and therefore, experience those social interactions in a deeper and more effective manner. Fisk and Rogers discuss the needs of the elderly in the realm of technology. They argue that much of modern technology leaves the elderly in a difficult position. Manuals are difficult to read, and older people often struggle with some of the physical characteristics of new technology.

Many of these issues, however, are avoidable with proper care and attention placed on design and implementation of technological products.

Both articles raise questions about how we view the elderly. Do we really view aging people as stronger emotionally than their younger counterparts? Do we tend to think of the aged as having at least as many experiences involving positive emotions as younger adults have and as having better recall for emotional content than younger adults have? Do manufacturing companies consider the elderly when they design a product or write their instruction manuals? Students will be able to name many technological products that they, themselves, have trouble with, and therefore, they should be able to easily imagine how difficult those products may be for the elderly to operate. What is our current view of the elderly in our society? Is it a realistic and accurate one?

Ageism: What are the defining characteristics of ageism? What are its sources? If these questions do not promote a response, you may want to rephrase them in the following way: what are some common stereotypes about old people? Are they true? Completely false? Partially true? Finally, you would want to ask the question of how ageism actually causes problems for the elderly. You may wish to "fuel the fire" by talking about the prevalence of depression and even suicide among the elderly, especially following involuntary retirement. This may raise the question of whether employers should be allowed to enforce mandatory retirement based on age.

Stigma and stereotypes around sexuality and aging: The textbook mentioned that 73 percent of older adults at ages 57 to 64 are sexually active, 53 percent are sexually active at ages 65–74, and 26 percent are sexually active at ages 75–85. Ask students to discuss their thoughts about older adulthood and sexuality. What are the stereotypes they have heard about sexuality and aging for men and women? Is there a stigma associated with older adults engaging in sexual activity into late adulthood?

What type of sexual education would need to be provided for this population?

Why are people cohabitating more in today’s society?

Over half of people in the U.S. cohabitate before they enter marriage. Why do you think this is? What are the pros and cons of living together before marriage? Do you think living together may prolong the actual act of marriage? Does that fact that around 40 perent of couples in the U.S. end up in divorce impact the process of living together? Why or why not? What are your personal views of living together before marriage?

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CLASSROOM ACTIVITIES Resolving the identity crisis: Have students form small groups to respond to the following prompt: Describe the importance of each of the following in resolving the identity crisis: (1) parental support, (2) exploration, (3) rebellion, (4) education, and (5) social class. What aspects of each might be important to successful resolution?

Family communication: Ask for volunteers to demonstrate family communication problems. The volunteers should be organized into a family, with a father, a mother, and two or three children. Ask them to first plan, and then act out, a family argument that begins at the dinner table (e.g., an argument over one of the children reporting an interest in attending a music concert, a dispute over friendships, or over career choices, etc). Instruct the class to look for examples of Gottman's four basic communication problems during the volunteer family’s argument. These four basic commnication problems are criticism, contempt, defensiveness, and stonewalling. Students should keep notes citing examples of each problem, and following the demonstration, the class can discuss them. If you'd like to extend the discussion to include the treatment issue, you can ask, "How might a family therapist intervene to improve the communication in this family?"

Create a bereavement group curriculum for each different life transition: Divide the class into small groups and then assign to each group a different stage of the life transition cycle in adulthood, such as adolescence, young adulthood, middle adulthood, and late adulthood. Then ask the students to discuss how the different stages of grief would present developmentally based on the stage of life. What typical losses would be associated with the life cycle? What considerations would need to be taken into account? Then ask the students to create a therapy group, self-help group, or a support group for the developmental stage assigned to them. Ask them to consider what types of topics would be covered, what kinds of activities encouraged, who would run the group, etc.

Fears around death: Set up the following scenario for the students: they have just found out that either themselves or a loved one has been diagnosed with a terminal illness. Then on a scrap sheet of paper, ask them to anonymously write down their fears or worries, such as how would life change, what would be left behind, what fears or worries would they have about not completing something, etc. Ask the students to fold up the small sheets of paper and place them all in a basket or a hat. Then shuffle the small pieces of paper and redistribute the pieces of paper, one per student. Ask them to read the sheets and comment on what is written.

Presentation of Kubler-Ross’s (1969) stages of grief: Kubler-Ross (1969) identified the stages of grief as denial, anger, bargaining, depression, and acceptance.

Ask the students to share within small groups their personal experiences of losing a loved one, friend, or even a pet.

Then ask the students to answer the following questions: how did you experience the stages of grief? What did each stage look like for you? Did you actually experience each stage? How have you witnessed others progress through the different stages of grief? What did this look like and how was it different from your experiences?

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VIDEO RESOURCES

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Julia_HIV_Positive_ and_Adjustment_Disorder.html Julia: HIV Positive and Adjustment Disorder (2:26) In this video, an HIV-positive woman discusses her adjustment problems. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Stress_and _Wellness.html Stress and Wellness (0:55) This video discusses the relationship of stress and its impact on wellness. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/mydevelopmentlab/2011/LifeSpanDevNKP/ Jeff_Work.html Middle Adulthood: Work, Jeff (2:25) In this video, 45-year-old Jeff talks about his working life. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Adolescence _Identity_and_Role_Development.html Adolescence: Identity and Role Development (0:41) In this video, an adolescent girl talks candidly about her parents' expectations that she go to college versus her own interests, and how difficult it can be to balance all of these things. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/Dev_psych_world_of _psych/Conflict_with_Parents_in_Adolescence.html Conflict with Parents in Adolescence (4:16) This video discusses adolescents’ conflict with parental and authority figures.

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Chapter 18 Mental Health and the Law Chapter-at-a-Glance DETAILED OUTLINE

INSTRUCTOR RESOURCES

Overview: p. 490 Expert Witness Free Will vs. Determinism Rights and Responsibilities Mental Illness & Criminal Responsibility: p. 492 The Insanity Defense Competence to Stand Trial Sentencing and Mental Health

Lectures: Guilty with diminished responsibility Predicting violence Discussion Ideas: Mental health expert testimony The insanity plea Classroom: Insanity criteria

Civil Commitment: p. 500 A Brief History of U.S. Mental Hospitals Libertarianism vs. Paternalism Involuntary Hospitalization The Rights of Mental Patients Deinstitutionalization Mental Health and Family Law: p. 507

Discussion Ideas: Paternalism vs. libertarianism The right to refuse treatment

Lectures: Violent men and violent stepparents

Child Custody Disputes Child Abuse Professional Responsibilities and the Law: p. 511

Classroom: Psychotherapist infractions

Professional Negligence and Malpractice Confidentiality 306 C.

PROFESSOR NOTES

CHAPTER OUTLINE I.

Overview A.

Historical perspective: Many Soviet political dissidents were detained under the guise of treating their “mental illness.”

B.

Famous case of John Hinckley’s use of the insanity defense: In 1981, Hinckley attempted to assassinate President Reagan and was later found not guilty for reasons of insanity.

C.

Expert witnesses 1. Expert witnesses are mental health professionals or others with specific expertise; may be permitted to testify in court regarding matters of opinion (otherwise not permitted) that lie within their areas of expertise; expert opinion should be based on established science.

D.

One trend to limit conflict and improve expert testimony is for courts to appoint neutral experts rather than “hired guns.”

E.

Free will versus determinism 1. Free will—capacity to make choices and act freely upon them; criminal law assumes that when people violate the law, they are accountable for their actions 2.. Determinism—the view that behavior is determined by forces outside of voluntary control (biological, psychological, and social); necessary for psychology to be a science 3. Insanity—a legal term signifying the lack of criminal responsibility, which holds that because people act out of free will, they are accountable for their actions when they violate the law

F.

Rights and responsibilities 1.

Thomas Szasz asserted that all behavior is a product of free will and that all people with emotional disorders are responsible for their actions; his positions argue a.

For the abolition of the insanity defense and greater recognition of patients' rights in the legal and mental health systems

b.

That the mentally ill and healthy should be treated with the same in terms of social responsibility and dignity; he therefore believed in more patient’s rights

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II.

Mental illness and criminal responsibility A.

The insanity defense 1.

Historically, mental disability limited criminal responsibility in ancient Greek and Hebrew traditions as well as in early English law; Daniel M'Naghten claimed that the "voice of God" ordered him to kill the British Prime Minister, but he mistakenly murdered the secretary—found not guilty of murder by reason of insanity (NGRI)

2.

Tests and legislation a.

M'Naghten test (1843; Britain)—it must be proven that the person "did not know the nature and quality of the act he was doing" or that he did "not know he was doing what was wrong"

b.

Irresistible impulse test (1886; U.S.)—Alabama court ruled defendants could also be found insane if they could not "avoid doing the act in question" because of a mental disease; it was argued that convicting people of crimes when they could not control themselves would serve no deterring purpose, which is one of the major goals of law.

c.

Product test (1954, Durham v. United States)—"an accused is not criminally responsible if his unlawful act was the product of mental disease or defect"; overruled in 1972 because the terms were too broad

d.

Model legislation (American Law Institute, 1955) combined the M'Naghten rule and the irresistible impulse test—"a person is not responsible for criminal conduct if...as a result of mental disease or defect, he lacks substantial capacity either to appreciate the criminality of his conduct or to conform his conduct to the requirements of the law"

e.

1984—the "irresistible impulse" component is eliminated in federal law; the guilty but mentally ill verdict (GBMI) was adopted after the acquittal of Hinckley (1984); defendant is found guilty but also considered mentally ill, though not legally insane, at time of crime

3.

The burden of proof is now placed upon the defense (in federal and most state courts); it must prove the defendant's insanity rather than the prosecution proving sanity; the standard of proof is high in federal court:"clear and convincing evidence"; in most states, by a "preponderance of the evidence"

4.

Perception of what defines "mental disease or defect" varies—American Psychiatric Association says that disorders that qualify are limited to “severe abnormal mental conditions that grossly impair perception or understanding of reality.” In 1955, the American Law Institute adopted the definition (which has been endorsed by many states): “A person is not responsible for criminal conduct if at the time of such conduct as a result of mental disease or defect he lacks substantial capacity either to appreciate the criminality of his conduct or to conform his conduct to the requirements of the law.”

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5.

6.

B.

The verdict of guilty but mentally ill (GMBI) represents an attempt to reform the insanity defense. a.

This is used when a person with a mental illness commits a crime, but is not insane.

b.

In the United States, the burden of proof rests with the prosecution, and the standard of proof is to demonstrate guilt “beyond a reasonable doubt.” However, in most states, insanity must be proven beyond a reasonable doubt by the defense.

Use and consequences of the insanity defense a.

About 1 percent of all criminal cases in the U.S. involve the insanity defense; about 25 percent of these defendants are found NGRI, usually as a result of a plea bargain.

b.

On average, defendants who are found NGRI spend about the same amount of time confined in an institution as they would have served in prison if given a prison sentence.

c.

Some state laws limit the amount of confinement following a NGRI verdict to the maximum sentence for that crime, but the U.S. Supreme Court ruled that longer confinements are permitted.

Competence to stand trial: defendants must be competent to make legal decisions and engage in the legal process 1.

Competence to stand trial—defendants’ ability to understand the proceedings that are taking place against them and to participate in their own defense; proceedings are suspended when a defendant is judged to be incompetent a.

Refers to a defendant's current mental state

b.

Legal definition of incompetence is not synonymous with psychological definition of mental illness

c.

Refers to ability, not willingness, to participate in the legal proceedings

d.

"Reasonable degree" of understanding necessary to establish competence is low; only those with severe emotional disorders are likely to be found incompetent

e.

Not dependent on the presence of a “mental disease or defect”

2.

The most common finding of incompetence occurs when defendants are to stand trial, but the issue of competence can arise at many stages of the criminal process—during arrest, at time of sentencing, or even at time of execution (if the convicted received the death penalty)

3.

Many more people are institutionalized because of incompetence than because of insanity rulings; some are even kept institutionalized for longer periods of time than they would have been if convicted of the crime.

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C.

III.

4.

Defendants must be competent to understand the Miranda warning issued during their arrests, which details the suspect’s rights to remain silent and have an attorney present during police questioning.

5.

75 percent of incompetent defendents are restored to competence within six months.

Sentencing and mental health 1.

Mental health problems are often seen as mitigating factors in criminal responsibility and may be seen as justifying less severe sanctions.

2.

Mitigation evaluations, which include an assessment of mental health, are required in death penalty cases.

3.

A recent U.S. Supreme Court ruling (Atkins v. VA [2002]) found that it is unconstitutional to execute intellectually disabled defendants; now, whether or not a defendant is intellectually disabled has life and death consequences; also, a capital crime committed by a minor (under the age of 18) cannot be given the death penalty, as ruled by the Supreme Court.

4.

Sexual predator laws—designed to keep sexual offenders confined for indefinite periods—are justified as protecting society from the danger of the person committing the crime again; recidivism rates for sexual predators are not as high as people believe, however (burglars have a higher recidivism rate, for example)

Civil commitment A.

B.

U.S. historical overview 1.

A movement to provide “moral treatment” in the early nineteenth century focused on support, adequate care, and greater freedom rather than simple confinement.

2.

The number of patients in mental hospitals shrunk dramatically in the 1950s following advances in psychopharmacology and the deinstitutionalization movement.

3.

Four times as many people with mental illnesses are incarcerated in prisons as are housed in state mental hospitals.

4.

Establishment of mental health courts could provide a more humane approach to the mentally ill in terms of making sure the mentally ill get proper treatment; currently, this is just an experiment.

Libertarianism vs. paternalism—emphasis on protecting the rights of the individual versus the state's duty to protect its citizens; pendulum has swung towards paternalism 1.

Civil commitment—the involuntary hospitalization of the mentally ill

2.

In the 1960s, society was becoming more libertarian; since the 1990s, more paternalistic.

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C.

Involuntary hospitalization—the involuntary hospitalization of the mentally ill based on the following concepts: 1.

Parens patriae (“state as parent")—the government has a humanitarian responsibility to care for its weaker members; commitment is justified when the mentally disturbed are either dangerous to themselves or unable to care for themselves

2.

Police power—the state's duty to protect the public's safety, health, and welfare; commitment is justified for the good of the public (e.g., civil commitment); dangerous to others is the requirement

3.

Grounds and procedures

4.

5.

a.

In emergency commitment procedures, acutely disturbed individuals can be temporarily (usually only a few days) confined based on judgments of physicians, mental health professionals, or police

b.

Formal commitment procedures can be ordered only by a court; an adversary hearing must be available to those who object to involuntary hospitalization. The formal grounds include the following: 1.

Inability to care for self

2.

Dangerousness to self

3.

Dengerousness to others

c.

Civil commitment laws vary from state to state, but the dominant three grounds for commitment are inability to care for self, imminent danger to self, and danger to others.

d.

The stakes are high in predicting dangerousness, since either false positives or false negatives have very severe consequences.

Dangerousness and suicidal risk a.

There is a strong public perception that people with serious mental illnesses are likely to be dangerous.

b.

Dangerousness predictions and suicide risk predictions are very unreliable; there is a high false-positive rate in the prediction of violence and suicide.

Abuses of civil commitment a.

United States history is filled with cases of police power utilized to confine people who were believed to be insane or dangerous.

b.

Most prominent case was Mrs. Elizabeth Parsons Ware Packard: she was confined to psychiatric institution by her husband, who claimed that she was a ‘religious bigot’; she later became an advocate for the reformation of commitment standards.

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6.

D.

Hospitalization of minors a.

Minors are often classified as voluntary even when hospitalized against their wishes.

b.

Parham v. J.R. (1979)—ruling determined that minors are not entitled to a full court hearing for commitment; parents can commit a minor against his or her will as long as an “independent finder of fact” agrees

c.

Thus, there is a risk that minors may be hospitalized for being “problems” rather than because they have serious mental illnesses.

The rights of mental patients 1.

2.

3.

Right to treatment a.

Wyatt v. Stickney (1972)—ruling determined that public mental institutions must at least provide a humane psychological and physical environment, sufficient and qualified staff, and individualized treatment plans

b.

O'Connor v. Donaldson (1975)—ruling determined that the state cannot confine a person who is not dangerous to himself or others, or confine someone who is said to be in need of treatment, yet fail to provide that treatment

c.

Lake v. Cameron (1966)—ruling determined that patients have the right to treatment in the least restrictive alternative environment needed for treatment; if suitable alternatives are not available, however, institutionalization may be utilized

d.

Olmstead v. L.C. (1999)—ruling determines that states must try to find appropriate community placements for patients who can be treated in the community

Right to refuse treatment a.

Informed consent—patients must be told about treatment and risks, understand the information, freely consent to the treatment, and be competent to give consent

b.

Substituted judgment— regarding what the patient would have been likely to do if competent—is offered by an appointed independent guardian for a patient who is incompetent to give consent

c.

Whether patients have the right to refuse medications is still controversial; half of states allow committed patients the right to refuse medication if they are not a danger to self or others

Outpatient commitment procedures and standards are, generally, the same as inpatient commitment standards for involuntary hospitalization. a.

Dangerousness and inability to care for self are the most commonly used standards.

b.

Public protection concerns were fueled by the recent Virginia Tech shootings by Seung-Hui Cho, who had a history of mental health problems and threatening behavior but was simply ordered to seek outpatient treatment; Virginia has since extended its commitment law to include danger that appears to be “in the near future.”

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c.

E.

Advance psychiatric directives—patients can use these legal instruments to declare their treatment preferences or appoint a surrogate to make decisions for them

Deinstitutionalization—the movement to bring the mentally ill back into the community (out of hospitals) 1.

2.

Development of community mental health a.

Community Mental Health Centers Act (1963) provided for the creation of community care facilities as alternatives to institutional care.

b.

No community mental health centers (CMHCs) in operation in 1965; almost 800 CMHCs in 1981

c.

Over 558,239 inpatients in psychiatric hospitals in 1955; less than 52,539 in 2005

Problems with deinstitutionalization a.

Sufficient community services have not been implemented.

b.

Many CMHCs focus on patients with less serious problems; some do not even serve the seriously mentally ill.

c.

The homeless population consists largely of the seriously mentally ill; most are transferred from hospitals to the streets.

d.

Many people with serious mental illnesses end up in jails and prisons.

e.

The revolving door—patients are admitted more frequently but for shorter periods of time

f.

Some problems of deinstiutionalization are compounded by restrictive civil commitment laws.

IV. Mental health and family law A.

B.

Commitment of minors—balancing interests of minors, families, and the state 1.

Children’s advocates assert that children are entitled to the same rights as adults.

2.

Advocates of parens patriae support states’ rights to involuntarily commit minors.

3.

Family rights advocates want to minimize the involvement of the state in family matters.

Child custody disputes following divorce 1.

Child custody decisions are made outside the courts by attorneys who negotiate for the parents, the parents themselves (with the help of a mediator), or by a judge in court

2.

Types of custody 313 C.

3.

C.

D.

a.

Physical—where and with whom the children reside

b.

Legal—which parent will make decisions about the children

c.

Sole vs. joint—only one or both parents retain custody

Custody evaluations determine a child’s best interests a.

Important factors include the quality of the child’s relationship with each parent, the family environment provided by each parent, each parent’s mental health, the relationship between the parents, and the child’s expressed wishes.

b.

Because the child’s best interest standard is vague, the likelihood of custody hearings becoming acrimonious is high, leading to more difficulties for the children

c.

some commentors argue that mental health professionals should never conduct these evaluations because of their scientific inexactness.

Divorce mediation 1.

An alternative to litigation: a neutral third party assists parents to negotiate and resolve their differences

2.

One advantage is that divorce mediation allows for less court involvement, for greater involvement of nonresidential parents, and for better co-parenting relationships.

Child abuse 1.

Child abuse has only relatively recently been considered a problem; the first U.S. child protection efforts began in 1875.

2.

Forms of child abuse a.

Physical—involves the intentional use of physically painful and harmful actions; 2,000–5,000 children die every year as a result of physical abuse

b.

Sexual—involves sexual contact between an adult and child

c.

Neglect—involves placing a child at risk for serious physical or psychological harm by failing to provide basic and reasonable care; the most commonly reported form of child abuse

d.

Psychological—repeated denigration in the absence of physical harm

e.

Munchausen-by-proxy syndrome is a rare form of child abuse in which a parent feigns, exaggerates, or creates a physical ailment in the child.

3.

Reported cases of abuse rose from 669,000 in 1976 to over 3,600,000 in 2009; this increase may be due to increased child abuse or increased reporting (or both).

4.

About two-thirds of reports of child abuse or neglect are found to be unsubstantiated.

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V.

5.

Some maltreated children are placed in foster care, which can offer psychological benefits as well as physical protection; some children in foster care, however, endure multiple changes in residence and long-term separation from their families.

6.

In cases of particularly severe or persistent abuse or neglect, parental rights may be terminated.

Professional responsibilities and the law A.

Professional responsibilities—obligations to meet the ethical standards of a profession and to uphold the law

B.

Professional negligence and malpractice 1.

Negligence—failing to perform in a manner that is consistent with the level of skill exercised by others in the field

2.

Malpractice—professional negligence resulting in harm to clients or patients

3.

C.

a.

If found to be guilty, professionals are subject to disciplinary action from their professional organizations and state licensing boards, and subject to civil suits, and possibly to criminal actions.

b.

The inappropriate use of medication and negligent treatment are two of the more common reasons for malpractice claims against mental health professionals.

c.

Failure to prevent suicide, failure to prevent violence, breaches of confidentiality, the existence of a sexual relationship between therapists and their clients, and encouraging false recovered memories of child abuse are all grounds for malpractice claims.

d.

A professional has a duty to conform to a standard of conduct.

e.

The professional is negligent in that duty if the professional’s client experiences damages or loss, and if it is reasonably certain that the negligence caused the damages.

Informed consent and the efficacy of alternative treatments a.

Mental health professionals with specific orientations are most likely to offer the forms of treatment supported by their specific orientations, but other treatments may have greater empirical support for being more effective for specific disorders.

b.

Osherdoff v. Chestnut Lodge (1985) suggests that mental health therapists should offer alternative treatments, referrals for such treatment, or at least inform patients about the efficacy of alternative treatments.

Confidentiality—the ethical obligation not to reveal private communication 1.

Mental health professionals may be compelled by law to reveal confidential information in some 315 C.

situations (e.g., in situations of child abuse or when there is a threat of physical harm to others) 2.

Duty to protect potential victims a.

Tarasoff v. Regents of the University of California (1969): A patient made threats to kill a woman. The therapist contacted the police but did not warn the intended victim. The patient murdered the woman, and the woman’s family won a lawsuit, contending that she should have been warned.

b.

Subsequent California cases and legislation extended the duty to warn victims to a more general duty to protect, which could involve not only warning a potential victim but also hospitalizing a dangerous patient.

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LEARNING OBJECTIVES LO 18.1: Is “insanity” the same thing as “mental illness”?

LO 18.2: When and why can someone be hospitalized involuntarily?

LO 18.3: How can being wrong two times out of three beat a coin flip?

LO 18.4: What rights do mental patients retain when hospitalized against their will?

LO 18.5: What is deinstitutionalization, and how has it worked?

LO 18.6: What custody arrangements are in children’s “best interests”?

LO 18.7: When must therapists break confidentiality?

LECTURE SUGGESTIONS Guilty with diminished responsibility: Some states allow a third verdict (beside NGRI and GBMI) called “guilty with diminished responsibility.”

Generally, this verdict leads to conviction of a lesser offense, thus reducing the penalty. This verdict was utilized by the jury in the case of Dan White, who murdered George Moscone, the mayor of San Francisco, and the mayor’s assistant, Harvey Milk.

Dan White had resigned his position as a city supervisor, but then he had a change of heart and asked for his job back. The mayor refused him, and Harvey Milk backed the mayor’s decision. Some speculated that White’s opposition to gay rights might have played a role in the mayor’s decision (Milk was an outspoken gay activist). In late November of 1978, White loaded his .38 caliber gun and headed for City Hall. He knew how to avoid the metal detectors, since he had previously worked at the facility. He walked into Moscone’s office and asked to speak with the mayor. He pleaded for his job again, and after being denied, he fired several shots into the mayor, two of which were fired at point-blank range after the mayor had been debilitated by the first shots. He repeated this procedure with Harvey Milk after reloading his gun.

The defense argued that White was “guilty with diminished responsibility,” and therefore, guilty of voluntary manslaughter and not murder. This means that he was not guilty of “intent to kill”—manslaughter is defined as the illegal killing of a human being without malice, without forethought, and without planfulness. The case became even more controversial when the defense argued that White’s responsibility should be considered lessened because of his junk-food eating habit.

Martin Blinder, one of White’s attorneys, and a very respected one, argued that White had been “gorging himself on junk food: Twinkies, Coca Cola” and claimed this consumption led to an inability to think clearly, and eventually to the homicides. This case has become known as “the Twinkie defense.” In fact, however, the junk-food argument was only one of many points that led the jury to believe that Dan White could not have planned the murder given the “dissociated state” of mind he was in. White was given the light sentence of seven years and eight months and was released on parole having served less than five years. This case, along with the Hinckley case, has led to a more skeptical attitude regarding any criminal defense claiming that the criminal has diminished responsibility due to a mental illness or a mental state at the time the crime was committed.

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Coleman, L. (1984). The reign of error: Psychiatry, Authority, and Law. Boston: Beacon.

Predicting violence: The controversy over the ability of professionals to predict violence is long standing. Although the prediction of violence is difficult and will probably never be extremely accurate, we now know that professionals’ judgments are valuable and much better than chance (see text). Some of the factors that make predicting violence difficult are as follows: (1) It is easier to recognize violent tendencies after a violent event than to predict specific acts of violence.

(2) Generalized perceptions of violent tendencies may not predict specific acts of violence.

(3) There is a lack of agreement in the definitions of violence and dangerousness.

(4) The relative rarity of violent events like murder makes it difficult to predict such events.

(5) Direct threats of violence are not likely to precede specific violent acts.

(6) Predictions based on behavior in one setting (e.g., a hospital) may not generalize to other settings (e.g., the community).

Violent men and violent stepparents: Current directions APS reader (1E, p. 176) The Holtzworth-Munroe article on classification of violent men and the Daly and Wilson article on aggression against step-children both deal with the pervasive problem of violence within families.

Holtzworth-Munroe argues that we have made the mistake of viewing violent men as homogeneous when, in fact, there are some distinct types that can be delineated. The family-only batterers engage in the least marital violence, the lowest levels of psychological and sexual abuse, and very little violence outside the home.

Dysphoric-borderline batterers engage in moderate to severe abuse, with some extra familial violence also possible. The generally violent antisocial batterers are the most violent subtype, engaging in high levels of marital violence and high levels of extra familial violence. They also might be likely to be diagnosed as having antisocial personality disorder. By recognizing the heterogeneity among violent men, we can begin to address treatment plans that would target the specific forms of violence and the specific subtypes more precisely and effectively.

Daly and Wilson argue that the differential between violence directed towards stepchildren and violence against biological children is so great that it calls for an evolutionary hypothesis. The investment parents have towards their own biological children makes it less likely for aggression to occur; stepparents have a smaller investment (in an evolutionary sense, none) in their children, which allows for more aggression to occur. Of course, Daly and Wilson recognize that most stepparents are affectionate, caring, and not at all violent towards their stepchildren. One interesting finding that they reveal is that, when stepparents kill their stepchildren, they rarely commit suicide as part of the event. A little over 1 perent completed a suicide in these situations, whereas 28 percent of biological fathers did complete a suicide after killing their preschool child or children. What are some implications of the Daly/Wilson hypothesis in terms of reducing domestic violence in stepparents?

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DISCUSSION IDEAS Mental health expert testimony: Given the unreliability of diagnosis and professional judgments, should mental health professionals be involved in testimony regarding the mental state of defendants? If the defense and prosecution can always find a mental health professional to support their case, does it not serve to reduce the credibility of the fields of psychology and psychiatry in general? Further, since insanity is a legal, not mental health issue, is there reason to consider mental health professionals to be experts on the subject?

When challenged regarding the use of mental health professionals in criminal cases, students may correctly argue that if professionals limit their testimony to their area of expertise, then some of the issues may be resolved.

Students may argue that juries should be instructed to draw their own conclusions regarding insanity, while mental health professionals should restrict their input to judgments related to assessment and diagnosis. Students who argue that mental health professionals should not be involved in the process at all, however, should be taken seriously. A reasonable case can be made for this position (and is supported by respected professionals in the field).

The insanity plea: Discuss the insanity plea. How do students feel about a person accused of a vicious crime being declared “not guilty by reason of insanity”? What are the pros and cons of the alternative “guilty but mentally ill” verdict? Do students feel that both of these pleas should be eradicated from our system and that the state of mind of the criminal should not be considered in court?

Do students feel that most people who are accused of crimes get off on the insanity defense? In fact, only a small percentage of criminals use the defense (approximately 1 percent), and only a small percentage of these use the defense successfully (about 20 percent), meaning that only .2 percent of cases arrive at a ‘not guilty by reason of insanity’ verdict. Is part of the public outcry based on the belief that those who are deemed NGRI spend less time in confinement than those found guilty of the same crime? This is simply not true; the average person who receives the NGRI verdict spends more time (on average) confined—but in a psychiatric institution, not a prison.

In discussing this issue, you might mention that recently, one state legislature passed a bill requiring that psychiatrists and psychologists giving testimony in court cases wear a tall, conical hat and wave a ‘magic’ wand during their testimonies. The bill was vetoed by the governor, but you can see the sentiment of legislatures regarding the validity of the psychiatric field’s judgments of accused criminals. How has the insanity plea contributed to the public’s view of the psychiatric field? How is this perception based on false facts and misperceptions? Why does it persist?

Paternalism versus libertarianism: Ask students to consider the following situation: Your neighbor’s son, a 19-year-old boy, has been walking around the neighbor’s grounds aimlessly at all hours of the day and night. When you stop to talk to him, he often responds inappropriately with comments like, “He told me to do it,” but when you ask who “he” is, the boy begins muttering about unrelated topics. He appears to be responding to internal stimuli (voices), and occasionally he becomes agitated for no apparent reason. You are able to ascertain that he has dropped out of college and is not working or doing anything productive with his time, but the boy and his family have not consulted with a mental health professional. His parents are extremely religious and 319 C.

claim that the boy “just needs some time…the Lord will come to him.” The boy, himself, apparently does not see any particular problem with his behavior and is not interested in a psychological or psychiatric evaluation.

Should there be an involuntary commitment procedure for situations like this? Ask students if they would take a paternalist position, that society should be responsible for treating such a person, or a libertarian position, that the family has a right to handle family matters according to their own beliefs and principles and without outside interference. You may want to point out the benefits of early intervention and the value of medication in reducing the likelihood and severity of future psychotic episodes for this boy. This discussion may be helpful in clarifying the essence of the paternalist and libertarian positions and helping students identify situations in which they would argue on one side or the other.

The right to refuse treatment: Considering the protections that patients already have (regarding civil commitment, rights to humane treatment, and to the least restrictive environments), should patients with serious mental illnesses also have the right to refuse treatment that mental health professionals prescribe? Psychiatrists and psychologists who work in inpatient treatment settings encounter ongoing difficulties with patients who refuse to take their medications, for example, despite diagnoses of bipolar disorder or schizophrenia. In many institutions, patients are provided with a patients’ rights advocate with whom they can meet regarding their rights. Although this procedure helps to protect patients, it tends also to lead to more treatment refusal. Since psychopharmacologic treatments are often the most effective interventions for those with serious mental illnesses, patients’ refusal to take medications in effect ties the hands of the professional and reduces the likelihood of successful treatment. Furthermore, refusal of treatment can itself be a symptom of the disorder, confusing the issue of what refusal of treatment means. In some cases, the institution can challenge the patient’s refusal to take medication through a court hearing and force the patient to accept the treatment. Is the right to refuse treatment a necessary right, or are patients sufficiently protected by other existing rights?

Deinstitutionalization: The text defines deinstitutionalization as a movement to bring people with mental illness back into the community. In 1955, there were close to 600,000 beds in U.S. public mental hospitals, but in 2005, there were just a little over 52,000. Ask students, “Would you prefer people with severe mental illness to live in their neighborhoods or in an institution?” After you ask the question, divide the classroom space in half, labeling one side of the room as “the community” and the other side of the room as “institutions.” Then, have the students move to the respective side of the room that correlates with their thoughts. This can spark a discussion as to reasons for or against deinstitutionalization. In addition, after this discussion, you could ask the students to make a list of the pros and cons of the concept of deinstitutionalization.

CLASSROOM ACTIVITIES Insanity criteria: Divide the class into small groups of students. Ask them to develop objective criteria for insanity and a method for determining insanity. Which mental health professionals would be involved and what form of interviews and psychological tests they would use. Compare the different groups’ criteria to the M’Naghten test, the irresistible impulse test, the product test, and the American Law Institute’s model legislation. Likely, common criteria will appear across groups, but note the lack of clear consensus. Students may appreciate (1) the difficulties involved in creating a good set of agreed-upon criteria and (2) that all methods use criteria difficult to reliably assess.

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Psychotherapist infractions: Have students rank the severity of a number of possible psychotherapist infractions. Have them also provide recommended penalties for each infraction.

(1) Inappropriate use of ECT (2) Inappropriate prescribing of medication (3) Psychotherapist sexual relations with client (4) Failure to prevent a suicide by not accurately identifying risk and/or taking appropriate action to ensure safety (5) Failure to provide information regarding the efficacy of alternative treatments (6) Failure to warn a third party of planned violence (7) Breach of confidentiality (8) Misdiagnosis Of course, these descriptions are general, and the appropriate penalty would depend on the specific nature of each case (perhaps including the psychotherapist’s individual record), but the focus is on students’ perceptions of the relative severity and importance of the infractions. You may wish to examine gender differences in students’ responses, particularly related to therapist-client sexual relations.

Debate: Should psychologists be able to enter into an intimate relationship with former patients?

For this activity, you can notify the students in advance that this debate will happen in class, and ask the students to go out and actively research both sides of the argument, looking at the state’s board of mental health professionals and psychologists, as well as some other professional organizations such as the American Psychological Association, the American Counseling Association, and the American Association for Marriage and Family Therapists to see what each of these professional organizations state about dual relationships with former patients. Then schedule the debate for a specific date and randomly assign the students to a side of the argument.

Allow the students three to five minutes to gather their resources for the argument. Act as the mediator so that each side has an equal opportunity to share information.

Sample case vignettes: For this activity, break the class into small groups of students to review a case vignette related to some type of professional or ethical issue in the field of psychology. Ask the students to identify the potential violation and the steps of action that would need to be taken for the following: 1.

You are seeing both Diana and Bob for couple therapy, and Bob requests an individual therapy session with you. In this session, Bob reveals that he has been having an affair for the past three months and thinks he is in love with the other woman. The next week you have Bob and Diana scheduled for a couple therapy session.

Can you tell Diana about the affair Bob disclosed in the individual session?

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2.

Judy attended a day workshop on eye movement and desensitization reprocessing (EMDR), and she decided that it was an excellent treatment method to use with clients at her private practice. Judy now markets to potential and current clients that she uses EMDR as a therapeutic method. What are the concerns with this situation?

3.

John, a seven-year-old boy, discloses in session that his mother hits him on a regular basis and that normally there is no food in the house. He continues to state that he has to go over to the next door neighbor’s house to get some food. John then shows you some scratches and bruises on his arms and legs. What should you do as the professional?

Guest speaker: Contact a community professional in the field of psychology to come to the class and offer a question and answer session. It would be helpful to invite a licensed psychologist to speak about education requirements, licensure, continuing education units, malpractice, and affiliation with professional organizations like the American Psychological Association. Or you may want to find a psychologist that specializes in forensics, a forensic psychiatrist, or a criminal profiler to come in to speak to the class.

VIDEO RESOURCES

http://visual.pearsoncmg.com/mypsychlab/episode03/index.html?clip=5&tab=tab0 Thinking Like a Psychologist: The Pre-Frontal Cortex: The Good, the Bad, and the Criminal (3:28) In this video, you will learn about how different parts of the brain control different types of behavior and how both biological and environmental factors can lead a person to become a violent criminal later in life. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Ill_Treatment_at_ Developmental_Center.html Ill Treatment at Developmental Center (2:25) A man discusses the questionable treatment of his mentally ill sister at a developmental center. http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Asylum_A_History_ of_the_Mental_Institution_in_America.html Asylum: A History of the Mental Institution in America (3:30) Here is classic video footage from the 30s, 40s, and 50s of mental patients undergoing various experimental treatments: swaddling, water, heat, electric shock, induced convulsions, and finally, medications are used.

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http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/APS2010/AlanKazdin4.html Alan Kazdin: How Do We Reach Out to People Who Need Help for Mental Illness? (1:29) Professor Kazdin of Yale University suggests that in order to reduce mental illness, it will mean using psychology in collaboration with technology and many other disciplines.

http://media.pearsoncmg.com/ph/hss/SSA_SHARED_MEDIA_1/psychology/videos/MPL/Divorce_and_Co_ parenting.html Divorce and Co-parenting (2:53) This video explores whether there is such a thing as a good divorce family. If the divorced parents can support each other in co-parenting, the children can do well. In contrast, chronic marital conflict can be very destructive for children.

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