Abnormal Psychology Core Concepts, 2E James N Butcher Susan Mineka Jill M Hooley Solution Manual

Instructor’s Manual for

Butcher, Mineka, and Hooley

Abnormal Psychology: Core Concepts Second Edition

prepared by

Robin K. Morgan Indiana University Southeast

Contents Preface ...................................................................................................................................... iv Sample Syllabus ....................................................................................................................... vii CHAPTER 1

Abnormal Psychology Over Time..................................................................1

CHAPTER 2

Causal Factors and Viewpoints ...................................................................25

CHAPTER 3

Clinical Assessment, Diagnosis, and Treatment Approaches ..................43

CHAPTER 4

Stress and Physical and Mental Health.......................................................74

CHAPTER 5

Panic, Anxiety, and Their Disorders............................................................93

CHAPTER 6

Mood Disorders and Suicide......................................................................114

CHAPTER 7

Somatoform and Dissociative Disorders ..................................................135

CHAPTER 8

Eating Disorders and Obesity ....................................................................154

CHAPTER 9

Personality Disorders .................................................................................170

CHAPTER 10 Substance-Related Disorders ....................................................................186 CHAPTER 11 Sexual Variants, Abuse, and Dysfunctions...............................................208 CHAPTER 12 Schizophrenia and Other Psychotic Disorders ........................................225 CHAPTER 13 Cognitive Disorders ....................................................................................246 CHAPTER 14 Disorders of Childhood and Adolescence ................................................260 CHAPTER 15 Contemporary and Legal Issues in Abnormal Psychology .....................283

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Preface This Instructor’s Manual bridges the gap between the textbook, which is designed for introductory Abnormal Psychology students, and the instructor, who knows the material and who instead needs help coordinating lecture presentations, activities, and assignments with the text. The Manual will help you focus on being a lively and engaging instructor by lightening your organizational load.

You will notice that this Instructor’s Manual offers some extra advice to beginning Abnormal Psychology instructors. This extra attention is provided because newer instructors are often especially in need of efficiently organized and readily available tips for handling material in the classroom. Nevertheless, more experienced instructors will also benefit from this Manual.

Indeed, it is hoped that there is enough new and interesting material in this Manual to sustain the attention of Abnormal Psychology instructors who are more experienced than the beginning instructors for whom it will probably be a more regular reference.

Each chapter of this Instructor’s Manual corresponds to a chapter in the textbook. To make this Manual as accessible as possible, each chapter follows the same structure. Instructors who familiarize themselves with this structure will find that they can readily find exactly what they need.

Chapter At-A-Glance Each chapter begins with a Chapter At-A-Glance grid, which is your one stop spot for pointers to chapter materials provided by the textbook publisher to help you with each chapter. The usefulness of this resource comes from its extensive cross-listings among the various ancillary materials. The leftmost column of the grid indicates the chapter’s major content, and the remaining columns direct you to materials designed to help you teach that material. Lecture activities, films, CD clips, PowerPoint slides, Web Links, and other resources are all referenced for you in the Chapter At-A-Glance grid alongside the chapter content they were designed to help you with.

Teaching Objectives Even though much of the Manual is devoted to the various means of teaching your students about Abnormal Psychology, it is important to keep the ends in mind as well. Teaching Objectives are given to provide clear goals for your various pedagogical efforts. Teaching Objectives articulate the ideas, concepts, findings, facts, controversies, and principles you are hoping to convey to your students. These same Objectives are provided to the students in their Study Guide, assuring that everyone is working toward the same ends!

Chapter Overview/Summary The Chapter Overview is a narrative version of the bullet-point Summary that is given at the end of each chapter of the textbook. Not only does it provide a refresher on major points from the chapter, it is an easy way to identify important principles, findings, and crucial issues. . iv

Reading the Summary is a good way to get the big picture firmly in mind before giving the chapter closer study. Some instructors find that the Chapter Overview can even serve as an annotated set of notes to lecture from.

Detailed Lecture Outline Once the big picture is appreciated, the Detailed Lecture Outline drills down into the specific items the chapter covers. What the Outline lacks in explanation, it makes up for in detail, touching as it does on most of the specifics that make up each of the broader points the chapter seeks to convey. The Outline also exposes the precise structure of the chapter, giving the sequencing the authors felt was most natural given the content to be covered. Of course it would be unwise to lecture directly from this outline, not least of all because it would be impossible to cover all of it within the traditional semester- or quarter-length course! Instead, instructors are encouraged to identify the chapter points they seek to elaborate upon in the classroom, identify and highlight the location of these points in the Outline, and use adjacent material to contextualize this material. You might also want to keep the Outline handy during your lecture to prompt you about each of the pieces necessary to support the conclusions you are building toward – or at least to back-up your memory for dates and spelling!

Key Terms As is the case with any scientific field, learning Abnormal Psychology requires learning its technical vocabulary. To help assure that technical terms are learned, and especially to learn the technical meanings of terms having non-technical meanings, a list of Key Terms is provided for each chapter. Note that these same terms are listed at the end of each textbook chapter, so you can expect that your students will be interested in focusing on the same ones you are.

Lecture Examples / Discussion Topics Each chapter gives at least five different Lecture Launchers. These are designed to help capture the attention of your students and to get them focused on the class. They are helpful at the start of class to get everyone thinking about abnormal psychology rather than thinking about their last class, where they are going for lunch, what they will be doing that night, or what’s in the news. Although they are called Lecture Launchers, many work well in the middle of class, which is helpful for breaking up long lectures, or even at the end of class, to encourage thinking and discussion between classes. When working with these ideas, be sure to turn off the overhead or PowerPoint projector, walk around the room, make eye contact with as many students as possible, engage quiet students, balance encouragement with challenge and persistence with tolerance for pauses. Especially early in the semester, socialize your students to your expectation of an active classroom. If they learn that you give up easily and that you will quickly revert to lecturing, they will socialize you to do so.

Demonstrations / Activities The various Demonstrations / Activities are also designed to stimulate student engagement with the course. They involve group projects, personal reflections, questionnaires, light research, and other small projects that can be done in or out of class. More often than you might imagine, the best teaching can be accomplished by getting out of the way and letting students teach each other. Cooperative education has sound empirical credentials, and it . v

makes sense to let this powerful process work for you whenever possible. Again, apparent student passivity may be a deterrent, but persistence and enthusiasm will be amply rewarded!

Realize that students are probably more interested in the activity than they care to reveal in front of their peers.

Web Links The web is an especially tricky resource for students and instructors of Abnormal Psychology.

On the one hand, an enormous amount of excellent information is available to those who know where to find it. On the other hand, there is an unusually large proportion of bad information as well. While it is no doubt true that there is misinformation on the web about any scholarly topic you’d care to name, psychology in general, and Abnormal Psychology in particular, seems especially susceptible. Therefore, web links are provided for each chapter. Some very high quality sites are given along with some especially egregious ones, each clearly indicated as such. It is probably worth mentioning that the web is also somewhat unstable, inasmuch as links seem to change fairly frequently. Therefore, if you find a dead link in this Manual it might be worth using a major search engine, like Google.com, to try to find it, just in case it is merely moved, not entirely abandoned.

Video Resources Allyn & Bacon makes an extensive collection of videotaped material available to Abnormal Psychology instructors. In particular, Abnormal Psychology Video: ABC News and Client Interviews is a collection of custom video segments highlighting issues related to diagnosis and treatment that is available to adopters of this text. Depending on course enrollment, Allyn & Bacon also makes available videos from the American Psychiatric Press video series and from the Annenberg/CPB “World of Abnormal Psychology” series. Contact your Allyn & Bacon representative or visit the Allyn & Bacon website (www.pearsonhighered.com) for details. The Video Resources section of each chapter of this Manual also lists some of the most relevant and readily-available videos available from other sources. Finally, students can be fairly good at identifying examples of psychopathology from major motion pictures (e.g., Russell Crowe in A Beautiful Mind, Glenn Close in Fatal Attraction). It is especially educational if students who bring clips to class are asked to explain in detail which symptoms their chosen clips portray.

One has to be quite careful, though, not to perpetuate erroneous stereotypes or to leave students with the mistaken impression that the fictionalized depictions represent the phenomenon in its prototypic form.

Handouts and Activities Following the individual chapters, this Manual gives handouts and other materials that are freely available for photocopying and distribution to your students. These include questionnaires, short essay assignments, personal reflections, compilations of information, and other items that instructors might find useful. Most often the handouts and activities go along with items in the Demonstrations / Activities section.

Abnormal Psychology is inherently fascinating – but you probably know that already!

Abnormal Psychology can be a pleasure to teach. Butcher, Mineka, and Hooley have pulled an enormous amount of information together in the textbook, and the publisher has provided a useful array of ancillary materials to support you. Hopefully, this Manual ties it all together and lightens your load along the way. . vi

Sample Syllabus Instructor: You R. Organized, Ph.D., ABPP 109 Meehl Hall O: 555-7763 H: 555-4993 You.R.Organized.1@state.edu www.state.edu/~YRO1 Description:

Class Location: 208 Chapman Hall Time: Tu Th 3:30 - 4:45 Credits: 3.0 (PSY 354) Office Hours: Mon 2:45-3:45 Wed 9:00-10:30 TA: Jane Doe – Jane.Doe.1@state.edu

This course covers the domain of psychopathology as it is represented in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (2000: 4th ed., Text Revision).

In this course I will; a) explain the scientific bases of contemporary theories of major psychological disorders such as schizophrenia, depression, and anxiety, b) encourage empathy for people suffering from mental illness, c) inform students, as future policy-makers and citizens, about societal implications of mental disorders, d) educate about mental health treatment for students who will be future consumers and referrers to such services, e) promulgate preventive information, and f) prepare students for further graduate-level training in psychopathology.

Learning Objectives: Specific learning objectives will be provided for each chapter. However, there are certain basic learning objectives that apply to the course as a whole. By the end of this course, it is expected that students will be able to: • Define & evaluate criteria for abnormal behavior and specific psychological disorders, • Recognize or "diagnose" common psychological disorders, • Describe common explanations for the etiology of psychological disorders, and • Outline effective treatments for specific psychological disorders Required Texts: Butcher, J.M., Mineka, S., & Hooley, J. (2008). Abnormal Psychology: Core Concepts.

Boston, MA: Allyn & Bacon. (ISBN: 0-205-48683-5) Meyer, R.G. (2006). Case Studies in Abnormal Behavior (7th Ed.). Boston, MA: Allyn & Bacon.

(ISBN: 0-205-45222-1) Websites:

Quizzes, chapter summaries, abnormal psychology current events, etc. can be found at the course’s website: http://www.ababnormalpsychology.com A website with overheads, handouts, this syllabus, etc. can be accessed via the “354” link at www.state.edu/~YRO1 Emendations welcome!

Exams:

There will be three exams during class time, and a final exam during Finals Week. The attached “Class Schedule” shows the dates. Each exam will have 50 multiple-choice questions that you will have 75 minutes to answer. Since the textbook is comprehensive and provides a disproportionate share of the course material, exam content will come approximately 70% from the texts and 30% from lecture, cases, class discussion, and film clips. Exams are not cumulative; they will cover only material assigned since the prior exam. You will be responsible for text material that is assigned but not covered in class. In order to reward close study of the text, some exam items will be quite difficult.

Makeup Exams: Essay makeup exams will be given only for previously approved absences or in cases of documented emergencies. They must be taken within one week of the regular exam.

Grading:

Grades are based on the sum of the four exam scores (200 points), in-class essays (50 points), and extra credit (12 points: described separately), according to the following system. If scores are unusually low, a curve will be used with the third highest score in the class taken as the 100% value against which the remaining scores are compared, in which case extra credit points will be added after the curve is set.

Class attendance is required, and participation will help students on grade borderlines.

A A-

93% and above 90-92%

B+ B B-

87-89% 83-86% 80-82%

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C+ C C-

77-79% 73-76% 70-72%

D F

60-69% 59% and below

Class Schedule and Assigned Readings Week 1

2

Day

Topic

Tuesday

Introduction, Research Methods

1

Thursday

Historical and Contemporary Views of Abnormal Behavior

2

Tuesday

Classification & Diagnosis

3

Thursday 3

- continued

Tuesday

5

6

7

8

9

10

12

13

14

3

- continued

Tuesday

Exam #1 (6 classes: bring pencils and eraser)

Thursday

Sexual Disorders & Dysfunctions, Gender Identity

11

8, 9

Tuesday

Stress, PTSD, and Adjustment Disorders

4

5

Thursday

Anxiety Disorders

5

4, 6

Tuesday

- continued

Thursday

Somatoform and Dissociative Disorders

7

6

Tuesday

Eating Disorders

8

17

Thursday

Exam #2 (6 classes: bring pencils and eraser)

Tuesday

Mood Disorders and Suicide

6

10

Thursday

- continued

11

Tuesday

- continued

12

Thursday

Schizophrenia

Tuesday

- continued

Thursday 11

Casebook

1

Assessment and Treatment Approaches

Thursday 4

Text Chapter

Personality Disorders

Tuesday

12

13

9

2, 3

- continued

Thursday

Exam #3 (7 classes + break: bring pencils and eraser)

Tuesday

Forensic and Social Policy Issues

15

Thursday

Substance-Related Disorders

10

Tuesday

- continued

Thursday

- continued

Tuesday

Cognitive Disorders

Thursday

- continued

13

15

Tuesday

(Disorders of Childhood /Adolescence – time permitting)

16

Monday

Final Exam -- 10:30 to 12:30 pm

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(7 classes)

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16

CHAPTER 1: Abnormal Psychology over Time Chapter At-A-Glance Detailed Outline

Instructors’ Resources

Print Supplements

Media Supplements

What Do We Mean by Abnormality?

• The DSM-IV Definition of Mental Disorder • Why Do We Need to Classify Mental Disorders?

• What Are the Disadvantages of Classification?

• How Does Culture Affect What Is Considered Normal?

• Culture-Specific Disorders

Teaching Objectives 1.1–1.6 Chapter Guide Lecture Launchers 1.1, 1.2, 1.3, 1.4, 1.5, 1.6 Activities 1.1, 1.3, 1.4 Web Links 1.1, 1.2, 1.3, 1.4, 1.5

Test Bank Grade Aid Transparencies T-1

CD-ROM PowerPoint

How Common Are Mental Disorders?

• Prevalence and Incidence • Prevalence Estimates for Mental Disorders

Teaching Objectives 1.7–1.9 Chapter Guide Lecture Launchers 1.2, 1.5, 1.6 Activities 1.1, 1.2, 1.3, 1.4 Web Links 1.4, 1.5

Test Bank Grade Aid

CD-ROM PowerPoint

Historical Views of Abnormal Behavior • Demonology, Gods, and Magic • Hippocrates’ Early Medical Concepts • Later Greek and Roman Thought • Views of Abnormality during the Middle Ages • The Resurgence of Scientific Questioning in Europe • The Establishment of Early Asylums • Humanitarian Reform • Mental Hospital Care in the Twenty-First Century

Teaching Objectives 1.10– 1.14 Chapter Guide Lecture Launchers 1.7, 1.8, 1.9, 1.10 Activities 1.7, 1.10 Web Links 1.6, 1.7, 1.9

Test Bank Grade Aid

CD-ROM PowerPoint

The Emergence of Contemporary Views of Abnormal Behavior • Biological Discoveries: Establishing the Link between the Brain and Mental Disorder • The Development of a Classification System • The Development of the Psychological Basis of Mental Disorder • The Evolution of the Psychological Research Tradition: Experimental Psychology

Teaching Objectives 1.15– 1.21 Chapter Guide Lecture Launchers 1.7, 1.10, 1.11 Activities 1.6, 1.7, 1.8, 1.9, 1.10 Web Links 1.8, 1.10

Test Bank Grade Aid Transparencies T-11, T-13, T14, T-15, T-21, T-22, T-23,

CD-ROM PowerPoint

Research Approaches in Abnormal Psychology • Sources of Information • Forming and Testing Hypotheses • Research Designs

Teaching Objectives 1.22– 1.27 Chapter Guide Lecture Launchers 1.4, 1.5 Activities 1.2, 1.5 Web Links 1.2, 1.3, 1.5

Test Bank Grade Aid Transparencies T-3, T-4, T-5, T-6, T-7,

CD-ROM

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Professor Notes

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Chapter 1 Abnormal Psychology over Time

Unresolved Issues • Are We All Becoming Mentally Ill? The Expanding Horizons of Mental Disorder

Teaching Objectives 1.3–1.5, 1.7–1.9 Chapter Guide Lecture Launchers 1.5, 1.6 Activities 1.3, 1.4 Web Links 1.4, 1.5

Test Bank Grade Aid

CD-ROM PowerPoint

Teaching Objectives 1.

2.

3.

Explain the authors’ approach to the study of Abnormal Psychology.

Discuss common topics and issues relevant to Abnormal Psychology.

Explain why we need to classify mental disorders and the advantages and disadvantages of classification.

4. Summarize the DSM-IV definition of mental disorders, illustrating several problems with this approach.

5. Identify how cultural issues can influence the definition of Abnormal Psychology.

6. Identify the professionals responsible for working on the mental health “team.”

7. Explain the difference between the prevalence and the incidences of mental disorders.

8. Discuss the prevalence rates for mental disorders.

9. Summarize current trends in patient care including inpatient and outpatient treatment.

10. Explain why in ancient times abnormal behavior was attributed to possession by a demon or god and describe how shamans and priests administered exorcism as the primary treatment for demonic possession.

11. Describe the important contributions from 460 B.C. to 200 A.D. of Hippocrates, Plato, Aristotle, and Galen to the conceptualization of the nature and causes of abnormal behavior.

12. Discuss how mental disorders were viewed during the middle Ages.

13. Describe the work of Avicenna and the differences between conceptions of mental health in Europe and the Middle East during the middle Ages.

14. Give examples of mass madness or mass hysteria and summarize the explanations offered for this unusual phenomenon.

15. Explain how both the discovery of a biological basis for general paresis and a handful of other disorders (such as, the senile mental disorders, toxic mental disorders, and certain types of mental retardation) contributed in a major way to the development of a scientific approach to Abnormal Psychology as well as to the emergence of modern experimental science that is largely biological.

16. Distinguish between biological and nonbiological versions of medical model thinking about psychopathology.

17. Trace the important events in the development of psychoanalysis and the psychodynamic perspective.

18. Contrast the biological and psychodynamic views of abnormal disorders.

19. Describe how the techniques of free association and dream analysis helped both analysts and their patients.

20. List the major features of the behavioral perspective.

21. Discriminate between classical and operant conditioning.

22. Describe the scientific inquiry process.

23. Describe the importance of hypotheses in the research process.

24. Identify the critical elements of sampling and generalization.

25. Compare and contrast observational research strategies, experimental research designs, and single-case experimental designs.

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Chapter 1 Abnormal Psychology over Time

26. Illustrate how research designs allow psychologists to make statements about the efficacy of treatment.

27. Discuss the importance of animal research to understanding abnormal behavior.

Chapter Overview / Summary Encountering instances of abnormal behavior is a common experience for all of us. This is not surprising given the high prevalence of many forms of mental disorder. A precise definition of abnormality is still elusive. Even though we lack consensus on the precise definition of abnormality, there are clear elements of abnormality: suffering, maladaptiveness, deviancy, violations of the standards of society standards, social discomfort, and irrationality or unpredictability. These elements allow for the adoption of a prototype model of abnormality. Although this model is helpful, we have the additional problem of changing values and expectations in society at large.

The DSM-IV is the accepted standard in the United States for defining abnormality. The DSM system attempts to be atheoretical, focusing on a clinically significant behavioral or psychological syndrome or pattern that is associated with distress or disability (impairment in one or more areas of functioning), and not simply a predictable or culturally sanctioned response to a particular event. Mental disorders, then, are the product of dysfunctions within the individual. As might be expected, there are many criticisms of this definition. For example, what is meant by the term clinically significant, who determines what is culturally sanctioned, and how much impairment is necessary for a diagnosis to be made? Wakefield has proposed a definition that describes a mental disorder as a “harmful dysfunction.” His approach focuses on social values in defining abnormality as well as an evolutionary model to determine what is functional, creating potential new difficulties.

This current text uses the prototype model adopted by the DSM classification system. Even though it is not without problems, the DSM provides us with a working set of criteria that help clinicians and researchers to identify and study specific and important problems that affect people’s lives. Although it is far from a finished product, knowledge of the DSM is essential to a serious study of the field.

Despite these difficulties, psychologists continue to classify mental disorders for several reasons: provides a nomenclature that allows us to structure information in a more helpful way, enables research on etiological factors, helps in deciding on treatments, makes social and political implications, and facilitates insurance reimbursement. There are also many disadvantages to classifying mental disorders: loss of information, stigma, stereotyping, and labeling. In each case, however, it is important to remember that classification systems do not classify people; they classify the disorders experienced by people.

Culture shapes the presentation of clinical disorders in some cases. There are also certain disorders, such as taijin kyofusho, that appear to be highly culture-specific.

The extent of mental disorders may be surprising. Several epidemiological studies have been conducted in recent years. The lifetime prevalence of having a DSM-IV disorder is 46.4 percent. In addition, there is significant comorbidity, especially among those individuals who have severe disorders.

Progress in understanding abnormal behavior over the centuries has not been smooth or uniform. The steps have been uneven, with great gaps in between. Unusual, even bizarre, views or beliefs have often sidetracked researchers and theorists. The dominant social, economic, and religious views of the times have had a profound influence over how people view abnormal behavior.

In the ancient world, superstitions were followed by the emergence of medical concepts in many places such as Egypt and Greece. The Greek physician Hippocrates, for example, believed that the brain was the center of intelligence and that mental disorders were due to brain pathology.

Hippocrates described mania and melancholia, the four humors, and believed that dreams revealed one’s personality. Many of these concepts were developed and refined by later Greek and Roman .

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Chapter 1 Abnormal Psychology over Time

physicians. With the fall of Rome near the end of the 5th century A.D, superstitious views dominated popular thinking about mental disorders in Europe for more than a thousand years. The more scientific aspects of Greek medicine survived only in the Islamic counties of the Middle East. As late as the 15th and 16th centuries in Europe, it was still widely believed, even by scholars, that some mentally disturbed people were possessed by a devil.

Great strides have been made in our understanding of abnormal behavior. For example, during the latter stages of the middle Ages and early Renaissance, a spirit of scientific questioning reappeared in Europe, and several noted physicians spoke out against inhumane treatments. There was a general movement away from superstitions and magic toward reasoned, scientific studies.

With the recognition of the need for the special treatment of disturbed people came the founding of various asylums toward the end of the 16th century. However, with institutionalization came the isolation and maltreatment of mental patients. Slowly this situation was recognized and, in the 18th century, further efforts were made to help afflicted individuals by providing them with better living conditions and humane treatments, though these were likely the exception rather than the rule.

The development of the mental hospital movement continued into the 20th century. However, over the last four decades of the century there was a strong movement to close mental hospitals and release people into the community. This movement remains controversial.

The 19th and early 20th centuries witnessed a number of scientific and humanitarian advances. The work of Philippe Pinel in France, William Tuke in England, and Benjamin Rush and Dorothea Dix in the United States prepared the way for several important developments in contemporary Abnormal Psychology. Among these were the gradual acceptance of mental patients as afflicted individuals who needed and deserved professional attention; the success of biomedical methods as applied to disorders; and the growth of scientific research into the biological, psychological, and sociocultural roots of abnormal behavior. The publication of the book, The Snake Pit, in 1946 called attention to the plight of those in mental hospitals. The 1963 Community Health Services Act and the Hill-Burton Act led to the funding of community mental health facilities. The resulting deinstitutionalization led to many mental hospitals closing; today, problems associated with deinstitutionalization are evident.

Our modern scientific views of abnormal behavior have several historical branches. Four main themes were highlighted in this chapter: (1) the biological, (2) development of classification schemes, (3) emergence of psychological causation views, and (4) experimental psychological research developments.

Great technological discoveries and scientific advancements were made in the biological sciences that aided in the understanding and treatment of disturbed individuals. A major biomedical breakthrough, for example, came with the discovery of the organic factors underlying general paresis—syphilis of the brain—one of the most serious illnesses of the day.

In the early part of the 18th century, knowledge of anatomy, physiology, neurology, chemistry, and general medicine increased rapidly. These advances led to the identification of the biological, or organic, pathology underlying many physical ailments.

The development of a psychiatric classification system by Kraepelin played a dominant role in the early development of the biological viewpoint. Kraepelin’s work (a forerunner to the DSM system) helped to establish the importance of brain pathology in mental disorders and made several related contributions that helped establish this viewpoint.

The first major steps toward understanding psychological factors in mental disorders were taken by Sigmund Freud. During five decades of observation, treatment, and writing, he developed a theory of psychopathology—known as psychoanalysis—that emphasized the inner dynamics of unconscious motives. Over the last half-century, other clinicians have modified and revised Freud’s theory, evolving new psychodynamic perspectives.

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Chapter 1 Abnormal Psychology over Time

Scientific investigation into psychological factors and human behavior began to make progress in the latter part of the 19th century also. Two major schools of learning—classical and operant conditioning—developed, and behaviorism emerged as an explanatory model in Abnormal Psychology. The behavioral perspective is organized around a central theme—that learning plays an important role in human behavior. Although this perspective was initially developed through research in the laboratory, unlike psychoanalysis, which emerged out of clinical practice with disturbed individuals, it has been shown to have important implications for explaining and treating maladaptive behavior.

Research in Abnormal Psychology allows us to learn about the symptoms of a disorder, its prevalence, whether it tends to be acute or chronic, the problems and deficits that accompany the disorder, etiology, and treatment. Researchers may collect data from many sources including case studies, self-report data, or from observational approaches such as direct observation or brain imaging. Researchers form hypotheses to explain, predict, or explore something. In designing research studies, the researcher must consider sampling and generalization, internal and external validity, and criterion and comparison groups. Research designs may be observational or experimental. Observational (or correlational) research studies things as they are, involving no manipulation of variables. Observational research leads to a determination of correlation as measured by a correlation coefficient. Mere correlation between variables does not allow us to conclude that there is a causal relationship between them. Simply put, correlation does not imply causation. To draw conclusions about causality, experimental research designs must be used. Experimental research involves manipulating one variable (the independent variable) and seeing what impact this has on another variable (the dependent variable). Although most experiments involve studies of groups, single case experimental designs (e.g., ABAB designs) can also be used to make causal inferences in individual cases. Although generalization can be a problem, animal research has been very informative.

Detailed Lecture Outline I.

What Do We Mean by Abnormality?

A. The Elements of Abnormality 1.

Suffering 2.

Maladaptiveness 3.

Deviancy 4.

Violation of the standards of society 5.

Social discomfort 6.

Irrationality and unpredictability B. The DSM-IV-TR Definition of Mental Disorder 1.

Mental disorder as clinically significant distressing or disabling syndrome in the individual 2.

DSM utilizes “prototype” approach 3.

Atheoretical—causal mechanisms are not described 4.

Rules out culturally sanctioned behaviors 5.

DSM definition still problematic – what is “clinically significant?”

6.

Wakefield – “harmful dysfunction” as alternative to DSM definition 7.

Classifies “harm” in terms of social value 8.

“Dysfunction” determined according to evolutionary theory 9.

DSM is a work-in-progress C. Why Do We Need to Classify Mental Disorders?

1.

Nomenclature helps structure information .

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Chapter 1 Abnormal Psychology over Time

II.

6

2.

Promotes research 3.

Directs treatment 4.

Delimits domain of professional expertise 5.

Delineates insurance reimbursement D. What Are the Disadvantages of Classification?

1.

Loss of information/detail 2.

Stigmatizing 3.

Stereotyping 4.

Labeling E. How Does Culture Affect What is Considered Abnormal?

1.

Culture shapes the clinical presentation of disorders F. Culture-Specific Disorders 1.

Examples a.

Taijin kyofusho: Japan—marked fear of giving offense b.

Ataque de nervios: Caribbean—distress triggered by a stressful event 2.

Nevertheless, certain unconventional actions and behaviors such as hearing voices, laughing at nothing, defecating in public, drinking urine, and believing things that no one else believes are almost universally considered to be the product of mental disorder How Common Are Mental Disorders?

A. Prevalence and Incidence 1.

Frequencies of particular disorders are of great interest to professionals a.

Research efforts are guided by frequencies b.

Allocation of treatment resources depends upon the extent of the disorder 2.

Epidemiology is the study of the distribution of mental disorders 3.

Prevalence is the number of actual, active cases in a given population during any given period—typically expressed as a percentage 4.

Point prevalence—at any instant 5.

One-year prevalence—during an entire year 6.

Lifetime prevalence—full lifespan—tends to be higher than other prevalence rates 7.

Incidence is a rate—specifically, the number of new cases occurring over a period of usually one year B. Prevalence Estimates for Mental Disorders 1.

The Epidemiologic Catchment Area study: sampled citizens of five communities (Baltimore, New Haven, St. Louis, Durham, and Los Angeles) 2.

The National Comorbidity Survey: sampled the entire United States 3.

One-year prevalence—based on the replication of the National Comorbidity Survey a.

18.1% anxiety disorder b.

26.2% any disorder 4.

Lifetime prevalence of having a DSM-IV disorder—46.4% a. May be an underestimate as did not assess for eating disorders, schizophrenia, autism, nor most personality disorders b. Disorder with the highest lifetime prevalence—major depressive disorder c. Although lifetime prevalence high, remember that duration may be brief or severity may be mild 5.

Comorbidity especially high in people who have severe forms of mental disorders (50%) in comparison to those who have milder forms of mental disorders (7%)

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Chapter 1 Abnormal Psychology over Time

III.

Historical Views of Abnormal Behavior A. Demonology, Gods, and Magic 1.

Abnormal behavior attributed to demonic possession a. Differentiated good vs. bad spirits based on the individual’s symptoms b. Religious significance of possession 2.

Treatment for possession was through exorcism B. Hippocrates’ Early Medical Concepts 1.

Hippocrates insisted mental disorders due to natural causes—believed brain was the central organ of intellectual activity and that mental disorders were due to brain pathology 2.

Hippocrates also emphasized the importance of heredity and predisposition; pointed out that head injuries could lead to sensory and motor disorders 3.

Classified all mental disorders into three categories based on detailed clinical observations: a. Mania b. Melancholia c. Phrenitis (brain fever) 4.

Doctrine of the four humors (Hippocrates and, later, Galen) a. Blood (sanguis) b. Phlegm c. Bile (choler) d. Black bile (melancholer) e. Treatments were designed for the specific classifications and recognized the importance of the environment 5.

Considered dreams to be important in understanding a person’s personality 6.

Misconceptions were perpetuated such as Hysteria caused by a wandering uterus C. Later Greek and Roman Thought 1.

Greek and Roman thought influenced medical thought in Alexandria, Egypt a. Environmental factors considered important b. Wide range of treatments provided 2.

The Greek physician Galen a. Elaborated upon anatomy of the nervous system based on animal dissection b. Divided causes of psychological disorders into physical and mental categories 3.

Roman medicine a. Pragmatic approaches b. Treatment via contrarius contrarius (opposite by opposite), for instance giving chilled wine while patient was in warm tub D. Views of Abnormality during the Middle Ages 1.

Islamic countries preserved some scientific aspects of Greek medicine a. First mental hospital established in Baghdad in A.D. 792 b. Avicenna, the “prince of physicians,” wrote the Canon of Medicine, which may be the most widely studied medical work ever written 2.

European attitudes toward mental disorder were marked by superstition a. Isolated areas afflicted with outbreaks of lycanthropy, a condition in which the person was believed to be possessed by a wolf b. Management of the mentally disturbed was left largely to the clergy c. Treatment occurred mainly in monasteries and was relatively kind

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d.

Although we used to think that a connection between witchcraft and mental illness was common during the Middle Ages, it now appears substantially overestimated E. The Resurgence of Scientific Questioning in Europe 1.

Paracelsus, Swiss physician, was an early critic of mental illness as possession a. Formulated the idea of psychic causes for mental illness b. Advocated treatment by “bodily magnetism,” later called hypnotism c. Believed in astral influences on behavior 2.

Weyer, German physician, is considered a founder of modern psychopathology a. First physician to specialize in mental disorders b. Scorned by his peers, and his works were banned by the church until the 20th century 3.

St. Vincent de Paul declared mental disease no different than physical F. The Establishment of Early Asylums 1. Early asylums were simply places to warehouse troublesome people 2.

First hospital in Europe was probably the Valencia mental hospital in Spain in 1409 3.

1547—monastery of St. Mary of Bethlehem in London was officially made into an asylum by Henry VIII a. “Bedlam” and its deplorable conditions b. More violent patients were exhibited to the public for one penny a look c. More harmless inmates forced to seek charity on the streets G. Humanitarian Reform 1.

Pinel’s Experiment–1792 at La Bicetre in Paris a. Removed chains from mental patients as an experiment b. Patients treated with kindness, as sick people would be c. Fortunately, the experiment was a success with increased peace and order 2.

Tuke’s work in England—the York Retreat a. Based on Quaker principles b. Provided humane mental health treatment 3.

Benjamin Rush and moral management in America a. Rush founded American psychiatry (1) Encouraged more humane treatment (2) Wrote first systematic treatise on psychiatry in America (3) First American to organize a course in psychiatry (4) Despite these advances, he believed in astrology, bloodletting, and purgatives (5) Rush invented the “tranquilizing chair” b.

Moral Management—wide-ranging method of treatment that focuses on social, individual, and occupational needs (1) Achieved a high degree of effectiveness (2) Nearly abandoned by the late 19th century (a) Ethnic prejudice that came with rising immigrant population (b) Failure to train replacements (c) Overextension of hospital facilities (d) Rise of Mental Hygiene movement condemned patients to dependency (e) An emphasis on physical basis of mental illness countered moral treatment 8

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4.

Dorothea Dix and the Mental Hygiene Movement (1841–1881) a.

Aroused worldwide awareness of inhumane treatment for the mentally ill b.

Established thirty-two mental hospitals in the United States, Canada, Scotland, and other countries c.

Movement can be criticized as leading to the warehousing of the mentally ill in overcrowded facilities H. Mental Hospital Care in the 21st Century 1.

Substantial growth in numbers of hospitals in first half of 20th century a.

Lengthy hospital stays b.

Little effective treatment 2.

1946—Changing views of mental health services a.

Mary Jane Ward published The Snake Pit b.

The National Institute of Mental Health is organized c.

The Hill-Burton Act is passed funding community mental health agencies d.

Community Health Services Act of 1963 helped fund outpatient clinics 3.

Deinstitutionalization a.

Replacement of inpatient hospitals by community-based care, daytreatment hospitals, and outreach programs b.

Impetus for this movement was that it was considered more humane, and cost effective, to treat mental disorders outside of hospitals, thereby preventing the learning of negative behaviors people acquired as they adapted to institutionalization c.

International movement d.

Failure of deinstitutionalization illustrated by homeless mentally ill people may be due, in part, to the failure of society to develop ways to fill the gaps in mental health care IV. The Emergence of Contemporary Views of Abnormal Behavior A. Biological Discoveries: Establishing the Link between the Brain and Mental Disorder 1.

General paresis and syphilis a.

General paresis produced paralysis and insanity; typically causing death within 2–5 years b.

1917—von Wagner-Jauregg introduced the malarial fever treatment of syphilis; the high fever associated with the malaria killed off the bacteria c.

Early malarial treatment represented the first clear-cut conquest of a mental disorder by medical science d.

Raised hopes that medical science would uncover organic bases for all mental disorders 2.

Brain pathology as a causal factor a.

Von Haller, Elements of Physiology (1757) b.

Griesinger, The Pathology and Therapy of Psychic Disorders (1845) c.

Alzheimer established the brain pathology in cerebral arteriosclerosis and in the senile mental disorders d.

Identified organic pathologies underlying the toxic mental disorders, certain types of mental retardation, and other mental illnesses e.

Important to note that although this has led us to understanding how these disorders are caused, we don’t always know why disorders afflict one person and not another B. The Development of a Classification System 1.

Emil Kraepelin .

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C.

D.

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2.

Recognizing symptom patterns was a forerunner of the modern DSM The Development of the Psychological Basis of Mental Disorder 1.

Mesmerism a.

Mesmer believed that the planets affected a universal magnetic fluid in the body—the distribution of this fluid determined health or disease b.

Paris, 1778: Mesmer opened a clinic where he treated all kinds of diseases through “animal magnetism” c.

Branded a charlatan by medical colleagues and an appointed body of noted scholars including Benjamin Franklin 2.

The Nancy School, viewed hysteria as self-hypnosis a.

Jean Charcot clashed with the Nancy School b.

Believed that degenerative brain changes led to hysteria c.

Eventually was proven wrong and the Nancy School triumphed d.

First recognition of a psychologically caused mental disorder 3.

The beginnings of psychoanalysis a.

Freud and the psychoanalytic perspective b.

Discovery of the unconscious (1) Breuer—unlike others using hypnotism, Freud and Breuer allowed their patients to talk freely about their problems while under hypnosis (2) Catharsis—this emotional release not only helped patients but revealed to the therapists the nature of the problems that had brought about the symptoms (3) Patients, however, upon awakening from the hypnosis, did not see any connection between their problems and their symptoms (4) Led to formation of the notion of the unconscious (5) Free association and dream analysis The Evolution of the Psychological Research Tradition: Experimental Psychology 1.

The early psychology laboratories a.

1879: Wilhelm Wundt at University of Leipzig b.

J. McKeen Cattell brought Wundt’s methods to the U.S. c.

Witmer’s psychological clinic at University of Pennsylvania (1) Clinic focused on the problems of mentally deficient children (2) Witmer seen as the founder of clinical psychology d.

Other clinics soon established (1) Chicago Juvenile Psychopathic Institute in 1909 by William Healy (2) Healy was the first to view juvenile deviancy as a symptom of urbanization; first to recognize environmental, or sociocultural, factors e.

Rapid and objective communication of scientific findings with the publication of journals 2.

The behavioral perspective a.

Classical conditioning—antecedent stimulus conditions and their relation to behavioral responses (1) Pavlov, conditioned reflex (2) Watson, psychology should study overt behavior b.

Operant conditioning—consequences of behavior influence future behavior (1) Thorndike (2) Skinner .

Chapter 1 Abnormal Psychology over Time

V. Research Approaches in Abnormal Psychology A. Sources of Information 1.

Case studies a.

Information may be subject to bias and low generalizability 2.

Self-report data may be misleading 3.

Observation approaches a.

Overt behavior b.

Biological variables such as heart rate c.

Brain imaging technology allows us to observe brain functioning B. Forming and Testing Hypotheses 1.

Sampling and generalization a.

Studies that examine groups of people are valued over single cases (1) May identify multiple causes for disorders (2) Can generalize results to other cases b.

Sampling is the careful selection of a subgroup that is representative of a larger population for close study 2.

Internal and external validity a.

The more representative the sample the more able we are able to generalize – external validity b.

Internal validity reflects how confident we can be in the results of a particular study; that is, is the study is methodologically sound, free of confounds or other sources of error, and able to be used to draw valid conclusions 3.

Criterion and comparison groups a.

People with the disorder are the criterion group b.

Control groups—typically healthy people—are used for comparisons C. Research Designs 1.

Studying the world as it is a.

Experimental studies of etiological factors unethical and impractical b.

Observational (correlational) research requires no manipulation of key variables 2.

Measuring correlation a.

Positive and negative correlation b.

Uncorrelated or independent of one another c.

The strength of a correlation is measured by a correlation coefficient 3.

Correlations and causality a.

Correlation or association of variables is not evidence of causation b.

Third variable problem 4.

Retrospective versus Prospective Strategies a.

Retrospective studies look back in time (1) Retrospective memories can be both faulty and selective (2) Such a strategy may increase the odds that investigators discover what they expect to discover b.

Prospective studies look ahead (1) Prospective studies often focus on high-risk populations before they develop the disorder (2) When hypotheses correctly predict behavior, we are much closer to establishing a causal relationship

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(3)

VI.

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Studies that follow people over time and that tries to identify factors that predate the onset of a disorder employs a longitudinal design D. Manipulating Variables: the Experimental Method in Abnormal Psychology 1.

Experimental research involves the scientific control of all but one variable a.

Independent variable is manipulated b.

Dependent variable is observed for experimentally induced changes 2.

Studying the efficacy of therapy a.

Comparison of treated and untreated group b.

Random assignment means that every research participant has an equal chance of being placed in the treatment or the no-treatment condition c.

Standard treatment comparison study occurs when the ‘control’ group is given the standard, currently accepted treatment eliminating some ethical concerns 3.

Single Case Experimental Designs a.

Many observations of one subject b.

ABAB design 4.

Animal Research a.

Permits experimental manipulation b.

Ethical considerations still apply c.

“Analogue” of human conditions d.

Findings from animal research provided impetus for learned helplessness model of depression Unresolved Issues A. Are We All Becoming Mentally Ill? The Expanding Horizons of Mental Disorder 1.

Economic interests of mental health professionals support expansion 2.

For instance, “Road Rage” 3.

Too much expansion would make DSM scientifically useless

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Key Terms ABAB design (p. 29) abnormal behavior (p. 3) acute (p. 22) asylums (p. 13) behavioral perspective (p. 20) behaviorism (p. 21) bias (p. 22) case study (p. 22) catharsis (p. 19) chronic (p. 22) classical conditioning (p. 20) comorbidity (p. 10) comparison or control group (p. 24) correlation (p. 26) correlational research (p. 25) correlation coefficient (p. 26) criterion group (p. 25) deinstitutionalization (p. 16) dependent variable (p. 27) direct observation (p. 22) double-blind study (p. 28) dream analysis (p. 19) epidemiology (p. 9) etiology (p. 5) exorcism (p. 12) experimental research (p. 27) external validity (p. 24) family aggregation (p. 2) free association (p. 19) generalizability (p. 22) incidence (p. 9)

independent variable (p. 27) internal validity (p. 24) labeling (p. 7) lifetime prevalence (p. 9) longitudinal design (p. 26) lycanthropy (p. 12) mental hygiene movement (p. 14) mesmerism (p. 18) moral management (p. 14) Nancy School (p. 18) negative correlation (p. 25) nomenclature (p. 6) observational research (p. 25) one-year prevalence (p. 9) operant conditioning (p. 21) placebo (p. 28) point prevalence (p. 9) positive correlation (p. 25) prevalence (p. 9) prospective research (p. 26) psychoanalysis (p. 18) psychoanalytic perspective (p. 18) random assignment (p. 29) retrospective research (p. 26) sampling (p. 24) self-report data (p. 22) single-case research design (p. 29) stereotyping (p. 6) stigma (p. 6) third-variable problem (p. 26) unconscious (p. 19)

Lecture Examples / Discussion Topics Lecture Launcher 1.1: Why Are You Taking This Course?

Students taking Abnormal Psychology often have a variety of reasons for doing so. These range from satisfying a degree requirement to a desire for enhanced personal insight. The expectations of the students regarding the course and what they may or may not get out of it are interesting issues to explore at the very outset. Students should be encouraged to volunteer their reasons for enrolling in the course.

Common answers that usually arise include learning more about my own behavior, to understand others, and to learn about the different mental health professions. Hearing other peoples’ answers to this question can also help students expand their ambitions in the course beyond the ones they originally held. This discussion can also provide a good opportunity to present the rationale behind studying Abnormal Psychology and how the scientific tradition assists in increasing our understanding of behavior and its determinants. After this discussion students should have a clear understanding of the demands and expectations of this course and how their expectations fit into the course design. .

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Lecture Launcher 1.2: Stigma Progress?

Using an overhead transparency, a PowerPoint slide, a whiteboard, or a chalkboard, write the following question: “Your city is planning to create a half-way house for adult men who have been hospitalized for paranoid schizophrenia. Where would be the best place to put this home? A. Next door to your home; B. In your neighborhood; C. Anywhere in town would be fine; D. In the next town. Asking students to answer privately on their own paper prior to beginning any discussion of this topic is typically necessary.

Lecture Launcher 1.3: What’s Your Frame of Reference?

The concept of social labeling provides an excellent topic for a lecture-discussion session. Any number of cultural groups can be used as examples to provide contrasts in how societies label pathology.

Students can be asked to generate their own examples of social labeling, using experiences with subcultural groups. The behaviors found among different age groups are often labeled as abnormal by the dominant age group in our society. For instance, street slang may be evaluated as maladaptive by the school system, yet it provides rich communication in its own subcultural context. The behavior of adolescents may be labeled as pathological by adults who see the behavior as maladaptive (an example from the text is body piercing or tattooing). Students should find the discussion of social labeling an interesting one because they can contribute experiences from their own subcultural group. In-class lecture can illustrate that, although social labeling can be a powerful process; some behaviors (such as depression) are generally assumed to be maladaptive in all subcultures and societies. Students can be asked to identify other behaviors whose maladaptiveness transcends cultural boundaries. An easy way to begin a discussion of this type might be to ask students the number of piercings that they have. Tally the number of students who report 0, 1, 2, 3, 4, 5 or more piercings and talk about how the acceptance of piercing has changed in the past few years in our culture.

Lecture Launcher 1.4: On Being Sane in Insane Places Rosenhan (1973) published a classic Abnormal Psychology study in the high-profile journal Science (vol. 179, pp. 250–258). This study raises many interesting questions about research methods, definitions of abnormality, and the ability of mental health professionals to distinguish actual from feigned mental illness. In this study, eight healthy volunteers, several of them psychologists and psychiatrists, went to mental hospitals and complained of hearing voices saying “empty,” “hollow,” or “thud.” These pseudo-patients acted normally in every way except for the reported auditory hallucinations. As soon as they were admitted, they stopped complaining of these symptoms. Although many of the real hospitalized patients suspected the pseudo-patients were faking, none of the hospital staff apparently did. All pseudo-patients were labeled schizophrenic and their stays ranged from 7 to 52 days, with an average stay of 19 days. Originally, this was taken as evidence of how important labels and expectations affect interpretations of people’s behavior. However, it is worth envisioning a control group of pseudo-patients who report equally severe physical symptoms to physicians. Indeed, people with some kinds of somatoform disorder (chapter 8) succeed in getting fairly dramatic treatments, including surgery, in the absence of genuine organic pathology. It is also worth noting that many pseudo-patients were diagnosed with atypical subtypes of schizophrenia, suggesting that the hospital staff recognized there was something quite different about these patients. The Rosenhan study also raises questions about securing informed consent from research participants, draining precious treatment resources, and the length of time it is reasonable to observe an apparently recovered psychotic person to ensure that relapse is not imminent. These, and other design, ethical, and statistical matters, many of which were published in a subsequent issue of Science (1973, vol. 180, pp. 1116–1122), qualify the interpretation of this classic report substantially.

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Lecture Launcher 1.5: Evolving Conceptualizations of Homosexuality Prior to the publication of DSM-III in 1980, homosexuality was considered a mental illness. In DSM-III it was considered a disorder only if the homosexual person was emotionally troubled by it—that is, only if it was ego-dystonic. In DSM-IIIR (1987), homosexuality moved into a general category of sexual disorders “not otherwise specified,” where it was recast as “persistent and marked distress about one’s sexual orientation” for ego-dystonic heterosexuality as well as homosexuality. These transitions were not driven by scientific research but by evolving societal norms and political pressure. Evolving conceptualizations of homosexuality provide interesting material for discussing diagnosis, science, and politics. It is also sometimes quite interesting to discuss the kinds of research that could be conducted to establish the diagnostic status of behaviors, including homosexuality. Are there data that would certify behaviors as abnormal, or are societal values absolutely necessary?

Lecture Launcher 1.6: Abnormality as “Harmful Dysfunction” An interesting article that can be used for a brief lecture and discussion session is one by J. Wakefield published in 1998 (“Diagnosing DSM-IV: DSM-IV and the concept of disorder.” Behavior Research and Therapy 35, pp. 633–649). The author suggests that the DSM-IV is overinclusive of its diagnostic criteria. The DSM does not distinguish harmful conditions due to internal dysfunction from harmful conditions that are not disordered and do not cause problems in living. The author recommends a dimensional approach to diagnosing mental disorder. Students can be asked about the value of having a diagnostic system, such as the DSM-IV, that does not examine the context of the individual’s life. The events that trigger mental disorder would have a more meaningful place in the dimensional approach than in the DSM classification system. Students can be asked to discuss the events that may lead to problems in living conditions that are harmful to the individual, yet don’t cause internal dysfunction.

Would there be different outcomes for the different situations? Have students list the problems of living that may cause dysfunction in life. Should a person be diagnosed with a mental disorder if experiencing these situations?

Lecture Launcher 1.7: Are We Smarter than Hippocrates?

Hippocrates’ “Doctrine of the Four Humors” often strikes students as quaint at best, or obviously wrong at worst. The general idea, though, that imbalances in bodily fluids cause mental illness, is commonly held to this day, though we discuss imbalances in brain neurotransmitters rather than imbalances in blood, phlegm, and yellow and black biles. It might be objected that today we know about these imbalances from direct observations of the relevant substances in contrast to Hippocrates and Galen who made claims about them in the absence of direct empirical scrutiny. It must be pointed out, though, that we do not have such data available with respect to neurotransmitters either. Such data would require conducting neurotransmitter assays from samples taken from the brains of living people— a procedure simply impossible with presently available technology. Some students might mention that blood tests are often taken during the course of pharmacotherapy. These tests, however, do not pertain to brain neurotransmitters. Instead, they track plasma levels of the medication as well as monitoring for side effects by observing white blood cells and liver enzymes, among other things. If we really had a way to establish neurotransmitter imbalances then surely there would be a diagnostic test for psychiatric disorders that used this procedure. Instead, we infer neurotransmitter problems from the therapeutic effects of neurotransmitter-altering medications. This might seem to be a reasonable inference to students until they ponder the fact, for example, that bloodletting—particularly when done to extreme degrees—was also claimed to be therapeutic, notably for its “calming” effect on patients!

Lecture Launcher 1.8: How Could They Think That?

The appeal to supernatural causes of mental illness strikes many students as rather incomprehensible.

This is an interesting opportunity to ask whether they think people today are smarter than they were 500, .

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1,000, or more years ago. It is probably not too much of a stretch to assert that smart people of every age make use of the best of contemporary thinking to inform their efforts in their own fields. Prevailing views about the causes of physical events like earthquakes and astrological events would then be good sources for ideas about the causes of psychological events. Viewed in this light, early speculations about the causes of mental disorders seem much more comprehensible.

Lecture Launcher 1.9: Why Do Bad Ideas Persist?

One explanation for the enduring nature of erroneous accounts for mental illness throughout history is the irrefutable manner in which they were framed. This would be an opportune time to describe the desirability of refutability as a property of theory development. Other reasons erroneous accounts persist can also be introduced profitably at this point in the course. Among these are placebo effects, “Barnum”-type predictions, selective perception, the power of authority, and the lack of familiarity with relatively rare forms of psychopathology. The advantages of choosing science as the ultimate frame of reference for the acquisition of one’s beliefs about mental illness can also be debated in an effort to expose and challenge objections that could interfere with student appreciation for the text and course.

Lecture Launcher 1.10: How Can Social Progress Be Accelerated?

In 1758, a physician, Tissat, proposed that the loss of seminal fluid during masturbation resulted in a number of disorders including insanity. Tissat felt that a “life force” would be used up too soon if one masturbates frequently or engages in excessive sexual intercourse. Once the life force is depleted, insanity ensues. This theory produced an obvious treatment approach in which the goal was to stop excessive sexual activity. Benjamin Rush’s tranquilizing chair was a form of restraint used for those exhibiting excessive masturbation. Severe forms of treatment were also developed and used including severance of the dorsal nerve in the penis, and removal of the clitoris. A discussion in class can center on how attitudes concerning masturbation have changed and not changed in our society. What other behaviors that have been previously labeled as abnormal are now gaining approval? What helps to maintain such beliefs? What can speed the change in societal approval of previously rejected behaviors in the area of sexuality?

Lecture Launcher 1.11: The Impact of Early Relationships The psychoanalytic perspective suggests that our early relationships carry forward into our lives by influencing current friendships. Have students describe the characteristics of people influential in their early childhood; e.g., parents, grandparents, or elementary school teachers. Next, have the students provide descriptions of recent friends. Do students select friends or dating partners based upon similarities with past significant others? Are friendship choices the result of conscious choices or is there some unconscious directive? Students can be asked to rate the similarity of current friends to past relationships using a numerical scale for dominant traits. Handout 1.1

Demonstrations / Activities Activity 1.1: Stereotypes and the Media Stereotypes and stigma often originate in media portrayals of both the mentally ill and the professionals who treat and study them. Television and the movies consistently use psychological labels to describe unpleasant and dangerous characters. The written media likewise often use lurid descriptions of crimes, including psychological diagnoses of the criminal and terms. Most students in the class will be able to cite examples of such portrayals from their own experience. An excellent way to combat erroneous beliefs about Abnormal Psychology is to rebut these salient portrayals. This is readily accomplished by 16

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asking students to bring examples to discuss in class. Each student can be required to bring at least one newspaper or magazine article, video clip, or even Web site portraying some aspect of Abnormal Psychology. The class can be asked to comment on these materials before the instructor points out what is generally representative and accurate, given the scientific literature on the topic, versus what is not representative or even inaccurate. For instance, a student might bring a clip from A Beautiful Mind, which provides vivid images of visual hallucinations, even though these are much less common in schizophrenia than auditory hallucinations. This film also provides a good opportunity to discuss medications and the prospects for overcoming schizophrenia through mere effort of will. Large classes can be broken into groups that can compile materials and present their observations and questions to the rest of the class.

Activity 1.2: Journal Browsing Students can gain a greater appreciation for scientific approaches to the study of Abnormal Psychology by perusing current issues of some of the more rigorous journals in the field. Either individually or in groups, students can be sent to the library to browse recent issues of Journal of Abnormal Psychology, Journal of Consulting and Clinical Psychology, Archives of General Psychiatry, and American Journal of Psychiatry to find at least one article of interest. They can then be asked to present this article to the class, summarizing its purpose and main findings. It can also be instructive to ask that students make some general classifications of the research design. Is the selected study correlational or experimental?

Retrospective or prospective? What diagnosis is under consideration? Does the article address etiology, descriptive psychopathology, or treatment? Is there a control group? A historical perspective can be encouraged by randomly assigning students to study articles from various decades.

Activity 1.3: Cultural Relativity Students sometimes view stigma, cultural relativity, and social causation as rather weak compared to biological factors and cultural universals. The force of cultural and social phenomena can be established experientially by assigning students to violate an innocuous norm in a way that would be inconsequential elsewhere. Caution them to avoid illegal activities or ones that infringe on the rights of others. For instance, if social and interpersonal forces are innocuous, it should be inconsequential to wear a football helmet all day or to carry around a houseplant adorned with Christmas ornaments.

Activity 1.4: Defining Abnormality Students can be introduced to the numerous definitions of abnormality by trying to formulate their own definition of what is abnormal. The question “How would you define abnormal behavior?” can be used to initiate the discussion. A number of different answers will be generated, and these should be recorded on the blackboard. The instructor will have to challenge each of the answers to illustrate the concepts expressed in the text. The responses generated by the students can then be categorized into the different areas identified in chapter 1—for example, the view that abnormality is always dangerous or that mental disorder is something to be scorned. Through the course of the discussion, students should come to appreciate the problem in defining abnormal behavior and gain an insight into factors affecting the labeling of abnormality.

Activity 1.5: Single-Case Experimental Design James Carr and John Austin (1997) developed a demonstration of single-case experimental design that can be used easily in a classroom setting. Students are instructed on how to take their own pulse rate and record these data for five one-minute intervals. This constitutes baseline. The treatment phase then begins by asking students to stand up and do jumping jacks for twenty seconds. The students then sit and take their pulse rate again for one minute. Students repeat the treatment phase four additional times.

Following the collection of the five pulse rates during “treatment,” the students once again sit and record .

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five resting pulse rates in one-minute intervals. Students could repeat the treatment phase if the instructor wishes to demonstrate an ABAB design. Once the data collection is complete, students could draw a graph of their results and attempt to draw some conclusions regarding how “treatment” impacted heart rate.

Activity 1.6: Modern Non-Science and Pseudo-Science Lecture Launcher 1.9 ends with an appeal to science as the final arbiter of theoretical conflicts about the origins of mental illness. Many will accept this posture relatively uncritically and wonder why it needs to be advanced at all. To enliven the need to promote this idea, it is interesting to have students collect contemporary examples of unscientific ideas about behavior. The self-help section of the local bookstore or library is fertile ground for gathering such examples. Newspapers also are prone to report “alternative” approaches to health and emotional wellness. Unconventional religious practices, occult groups, astrology, and dietary recommendations are also frequently packaged along with obviously unscientific explanations. A bit more challenging, but pedagogically superior, is the collection of pseudo-science material. These would be things that are at pains to look scientific but actually are not.

Bogus science detection is an invaluable skill in modern society and inculcation of the habits of thinking that support it are a terrific aspiration for teachers of Abnormal Psychology. Handout 1.2 Activity 1.7: The History Channel Have students simulate a modern television talk show with volunteers playing guests drawn from the history of Abnormal Psychology. The format of the show would be chosen by the class. Would someone play Oprah, or would the Jerry Springer format be more interesting? Perhaps a late-night talk show would be more suitable? Or maybe a PBS-type program or extended documentary-type interview format. In any event, some of the more flamboyant members of the class could be asked to play the roles of various figures discussed in chapter 2. They might want to do some additional research to help flesh out their portrayals. The class might also discuss who would be interesting to see appearing together —say, Rush and Dix—for purposes of facilitating debate. The instructor might serve as moderator to ensure important points are drawn out of these celebrity appearances.

Activity 1.8: Catharsis and Writing about Trauma Breuer, Freud, and others have been impressed with the cathartic effects of emotional self-disclosures in therapy. Recently, researchers have shown many positive effects of simply writing about emotional or traumatic events. Students could be asked to undertake such an exercise on their own, writing a detailed account of a personally traumatic or emotional event, especially one that they have not shared with others. Students can be asked to leave their names off these essays to ensure their anonymity. If records of having completed the assignment are desired, students can be asked to write their name on someone else’s essay so that people completing the assignment can be credited without their disclosures being identified. Later, students can be asked to write about or discuss their experience following the essay assignment. It would be expected that students would feel slightly worse following the writing task but to feel better in the longer term. Why this is so fascinating a topic for discussion, and how one gets from observing these effects to an elaborate theory about the dynamics of the unconscious, is also worth contemplating in anticipation of learning about Freud’s theories in the next chapter.

Activity 1.9: Hospital Field Trip A field trip to a local mental health center with inpatient facilities is a classic means for students to gain first-hand exposure to current treatment practices. Such a visit can provide a fertile ground for later classroom discussion. The students’ attention can be focused on the general living conditions of the patients, and what privileges and/or opportunities exist for them. Students can be asked how they would feel living in an institution, and what improvements they would like to see take place. Also, students 18

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should be sensitized to observe any present conditions that may still be influenced by attitudes and practices from the historical record. It is very important to prepare students for such a visit by discussing professional behavior, confidentiality, and any special requests offered by administrators of the facility. This can be an excellent way for facilities to secure volunteer assistance and for students to gain experiences that inform and bolster their applications for advanced study in the various mental health fields.

Activity 1.10: Connecting Treatment to Etiology A small group exercise that enables students to review how attitudes affect the treatment of mental disturbance involves designing treatment strategies for disorders “caused” by different things. Once students have been divided into small groups, present them with the task of contrasting treatment approaches for (a) a mental disorder blamed on weakness of character; (b) a mental disorder blamed on sinfulness; (c) a mental disturbance caused by poor heredity; (d) a mental disorder developed because of poor and faulty learning situations; (e) a mental disorder due to some physical illness; and (f) a mental disorder created by a poor social environment. Students are not expected to develop professional types of treatment, but rather be able to identify those attitudes that could affect how one person with mental disturbance would be treated considering the “cause” of the condition. Following the group activity, discussion can focus on relating past and present activities concerning mental disorder to the student ideas. Handout 1.3

Web Links Web Link 1.1: http://www.sfasu.edu/sfapsych/links.html Psychology associations (APA, APS, Psi Chi, etc.), academic departments, journals, licensing information and other items of interest to students of Abnormal Psychology are given at this site.

Web Link 1.2: http://www.psychopathology.org/call.asp?programid=9 Official Web site of the Society for Research in Psychopathology, the premier organization for psychologists studying psychopathology.

Web Link 1.3: http://pantheon.yale.edu/~tat22/ Section 3 of Division 12 (Clinical) of the American Psychological Association is the Society for a Science of Clinical Psychology. Its purpose is “to affirm and continue to promote the integration of the scientist and the practitioner in training, research, and applied endeavors. The common bond of the membership is a commitment to empirical research and the ideal that scientific principles should play a role in training, practice, and establishing public policy for health and mental health concerns.”

Web Link 1.4: http://www.nami.org/ This is the homepage for The National Alliance for the Mentally Ill (NAMI), a nonprofit, grassroots, self-help, support and advocacy organization of consumers, families, and friends of people with severe mental illnesses, such as schizophrenia, major depression, bipolar disorder, obsessive-compulsive disorder, and anxiety disorders.

Web Link 1.5: www.psych.org/ Web site for the American Psychiatric Association, publisher of the DSM, founded by Benjamin Rush, and the biggest psychiatric association in the country.

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19

Chapter 1 Abnormal Psychology over Time

Web Link 1.6: http://www.trepan.com Students frequently learn that trephining was a prehistorical attempt to deal with abnormal behavior. It is worth pointing out that it survives to this day. At this Web site they learn that “The International Trepanation Advocacy Group is dedicated to accumulating the largest base of information about trepanation ever before assembled. I-TAG is interested in presenting all the information about trepanation, be it positively or negatively construed.”

Web Link 1.7: http://www.cwu.edu/~warren/today.html Search engine for the Historical Database of the American Psychological Association. Keyword (e.g., “bedlam”), name (e.g., Dorothea Dix), and date (e.g., June 1) searches are permitted.

Web Link 1.8: http://psychclassics.yorku.ca/ Full-text copies of a large number of historical documents from the history of psychology with more than 200 articles and 25 books with links to many more at other sites. Freud, Janet, Jung, Szasz, and Witmer are among the many authors represented. All documents are in the public domain.

Web Link 1.9: http://academic.udayton.edu/gregelvers/hop/welcome.asp Extensive history of psychology site, with many links out to other comprehensive sites describing historical treatments of the mentally ill, pictures of experimental apparatus, and classic texts.

Web Link 1.10: http://www.psych.yorku.ca/orgs/resource.htm Division 26 (History) of the American Psychological Association Web resources page of links.

Video Resources A Century of Assassins. Mind of the Assassin Series. Princeton, NJ: Films for the Humanities and Sciences.

The Dark Side of the Moon. Boston, MA: Fanlight Productions.

Health, Mind and Behavior. Discovering Psychology Series. South Burlington, VT: Annenberg/CPB Collection.

Looking at Abnormal Behavior. The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection.

Mental Illness. Princeton, NJ: Films for the Humanities and Sciences.

Myths about Madness: Challenging Stigma and Changing Attitudes. Allyn and Bacon Video Library.

Out of My Mind. New York, NY: Filmmakers Library.

Placebo Effect: Mind/Body Relationship. The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection.

Psychological Disorders. South Burlington, VT: Annenberg/CPB Collection.

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Chapter 1 Abnormal Psychology over Time

Psychopathology—Vol. 21, Discovering Psychology. South Burlington, VT: Annenberg/CPB Collection.

R. D. Laing’s Discussion with Richard Evans: Dilemma of Mental Illness. Notable Contributors to the Psychology of Personality Series. University Park, PA: Penn State Media Sales.

R. D. Laing’s Discussion with Richard Evans: Reactions and Reflections. Notable Contributors to the Psychology of Personality Series. University Park, PA: Penn State Media Sales.

Understanding Research. Discovering Psychology Series. South Burlington, VT: Annenberg/CPB Collection.

Anatomy of Desire. New York: NY: The Cinema Guild.

A Place for Madness. New York, NY: Public Broadcasting Service.

Back from Madness: The Struggle for Sanity. Princeton, NJ: Films for the Humanities and Sciences.

The Enlightened Machine. The Brain Series. South Burlington, VT: Annenberg/CPB Multimedia Collection.

Madness by Jonathon Miller. New York, NY: Public Broadcasting Service.

Myths about Madness: Challenging Stigma and Changing Attitudes. Princeton, NJ: Films for the Humanities and Sciences.

Not by the Book. Berkeley, CA: University of California Extension Center for Media and Independent Learning.

The Psychological Residuals of Slavery. New York, NY: Guilford Publications.

Wisdom of the Dream: The World of C. G. Jung. New York, NY: Insight Media.

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21

Chapter 1 Abnormal Psychology over Time

Handout 1.1 Childhood Role Models

1.

Select a person who was most influential in your early years of psychological development.

Describe the characteristics and traits of that individual.

Role Model

2.

3.

Traits and Characteristics

Select friends from high school and college and list them below. Describe their characteristics and traits.

Friend 1

Traits and Characteristics

Friend 2

Traits and Characteristics

Friend 3

Traits and Characteristics

Friend 4

Traits and Characteristics

Rate the level of similarity of each friend to the childhood role model. Use the scale 1–10, where 1 is not at all similar and 10 is extremely similar.

Ratings: Friend 1: _____,

22

Friend 2: _____,

Friend 3: _____,

.

Friend 4: _____.

Chapter 1 Abnormal Psychology over Time

Handout 1.2 Pseudoscience Detection

Michael Shermer gives a Carl Sagan–inspired “Baloney Detection Kit” in the journal Scientific American (2001, November & December). Use his ten questions to evaluate allegedly scientific claims.

1.

How reliable is the source of the claim?

2.

Does the source make similarly extreme or unusual claims about other matters?

3.

Have the claims been verified by other sources?

4.

How does the claim fit with what we already know?

5.

Has anyone gone out of the way to disprove the claim, or has only supportive evidence been sought?

6.

Does the preponderance of evidence point to the claimant’s conclusion or to a different one?

7.

Is the claimant employing the accepted rules of reason and tools of research, or have these been abandoned in favor of others that lead to the desired conclusion?

8.

Is the claimant providing an explanation for the observed phenomena or merely denying the existing explanation?

9.

If the claimant proffers a new explanation, does it account for as many phenomena as the old explanation did?

10.

Do the claimant’s personal beliefs and biases drive the conclusions, or vice versa?

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23

Chapter 1 Abnormal Psychology over Time

Handout 1.3 Treating the Cause of Mental Disorder

Group 1:

Mental disorder due to weak character

Group 2:

Mental disorder due to sinfulness

Group 3:

Mental disorder due to genetics

Group 4:

Mental disorder due to poor parenting

Group 5:

Mental disorder due to physical illness

Group 6:

Mental disorder due to social interactions with peers

24

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CHAPTER 2: Causal Factors and Viewpoints Chapter At-A-Glance Detailed Outline

Instructors’ Resources

Print Supplements

Media Supplements

Causes and Risk Factors for Abnormal Behavior • Necessary, Sufficient, and Contributory Causes • Diathesis-Stress Models

Teaching Objectives 2.1 Chapter Guide Lecture Launchers 2.1, 2.2, 2.5 Activities 2.1, 2.2, 2.3, 2.4, 2.6 Web Links 2.2, 2.3, 2.6

Test Bank Grade Aid Transparencies T-11

CD-ROM PowerPoint

Teaching Objectives 2.6 Lecture Launchers 2.2 Activities 2.2

Test Bank Grade Aid

CD-ROM

The Biological Viewpoint and Biological Causal Factors • Neurotransmitter and Hormonal Abnormalities • Genetic Vulnerabilities • Temperament • Brain Dysfunction and Neural Plasticity • The Impact of the Biological Viewpoint

Teaching Objectives 2.2 Chapter Guide Lecture Launchers 2.1, 2.3, 2.4, 2.5 Activities 2.1 Web Links 2.6

Test Bank Grade Aid Transparencies T-13 to T-20

CD-ROM PowerPoint

The Psychological Viewpoints • The Psychodynamic Perspectives • The Behavioral Perspective • The Cognitive-Behavioral Perspective

Teaching Objectives 2.3–2.4 Chapter Guide Lecture Launchers 2.1, 2.3, 2.5 Activities 2.1, 2.5 Web Links 2.1, 2.4, 2.5

Test Bank Grade Aid Transparencies T-22, T-23

CD-ROM PowerPoint

Psychological Causal Factors • Early Deprivation or Trauma • Inadequate Parenting Styles • Marital Discord and Divorce • Maladaptive Peer Relationships

Teaching Objectives 2.4 Chapter Guide Lecture Launchers 2.1, 2.5 Activities 2.1, 2.6 Web Links 2.4, 2.5, 2.6

Test Bank Grade Aid

CD-ROM PowerPoint

The Sociocultural Viewpoint and Causal Factors • Uncovering Sociocultural Factors through Cross-Cultural Studies • Harmful Societal Influences • The Impact of the Sociocultural Viewpoint

Teaching Objectives 2.5 Chapter Guide Lecture Launchers 2.1, 2.5 Activities 2.1, 2.3 Web Links 2.1, 2.4

Test Bank Grade Aid

CD-ROM PowerPoint

Unresolved Issues: Theoretical Viewpoints and the Causes of Abnormal Behavior

Teaching Objectives 2.6 Chapter Guide Lecture Launchers 2.1, 2.5 Activities 2.1, 2.4 Web Links 2.1, 2.2, 2.3

Test Bank Grade Aid Transparencies T-21

CD-ROM

Viewpoints for Understanding the Causes of Abnormal Behavior

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Professor Notes

25

Chapter 2 · Causal Factors and Viewpoints

Teaching Objectives 1.

2.

3.

4.

5.

6.

Discuss the different conceptual approaches to understanding the causes of abnormal behavior. These approaches will include (a) necessary, sufficient, and contributory causes; and (b) the diathesis-stress model.

Summarize the biological theories of abnormal behavior including neurotransmitter/hormonal imbalances, genetic vulnerabilities, temperament, and physical damage to brain structures.

Outline the major psychosocial theoretical approaches to abnormal behavior including the psychodynamic, behavioral, and cognitive-behavioral perspectives.

Discuss the substantive contributions of the psychosocial factors of deviant cognitions (schemas and self-schemas), early deprivation or trauma (e.g., parental deprivation, institutionalization, abuse, etc.), inadequate parenting and pathogenic family structures, and problems with peer relationships.

Describe the sociocultural perspective and its contributions to understanding abnormal behavior.

Explain why the field needs a unified viewpoint and how the biopsychosocial viewpoint may fulfill that need.

Chapter Overview / Summary Usually the occurrence of abnormal or maladaptive behavior is considered to be the joint product of a person’s vulnerability (diathesis) to disorder and of certain stressors that challenge his or her coping resources. In considering the causes of abnormal behavior, it is important to distinguish among necessary, sufficient, and contributory causal factors, as well as between relatively distal causal factors and those that are more proximal. The concept of protective factors is important for understanding why some people with both a diathesis and a stressor may not develop a disorder, but may remain resilient.

Both the distal and proximal (immediate) causes of mental disorder may involve biological, psychological, and sociocultural factors. These three classes of factors can interact with each other in complicated ways. This chapter discusses biological, psychosocial, and sociocultural viewpoints, each of which tends to emphasize the importance of causal factors of the same type.

In examining biologically based vulnerabilities, we must also consider genetic endowment, biochemical and hormonal imbalances, temperament, and brain dysfunction and neural plasticity.

Investigations in this area show much promise for advancing our knowledge of how the mind and the body interact to produce maladaptive behavior.

The oldest psychological viewpoint on abnormal behavior is Freudian psychoanalytic theory. For many years this view was preoccupied with questions about libidinal energies and their containment.

More recently psychodynamic theories have shown a distinctly social or interpersonal thrust under the influence, in part, of object-relations theory that emphasizes the importance of the quality of very early (pre-Oedipal) mother-infant relationships for normal development. The originators of the interpersonal perspective were also defectors from the psychoanalytic ranks who took exception to the Freudian emphasis on the internal determinants of motivation and behavior and instead emphasized that important aspects of human personality have social or interpersonal origins, especially unsatisfactory relationships in the past or present. Psychoanalysis and closely related therapeutic approaches are termed psychodynamic in recognition of their attention to inner, often unconscious, forces.

The behavioral perspective on abnormal behavior, which was rooted in the desire to make psychology an objective science, was slow in overcoming the dominant psychodynamic bias of the time, but in the past thirty years, it has established itself as a major force. Behaviorism focuses on the role of learning in human behavior and it views maladaptive behavior either as a failure of learning appropriate 26

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Chapter 2 · Causal Factors and Viewpoints

behaviors, or learning maladaptive behaviors. Adherents of the behavioral viewpoint attempt to alter maladaptive behavior either by extinguishing it and/or by training new, more adaptive behaviors.

Initially a spin-off from (and in part a reaction against) the behavioral perspective, the cognitivebehavioral viewpoint attempts to incorporate the complexities of human cognition and how it can become distorted into understanding the causes of psychopathology. Adherents of the cognitivebehavioral viewpoint attempt to alter maladaptive thinking and improve a person’s abilities to solve problems and to plan.

People’s schemas and self-schemas play a central role in the way they process information and in the kinds of attributions and values they have concerning the world. The efficiency, accuracy, and coherence of a person’s schemas and self-schemas appear to provide an important protection against psychopathology. Sources of psychologically determined vulnerability include early social deprivation or severe emotional trauma, inadequate parenting styles, marital discord and divorce, and maladaptive peer relationships.

The sociocultural viewpoint is concerned with the social environment as a contributor to mental disorder because sociocultural variables are important sources of vulnerability, or, conversely, of resistance. Although many serious mental disorders are fairly universal, the prevalence and form that some disorders take varies widely among different cultures. Having low socioeconomic status, being unemployed, experiencing prejudice and discrimination, experiencing social change and uncertainty, and urban stressors such as violence and homelessness are associated with greater risk for various disorders.

We are still a long way from the goal of a complete understanding of abnormal behavior. The many theoretical perspectives that exist have given us a very good start, but they fall short. To obtain a more comprehensive understanding of mental disorder, we must draw on a variety of sources including the findings of genetics, biochemistry, psychology, sociology, and so forth. The biopsychosocial approach comes closest, but in many ways it is merely a descriptive acknowledgment of these complex interactions rather than a clearly articulated theory of how they interact. It is the task of future generations of theorists to devise a general theory of psychopathology, if indeed one is possible.

Detailed Lecture Outline I.

Causes and Risk Factors for Abnormal Behavior A. Necessary, Sufficient, and Contributory Causes 1.

Etiology is the causal pattern of abnormal behavior 2.

A condition that must exist for a disorder to occur is a necessary cause 3.

A sufficient cause guarantees the occurrence 4.

A contributory cause increases the probability 5.

Distal causal factors are causal factors occurring relatively early in life but do not show their effects for years 6.

Proximal causal factors are causal factors that operate shortly before the occurrence of the symptoms of a disorder 7.

A reinforcing contributory cause is a condition that maintains maladaptive behavior B. Diathesis-Stress Models 1.

A predisposition toward a given disorder is termed a diathesis or vulnerability 2.

Diathesis can derive from biological, psychosocial, and sociocultural causal factors 3.

Diathesis may be perceived as the distal necessary or contributory cause; a more proximal undesirable event or situation (the stressor) produces the disorder in someone with the distal necessary or contributory cause .

27

Chapter 2 · Causal Factors and Viewpoints

4.

5.

II.

III.

28

Stress is a response to an adjustment demand Several models of how diathesis and stress may combine to produce a disorder: a.

Additive model: diathesis and stress together must reach a particular level; may reach this level with only diathesis or stress but easier if both are present b.

Interactive model: some amount of diathesis and stress required; if both are not present, the disorder will not develop 6.

Protective factors are influences that modify a person’s response to environmental stressors making it less likely that the person will experience the adverse consequences of the stressors a.

Having at least one parent who is warm and supportive b.

Exposure to moderate stressful experiences dealt with successfully c.

Girls are less vulnerable than boys d.

Other protective attributes: easygoing temperament, high self-esteem, high intelligence, and school achievement e.

Protective factors may lead to resilience—the ability to cope successfully with very difficult circumstances 7.

Diathesis-stress models are multicausal developmental models emphasizing that we must know what is normal development to understand what constitutes abnormal development (developmental psychopathology) Viewpoints for Understanding the Causes of Abnormal Behavior A. Viewpoints help organize observations, provide a system of thought in which to place the observed data, and suggest areas of focus for research and treatment B. Biopsychosocial viewpoint acknowledges that biological, psychosocial, and sociocultural factors all interact and play a role in psychopathology and treatment The Biological Viewpoint and Biological Causal Factors A. Mental disorders are viewed as disorders of the central nervous system, the autonomic nervous system, and/or the endocrine system that are inherited or caused by some pathological process B. Neurotransmitter and Hormonal Abnormalities 1.

Imbalances of neurotransmitters a.

May be excessive production and release of the neurotransmitter substances into the synapses b.

Dysfunction may occur in how neurotransmitters are deactivated c.

May be a problem with receptors in the postsynaptic neuron 2.

Hormonal abnormalities C. Genetic Vulnerabilities 1.

Abnormalities in the structure or number of chromosomes 2.

Vulnerabilities to mental disorders are almost always polygenic, which means they are influenced by multiple genes 3.

Genes affect behavior indirectly; expression is not a simple outcome of the information encoded in the DNA but is the end product of a process that is influenced by the internal and external environment 4.

The relationship of genotypes to phenotypes 5.

Genotype-environment correlations occur when the genotype shapes the environmental experiences a child has a.

Passive effect b.

Evocative effect c.

Active effect .

Chapter 2 · Causal Factors and Viewpoints

6.

IV.

People with different genotypes may be differentially sensitive or susceptible to their environment; this is known as genotype-environment interactions 7.

Methods for studying genetic influences, used by those in the field of Behavior Genetics, include: a.

Pedigree or family history method b.

Twin method c.

Adoption method 8.

Separating genetic and environmental influences a.

Shared environmental influences are those that would affect all children in a family similarly b.

Nonshared environmental influences are those in which children in the same family differ 9.

Linkage analysis and association studies a.

These studies attempt to determine the actual location of genes for certain disorders b.

Linkage analysis has proven successful with Huntington’s disease but not conclusively with any psychological disorders c.

Association studies are proving to be more promising D. Temperament 1.

Approximately five dimensions of temperament have been identified: a.

Fearfulness b.

Irritability or frustration c.

Positive affect d.

Activity level e.

Attentional persistence 2.

Temperamental characteristics seem to be related to three important dimensions of adult personality: a.

Neuroticism or negative emotionality b.

Extraversion or positive emotionality c.

Constraint (conscientiousness and agreeableness) 3.

May set the stage for various forms of psychopathology later in life E. Brain Dysfunction and Neural Plasticity 1.

Considerable neural plasticity or flexibility of the brain in making changes in organization and function in response to pre- and post-natal experiences, stress, diet, disease, drugs, maturation, etc.

2.

Animal studies clearly document that both positive and negative events can lead to changes in the structure and functioning of the brain 3.

Recent evidence suggests that unstimulating, deprived environments can cause retarded development in humans 4.

Recent research emphasizes the importance of a developmental systems approach, genetic activity influences neural activity which in turn influences behavior which in turn influences the environment, but also that these influences are bidirectional F. The Impact of the Biological Viewpoint 1.

Host of new drugs has brought attention to biological viewpoints 2.

Gorenstein points out that it is illusory to say biological differences signal illness 3.

Gorenstein also points out that dysfunctions in the nervous system could have arisen from psychological causes as well as biological causes The Psychological Viewpoints A. The Psychodynamic Perspectives .

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Chapter 2 · Causal Factors and Viewpoints

1.

2.

3.

4.

5.

6.

7.

30

Sigmund Freud founded the psychoanalytic school, which emphasizes the role of unconscious motives and thoughts The structure of personality: id, ego, superego a.

Life instincts and libido b.

Death instincts c.

Pleasure principle d.

Primary process thinking e.

Secondary process thinking f.

Reality principle g.

Intrapsychic conflicts Anxiety, defense mechanisms, and the unconscious a.

Freud believed that anxiety played a key causal role in most forms of psychopathology b.

Neurotic and moral anxiety, because they are unconscious, cannot be dealt with rationally, thus the ego resorts to irrational protective mechanisms referred to as ego-defense mechanisms Psychosexual stages of development a.

Oral stage b.

Anal stage c.

Phallic stage d.

Latency period e.

Genital stage The Oedipus Complex and the Electra Complex a.

Castration anxiety b.

Penis envy Newer psychodynamic perspectives a.

Ego psychology emphasized the role of the ego b.

Object relations theory focuses on individuals’ interactions with real and imagined other people and on the relationships that people experience between their internal and external objects c.

The interpersonal perspective views psychopathology as rooted in unfortunate tendencies we have developed while dealing with our interpersonal environments d.

Attachment theory emphasizes the importance of early experience, specifically the quality of parental care to the development of secure attachments Impact of the psychoanalytic perspective a.

Development of therapeutic techniques such as free association and dream analysis leading to recognition and influence of the unconscious, early childhood experiences, and sexual factors b.

Problems develop as failed coping strategies c.

Two important criticisms (1) Failure to recognize scientific limits of personal reports of information (2) Lack of scientific evidence to support many of its assumptions or the effectiveness of traditional psychoanalysis d.

Impact of newer psychodynamic perspectives (1) Increasing scientific rigor (2) More focus on documenting effectiveness of treatment .

Chapter 2 · Causal Factors and Viewpoints

(3) (4)

B.

C.

Enormous amount of research generated by attachment theory Interpersonal approaches have become treatment of choice in depression, bulimia, and some personality disorders The Behavioral Perspective 1.

Classical conditioning a.

Unconditioned stimulus b.

Unconditioned response c.

Conditioned stimulus d.

Conditioned response e.

Stimulus-stimulus expectancy f.

Extinction g.

Spontaneous recovery 2.

Instrumental (or operant) conditioning a.

Reinforcement b.

Response-outcome expectancy c.

Conditioned avoidance response 3.

Generalization and discrimination 4.

Observational learning 5.

Impact of the behavioral perspective a.

Maladaptive behavior is viewed as essentially the result of (1) Failure to learn necessary adaptive behaviors or competencies (2) Learning of ineffective or maladaptive responses b.

Focus of therapy is to change specific behaviors and emotional responses c.

Hailed for precision and objectivity, wealth of research, and for its demonstrated effectiveness in changing specific behaviors d.

Criticized by many for focusing on specific behaviors and for the misconception that it simplifies human behavior The Cognitive-Behavioral Perspective 1.

Schemas and Cognitive Distortions a.

Today, the cognitive or cognitive-behavioral perspective focuses on how thoughts and information processing can become distorted and lead to maladaptive emotions and behavior b.

Beck developed the concept of a schema or underlying representative of knowledge that guides the current processing of information and often leads to distortions in attention, memory, and comprehension c.

Self-schemas include our views about who we are, what we might become, and what is important to us d.

Different forms of psychopathology are characterized by different maladaptive schemas that have developed as a function of adverse early learning experiences e.

Information may be processed nonconsciously, outside of our awareness as evidenced by implicit memories 2.

Attributions, Attributional Style, and Psychopathology 3.

Cognitive therapy 4.

Impact of the cognitive-behavioral perspective a.

Has received widespread support b.

Traditional behaviorists remain skeptical, as cognitions are not observable; must rely on client report

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Chapter 2 · Causal Factors and Viewpoints

c.

V.

32

Research studies documenting effectiveness of cognitive-behavioral techniques Psychological Causal Factors A. Early Deprivation or Trauma 1.

Institutionalization a.

Many children institutionalized in infancy or early childhood show severe emotional, behavioral, and learning problems, and are at risk for disturbed attachment relationships and psychopathology b.

Adoption can lead to significant improvement: the earlier the adoption, the better the children did 2.

Neglect and abuse in the home a.

Among infants, gross neglect may be worse than abuse b.

Abused children may be overly aggressive, suffer difficulties in linguistic development, and develop significant problems in behavioral, emotional, and social functioning including conduct disorder, depression, anxiety, and impaired relationships with peers c.

Atypical patterns of attachment are common—most often a disorganized and disoriented style d.

These early experiences may never be overcome e.

30% chance of intergenerational transmission f.

Improvements may be seen when the caregiving environment changes B. Inadequate Parenting Styles 1.

Parent-child relationships are always bidirectional 2.

Parental psychopathology a.

Parents suffering from schizophrenia, depression, antisocial personality disorder, or alcoholism tend to have children at heightened risk for a wide variety of developmental difficulties b.

Effects do not seem to be due simply to genetic variables c.

Four parenting styles, varying in parental warmth and control, seem to be related to different developmental outcomes: Authoritative, Authoritarian, Permissive-indulgent, and Neglectful-uninvolved.

C. Marital Discord and Divorce 1.

Marital discord a.

When marital discord is longstanding, may lead to frustrating, hurtful, and generally damaging effects on both adults and children b.

Effects may be buffered if one parent is warm, prone to praise and approval, and able to inhibit rejecting behavior toward child or if child has supportive peers 2.

Divorced families a.

Effects of divorce on parents b.

Effects of divorce on children (1) Long-lasting modest negative effects documented (2) Effects of divorce are often more favorable than the effects of remaining in a home with marital discord (3) Children living with stepparents—especially very young children—are at increased risk for physical abuse D. Maladaptive Peer Relationships 1.

Despite attitudes against bullying, most children do nothing to discourage bullying, 20–30% of children actually encourage the bully .

Chapter 2 · Causal Factors and Viewpoints

2.

VI.

Sources of popularity versus rejection a.

Popular children tend to be either prosocial or antisocial b.

Rejected children tend to be too aggressive or too withdrawn The Sociocultural Viewpoint and Causal Factors A. Uncovering Sociocultural Factors through Cross-Cultural Studies 1.

Universal and culture-specific disorders and symptoms a.

Research with the MMPI reveals that the basic pattern of disturbed thoughts and behaviors that we call “schizophrenia” can be found among nearly all people b.

Sociocultural factors appear to influence which disorders develop, the forms that they take, how prevalent they are, and their courses c.

Depression is seen across cultures but in varying rates and in different forms—in China, for example, there is a relatively low rate of depression; there is decreased reporting of guilt, and the effects of stress are more typically manifested in physical problems 2.

Culture and over- and under-controlled behavior a.

Children in Thailand show greater prevalence of overcontrolled problems such as shyness, anxiety, and depression as compared to American children b.

Also found differences in likelihood of parents referring children for treatment with Thai parents less likely than their American counterparts B. Harmful Societal Influences 1.

Low socioeconomic status and unemployment a.

Inverse correlation between socioeconomic class and mental disorder varies by disorder b.

Rates of depression, marital problems, and somatic complaints increase during periods of unemployment 2.

Prejudice and discrimination in race, gender, and ethnicity a.

Perceived discrimination may serve as a stressor that threatens self-esteem, which in turn increases physiological distress b.

Greater rates of depression and anxiety disorders among women may, at least partly, be a consequence of the vulnerabilities (such as passivity and dependence) intrinsic to the traditional roles assigned to women and the sexual discrimination that still occurs in the workplace 3.

Social change and uncertainty a.

Numerous adjustments demanded by change in our society b.

Helplessness engendered by events such as September 11, 2001 4.

Urban stressors: Violence and homelessness a.

Annually 3.5 million people worldwide die from violence b.

Domestic violence impacts physical health, lost productivity, and increased rates of anxiety, PTSD, depression, and suicide c.

One third of homeless people suffer from mental illness C. The Impact of the Sociocultural Viewpoint 1.

Broadened view from a focus on the individual to include a concern with societal, communal, familial, and other group settings 2.

Led to design of programs 3.

Led to community facilities 4.

Possible changes in the DSM system

.

33

Chapter 2 · Causal Factors and Viewpoints

VII.

34

Unresolved Issues: Theoretical Viewpoints and the Causes of Abnormal Behavior A. Advantages of Having a Theoretical Viewpoint 1.

Consistent approach 2.

However, may also blind researchers to other approaches 3.

Corrective interpretations attempt to update theoretical perspectives but may not always be accepted B. The Eclectic Approach 1.

Accepting working ideas from several viewpoints and incorporating whatever is found to be useful 2.

Works best in clinical practice rather than at a theoretical level C. Biopsychosocial Viewpoint 1.

Attempt at a unified perspective 2.

Particular combination of factors may be unique for each individual

.

Key Terms adoption method (p. 44) association studies (p. 45) attachment theory (p. 51) attribution (p. 57) behavior genetics (p. 43) biopsychosocial viewpoint (p. 38) castration anxiety (p. 50) chromosomes (p. 42) classical conditioning (p. 52) cognitive-behavioral perspective (p. 56) concordance rate (p. 43) contributory cause (p. 35) cortisol (p. 41) developmental psychopathology (p. 37) developmental systems approach (p. 47) diathesis (p. 36) diathesis-stress models (p. 36) discrimination (p. 55) ego (p. 48) ego psychology (p. 50) ego-defense mechanisms (p. 49) Electra complex (p. 50) etiology (p. 35) extinction (p. 54) family history (or pedigree) method (p. 43) generalization (p. 55) genes (p. 42) genotype (p. 42) genotype-environment correlation (p. 42) genotype-environment interaction (p. 43) hormones (p. 41) hypothalamic-pituitary-adrenalcortical axis (HPA axis) (p. 41) id (p. 48) instrumental (or operant) conditioning (p. 54)

interpersonal perspective (p. 51) intrapsychic conflicts (p. 52) learning (p. 52) libido (p. 48) linkage analysis (p. 45) necessary cause (p. 35) neurotransmitters (p. 39) object-relations theory (p. 50) observational learning (p. 55) Oedipus complex (p. 50) phenotype (p. 42) pituitary gland (p. 41) pleasure principle (p. 48) polygenic (p. 42) primary process thinking (p. 48) protective factors (p. 37) psychosexual stages of development (p. 49) reality principle (p. 48) reinforcement (p. 54) resilience (p. 37) schema (p. 56) secondary process thinking (p. 48) self-schema (p. 56) spontaneous recovery (p. 54) sufficient cause (p. 35) superego (p. 48) synapse (p. 39) temperament (p. 45) twin method (p. 43)

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35

Lecture Examples / Discussion Topics Lecture Launcher 2.1: Is Crying Biological?

At this point in the course, students are ordinarily not equipped to discuss causal factors and viewpoints with respect to specific disorders. However, they are able to apply these ideas to more familiar phenomena. For instance, the lecture could begin with a discussion of the various components of crying, setting the stage for later discussion of the ideas students offer. That is, it would be typical to have crying explained by students as involving components that are cognitive (“I realized I wouldn’t get into medical school”), interpersonal (“My best friend betrayed me”), biological (“Tears clear debris from the eye and come from special tear ducts”), and sociocultural (“Everyone started crying at the same time”).

These could be named as they come out. Then, there would be some foundation for them when they are covered subsequently in the lecture. Alternatively, the various causal factors and viewpoints can be covered first, and then they could later be applied to crying. If not crying, other topics might include love, joy, anger, and jealousy. Or students could be asked to name psychological phenomena that baffle them. These could then be analyzed according to the principles described in the chapter and lecture on causal factors and viewpoints. It is very helpful to emphasize early in the course that it is not a matter of which viewpoint is “right” or “best.” Rather, all the viewpoints are necessary, and the challenge of the course is an integrative understanding of disorders. Just as biological components of crying do not negate cognitive ones, neither do biological components of schizophrenia negate social ones. A companion activity to this discussion topic is given below as Activity 2.1.

Lecture Launcher 2.2: Implicit Theoretical Orientations Students of Abnormal Psychology love case studies, and it is helpful to introduce them early and often.

At this point in the course, though, students do not necessarily have the knowledge of disorders necessary to make cases educational as far as the disorders themselves are concerned. Nevertheless, students are quite willing to speculate about the causes of psychopathology in individual cases and in doing so they can expose the implicit theoretical orientations they will have to be mindful of throughout the course. Therefore, an interesting class discussion can be prompted by giving a fairly straightforward case study of a common disorder like depression. Most students will be familiar with the basic features of depression and they are likely even to have an opinion about what causes it and how it ought to be treated. This is also a good opportunity to introduce something about your own background, mentioning how the case is one of your own or where you learned about it. Alternatively, many excellent cases are available to you from among the many case studies given in the text or other case study resources, like journals, books, and even newspapers and magazines or celebrity autobiographical articles. In any event, after describing the case, students are asked to come up with as many explanations as they can and then to reflect upon the ones that seem most plausible to them. What kinds of explanations do they gravitate toward? Which ones do they dislike? Why? Are there background experiences or factors coming into play? Are they being overly influenced by something they read or saw on TV? Lecture Launcher 2.3: Pills or Skills for ADHD? Without needing a detailed understanding of the disorder, a fairly active discussion can usually be started by asking students about treatments for Attention-Deficit/Hyperactivity Disorder. Most of them know people who take psychostimulants and many have taken them themselves. The accelerating prescribing rate of psychostimulants has given rise to many media examinations of the wisdom and necessity of this therapy in contrast with more behavioral approaches or no treatment at all. It is not worth debating the effectiveness of various treatments, as these are empirical questions students are not yet equipped to analyze. Therefore, it is probably worth stipulating, at least for purposes of the discussion, that the treatments are for the most part equally effective for the primary ADHD symptoms/behaviors. Some careful management of the discussion may be necessary to avoid offending 36

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Chapter 2 · Causal Factors and Viewpoints

students who have been treated themselves in ways others might find objectionable. Of course, treatment preferences are another clue to implicit theoretical orientations.

Lecture Launcher 2.4: Why Is It So Hard to Quit Smoking?

Students often see cigarette addictions as clearly biological in nature. It is, of course, the body’s acquired need for the chemical nicotine that causes people to smoke, even though they vow not to, right?

The question to pose about this is why, then, nicotine patches and gum don’t work perfectly. If one can get nicotine into one’s system, one ought to eliminate the need for the cigarette, right? This can often produce insights about “doing something with one’s hands,” “coping with stress,” “automatic cigarettes, say, after meals,” “looking cool,” and “not caring about one’s health.” A related discussion can be conducted concerning alcohol, though there is not as clean a substitute for the molecule in question.

Nevertheless, the multiple determinants of otherwise apparently strict chemical addictions are evident for alcoholism as well. Note that students will be challenged throughout the term to integrate causal factors in consideration of the various forms of psychopathology presented in the text.

Lecture Launcher 2.5: Would It Clone?

Another way to expose students’ ideas about the distribution of causes of psychopathology is to ask whether a clone of someone with the disorder or personality would be the same, insofar as the characteristic under consideration is concerned. Point out that this is not entirely an academic thought experiment because throughout the text there are citations to how similar genetic clones are to people with the various disorders. That is because identical twins are genetic clones, and the concordance rates for identical, or monozygotic, twins give the concordance to be expected with a clone. The two highest concordance rates—in the .75 range for bipolar mood disorder and just under .50 for schizophrenia— might surprise students, especially if you point out that this means the identical twin or clone of a person with schizophrenia most likely won’t be schizophrenic.

Demonstrations / Activities Activity 2.1: Is Crying Biological?

A good way to get students working together in groups is to give each group a different assignment, and then the resulting group projects can be integrated via a classroom discussion to which they all contribute. A notable advantage of this approach is that all the students are well prepared for the classroom discussion because of their prior small group participation. This facilitates the early socialization to participation every instructor strives for. In terms of the present chapter, groups can be formed for the purpose of analyzing a psychological phenomenon such as crying (or love, enthusiasm, violence, fear, etc.) from a single perspective. Then the individual perspectives developed by each group can be integrated into a comprehensive biopsychosocial model via classroom discussion.

Activity 2.2: Etiological Thought Experiments A good way to get students thinking about the potentially powerful role played by the various etiological factors emphasized within each of the causal viewpoints given in this chapter is to conduct etiological “thought experiments.” Either on their own or in groups, students are given the task of designing a program to cause a form of psychopathology using the principles emphasized by a particular causal viewpoint. For instance, they can be asked to describe creating the cognitive conditions necessary for a random person to be clinically depressed. What would they do to such a person? What would they want to cause them to believe? How would they get them to believe such things? Would any person who was caused to believe such things then be depressed? What if you could only manipulate their interpersonal world? Or what if you only had access to their biology? What would you do to cause depression? What would you do to cause social phobia? If they can develop procedures they believe would work in .

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Chapter 2 · Causal Factors and Viewpoints

principle, they might be more amenable to imagining such things happening in reality, especially once one considers that various causal factors can combine and that some people carry extra vulnerabilities.

Activity 2.3: Bullying and American Culture Your book notes that American adolescents have higher scores than Thai adolescents on behaviors like fighting, bullying, and disobedience at school. Given the highly publicized school shootings such as those at Columbine, the fact that American adolescents score higher in these areas is of serious concern.

Place students in small groups and ask each group to determine what sociocultural factors in the United States might contribute to American adolescents scoring higher in these areas. Once students have completed this task, have groups share their answers with the class. Finish by asking students to think about what changes would have to occur in our society for the incidence of fighting, bullying, and disobeying in school to decrease.

Activity 2.4: Partitioning Causal Variance Especially with respect to one’s self, but also with respect to the other activities and discussion points given in this chapter, it is well to keep in mind that causes combine and that risk factors are not necessarily causal factors. Also, the outcome of a wide variety of complex processes may appear uniform. Therefore, it is important to keep the chapter’s distinction between necessary, sufficient, and contributory causes, as well as the general diathesis-stress formulation, in mind throughout the course.

This process can be supported by frequently asking students whether they believe or the evidence suggests that something can, at least in principle, serve in each capacity—that is, as a necessary cause, a sufficient cause, and a contributory cause. Keeping a worksheet with these concepts available and asking students to support their claims can sharpen their awareness of the issue. Handout 2.1 Activity 2.5: Own Your Mechanisms of Defense Table 2.1 in the textbook gives a nice compact description and summary of Freud’s mechanisms of defense. Although we are often in the worst possible position to recognize these in ourselves, it is enlightening to contemplate their application to our own lives. A good individual exercise in selfexploration that also teaches the mechanisms of defense is to ask students to replace the example column from Table 2.1 with ones from their own lives. Those who are unable to do so, of course, are just too well defended! If it is too difficult to do with respect to one’s self, students can be asked to do so with respect to people one knows well.

Activity 2.6: Predictable and Controllable When studying psychosocial causal factors, the extent to which negative events are predictable and controllable seem to be critical in understanding how much stress a child experiences and how likely the child is to develop anxiety and depression. Illustrating the importance of these variables to students may be extremely difficult. One way of emphasizing this issue is to create an unpredictable classroom setting where the actions of the students lead to no control over what happens to them. For the first 15 minutes of class, the professor can engage in seemingly unpredictable behavior. Lecturing from the back of the classroom, speaking only in a whisper, or speaking in a foreign language can all be used effectively to increase unpredictability. To create the sense of events being out of students’ control, a simple exercise is to assign extra credit points for seemingly no reason: the first student to use the word red gets an extra credit point; any student wearing green gets an extra credit point, etc. Of course, the instructor would not reveal the system being used until after the exercise is completed. Following the fifteen minutes of unpredictable and uncontrollable conditions, explore with the students what the experience was like and how growing up under such conditions would impact a child.

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Chapter 2 · Causal Factors and Viewpoints

Web Links Web Link 2.1: http://www.nal.usda.gov/awic/pubs/primates/4n4laule.htm This Animal Welfare Information Center Newsletter provides a wonderful introduction to the use of behavioral management techniques to reduce or eliminate abnormal behavior in animals.

Web Link 2.2: http://www.psychcrawler.com/ PsychCrawler is the American Psychological Association’s search engine for psychology. Try it out to expand your understanding of the causal factors and viewpoints described in chapter 2 of the text.

Web Link 2.3: http://psychclassics.yorku.ca/ Classics in the History of Psychology links out to the full texts of more than 25 books and 150 articles from the scholarly literature of psychology and allied disciplines. The site also contains links to nearly 200 relevant works posted at other sites.

Web Link 2.4: http://www.gestalt.org/yontef.htm This online essay by Gary Yontef provides an excellent overview of the Gestalt assumptions and approach to abnormality and therapy.

Web Link 2.5: http://www.freudarchives.org/ The Sigmund Freud Archives provides many links to personal papers, photos, correspondence, and memorabilia relating to Freud and the psychodynamic theory as well as access to essays and original publications.

Web Link 2.6: http://www.psychpage.com/family/library/temperm.htm This psychology resource site provides more detailed information about temperament including the nine behaviors identified by Thomas and Chess, the original three types of children identified, and a discussion of environmental differences.

Video Resources Adlerian Family Counseling. Minneapolis, MN: Educational Media.

Albert Bandura. New York, NY: Insight Media.

Albert Bandura: Part I. Notable Contributors to the Psychology of Personality Series. University Park, PA: Penn State Media Sales.

Albert Bandura: Part II. Notable Contributors to the Psychology of Personality Series. University Park, PA: Penn State Media Sales.

The Behaving Brain. Discovering Psychology Series. South Burlington, VT: Annenberg/CPB Multimedia Collection.

Being Abraham Maslow. New York, NY: Filmmaker’s Library.

B. F. Skinner and Behavior Change: Research, Practice, and Promise. Champaign, IL: Research Press.

B. F. Skinner: A Fresh Appraisal. San Luis Obispo, CA: Davidson Films. .

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Chapter 2 · Causal Factors and Viewpoints

Dopamine Seduction. Body Story Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Dr. B. F. Skinner: Part 1. Notable Contributors to the Psychology of Personality Series. University Park, PA: Penn State Media Sales.

Dr. B. F. Skinner: Part 2. Notable Contributors to the Psychology of Personality Series. University Park, PA: Penn State Media Sales.

Dr. Carl Rogers: Part 1. Notable Contributors to the Psychology of Personality Series. University Park, PA: Penn State Media Sales.

Dr. Carl Rogers: Part 2. Notable Contributors to the Psychology of Personality Series. University Park, PA: Penn State Media Sales.

Freud: The Hidden Nature of Man. New York, NY: Insight Media.

Inside Information—The Brain and How It Works. Princeton, NJ: Films for the Humanities and Social Sciences.

Mind Talk: The Brain’s New Story. Princeton, NJ: Films for the Humanities and Social Sciences.

Nervous System. New York, NY: Insight Media.

Nikolaas Tinbergen’s Discussion with Richard Evans: Ethology and Genetic Programming vs.

Learning. Notable Contributors to the Psychology of Personality Series. University Park, PA: Penn State Media Sales.

No Place Like Home. Berkeley, CA: University of California Extension Center for Media and Independent Learning.

Pavlov: The Conditioned Reflex. Princeton, NJ: Films for the Humanities and Social Sciences.

Physiology of Behavior. Princeton, NJ: Films for the Humanities and Social Sciences.

Prisoners of the Brain. New York, NY: Insight Media.

The Responsive Brain. Discovering Psychology Series. South Burlington, VT: Annenberg/CPB Multimedia Collection.

Sigmund Freud: His Offices and Home, Vienna, 1938. New York, NY: Filmmakers Library.

States of Mind. The Brain Series. South Burlington, VT: Annenberg/CPB Multimedia Collection.

Teaching Modules: The Brain. South Burlington, VT: Annenberg/CPB Multimedia Collection.

The Two Brains. The Brain Series. South Burlington, VT: Annenberg/CPB Multimedia Collection.

The Unknown Generation X. Princeton, NJ: Films for the Humanities and Social Sciences.

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Chapter 2 · Causal Factors and Viewpoints

A World of Differences: Understanding Cross-Cultural Communication. Berkeley, CA: University of California Extension Center for Media and Independent Learning.

A World of Gestures: Culture and Non-Verbal Communication. Berkeley, CA: University of California Extension Center for Media and Independent Learning.

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Chapter 2 · Causal Factors and Viewpoints

Handout 2.1 Necessary, Sufficient, and Contributory Causes

1. State the etiological process you are analyzing (e.g., serotonin insufficiency in unipolar depression):

2. Give the evidence for and against this (#1 above) being a necessary cause:

3. Give the evidence for and against this (#1 above) being a sufficient cause:

4. Give the evidence for and against this (#1 above) being a contributory cause:

5. Summarize your position on the etiological (causal) status of this process (#1 above):

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CHAPTER 3: Clinical Assessment, Diagnosis, and Treatment Approaches Chapter At-A-Glance Detailed Outline

Instructors’ Resources

Print Supplements

Media Supplements

The Basic Elements in Assessment • The Relationship between Assessment and Diagnosis • Taking a Social or Behavioral History • Ensuring Culturally Sensitive Assessment Procedures

Teaching Objectives 3.1–3.4 Chapter Guide Lecture Launchers 3.2, 3.4, 3.5, 3.6 Activities 3.1, 3.2 Web Links 3.1

Test Bank Grade Aid

CD-ROM PowerPoint

Assessment of the Physical Organism • The General Physical Examination • The Neurological Examination • The Neuropsychological Examination

Teaching Objectives 3.5–3.6 Chapter Guide Lecture Launchers 3.4 Activities 3.7 Web Links 3.6

Test Bank Grade Aid Transparencies T-3

CD-ROM PowerPoint

Psychosocial Assessment • Assessment Interviews • The Clinical Observation of Behavior • Psychological Tests • Advantages and Limitations of Objective Personality Tests

Teaching Objectives 3.7–3.14 Chapter Guide Lecture Launchers 3.3, 3.2, 3.5 Activities 3.3, 3.5, 3.8 Web Links 3.2, 3.5

Test Bank Grade Aid Transparencies T-2

CD-ROM PowerPoint

The Integration of Assessment Data Classifying Abnormal Behavior • Reliability and Validity • Formal Diagnostic Classification of Mental Disorders

Teaching Objectives 3.15–3.22 Chapter Guide Lecture Launchers 3.1, 3.2, 3.3, 3.4, 3.5, 3.6 Activities 3.1, 3.2, 3.4, 3.5, 3.6, 3.7, 3.8 Web Links 3.1, 3.3, 3.4

Test Bank Grade Aid

CD-ROM

An Overview of Treatment

Teaching Objectives 3.23 Chapter Guide Lecture Launchers 3.7, 3.8 Activities 3.9, 3.10, 3.11 Web Links 3.7–3.11 Teaching Objectives 3.31–3.35 Chapter Guide Lecture Launchers 3.9, 3.11 Activities 3.9, 3.10 Web Links 3.7–3.10

Test Bank Grade Aid

CD-ROM PowerPoint

Psychological Approaches to Treatment • Behavior Therapy • Cognitive and Cognitive-Behavioral Therapy • HumanisticExperiential Therapies

Test Bank Grade Aid Transparencies T-26, T-114 to T-116

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Professor Notes

CD-ROM

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Chapter 3: Clinical Assessment, Diagnosis, and Treatment Approaches • Psychodynamic Therapies •Couple and Family Therapy • Eclecticism and Integration

Measuring Success in Psychotherapy • Objectifying and Quantifying Change • Would Change Occur Anyway?

• Can Therapy Be Harmful?

Pharmacological Approaches to Treatment • Antipsychotic Drugs • Antidepressant Drugs • Anti-Anxiety Drugs • Lithium and Other Mood-Stabilizing Drugs • Electroconvulsive Therapy • Neurosurgery Unresolved Issues: • Is There a Bias in the Reporting of Drug Trials?

Teaching Objectives 3.24, 3.25 Chapter Guide Lecture Launchers 3.9–3.11 Activities 3.11, 3.13 Web Links 3.9, 3.10

Test Bank Grade Aid Transparencies T-4 and T-5

Teaching Objectives 3.27–3.30 Chapter Guide Lecture Launchers 3.7, 3.9 Activities 3.12, 3.13 Web Links 3.8, 3.11

Test Bank Grade Aid Transparencies T31 to T-35, T-50, T-51

CD-ROM PowerPoint

Teaching Objectives 3.36 Chapter Guide Lecture Launchers 3.11 Activities 3.12, 3.13 Web Links 3.11

Teaching Objectives 1.

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Identify the purposes of clinical assessment and explain the conditions under which clinical assessment would be most useful.

Describe the types of information sought in a clinical assessment and how the clinician would go about obtaining this information.

Describe how clinicians with different professional orientations might individualize their assessment process.

Explain what is meant by rapport between the clinician and client, and outline the components of a relationship that leads to good rapport.

Summarize the conditions under which a medical evaluation might be necessary.

Describe the various approaches to assessment of physical problems including the general physical examination, the neurological examination, and the neuropsychological examination.

Explain why an individual would receive an EEG, a CAT scan, an MRI, a PET scan, or a functional MRI. List types of psychosocial assessments and explain their appropriate use.

Discriminate between structured and unstructured interviews for the assessment of psychosocial functioning, and evaluate the relative merits of the two.

Discuss various approaches to the clinical observation of behavior and identify the advantages of each.

Explain the importance of rating scales in clinical observations. .

Chapter 3 · Clinical Assessment, Diagnosis, and Treatment Approaches

11.

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Describe the major intelligence tests.

Discuss the advantages and disadvantages of projective personality tests.

Discuss the advantages and disadvantages of objective personality tests.

Discuss the advantages and disadvantages of computerized personality assessment.

Summarize the process of integrating assessment data into a model for use in planning or changing treatment.

Explain the ethical issues involved in assessment.

Explain the purpose and outline the advantages and disadvantages of classification systems for abnormal behavior.

Discuss reliability and validity as they relate to a classification system.

Distinguish between signs and symptoms.

Describe the differing models of classification.

Explain the DSM classification of mental disorders.

Explain how structured clinical interviews may increase reliability of diagnosis.

Provide a general overview of the (a) assumptions and goals of psychotherapy; (b) varied types of individuals who receive psychotherapy; (c) various categories of providers of psychotherapeutic services and their specialized training; (d) critical elements of the therapeutic relationship; and (e) qualities that enhance therapy.

Discuss the many difficulties associated with attempting to evaluate the effectiveness of psychotherapy.

Explain what is meant by negative process, and describe potential deteriorative effects in psychotherapy.

Discuss the methodology as well as the value and limitations of efficacy psychotherapy outcome studies, and other issues related to determining a therapeutic approach.

Summarize the major psychopharmacological treatments currently in use (antipsychotics, antidepressants, antianxiety drugs, and lithium and other mood-stabilizers), discussing their history, major effects, side effects, modes of action, and effectiveness.

Outline the issues associated with the possibility of “cosmetic psychopharmacology” drugs such as Prozac.

Describe early attempts at biological intervention including convulsive therapies and neurosurgery, and indicate which are currently believed to be effective.

Discuss the advantages of combining biological and psychological forms of treatment.

List and describe the basic goals and techniques of the behavior therapies. Summarize recent developments in the behavior therapies and evaluate their effectiveness in the treatment of maladaptive behavior.

List and describe the basic goals and techniques of the cognitive and the cognitive-behavior therapies. Summarize recent developments, and evaluate their effectiveness in the treatment of maladaptive behavior.

List and describe the basic goals and techniques of the humanistic-experiential therapies.

Summarize recent developments in the humanistic-experiential therapies and evaluate their effectiveness in the treatment of maladaptive behavior.

List and describe the basic goals and techniques of psychoanalysis, as well as developments in psychodynamic therapy since Freud. Evaluate the effectiveness of the psychodynamic approach to the treatment of maladaptive behavior.

Describe the basic goals and techniques of martial and family therapy. Summarize recent developments in these therapies, and evaluate their effectiveness in the treatment of maladaptive relationships.

Describe possible biases in drug trials.

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Chapter 3: Clinical Assessment, Diagnosis, and Treatment Approaches

Chapter Overview / Summary Understanding and appropriately treating psychological disorders depends in large part on the adequacy of clinical assessment. The assessment process typically involves interviews, observations, and psychological tests that are then integrated to develop a summary of the client’s symptoms and problems. Assessment results are frequently used to establish a baseline of client behavior from which subsequent behavior can be judged, and they are used in the process of clinical diagnosis; that is, classifying a disorder according to a clearly defined system such as the DSM-IV TR or the ICD-10.

Even after this initial assessment and diagnosis, continued assessment is critical to determine the course and effectiveness of treatment procedures.

There are several basic elements of clinical assessment. Identification of the presenting problem or the major symptoms and behavior is most likely the first step in the assessment process. Providing a diagnosis may assist in treatment planning and may be required for insurance purposes. Clinically, assessment will most likely involve collecting information about the client’s social or behavioral history, personality factors, and the social context in which behaviors occur. The precise nature of the information collected will of course depend on the nature of the presenting problem. The Ethics Code of the American Psychological Association recommends that psychologists consider various test factors, test-taking abilities, and other characteristics of the person being assessed, such as situational, linguistic, and cultural differences that might affect his or her judgments or reduce the accuracy of his or her interpretations. Because a wide range of factors may contribute to maladaptive behavior, assessment may also include medical evaluation. A general medical examination may be followed by a more comprehensive neurological examination that could involve neuropsychological testing or, in some circumstances, neurological tests—such as an EEG or a CAT, PET, or MRI scan—to aid in determining the site and extent of organic brain disorder.

Psychosocial assessment methods focus on providing realistic pictures of how the clients interact with their social environment. Data is gathered allowing the clinician to form hypotheses that are confirmed, modified, or discarded as the clinician proceeds. The most widely used and most flexible psychosocial assessment methods are the clinical interview and behavior observation. These methods provide a wealth of clinical information and can vary from highly structured and reliable procedures to more unstructured and less reliable procedures.

Psychological tests represent a more indirect method of assessing psychological characteristics.

The tests used by psychologists compare the client’s responses to standardized stimuli with the responses of other people with similar demographic characteristics, usually through established test norms or test score distributions. For all psychological tests, the competence of the person administering, scoring, and interpreting the test will dictate their value. This issue becomes even more important when computerized administration, scoring, and interpretation of psychological tests have become widespread.

Psychological tests can be divided into two major categories: intelligence tests and personality tests. The most common intelligence tests are the individually administered Wechsler scales (WISC-III and WAIS-III) and the Stanford-Binet Intelligence Scale. Personality tests can be subdivided into two additional categories based on their approach: (1) projective tests, such as the Rorschach, in which unstructured stimuli are presented to a subject, who then projects meaning or structure on to the stimulus, thereby revealing hidden motives, feelings, and so on; and (2) objective tests, or personality inventories, in which a subject is required to read and respond to itemized statements or questions.

Objective personality tests, such as the MMPI-2, provide a cost-effective, reliable, and valid means of collecting a great deal of personality information rapidly.

Once assessment data are collected, their significance must be interpreted so that they can be integrated into a diagnosis or treatment plan. In evaluating test results, several factors must be considered: potential cultural bias of the instrument or the clinician, theoretical orientation of the 46

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Chapter 3 · Clinical Assessment, Diagnosis, and Treatment Approaches

clinician, underemphasis on the external situation, insufficient validation, and inaccurate data or premature evaluation.

Assessment also allows clinicians to engage in classification. Classification aids in communication, research, gathering statistics, and meeting the needs of insurance companies.

Classification, however, is a constantly evolving process subject to human error.

All classification systems depend on reliability and validity. There are two major classification systems used today. One, the ICD-10, is used widely in Europe. The DSM-IV-TR is used in the United States. Both systems are similar in that they focus on symptoms and define problems into different facets. In the DSM-IV-TR, for example, behavior can be diagnosed along five axes. Although the DSM system is standard in the United States, there are many doctors who do not like providing any diagnosis for a client. One of the major objections to any such diagnostic classification is the problem of labeling.

In the final analysis, any such classification should be seen only as a first step, subject to revision, in the overall process of understanding and treating abnormality.

Treatment may be broadly grouped into two categories: psychological treatment (psychotherapy) and biologically based treatment (medications, ECT, and neurosurgery). Many approaches to psychological treatment have been developed to treat individuals with psychological disorders.

Behavior therapy is extensively used to treat many clinical problems. Behavior therapy approaches include exposure, aversion therapy, modeling, and reinforcement approaches including token economies. Behavioral activation therapy has been shown to be an effective treatment for depression.

Cognitive or cognitive-behavioral therapy attempts to modify a person’s self-statements and construal of events to change his or her behavior. Cognitive-behavioral methods have been used for a wide variety of clinical problems—from depression to anger control—and with a range of clinical populations. Two of the most studied approaches include Ellis’ rational emotive behavior therapy and Beck’s cognitive therapy. The efficacy of Beck’s cognitive treatment methods has been well documented.

Humanistic-experiential therapies emerged after WWII and are based on the assumption that we have the freedom and the responsibility to control our own behavior. Roger’s client centered approach focuses on helping clients to become able to accept and be themselves. Gestalt approaches emphasize the unity of mind and body. Process-experiential therapy is a relatively new approach developed by Greenberg that combines Roger’s client-centered approach and Gestalt therapy. This therapy emphasizes the experiencing of emotions during therapy. Humanistic concepts have been influential within psychology but the treatment approaches have been criticized for their vagueness and past lack of outcome data.

One of the oldest approaches to psychological treatment, classical psychoanalysis, was originated a century ago by Sigmund Freud. Classic psychoanalysis involves four basic techniques: free association, dream analysis, analysis of resistance, and analysis of transference. Due to its expense, traditional psychoanalysis is rarely practiced today. As research on treatment outcomes becomes more common, there is some evidence that some psychoanalytic approaches may show promise for some disorders.

In addition to individual treatment approaches, some psychological treatment methods are applied to problematic relationships through couple or family therapy. These approaches typically assume that people’s problems lie partly in their interactions with others. Consequently, the focus of treatment is to change ways of interacting among individuals in the social or family context.

Rather than adhering to any individual approach to therapy, many therapists today might describe themselves as eclectic or as integrating several approaches. Examples include multimodal therapy and interpersonal therapy.

Evaluating the effectiveness of treatment can be difficult. Common sources of information to assess efficacy include: therapist’s impressions, clients’ reports of change, reports from clients’ family .

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and friends, comparison of pretreatment and post-treatment scores on personality tests, and measure of change on selected overt behaviors. It is increasingly important to objectify and quantify change as a function of therapy. Although some individuals improve with no treatment, it is clear that therapy can accelerate improvement or change behaviors that would not have improved without therapy. However, 5 to 10% percent of clients deteriorate in therapy perhaps due to a mismatch between the therapist and client or due to boundary violations.

Medications are also important in the treatment of many disorders. It is now common clinical practice for medication and psychological treatments to be combined. The most commonly used antipsychotic medications are the atypical neuroleptics. These improve both positive and negative symptoms and have fewer extrapyramidal symptoms (unwanted movement side effects) than do conventional antipsychotics. Some of the earlier antidepressant medications (e.g., tricyclics and monoamine oxidase inhibitors) have now been replaced by SSRIs and SNRIs. In general, antidepressants work through their influence on the serotonin and norepinephrine neurotransmitter systems. Anxiolytic medications work via their effect on the GABA system to decrease anxiety. They are widely prescribed. Lithium is an important medication in the treatment of mania. However, some of the newer mood stabilizing drugs (that also treat epilepsy) are now more frequently used. Although not frequently used, ECT is a safe and effective treatment for depression and other disorders. It causes some short-term cognitive side effects, especially when administered bilaterally. Neurosurgery today involves the selective destruction of minute areas of the brain but may lead to long-term difficulties with frontal lobe dysfunction. Deep brain stimulation is a new treatment approach that appears to hold promise for depression.

Detailed Lecture Outline I.

II.

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The Basic Elements in Assessment A. The Relationship between Assessment and Diagnosis 1.

Formal diagnoses are needed for insurance purposes 2.

Planning for treatment follows from diagnosis 3.

It is essential for administrative purposes B. Taking a Social or Behavioral History 1.

Personality factors a.

Descriptions of long-term personality characteristics are included b.

How has the person responded to different situations?

2.

The Social Context a.

Environmental stressors and supports are identified b.

Conflicting information integrated leading to understanding of what may drive the person (what some call a dynamic formulation) c.

Hypotheses about future behavior are derived d.

Decisions about treatment are made with consent of the client e.

Varying types of assessment data depending on nature of problems f.

Coordination of physical, psychological, and environmental procedures is needed in assessment C. Ensuring Culturally Sensitive Assessment Procedures 1.

Psychologist must be culturally competent 2.

Must consider situational, linguistic, and cultural differences Assessment of the Physical Organism A. The General Physical Examination 1.

A medical history is obtained

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Chapter 3 · Clinical Assessment, Diagnosis, and Treatment Approaches

2.

III.

This medical exam is needed when presenting problems include physical symptoms, especially when clients may be experiencing somatoform, addictive, or organic brain disorders 3.

Such medical exams may eliminate costly and ineffective treatments B. The Neurological Examination 1.

Anatomical brain scans a.

Computerized axial tomography (CAT scan) can reveal diseased parts of the brain. Technique involves computer analysis of x-rays. b.

Magnetic resonance imaging (MRI) allows visualization of the interior of the brain. Images are typically much sharper with the MRI and the MRI is less complicated to administer and does not expose the client to ionizing radiation. Only major problem is that some clients have a claustrophobic reaction.

2.

PET scans: A metabolic portrait a.

Positron emission tomography (PET scan) appraises how an organ is functioning rather than simply the anatomical structure like those above.

PET scans work by tracking natural compounds such as glucose as they are metabolized. Unfortunately, the pictures produced are of low-fidelity and the equipment is fairly expensive.

3.

The functional MRI (fMRI) measures changes in local oxygenation of specific areas of brain tissue allowing a “map” of brain activity to be developed. This technique may lead to more detailed information of how psychological disorders develop, but at this time there are significant problems with the procedure.

C. The Neuropsychological Examination 1.

Measurement of alteration in behavioral or psychological functioning involves neuropsychological assessment 2.

Neuropsychologists may administer a standard test battery or, more frequently, administer a highly individualized array of tests depending on the particular client’s problems.

Psychosocial Assessment A. Assessment Interviews 1.

Structured interviews a.

Reliability increases with structured interviews b.

Follow predetermined set of questions c.

May take longer than unstructured interviews and the level of detail may be frustrating to clients 2.

Unstructured Interviews a.

Typically subjective and do not follow a predetermined set of questions b.

May be viewed by clients as more sensitive to their needs c.

Spontaneous follow-up questions may result in information that would not have been uncovered in a structured interview d.

Interviews are subject to error as they rely on human judgment B. The Clinical Observation of Behavior 1.

Direct observation a.

Should occur ideally in the natural environment b.

Self-monitoring or self-observations and objective reporting of behavior are often used in the natural environment c.

The client can be an excellent source of information 2.

Rating scales help to organize observations and increase reliability .

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a.

IV.

50

Ratings may be made not only as part of an initial evaluation but also to check on the course or outcome of treatment b.

The Brief Psychiatric Ratings Scale (BPRS) is widely used to record observations for clinical research c.

Comparisons to other clients’ symptoms can be made C. Psychological Tests 1.

Intelligence tests a.

Wechsler Intelligence Scale for Children – Revised (WISC-IV) b.

Stanford-Binet Intelligence Scale c.

Wechsler Adult Intelligence Scale – Revised (WAIS-III) d.

These tests are used when detailed information about cognitive functioning is required 2.

Projective personality tests a.

Underlying assumption in using projective techniques is that people project their own problems, motives and wishes onto the vague, unstructured stimuli b.

The Rorschach Inkblot Test c.

The Thematic Apperception Test (TAT) d.

Sentence Completion Test e.

Interpretation of these tests is generally subjective, unreliable, and difficult to validate f.

Administering and scoring these tests is frequently time consuming and requires advanced skills 3.

Objective personality tests a.

More structured than projective techniques leading to greater precision b.

The Minnesota Multiphasic Personality Inventory MMPI is the most widely used personality test in the United States c.

The clinical scales of the MMPI were developed through empirical keying d.

Clinical scales measure tendencies to respond in psychologically deviant ways e.

Validity scales designed to detect whether a patient has answered the questions in an honest manner f.

Special problem scales have also been developed g.

Criticisms of the MMPI led to MMPI-2 D. Advantages and Limitations of Objective Personality Tests 1.

Advantages include being cost-effective, highly reliable, and objective 2.

Disadvantages include some believing they are too mechanistic to portray the complexity of human behavior and the tests require the client to be literate and cooperative The Integration of Assessment Data A. Integration of assessment data prior to treatment allows the clinician to formulate a plan for treatment and allows for the discovery of gaps or discrepancies in knowledge about the client B. Additional assessment data collected during treatment can allow clinician to determine how effective treatment is and allow for modification to improve success C. When evaluating test results, must keep in mind several factors.

1.

Potential cultural bias of the instrument or the clinician 2.

Theoretical orientation of the clinician 3.

Underemphasis on the external situation .

Chapter 3 · Clinical Assessment, Diagnosis, and Treatment Approaches

V.

VI.

VII.

4.

Insufficient validation 5.

Inaccurate data or premature evaluation Classifying Abnormal Behavior A. Classification allows communication, improves research, and is required by many insurance companies for reimbursement B. Classification systems are ongoing works-in-progress as new knowledge allows more precision C. Reliability and Validity 1.

Reliability is the degree to which a measuring device produces the same results each time it is used to measure the same thing 2.

Validity is the extent to which a measuring instrument actually measures what it is supposed to measure D. Formal Diagnostic Classification of Mental Disorders 1.

Two major systems in use today are the International Classification of Disease System (ICD-10), used mainly in Europe, and the Diagnostic and Statistical Manual of Mental Disorders (DSM), used mainly in the United States 2.

Criteria used consist of symptoms (subjective description of the client) and signs (objective observations) 3.

Limitations of the DSM classification system still exist especially in relation to the artificial, categorical system adopted 4.

The five axes of DSM-IV-TR a.

Axis I, clinical syndromes b.

Axis II, personality disorders and mental retardation c.

Axis III, general medical conditions relevant to understanding or managing the case d.

Axis IV, psychosocial and environmental problems during the past year e.

Axis V, global assessment of functioning 5.

Main categories of Axis I and Axis II disorders 6.

Labeling may lead to the closing off of further inquiry, create preconceptions about people, or even lead people to act in ways consistent with their view of how a person with that label “should” act An Overview of Treatment A. Belief that people can change underlies all psychotherapy B. Several hundred therapeutic approaches exist although managed care has prompted new and increasingly stringent demands that the efficacy of treatment be demonstrated Psychosocial Approaches to Treatment A. Behavior Therapy 1.

Exposure therapy a.

Widely used in the treatment of anxiety disorders b.

Involves guided exposure to anxiety-provoking stimuli; can be accomplished slowly (systematic desensitization) or quickly (flooding) either in vivo (real) or imaginal 2.

Aversion therapy a.

Punishment is used to modify behavior b.

Most commonly used aversive stimuli used today are drugs that have noxious effects such as Antabuse 3.

Modeling a.

Behavior is learned by imitating others b.

Modeling is combined with instruction .

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4.

B.

C.

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Systematic use of reinforcement a.

Often referred to as contingency management b.

Must first identify and remove reinforcing contingencies maintaining maladaptive behavior and then replace and reinforce more adaptive behavior 5.

Token economies a.

Originally developed for use with chronic psychiatric inpatients b.

Patients earned tokens that could later be exchanged for rewards or privileges 6.

Evaluating behavior therapy a.

Distinct advantages over other treatments (1) Achieves results quickly (2) Lower costs (3) Methods clear and can be readily evaluated (4) Proven effective b.

Works better with some types of problems c.

Effectiveness of behavioral activation therapy with depression Cognitive and Cognitive-Behavioral Therapy 1.

Rational - Emotive behavior therapy a.

Ellis’s attempt to change maladaptive thought processes b.

Irrational beliefs are at the core of maladjustment c.

Beliefs are reconstructed through several techniques including rational confrontation and behaviorally oriented techniques 2.

Beck’s cognitive therapies a.

Originally developed for depression but later extended to anxiety disorders, eating disorders and obesity, conduct disorder in children, personality disorders, and substance abuse b.

Information processing model of psychopathology; problems result from biased processing of external events or internal stimuli leading to cognitive errors c.

Taught connection between thinking and emotional responses; identify automatic thoughts and logical errors d.

Clients gather information about themselves and then are assigned tasks to test their hypotheses e.

The precise underlying automatic thoughts and accompanying dysfunctional schemas vary from one disorder to another 3.

Evaluating cognitive-behavioral therapies a.

Rational emotive therapy has not been shown to be an effective treatment approach b.

Beck’s type of therapy is extremely effective for many disorders (1) Comparable to medication for depression; better than medication at preventing relapse (2) Panic disorder, bulimia, personality disorders, conduct disorders in children, substance abuse, and generalized anxiety disorder c.

Combined use of cognitive and behavioral techniques quite common Humanistic-Experiential Therapies 1.

Client-centered therapy a.

The primary objective is to resolve incongruence—help clients accept and be themselves .

Chapter 3 · Clinical Assessment, Diagnosis, and Treatment Approaches

b.

D.

Nondirective techniques such as empathic reflecting or restatement of the client’s description of life difficulties are used c.

Psychological climate of acceptance is created d.

Self-concept becomes congruent with actual experiences e.

Pure client-centered therapy is rarely used today in North America although it is popular in Europe 2.

Gestalt therapy a.

Fritz Perls developed this therapy b.

Gestalt means whole; therapy emphasizes the unity of mind and body— integrating thought, feeling, and action c.

Goal is to increase self-awareness and self-acceptance d.

Commonly used in a group setting but emphasis is on one person at a time e.

Dreams are thought to be representations of the dreamer’s self 3.

Process-Experiential therapy a.

Combines client-centered and Gestalt therapy b.

Developed by Greenberg and his colleagues c.

Emphasizes the experiencing of emotions during therapy; clients also reflect on their emotions and are encouraged to create meaning from them d.

Therapist plays a more active role 4.

Evaluating humanistic-experiential therapies a.

Have influenced contemporary views of human nature and good psychotherapy b.

Criticized for lack of agreed-upon therapeutic procedures and vagueness c.

Research in past lacking; newer research suggests these approaches may be helpful for depression, anxiety, trauma, and marital difficulties Psychodynamic Therapies 1.

Freudian psychoanalysis a.

Free association b.

Analysis of dreams (1) Manifest content (2) Latent content c.

Analysis of resistance (1) Prevents talking about painful experiences (2) “Forgetting” is employed by client d.

Analysis of transference (1) React as to a person from the past (2) Recognize transference and provide insight (3) Transference neurosis (4) Counter-transference e.

Psychodynamic therapy since Freud (1) Practiced only rarely (2) May take several years; very costly in time, money, and emotional commitment 2.

Object relations, Attachment-based approaches, and Self - psychology a.

In psychodynamic jargon, objects are other people b.

Procedures focus on interpersonal relationship issues, particularly as they play themselves out in the client-therapist relationship 3.

Evaluating psychodynamic therapy

.

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a.

VIII.

54

Classical psychoanalysis is time-consuming, expensive, based on questionable approach, neglects a person’s immediate problems, and, in the past, lacked proof of effectiveness b.

Newer studies suggest that approach may still be of benefit c.

Newer, brief versions of psychodynamic-interpersonal therapies show some efficacy (1) Kernberg’s transference-focused psychotherapy for borderline personality disorder (2) Additional research underway E. Couple and Family Therapy 1.

Couple therapy a.

Growing field b.

Gold standard is Traditional Behavioral Couple therapy: based on a social learning model; established as empirically effective c.

Integrative Behavioral Couple Therapy focuses on acceptance rather than change; preliminary findings are quite positive 2.

Family therapy a.

Developed from fact that many patients relapse when returned to their families b.

Structural family therapy, developed by Minuchin, is based upon systems theory and focuses on changing the organization of the family F. Eclecticism and Integration 1.

Different schools of thought used to be in great opposition; relaxation of boundaries has taken place 2.

Multimodal therapy 3.

Interpersonal therapy developed by Klerman, Weissman, and colleagues Measuring Success in Psychotherapy A. Assessing treatment change typically depends on one or more of the following sources: 1.

Therapist’s impression 2.

Client’s self-report 3.

Report from the client’s family or friends 4.

Comparison of pre- and post-treatment scores 5.

Measures of change in certain selected overt behaviors B. Objectifying and Quantifying Change 1.

Generalized terms such as recovery, marked improvement, and moderate improvement are open to interpretation 2.

Today, focus is on the use of more quantifiable methods of measuring change C. Would Change Occur Anyway?

1.

Improvement takes place without professional help 2.

Some disorders have a specific brief course 3.

Treatment accelerates change or provides change where none would likely occur without treatment 4.

50% of patients show clinical improvement after 21 sessions; 75% after 40 sessions D. Can Therapy Be Harmful?

1.

5 to 10% of patients deteriorate during treatment; highest rates among borderline personality disorder and obsessive-compulsive disorder 2.

In some cases, a mismatch between the therapist and the client is the likely problem .

Chapter 3 · Clinical Assessment, Diagnosis, and Treatment Approaches

3.

IX.

Boundary violations, such as sex between therapist and patient, is unethical and nearly always destructive Biological Approaches to Treatment A. Antipsychotic Drugs 1.

Alleviate or reduce the intensity of delusions and hallucinations in 60% of patients by blocking dopamine receptors 2.

Problematic side effects including tardive dyskinesia 3.

Atypical antipsychotic medications such as clozapine (Clozaril) and olanzapine (Zyprexa) reduce the incidence of movement-related side effects and may effectively treat both positive and negative symptoms of schizophrenia B. Antidepressant Drugs 1.

Selective serotonin re-uptake inhibitors (SSRIs) a.

A second generation of drugs (Prozac) has appeared that increases the availability of serotonin by blocking the re-uptake process b.

Pharmacological treatment often produces dramatic results within three to five weeks; at least a 50% improvement in symptoms c.

Better tolerance and fewer side effects than tricyclics; not more effective than prior drugs d.

SNRIs, such as venlafaxine (Effexor) and duloxetine (Cymbalta), block the re-uptake of both serotonin and norepinephrine and seem to help those who have not responded well to other antidepressants 2.

Monoamine oxidase inhibitors (MAOIs) a.

Infrequently used now b.

Inhibit the activity of monoamine oxidase c.

Patients must avoid foods rich in the amino acid tyramine, limiting clinical usefulness 3.

Tricyclic antidepressants (TCAs) a.

Inhibit the re-uptake of norepinephrine and serotonin b.

They alter a number of aspects of cellular functioning, including how neurons function and how cells respond to activation of receptors and the synthesis of neurotransmitters 4.

Other antidepressants a.

Trazodone first antidepressant introduced in U.S. not lethal on overdose b.

Bupropion (Wellbutrin) increases noradrenergic function but does not inhibit sexual functioning as do many of the SSRIs C. Antianxiety Drugs 1.

Benzodiazepines a.

These are widely prescribed by physicians b.

Benzodiazepines are used as sleeping pills and diminish generalized fear c.

The potential for abuse is significant; patients must be weaned gradually due to serious withdrawal symptoms d.

Relapse rates are extremely high e.

Believed to work by enhancing the activity of GABA receptors 2.

Other Anti-Anxiety Drugs—Buspirone (Buspar) a.

Completely unrelated to the benzodiazepines and is thought to act on serotonin rather than GABA b.

Those who have previously taken benzodiazepines do not respond as well to Buspirone c.

Low potential for abuse; has no sedative or muscle-relaxing properties .

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D.

E.

F.

56

d.

Major drawback is that it takes two to four weeks to show symptom relief Lithium and Other Mood-Stabilizing Drugs 1.

Lithium (marketed as Eskalith and Lithobid) a.

Biochemical mechanism unknown; thought to alter neurotransmitter systems b.

70–80% effective in resolving manic states; maintenance treatment may be less reliable at preventing future episodes than once thought although discontinuation is very risky with relapse rates twenty-eight times higher after withdrawal c.

Side effects include increased thirst, GI difficulties, weight gain, tremor, and fatigue; can be toxic if recommended dose is exceeded 2.

Other mood-stabilizing drugs a.

Other first-line drugs for bipolar disorder include divalproic acid (Depakote) and carbamazepine (Tegretol) b.

Tegretol associated with significant side effects: blood problems, hepatitis, and serious skin conditions; careful blood monitoring required c.

Depakote has the fewest and mildest side effects: nausea, diarrhea, sedation, tremor, and weight gain d.

Abilify, an antipsychotic medication, is also now being marketed for bipolar disorder Electroconvulsive Therapy 1.

Dates back to Paracelsus (1493–1591), who induced a patient to drink camphor until he experienced convulsions 2.

Von Meduna generally regarded as modern originator of this treatment approach who made the erroneous observation that schizophrenia rarely occurred in those with epilepsy 3.

Chemical methods (camphor, Metrazol, and insulin) provided no control over the induction and timing of convulsions 4.

Cerletti and Bini (1938) tried passing an electric current through a patient’s head to induce convulsions 5.

ECT still engenders controversy 6.

Results indicate that ECT can be safe and effective especially for a.

Severely depressed pregnant women b.

Elderly depressed patients c.

Severely depressed and suicidal patients who have failed to respond to other treatments d.

Patients with manic disorders who have not responded to treatment (80% effective) 7.

Can be administered in two ways: bilateral (more effective but associated with more severe cognitive side effects—memory problems) and unilateral 8.

Amnesia always occurs for period immediately preceding the therapy and the patient may be confused for the next hour or so Neurosurgery 1.

Prefrontal lobotomy was developed by Moniz 2.

Tens of thousands of patients received the procedures from 1935 to 1955 despite deaths (1–4%) and undesirable side effects 3.

Introduction of antipsychotic drugs led to an immediate decrease in psychosurgery

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Chapter 3 · Clinical Assessment, Diagnosis, and Treatment Approaches

4.

X.

Current practice is more circumspect than years ago in that it is used only as a last resort and involves the selective destruction of minute areas of the brain 5.

Today most commonly used for debilitating obsessive compulsive disorders, treatment-resistant severe self-mutilation, and intractable anorexia nervosa 6.

Deep brain stimulation is a new technique that does not lead to permanent brain lesions Unresolved Issues A. Is There Bias in the Reporting of Drug Trials 1.

Researchers may receive money from pharmaceutical industry 2.

Perlis and colleagues examined all clinical drug trials reported in four of the most prestigious psychiatry journals 3.

60% funded by pharmaceutical industry; in 47% of cases author had a financial conflict of interest 4.

Positive findings not associated with who funded the research 5.

There was an association between author conflict of interest and positive results

.

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Key Terms acute (p. 90) anti-anxiety drugs (p. 107) antidepressant drugs (p. 103) antipsychotic drugs (p. 102) behavior therapy (p. 91) behavioral activation (p. 92) Brief Psychiatric Rating Scale (BPRS) (p. 81) chronic (p. 90) clinical diagnosis (p. 75) client-centered therapy (p. 94) cognitive/cognitive-behavioral therapy (p. 92) computerized axial tomography (CAT scan) (p. 77) counter-transference (p. 97) couple therapy (p. 94) cultural competence (p. 76) dysrhythmia (p. 77) electroconvulsive therapy (ECT) (p.109) electroencephalogram (EEG) (p. 77) episodic (p. 90) family therapy (p. 99) flooding (p. 91) forensic (p. 84) free association (p. 97) functional MRI (fMRI) (p. 78) Gestalt therapy (p. 95) imaginal exposure (p. 91) intelligence test (p. 81) integrative behavioral couple therapy (p. 99) in vivo exposure (p. 91) latent content (p. 97) magnetic resonance imaging (MRI) (p. 78) manifest content (p. 97) mild (p. 90) Minnesota Multiphasic Personality Inventory (MMPI) (p. 84) modeling (p. 91) moderate (p. 90) neuropsychological assessment (p. 79) neurosurgery (p. 110) objective personality tests (p. 84)

58

personality tests (p. 82) positron emission tomography (PET scan) (p. 78) presenting problem (p. 75) projective personality tests (p. 82) psychodynamic therapy (p. 96) psychopharmacology (p. 102) psychotherapy (p. 90) rating scales (p. 81) rational emotive behavior therapy (REBT) (p. 92) recurrent (p. 90) reliability (p. 88) resistance (p. 97) response shaping (p. 92) Rorschach Inkblot Test (p. 82) self-monitoring (p. 80) sentence completion test (p. 83) severe (p. 90) signs (p. 88) structural family therapy (p. 99) structured assessment interview (p. 80) symptoms (p. 88) systematic desensitization (p. 91) tardive dyskinesia (p.103) Thematic Apperception Test (TAT) (p. 83) token economy (p. 92) traditional behavioral couple therapy (p. 94) transference (p. 97) unstructured assessment interview (p. 80) validity (p. 88)

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Chapter 3: Clinical Assessment, Diagnosis, and Treatment Approaches

Lecture Examples / Discussion Topics Lecture Launcher 3.1: Cultural Formulation and Culture-Bound Syndromes DSM-IV-TR gives an appendix of information about multicultural aspects of diagnosis. It is divided into two sections. The first section is an “outline for cultural formulation” that is intended to supplement the multiaxial diagnostic assessment and to address complexities that arise when applying DSM-IV criteria in a multicultural environment. It systematically reviews peoples’ cultural backgrounds, the role of cultural context in symptomatology, and also cultural differences between the patient and clinician. The second section is a glossary of “culture-bound syndromes.” For instance, hwa-byung (also known as wool-hwa-byung) is a Korean folk syndrome attributed to the suppression of anger. Its symptoms include insomnia, fatigue, panic, fear of impending death, dysphoric affect, indigestion, anorexia, dyspnea, palpitations, generalized aches and pains, and a feeling of a mass in the upper-middle region of the abdomen. What aspects of culture are diagnostically important to consider? How about gender?

What customs or behaviors do your students have that might be perceived as odd to others? What about them separates them from actual symptoms of psychopathology? Should different criteria, cutoffs, or standards be applied when diagnoses are made of different cultural groups? Would this inappropriately eliminate genuine group differences?

Lecture Launcher 3.2: Too Much Information Clinicians are sometimes reluctant to disclose to their clients all the information gathered during a comprehensive assessment. In fact, they are usually taught to release only summary information and to retain raw data, unless communicating with a professional who is trained to interpret the raw data. Do you think withholding information is sensible? How about information that is not germane to the treatment? Imagine a client presenting for treatment of depression who scores high on a measure of paranoia, though not reaching a clinical level. Is it worth expending session time disclosing this information and explaining its meaning to the client, or would it be best to focus on other things? If you were this client, would you want to know everything learned in the assessment? How do you balance the client’s right to know against the expense of communicating information that may not be useful, especially when the meaning of some test scores requires substantial education to grasp (indeed, entire graduate-level courses are necessary to understand scores well)?

Lecture Launcher 3.3: Is Everybody a Little Crazy?

According to most reports, as many as 46% of Americans will be diagnosed with a psychological disorder during their lifetime. This figure does not include people with symptoms of a disorder who do not receive a diagnosis. Are psychological disorders being over-diagnosed? Have the criteria for psychological disorders become so broad that anyone can be seen as having a disorder?

Lecture Launcher 3.4: Can You Treat without Knowing the Cause of a Disorder?

Inasmuch as DSM is atheoretical, making a DSM diagnosis does not tell one what caused the diagnosed disorder. This situation is quite different from many medical diagnostic situations, in which diagnoses are made only once etiology is known (e.g., positive test for Strep infection). An etiologically informed diagnosis has obvious advantages over etiologically silent ones when it comes to choosing a course of treatment, but etiology is not always necessary for successful treatment, even of biological conditions.

“Take two aspirin and call me in the morning” is often pretty effective. And often treatments are so general the specific nature of the condition need not be established before prescribing one (e.g., antibiotics). Essentially, the implication is that DSM disorders, like depression, can be successfully treated without knowing exactly what caused them. The disconnection between treatment and etiology can be further emphasized by asking whether a headache is an aspirin deficiency. .

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Lecture Launcher 3.5: What Do You Do If…?

Ethical principles seem relatively straightforward to students until they try to apply the principles.

Beginning the lecture with an overhead transparency or PowerPoint slide with the following questions facilitates students learning how to apply these principles: What should I do if clients tell me they are being abused? What should I do if clients tell me they are suicidal? What should I do if clients tell me that their children are being abused? What should I do if clients want me to reveal their IQ scores? What should I do if clients refuse to take tests? What should I do if clients want testing that I don’t know how to give? What should I do if the parents of clients insist on tests unrelated to the clients’ problems? What should I do if the computer-generated reports don’t match my own interpretations of the tests? What should I do if I believe clients need particular tests but their insurance companies refuse to pay for it?

Lecture Launcher 3.6: What’s Right and What’s Wrong with Diagnosis?

It is said that nobody likes to be pigeon-holed, but that is what a diagnosis does. Clearly, any time an object or person is assigned to a category there is a loss of information about that object or person. The rest of the course is predicated upon the acceptance of the idea that for most purposes the benefits of diagnosis outweigh their costs. Nevertheless, it is a good idea to spend some time early in the course recognizing these costs and benefits. Avoid putting up a list of costs and benefits for the class to copy down. Instead, lead the class to see them for themselves by asking students to offer some.

Lecture Launcher 3.7: Designer Personalities?

Prozac and Valium are widely used by people not diagnosable with mental disorders. Should drugs be developed to make healthy people feel “better than well”? Would you take such a drug? Would you give your children a drug to make them behave “better” if they were not necessarily “ill”? What do you think about “designer personalities”? PBS’s Frontline produced the film Welcome to Happy Valley on this very topic. The film is about “the Prozac capital of the world,” Wenatchee, Washington, where the “Pied Piper of Prozac,” Dr. Jim Goodwin, says Prozac is “probably less toxic than salt” and has had it prescribed for all seven hundred of his patients.

Lecture Launcher 3.8: Barriers to Seeking Treatment Consistently, men are reported as being more reluctant to seek therapy than women. What factors might explain these differences? If the effectiveness of therapy requires the client to disclose personal information and to express emotion, and if this is something that males are socialized not to do, does it follow that males are at a distinct disadvantage in therapy? In other words, might the therapy environment be tailor-made for females, and an environmental mismatch for males? Encourage students to develop a plan to encourage more men to seek therapy. What would “male-friendly” therapy look like?

Lecture Launcher 3.9: Is It Ethical to Withhold Treatment?

Much of the evidence supporting the effectiveness of various forms of treatment comes from randomized, controlled treatment trials in which treated subjects are compared to nontreated control subjects. As a matter of research design, the desirability of withholding treatment in order to provide proper controls for the mere passage of time is easy to appreciate. However, a significant treatment effect also proves that symptoms evidenced by those in the control group were prolonged by the delay in providing treatment. What are the ethical issues arising in treatment studies of this sort? How might they be avoided or at least mitigated to some reasonable extent? How would students in the class like to be handled were they to become candidates to participate in such a study? What are the costs and benefits to individual research subjects and to society? Are they worth it? What if it were lives at stake rather than emotional disorders?

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Lecture Launcher 3.10: Where Are the “Chemical Imbalance” Test Results?

People who take medications for their emotional problems are often told that the medications correct a “chemical imbalance in the brain.” It seems reasonable, then, to examine the test results showing this chemical imbalance and to monitor the “balance” regularly to ensure it is corrected by the medications being taken. However, this is not the case. Instead, diagnoses are based on symptoms and the chemical imbalance is inferred. It might be argued that the research has already established chemical imbalances underlying these symptoms. If that were the case, then the tests the researchers used to look at the chemical imbalances would be used by practicing clinicians for diagnostic purposes. The fact is that there are no such tests—not for researchers and not for clinicians. As a specific example, SSRIs clearly block re-uptake of serotonin, and they alleviate symptoms of depression, but there is no way to determine whether any individual person’s serotonin transmission is abnormal. This is not to say medications do not work. On the contrary, it is clear that they do. The point is simply that they are much less well understood than the accounts for their effectiveness might lead one to believe.

Lecture Launcher 3.11: The Dose-Effect Relationship in Psychotherapy The concept of dosage is clear when medications are considered, but there is also a dose concept that applies to psychotherapy. In a classic investigation, Howard and his colleagues (1986) studied the relation between psychotherapy effects and the number of therapy sessions. Among the findings were indications that one third of psychotherapy clients improved after three sessions, half improved after eight sessions, and three fourths improved by twenty-six sessions. There were also effects related to diagnostic category. Depressed clients improved most quickly, anxiety disordered clients took longer, and psychotic clients took longer still. Data such as these have been used by managed care companies to establish session limits on psychotherapy insurance benefits. Is that reasonable? In what ways is it not reasonable? Do medical benefits terminate when they are not effective in a timely fashion? How might a variation on empirically guided session limits be crafted that balances economics with care?

Demonstrations / Activities Activity 3.1: What’s My Diagnosis?

A classic Abnormal Psychology activity, which is as entertaining as it is educational, is to pin diagnoses on students’ backs and have them interview others until they discover what they have. “Would I likely be taking medication or be hospitalized at some point?” “Are my symptoms more emotional, behavioral, perceptual, or cognitive?” Once students have a little experience with this exercise they are in a better position to talk about what a standard set of questions might look like for use in making efficient diagnoses in a structured manner with a wide variety of people.

Activity 3.2: What Is “Abnormal”?

The most fundamental issue for students of Abnormal Psychology is the delineation of the scope of the topic. That is, where do you draw the line between normal and abnormal? DSM contains one such definition, and others appear in various scholarly journals. Nevertheless, the issue is far from settled, and this seemingly innocuous question can quickly turn into a very lively debate about the abnormality of various behaviors. Stepping into traffic is abnormal but sky-diving or willingly going into combat is not?

Why is hyposexuality abnormal but hypersexuality not? What about the person who has strange .

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thoughts and perceptions but does not disclose them to others, or does so only through critically acclaimed art? Or people who are geniuses in a field like science or music but are interpersonally so strange that they might be hospitalized were it not for their phenomenal abilities? If enough people experience something like depression does it become normal? Why is PTSD a disorder when it is explained by the trauma causing it?

Activity 3.3: Projective Assessment Ask students to write their responses to a TAT-like picture you have found in a magazine. Display the picture and ask them: “What are the people in this picture doing?” “What are they saying to each other?”

“How do you think the situation will turn out?” Then ask students to share their responses with the class, emphasizing that there is no magical interpretation or insight that can be revealed by responses to a single picture. Only after responding to many cards might patterns of interpretation emerge, and even then there is significant disagreement when it comes to making sense of the themes. The purpose of the exercise is not to expose their underlying psychopathology but, rather, to emphasize the wide variety of responses people make. It is the open-ended response format that makes tests projective. Objective tests give only a few response options, the scoring of which are clerical and algorithmic in nature.

Activity 3.4: When to Be Impressed by Agreement How much agreement between diagnosticians is impressive? 75%? 85%? 95%? It depends. Among other things, it depends on how often each diagnostician makes the diagnosis in question. What percent agreement do we expect to observe between tosses of two fair coins? There are four possible outcomes; heads-heads, heads-tails, tails-heads, and tails-tails, each occurring 25% of the time. The two coins will therefore “agree” on a “diagnosis” of heads 25% of the time by chance alone. Similarly, they will agree on a diagnosis of tails 25% of the time, giving an overall agreement rate of 50%. Now substitute depression and schizophrenia for heads and tails, and it is easy to see that rates near 50% are mostly due to chance. Now consider a university counseling center in which few people are diagnosed with schizophrenia. Let’s say that 90% are not schizophrenic. By chance alone, there will be 81% agreement that people being seen at the counseling center are not schizophrenic. Bottom line: percent of diagnostic agreement is not a meaningful indicator of the quality of diagnoses being made. Percent of agreement is only meaningful if you know the base rates of the diagnosis for each of the diagnosticians. Students benefit from working out a few examples of chance agreement in order to really understand the idea and its application to diagnostic reliability.

Activity 3.5: Intake Interviews Students are fascinated with the interviewing process. After lecturing about intake interviews, offer students the opportunity to conduct one. Tell students that a client, “Bill” or “Helen,” will be coming to class for them to interview. Break the group into smaller groups of four to five and allow each group to develop questions they might like to ask the client. Provide each group with a copy of the handout so they know what types of decisions they will need to make based on the interview. The client, of course, will be the instructor. Think through what symptoms you wish to present. Actually writing out the symptoms is easiest for your first time portraying a client. After the client leaves, the groups discuss the interview and complete the handout. Allow the students to use their text to arrive at a possible diagnosis.

Once each group is finished, allow groups to share their results with the entire class. Handout 3.1 Activity 3.6: Diagnosing Mrs. Simon For this exercise, divide students into small groups and ask them to make a differential diagnosis of “Mrs. Simon.” Because Mrs. Simon’s case is somewhat ambiguous, making the diagnosis is not straightforward. The exercise helps students appreciate various aspects of diagnosis including how to

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assess symptoms, how to apply inclusion/exclusion criteria, the necessity of obtaining accurate information about the patient, and the sometimes unavoidable ambiguity of diagnostic categories.

Handout 3.2 Activity 3.7: What Do Neuropsychologists Do? Neuropsychological assessment involves the use of various testing devices to measure a person’s cognitive, perceptual, and motor performance as clues to the extent and location of brain damage. Strub & Black (1999) have published a wonderful text outlining the Mental Status Examination in Neurology and the Mini-Mental Status Examination is a commonly used tool in this area. Place students in pairs and allow them to administer the Mental Status Examination provided on the handout. Handout 3.3 Activity 3.8: Developing Your Own Test Split students into groups and allow them to create their own diagnostic test. Allow groups to decide if they wish to develop an objective personality test, a projective personality test, or a structured clinical interview. Tell all students that the test they construct must allow for the clinician to determine whether a person is depressed. Have each group share its test with the class. Talk about reliability and validity.

Activity 3.9: The Purchase of Friendship?

Psychotherapy has been called “the purchase of friendship.” Most students are familiar with giving and getting advice from their friends. How do they imagine therapy is different? What advantages accrue from seeking the “friendship” of a trained professional over and above that available via a friend, bartender, member of the clergy, etc.? Working in groups, have students develop a list of questions they would want to have answered before choosing a therapist. Once completed, have students share their list with the class.

Activity 3.10: What Makes a Good Listener?

All good therapists are good listeners, but what makes a good listener? A number of skills require professional training and extensive practice and feedback to perfect, but some seem to come naturally to some people. Ask students in the class to think of a readily available person they consider a good listener and to write down why they think they are so good. Then give the assignment to actually observe this person and pay particular attention to the specific behaviors making them a good listener.

Things to watch for include open posture and an attentive orientation, subtle encouragements to “go on” and to talk about one’s feelings, empathy and nonjudgmental feedback, and minimal attempts to take control of the conversation by switching the focus to one’s self. Good listeners make clear that the other person is the focus of the conversation. This is also facilitated by simply minimizing one’s own talking.

With this minimal orientation to the task, ask students to be observers and reporters on the behavior of a “good listener” they know. Handout 3.5 Activity 3.11: Self-Help Babylon Ask students to imagine they have a specific problem, such as depression, panic disorder, alcoholism, or sexual dysfunction. Then, send them to a bookstore to research the self-help offerings pertaining to this topic. Have them view the available materials keeping in mind what they have learned about the problem they have and to evaluate the basis for the advice these books provide. In addition, ask students to critically evaluate the credentials of the individual(s) writing the self-help book. Handout 3.4 Activity 3.12: Self-Medication People have a tendency to self-medicate. What drugs and dietary supplements are widely used by people? Have students examine their own tendencies toward self-medication. List examples of students’ attempts to “cure” themselves. Can people treated with psychoactive medications inhibit the .

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effectiveness of the drugs with their own self-medications or supplements? The vitamin and herbal remedy industry has been threatened with regulation for a number of years. Should vitamins be restricted? Have students gather literature concerning the claims made for the effects of vitamins and herbs. Have students compare the claims that are made. Are the claims justified by research? Students may be assigned to collect examples of the variety of vitamins and mineral supplements that are suggested for various disorders. Have students collect literature on this subject that is supplied by the manufacturers of such products. Herbal remedies have been marketed for such mental disorders as depression. What are the potential problems of this marketing?

Activity 3.13: Medication Side-Effects Students or teams of students can be assigned the task of researching the potential side effects of different categories of drugs. When are the benefits of a drug outweighed by the side effects? How are side effects usually reported? How are they dealt with clinically? Are patients routinely completely informed of the potential side effects before they start taking a drug? Would the suggestion of certain side effects possibly increase their rates of occurrence via placebo effects?

Web Links Web Link 3.1: http://www.apa.org/science/testing.html This is the “Testing and Assessment” site of the American Psychological Association’s Science Directorate. It includes a “Frequently Asked Questions” resource as well as information about standards for tests, links to other testing Web sites, and specific test resources.

Web Link 3.2: http://www.unl.edu/buros/ The Buros Institute of Mental Measurements has published critical reviews of tests and testing for more than six decades. Their Mental Measurement Yearbook has long been the standard testing and assessment reviews reference in the field.

Web Link 3.3: http://www.apa.org/science/jctpweb.html The Joint Committee on Testing Practices was established in 1985 by a group of major national associations with an interest in testing. The Joint Committee provides “a means by which professional organizations and test publishers can work together to improve the use of tests in assessment and appraisal.” Their Web site provides an assortment of their publications on fair and responsible test use, test user qualifications, rights and responsibilities of test takers, etc.

Web Link 3.4: http://www.apa.org/science/standards.html The APA’s “Standards for Educational and Psychological Testing” address professional and technical issues of test development and use in education, psychology, and employment. It is an extremely important reference for test developers, publishers, users, policymakers, employers, and students in psychology.

Web Link 3.5: http://en.wikipedia.org/wiki/Race_and_intelligence This is possibly one of the best researched articles on this issue. The article provides a history of the topic, numerous graphs and tables documenting findings, and links to additional sites with explanatory material.

Web Link 3.6: http://www.emedicine.com/pmr/topic149.htm This site provides an article describing the purposes of neuropsychological testing, the conditions under which such testing might be appropriate, a detailed discussion of the various types of tests used in 64

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neuropsychological testing, and the information obtained from such testing. This would be an excellent resource for the instructor unfamiliar with neuropsychological testing or a site to which students could be directed for more information on this topic.

Web Link 3.7: http://www.aamft.org/index_nm.asp The American Association for Marriage and Family Therapists is the premier association for people interested in marital and family therapy.

Web Link 3.8: http://www.4therapy.com/ 4Therapy.com is an interesting therapy referral resource that includes a number of unique essays and resources about the process of getting together with the right therapist and making it work.

Web Link 3.9: http://www.abct.org/dHome/ The Association for Behavioral and Cognitive Therapies is an especially science-oriented organization with interests in applications of cognitive and behavioral therapies. Their web site has a number of useful resources for consumers and researchers including some good links to other sites.

Web Link 3.10: http://www.apa.org/divisions/div12/rev_est/ The Division of Clinical Psychology (Division 12) of the American Psychological Association, along with one of its sections, the Society for a Science of Clinical Psychology (Section III of Division 12), distributes reports on empirically supported treatments from this site.

Web Link 3.11: http://www.psych.org This link is to the American Psychiatric Association’s home page, which contains information about pharmacotherapy for mental disorders and has sections for providers and consumers as well as links to other sites.

Video Resources Addressing Economic Inequality in Marriage: A New Therapeutic Approach. New York, NY: Guilford Publications.

Approaches to Therapy. New York, NY: Insight Media.

Another First Step: From Institutions to Independence: A Family Saga. New York, NY: Filmmakers Library.

Assessing Diverse Populations. Assessment and Evaluation: Developing Tools to Measure Effectiveness Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Assessment, Intervention, and Treatment. Psychotropic Medications: Caring for Patients with Psychiatric Disorders Series. Irvine, CA: Concept Media.

Basic Interviewing Skills for Psychologists. New York, NY: Insight Media.

Behavioral Interviewing with Couples. Champaign, IL: Research Press.

Bitter Potion: Psychological Profiling. Allyn and Bacon Video Library.

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Carl Rogers. New York, NY: Insight Media.

Client-Centered Therapy. APA Psychotherapy Video Series I: Systems of Psychotherapy Series.

Washington, DC: American Psychological Association.

Clinical Dilemmas in Marriage: The Search for Equal Partnership. New York, NY: Guilford Publications.

Cognitive-Affective Behavior Therapy. APA Psychotherapy Video Series I: Systems of Psychotherapy Series. Washington, DC: American Psychological Association.

Cognitive-Behavior Therapy. APA Psychotherapy Video Series I: Systems of Psychotherapy Series.

Washington, DC: American Psychological Association.

Conversation with Viktor Frankl. Notable Contributors to the Psychology of Personality Series.

University Park, PA: Penn State Media Sales.

Couples Therapy for Extramarital Affairs. APA Psychotherapy Video Series II: Specific Treatments for Specific Populations. Washington, DC: American Psychological Association.

Cross Cultural Therapeutic Alliance. Topeka, KS: Menninger Video.

Crossing the Line: The Dilemma of Staff-Patient Involvement. Irvine, CA: Concept Media.

Diagnosis According to the DSM-IV. Diagnosis According to the DSM-IV Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Dynamics of Treatment Planning. Psychiatric Intervention and Care Series. Irvine, CA: Concept Media.

EMDR (Eye Movement Desensitization and Reprocessing) for Trauma. APA Psychotherapy Video Series II: Specific Treatments for Specific Populations. Washington, DC: American Psychological Association.

EMDR: A Closer Look. New York, NY: Guilford Publications.

Ericksonian Hypnotherapy for an Impulse Problem. APA Psychotherapy Video Series II: Specific Treatments for Specific Populations. Washington, DC: American Psychological Association.

Ethnocultural Psychotherapy. APA Psychotherapy Video Series I: Systems of Psychotherapy Series.

Washington, DC: American Psychological Association.

Experiential Psychotherapy. APA Psychotherapy Video Series I: Systems of Psychotherapy Series.

Washington, DC: American Psychological Association.

Extending Successful Clinical Outcomes: Alternatives to Inpatient Care. Carrolton, TX: Interactive Medical Networks.

Feminist Therapy. APA Psychotherapy Video Series I: Systems of Psychotherapy Series. Washington, DC: American Psychological Association.

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Getting Help. Allyn and Bacon Video Library.

Group Work: Fundamentals of Group Process. Irvine, CA: Concept Media.

Humanistic Psychotherapy. Oakland, CA: Thinking Aloud Productions.

Individual Therapy From a Family Systems Perspective. APA Psychotherapy Video Series I: Systems of Psychotherapy Series. Washington, DC: American Psychological Association.

Interview and Assessment. Substance abuse: Assessment and Intervention Series. Irvine, CA: Concept Media.

Interviewing for Child Sexual Abuse: A Forensic Guide. New York, NY: Guilford Publications.

Men in Therapy. Topeka, KS: Menninger Video.

Multimodal Therapy. APA Psychotherapy Video Series I: Systems of Psychotherapy Series. Washington, DC: American Psychological Association.

New Therapy for Depression—#12 ABC News and Client Interviews. Allyn and Bacon Abnormal Psychology Video.

Prescriptive Eclectic Therapy. APA Psychotherapy Video Series I: Systems of Psychotherapy Series.

Washington, DC: American Psychological Association.

Process Experiential Therapy. APA Psychotherapy Video Series I: Systems of Psychotherapy Series.

Washington, DC: American Psychological Association.

Prozac Diary. Allyn and Bacon Video Library.

Psychosurgery: Best Hope or False Hope? Allyn and Bacon Video Library.

Psychotherapies. The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection.

Psychotherapy. Discovering Psychology. South Burlington, VT: Annenberg/CPB Collection.

Rational Emotive Therapy. Champaign, IL: Research Press.

The Relaxation Response. Princeton, NJ: Films for the Humanities and Social Sciences.

Short-Term Dynamic Therapy. APA Psychotherapy Video Series I: Systems of Psychotherapy Series.

Washington, DC: American Psychological Association.

Techniques of Play Therapy: A Clinical Demonstration. New York, NY: Guilford Publications.

Testing and Intelligence. Discovering Psychology Series. South Burlington, VT: Annenberg/CPB Multimedia Collection. .

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Therapy Choices. New York, NY: Insight Media.

Three Approaches to Psychotherapy. Corona del Mar, CA: Psychological and Educational Films.

Treating Time Effectively: The First Session in Brief Therapy. New York, NY: Guilford Publications.

Understanding Group Psychotherapy: Inpatients. Berkeley, CA: University of California Extension Center for Media and Independent Learning.

Understanding Group Psychotherapy: Outpatients. Berkeley, CA: University of California Extension Center for Media and Independent Learning.

Using Pharmaceutical Drugs Safely, Module IX, The Total Health Video Series. EMG / Allyn and Bacon Video Library.

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Handout 3.1 University Psychology Clinic Intake Diagnostic Assessment Form A. Patient Summary:

B. Multi-axial Diagnosis (based on DSM-IV criteria): 1. Primary diagnosis: __________________________________ 2. Personality disorder: __________________________________ 3. Physical disorder: __________________________________ 4. Severity of psychosocial stressors (check one): _____ mild _____ moderate _____ severe 5. Highest level of adaptive functioning (check one): _____ poor _____ fair _____ good C. Recommendations:

D. Assessment of prognosis (select 1): ____ good ____ fair ____ poor

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Handout 3.2 Mrs. Simon, a 37-year-old elementary teacher, was referred by her principal. Although she has been teaching for three years, her performance has always been problematic. Mrs. Simon misses two to three days per month because she “can’t get out of bed.” She reports that she is tired all the time, even when she goes to bed early and that she rarely sleeps all night, typically awakening around 3A.M. Upon questioning, Mrs. Simon denied being depressed but reported she “feels down” all the time and frequently finds herself crying for no reason.

She reports that she doesn’t enjoy any activities and believes that her life will always be this way. She went on to report that she has difficulty concentrating on her responsibilities and was dismayed to discover she had taught the students the wrong material on several occasions.

Diagnostic Criteria for a Dysthymic Disorder: Depressed mood for most of the day, for more days than not, for at least two years.

A. While depressed, reports two (or more) of the following: 1. Poor appetite or overeating 2. Insomnia or hypersomnia 3. Low energy or fatigue 4. Low self-esteem 5. Poor concentration or difficulty making decisions 6. Feelings of hopelessness B. During the two-year period of the disturbance the person had never been without symptoms for more than two months at a time.

C. No major depressive episode has been present during the first two years of the disturbance and there has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria have never been met for cyclothymic disorder.

D. Not due to an organic or physical cause.

Diagnostic Criteria for a Major Depressive Episode: 1. At least five of the following symptoms are present every day for a period of at least two weeks and represent a change from a previous level of functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure: a. Depressed mood b. Loss of interest or pleasure in usual activities, or a decrease in sexual drive c. Poor appetite with weight loss, or increased appetite with weight gain d. Insomnia or hypersomnia e. Psychomotor agitation or retardation f. Loss of energy or fatigue g. Feelings of worthlessness, guilt, self-reproach h. Complaints or evidence of a decreased ability to concentrate (slow thinking, indecisiveness) i. Recurrent thoughts of death, wishes to be dead, suicide attempt 2. None of the symptoms of schizophrenia are present (see above) 3. Not due to an organic or physiological cause

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Handout 3.3

What is your name? ____________________________________________ What day is it? ________________________________________________ What time is it? ________________________________________________ Where are you? ________________________________________________

What does it mean when someone says, “The apple doesn’t fall far from the tree?”

What does it mean when someone says, “Still waters run deep?”

Repeat after me (Pause one second between numbers): 3, 4, 8 _________________ 2, 6, 4, 7 _________________ 1, 3, 2, 7, 4 _________________ 2, 5, 6, 9, 3, 8 _________________ What should come next?

X, O, X, ____, _____, _______ bird 1234 shirt 56237 rat 387 bash _ _ _ _

Pretend you are folding a towel. Show me how you would do this.

Pretend you are tying your shoe. Show me how you would do this.

Using your left hand, touch your right knee.

Using your right hand, point to my left hand.

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Handout 3.4 Self-Help Babylon

Research self-help books with a critical eye toward the origins of the ideas and advice they convey.

Book

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Source of Information

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Chapter 3: Clinical Assessment, Diagnosis, and Treatment Approaches

Handout 3.5 What Makes a Good Listener?

Think of someone you consider a really good listener and write down what makes this person so good.

Observe this person and pay particular attention to the specific behaviors making him or her a good listener. Things to watch for include open posture and an attentive orientation, subtle encouragements to “go on” and to talk about one’s feelings, empathy and nonjudgmental feedback, and minimal attempts to take control of the conversation by switching the focus to one’s self. Good listeners make clear that the other person is the focus of the conversation. This is also facilitated by simply minimizing one’s own talking. Try to be an especially astute observer and reporter on the behavior of a “good listener” you know.

Verbal Behavior: What does the person actually say? What does he or she talk about? Does he or she ask questions? What kinds of comments does he or she make? How much is he or she saying?

Non-Verbal Behavior: How does the person act? What is his or her posture like? His or her facial expression? His or her movements? His or her non-verbal utterances (e.g., uh-huh, mmmm)?

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CHAPTER 4: Stress and Physical and Mental Health Chapter At-A-Glance

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Detailed Outline

Instructors’ Resources

Print Supplements

Media Supplements

What is Stress?

•Stress and the DSM • Factors Predisposing a Person to Stress • Characteristics of Stressors

Teaching Objectives 4.1 Chapter Guide Lecture Launchers 4.1, 4.2 Activities 4.1 Web Links 4.1, 4.2, 4.5

Test Bank Grade Aid

CD-ROM PowerPoint

Stress and the Stress Response • Biological Costs of Stress • The Mind-Body Connection • Understanding the Immune System

Teaching Objectives 4.2 Chapter Guide Lecture Launchers 4.3 Activities 4.1, 4.2 Web Links 4.1, 4.3, 4.6

Test Bank Grade Aid Transparencies T-58 to T-66

CD-ROM PowerPoint ABC Video: Clip #2

Stress and Physical Health Attitudes and Health • Optimism • Negative Affect

Teaching Objectives 4.3 Chapter Guide Lecture Launchers 4.2 Activities 4.1, 4.2 Web Links 4.4

Test Bank Grade Aid

CD-ROM PowerPoint

Cardiovascular Disease •Hypertension •Coronary Artery Disease •Risk and Causal Factors in Cardiovascular Disease Treatment of Stress-Related Disorders • Emotional Disclosure • Biofeedback • Relaxation and Meditation

Teaching Objectives 4.4 Chapter Guide Lecture Launchers 4.2 Activities 4.1 Web Links 4.4 Teaching Objectives 4.5 Chapter Guide Lecture Launchers 4.2 Activities 4.1 Web Links 4.4

Psychological Reactions to Stress Adjustment Disorder PostTraumatic Stress Disorder • Clinical Description • Prevalence of PTSD in the General Population • Rates of PTSD After Exposure to Specific Stressors • Causal Factors in PostTraumatic Stress Disorder • Long-Term Effects of PostTraumatic Stress

Teaching Objectives 4.6, 4.7, 4.8, 4.9 Chapter Guide Lecture Launchers 4.1, 4.3, 4.4, 4.5 Activities 4.3, 4.5 Web Links 4.1, 4.2, 4.3

Test Bank Grade Aid

CD-ROM PowerPoint ABC Video: Clip #1

Prevention and Treatment of Stress Disorders • Prevention • Treatment for Stress Disorders • Trauma and Physical Health

Teaching Objectives 4.10 Chapter Guide Lecture Launchers 4.2, 4.4, 4.5 Activities 4.3, 4.4 Web Links 4.4

Test Bank Grade Aid

CD-ROM PowerPoint

Unresolved Issues: What Should the Diagnostic Criteria for PTSD Be?

Teaching Objectives 4.11 Chapter Guide Lecture Launchers 4.5

Test Bank Grade Aid

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Professor Notes

Chapter 4 · Stress and Physical and Mental Health

Teaching Objectives 1.

2.

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8.

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11.

Differentiate and provide an example of a stressor, stress, and coping; describe the factors predisposing a person to stress; and discuss characteristics of stressors.

Describe the two systems within the body that are involved in the stress response.

Describe how the immune system responds to a threat.

Summarize what is known about how our attitudes influence health.

Outline how psychological factors are involved in hypertension and CHD. Be sure to describe both Type A personality and Type D personality.

Compare and contrast the three approaches for the treatment of stress-related physical disorders: emotional disclosure, biofeedback, and relaxation and meditation.

Characterize the DSM-IV diagnosis of adjustment disorder.

List the diagnostic criteria for acute stress disorder and post-traumatic stress disorder (PTSD), and compare and contrast the two disorders.

Summarize what is known about PTSD following military combat.

Discuss the causal factors in PTSD. Summarize the approaches that have been used to treat or to prevent stress disorders and evaluate their effectiveness.

Discuss the issue of diagnostic criteria for PTSD.

Chapter Overview/Summary Behavioral Medicine is an interdisciplinary field focusing on the role psychological factors play in the medical problems. Health psychology is the psychological subspecialty within this field concerned with the effects of stress and other psychological factors on the development and maintenance of physical problems. Dealing with stress is an inevitable part of life; all situations, positive and negative, can be stressful.

The relationship between stress and psychopathology is considered so important that the role of stress is recognized in diagnostic formulations. Three disorders—PTSD, adjustment disorder, and acute stress disorder—are diagnosed on Axis I of the DSM; stress may also be considered using Axis IV. A person’s response to stressful situations depends not only on the severity of the stressor but also on the person’s perceptions, preexisting stress vulnerabilities, and amount of external resources and social supports. In addition, prior stressful experiences may sensitize us biologically, making us more reactive to later stressful experiences.

Factors impacting the severity of a stressor include: severity, chronicity, timing, how closely it affects our lives, how expected it is, and how controllable it is. The term crisis is used to describe times when a stressful situation threatens to exceed or exceeds the adaptive capacities of a person or a group.

Life changes, even positive ones, may be stressful; the faster life changes occur, the more stress we may feel. The Social Readjustment Rating Scale and the Life Event and Difficulty Schedule were developed to assess such changes. Being able to perceive a positive benefit to a stressor may increase adaptation and growth.

There are specific biological changes associated with the experience of stress, involving two distinct systems: sympathetic-adrenomedullary (SAM) and the hypothalamic-pituitary adrenocortical (HPA). SAM is designed to mobilize resources and prepare for a ‘fight-or-flight” response. The SAM stress response begins in the hypothalamus, stimulating the sympathetic nervous system causing the adrenal glands to secrete adrenaline and noradrenaline leading to an increase in heart rate and a more rapid metabolization of glucose. The HPA stress response begins with the hypothalamus releasing a hormone, CRH, leading to stimulation of the pituitary gland that produces ACTH causing the adrenal cortex to produce cortisol. .

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Among the consequences of extreme or prolonged stress can be extensive physical and psychological problems. Psychoneuroimmunology is a developing field that focuses on the effects of stressors on the immune system. Evidence continues to grow that the brain influences the immune system and the immune system influences the brain. The immune system responds to threats through leukocytes such as B-cells and T-cells. In AIDS, for example, greater overall levels of stressful life events are associated with faster progression from HIV+ to AIDS. Likewise, higher levels of stress hormones, use of denial as a means of coping, and greater dissatisfaction with available social support were also predictive of faster development of AIDS. Because the brain influences the immune system, psychological factors are of importance.

Specifically, optimism may serve as a buffer against disease and negative emotions may increase negative health consequences. The field of positive psychology focuses on human traits and resources that might have direct implications for our physical and mental well being.

Cardiovascular disease, a leading cause of death in the United States, is used to illustrate the many links between lifestyle factors and physical disease. Ideally, blood pressure should be below 120/80. In certain people, hypertension may begin when a person has a biological tendency toward high cardiovascular reactivity to stress. Due to biological and psychological reasons, African Americans are more likely to have higher levels of hypertension. Constructively expressing anger leads to lower hypertension, self-reported anxiety and depression, and destructive hostility. Coronary heart disease is increased by both chronic and acute stress, hostile Type A personality, Type D personality, depression, phobic anxiety, social isolation, and lack of social support.

Stress management focuses on increased appropriate emotional disclosure, biofeedback, and relaxation and meditation.

Psychological reactions to common life stressors are referred to as adjustment disorders.

Reactions to catastrophic events are referred to as acute stress disorder (maximum length of symptoms is 4 weeks) or post-traumatic stress disorder (PTSD). PTSD appears to occur in almost 7 percent of adults at some time in their lives with women showing higher rates of PTSD. Trauma that results from human intent (childhood physical abuse, rape, being threatened with a weapon) is more likely to cause PTSD than are traumatic events (such as accidents or natural disasters). Service in the military during combat presents a unique pattern of events that increases the probability of PTSD. The specific symptoms associated with combat-related stress vary considerably depending on the type of duty, the severity and nature of the traumatic experience, and the personality of the individual.

Although given sufficiently high levels of stress, almost anyone might develop PTSD, most people function relatively well during catastrophic events. Individual risk factors for exposure to traumatic events include being male, having less than a college education, conduct problems during childhood, having a family history of psychiatric disorder, and scoring higher on measures of extraversion and neuroticism. Individual risk factors for developing PTSD include being female, low levels of social support, neuroticism, prior depression or anxiety, and one’s appraisals of their stress symptoms immediately after the traumatic event. Those with higher IQ scores appear to be at less risk for being exposed to traumatic events and for developing PTSD. Biological factors under investigation are cortisol levels and hippocampal volume. Sociocultural factors associated with adjustment to combat stress include justification for the combat, identification with the combat unit, esprit de corps, and quality of leadership.

Psychologically preparing people for possible traumatic events, as in stress inoculation training, may result in lower rates of PTSD. Most of those exposed to trauma will experience symptoms but gradually recover without any professional help. Providing assistance may include a range of treatments from telephone hotlines, ‘psychological first aid,’ crisis intervention, psychological debriefing (has not been found to be effective however), medications, and cognitive-behavioral treatments. Treatments in the last category may include prolonged exposure (including virtual reality exposure treatment) and cognitive therapy.

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Detailed Lecture Outline I.

II.

What is Stress?

A. Stress and the DSM 1.

All situations, positive and negative, that require adjustment can lead to stress.

2.

Hans Selye—stress can be positive or negative (distress) 3.

Three Axis I disorders relating to stress: adjustment disorder, acute stress disorder and PTSD 4.

Axis IV can be used to report any specific stressor that may contribute to or result from a person’s disorder B. Factors Predisposing a Person to Stress 1.

Individual characteristics that improve a person’s ability to handle stress a.

Higher levels of optimism b.

Greater psychological control or mastery c.

Increased self-esteem d.

Social support 2.

Differences in coping styles may be linked to underlying genetic differences 3.

Amount of stress experienced early in life may make us more sensitive to stress later 4.

Stress tolerance refers to a person’s ability to withstand stress without becoming seriously impaired 5.

Stressful experiences may also create a self-perpetuating cycle by changing how we think about, or appraise, the thing that happen to us C. Characteristics of Stressors 1.

Key factors include a.

Severity of the stressor b.

Chronicity c.

Timing d.

How closely it affects our own lives e.

How expected it is f.

How controllable it is 2.

The term crisis is used to refer to times when a stressful situation threatens to exceed or exceeds the adaptive capacities of a person or a group 3.

The faster that life changes occur, the greater the stress that is experienced a.

Holmes and Rahe (1967) developed the Social Readjustment Rating Scale b.

Life Event and Difficulty Schedule 4.

The extent to which a person can perceive some ‘benefit’ in adapting to the consequences of a disaster depends in part on the nature to the disaster itself Stress and the Stress Response A. Biological Costs of Stress 1.

Biological cost of adapting to stress is called the allostatic load 2.

Two distinct biological systems for responding to stressors a.

Sympathetic-adrenomedullary system (SAM) b.

Hypothalamic-pituitary adrenocortical system (HPA) 3.

Short-term cortisol release is highly adaptive, long-term production can have negative effects B. The Mind-Body Connection

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1.

III.

IV.

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Psychoneuroimmunology is the study of the interaction between the nervous system and the immune system 2.

A person’s behavior and psychological states affect immune functioning, but the status of the immune system also influences current mental states and behavioral dispositions by affecting the blood levels of circulating neurochemicals; these, in turn, modify brain states C. Understanding the Immune System 1.

Immune system protects the body from such things as viruses and bacteria a.

Front line of defense is the white blood cells (leukocytes or lymphocytes) (1) B-cell (2) T-cell b.

AIDS: Illustrating the link between stress and immune functioning (1) Greater overall levels of stressful life events were associated with more rapid transition from HIV+ to AIDS (2) Faster development of AIDS also associated with higher levels of circulating stress hormones, use of denial as a means of coping, and greater dissatisfaction with available social support Stress and Physical Health; Attitudes and Health A. Optimism: serves as a buffer against disease B. Negative Affect: associated with poor health 1.

Associated with increased mortality from all causes 2.

Heightens risk of osteoporosis 3.

Growing interest in the study of positive psychology Cardiovascular Disease A. Hypertension 1.

Ideally 120/80 2.

Hypertension is 140 or more (systolic); over 90 or higher (diastolic) 3.

Increases as a function of aging 4.

Before 50, higher in men than women. After 50, higher in women probably due to the fact that menopause amplifies the stiffness in the arteries.

5.

Hypertension afflicts almost 50 million Americans 6.

Essential hypertension: no specific physical cause 7.

Probably due to biological tendency toward high cardiovascular reactivity compounded by difficult life circumstances 8.

Hypertension and African Americans a.

Higher levels of stress from inner-city living, economic disadvantage, exposure to violence, and race-based discrimination b.

Lifestyle: African American women more likely to be overweight and African Americans in general are less likely to exercise c.

Heavy salt usage compounded by excessive retention of sodium leading to fluid retention and endocrine changes d.

Renin, an enzyme produced by the kidneys linked to high blood pressure, is processed differently in African Americans e.

Nitric oxide, dissolved gas crucial for proper functioning of blood vessels and blood cells, produced in lower levels in African Americans 9.

Hypertension and anger a.

Importance is whether anger is communicated constructively b.

Constructive anger: express why feeling angry, deal with target of anger more directly, try to reach an understanding by engaging in open .

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V.

communication, and solicit opinions of other people to obtain objective view and to find other ways to resolve problem B. Coronary Heart Disease 1.

Potentially lethal blocking of the arteries that supply blood to the heart muscle, or myocardium 2.

Chief clinical manifestations are a.

Myocardial infarction b.

Angina pectoris c.

Disturbance of the heart’s electrical conduction C. Risk and Causal Factors in Cardiovascular Disease 1.

Chronic and Acute Stress a.

Documented rises in deaths due to CHD subsequent to earthquakes b.

Work-related stress increases risk for future CHD c.

Mental stress, such as giving short talk, associated with changes in cardiac function in about 20 percent of those with existing coronary artery disease 2.

Personality a.

Began with identification of the Type A personality (1) Excessive competitive drive (2) Extreme commitment to work (3) Impatience or time urgency (4) Hostility b.

Research has clearly identified the hostility component as most closely correlated with coronary artery deterioration c.

Type D personality (1) Tendency to experience negative emotions and feel insecure and anxious (2) Men with CHD who scored high on Type D characteristics were more likely to have fatal and nonfatal heart attacks over a five-year period 3.

Depression a.

3 times more common in those with heart disease b.

If depressed following a heart attack, 3 times increased risk for future coronary events and death c.

Depression predicts future heart disease: 8% of those who had suffered major depression and 6% of those who had suffered mild depression experienced a heart attack within 14 years while only 3% of those who had not suffered depression experienced a heart attack in the same period d.

Critical variable may be that stress triggers the production of proinflammatory cytokines leading to symptoms of depression and triggering the growth of plaques in the blood vessels that may lead to a heart attack 4.

Anxiety: association between phobic anxiety and fatal heart attacks 5.

Social isolation and lack of social support a.

Monkeys housed alone have 4 times more atherosclerosis b.

People with little to no social support are more likely to develop CHD c.

For those who have already experienced CHD, low levels of emotional support led to 3 times higher likelihood of experiencing another cardiac event Treatment of Stress-Related Disorders A. Emotional Disclosure .

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1.

VI.

80

May be of help due to opportunity for emotional catharsis or that writing gives people an opportunity to rethink their problems B. Biofeedback 1.

Aim to make patients more aware of such things as their heart rate, level of muscle tension, or blood pressure 2.

Proven helpful in treating headaches C. Relaxation and Meditation 1.

Relaxation has proven effective for reducing hypertension and tension headaches 2.

Meditation proven effective in reducing diastolic blood pressure Psychological Reactions to Stress; Adjustment Disorder; Post-Traumatic Stress Disorder A. Adjustment Disorder 1.

Psychological response to a common stressor that disappears when stressor ends or the person learns to adjust; does not last longer than 6 months 2.

Probably least stigmatizing and mildest diagnosis in DSM B. PTSD and Clinical Description 1.

PTSD classified as an anxiety disorder 2.

Formal diagnosis not defined until 1980 when PTSD was considered a normal response to an abnormal stressor 3.

Research, though, has made it clear that certain preexisting vulnerabilities also play an important role 4.

Acute stress disorder occurs within 4 weeks of the traumatic event and lasts for a minimum of 2 days and a maximum of 4 weeks 5.

PTSD diagnosed when a traumatic event causes a pathological memory creating characteristic symptoms lasting longer than 4 weeks in three main areas: a.

Recurrent experiencing of the traumatic event through nightmares or intrusive memories b.

Avoidance of stimuli associated with the trauma and emotional numbing c.

Increased arousal, which may involve insomnia, the inability to tolerate noise, and an excessive response when startled C. Prevalence of PTSD in the General Population 1.

9.7% of women and 3.6% of men will develop PTSD 2.

More common in women even when exposure is equal D. Rates of PTSD After Exposure to Specific Stressors 1.

After earthquake in Turkey, PTSD rates reported of 23 percent at the epicenter 2.

Common specific stressors include: tornados, plane crashes, car accidents, explosions, fires, earthquakes, and sexual assaults 3.

Rates of PTSD vary widely a.

Traumatic events that result from human intent (childhood physical abuse, rape, being threatened with a weapon) are more likely to cause PTSD than traumatic events (accidents and natural disasters) b.

Method of assessment also important with higher rates from questionnaires than interviews 4.

Trauma of Military Combat a.

Combat brings with it constant fear, unpredictability, largely uncontrollable circumstances, necessity of killing, and prolonged harsh conditions b.

Reductions in personal freedom, frustrations, and separation from home and loved ones

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c.

E.

Rates of PTSD increase with the reported extent of combat and with being wounded in combat 5.

Clinical Picture in Combat-Related Stress a.

Symptoms vary considerably based on the type of duty, the severity and nature of the traumatic experience, and the personality of the individual b.

Surprisingly uniform clinical picture with first symptoms being increasing irritability and sensitivity, sleep disturbances, and often recurrent nightmares c.

Anger and anger-control problems are strong components as well as substance abuse Causal Factors in Post-Traumatic Stress Disorder 1.

Study of causal risk factors somewhat controversial as many believe trauma itself is the cause and that searching for risk factors results in double victimization 2.

Individual risk factors a.

Risk for Experiencing Trauma (1) Certain occupations (2) Being male (3) Having less than a college education (4) Conduct problems in childhood (5) Family history of psychiatric disorder (6) High scores on measures of extraversion and neuroticism (7) African American b.

Risk for Developing PTSD (1) Being female (2) Lower levels of social support (3) Neuroticism (4) Preexisting problems with anxiety and depression (5) Family history of anxiety, depression and substance abuse (6) Appraisals that stress symptoms are a sign of personal weakness or believing that others will be ashamed of them c.

Higher IQ scores serve as a buffering factor d.

Biological factors (1) Women with PTSD have higher baseline cortisol levels than women without PTSD (2) Levels of cortisol are lower in those with PTSD from physical or sexual abuse (3) Small hippocampal volume may be a vulnerability factor for developing PTSD e.

Sociocultural factors (1) Clarity and acceptability of war goals (2) Identification with the combat unit (3) Esprit de corps (4) Quality of leadership (5) Returning to an unaccepting social environment (6) Interventions promoting morale and encouraging cohesion have been developed including time in ‘safe’ zones and access to the Internet (7) Treatment strategy based on “proximity, immediacy, expectancy, and simplicity. That is, simple immediate treatment, without evacuation, with the expectation that the soldiers will return to duty .

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VII.

VIII.

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Long-Term Effects of Post-Traumatic Stress 1.

Delayed PTSD somewhat controversial as it is difficult to document that symptoms are due to specified trauma rather than some other factor in the person’s life 2.

Increased prevalence may be due to popularity and plausibility rather than true incidence Prevention and Treatment of Stress Disorders A. Prevention 1.

Stress-inoculation training a.

Stage 1: information provided about the stressful situation and how people can deal with such dangers b.

Stage 2: self-statements that promote effective adaptation are rehearsed c.

Stage 3: person practices self-statements while being exposed to a variety of ego-threatening or pain-threatening stressors 2.

Stress-inoculation would not work for unpredictable or uncontrollable traumas B. Treatment for Stress Disorders 1.

Telephone hotlines 2.

Psychological first aid in the immediate aftermath consisting of a systematic set of helping actions that are aimed at reducing the post-traumatic distress and supporting short- and long-term functioning 3.

Short-term crisis intervention involving face-to-face discussion and an active therapist 4.

Psychological debriefing, while extremely popular, has not provided evidence of its effectiveness 5.

Medications a.

Antidepressants may be helpful in alleviating symptoms of depression, intrusive thoughts, and avoidance b.

Since symptoms fluctuate, medication needs to be closely monitored 6.

Cognitive-Behavioral Treatments for continuing symptoms a.

Behaviorally oriented techniques involving prolonged (repeated or extended) exposure, either in vivo or in the imagination, to objectively harmless but feared stimuli b.

Cognitive therapy is designed to modify excessively negative appraisals of the trauma or its consequences, and decrease the thereat that patients experience when they have memories of the traumatic event, and remove problematic cognitive and behavioral strategies c.

Virtual reality exposure treatment is associated with substantial decreases in PTSD symptoms and improvements in overall functioning and is well received by patients C. Trauma and Physical Health 1.

Importance of mind-body connection 2.

Experience of early trauma has been found to be associated with increased risk of death from AIDS Unresolved Issues: What Should the Diagnostic Criteria for PTSD be?

A. Originally, focus was on the nature of the stressor B. In DSM IV TR, shift in emphasis from the characteristics of the stressor to the experience of the victim 1.

89.6 percent of people now reported exposure to a traumatic event

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2.

3.

Females more likely to report emotional reaction severe enough to qualify as PTSD Is DSM IV TR criteria overly broad?

Key Terms acute stress disorder (p. 129) adjustment disorder (p. 128) allostatic load (p. 120) antigens (p. 121) B-cell (p. 121) behavioral medicine (p. 116) coping strategies (p. 116) cortisol (p. 119) crisis (p. 118) crisis intervention (p. 136) cytokines (p. 121) debriefing sessions (p. 136) distress (p. 116) essential hypertension (p. 124) health psychology (p. 116) hypertension (p. 123) hypothalamic-pituitary adrenocortical (HPA) axis (p. 119)

immune system (p. 120) immunosuppression (p. 120) leukocytes (p. 121) lymphocytes (p.121) positive psychology (p. 123) post-traumatic stress disorder (PTSD) (p. 116) prolonged exposure (p. 136) psychoneuroimmunology (p. 120) stress (p. 116) stress-inoculation training (p. 135) stress tolerance (p. 117) stressors (p. 116) sympathetic-adrenomedullary (SAM) system (p.

121) T-cell (p. 121) Type A behavior pattern (p. 125) Type D personality (p. 126)

Lecture Examples / Discussion Topics Lecture Launcher 4.1: Holmes & Rahe Social Readjustment Rating Scale Using Handout 4.1, ask students to rate their own level of stress on Holmes & Rahe’s classic scale.

You may use the following scale to provide students the meaning of their score: Score 300+: Be extremely careful ------ you are at a greatly increased risk of serious illness (reduce stress now).

Score 150–299+: Be cautious ------ your risk of illness is moderate (reduced by 30% from the above risk).

Score 150-: Be glad ------- you only have a slight risk of illness (but still need to take care of yourself).

Handout 4.1

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Lecture Launcher 4.2: Student Stress and Coping Stress-reduction is often a goal in organizational settings, not only to improve morale, employee retention, and productivity, but also to reduce healthcare costs associated with stress-related disease.

The nature of stress, coping, and social policy implications can all be illustrated via a conversation in which college is treated as an organization that could benefit from stress-reduction efforts. Toward that end, students can be asked to list the most common and problematic stressors associated with being a college student. Then, they can be asked about the most effective means of coping with these stressors on one’s own. Finally, they can be asked about what could be done at an institutional level to relieve the stresses identified earlier, particularly the ones that do not yield as well to individual coping strategies.

Handout 4.2 Lecture Launcher 4.3: Date Rape Since Mary Koss and her colleagues published information about date or acquaintance rape in the mid1980s, awareness of this issue has grown exponentially. Unfortunately, college students frequently have erroneous beliefs concerning this topic. Using Handout 4.3, provide students with a copy of the myths or convert Handout 4.3 to an overhead transparency. Begin class by allowing students to read through the myths and then discuss what we have learned that dispels each myth. Handout 4.3 Lecture Launcher 4.4: Media Trauma Especially following the extensive television coverage of the events of September 11, 2001, and the war in Iraq, students have a good sense of how the media can make traumatic events quite immediate to a global audience. Cable and satellite television have expanded coverage to 24 hours and provide specialized channels and programs that make it a relatively simple matter to see fairly gruesome footage from battlefields, sites of horrific natural disasters, terrorist attacks, and even medical procedures that can leave a lasting impression. Some movies, such as Saving Private Ryan, come to be well-known for their realistic depictions of traumatic events. Whether clinically diagnosable post-traumatic stress disorder can be acquired via televised exposure is not known, but it is clear that some people become quite upset by what they see, even to the point of experiencing sleep disturbances, concentration difficulties, and intrusive imagery. Efforts are made to shield children from some of this material, and surely there are images that broadcasters judge to be too disturbing even for adults. A classroom discussion of media presentation of traumatizing images can be started by simply asking students whether they have ever been traumatized by what they’ve seen on TV or in a movie. Follow-up questions can then center on who is responsible for these experiences, whether our senses are dulled by exposure of this type, whether that is a bad thing or not, how far broadcasters will go in depicting real or realistic events that may be traumatic to the audience, why viewers are attracted to this material, etc.

Lecture Launcher 4.5: Is Help Necessary?

Although many people were severely traumatized by the terrorist attacks of September 11, 2001, it was quite surprising to many in the mental health professions how relatively few presented for treatment.

The magnitude of the expressed need for professional care was widely perceived as low in proportion to the magnitude of the precipitating events. In retrospect, however, this may not be surprising.

Throughout history, humans have coped with extremely traumatic events, many that were much worse than September 11, and they have done so without the mental health professions even existing. One explanation for this phenomenon emphasizes the role of family and community support. An interesting class discussion can center on the question of what mental health professionals can provide that family and community cannot. Or perhaps it is the case that the mental health professional’s role in disaster relief is to provide the family and community supports for those who otherwise would have none.

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Demonstrations / Activities Activity 4.1: Social Readjustment The Holmes and Rahe Social Readjustment Rating Scale (1967) is frequently used to measure stress. It includes both negative and positive events because it views stress as anything requiring “social readjustment.” Despite its popularity, the Holmes and Rahe Scale has often been criticized. Targets of criticism include its out-of-date items (e.g., a $10,000 mortgage), the failure to cover stressors relevant to various populations of interest (e.g., college students), and the specific weights. A greater appreciation for the complexity of stress can be achieved via a classroom discussion of how to improve this measure. Students could discuss (a) how to reword items to make them more current, (b) different weights or research methods for deriving weights, (c) the role of positive events on the list, (d) what items should be added to make it more relevant to college-age people, (e) how to improve the coverage of items weighted in the 70s, 80s, and 90s, and (f) what might be a good anchor item with a weight of 100. Handout 4.1 and Transparency T-61 Activity 4.2: Illness and Stress As part of the discussion of stress and its measurement, a “student stress” checklist could be developed.

As well, a checklist of various physical symptoms could be compiled (e.g., headache, runny nose, skin rash). If there are about thirty items on each list, then the two checklists could be administered together either to the entire class, if the class is relatively small, or to a group of about twenty students. A simple count of the stressors and of the physical symptoms would be all that is necessary to calculate the illness and stress correlation. Various weighting schemes have not out-performed simple counts in the research literature on this topic. The actual calculation of the correlation coefficient is fairly tedious to do in front of the entire class, but plotting of the data on a scatterplot goes fairly quickly and can help students visualize the meaning of the correlation coefficient.

Activity 4.3: Crisis Intervention Hotlines Many students, psychology majors especially, have volunteered to work on crisis-intervention or suicide hotlines. If there are any in your class, ask them to tell the rest of the class about the experience. In particular, get a description of the major points emphasized during training. Students may even have various handouts and educational material you could copy and distribute. If there are no students in the class with such experience, a small group of students interested in the topic could research the available resources, interview staff and administrators, and collect answers to class-generated questions about the service. Alternatively, a representative from the crisis center could be invited to visit the class to give a presentation. Actual case examples are always well received, though care must be taken to mask the identities of clients.

Activity 4.4: Disaster Plan Most universities have detailed disaster plans. Although such plans often emphasize physical safety and material logistics, they also incorporate more psychological components directed at preventing and managing panic and providing for people’s emotional needs once the disaster is over. A representative of the university office of public safety could be invited to discuss psychological aspects of the university’s disaster plan with the class. Alternatively, students could be asked to go through the process of creating such a plan for their university, focusing primarily on psychological aspects. Most cities also have disaster plans, so if the university office of public safety is not available or appropriate, perhaps a representative of the city can be invited instead. Handout 4.4

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Activity 4.5: Combat Stress Students can gain insight into the stresses of military combat by hearing first-hand descriptions. Local veteran organizations can be contacted to supply a person willing to speak about combat-related stresses.

The speaker could also provide valuable information concerning the problems in adjusting to civilian life after combat experience. The special stresses associated with war could then be related to those factors that may modify or help a combatant handle the stress successfully. After hearing such a speaker, students could discuss how the real-life experience of military combat compares to the way it is portrayed in films and television. As part of a class discussion, excerpts from various combat movies may be shown that illustrate the stresses associated with war.

Web Links Web Link 4.1: http://www.istss.org/ The International Society for Traumatic Stress Studies home page provides Society-published fact sheets about traumatic stress and a wide variety of other materials for professionals, media, and the general public.

Web Link 4.2: http://www.aaets.org/arts/art13.htm The American Academy of Experts in Traumatic Stress home page provides articles and information on traumatic events.

Web Link 4.3: http://www.ncptsd.org/index.html The National Center for PTSD sponsors this Web site, which serves as an educational resource concerning PTSD and other enduring consequences of traumatic stress.

Web Link 4.4: http://www.emedicine.com/med/topic3348.htm This Web site provides a brief summary of treatments for adjustment disorder, provided by emedicine.com.

Web Link 4.5: http://www.mentalhealthamerica.net/index.cfm?objectid=ABD3DC4E-1372-4D20C8274399C9476E26 This is an article that uses the FAQ format to discuss how to become aware of stressors and how to recognize what you can change to reduce stress.

Web Link 4.6: http://psychcentral.com/disorders/sx44.htm Here is an overview of acute stress disorder, which describes the symptoms of this disorder and provides diagnostic information.

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Video Resources Abused Women Who Fought Back: The Framingham Eight. Princeton, NJ: Films for the Humanities and Social Sciences.

Breaking Silence. Sherborn, MA: Aquarius Health Care Videos.

Breathing Away Stress. Beyond Stress Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Can’t Slow Down. Allyn and Bacon Video Library.

Caught in the Speed Trap: Information Age Overload. Allyn and Bacon Video Library.

Coping with Stress. Allyn and Bacon Video Library.

Focusing the Mind. Beyond Stress Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Grief and Healing. Allyn and Bacon Video Library.

Handling Stress: Today and Tomorrow. Princeton, NJ: Films for the Humanities and Social Sciences.

Kids and Stress. Princeton, NJ: Films for the Humanities and Social Sciences.

Managing Stress. Allyn and Bacon Video Library.

The Nature of Stress—Vol. 2, The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection.

Off Limits. New York, NY: The Cinema Guild.

A One and a Two. New York, NY: Filmmakers Library.

One Nation Under Stress. Allyn and Bacon Video Library.

Post-Traumatic Stress Disorder. Princeton, NJ: Films for the Humanities and Social Sciences.

Post-Traumatic Stress Disorder—#1 ABC News and Client Interviews. Allyn and Bacon Abnormal Psychology Video.

Post-Traumatic Stress Disorder—Anxiety-Related Disorders: The Worried Well Video Series.

Princeton, NJ: Films for the Humanities and Social Sciences.

Post-Traumatic Stress Disorder: The Woman’s Perspective. Princeton, NJ: Films for the Humanities and Social Sciences.

Reducing Stress. Princeton, NJ: Films for the Humanities and Social Sciences.

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The Relaxation Response. Beyond Stress Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Relaxing Muscle Tension. Beyond Stress Series. Princeton, NJ: Films for the Humanities and Social Sciences.

A Room Full of Men: Therapy for Abusive Men. New York, NY: Filmmakers Library.

Running Out of Time: Time Pressure, Overtime, and Overwork. Princeton, NJ: Films for the Humanities and Social Sciences.

The Session. Beyond Stress Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Sexual Harassment. Princeton, NJ: Films for the Humanities and Social Sciences.

Stress and Emotion. The Brain Series. South Burlington, VT: Annenberg/CPB Collection.

Stress: Keeping Your Cool. Allyn and Bacon Video Library.

Stress: Locus of Control and Predictability—The Brain Teaching Modules Video Series. South Burlington, VT: Annenberg/CPB Collection.

Stress, Trauma, and the Brain. Allyn and Bacon Video Library.

Strong at the Broken Places: Turning Trauma into Recovery. Cambridge, MA: Cambridge Documentary Films.

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Handout 4.1 The Social Readjustment Rating Scale 1.

Death of a spouse ...........................................

100 2.

Divorce...........................................................

73 3.

Marital separation ..........................................

65 4.

Jail term..........................................................

63 5.

Death of a close family member ....................

63 6.

Personal injury or illness................................

53 7.

Marriage.........................................................

50 8.

Fired from work .............................................

47 9.

Marital reconciliation.....................................

45 10.

Retirement......................................................

45 11.

Change in health of family member...............

44 12.

Pregnancy.......................................................

40 13.

Sex difficulties ...............................................

39 14.

New family member ......................................

39 15.

Business readjustment....................................

39 16.

Change in financial state................................

38 17.

Death of close friend......................................

37 18.

Change to a different line of work .................

36 19.

Change in number of arguments with spouse .

35 20.

Mortgage over $10,000..................................

31 21.

Foreclosure of mortgage or loan ....................

30 22.

Change in responsibilities at work.................

29 23.

Child leaving home ........................................

29 24.

Trouble with in-laws ......................................

29 25.

Outstanding personal achievement ................

28 26.

Spouse begins or stops work..........................

26 27.

Begin or end school .......................................

26 28.

Change in living conditions ...........................

25 29.

Revision of personal habits............................

24 30.

Trouble with boss...........................................

23 31.

Change in work hours or conditions ..............

20 32.

Change in residence .......................................

20 33.

Change in schools ..........................................

20 34.

Change in recreation ......................................

19 35.

Change in church activities............................

19 36.

Chance in social activities..............................

19 37.

Mortgage or loan less than $10,000...............

17 38.

Change in sleeping habits ..............................

16 39.

Change in number of family get-togethers ....

15 40.

Change in eating habits..................................

15 41.

Vacation .........................................................

13 42.

Christmas .......................................................

12 43.

Minor violations of the law............................

11 From: Holmes and Rahe (1967)

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Handout 4.2 Institutional Stress Reduction

Many institutions are trying to reduce or eliminate stress wherever possible. This effort begins with a process of identifying the sources of stress by consulting the people who ought to know—the people experiencing the stress. At your school, that’s you! Imagine that your school wants to eliminate unnecessary stress. What should they focus on, and how should they go about doing it?

1.

What are some major sources of stress at your school?

2.

On a scale from 1 to 10, where 1 is not at all stressful and 10 is extremely stressful, weight the stressfulness of each of the items listed in #1 above.

3.

Starting with the most stressful, and working your way down to the least stressful, briefly describe how your school could deal with the stressors you’ve identified. Try to think of stress reduction programs that reduce stress without altering the fundamental nature of the activities.

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Handout 4.3 Date Rape—Myths or Reality?

•

A woman who gets raped usually deserves it, especially if she has agreed to go to a man’s house or park with him.

•

If a woman agrees to allow a man to pay for dinner, drinks, etc., then it means she owes him sex.

•

Acquaintance rape is committed by men who are easy to identify as rapists.

•

Women who don’t fight back haven’t been raped.

•

Intimate kissing or certain kinds of touching mean that intercourse is inevitable.

•

Once a man reaches a certain point of arousal, sex is inevitable and he can’t help forcing himself upon a woman.

•

Most women lie about acquaintance rape because they have regrets after consensual sex.

•

Women who say “no” really mean “yes.”

•

Certain behaviors, such as drinking or dressing in a sexually appealing way, make rape a woman’s responsibility.

.

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Handout 4.4 Crisis Intervention

Interview civic, institutional, or facility authorities about their disaster plans: 1.

What training is given for crisis intervention?

2.

What services are available for people following a crisis?

3.

What use is made of volunteers?

4.

What are the most common problems encountered?

5.

What are the typical outcomes following services?

6.

Are there any special or unique issues requiring special handling within your disaster plan?

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CHAPTER 5: Panic, Anxiety, and Their Disorders Chapter At-A-Glance Detailed Outline

Instructors’ Resources

Print Supplements

Media Supplements

The Fear and Anxiety Response Patterns

Teaching Objectives 5.1, 5.2 Chapter Guide Lecture Launchers 5.1, 5.2 Activities 5.3 Web Links 5.1, 5.4

Test Bank Grade Aid Transparencies T-40

CD-ROM PowerPoint

Overview of the Anxiety Disorders and Their Commonalities

Teaching Objectives 5.3, 5.4 Chapter Guide Lecture Launchers 5.1, 5.2 Activities 5.4, 5.5 Web Links 5.1, 5.4

Test Bank Grade Aid

CD-ROM PowerPoint

Specific Phobias • Prevalence, Age of Onset and Gender Differences • Psychological Causal Factors • Biological Causal Factors • Treatments

Teaching Objectives 6.3 Chapter Guide Lecture Launchers 6.4 Activities 6.1, 6.2, 6.5 Web Links 6.1, 6.4

Test Bank Grade Aid

CD-ROM PowerPoint

Social Phobias • Prevalence, Age of Onset and Gender Differences • Psychological Causal Factors • Biological Causal Factors • Treatments

Teaching Objectives 5.3 Chapter Guide Lecture Launchers 5.1, 5.2, 5.3, 5.4, 5.5 Activities 5.4, 5.5 Web Links 5.1

Test Bank Grade Aid

CD-ROM PowerPoint

Panic Disorder with and without Agoraphobia • Panic Disorder • Agoraphobia • Prevalence, Age of Onset, and Gender Differences • The Timing of a First Panic Attack • Biological Causal Factors • Psychological Causal Factors • Treatments

Teaching Objectives 5.4–5.8 Chapter Guide Lecture Launchers 5.1, 5.2, 5.4, 5.5 Activities 5.5 Web Links 5.2, 5.3

Test Bank Grade Aid Transparencies T-41 to T-44

CD-ROM PowerPoint

Generalized Anxiety Disorder • Prevalence, Age of Onset and Gender Differences • Psychological Causal Factors • Biological Causal Factors • Treatments

Teaching Objectives 5.9–5.10 Chapter Guide Lecture Launchers 5.3, 5.5 Activities 5.1, 5.2, 5.5 Web Links 5.1, 5.4

Test Bank Grade Aid

CD-ROM PowerPoint

Obsessive-Compulsive Disorder • Prevalence, Age of Onset and Gender Differences • Psychological Causal Factors • Biological Causal Factors • Treatments

Teaching Objectives 5.11 Chapter Guide Lecture Launchers 5.3 Activities 5.1, 5.2, 5.5 Web Links 5.1, 5.2, 5.4

Test Bank Grade Aid Transparencies T-45

CD-ROM PowerPoint ABC Video Clip #3

Sociocultural Causal Factors for All Anxiety Disorders • Cultural Differences in Sources of Worry • Taijin Kyofusho

Teaching Objectives 5.12 Chapter Guide Lecture Launchers 5.1, 5.2 Activities 5.4 Web Links 5.5, 5.6

Test Bank Grade Aid

CD-ROM PowerPoint

Unresolved Issues: Compulsive Hoarding: Is it a

Teaching Objectives 4.11 Chapter Guide Lecture Launchers 4.5

Test Bank Grade Aid

Subtype of OCD?

.

Professor Notes

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Chapter 5: Panic, Anxiety, and Their Disorders

Teaching Objectives 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Compare and evaluate the merits of Freud’s use of the concept of anxiety in the etiology of the neuroses versus the descriptive approach used in DSM since 1980.

Distinguish between fear and anxiety.

Describe the major features of phobias, identify and differentiate different subtypes of phobia, explicate the major etiological hypotheses, and discuss the most effective treatment approaches.

List the diagnostic criteria for panic disorder, contrast panic attacks and other types of anxiety, and explain the association with agoraphobia. Summarize prevalence, age of onset, and comorbidity.

Describe recent findings on biological, behavioral, and cognitive influence for anxiety proneness.

Summarize the evidence that anxiety sensitivity constitutes a diathesis for development of panic attacks.

Describe how safety behaviors and cognitive biases help to maintain panic.

Compare and contrast the major treatment approaches for panic disorder and agoraphobia.

Summarize the central features of generalized anxiety disorder, and distinguish among psychoanalytic, conditioning, and cognitive theories of etiology.

Identify the central nervous system processes and structures associated with generalized anxiety disorder and evaluate treatments for the disorder.

Describe the defining features of obsessive-compulsive disorder, summarize theories of etiology along with supporting evidence (or the lack thereof), and outline the treatment of OCD. Provide several examples of sociocultural effects on anxiety disorders.

Chapter Overview/Summary Although anxiety disorders were initially considered neuroses, this term has been largely abandoned ever since DSM-III (1980). The anxiety disorders have panic or anxiety or both at their core.

Panic is a basic emotion that involves activation of the fight-or-flight response of the autonomic nervous system. Anxiety is more diffuse, including blends of high levels of negative affect, worry about possible threat or danger, and a sense that threats are unpredictable or uncontrollable. Although everyone has identifiable, rational, realistic sources of anxiety, people with anxiety disorders, by definition, have irrational sources of, and unrealistic levels of, anxiety. Mood-congruent information processing, such as attentional and interpretive biases, seems to maintain all anxiety disorders.

Specific phobias are intense and irrational fears of specific objects or situations accompanied by avoidance of the feared object. Stimuli may acquire phobic properties through conditioning or other learning mechanisms or through activation of constitutional predispositions. Because stimuli such as heights and menacing animals that posed a threat to our early ancestors are better able to become the target of phobias, it is thought that we are biologically “prepared” to associate them with trauma.

Social phobia involves disabling fears, or even panic attacks, in one or more social situations, usually out of fear of negative evaluation by others or fear of acting in an embarrassing or humiliating manner. Social stimuli signaling dominance and aggression from other humans, including facial expressions of anger or contempt, make a person appear “prepared” in the evolutionary sense to elicit phobic responses. The preoccupation with negative self-evaluative thoughts characteristic of social phobia tends to interfere with the ability to interact in socially skillful ways.

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Panic disorder involves unexpected panic attacks that often create a sense of stark terror, which usually subsides in a matter of minutes. The fear of future panic attacks is known as “anxious apprehension.” Many people with panic disorder also develop agoraphobic avoidance of situations in which they fear they might have an attack and would find it difficult to escape or would be especially embarrassing. According to the conditioning theory of panic disorder, interoceptive bodily symptoms associated with early stages of prior attacks themselves become able to elicit panic attacks. According to the cognitive theory of panic disorder, it is the catastrophic misinterpretation of these bodily cues that produces panic attacks, especially among those with high levels of preexisting anxiety sensitivity.

Biological theories of panic disorder emphasize biochemical abnormalities in the brain as well as abnormal activity of the neurotransmitter norepinephrine and probably also serotonin. The area of the brain known as the amygdala is thought to be an especially important source of panic attacks.

Generalized anxiety disorder (GAD) involves chronic and excessive worry about a number of events or activities and high levels of psychic and muscle tension. People with GAD may have extensive experience with unpredictable and/or uncontrollable life events as well as having schemas through which strange and dangerous situations promote automatic thoughts focused on possible threats. The neurobiological bases of GAD differ from those related to panic disorder involving the neurotransmitter GABA and the limbic system of the brain.

Obsessive-compulsive disorder (OCD) involves unwanted and intrusive distressing thoughts or images usually accompanied by compulsive behaviors designed to neutralize those thoughts or images.

Checking and cleaning rituals are most common. Genetic, brain function imaging, and psychopharmacological studies all suggest significant biological contributions to OCD. The anxietyreducing qualities of the compulsive rituals may help maintain OCD. Medical treatments of people with anxiety disorders often include antianxiety and antidepressant medications. These medications suppress anxiety symptoms, have high addiction potential, and tend to be associated with high relapse rates once the medications are discontinued. Behavioral and cognitive therapies are effective for anxiety disorders. Behavior therapies involve prolonged exposure to feared situations to allow fear or anxiety to habituate. With OCD, the rituals also must be prevented following exposure to the feared situations. Cognitive therapies focus on getting clients to understand their underlying automatic thoughts, which often involve cognitive distortions such as unrealistic predictions of catastrophes that in reality are very unlikely to occur, and to change these thoughts and beliefs through cognitive restructuring.

Detailed Lecture Outline I.

II.

The Fear and Anxiety Response Patterns A. Fear and panic activate the fight-or-flight response 1.

Cognitive/subjective components 2.

Physiological components 3.

Behavioral components B. Anxiety is a complex blend of unpleasant emotions and cognitions that is both more oriented to the future and much more diffuse than fear 1.

Adaptive value 2.

Has cognitive/subjective, physiological, and behavioral components C. Unconditional versus learned sources of fear and anxiety 1.

Conditionability of fear 2.

External versus internal (interoceptive) cues Overview of the Anxiety Disorders and Their Commonalities A. Unrealistic and Irrational Fears of Disabling Intensity B. DSM-IV-TR recognizes seven anxiety disorders .

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III.

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1.

Phobic disorders—specific and social 2.

Panic disorder with or without agoraphobia 3.

Generalized anxiety disorder 4.

Obsessive-compulsive disorder 5.

Post-traumatic stress disorder (discussed in Chapter 4) C. Anxiety Disorders Are Relatively Common 1.

Most common group of disorders among women 2.

Comorbidity is typical 3.

Phobias are the most common of the anxiety disorders 4.

Commonalities in causes across these disorders a.

Common genetic vulnerability is the personality trait of neuroticism b.

Brain structures most commonly involved are generally in the limbic system c.

Most common neurotransmitters involved are GABA, norepinephrine, and serotonin d.

Classical conditioning is common e.

People with perceptions of lack of control over their environment and their emotions are more vulnerable 5.

Commonalities across effective treatments a.

Graduated exposure is the single most effective treatment b.

Cognitive restructuring c.

Anti-anxiety and antidepressants medications Specific Phobias A. Five subtype of specific phobias: 1.

Animal 2.

Natural Environment 3.

Blood-Injection-Injury Phobia a.

Occurs in about 3 to 4% of the population b.

Disgust is as typical a response as fear c.

Initial heart acceleration followed by drop in rate and pressure d.

Nausea, dizziness, and fainting 4.

Situational 5.

Other (choking, vomiting, ‘space phobia’) B. Prevalence, Age of Onset, and Gender Differences 1.

Common in women 2.

Lifetime prevalence rate of about 12% 3.

Animal, dental, and blood-injection-injury phobias begin in childhood 4.

Driving phobia and claustrophobia begin in adolescence and early adulthood C. Psychological Causal Factors 1.

Psychodynamic view of phobia as defense against anxiety via repression of id impulses; anxiety is then displaced onto some external object or situation symbolically linked to the real object of the anxiety 2.

Phobias as learned behavior a.

Classical conditioning and generalization b.

Direct traumatic conditioning 3.

Vicarious conditioning of phobic fears 4.

Individual differences in learning a.

History of previous positive experiences reduces the likelihood of a phobia developing .

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IV.

b.

Events during conditioning such as inescapable and uncontrollable events c.

Experiences after a conditioning event such as the inflation effect d.

Cognitive factors maintaining phobias 5.

Evolutionary preparedness for learning certain fears and phobias a.

Primates and humans seem to be evolutionarily prepared to rapidly associate certain objects—such as snakes, spiders, water, and enclosed spaces—with frightening or unpleasant events b.

Subliminal activation of responses to phobic stimuli may explain why those with phobias may not be able to control their fear because the fear may arise from cognitive structures that are not under conscious control D. Biological Causal Factors 1.

Affect the speed and strength of conditioning of fear 2.

Behavioral inhibition and fear E. Treatments 1.

Exposure therapy 2.

Participant modeling 3.

Cognitive and pharmacological treatments ineffective 4.

Some evidence that anti-anxiety medications may interfere with the positive effects of exposure therapy 5.

Recent evidence that a drug called d-cycloserine may enhance the effectiveness of exposure therapy in a virtual reality environment; by itself, it has no effect Social Phobias A. Prevalence, Age of Onset, and Gender Differences 1.

12 percent of the population 2.

60 percent of those diagnosed with a social phobia are women 3.

Typically begin during adolescence or early adulthood 4.

Half will experience a second anxiety disorder or depression 5.

Approximately 1/3 abuse alcohol to help them deal with their fear 6.

Only 37 percent recover spontaneously B. Psychological Causal Factors 1.

Social phobias as learned behavior a.

Direct or vicarious conditioning, such as experiencing or witnessing a perceived social defeat or humiliation, or being or witnessing someone else being the target of anger or criticism b.

Those with social phobia are also more likely to have grown up with parents who were socially isolated and avoidant 2.

Social fears and phobias in an evolutionary context a.

Proposes that social phobias are a by-product of dominance hierarchies b.

Evolutionarily based predisposition involving activation of the amygdala 3.

Perceptions of uncontrollability and unpredictability a.

Lead to submissive and unassertive behavior b.

Likelihood increases if person has experienced an actual social defeat c.

Diminished sense of personal control that may, in part, have developed from overprotective parents 4.

Cognitive biases a.

Danger schemas concerning others b.

Expect they will behave in an awkward and unacceptable way resulting in rejection

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c.

V.

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Preoccupied with bodily responses and negative self-images in social situations C. Biological Causal Factors 1.

Genetic and temperamental factors a.

Most important temperamental variable is behavioral inhibition b.

Twin studies show modest contribution of genetics; about 20% of the variance D. Treatments 1.

Cognitive and behavioral therapies a.

Prolonged and graduated exposure b.

Cognitive restructuring focused on identifying and challenging negative, automatic thoughts may be more effective than traditional cognitive approaches, exposure, or medications 2.

Medications a.

Antidepressants may also be effective Panic Disorder with and without Agoraphobia A. Panic Disorder 1.

As many as 85% seek help from an emergency room or doctor’s office 2.

Attacks may be “unexpected” or uncued; may also be related to situational factors B. Agoraphobia 1.

Conceptualized as a complication of repeated panic attacks in varied situations 2.

“Agora” is the Greek word for public places of assembly 3.

Case study of John D. C. Agoraphobia without Panic 1.

Usually a gradually spreading fearfulness 2.

Most recent estimate of lifetime prevalence is 1.4 percent D. Prevalence, Age of Onset, and Gender Differences 1.

4.7 percent of adult population reports panic disorder with or without agoraphobia 2.

Panic disorder with or without agoraphobia often starts in late adolescence but the average age of onset is 23-34 3.

Panic disorder is twice as common in females and agoraphobia is also more common in women, probably for sociocultural reasons 4.

High comorbidity of panic disorder, at least 83 percent, with other anxiety disorders 5.

50–70% of those with panic disorder will experience serious depression E. The Timing of a First Panic Attack 1.

Frequently follows feelings of distress or a highly stressful life situation 2.

Panic attacks more common (23% of population) than panic disorder F. Biological Causal Factors 1.

Genetic factors a.

Only moderate heritability; 33 to 43 percent of the variability b.

Vulnerability is manifested at a psychological level by neuroticism c.

Heritability is probably for panic disorder and phobias 2.

Panic and the brain a.

Increased activity of the amygdala—emotion of fear b.

Amygdala connects to locus coeruleus and the prefrontal cortex in a fear network that may be abnormally sensitive in those who develop panic disorder c.

Hippocampus implicated in conditioned anxiety .

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d.

Higher cortical centers mediate cognitive symptoms Biochemical abnormalities a.

Biological challenge procedures or panic-provocation procedures suggest that no single neurobiological mechanism is implicated b.

Noradrenergic and serotonergic systems implicated c.

GABA recently shown to be implicated in anticipatory anxiety Psychological Causal Factors 1.

Comprehensive learning theory of panic disorder a.

Initial panic attacks become associated with initially neutral internal (interoceptive) and external (exteroceptive) cues through a conditioning process b.

Sets the stage for anticipatory anxiety and agoraphobia c.

Panic attacks themselves are likely conditioned to certain internal cues d.

People with certain genetic, temperamental/personality (neuroticism), or cognitive-behavioral vulnerabilities will show stronger conditioning of both anxiety and panic 2.

The cognitive theory of panic a.

Catastrophic interpretations of bodily sensations b.

Automatic thoughts become the triggers of panic c.

Evidence that cognitive therapy for panic is successful supports the prediction that changing cognitions about bodily symptoms may reduce or prevent panic 3.

Learning and cognitive explanations of results from panic provocation studies a.

Cognitive theorists argue that people with panic attacks misinterpret these symptoms as the beginning of a panic attack or a heart attack, which in turn induces the vicious circle of panic b.

Learning theorists argue that only those with panic disorder for whom these cues might serve as interoceptive CSs that can trigger anxiety and panic because of their prior associations with panic c.

Learning theory better than cognitive model at explaining nocturnal panic attacks and panic attacks that occur without any preceding negative (catastrophic) automatic thoughts 4.

Anxiety sensitivity and perceived control a.

Anxiety sensitivity is a trait-like belief that certain bodily sensations may have harmful consequences b.

Anxiety sensitivity predicted development of spontaneous panic attacks during a highly stressful period c.

Psychological manipulations, such as having a sense of perceived control or having a “safe” person, may block panic 5.

Safety behaviors and the persistence of panic a.

Disconfirmation does not occur because people with panic disorder engage in “safety behaviors” such as breathing slowly b.

Safety behaviors believed to prevent catastrophe c.

Safety behaviors need to stop for effective treatment 6.

Cognitive biases and the maintenance of panic a.

People with panic disorder interpret ambiguous bodily sensations and situations as threatening b.

Attentional bias toward threat cues c.

Memory bias favoring threatening information 3.

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Treatments 1.

Medications a.

Benzodiazepines/Anxiolytics, e.g., Xanax and Klonopin (1) Rapid effects within 30 to 60 minutes (2) Addictive (3) Withdrawal must be gradual (4) Rebound panic and relapse (5) Because of these problems, no longer used as first choice of drug b.

Antidepressants (primarily the SSRIs) (1) Non-addictive and can alleviate comorbid depressive symptoms (2) Slow effects—may take up to four weeks (3) Side-effect problems—SSRIs interfere with sexual arousal (4) High relapse rates 2.

Behavioral and cognitive-behavioral treatments a.

Prolonged exposure alone effective in 60–75% of patients b.

Interoceptive exposure to target internal sensations c.

Cognitive restructuring to address catastrophic thought d.

Panic control treatment targets both avoidance and panic attacks and is an example of an integrate cognitive-behavioral treatment e.

Effective in 75-95% of those with panic disorder and results superior to medication f.

Clients who have been on medication, with or without cognitivebehavioral treatments, have a higher rate of relapse

Generalized Anxiety Disorder A. Prevalence, Age of Onset, and Gender Differences 1.

GAD involves a future-oriented mood state of chronic worry and “anxious apprehension” 2.

Common symptoms include being restless, easily fatigued, poor concentration, irritable, tense, indecisive with high vigilance, muscle tension, and sleep disturbance 3.

Relatively common with lifetime prevalence around 5.7% 4.

42% do not spontaneously recover 5.

Twice as common in women 6.

Most continue to function despite symptoms 7.

Age of onset difficult to determine with as many as 60–80% report being anxious all their lives 8.

Seen with other Axis I disorders, especially other anxiety and mood disorders 9.

Excessive use of tranquilizing drugs, sleeping pills, and alcohol complicates the clinical picture B. Psychological Causal Factors 1.

The psychoanalytic viewpoint a.

Unconscious conflict between id and ego b.

Defenses broken down or never developed c.

Theory is not testable and has basically been abandoned 2.

Perceptions of uncontrollability and unpredictability a.

Cognitive processes associated with prior aversive events b.

Unpredictability of important past events generalizes to future ones c.

Lack of safety signals .

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3.

VII.

The central role of worry and its positive functions a.

Benefits of worry identified by people with GAD: superstitious avoidance of catastrophe, avoidance of deeper emotional topics, and coping and preparation for events b.

Suppression of emotional and aversive physiological responding may serve to reinforce the process of worry c.

Worry impairs the processing of the event thereby preventing fear from being extinguished 4.

The negative consequences of worry a.

Worrying is itself not pleasant b.

Attempts to control thoughts and images actually increase them 5.

Cognitive biases for threatening information a.

Attention is drawn toward threat cues b.

Interpret ambiguous stimuli as threats C. Biological Causal Factors 1.

Genetic factors a.

Small to modest heritability with 15 to 20% of variance b.

Inherited predisposition is to neuroticism (proneness to experience negative mood states); shared with major depression 2.

Neurotransmitter and neurohormonal abnormalities a.

A functional deficiency of GABA b.

The corticotrophin-releasing hormone system and anxiety c.

Neurobiological differences between anxiety and panic (1) Biology of panic and GAD are not the same (2) Amygdala and fight-or-flight for fear and panic, limbic system for GAD D. Treatments 1.

Medications a.

Benzodiazepines not as effective as believed by public b.

Buspirone is a new, nonaddictive, nonsedating, but slow drug c.

Antidepressants are useful 2.

Cognitive behavior therapy that involves applied muscle relaxation and cognitive restructuring is as effective as benzodiazepines and with fewer drop-outs Obsessive-Compulsive Disorder A. Prevalence, Age of Onset, and Gender Differences 1.

Not as rare as once thought, 1.6% lifetime prevalence 2.

Over 90% of those who present for treatment experience both obsessions and compulsions; if including mental rituals and compulsions, this jumps to 98% 3.

Divorced and unemployed people overrepresented 4.

Little or no gender difference in many studies; recent British study show women with slightly higher rates (1.4% to 1%) 5.

Typically begins in late adolescence or adulthood but is not uncommon in children 6.

Early onset more common in boys and is usually associated with more severe symptoms 7.

Gradual onset and chronic once serious 8.

Depression is especially common, up to 80% may experience significant depressive symptoms

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9.

B.

C.

D.

A related disorder is Body Dysmorphic Disorder (BDD) with 12% of those with OCD also exhibiting BDD Characteristics of OCD 1.

Types of obsessive thoughts a.

Contamination fears, harming self or others, lack of symmetry, pathological doubt, sexual obsessions, and obsessions concerning religion or aggression b.

Obsessions rarely carried out 2.

Types of compulsions a.

Five primary types: cleaning, checking, repeating, ordering/arranging, and counting b.

Performance of act brings feeling of reduced tension and satisfaction, as well as a sense of control Psychological Causal Factors 1.

OCD as learned behavior a.

Mowrer’s two-process theory of avoidance learning b.

Core of the most effective form of behavior therapy for OCD c.

Does not explain development of obsessions or abnormal assessments of risk 2.

OCD and preparedness a.

Some fears have occurrence rates that seem nonrandom b.

Obsessions also adaptive in evolutionary terms c.

Displacement activities seen in animals under stress seem similar to compulsive rituals seen in OCD 3.

Cognitive causal factors a.

The effects of attempting to suppress obsessive thoughts (1) Thought suppression may lead to paradoxical increase in those thoughts later (2) Normal and abnormal obsessions differ in degree to which they are resisted b.

Appraisals of responsibility for intrusive thoughts (1) Inflated sense of responsibility may lead to thought-action fusion Biological Causal Factors 1.

Genetic factors a.

Moderately high heritability with 54/80 monozygotic twins concordant b.

Heritability may be explained, partially, in terms of neuroticism c.

Early onset OCD has a higher genetic loading than later onset OCD 2.

OCD and the brain a.

Abnormally active metabolic levels in the orbital frontal cortex, caudate nucleus (part of the basal ganglia), and the cingulate cortex b.

Brain functions normalize after behavior or pharmacotherapy c.

Dysfunction of the cortico-basal-ganglionic-thalamic circuit leading to inappropriate behavioral responses that are normally inhibited 3.

Neurotransmitter abnormalities a.

Anafranil (clomipramine) and Prozac, that specifically target serotonin, often effective b.

Drugs must be taken at least six to twelve weeks before changes noted c.

Leads to a functional decrease in availability of serotonin .

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d.

Serotonin, by itself, is not a sufficient explanation; investigating other neurotransmitters

E.

VIII.

IX.

Treatments 1.

Behavioral and cognitive-behavioral treatments a.

Exposure and response prevention most effective b.

Success in 50–75% of patients; this is superior to medication 2.

Medications a.

Anafranil and Prozac, both impacting serotonin levels, most commonly used; 40 to 60% of patients show a least a 25 to 35% reduction in symptoms b.

Mau use small doses of antipsychotics if patients fail to respond c.

Relapse rates high (up to 90%) following medication discontinuance d.

Combining medication with behavioral treatment has not been shown to be more effective in adults; one study showed promise in children e.

Neurosurgery being investigated once again with 35 to 45% of patients showing a 1/3 reduction in symptoms Sociocultural Causal Factors for All Anxiety Disorders A. Cultural Differences in Sources of Worry 1.

Within the United States, lifetime prevalence rates of off several anxiety disorders vary across racial/ethnic groups.

2.

Latin Americans from the Caribbean show higher rates of a variant of panic disorder called ataque de nervios 3.

Although almost all countries report anxiety disorders, rates vary from 2.4 percent (Shanghai, China) to 18.2 percent (United States) 4.

Yoruba culture in Nigeria indicates three clusters of symptoms associated with generalized anxiety: worry, dreams, and bodily complaints 5.

Culturally-related syndrome in China is called Koro B. Taijin Kyofusho 1.

Anxiety disorder symptoms unique to Japanese cultural patterns 2.

Fear of blushing, making eye contact, emitting an offensive odor Unresolved Issues: Compulsive hoarding: Is it a subtype of OCD? A. Occurs in approximately 10 to 30 percent of those diagnosed with OCD B. Increasing recognition that, on average, compulsive hoarders are more disabled than people with OCD without compulsive hoarding C. Poorer prognosis although behavioral approaches that have been modified are working and at least one medication has been identified D. Brain imaging studies find activity in different areas when comparing compulsive hoarders with OCD patients without compulsive hoarding suggesting that this may be a separate disorder

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Key Terms agoraphobia (p. 155) amygdala (p. 157) anxiety (p. 143) anxiety disorders (p. 144) anxiety sensitivity (p. 160) blood-injection-injury phobia (p. 146) cognitive restructuring (p. 153) compulsions (p. 169) exposure-and-response prevention (p. 174) exposure therapy (p. 149) exteroceptive conditioning (p. 143) fear (p. 143) generalized anxiety disorder (GAD) (p. 163)

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interoceptive conditioning (p. 158) neurosis (p. 142) neurotic disorders (p. 142) obsessions (p. 168) obsessive-compulsive disorder (OCD) (p. 168) panic attack (p. 154) panic disorder (p. 154) panic provocation procedures (p. 158) phobia (p. 145) prepared learning (p. 148) social phobia (p. 150) specific phobia (p. 145)

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Lecture Examples / Discussion Topics Lecture Launcher 5.1: “False Alarms” In discussing the comprehensive learning theory of panic, reactions to initial panic attacks are emphasized. A variety of external circumstances can lead up to initial attacks, but if people experiencing attacks fail to attribute the attacks to external circumstances, they might be left to imagine they are having heart attacks, dying, or going crazy instead. For instance, one might run up the stairs to get to an important meeting but nevertheless attribute physiological symptoms to cardiac problems, neglecting to consider the roles of upcoming meeting stress and of bounding up the stairs. Similarly, one might attribute feelings of dizziness and disorientation to “going crazy” when it might be more accurate to attribute these feelings to, say, a missed lunch and physical exertion. These points can be emphasized through a discussion of why pregnant women rarely experience panic attacks. One likely explanation is that pregnant women have a readily available attribution for any physiological symptoms they experience—the physiological changes associated with pregnancy. If students appreciate the role of attributions, they should be able to offer this explanation with fairly minimal prompting. It can further emphasize elements of the theory to discuss ambiguous circumstances, where ready attributions to external circumstances are not available to anyone. That is, even people prone to appropriately attribute panic symptoms to external circumstances might sometimes fail to identify any. In these ambiguous circumstances, any particular attribution is arbitrary, and the preference for catastrophizing attributions is what sets those prone to panic disorder apart from those who are not. The class might be asked to brainstorm benign alternatives to catastrophic interpretations. This would also be a good time to emphasize that medical rule-outs are always necessary before pursuing such psychological aspects of panic disorder.

Lecture Launcher 5.2: Thrills or Chills?

Bungee jumping, riding roller coasters, participating in extreme sports, watching scary movies, and parachuting all produce physiological reactions extraordinarily similar to panic attacks. Of course, they are not panic attacks, and this is likely to be related to the fact that the sensations being experienced are expected and, indeed, even sought after. Nevertheless, they are also frequently described as very fearprovoking—and that’s a big part of their appeal! A classroom discussion of fear-seeking and fearavoidance can help illustrate how cognitive and environmental factors can influence the experience of fear to a remarkable degree.

Lecture Launcher 5.3: Superstitious Behavior and Compulsions The behaviorist B. F. Skinner compared the compulsions observed in OCD with superstitious behavior he produced in pigeons under fixed-time schedules of reinforcement. These pigeons acted as if whatever they were doing before reinforcement had actually produced the reinforcement, even though their behavior was in fact irrelevant. Students will often admit to superstitious behaviors, like using their “lucky” exam pencil, wearing a special hat when their favorite sports team is playing, or avoiding stepping on sidewalk cracks. They are also likely to know some of the many superstitious behaviors engaged in by professional athletes and celebrities. What do superstitious behaviors and compulsions have in common? How are they different? Why don’t they extinguish? How do “popular” superstitions spread to many people? This might also be a good place to remind the students about negative reinforcement, which is the name given to increases in behavior due to the removal of a stimulus.

Superstitious behaviors and compulsions might appear to be negatively reinforced inasmuch as bad things don’t happen after they are engaged in. The compulsive cleaner can point to a long history of not catching deadly diseases in the same way the superstitious athlete can point to a long history of not failing. Handout 5.1 .

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Lecture Launcher 5.4: Overcoming Phobias Students are often more comfortable talking about their phobias when asked how they defeated them.

Alternatively, they can be asked how they intervened with their fears before they became full-blown phobias. For instance, they might be asked whether they recall things that made them fearful initially but about which they later became at ease. How did the initial apprehension come about? What did they think about it? Was there anything they did deliberately to combat the fear? What worked and what didn’t? These informal attempts can be compared to the more formal ones described in the book, and the characteristics of effective and ineffective self-help strategies can be explored in the context of therapeutic principles drawn out in the text.

Lecture Launcher 5.5: Medications A variety of issues about medications are nicely illustrated in the context of anxiety disorders. For one, students often associate medication with “cure” and are surprised to learn that once anxiety medications are discontinued, the underlying physiology of the disorder returns. That is, these medications control but do not cure the disorders for which they are being taken. Another medication issue concerns the way medications can undermine the effectiveness of behavior therapy for panic disorder. This can be used to re-examine the important features of effective behavior therapy. When students are asked why medication might undermine behavior therapy, they should recognize that medications can weaken exposure experiences and that medications provide complicating additional targets to which attributions about fear can be made and to which therapeutic progress can be credited.

Demonstrations / Activities Activity 5.1: Progressive Muscle Relaxation Progressive muscle relaxation (PMR) can be conducted on the entire class while they remain in their seats or else they can lie on the classroom floor if the room is suitable. Emphasize that PMR is a skill and that once people are skilled at relaxation they are well-equipped to benefit from many anxietyreducing therapies, such as systematic desensitization. Students often have many comments about the experience immediately after you complete the demonstration. An alternative approach to this exercise involves pairing students up and having them take turns being the therapist and the client. Handout 5.2 Activity 5.2: Systematic Desensitization Exercise Systematic desensitization is a popular technique to demonstrate in the classroom. To demonstrate systematic desensitization, a volunteer must be secured from the class or else a “guest” can be brought in especially for this purpose. The demonstration begins with a brief interview to determine what is anxiety-provoking for this person (simulated symptoms are suitable). Prompt the person for as many details as possible about the circumstances surrounding the fear; when it occurs, where it occurs, who else is there, coping strategies, how long it lasts, how it feels, etc. Write each scenario onto a separate index card. Then, you construct a fear hierarchy of about fifteen specific fear situations, ordered in terms of how anxiety-provoking they are. Tell the subject to signal you with a raised finger anytime anxious feelings occur. When the subject seems and reports being very relaxed, begin by describing the least anxiety-provoking situation from the hierarchy. Pause and let the subject imagine it for about ten seconds. Then ask the volunteer to stop imagining this situation and to relax once again. Proceed to the next scene from the hierarchy in the same way. If the person signals anxiety, ask him or her to stop visualizing the scene and to relax. If this is difficult to do, it might help to prearrange a relaxing scene to visualize. Once the volunteer is relaxed again, start with the image one step lower on the hierarchy than

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the one that prompted the anxiety and proceed as before. If the next step again provokes anxiety, it may be necessary to construct an intermediate step to soften the transition.

Activity 5.3: Rollercoasters Working individually, have each student imagine him or herself waiting in line to ride a rollercoaster.

Students are to record the physical sensations they would experience while waiting to get on the ride.

Warn students that you are interested only in physical sensations and that they are not to list their emotional reactions or thoughts. Once students have completed this task, have volunteers read their physical sensations. Make a list on the board or an overhead projector. Once again, eliminate any descriptors that interpret their physical sensations such as emotional reactions or thoughts. Once a thorough listing has been created that represents the responses of all students, have students raise their hands to indicate if they like rollercoasters or dislike them. Point out that their physical sensations are identical. Use this activity as a launching point to discuss cognitive appraisal and the importance of past experiences in interpreting events.

Activity 5.4: Commonalities among Social Phobias Social phobias are characterized by a fear of being humiliated or embarrassed in a public setting. These types of fears are quite common among college students. Using Handout 6.3, have each student find three people with different religious, cultural, or socioeconomic backgrounds to interview. Each person interviewed should be able to describe a social fear they have that might be similar to a social phobia.

Once the information is collected, have students share their findings with other students in a small group setting. Finally, have groups share what they found as similar features of social fears and describe how these commonalities cut across the different individuals they interviewed. Handout 5.3 Activity 5.5: Cognitive Restructuring For this exercise, ask the class to report the automatic thoughts associated with the various anxiety disorders. It can be helpful to select one disorder or else to structure the task by going through the disorders one-by-one. Student responses often feed off of each other and fairly comprehensive sets of thoughts are fairly quickly produced. Once a detailed set of these dysfunctional thoughts is produced, students can brainstorm therapeutic “challenges” to these thoughts as well as more functional coping thoughts. Alternatively, once the dysfunctional thoughts are listed, students can be asked to write them down and to generate challenges and replacement thoughts on their own as a homework assignment.

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Web Links Web Link 5.1: http://www.nimh.nih.gov/health/publications/anxiety-disorders/index.shtml National Institute of Mental Health brochure on anxiety disorders, covering symptoms and treatment of the major anxiety disorders. Also lists organizations to contact for further information.

Web Link 5.2: http://www.lexington-on-line.com/naf.html The National Anxiety Foundation home page provides information and links about panic disorder and obsessive-compulsive disorder.

Web Link 5.3: http://familydoctor.org/handouts/137.html This link takes you to the American Academy of Family Physicians “Panic Attacks and Agoraphobia” fact sheet.

Web Link 5.4: http://www.mentalhelp.net/poc/center_index.php?id=1 Mental Help Net provides an enormous amount of basic information as well as many Web links for anxiety disorders.

Web Link 5.5: http://www.emro.who.int/Publications/Emhj/0503/21.htm Useful description and case study of Koro including an historical explanation of the origin of this disorder.

Web Link 5.6: http://anthro.palomar.edu/medical/med_4.htm This site provides a list and description of many culture bound syndromes by culture. The site also provides links to other sites that describe culture bound syndromes.

Video Resources Anxiety Disorders—DSM-IV: New Diagnostic Issues Videotape Series. Allyn and Bacon Video Library.

The Anxiety Disorders—Vol. 3, The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection.

Body Dysmorphic Disorder—Anxiety-Related Disorders: The Worried Well Video Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Challenge Cases for Differential Diagnosis. Differential Diagnosis in Psychiatry Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Chronic Anxiety in the Elderly. Princeton, NJ: Films for the Humanities and Social Sciences.

Cognitive Therapy for Panic Disorder. Psychotherapy Videotape Series II: Specific Treatments for Specific Populations. Washington, DC: American Psychological Association.

Coping with Phobias. Princeton, NJ: Films for the Humanities and Social Sciences.

Getting Anxious. New York, NY: Insight Media.

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Mixed Anxiety and Depression: A Cognitive-Behavioral Approach with Dr. Donald Meichenbaum.

Assessment and Treatment of Psychological Disorders Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Obsessive-Compulsive Disorder: An Alternative Treatment. Allyn and Bacon Video Library.

Obsessive-Compulsive Disorder—Anxiety-Related Disorders: The Worried Well Video Series.

Princeton, NJ: Films for the Humanities and Social Sciences.

Obsessive-Compulsive Disorder: Pharmacotherapy and Psychotherapy—Treatments of Psychiatric Disorders Videotape Series. Allyn and Bacon Video Library.

Obsessive-Compulsive Disorder, Tanya—Patient Interview Video for Abnormal Psychology (12th ed.).

Allyn and Bacon Video Library.

OCD Clinic—#2 ABC News and Client Interviews. Allyn and Bacon Abnormal Psychology Video.

Panic. Sherborn, MA: Aquarius Health Care Videos.

Panic. Princeton, NJ: Films for the Humanities and Social Sciences.

Panic Attacks—Anxiety-Related Disorders: The Worried Well Video Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Panic Attacks: Causes and Treatments. Princeton, NJ: Films for the Humanities and Social Sciences.

Phobias: Overcoming the Fear. New York, NY: Filmmakers Library.

Secret Fears: Phobias. The Nature of Things Series. New York, NY: Filmmakers Library.

Sedatives. Drugs: Uses and Abuses Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Self-Harm. Anxiety-Related Disorders: The Worried Well. Princeton, NJ: Films for the Humanities and Social Sciences.

Step on a Crack: Obsessive Compulsive Disorder. Boston, MA: Fanlight Productions.

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Handout 5.1 Superstitious Behavior List common superstitious behaviors. Provide a possible reason for the development of the behavior.

Superstition

Reasons for the superstition

1.

2.

3.

4.

5.

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Handout 5.2 Progressive Muscle Relaxation

The idea behind Progressive Muscle Relaxation (PMR) is that muscle relaxation is incompatible with anxiety. In addition, PMR is a skill that can be learned. Therefore, it is important to pay very close attention to the differences between muscle tension and relaxation.

We will walk through a series of muscles. As we focus on each, you will flex each muscle for seven to ten seconds, in a smooth, strong squeeze. Do not strain or squeeze as hard as you can. Take special care when squeezing painful or injured parts of the body. Continue breathing throughout the lesson. After flexing each muscle group, abruptly let the muscle go completely limp, as limp as you can possibly get it, for about 15-20 seconds, focusing especially carefully on how it feels as you go from tense to relaxed.

As you let the muscle go completely limp, think to yourself “Re-laaaax.”

• • • • • • • • • • • • • • •

Start with three deep abdominal breaths, exhaling very slowly each time. As you exhale, imagine that tension throughout your body is already flowing away.

Clench your fists tightly. Hold for 7-10 seconds and then release for 15-20 seconds. Use these same time intervals for all other muscle groups.

Tighten your biceps by drawing your forearms up toward your shoulders and “making a muscle” with both arms. Hold . . .and then relax.

Tighten your triceps—the muscles on the undersides of your upper arms—by extending your arms out straight and locking your elbows. Hold . . . and then relax.

Tense the muscles in your forehead by raising your eyebrows as far as you can. Hold . . . and then relax. Imagine your forehead muscles becoming smooth and limp as they relax.

Tense the muscles around your eyes by clenching your eyelids tightly shut. Hold . . . and then relax.

Imagine sensations of deep relaxation spreading all around your eyes.

Tighten your jaws by opening your mouth so widely that you stretch the muscles around the hinges of your jaw. Hold . . . and then relax. Let your lips part and allow your jaw to hang loose.

Tighten the muscles in the back of your neck by pulling your head way back, as if you were going to touch your head to your back (be gentle with this muscle group to avoid injury). Focus only on tensing the muscles in your neck. Hold . . . and then relax.

Take a few deep breaths and tune in to the weight of your head sinking into whatever surface it is resting on.

Tighten your shoulders by raising them up as if you were going to touch your ears. Hold . . . and then relax.

Tighten the muscles around your shoulder blades by pushing your shoulder blades back as if you were going to touch them together. Hold the tension in your shoulder blades . . . and then relax.

Tighten the muscles of your chest by taking in a deep breath. Hold for up to 10 seconds . . . and then release slowly. Imagine any excess tension in your chest flowing away as you exhale.

Tighten your stomach muscles by sucking your stomach in. Hold . . . and then release. Imagine a wave of relaxation spreading through your abdomen.

Tighten your lower back by arching it up. (You should omit this exercise if you have lower back pain.) Hold . . . and then relax.

Tighten your buttocks by pulling them together. Hold . . . and then relax. Imagine the muscles in your hips going loose and limp.

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• •

Squeeze the muscles in your thighs all the way down to your knees. You will probably have to tighten your hips along with your thighs, since the thigh muscles attach at the pelvis. Hold . . . and then relax. Feel your thigh muscles smoothing out and relaxing completely.

Tighten your calf muscles by-pulling your toes toward you (flex carefully to avoid cramps). Hold . . . and then relax.

Tighten your feet by curling your toes downward. Hold . . . and then relax.

Mentally scan your body for any residual tension. If a particular area remains tense, repeat one or two tense-relax cycles for that group of muscles.

Now imagine a wave of relaxation slowly spreading throughout your body, starting at your head and gradually penetrating every muscle group all the way down to your toes.

• • •

The entire progressive muscle relaxation sequence should take you 20-30 minutes the first time. With practice you may decrease the time needed to 15-20 minutes. You can record the above exercises on an audio cassette to expedite your early practice sessions. Or you may wish to obtain a professionally made tape of the progressive muscle-relaxation exercise. Some people always prefer to use a tape, while others have the exercises so well learned after a few weeks of practice that they prefer doing them from memory.

Adapted from Goldfried, M.R., & Davison, G. (1994). Clinical behavior therapy (expanded edition).

New York: Wiley.

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Handout 5.3 Social Fears and Phobias Characteristics of person

Description of fear

What problems has this fear caused the person?

• Does the person avoid certain activities?

• Does the person experience any physical symptoms?

How does the person attempt to cope with this fear?

Interview #1

Interview #2

Interview #3

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CHAPTER 6: Mood Disorders and Suicide Chapter At-A-Glance Detailed Outline

Instructors’ Resources

Print Supplements

Media Supplements

Mood Disorders What Are Mood Disorders?

• Type of Mood Disorders • The Prevalence of Mood Disorders

Teaching Objectives 6.1, 6.2 Chapter Guide Lecture Launcher 6.2 Activity 6.3 Web Links 6.1, 6.2, 6.3

Test Bank Grade Aid

CD-ROM PowerPoint

Unipolar Mood Disorders • Depressions That Are Not Mood Disorders • Dysthymic Disorder • Major Depressive Disorder

Teaching Objectives 6.3–6.6 Chapter Guide Lecture Launchers 6.1, 6.2 Activity 6.3 Web Links 6.1, 6.2, 6.3

Test Bank Grade Aid

CD-ROM PowerPoint

Causal Factors in Unipolar Mood Disorders • Biological Causal Factors • Psychosocial Causal Factors

Teaching Objectives 6.7 Chapter Guide Lecture Launcher 6.1 Activities 6.2, 6.3, 6.4 Web Links 6.1, 6.2, 6.3, 6.4

Test Bank Grade Aid Transparencies T-25 to T-27

CD-ROM PowerPoint

Bipolar Disorders • Cyclothymic Disorder • Bipolar Disorders (I and II)

Teaching Objectives 6.8 Chapter Guide Lecture Launcher 6.3 Activity 6.1 Web Links 6.1, 6.2, 6.4, 6.5

Test Bank Grade Aid Transparencies T-28

CD-ROM PowerPoint

Causal Factors in Bipolar Disorder • Biological Causal Factors • Psychological Causal Factors

Teaching Objectives 6.9 Chapter Guide Lecture Launcher 6.2 Activity 6.1 Web Links 6.1, 6.2, 6.4, 6.5

Test Bank Grade Aid

CD-ROM PowerPoint

Sociocultural Factors Affecting Unipolar and Bipolar Disorders • Cross-Cultural Differences in Depressive Symptoms • Cross-Cultural Differences in Prevalence • Demographic Differences in the United States

Teaching Objectives 6.10 Chapter Guide Lecture Launcher 6.2 Activity 6.3 Web Links 6.1, 6.2, 6.4, 6.5

Test Bank Grade Aid Transparencies T- 29 to T-30

CD-ROM PowerPoint ABC Video Clip #4

Treatments and Outcomes • Pharmacotherapy • Alternative Biological Treatments • Psychotherapy

Teaching Objectives 6.11- 6.13 Chapter Guide Lecture Launcher 6.5 Activities 6.2, 6.4 Web Links 6.2, 6.3, 6.4, 6.5

Test Bank Grade Aid Transparencies T-31 to T-35, T115

CD-ROM PowerPoint ABC Video Clip #5

Suicide The Clinical Picture and the Causal Pattern • Who Attempts and Who Commits Suicide?

• Suicide in Children • Suicide in Adolescents and Young Adults • Other Psychosocial Factors Associated with Suicide • Biological Causal Factors

Teaching Objectives 6.14–6.17 Chapter Guide Lecture Launchers 6.1, 6.3, 6.4, 6.5 Activities 6.5 Web Links 6.1, 6.2, 6.4, 6.5

Test Bank Grade Aid Transparencies T-36 to T-39

CD-ROM PowerPoint

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Chapter 6 · Mood Disorders and Suicide • Sociocultural Factors • Communication of Suicidal Intent • Suicide Notes Suicide Prevention and Intervention • Treatment of Mental Disorders • Crisis Intervention • Focus on High-Risk Groups and Other

Teaching Objectives 6.14–6.17 Chapter Guide Lecture Launchers 6.1, 6.3, 6.4, 6.5 Activities 6.5 Web Links 6.1, 6.2, 6.4, 6.5

Test Bank Grade Aid Transparencies T-36 to T-39

CD-ROM PowerPoint

Teaching Objectives 6.18 Chapter Guide Lecture Launchers 6.3, 6.4, 6.5 Activities 6.5 Web Links 6.4, 6.5

Test Bank Grade Aid

CD-ROM PowerPoint

Measures Unresolved Issues: Is There a Right to Die?

Teaching Objectives 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

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Describe mania and depression.

Discuss the prevalence of mood disorders in the United States as well as in other parts of the world and subgroup differences in prevalence rates.

Describe unipolar mood disorders.

Differentiate depressions that are not mood disorders from those that are.

Describe how dysthymia differs from major depressive disorder.

Describe criteria for diagnosing major depressive disorder and the subtypes.

Identify the major biological and psychosocial etiological theories and describe the best explanation for how depressions occur.

Differentiate among cyclothymia, bipolar I disorder, and bipolar II disorder.

Identify the major biological and psychosocial etiological theories in the bipolar disorders.

Explain how various sociocultural factors affect unipolar and bipolar disorders.

Trace the history of the development of antidepressants explaining how one class of antidepressants was replaced by another.

Present evidence for the effectiveness of biological and nonbiological treatments for unipolar depression. Identify what treatment(s) might be most supported.

Identify the most effective treatment package for bipolar disorders.

Discuss prevalence rates of suicide among people with mood disorders.

Describe who is likely to attempt suicide and who is likely to complete suicide.

Describe the various motives for suicide.

Explain the sociocultural and biological variables that affect suicide.

Evaluate the ethical issues involved in the right to die.

Chapter Overview/Summary Mood disorders (formerly called affective disorders) are those in which extreme variations in mood—either low or high—are the predominant feature. We all experience such variations at mild to moderate levels in the natural course of life, but for some people the extremity of moods in either direction becomes seriously maladaptive, even to the extent of suicide.

The vast majority of people with mood disorders have some form of unipolar depression— dysthymia or major depression. In these disorders, the person experiences a range of affective, cognitive,

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motivational, and biological symptoms including persistent sadness, negative thoughts about the self and the future, lack of energy or initiative to engage in formerly pleasurable activities, too much or too little sleep, and gaining or losing weight.

Unipolar depression may have multiple causes; traditional biological explanations have increasingly been shown to interact with more psychosocial factors. Among biological causal factors for unipolar depression there is evidence of a moderate genetic contribution to the vulnerability for major depression, but such evidence is not available for dysthymia. Moreover, major depressions are clearly associated with multiple interacting disturbances in neurobiological regulation including neurochemical, hormonal, and neurophysiological systems. Disruptions in sleep, circadian rhythms, and seasonal rhythms in depression are also prominent features of depression.

Among psychological theories of the causes of unipolar depression are those postulating stressful life events as causal factors and chronic stress. Personality variables, such as neuroticism or negative affect, may also serve as diatheses for depression. Psychodynamic and interpersonal theories of unipolar depressions emphasize the importance of early experiences (especially early losses and the quality of the parent-child relationship) as setting up a predisposition for depression. Beck’s cognitive theory focuses on dysfunctional beliefs (depressogenic schemas) as predispositions for depression. The reformulated helplessness theory focuses on attributions, arguing that attributions that are internal, stable, and global attributions would lead to depression. Hopelessness theory, a reformulation of helplessness theory, argues that when one feels hopeless and has a pessimistic attributional style, they are much more likely to become depressed. Interpersonal approaches have focused on social support, the effects of depression on others and marriage and family life.

In the bipolar disorders (cyclothymia and bipolar I and II disorders), the person experiences episodes of both depression and hypomania or mania. During manic or hypomanic episodes, the symptoms are essentially the opposite of those during a depressive episode.

For bipolar disorders, biological causal factors probably play an even stronger role than for unipolar disorders. The genetic contribution to bipolar disorder is among the strongest of any psychiatric disorders. Biochemical imbalances, abnormalities of the hypothalamic-pituitary-adrenal axis and disturbances in biological rhythms all play a role in bipolar disorder. Stressful life events may be involved in precipitating manic or depressive episodes. It is unlikely that they cause the disorder, but rather affect the timing and frequency of episodes of illness.

Mood disorders vary widely from culture to culture due to differing diagnostic practices and because the symptoms of depression appear to vary considerably across cultures. For example, in some non-Western cultures such as China and Japan where rates of depression are low, many of the psychological symptoms are not present. Prevalence rates for bipolar disorder are quite similar across cultures. Recurrent suicide attempts are higher in western societies. Within the United States, lower rates of depression are found among African Americans and Native Americans have higher rates. Higher rates of depression are also found in lower SES groups; bipolar disorder does not appear to be related to SES. Higher rates of both depression and bipolar have been found among individuals with high levels of achievement in the arts.

Treatment of unipolar depression may be successfully accomplished through CBT, behavioral activation therapy, interpersonal therapy, antidepressant drugs, and ECT. The biologically based treatments are more likely to lead to negative side effects, sometimes severe, and to result in greater chance of relapse or recurrence. Married couples in which one partner is experiencing depression are probably better treated with marital therapy. Bipolar disorder is most frequently treated with moodstabilizing drugs such as Lithium or one of the newer anticonvulsant drugs. Increasingly, however, psychosocial treatments are also being used with good effectiveness, especially in reducing the incidence of relapse or recurrence.

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Suicide is a constant danger with depressive syndromes of any type or severity. Accordingly, an assessment of suicide risk is essential in the proper management of depressive disorders. Until recently, suicide attempts were most common in people between the ages of 25 and 44 but it is now people between 18 and 24 who are most likely to attempt suicide. Although women are three times more likely to attempt suicide than men, men are four times more likely to complete suicide. The highest rate of completed suicides is in the elderly. Alarmingly, rates of suicide in young children and adolescents are increasing. Personality traits most associated with suicide are impulsivity, aggression, and pessimism.

Suicide is also associated with negative events that lead either to the loss of a sense of meaning in life and to hopelessness about the future. Biological factors may include genetic factors and alterations in serotonergic activity. Looking at sociocultural factors suggests that white males and young, Native American males have significantly higher suicide rates, suicide rates vary from one country to another, and that rates among Catholics and followers of Islam are low. Socially acceptable suicide is rare but occurred during WWII in Japan and among Islamic extremists today.

Research has demonstrated that more than 40% of those who commit suicide had communicated their suicidal intent in very clear and precise terms and another 30% had talked about death or dying in the months preceding their suicide. Only about 10 to 15 percent leave notes.

Suicide prevention (or intervention) programs generally consist of treating underlying mental disorders, crisis intervention in the form of suicide hotlines, and focusing on high-risk groups.

Detailed Lecture Outline I.

II.

Mood Disorders: What Are Mood Disorders?

A. Types of Mood Disorders 1.

Two key moods are mania and depression; can be mixed 2.

Unipolar depressive disorders 3.

Bipolar disorders 4.

Customary to differentiate among the mood disorders by severity and duration 5.

Hypomania is a milder form of mania B. The Prevalence of Mood Disorders 1.

Mood disorders occur with alarming frequency 2.

Lifetime prevalence rates of unipolar major depression is nearly 17%; lifetime rate of bipolar is 1% 3.

Women are overly represented in unipolar depression; no gender differences are typically found in bipolar disorder Unipolar Mood Disorders A. Depressions That Are Not Mood Disorders 1.

Loss and the grieving process a.

Bowlby identified four phases of normal response to the loss of a spouse or close friend b.

Four phases include numbing and disbelief, yearning and searching for the dead person, disorganization and despair, and reorganization 2.

Postpartum “blues” a.

May occur in mothers or fathers b.

Symptoms include emotional lability, crying easily, and irritability, often intermixed with happy feelings c.

50–70% of women experience the “blues” within ten days of giving birth d.

Incidence of major depression following childbirth no higher than at any other time unless postpartum “blues” is severe e.

Rare to have accompanying psychotic features .

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f.

III.

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Especially likely if new mother lacks social support, has difficulty adjusting to new demands, or if there is a history of depression B. Dysthymic disorder 1.

Depressed mood of mild to moderate intensity 2.

Primary hallmark is chronicity a.

Lifetime prevalence estimated at 2.5 to 6 percent b.

Average duration is five years c.

Chronic stress increases the severity of symptoms d.

High rates of relapse C. Major depressive disorder 1.

Cognitive, motivational, and biological symptoms a.

Intense symptoms marked with sadness, insomnia, diminished cognitive capacity, and low self-esteem b.

Lethargy and lack of motivation 2.

Anxiety symptoms are common 3.

Depression as a recurrent disorder a.

Average duration of an untreated episode is about 6 to 9 months b.

Recurrence is distinguished from relapse c.

Even between occurrences, many people continue to show some depressed symptoms 4.

Depression throughout the life cycle a.

1 to 3 percent of children can be diagnosed with major depression b.

Rates rise sharply during adolescence c.

Rates of depression among physically ill residents of nursing homes or residential care facilities are significantly higher than among older adults living at home 5.

Specifiers for major depressive episodes a.

Major depressive episode with melancholic features b.

Severe major depressive episode with psychotic features c.

Major depressive episode with atypical features d.

Recurrent major depressive episode with a seasonal pattern 6.

Double depression is defined as major depression co-existing with dysthymia Causal Factors in Unipolar Mood Disorders A. Biological Causal Factors 1.

Genetic influences a.

Three times more common among blood relatives b.

The monozygotic twin of a person with unipolar depression is twice as likely to develop unipolar depression as is a dizygotic twin c.

31–42% of variance in unipolar depression due to genetics d.

Serotonin transporter gene 2.

Neurochemical factors a.

Focus on two neurotransmitters of the monoamine class: norepinephrine and serotonin—monoamine hypothesis b.

Failure of research to support monoamine hypothesis c.

Dopamine dysfunction also plays a significant role in at least some forms of depression d.

Focus now on the interaction of neurotransmitters and how they affect cellular functioning 3.

Abnormalities of hormonal regulatory systems .

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a.

B.

Hypothalamic-pituitary-adrenal axis (1) Cortisol levels elevated in 20–40% of depressed outpatients and 60– 80% of severely depressed hospitalized patients (2) Elevations in cortisol may be due to failure of feedback mechanisms—dexamethasone (3) Recent evidence suggests that dexamethasone nonsuppression may be a general indicator of mental distress rather than specific to depression 4.

Neurophysiological and neuroanatomical influences a.

Depressed individuals show lower levels of EEG activity in the left hemisphere and higher levels in the right hemisphere b.

May be able to use this to identify persons at risk for unipolar depression 5.

Sleep and other biological rhythms a.

Sleep problems range from early morning awakening, periodic awakening during the night, and difficulty falling asleep b.

Enter the first period of REM after only sixty minutes and show greater amounts of REM sleep c.

Circadian rhythms (1) Size or magnitude of the circadian rhythm may be blunted (2) Circadian rhythm becomes desynchronized d.

Sunlight and seasons (1) Clear disturbances in circadian rhythm (2) Therapeutic use of light therapy Psychological Causal Factors 1.

Stressful life events as causal factors a.

Stressful life events involved in precipitating depression include loss of a loved one, serious threats to important relationships or one’s occupation, severe economic or health problems, events involving humiliation b.

Independent life events vs. dependent life events c.

Severely stressful life events play a causal role in about 20–50% of cases 2.

Mildly stressful events and chronic stress 3.

Vulnerability and invulnerability factors in responses to stressors 4.

Different types of vulnerabilities for unipolar depression a.

Personality and cognitive diathesis (1) Neuroticism or negative affectivity (2) Introversion (3) Negative patterns of thinking: internal, stable, and global b.

Early adversity as a diathesis (1) Early environmental adversity such as abuse, family turmoil, parental psychopathology, etc.

(2) Can lead to “stress inoculation” if adversity is moderate rather than severe and mediated by strengthening socioemotional and neuroendocrine resistance 5.

Psychodynamic theories a.

1917—Mourning and Melancholia b.

Regression to the oral stage followed by incorporation of the lost person— anger turned inward c.

Later psychodynamic theorists such as Klein and Jacobson emphasized the quality of the early mother-infant relationship .

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d.

Bowlby—attachment theory Beck’s cognitive theory a.

Depressogenic schemas / Dysfunctional beliefs (1) Beliefs predispose a person to depression (2) Develop during childhood and adolescence as a function of one’s negative experiences with parents and significant others (3) Activated by current stressors or depressed mood creating a pattern of negative automatic thoughts (4) Negative cognitive triad: self, one’s experiences and the surrounding world, one’s future b.

Negative cognitive biases or errors maintain the negative cognitive triad (1) Dichotomous or all-or-none reasoning (2) Selective abstraction (3) Arbitrary inference 7.

Evaluating Beck’s theory as a descriptive theory a.

Generated a very effective form of treatment b.

Nondepressed people show a large positivity bias in attributions 8.

Evaluating the causal aspects of Beck’s theory a.

Results mixed b.

Recent studies suggest that those with high levels of dysfunctional attitudes and high stress are more likely to develop major depression than those with low stress or low dysfunctional attitudes and high stress 9.

The helplessness and hopelessness theories of depression a.

Learned helplessness in laboratory dogs proposed as useful model of human depression b.

The reformulated helplessness theory (1) Attributions: internal/external, global/specific, stable/unstable (2) Pessimistic attributional style associated with depression (3) Mixed results in testing whether this causes depression c.

The hopelessness theory of depression (1) Revision of reformulated helplessness theory (2) Hopelessness expectancy: one has no control over what will happen and something bad will happen (3) Internal/external dimension not important (4) Proposed two new dimensions: other likely negative consequences will occur and negative inferences about the implication of the event for the self-concept (5) Initial research supports this conceptualization 10.

Interpersonal effects of mood disorders a.

Lack of social support and social skills deficits b.

The effects of depression on others c.

Marriage and family life (1) High correlation between marital dissatisfaction and depression (2) Marital distress increases relapse for depression (3) Parental depression increases problems for children Bipolar Disorders A. Distinguished from unipolar disorders by the presence of manic or hypomanic episodes B. Cyclothymic disorder 1.

Cycles between hypomania and depression are signs of cyclothymia 6.

IV.

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2.

This disorder may be a mild form of major bipolar disorder Bipolar Disorders (I and II) 1.

Kraepelin—1899—manic-depressive insanity 2.

Bipolar I disorder a.

One episode of mania or a mixed episode is needed for diagnosis b.

Mania shows elevated mood, irritability, increases in activity, and a “flight of ideas” c.

A mixed episode, once thought rare but increasing in occurrence, is characterized by symptoms of both full-blown manic and major depressive episodes for at least one week, where the symptoms are mixed or alternating rapidly every few days 3.

Bipolar II disorder a.

Hypomanic episodes and major depressive episodes with atypical features b.

More common than bipolar I 4.

Features of bipolar disorder a.

Symptoms during depressive episodes of bipolar disorder are identical to depressive symptoms in unipolar major depression b.

Suicide attempts may be more common than in unipolar c.

May be misdiagnosed until first manic episode appears d.

Some drugs used to treat unipolar depression may actually trigger manic episodes in patients who have been misdiagnosed e.

Rapid cycling in 5–10% of patients f.

24% relapse within six months; 77% have a new episode within four years; 82% by seven years Causal Factors in Bipolar Disorder A. Biological Causal Factors 1.

Genetic Influences a.

Genes account for about 80–90% of the variance in the development of bipolar disorder b.

Genetic influences are even stronger in early- as opposed to late-onset bipolar disorder c.

Polygenic transmission; have not identified precise genes 2.

Neurochemical factors a.

Monoamine hypothesis of unipolar disorder extended to bipolar; however, although there is evidence of increased norepinephrine activity during manic phases, serotonin levels remain low b.

Increased levels of dopamine may be related to manic symptoms of hyperactivity, grandiosity, and euphoria 3.

Abnormalities of hormonal regulatory systems a.

HPA axis involved as levels of cortisol elevated during bipolar depression (but not mania) b.

Evidence of abnormalities on the dexamethasone suppression test 4.

Neurophysiological and neuroanatomical influences a.

PET scans reveal that blood flow to the left prefrontal cortex is reduced during depression and increased during mania b.

More changes in subcortical structures than in unipolar including enlarged basal ganglia and amygdala 5.

Sleep and other biological rhythms C.

V.

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B.

VI.

VII.

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Psychosocial Causal Factors 1.

Stressful life events appear to precipitate episodes 2.

Other psychological factors in bipolar disorder a.

Low social support b.

Personality and cognitive variables: neuroticism, high levels of achievement striving, increased sensitivity to rewards in the environment, pessimistic attributional style Sociocultural Factors Affecting Unipolar and Bipolar Disorders A. Cross-Cultural Differences in Depressive Symptoms 1.

China and Japan—psychological symptoms of depression are low; somatic and vegetative manifestations are higher 2.

As Asian cultures have incorporated Western values, rates of depression have increased B. Cross-Cultural Differences in Prevalence 1.

Varies tremendously—Taiwan: 1.5%, whereas United States and Lebanon: 17– 19% 2.

Need to identify risk factors in each culture C. Demographic Differences in the United States 1.

Prevalence among African Americans slightly lower; Native Americans have elevated rates 2.

Inversely related to socioeconomic status in unipolar depression; bipolar is unrelated to SES 3.

Mania or hypomania may facilitate the creative process; intense negative emotional experiences of depression provide material for creative activity Treatments and Outcomes A. Only about 40% of people with mood disorders receive minimally adequate treatment B. Pharmacotherapy 1.

First category of antidepressant drugs developed were the monoamine oxidase inhibitors 2.

Treatment of choice from 1960s –1990 was one of the tricyclic antidepressants such as imipramine 3.

Selective Serotonin Re-uptake Inhibitors (SSRIs) 4.

Recently several atypical antidepressants (Wellbutrin, Serzone, Remeron) have become popular as they have fewer side effects or are more effective with severe depression 5.

The course of treatment with antidepressant drugs a.

Require three to five weeks to take effect b.

50% do not respond to first drug tried c.

Discontinuing drug may lead to relapse d.

25% of patients relapse while on drugs 6.

Lithium and other mood-stabilizing drugs a.

Lithium (1) 75% of patients show at least partial improvement on Lithium (2) Some unpleasant side effects can be seen such as lethargy, decreased motor coordination, and GI difficulties; long-term use can cause kidney damage (3) Compliance is a major problem b.

Anticonvulsants (carbamazepine, divalproex, and valproate) (1) Often effective in those who do not respond to Lithium .

Chapter 6 · Mood Disorders and Suicide

C.

VIII.

Alternative Biological Treatments 1.

Electroconvulsive Therapy a.

Severely depressed patients who present an immediate and serious suicidal risk would be most appropriate for ECT b.

Typical treatment involves six to twelve sessions administered every other day c.

Varying levels of amnesia may persist d.

Has also been found to be of use in manic episodes 2.

Transcranial magnetic stimulation (TMS) a.

Noninvasive technique allowing focal stimulation of the brain in awake patients b.

Brief, but intense, pulsating magnetic fields that induce electrical activity in certain parts of the cortex are delivered c.

Some studies have shown TMS to be more effective than antidepressants without the side effects of ECT 3.

Bright light therapy a.

Originally used only for seasonal affective disorder b.

Recently shown to be effective for nonseasonal depression D. Psychotherapy 1.

Cognitive behavioral therapy a.

Focuses on here-and-now problems; teaches people to evaluate their beliefs and negative automatic thoughts systematically as well as to challenge their underlying depressogenic assumptions b.

Equally, or more, effective as antidepressants and more effective in preventing relapse c.

Mindfulness-based cognitive therapy: developed for highly recurrent depression; involves training in mindfulness meditation techniques aimed at increasing awareness of unwanted thought and feelings and sensations so they are accepted as simply thoughts and not reality; found effective in two studies 2.

Behavioral activation treatment a.

Relatively new; focuses on getting patients to become more active and engaged with their environment and their interpersonal relationships b.

May be even more effective, and easier to administer, than CBT 3.

Interpersonal therapy a.

Not as extensively studied or used b.

Research suggests it is as effective as CBT or antidepressants c.

Focuses on current relationship issues, trying to help the person understand and change maladaptive interaction patterns 4.

Family and marital therapy a.

For some types of bipolar disorder, reducing the level of expressed emotion or hostility and increasing coping information has been shown to be effective in preventing relapse b.

For unipolar, focusing on marital discord is as effective as CBT 5.

Conclusions Suicide: The Clinical Picture and the Causal Pattern A. Who attempts and who commits suicide?

1.

50 to 90% of those who commit suicide do so during a depressive episode or in the recovery phase .

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2.

3.

B.

C.

D.

E.

F.

G.

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Ranks among the ten leading causes of death in most Western countries Until recently the peak age for suicide attempts was 25–44 years; now the peak age is 18–24 with four times as many men as women dying from suicide 4.

Highest rate of completed suicides is in the elderly (65 and over) 5.

Methods of suicide vary between the genders 6.

High risk groups include the depressed, those suffering from schizophrenia, alcoholics, divorced persons, certain professionals (highly creative or successful scientists, physicians and psychologists, businessmen, composers, writers, and artists), people living alone, and people from socially disorganized areas Suicide in children 1.

Rates have been increasing 2.

Increased 70% for children aged 5–14 since 1981 3.

Increased risk if child has lost a parent or has been abused Suicide in adolescents and young adults 1.

Third most common cause of death in 15–19-year-olds 2.

Second leading cause of death among college students 3.

Increases in suicide rates for adolescents observed worldwide 4.

Known risk factors for adolescent suicide a.

Mood disorder, conduct disorder, and substance abuse (especially alcohol) b.

Treatment with antidepressants c.

Media exposure to suicides d.

For college students, the combined stressors of academic demands, social interaction problems, and career choices Other psychosocial factors associated with suicide 1.

Personality traits associated with suicide are impulsivity, aggression, and pessimism 2.

“Success suicides” can be seen following positive life events 3.

Hopelessness about the future may be a good predictor of suicide within one to two years 4.

Predictors of immediate suicide among the depressed: severe psychic anxiety, panic attacks, severe anhedonia, global insomnia, delusions, and alcohol abuse 5.

Psychosocial causes: combination of family psychopathology, child maltreatment, and family instability associated with low self-esteem, hopelessness, and poor problem-solving skills Biological causal factors 1.

Concordance rate in monozygotic twins about 3 times higher than in fraternal twins 2.

Reduced serotonergic activity Sociocultural factors 1.

Whites have much higher suicide rates than African Americans except among young males where rates are similar 2.

Rates vary from one society to another (Hungary is the highest) 3.

Religious beliefs are important determinants of suicide rates (Catholics and Muslims are low) 4.

Japan is one culture that sanctions certain suicides; Muslim extremists are another 5.

Subgroup differences exist within societies 6.

Durkheim’s view of group cohesiveness as a factor in suicide Communication of suicidal intent

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Chapter 6 · Mood Disorders and Suicide

1.

IX.

X.

40% communicate suicidal intent in very clear and specific terms; an additional 30% had talked about death and dying 2.

50% had never seen a mental health professional H. Suicide notes 1.

Only about 15–25% leave notes 2.

Suicide notes are typically coherent and legible; some include statements of love and concern; occasionally suicide notes contain very hostile content Suicide Prevention and Intervention A. Treatment of Mental Disorders B. Crisis intervention 1.

Suicide prevention centers try to avert an actual suicide attempt 2.

Primary objective is to help people regain their ability to cope with their immediate problems as quickly as possible 3.

Emphasis is placed on a.

Maintenance of supportive contact with person b.

Helping the person to realize that distress is impairing judgment c.

Helping the person see that present distress is not endless 4.

Establishment of suicidal hotlines since the 1960s—not much information to document success in reducing suicide rates C. Focus on high-risk groups and other measures 1.

Broad based programs are needed to alleviate life problems 2.

Involving older men in social and interpersonal activities that help others Unresolved Issues: Is There a Right to Die? A. Should people be allowed to take their own lives?

B. Terminally ill people are asking for the “right to commit suicide” 1.

Ancient Greeks provided hemlock to those who had received permission to commit suicide due to illness 2.

Some Western European countries allow terminally ill people to commit suicide 3.

Oregon Death with Dignity Act allows physician-assisted suicide 4.

Kevorkian C. Arguments against right to suicide 1.

Fears that the right to suicide may be abused 2.

Should those who are not terminally ill have the right to commit suicide?

3.

What if, through intervention, the person would no longer wish to commit suicide?

(1) Suicide intervention embodies a more neutral moral stance (2) Intervention may involve involuntary hospitalization or administration of medications; what are legal implications for therapists?

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Key Terms attributions (p. 198) behavioral activation therapy (p. 214) bipolar disorder with a seasonal pattern (p. 180) bipolar disorders (p. 182) bipolar I disorder (p. 204) bipolar II disorder (p. 205) chronic major depressive disorder (p. 187) cyclothymic disorder (p. 203) depression (p. 181) depressogenic schemas (p. 196) double depression (p. 189) dysfunctional beliefs (p. 196) dysthymic disorder (p. 185) hypomanic episode (p. 182) interpersonal therapy (IPT) (p. 180) learned helplessness (p. 198) lithium (p. 212) major depressive disorder (p. 186) major depressive episode (p. 182) major depressive episode with atypical features (p. 188) major depressive episode with melancholic features (p. 188) mania (p. 181)

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manic episode (p. 182) mixed episode (p. 204) monoamine oxidase inhibitors (MAOIS) (p.

180) mood disorders (p. 181) mood-congruent delusions (p. 180) negative automatic thoughts (p. 197) negative cognitive triad (p. 197) pessimistic attributional style (p. 198) rapid cycling (p. 206) recurrence (p. 187) recurrent major depressive episode with a seasonal pattern (p. 180) relapse (p. 187) rumination (p. 200) seasonal affective disorder (p. 189) selective serotonin reuptake inhibitors (SSRIs) (p. 212) severe major depressive episode with psychotic features (p. 188) specifiers (p. 188) suicide (p. 215) tricyclic antidepressants (p. 180). unipolar depressive disorder (p. 182)

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Chapter 6 · Mood Disorders and Suicide

Lecture Examples / Discussion Topics Lecture Launcher 6.1: Evolutionary Impact?

Mood disorders appear to be counterproductive and yet have not been eliminated by natural selection.

Why? Presenting this question to the students on an overhead or PowerPoint slide (CD-ROM PowerPoint Topic 6: Slide 35) is an easy way to encourage students to consider this seeming contradiction. Most students are already familiar with Darwin and the basic principles of selection.

However, it may be necessary to quickly review these principles prior to beginning this discussion.

Lecture Launcher 6.2: PMS in DSM-V? Should PMS be in DSM? An extremely distressing and psychosocially debilitating form of PMS, called premenstrual dysphoric disorder, has been proposed for inclusion in DSM. This controversial proposal pits the stigma of mental illness and systematic pathologizing of women against the desire to make access to healthcare easier by providing a reimbursable diagnostic category. What do students think of a disorder that can only be diagnosed in women? Is that so different from other categories that functionally only apply to men (e.g., transvestic fetishism)? Is premenstrual dysphoric disorder a psychiatric problem or a gynecological one? What process should be used to resolve controversies such as this one?

Lecture Launcher 6.3: Predicting Suicide Although every suicide is a tragedy, the base rate of suicide is low, especially in the general population.

This makes the challenge of predicting suicide even greater than it otherwise might be. If, hypothetically speaking, the rate of suicide in your university’s counseling center was a high 1%, then you would be correct in the “prediction” of suicide 99% of the time if you simply always predict “no suicide.” Any method of improving on your predictions will then have to exceed 99% correct, surely a daunting challenge.

Lecture Launcher 6.4: Preventing Suicide Should people who want to die be prevented from killing themselves? Most health care professionals, and a variety of people in other occupations as well, are obligated to try to prevent people from killing themselves. Laws require them to treat suicidal people in essentially the same manner they would treat homicidal people, even to the extent of breaking doctor-patient confidentiality to do so. At the other extreme are people like Jack Kevorkian, MD, a physician who believes doctors ought to help their patients commit suicide when asked. What do students think about suicide laws and the requirement that mental health professionals intervene to prevent suicide even when it goes against the wishes of their clients and their professional codes of ethics (viz. confidentiality)? Might awareness of these laws cause clients to refrain from discussing their suicidal feelings? Handout 6.1

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Lecture Launcher 6.5: Treating Depressed People Dishonestly People who are depressed are characteristically pessimistic and hopeless about the future. Extreme hopelessness can even lead to suicide. Clinicians treating depressed people have to take special care not to endorse this hopelessness in any way because their clients would then be even worse off than they were without treatment. This is fairly simple if one keeps in mind that depressed people have distorted perceptions of their circumstances and their situations are never as bleak as they make them sound.

Sometimes, however, the facts surrounding particular cases are bleak. In these cases, clients may cling to the erroneous hope that their view is distorted. After all, they have enough hope to be in treatment.

But if their psychologist suggests that the situation is indeed hopeless, then their distrust of their own thinking is eliminated, they have a professional certification for hopelessness, and as a result they are worse off than before. The first line of defense against this iatrogenic effect is to genuinely believe there is always hope, even for clients in the most desperate of situations. When this fails, however, it is a matter of professional responsibility to avoid concurring with clients’ pessimism, even if it is not entirely honest.

Demonstrations / Activities Activity 6.1: Bipolar Disorder or ADHD? Recently, increasing attention has been given to the possible confusion of ADHD and bipolar disorder in children and adolescents. To help students understand the complexities of this diagnostic, and treatment, dilemma, students may be placed into small groups (4–5 students per group) and provided a case description of a child or adolescent who is experiencing difficulties. Also provide each group with the diagnostic criteria for ADHD and bipolar disorder. Each group should decide on which diagnosis best describes the case. Class discussion should include a consideration of children who are diagnosed as ADHD initially, receive stimulant treatment, and then, later, are determined to have bipolar disorder.

Handout 6.2 Activity 7.2: Antidepressant Behavior Everyone experiences minor episodes of depression. Though clearly not to be confused with major depression, these episodes probably represent a stage through which all those progressing to major depression must pass. Therefore, it is not entirely insignificant to think about what can be done to beat the more common minor depressive episodes. In fact, minor depressions are problems in their own right, worth limiting as best one can. Along these lines, many students have pretty clearly laid plans for dealing with their own depressions. Others are not quite so deliberate but can, upon some reflection, recall the kinds of things they have done when depressed. A compendium of such techniques can be assembled as a class project. In doing so, one would want to emphasize antidepressant behaviors that actually work as opposed to listing out anything one does when depressed whether they are helpful or not.

Activity 6.3: Sex Differences in Antidepressant Behavior Susan Nolen Hoeksema (1990, 2001) argues that sex differences in depression are at least partly due to the way men and women react differently to stress. Whereas men tend to distract themselves through activities such as work, sports, or even drugs and alcohol, women tend to become less active, ruminating about the causes of their stress. It is the difference in coping with stress, then, that gives rise to the different rates of depression between men and women. If students in your class have undertaken Activity 7.2, then it would be a fairly simple matter to compare the responses of men and women. Alternatively, you can ask students to briefly list a few things they do when depressed and discuss these. In any event, it could be interesting to ask students where they got their ideas about how to cope with stress. In

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particular, it would be fascinating to see by whom the men and women in class were socialized to expect their way of coping to be appropriate (e.g., parents, media, school, friends).

Activity 6.4: Thought Worksheets Thought Worksheets are often used in therapy to help people identify and challenge their depressogenic thinking patterns between sessions. Students can do thought diaries using the same kind of worksheet, completing them once a day for a week, or else they can simply reflect on times they have felt badly, listing the thoughts that came to mind at that time and how to challenge them. Students frequently understand this assignment better after viewing Transparency T-115. The foundation for this exercise is the essential cognitive theory of depression that negative moods have their origin in distorted thinking.

Therefore, the instructor will want to firmly state that behind every negative mood is a series of automatic thoughts, the validity of which seems clear at the time but which are actually of dubious merit. For instance, one could feel bad and think that “nobody cares about me.” The apparent depth of this belief notwithstanding, it is clearly untrue, and thinking this kind of thought would clearly be upsetting to anyone. Fortunately, thoughts such as these are never literally true. Monitoring one’s own thoughts can be a useful exercise as a matter of good mental hygiene. Handout 6.3 Activity 6.5: Suicide Test / Myths Lists of myths about suicide can readily be converted into pretest questionnaires students can complete before covering this topic in class. For instance, the idea that asking about suicide can trigger someone into actually doing it could be placed on such a pretest, which could then be self-scored during a lecture that systematically covers the content of the pretest. A simple list of such myths can be found on the CD-ROM PowerPoint Topic 6: Slide 33. You may convert the slide into a questionnaire or present the slide to the class.

Web Links Web Link 6.1: www.DBSAlliance.org The Depression and Bipolar Support Alliance is a patient-directed support organization whose purpose is to educate people about mood disorders. Their extensive site provides consumer and advocacy information as well as help and support.

Web Link 6.2: http://www.depression.org The National Foundation for Depressive Illness seeks to inform the public about mood disorder research, treatment, and education.

Web Link 6.3: http://www.nmha.org The National Mental Health Association works to promote mental health through advocacy, education, research, and services.

Web Link 6.4: http://www.psycom.net/depression.central.html Depression Central is a very large clearinghouse of information about mood disorders. Many different aspects of mood disorders get attention, including the elderly, getting free medication, first person accounts, ECT, famous people with mood disorders, etc.

Web Link 6.5: http://www.pendulum.org/ Pendulum is a bipolar mood disorder resource “by consumers, for consumers.” It contains a link page of additional excellent Web pages devoted to bipolar mood disorder.

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Video Resources After a Suicide. New York, NY: Filmmakers Library.

Between the Lines. Boston, MA: Fanlight Productions.

Bipolar Disorder–#3 ABC News and Client Interviews. Allyn and Bacon Abnormal Psychology Video.

Bipolar Disorder, Tony—Patient Interview Video for Abnormal Psychology (12th ed.). Allyn and Bacon Video Library.

Brainstorm: The Hidden Epidemic of Depression. New York, NY: Filmmakers Library.

Breaking the Dark Horse: A Family Copes with Manic Depression. Boston, MA: Fanlight Productions Depression. Sherborn, MA: Aquarius Health Care Videos.

Depression and Anxiety. Psychotropic Medications Series. Irvine, CA: Concept Media.

Depression: Beating the Blues. Allyn and Bacon Video Library.

Depression: The Biology of the Blues. Princeton, NJ: Films for the Humanities and Social Sciences.

Depression and Manic Depression. Princeton, NJ: Films for the Humanities and Social Sciences.

Depression: Moving On. Allyn and Bacon Video Library.

Depression in Older Adults: The Right to Feel Better. Sherborn, MA: Aquarius Health Care Videos Depression: The Storm Within. Washington, DC: American Psychiatric Association.

“Don’t Kill Yourself”: One Survivor’s Message. Princeton, NJ: Films for the Humanities and Social Sciences.

Gender Differences in Depression: A Marital Therapy Approach. New York, NY: Guilford Publications Intervention Strategies. Suicide in Inpatient Settings Series. Irvine, CA: Concept Media.

A Journey Back: Coping with a Parent’s Suicide. New York, NY: Filmmakers Library.

Major Depression, Bob—Patient Interview Video for Abnormal Psychology (12th ed.) Allyn and Bacon Video Library.

Manic. New York, NY: Filmmakers Library.

Manic Depression / Brain Tumor, Steve—Patient Interview Video for Abnormal Psychology (12th ed.).

Allyn and Bacon Video Library.

Me Depressed? Don’t Make Me Laugh. Boston, MA: Fanlight Productions.

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Mood Disorders—DSM-IV: New Diagnostic Issues Videotape Series. Allyn and Bacon Video Library.

Mood Disorders: Hereditary Factors—Vol. 32, The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection.

Mood Disorders: Mania and Depression—Vol. 31, The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection.

Mood Disorders: Medication and Talk Therapy—Vol. 33, The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection.

Mood Disorders—Vol. 8, The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection.

Nature’s Antidepressant: St. John’s Wort. Allyn and Bacon Video Library.

No More Shame: Understanding Depression. Princeton, NJ: Films for the Humanities and Social Sciences.

Overview and Assessment. Suicide in Inpatient Settings Series. Irvine, CA: Concept Media.

Prozac Diary. Princeton, NJ: Films for the Humanities and Social Sciences.

Strategies and Tactics in the Treatment of Mood Disorders—Treatments of Psychiatric Disorders Videotape Series. Allyn and Bacon Video Library.

Suicide: A Guide for Prevention. Allyn and Bacon Video Library.

Suicide: Dead Is Forever. Allyn and Bacon Video Library.

Treating Depression: Electroconvulsive Therapy—Vol. 34, The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection.

Understanding Depression. No More Shame: Understanding Schizophrenia, Depression and Addiction Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Understanding Depression: Through the Darkness. Princeton, NJ: Films for the Humanities and Social Sciences.

Unmasking Depression. Princeton, NJ: Films for the Humanities and Social Sciences.

When the Blues Won’t Go Away: Women and Depression. Allyn and Bacon Video Library.

Women and Depression. Allyn and Bacon Video Library.

Women and Depression: When the Blues Won’t Go Away. Princeton, NJ: Films for the Humanities and Social Sciences.

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Handout 6.1 Suicidal Friend or Relative

How should you deal with a close friend or relative who you believe may be thinking about suicide?

This is a common question, and one that is the topic of many helpful Internet resources. Write down a list of questions you would ask an expert if you found yourself in this situation. Then research answers using the Internet. Sites about suicide and depression are probably good starting points as are university counseling centers.

1.

Questions you want answered:

2.

Advice on dealing with someone who is possibly suicidal:

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Handout 6.2 What’s My Diagnosis?

John is a 10-year-old child who is repeating the third grade. His teachers have requested that his parents have John evaluated for possible ADHD. At school, John talks excessively, is frequently out of his seat, and his teacher describes him as, at times, so difficult to control that she “can’t get a word in edgewise.”

His teacher reports that when John is very active it is as if he has a “motor” inside. He can also be somewhat irritable, “fidgety,” and has difficulty not interrupting the other children. His teacher notes that she likes the fact that when John is like this he believes he can be the best student in her class and focuses more on his assigned tasks. At home, his parents report few problems. They acknowledge he is extremely active at times but they report that they send him outside to play and that he will eventually “wear himself out.” His parents report that John sometimes has difficulty playing by himself quietly.

Once again, when this is a problem, they simply send him outside to play. Finally, they report that John may simply be one of those children who doesn’t need much sleep as when he is very active he may only sleep a few hours each night, spending the rest of the time working on his “special projects” to catch up at school.

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Handout 6.3 Thought Worksheet

Depressed feelings are the product of irrational or distorted thoughts. Whenever you feel depressed, there is an underlying automatic thought of this sort. Use this worksheet to track the role of cognitive processes in your negative moods. Whenever you have a negative mood, complete a row of this sheet.

Situation

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Emotion

Automatic Thought

Cognitive Distortion

.

Rational Responses

Outcome

CHAPTER 7: Somatoform and Dissociative Disorders Chapter At-A-Glance Detailed Outline

Instructors’ Resources

Print Supplements

Media Supplements

Somatoform Disorders What Are Somatoform Disorders?

• Hypochondriasis • Somatization Disorder • Pain Disorder • Conversion Disorder • Distinguishing s Somatization, Pain, and Conversion Disorders from Malingering and Factitious Disorder • Body Dysmorphic Disorder

Teaching Objectives 7.1–7.7 Chapter Guide Lecture Launchers 7.2, 7.3 Activities 7.4, 7.6 Web Links 7.1, 7.2

Test Bank Grade Aid Transparency T-67

CD-ROM PowerPoint

Dissociative Disorders What are Dissociative Disorders?

• Depersonalization Disorder • Dissociative Amnesia and Dissociative Fugue • Dissociative Identity Disorder (DID) • Sociocultural Factors in Dissociative Disorders • Treatment and Outcomes in Dissociative Disorders

Teaching Objectives 7.8–7.10 Chapter Guide Lecture Launchers 7.1, 7.4 Activities 7.1, 7.2, 7.3, 7.5 Web Links 7.3, 7.4, 7.5, 7.6

Test Bank Grade Aid Transparencies T-68 to T-72

CD-ROM PowerPoint

Unresolved Issues: DID and the Reality of “Recovered Memories”

Teaching Objectives 7.11 Chapter Guide Lecture Launchers 7.1, 7.4, 7.5 Activities 7.1, 7.2, 7.5 Web Links 7.3, 7.4, 7.5, 7.6

Test Bank Grade Aid Transparencies T-70 and T-71

CD-ROM PowerPoint

Professor Notes

Teaching Objectives 1.

2.

3.

4.

5.

6.

7.

Explain the historical usage of the term neurosis and why this term is no longer used by the DSM system.

Describe how somatoform disorders differ from physical conditions.

List the primary presenting symptoms of somatization disorder and hypochondriasis and note the similarities of and differences between these closely related disorders.

Explain what is meant by a pain disorder. What is meant by describing pain as a “subjective experience”?

Characterize the symptoms of conversion disorder, trace the history of the concept of “conversion,” and describe the likely cause and chain of events in the development of a conversion disorder.

Discuss the etiological contributions of biological, psychosocial, and sociocultural factors to the somatoform disorders.

Compare and contrast the treatments for somatoform disorders. What is known regarding their effectiveness as compared to no treatment at all? .

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8.

9.

10.

11.

Compare the major features of dissociative amnesia and fugue, dissociative identity disorder, and depersonalization disorder.

Discuss the causal factors that contribute to the dissociative disorders, and note the critical difficulty caused by the fallibility of memory in determining the contribution of childhood abuse to these disorders.

Describe the most appropriate treatments for the dissociative disorders, as well as the limitations of biological and psychological treatments.

Describe the issues related to DID and recovered memories.

Chapter Overview / Summary Somatoform disorders are those in which psychological problems are manifested in physical disorders (or complaints of physical disorders) that often mimic medical physical conditions, but for which there can be found no evidence of corresponding organic pathology. In hypochondriasis, one of the most commonly seen somatoform disorders, there is an anxious preoccupation with having a disease based on a misinterpretation of bodily signs or symptoms. Medical reassurance does not help.

Somatization disorder is characterized by many different complaints of physical ailments in four symptom categories spreading over several years. The symptoms need not actually have existed as long as they were complained about. Pain disorder is characterized by pain severe enough to cause life disruption. Although a medical condition can contribute to the pain, psychological condition must be judged to play an important role in the onset, severity, exacerbation, or maintenance of the pain.

Conversion disorder involves patterns of symptoms or deficits affecting sensory or voluntary motor functions, leading one to think there is a medical or neurological condition, even though medical examination reveals no physical basis for the symptoms. It can be difficult to distinguish between conversion disorder, pain, and somatization disorder from malingering and factitious disorder. Body dysmorphic disorder involves obsessive preoccupation with some perceived flaw or flaws in one’s appearance. Compulsive checking behaviors (such as mirror checking) and avoidance of social activities because of fear of being rejected are also common.

Dissociative disorders occur when the normal processes regulating awareness and the multichannel capacities of the mind apparently become disorganized, leading to various anomalies of consciousness and personal identity. Depersonalization disorder occurs in people who experience persistent and recurrent episodes of derealization (losing one’s sense of reality) and depersonalization (losing one’s own sense of self and one’s own reality). Dissociative amnesia involves an inability to recall previously stored information that cannot be accounted for by ordinary forgetting and seems to be a common initial reaction to stressful circumstances. The memory loss is primarily for episodic or autobiographical memory. In dissociative fugue, a person not only goes into an amnesiac state but also leaves his or her home surroundings and becomes confused about his or her identity, sometimes assuming a new one. In dissociative identity disorder, the person manifests at least two or more distinct identities or personality states that alternate in some way in taking control of behavior. Alter identities may differ in many ways from the host identity. There are many controversies about DID including whether it is real or faked, how it develops, whether memories of childhood abuse are real, and, if the memories are real, whether the abuse played a causal role.

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Detailed Lecture Outline I.

Somatoform Disorders: What are Somatoform Disorders?

A. Hypochondriasis 1.

Major characteristics a.

Vague and ambiguous physical symptoms are common b.

Sincere in their conviction that the symptoms represent illness c.

Prevalence of 2 to 7 percent; equally common in men and women d.

Onset can be at any age but early adulthood is most common e.

Once developed, tends to be chronic 2.

Causal factors in hypochondriasis a.

Minimal information available b.

May be closely related to the anxiety disorders c.

Misinterpretations of bodily sensations are seen as a causal factor in cognitive conceptualizations d.

Past experiences lead to a set of dysfunctional assumptions e.

Attentional bias for illness-related information f.

Role of secondary reinforcements 3.

Treatment of hypochondriasis a.

Cognitive-behavioral treatments have been found to be quite effective b.

SSRIs may also be effective B. Somatization Disorder 1.

Somatization disorder a.

Seen most often in primary medical care b.

Symptoms (1) Four pain symptoms (2) Two gastrointestinal symptoms (3) One sexual symptom (4) One pseudoneurological symptom 2.

Demographics, comorbidity, and course of illness a.

Usually begins in adolescence b.

3–10 times more common among women c.

Occurs more often in lower socioeconomic classes d.

Lifetime prevalence estimated to be about 0.2 to 2 percent in women and less than 0.2 percent in men e.

Co-occurs with major depression, panic disorder, phobic disorders, and GAD 3.

Causal factors in somatization disorder a.

Uncertain about developmental course and specific etiology b.

Familial linkage between antisocial personality disorder in men and somatization disorder in women c.

Interaction of personality, cognitive, and learning variables d.

Selectively attend to bodily sensations 4.

Treatment of somatization disorder a.

Identification of one physician who integrates patient care and reduces medications and unnecessary testing b.

Medical management more effective if combined with cognitivebehavioral therapy focused on promoting appropriate behavior such as

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better coping and personal adjustment, and discouraging inappropriate behavior and preoccupation with physical symptoms Reducing secondary gain is critical

C.

D.

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c.

Pain Disorder 1.

Pain disorder a.

The subjectivity of pain b.

Diagnosed more frequently in women c.

Comorbid with anxiety and mood disorders d.

An invalid lifestyle can result 2.

Treatment of somatoform pain disorder a.

Cognitive-behavioral treatment is successful b.

Treatment programs include relaxation training, support and validation that the pain is real, scheduling of daily activities, cognitive restructuring, and reinforcement of “no-pain” behaviors c.

Tricyclic antidepressants and certain SSRIs also reduce pain intensity Conversion Disorder 1.

Conversion disorder a.

Physical malfunction or loss of control is the central feature b.

Hysteria was an early term for the disorder c.

Freud used the term conversion hysteria to represent his belief that the symptoms were an expression of repressed sexual energy 2.

Precipitating circumstances, escape, and secondary gain a.

Physical symptoms as a socially acceptable means of escaping from negative responsibilities b.

Primary and secondary gain 3.

Decreasing prevalence and demographic characteristics a.

Common during World Wars b.

1–3% of all disorders referred for treatment c.

Prevalence in general population may be only about 0.005 percent d.

Decreasing prevalence may be closely related to increasing sophistication about medical and psychological disorders e.

More common among rural populations from lower socioeconomic circles f.

Two to ten times more common among women g.

Generally rapid onset after a significant stressor; often resolves within two weeks if stressor is removed 4.

Range of conversion disorder symptoms a.

Sensory symptoms or deficits (1) Today symptoms are most often in the visual system (blindness or tunnel vision), in the auditory system (deafness), or in the sensitivity to feeling (anaesthesias) (2) Glove anaesthesia is one of the most common (3) Sensory input appears to be received but screened from conscious recognition b.

Motor symptoms or deficits (1) Usually confined to a single limb; loss of function is usually selective (2) Aphonia (talking only in a whisper) is most common speech-related conversion disturbance c.

Seizures .

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(1) (2) (3)

E.

F.

Typically do not show any EEG abnormalities Do not show confusion and loss of memory following the seizure Often show excessive thrashing about and writhing; rarely injure themselves in falls or lose control over their bowels or bladder 5.

Important issues in diagnosing conversion disorder a.

Symptoms do not conform clearly to the particular disease or disorder simulated b.

Selective nature of the dysfunction c.

Hypnosis or narcosis (sleeplike state induced by drugs) can remove dysfunction 6.

Treatment of conversion disorder a.

No well-controlled studies have been conducted b.

Motor conversion symptoms have been successfully treated with behavioral therapy Distinguishing conversion from malingering and from factitious disorder 1.

Malingering diagnosed when symptom production is intentional to gain an external goal 2.

Factitious disorder diagnosed when symptom production is intentional to maintain a sick role 3.

Severe and chronic forms of factitious disorder have been called Munchausen’s syndrome 4.

Difficult diagnostic challenges Body Dysmorphic Disorder 1.

Most common locations for perceived deficits are a.

Skin – 73% b.

Hair – 56% c.

Nose – 37% d.

Stomach – 22% e.

Breasts/chest/nipples – 21% f.

Eyes – 20% g.

Face size/shape – 12% 2.

Prevalence, gender, and age of onset a.

No official estimates of prevalence b.

No gender differences in prevalence (1) Men obsess more about genitals, body build, and balding (2) Women obsess more about their skin, stomach, breasts, buttocks, hips, and legs c.

Age of onset is usually adolescence d.

Estimate 50% comorbid with depression e.

Often leads to suicide or attempted suicide f.

Over 75% seek nonpsychiatric treatment such as from a dermatologist 3.

Relationship to OCD a.

May be viewed as an obsessive-compulsive spectrum disorder: prominent obsessions, variety of ritualistic-like behaviors such as reassurance seeking, mirror checking, comparing themselves to others, and camouflage b.

Serotonin and the same brain structures have been implicated in both OCD and BDD c.

Same treatments are effective with OCD and BDD .

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4.

II.

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Why now? a.

BDD has existed for centuries b.

Prevalence may have increased c.

Sufferers rarely seek psychological treatment d.

Increased media attention to BDD 5.

Causal factors: A biopsychosocial approach to BDD a.

Suggestion that there is a partially genetically-based personality predisposition b.

Sociocultural context—focus on attractiveness; self-schemas c.

Reinforced as children; teased or criticized for appearance d.

Biased attention and interpretation of information relating to attractiveness 6.

Treatment of body dysmorphic disorder a.

SSRIs produce moderate improvement b.

Cognitive-behavioral treatment emphasizing exposure and response prevention leads to marked improvement in 50–80% of patients Dissociative Disorders: What are Dissociative Disorders?

A. Depersonalization Disorder 1.

Depersonalization disorder a.

Depersonalization (loss of self or one’s own reality) and derealization (one’s sense of the reality of the outside world) b.

Reality testing remains intact c.

Out-of-body experiences can occur d.

Sufferers often report that they are living in a dream e.

Emotional experience during event is attenuated or reduced f.

Comorbid anxiety and mood disorders g.

Average age of onset is 23 h.

Chronic course in 80% of cases i.

Differential diagnosis is important j.

Depersonalization symptoms can signal decompensation k.

Psychotic states often show early depersonalization symptoms B. Dissociative Amnesia and Fugue 1.

Retrograde amnesia involves the partial or total inability to recall or identify previously acquired information or past experiences while anterograde amnesia is the partial or total inability to retain new information 2.

Types of retrograde amnesia found in dissociative amnesia a.

Localized—specific period b.

Selective—forgets some but not all of what occurred during a specific period 3.

Typical symptoms associated with amnestic episodes a.

Amnestic episodes typically last between a few days and a few years b.

Basic habit patterns—such as reading, talking, performing skilled work— are maintained c.

Most commonly impacts episodic (experienced events) or autobiographical memory leaving intact semantic (language and concepts), procedural (how to do things), and short-term storage 4.

Dissociative fugue a.

New identities may be assumed b.

Fugue may last for days, weeks, or years 5.

Patterns of defense for amnesia and fugue are similar to conversion disorder .

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C.

a.

Threatening information becomes inaccessible b.

Suppression is involved in memory loss 6.

Memory and intellectual deficits in dissociative amnesia and fugue a.

Little systematic research b.

Semantic knowledge appears to be intact c.

Primary deficit is compromised episodic or autobiographical memory d.

When presented with autobiographical information, shows reduced activation in right frontal and temporal brain areas e.

Implicit memory generally intact (e.g., when asked to dial numbers randomly, one man dialed his mother’s number) Dissociative Identity Disorder (DID) 1.

Dissociative identity disorder a.

Two or more distinct identities that alternate in some way taking control of behavior b.

Identities may be dramatically different c.

Identity most frequently encountered and who carries the person’s real name is known as the host identity d.

Alter identities represent fragments of a single person; some alters may have more knowledge than others e.

Switches between alters and host may occur very quickly or may be more gradual f.

People with DID may also show depression, self-mutilation, and frequent suicidal ideation and attempts g.

Usually starts in childhood; diagnosis is typically not until 20s or 30s h.

Three to nine times more common in women i.

Females tend to have more alters than males j.

Believed this gender difference is due to the greater proportion of childhood sexual abuse among females k.

Number of alters has increased over time; 50% now show more than ten identities; increasing multiplicity suggests the importance of social factors l.

Another recent trend is bizarre and unusual identities m.

Host unaware of alters but alters know one another 2.

Prevalence—Why has DID been increasing? a.

Prior to 1979 only about 200 cases reported b.

Prevalence increasing dramatically in recent years; by 1999, more than 30,000 cases reported in North America alone (1) Increased public awareness through books and movies (2) Increased professional acceptance of disorder (3) Decreased misdiagnosis of cases as schizophrenia (4) Increases are artifactual—occurred because therapist suggested the existence of alter identities to patients, or therapists have reinforced patients for producing alter identities 3.

Experimental Studies of DID a.

Only a small number of experimental studies have been conducted b.

Traditionally, assumed that what one alter learns is not necessarily transmitted to other alters—interpersonality amnesia; at least one study has challenged this finding, documenting at least partial transfer of explicit and implicit memory across alters

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c.

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Emotional reactions learned by one identity are also transferred across identities d.

Putnam found differences in brain waves between identities and that these differences were larger than found between actors simulating different identities Causal factors and controversies about DID a.

Is DID real or is it faked?

(1) Use of DID as a criminal defense; deliberate faking in Bianchi trial (2) Factitious and malingering cases of DID are rare b.

If DID is not faked, how does it develop: post-traumatic theory or sociocognitive theory?

(1) Post-traumatic theory (a) Over 95% of DID patients report memories of severe abuse (b) DID as attempt to cope with overwhelming sense of hopelessness and powerlessness (c) Escape—dissociation—occurs through a process like selfhypnosis (d) That only some abused children develop DID leads to a diathesis-stress model i) Children prone to fantasy ii) Easily hypnotizable (e) DID as a variant of PTSD (2) Sociocognitive theory (a) DID develops when a highly suggestible person learns to adopt and enact the roles of multiple identities due to therapist suggestions and reinforcement and because the different identities allow the individual to achieve their personal goals (b) Unintentional process (c) Spanos and colleagues demonstrated that normal college students can be induced by suggestion under hypnosis to show DID symptoms (d) This theory is consistent with evidence of no clear DID symptoms prior to entering therapy and the fact that the number of alters increases as therapy progresses (e) Theory also consistent with increased DID when therapists became more aware of condition c.

Are recovered memories of abuse in DID real or false?

(1) Repressed memories may be false, a product of highly leading questions and suggestive techniques (2) Difficulty in determining which memories of abuse are real and which are false (3) Independent verification of abuse has been attempted but in many cases the verification has been very loose and suspect d.

If abuse has occurred, does it play a causal role in DID? (1) Childhood abuse tends to occur in families with many other sources of adversity and trauma

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(2)

III.

It may be that people with DID who have experienced childhood abuse are more likely than those who did not experience childhood abuse to seek treatment (3) Childhood abuse is associated with many forms of psychopathology; may play a nonspecific causal role e.

Comments on a few of these controversies about DID (1) Seems likely that there are some cases of DID not due to social enactment roles (2) Multiple different causal pathways are probably involved D. Sociocultural Factors in Dissociative Disorders 1.

Prevalence influenced by the degree to which they are accepted or tolerated by the surrounding cultural context 2.

Identified in all racial groups, socioeconomic classes, and cultures where it has been studied 3.

Dissociative trance disorder 4.

Possession trance 5.

Cross-cultural variations such as Amok E. Treatment and Outcomes in Dissociative Disorders 1.

Little is known about dissociative amnesia, fugues, and depersonalization 2.

Dissociative identity disorder treatment is focused on integration; treatment is typically psychodynamic and insight-based 3.

Outcome studies are few Unresolved Issues: DID and the Reality of “Recovered Memories” A. “Believers” Are Usually Practitioners 1.

View sexual abuse as the cause of DID 2.

Recovered memories are accurate; before treatment, such memories were repressed B. “Disbelievers” come from academics and science-oriented professionals 1.

Challenge that sexual abuse is the cause of DID 2.

DID due to social enactment of roles encouraged or induced by misguided therapy 3.

Recovered memories are inaccurate; human memory is malleable, constructive, and subject to modification C. Working Group on the Investigation of Memories of Childhood Abuse

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Key Terms alter identities (p. 241) body dysmorphic disorder (BDD) (p. 235) conversion disorder (p. 231) depersonalization (p. 238) depersonalization disorder (p. 238) derealization (p. 238) dissociation (p. 225) dissociative amnesia (p. 239) dissociative disorders (p. 225) dissociative fugue (p. 240) dissociative identity disorder (DID) (p. 241) factitious disorder (p. 226) host identity (p. 241) hypochondriasis (p. 226)

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factitious disorder by proxy (p. 234) hysteria (p. 231) implicit memory (p. 238) implicit perception (p. 238) malingering (p. 226) pain disorder (p. 230) post-traumatic theory (of DID) (p. 246) primary gain (p. 232) secondary gain (p. 232) sociocognitive theory (of DID) (p. 246) soma (p. 225) somatization disorder (p. 228) somatoform disorders (p. 225)

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Lecture Examples / Discussion Topics Lecture Launcher 7.1: Dissociative Identity Disorder or Schizophrenia?

Dissociative identity disorder (a.k.a., multiple personality disorder) is often confused with schizophrenia, even though there is no relationship at all between the two disorders. This is probably because the term schizophrenia evokes an image of the splitting of the mind or personality, coming as it does from Greek words for “split” and “mind.” For instance, if a country’s foreign policy is called schizophrenic because it penalizes some human rights violators but not others, then the policy is actually better compared to dissociative identity disorder than to schizophrenia. Even dictionary definitions of schizophrenia support the conflation between these disorders, but this just won’t do for purposes of this course. Once this is pointed out, it is not unusual for a student to ask “Well, then, what IS schizophrenia?,” revealing the depth of the confusion on this point. Schizophrenia will be described in detail later in the course, but for now it is reasonable to offer that the “split” in schizophrenia is between reality, perceptions, emotions, ideas, and behaviors—not between separate personalities. You might also tell students that if they would like to show off their erudition they should henceforth describe contradictory actions of single entities as “dissociative identity disordered” and not “schizophrenic”!

Lecture Launcher 7.2: Was Freud Right the First Time?

Freud’s initial investigations of hysteria suggested that childhood sexual abuse was common. Later, he dismissed reports of such abuse as fantasies because they started to seem far too frequent to be plausible.

Now, however, there is increasing recognition of high rates of childhood sexual abuse in society, and its role in somatoform and dissociative disorders has become the subject of etiological theorizing once again. By some estimates (Cutler and Nolen-Hoeksema, 1991), between 7 and 19% of females and between 3 and 7% of males were sexually assaulted in childhood. Even though there is clearly a very high rate of childhood sexual abuse in the histories of adults with somatoform and dissociative disorders, it is worth emphasizing that most people who are sexually abused as children do not grow up to suffer from these disorders. Indeed, childhood sexual assault increases risk for depression (Weiss et al., 1999).

Therefore, other factors must be taken into consideration. It is interesting to speculate about how Freud’s ideas would have developed had he not abandoned his initial ideas about actual sexual abuse.

Lecture Launcher 7.3: Is Hypochondriasis an Anxiety Disorder?

The difficulties inherent in organizing something as complex as the DSM can be underscored via a discussion about where hypochondriasis should be placed. Nominally, it is related to perceived aberrations of bodily function, making it a somatoform disorder. It actually shares many features of anxiety disorders, however, and might better be placed in that category. Hypochondriacs are fearful of disease and dysfunction to a degree that exceeds the magnitude of the actual risk, just as phobic fear is unreasonable. In fact, hypochondriasis might be seen as a disease phobia. Complicating things a little is the fact that hypochondriacs view their fears as reasonable, while many phobics do not. Nevertheless, fear is the primary emotion. It is also worth offering to the class that panic disorder, which is clearly an anxiety disorder, is rather like an acute fear response to interoceptive cues of pending physical calamity.

Hypochondriasis is a more chronic fear of the same thing.

Lecture Launcher 7.4: Developmental Variability in Dissociative Disorders While the etiology of the dissociative disorders is unclear, there are tantalizing clues that are interesting to discuss. The relation of dissociative disorders to childhood sexual abuse is examined in detail in the text. Students may have some of their own thoughts about this relation, particularly on the issue of why most abused children do not become afflicted adults. It is also of interest to discuss why dissociative

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disorders are more common among women. Finally, the relation to individual differences in suggestibility and hypnotic susceptibility are worth discussing.

Lecture Launcher 7.5: Repressed or False Memories of Abuse?

During the late 1980s and throughout the 1990s the U.S. legal system struggled to deal with recovered memories of childhood sexual abuse. Often elicited via hypnosis and other highly suggestive techniques by poorly trained therapists, these memories of events occurring decades previously were the basis of a wave of lawsuits against parents, friends, and relatives of people, mostly women, who were now adults and who believed various symptoms and life difficulties they were currently experiencing were the result of these previously forgotten episodes. The backlash against this trend, often termed the false memory syndrome, was quite vigorous (e.g., Gardner, 1993, Skeptical Enquirer). In retrospect, it appears that earnest and well-meaning therapists who truly believed their techniques were effective got caught up in the perceived pervasiveness of the phenomenon they were discovering, failing to recognize the limitations of their techniques.

Demonstrations / Activities Activity 7.1: Do You Have Multiple Personalities?

Dissociative identity disorder appears very strange and exotic indeed, but an analogous phenomenon is probably quite familiar to students in your class. Who doesn’t behave in different ways with different people or in different situations? Most college students report that they revert in many ways when they return home for vacations. Surely, their table manners vary depending on the circumstances. And who wouldn’t put their best foot forward for a job interview? Nobody is perfectly consistent. With this minimal orientation to the idea of normal multiple personalities, a student volunteer can then be solicited to participate in a brief exploration of the topic. In doing so, the instructor can demonstrate how multiple personalities can be encouraged iatrogenically in therapy. First of all, the student volunteer is asked about his or her different personalities. Then, the contradicting behaviors are grouped into categories like “neat” vs. “messy,” “responsible” vs. “irresponsible,” “serious” vs. “fun-loving.” If contradictions are not immediately evident, they can be elicited by questions like “yes, but isn’t the opposite also sometimes true?” Then ask the student to give a new name to each of these different personalities. The neat, responsible, and serious side can be given one name and the messy, irresponsible, and fun-loving side can be given another name. Then, the instructor can ask to talk to just one side. This “personality” can then be elaborated upon in detail, followed by a similar elaboration upon the other personalities.

Although the instructor has made clear that there is normal contradiction within all normal personalities, ask what effect it might have on a person to be told that the degree of personality elaboration “discovered” through this interview is abnormal and that one actually “has” multiple personality disorder?

Activity 7.2: Absorption Scale Hypnotic susceptibility and suggestibility can be rather abstract concepts. Therefore, it is helpful to show students some concrete examples of the traits that make up these constructs. In fact, students may enjoy gauging their standing on one such measure. Tellegen’s Absorption Scale (1982) is given in the last section of this instructor’s manual. Note that all the items are keyed true and that the mean/standard deviation for men is 21.4/6.9 and for women is 19.6/7.3. Handout 7.1 Activity 7.3: Film Screening and Discussion: Sybil Most students in Abnormal Psychology are aware of Sybil, either the best-selling 1973 book or the movie that was based on the book. As the result of childhood abuse, Sybil purportedly developed sixteen 146

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distinct personalities who did things without her knowledge. The book and movie cover how therapy with psychiatrist Cornelia Wilbur helped Sybil eventually overcome her disorder. Along with The Three Faces of Eve, Sybil is probably the most famous depiction of dissociative identity disorder and is worth screening for students, perhaps in an optional evening class meeting. Recently, psychologist Robert Rieber reported that taped conversations between Wilbur and the book author, Flora Rheta Schreiber, both deceased, show the story is incorrect. In fact, the psychiatrist and author appear themselves to have been “not totally unaware” that the story they told was wrong. Rieber’s report suggests that there was as much self-deception as deception of others going on between Wilbur and Schreiber. Wilbur was a colleague of Rieber’s at John Jay, and she gave him the tapes of her interactions with Schreiber. Rieber forgot about it for twenty-five years. Herbert Spiegel hypnotized Sybil and concluded that her so-called personalities actually arose from Wilbur’s therapeutic technique of giving names to various emotional states Sybil experienced. Wilbur then mistakenly came to believe that they really were distinct personalities. For example, when discussing something with Spiegel, Sybil asked whether she should be “Helen,” as Dr. Wilbur preferred. When he said no, she said, “Fine, I’d prefer it that way.”

Activity 7.4: Body Log Is it that hypochondriacs experience more bodily symptoms than other people, or is it that they attach excessive importance to the same symptoms experienced by everyone? Perhaps we all experience enough bodily symptoms to be hypochondriacs; we just ignore them. To test this hypothesis, it is of interest to survey the bodily symptoms normal people experience if they are instructed to attend more carefully to them. For this activity, students can be asked to keep a “body log” that tracks the physical symptoms they experience at various times throughout one week. Alternatively, one body log can be collected during class. Students might be surprised at the wide range of aches, pains, itches, numbness, dryness, palpitations, dizziness, and other symptoms that are observed without alarm by themselves and their classmates. Handout 7.2 Activity 7.5: Cultivating Dissociation Many people can report dissociative experiences, such as walking into another room but forgetting why, dialing the phone number of one friend when intending to call another, “reading” a paragraph only to realize the words weren’t processed, reaching for the stick shift in an automatic transmission car, being able to dial a phone number without being able to state it, etc. Ask students to describe their own dissociative experiences. Then talk about the dissociative continuum and how dissociative disorders are at the extreme end of that continuum. Some artists are described as being capable of cultivating dissociative experiences for artistic purposes. Students can try this through automatic writing, in which they try to let the words come automatically rather than deliberately, or through drawing, letting their hands move with minimal guidance from their conscious mind. Students who succeed in cultivating dissociation will gain a greater appreciation for its potential use as a way to cope with severe trauma, particularly for young children.

Activity 7.6: Secondary Gain for Somatic Symptoms Somatic symptoms are internal to the person experiencing them, but they can have external motives and even etiologies. These external reinforcements are called “secondary gain,” and they complicate physiological treatments because they tend to maintain symptomatology. It takes practice to recognize secondary gain from illness, but students often have some intuitions about what this involves. Ask them to reflect on various symptoms, describe the secondary gain associated with the symptoms, and think of ways to counteract secondary gain. Handout 7.3

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Web Links Web Link 7.1: http://www.psychological.com/somatofom_disorders.htm Psychological.com is the Web site of a practitioner in Atlanta, GA, that gives summary information about many disorders. This link takes you to the page concerning somatoform disorders.

Web Link 7.2: http://www.bddcentral.com/ This comprehensive site provides detailed information about body dysmorphic disorder, personal stories of people who have suffered with BDD, and resources geared toward those who are suffering from BDD, their family, and friends.

Web Link 7.3: http://www.issd.org/ The International Society for the Study of Dissociation is a nonprofit professional association to network clinicians and researchers, to provide education, and to promote dissociation theory, research, and training. Their Web site has an interesting FAQ section that describes, among other things, what to do if someone close to you has a dissociative disorder.

Web Link 7.4: http://counsellingresource.com/quizzes/des/index.html This site provides the Dissociative Experiences Scale, a popular self-report measure of individual differences in dissociative tendencies.

Web Link 7.5: http://www.mpdfriends.homestead.com/ MPD Friends is a rather idiosyncratic site authored by someone who lives with a person with MPD/DID. “My partner who we shall call Snowflake, is a 26 year old male with MPD/DID. He has over 25 alters and developed MPD/DID as a result of severe sexual and emotional abuse at the hands of close relatives, from the age of 2 until he was 16.”

Web Link 7.6: http://www.depersonalization.info This site explores the world of depersonalized people through their stories and interaction. It also gathers new treatment information. It describes itself as a place “where people who have been diagnosed with Depersonalization Disorder, and people who feel that they may have the condition, can reach out to each other and share information about symptoms and treatment.”

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Video Resources Body Dysmorphic Disorder. Anxiety-related Disorders: The Worried Well Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Broken Bond:Munchausen Syndrome by Proxy. Medical Detectives Series, Part 3. Princeton, NJ: Films for the Humanities and Social Sciences.

The Case of the Hillside Strangler. Mind of a Murderer Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Challenge Cases for Differential Diagnosis. Differential Diagnosis in Psychiatry Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Deception: Munchausen’s Disorder. New York, NY: Filmmakers Library.

Lost in the Mirror: Women with Multiple Personalities. Princeton, NJ: Films for the Humanities and Social Sciences.

The Madness of Children. New York, NY: Filmmakers Library.

Many Faces of Marsha. New York, NY: Insight Media.

Multiple Personality. The Brain Teaching Modules Video Series. South Burlington, VT: Annenberg/CPB Collection.

Multiple Personality Disorder: In the Shadows. Princeton, NJ: Films for the Humanities and Social Sciences.

Multiple Personality Puzzle. Allyn and Bacon Video Library.

Neurotic, Stress-Related, and Somatoform Disorders. Allyn and Bacon Video Library.

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Handout 7.1 Absorption Scale Indicate whether each of the following items is either “true” (if it is true or mostly true) or “false” (if it is false or mostly false) as applied to you: 1.

Sometimes I feel and experience things as I did when I was a child.

2.

I can be greatly moved by eloquent or poetic language.

3.

While watching a movie, a TV show, or a play, I may become so involved that I forget about myself and my surroundings and experience the story as if it were real and as if I were taking part in it.

4.

If I stare at a picture and then look away from it, I can sometimes “see” an image of the picture almost as if I were still looking at it.

5.

Sometimes I feel as if my mind could envelop the whole world.

6.

I like to watch cloud shapes change in the sky.

7.

If I wish, I can imagine (or daydream) some things so vividly that they hold my attention as a good movie or story does.

8.

I think I really know what some people mean when they talk about mystical experiences.

9.

I sometimes “step outside” my usual self and experience an entirely different state of being.

10.

Textures—such as wool, sand, wood—sometimes remind me of colors or music.

11.

Sometimes I experience things as if they were doubly real.

12.

When I listen to music I can get so caught up in it that I don’t notice anything else.

13.

If I wish, I can imagine that my body is so heavy that I could not move it if I wanted to.

14.

I can often somehow sense the presence of another person before I actually see or hear her or him.

15. The crackle and flames of a wood fire stimulate my imagination.

16.

It is sometimes possible for me to be completely immersed in nature or in art and to feel as if my whole state of consciousness has somehow been temporarily altered.

17. Different colors have distinctive and special meanings for me.

18.

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I am able to wander off into my thoughts while doing a routine task and actually forget that I am doing the task, and then find a few minutes later that I have completed it.

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19. I can sometimes recollect certain past experiences in my life with such clarity and vividness that it is like living them again.

20. Things that might seem meaningless to others might make sense to me.

21. While acting in a play I think I could really feel the emotions of the character and “become” her or him, for the time being forgetting both myself and the audience.

22. My thoughts often don’t occur as words but as visual images.

23. I often take delight in small things (like the five-pointed-star shape that appears when you cut an apple across the core or the colors in soap bubbles).

24. When listening to organ music or other powerful music I sometimes feel as if I am being lifted into the air.

25. Sometimes I can change noise into music by the way I listen to it.

26. Some of my most vivid memories are called up by scents and smells.

27. Some pictures remind me of changing color patterns.

28. I often know what someone is going to say before he or she says it.

29. I often have “physical memories,” for example, after I have been swimming I may still feel as if I am in the water.

30. The sound of a voice can be so fascinating to me that I can just go on listening to it.

31. At times I somehow feel the presence of someone who is not physically there.

32. I find that different odors have different colors.

33. I can be deeply moved by a sunset.

Scoring: One point for each item marked “True.” Mean/Standard Deviation for men is 21.4/6.9 and for women 19.6/7.3. From Tellegen (1982).

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Handout 7.2 Body Log

For each Body Log entry, focus as closely as you can on each specific part of your body, noting any sensations or feelings whatsoever. Try to make at least one comment about each area.

Skin: itchy, dry, tight, oily, crusty, etc.

Muscles: sore, tense, weak, tender, etc.

Heart: pounding, fluttering, etc.

Stomach: heavy, sour, weak, etc.

Breathing: shallow, labored, etc.

Bones/Joints: stiff, sore, painful, tender, weak, etc.

Glands: swollen, heavy, painful, etc.

Eyes/Vision: dry, crusted, blurred, hazy, etc.

Mouth: dry, cottony, pasty, painful, etc.

Feet/Hands: cold, clammy, sweaty, hot, itchy, sore, etc.

Back: uncomfortable, sore, stiff, tight, twisted, knotted, etc.

Throat: dry, sore, acidic, raw, scratchy, etc.

Other bodily sensations:

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Handout 7.3 Secondary Gain

What are some of the ways that a person receives reinforcement for being ill? Develop a list of possible symptoms. Then describe the secondary gain that a person may receive. Finally, provide ways to remove secondary gain.

Symptoms / Illness

Secondary Gain

Counteracting Secondary Gain

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CHAPTER 8: Eating Disorders and Obesity Chapter At-A-Glance Detailed Outline

Instructors’ Resources

Print Supplements

Media Supplements

Clinical Aspects of Eating Disorders • Anorexia Nervosa • Bulimia Nervosa • Other Forms of Eating Disorders • Age of Onset and Gender Differences • Prevalence of Eating Disorders • Medical Complications of Eating Disorders • Course and Outcome • The Long-Term Stability of Eating Disorders • Eating Disorders Across Cultures

Teaching Objectives 8.1–8.6 Chapter Guide Lecture Launchers 8.1, 8.2, 8.5 Activities 8.1, 8.2, 8.3, 8.5 Web Links 8.2, 8.3, 8.4, 8.5

Test Bank Grade Aid Transparencies T-73 to T-75

CD-ROM PowerPoint

Risk and Causal Factors in Eating Disorders • Biological Factors • Sociocultural Factors • Family Influences • Individual Risk Factors

Teaching Objectives 8.7 Chapter Guide Lecture Launchers 8.2, 8.4 Activities 8.3 Web Links 8.2, 8.3, 8.4, 8.5

Test Bank Grade Aid Transparencies T-74

CD-ROM PowerPoint

Treatment of Eating Disorders • Treatment of Anorexia Nervosa • Treatment of Bulimia Nervosa • Treatment of Binge-Eating Disorder

Teaching Objectives 8.8 Chapter Guide Lecture Launchers 8.1, 8.5 Activities 8.3, 8.5 Web Links 8.2, 8.3, 8.4, 8.5

Test Bank Grade Aid Transparencies T-76

CD-ROM PowerPoint

Teaching Objectives 8.9 Chapter Guide Lecture Launchers 8.3 Activities 8.6 Web Links 8.1, 8.6

Test Bank Grade Aid Transparencies T-74

CD-ROM PowerPoint

Teaching Objectives 8.10 Chapter Guide Lecture Launchers 8.3 Activities 8.4 Web Links 8.1, 8.6 Teaching Objectives 8.5 Chapter Guide Lecture Launchers Activities Web Links

Test Bank Grade Aid Transparencies T-74

CD-ROM PowerPoint

Obesity Risk and Causal Factors in Obesity • The Role of Genes • Hormones Involved in Appetite and Weight Regulation • Sociocultural Influences • Family Influences • Stress and “Comfort Food” • Pathways to Obesity

Treatment of Obesity • Lifestyle Modifications • Medications • Bariatric Surgery • The Importance of Prevention Unresolved Issues: What Should We Do About Eating Disorder NOS?

Test Bank Grade Aid Transparencies

Teaching Objectives 1.

2.

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Define anorexia nervosa and describe the two subtypes.

Define bulimia nervosa. .

ABC Video Clip #6

Professor Notes

Chapter 8 · Eating Disorders and Obesity

3.

4.

5.

6.

7.

8.

9.

10.

Compare and contrast anorexia nervosa, binge-eating/purging subtype and bulimia nervosa.

Describe the medical complications of the various eating disorders.

Identify other forms of eating disorders such as EDNOS and BED. Discuss age, gender, and prevalence rates of eating disorders in this culture and across cultures.

Describe the biological, sociocultural, individual and family risk, and causal factors associated with eating disorders.

Explain the various methods used for treating eating disorders and be able to evaluate each one.

Define obesity and identify risk and causal factors.

Discuss prevention and treatment methods for obesity.

Chapter Overview / Summary DSM-IV-TR recognizes three different forms of eating disorder: anorexia nervosa, bulimia nervosa, and eating disorder NOS. A fourth type of eating disorder, binge-eating disorder, is listed in the appendix and is not yet part of the formal DSM. Both anorexia nervosa and bulimia nervosa are characterized by an intense fear of becoming fat and a drive for thinness. Patients with anorexia nervosa are seriously underweight. This is not true of patients with bulimia nervosa.

Eating disorders are more common in women than they are in men. They can develop at any age, although they typically begin in adolescence. Anorexia nervosa has a lifetime prevalence of around 0.9% for women and 0.3% for men. Bulimia nervosa is somewhat more common, with a lifetime prevalence of 1.5% for women and 0.5% for men. Binge eating disorder is much more common with a lifetime prevalence of around 3.5% for women and 2% in men. During the 20th century, the rates of anorexia have been rising; rated of bulimia have decreased and remained stable since about 1992. The rate of adolescence showing disturbed eating patterns or distorted self-perceptions about their bodies are still extremely high with as many as 41.5% of girls and 24.9% of boys reporting distortions in these areas.

Medical complications of eating disorders can be severe with anorexia nervosa having the highest mortality rate of any psychiatric disorder with approximately 3% dying. Mortality from bulimia nervosa is about 0.5%. Suicide is also quite high among those with eating disorders with between 3 and 23% of those with anorexia making a suicide attempt; rates of completed suicide are 50 times greater than in the general population. In at least one long-term study, 16% had died from medical complications or suicide, 10% were still anorexic, 21% had partially recovered, and 51% had fully recovered. Recovery rates from bulimia and binge-eating appear to be higher with approximately 70% and 60% respectively reporting full recovery.

Diagnostic crossover among eating disorders is also quite common. Those with anorexia and bulimia anorexia frequently crossover into eating disorder, NOS. There are also frequent crossovers between the two subtypes of anorexia – restricting and binge/purging. However, no patient with binge eating developed anorexia or vice versa.

Eating disorders are not restricted to western countries, they are a worldwide problem.

Caucasians, however, appear to be at higher risk for body dissatisfaction, dietary restraint, and a desire for thinness. Members of ethnic minorities who identify with white, middle class values also appear to be at higher risk. Specific symptoms may also vary by culture such as a fear of stomach bloating rather than being fat. Based on the evidence, it seems that bulimia nervosa is a culture-bound syndrome while anorexia is not.

Eating disorders reflect a complex interaction between biological, sociocultural, family, and individual factors. Both anorexia and bulimia are heritable disorders. Preliminary evidence suggests that .

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chromosome 1 is implicated in anorexia and chromosome 10 in bulimia. The neurotransmitter serotonin has also been implicated in eating disorders. This neurotransmitter is also involved in mood disorders, which are highly comorbid with eating disorders. Sociocultural influences important in the development of eating disorders include the value society places on being thin. Western values about thinness may be spreading, as evidenced by Becker and her colleague’s reports of changes in body satisfaction and dieting among Fiji women following the arrival of western television shows. Family factors that have been associated with anorexia include rigidity, parental overprotectiveness, excessive control, and marital discord between the parents. Families of bulimic patients seem to share several risk factors most importantly making disparaging remarks about the woman’s appearance and the importance of dieting.

Finally, individual risk factors, such as internalizing the thin ideal, body dissatisfaction, perfectionism, negative body image, negative emotionality, childhood sexual abuse, and dieting are implicated in the development of eating disorders.

Anorexia nervosa is very difficult to treat. Treatment is long-term and many patients resist getting well. Current treatment approaches include refeeding, family therapy, and cognitive-behavior therapy. Medications are also used despite a lack of evidence of their effectiveness.

The treatment of choice for bulimia nervosa is CBT. Antidepressants are also commonly used.

CBT is also helpful for binge-eating disorder.

Obesity is defined as having a body mass index of thirty or above. Being obese is associated with many medical problems and increased risk of death from heart attack. Obesity is not viewed as an eating disorder or a psychiatric condition although some view it as a ‘food addiction’ or as a result of problems in key brain regions involved in motivation, reward, and inhibitory control. People are more likely to be obese if they are older, female, and from a lower SES group. Being a member of an ethnic minority group is also a risk factor for obesity A tendency to be thin or heavy may be inherited. Twin studies suggest that genes play a role in both the development of obesity and the tendency to binge. Leptin, produced by fat cells, acts to reduce our intake of food. Those who are overweight are resistant to the effects of leptin. Grehlin, a hormone produced in the stomach, is a powerful appetite stimulator. Those with Prader-WIlli syndrome have very high levels of grehlin. Sociocultural influences, family influences, and unhealthy lifestyles are also important influences on obesity. Overeating may also function as a means of reducing feelings of distress or depression. An important step to obesity may be binge-eating. Two pathways may lead to binge eating: social pressure to diet followed by a binge or depression and low self-esteem.

Obesity is a chronic problem. Three main treatments are used: lifestyle modifications, medications, and bariatric surgery. Lifestyle modifications and medications help patients to lose small amounts of weight; drastic weight loss usually requires bariatric surgery. Because obesity tends to be a life-long problem and because the treatment of obesity is so difficult, there is now a focus on trying to prevent people from becoming obese in the first place through a combination of increased energy expenditure and reduced food intake. Public policy recommendations such as improving opportunities for physical activity, regulating food advertising aimed at children, prohibiting the sale of fast food and sodas in schools, and subsidizing the sale of healthy foods may be especially difficult to implement.

Detailed Lecture Outline I.

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Clinical Aspects of Eating Disorders A. Anorexia Nervosa 1.

An intense fear of gaining weight or becoming fat is coupled with a refusal to maintain minimal weight 2.

First reports in early religious literature 3.

Usefulness of amenorrhea criterion questioned .

Chapter 8 · Eating Disorders and Obesity

4.

B.

C.

D.

E.

F.

Two types identified a.

Restricting type b.

Binge-eating/purging type Bulimia Nervosa 1.

Characterized by binge eating and weight gain efforts such as self-induced vomiting and excessive exercise 2.

The term bulimia was first proposed in 1979 3.

Argument has been made that binge-eating/purge subtype of anorexia (severely underweight) should be considered a subtype of bulimia (normal or slightly above normal weight) 4.

Anorexia and bulimia share a common fear of being or becoming “fat” 5.

Binging increases food costs and may result in stealing food 6.

Preoccupied with shame, guilt, self-deprecation, and efforts at concealment Other Forms of Eating Disorders 1.

Eating disorder not otherwise specified 2.

Binge-eating disorder Age of Onset and Gender Differences 1.

Although children as young as 7 have been known to develop anorexia, onset of eating disorders is typically not until adolescence 2.

15–19 is the most common age of onset for anorexia; 20–24 is the most common age of onset for bulimia 3.

Eating disorders are ten times more common in females Prevalence of Eating Disorders 1.

Despite media impressions, lifetime prevalence of anorexia is about 0.9% in women and 0.3% in men and the lifetime prevalence of bulimia is about 1.5% for women and 0.5% for men.

2.

Binge-eating disorder may be more common: 2–3% of general population and 6 to 8% of those who are obese 3.

Many more women have disordered eating patterns that do not reach a diagnosable level 4.

Increased cases of both anorexia and bulimia may be due to changing norms regarding the “ideal” size; although bulimia rates have decreased and remained steady in the past 20 years Medical Complications of Anorexia Nervosa and Bulimia Nervosa 1.

Anorexia a.

Hair and nails thin and become brittle b.

Dry skin c.

Downy hair called lanugo grows on face, neck, arms, back, and legs d.

Yellowish tinge to skin e.

Sensitive to cold f.

Low blood pressure leading to feeling tired, weak, dizzy, and faint g.

Thiamin deficiency may lead to depression and cognitive changes h.

Heart arrhythmias due to hypokalemia i.

Electrolyte imbalances j.

Kidney damage 2.

Bulimia a.

Electrolyte imbalances b.

Hypokalemia (low potassium) leading to heart problems c.

Damage to heart muscle .

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II.

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d.

Calluses on their hands e.

Tears to the throat f.

Mouth ulcers and cavities g.

Small red dots around eyes h.

Swollen salivary glands G. Course and Outcome 1.

High morbidity due to medical complications and suicide in anorexia 2.

Fewer completed suicides in bulimia; outcome more positive 3.

Even when “well,” still suffer from residual food issues: excessively concerned about shape and weight, restrict their dietary intakes, overeat and purge in response to negative mood states H. Long-Term Stability of Eating Disorders 1.

Shifts from anorexia nervosa to bulimia occur in about 1/3 of patients but no direct transitions form anorexia, restricting subtype to bulimia 2.

Bidirectional transitions between the two subtypes of anorexia are especially common, calling into question the current subtyping system for anorexia 3.

Very few transition from bulimia to anorexia 4.

Crossovers from binge-eating disorder to anorexia do not seem to occur leading to the conclusion that binge-eating and anorexia are distinct disorders I. Eating Disorders Across Cultures 1.

Most research conducted in the United States and Europe 2.

Eating disorders documented in South Africa, Japan, Hong Kong, Taiwan, Singapore, India, Iran, China, and Korea 3.

Being white is also associated with the type of subclinical problems that places people at high risk for eating disorders: body dissatisfaction, dietary restraint, and a drive for thinness 4.

Assimilation into white culture determines prevalence rates among minority women 5.

Clinical features of diagnosed eating disorders vary by culture a.

58% of anorexics in Hong Kong are excessively concerned not about fat but “stomach bloating” b.

Young women in Ghana emphasized religious ideas of self-control and denial of hunger c.

Japanese women report lower levels of perfectionism and less of a drive for thinness 6.

Anorexia nervosa occurs in all cultures; bulimia nervosa is a culture-bound syndrome Risk and Causal Factors in Eating Disorders A. Biological Factors 1.

Genetics a.

Risk of anorexia for relatives is 11.4 times greater than for the relatives of normal controls b.

Risk of bulimia for relatives is 3.7 times greater than for the relatives of normal controls c.

Restricting anorexia has been associated with chromosome 1 while bulimia has been associated with chromosome 10 2.

Set-points 3.

Serotonin

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Chapter 8 · Eating Disorders and Obesity

a.

B.

C.

D.

Neurotransmitter implicated in obsessionality, mood disorders, and impulsivity; also modulates appetite and feeding behavior b.

Those with anorexia and bulimia show low levels of 5-HIAA (metabolite of serotonin); higher levels than normal during recovery c.

Increased activity of the serotonin receptors is more characteristic of the bulimia type of anorexia than the restricting type d.

Research complicated by being unable to tell if serotonin alterations is due to the eating disorder rather than the altered serotonin causing the eating disorder Sociocultural Factors 1.

Peer and media influences 2.

Social pressure to be thin more powerful in higher SES backgrounds 3.

1960s — Twiggy 4.

Becker and her colleagues — research in Fiji a.

Initial research found absence of eating disorders; being fat was associated with being strong, able to work, and being kind and generous; being skinny was associated with being sickly, incompetent, or having somehow received poor treatment b.

When reassessed in 1998 after television was introduced, found women were dieting and expressing concern about their bodies/weight Family Influences 1.

One third of patients report that family dysfunction contributed to development of their anorexia 2.

No “typical” family profile with anorexia 3.

Associated family behaviors (anorexia) include rigidity, parental overprotectiveness, excessive control, and marital discord 4.

Many parents of anorexics have same issues: preoccupied with desirability of thinness, dieting, and good physical appearance 5.

Bulimic family characteristics include a.

High parental expectations b.

Other family members’ dieting c.

Critical comments from other family members about shape, weight, or eating Individual Risk Factors 1.

Gender a.

Women have higher rates than men b.

Greatest period of risk is adolescence c.

Exception is binge-eating where the onset is typically after adolescence 2.

Internalizing the thin ideal is associated with a.

Body dissatisfaction b.

Dieting c.

Negative affect 3.

Perfectionism a.

May be an enduring personality trait of people who are susceptible to eating disorders b.

More common in women 4.

Negative Body Image

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a.

III.

160

Sociocultural influences are implicated in the discrepancy between the way many young girls and women perceive their own bodies and the ‘ideal’ female form as represented in the media b.

Body dissatisfaction is a strong risk factor for pathological eating 5.

Dieting a.

At any one time, approximately 39% of women and 21% of men are dieting b.

When diets fail, we tend to feel badly about ourselves, thereby setting the stage for a possible eating disorder 6.

Negative Emotionality a.

Negative affect is a causal risk factor for body dissatisfaction b.

Depression and general negative affect are strong predictors of eating disorder 7.

Childhood sexual abuse a.

Research inconsistent: one prospective study found no link between early sexual abuse and binge-eating while retrospective studies have found a weak relationship b.

Causal pathway may be indirect Treatment of Eating Disorders A. Treatment of Anorexia Nervosa 1.

Patients are generally pessimistic about recovery and have a high drop-out rate 2.

Few controlled studies 3.

Must restore weight—may require hospitalization and tube feeding 4.

Short-term aggressive efforts may lead to temporary improvements but long-term problems 5.

No strong evidence that medications are helpful; antidepressants and antipsychotic medications are sometimes used 6.

Family therapy (Maudsley approach) considered the treatment of choice with adolescents who had developed anorexia before the age of 19 and who had been ill for less than three years 7.

Cognitive behavioral treatment focuses on modifying distorted beliefs; more effective than nutritional counseling but only 17% of patients in one study were fully recovered B. Treatment of Bulimia Nervosa 1.

Use of antidepressants is common; seems to decrease the frequency of binges as well as improving mood and preoccupation with shape and weight 2.

Cognitive behavior therapy is the treatment of choice: a.

Most current CBT approaches based on work of Fairburn b.

Multiple controlled studies show CBT superior to medications and interpersonal therapy c.

Behavioral components focus on meal planning, nutritional education, ending binging and purging cycles by teaching person to eat small amounts more frequently d.

Cognitive element focuses on challenging dysfunctional thought patterns C. Treatment of Binge-Eating Disorder 1.

Little information available 2.

Antidepressants, appetite suppressants, and anticonvulsant medications have been used

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3.

IV.

V.

Recent trial showed that sibutramine, a medication that inhibits the reuptake of serotonin and norepinephrine, has been shown to reduce the frequency of binges and be associated with weight loss Well designed CBT techniques are also helpful

4.

Obesity A. Widespread Epidemic 1.

In the United States, one third of the adult population is considered obese 2.

World Health Organization has recognized obesity as one of the top ten global health problems 3.

Body mass index a.

18.5 – 24.9 = healthy b.

25 – 29.9 = overweight c.

30 – 39.9 = obese d.

40 or more = morbidly obese 4.

Obesity is not an eating disorder or in the DSM although some believe it is a ‘food addiction’ or due to problems in key brain regions involved in motivation, reward, and inhibitory control 5.

In the United States, obesity is found in all racial and ethnic groups but is more common among ethnic minorities – especially black women – and, in general, the lowers social classes – especially white, lower SES girls 6.

Other risk factors include low parental education and children who are seriously neglected Risk and Causal Factors in Obesity A. Role of Genes 1.

Genes associated with thinness and leanness have been found in certain animals 2.

Genetic mutation associated with binge eating; all of the obese people with the gene reported problems with binge eating while only 14% of obese people who did not have the genetic mutation had a pattern of binge eating B. Hormones Involved in Appetite and Weight Regulation 1.

Leptin acts to reduce our intake of food; inability to produce the hormone leptin associated with morbid obesity 2.

People who are overweight tend to have high levels of leptin but are resistant to its effects 3.

The hormone grehlin, produced by the stomach, is a powerful appetite stimulator; in Prader-Willi syndrome, chromosomal abnormalities lead to high levels of grehlin and extreme obesity, often dying before the age of 30 C. Sociocultural Influences 1.

Culture that encourages consumption and discourages exercise 2.

Time pressure D. Family Influences 1.

Family behavior patterns 2.

Eating may become an habitual means of alleviating emotional distress 3.

Overfeeding infants and young children causes them to develop more adipose cells and may thus predispose them to weight problems in adulthood E. Stress and “Comfort Food” 1.

When under stress people and animals eat foods high in fat or carbohydrates 2.

Weight gain as a function of basic learning principles a.

Obese people are conditioned to eat more in response to both external and internal cues than normal-weight individuals .

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b.

VI.

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Eating is reinforced because the food is pleasurable and then emotional tension is reduced F. Pathways to Obesity 1.

Binge eating is a predictor of later obesity 2.

Binge eating may be caused by a.

Social pressure to conform to the thin ideal b.

Dieting c.

Depression and low self-esteem G. Treatment of Obesity 1.

Success rates are quite low 2.

Lifestyle Modifications a.

Average sustained weight loss is 7 pounds b.

Many groups exist; only Weight Watchers has been shown to be effective c.

Major problem is that energy expenditure decreases dramatically following weight loss so a person who has lost weight must consume fewer calories than a person weighing the same amount who has not lost weight 3.

Medications a.

Drugs fall into two categories: appetite suppressants and those that prevent some of the nutrients from being absorbed b.

Sibutramine (Meridia): inhibits re-uptake of serotonin and norepinephrine c.

Orlistat (Xenical): reduces the amount of fat that can be absorbed d.

Medications result in about 9% weight loss; placebo about 6% 4.

Bariatric surgery a.

Reduces amount of food that can be consumed at any one time b.

Recovery is difficult c.

Weight loss may be quite dramatic; average loss between 44 and 88 pounds d.

Most effective long-term treatment H. The Importance of Prevention 1.

Losing weight is contrary to biology 2.

Brownell: specific public policy recommendations: a.

Improve opportunities for physical activity b.

Regulate food advertising directed at children c.

Prohibit the sale of fast food and soft drinks in schools d.

Subsidize the sale of healthful foods Unresolved Issues: What Should We Do About Eating Disorder, NOS? A. Eating Disorder, NOS 1.

Residual category with the majority of diagnoses falling here 2.

Tends to attract little attentions from researchers so there is little information about causes or treatment B. Suggested solutions 1.

Make criteria for anorexia and bulimia less stringent 2.

Create new category called ‘mixed eating disorder’ 3.

Create a single category, called ‘eating disorder’, and eliminate all other diagnoses

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Chapter 8 · Eating Disorders and Obesity

Key Terms anorexia nervosa (p. 254) binge (p. 255) binge-eating disorder (BED) (p. 258) body mass index (BMI) (p. 272) bulimia nervosa (p. 256) cognitive-behavioral therapy (CBT) (p. 270) eating disorder (p. 254) eating disorder not otherwise specified (EDNOS) (p. 258)

grehlin (p. 273) leptin (p. 273) negative affect (p. 268) obesity (p. 272) perfectionism (p. 266) purge (p. 255) serotonin (p. 264) set point (p. 264)

Lecture Examples / Discussion Topics Lecture Launcher 8.1: Why Is the Thin Message So Effective When Others Are Not? It is easy to see that the media encourages an unhealthy focus on being thin, and that it thereby contributes to eating disorders, but is there more going on here? Inherent to the media influence theory of eating disorders is the presumption that the media can profoundly affect attitudes and behaviors, causing us to do extremely unhealthy things. But if the media is powerful enough to cause people to literally starve themselves to death, why is it so ineffective at other things? Why can’t the power of the media be harnessed for good? What makes the thin message especially powerful? Conversely, how are healthy media productions such as antismoking campaigns being hampered? What makes the two messages different?

Lecture Launcher 8.2: Bigorexia Nervosa?

Research on eating disorders focuses almost exclusively on women, but there has been a recent interest in studying men as well. With men, the issues are somewhat different because the ideal body type for men is muscular, and men who are preoccupied with their bodies are therefore trying to get bigger rather than smaller. This leads to obsessive weight-lifting, steroid use, and exercise. Men are often encouraged in this body preoccupation starting at a very young age when they are exposed to comic book heroes with unrealistic body characteristics. They can also gain encouragement from coaches and parents who want them to be successful athletes. Despite the obvious differences in what men and women are seeking to accomplish, how are men’s and women’s issues similar? How would preventive efforts target both sexes? How might they be customized for each sex? Handout 8.2 Lecture Launcher 8.3: Is Obesity an Eating Disorder?

Obesity has not been included as an eating disorder in the DSM-IV-TR. Ask students to provide reasons for this decision and then to suggest possible reasons for including obesity as an eating disorder. An interesting study finding that BMI is not associated with mental disorders or general psychopathologies was published by Lamertz, Jacobi, Yassouridis, Arnold, and Henkel (2002).

Lecture Launcher 8.4: Race and Eating Disorders Eating disorders are seven to eight times more likely in white females than among females of color.

Why is that? What cultural factors that are less pronounced among nonwhite females encourage eating disorders in white females? Alternatively, what protective cultural factors enjoyed by nonwhite females are missing from the lives of white females? What might be done to remedy this cultural difference so that the rates of eating disorders among white females are lowered?

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Lecture Launcher 8.5: What Kind of Disorder Is Anorexia?

Eating disorders in general, and anorexia in particular, are diagnostically complex owing to characteristics that overlap with other sections of the DSM. Students might have already noted the similarity between obsessional thinking characteristic of OCD and the body preoccupation characteristic of anorexia and bulimia. As well, the anxiety that is caused by preventing a bulimic from purging or causing an anorexic to eat normally is similar to that evoked when phobics are exposed to their feared stimuli or compulsives’ OCD rituals are interrupted. Are anorexia and bulimia anxiety disorders?

Alternatively, they can be viewed as mood disorders. The first clues to the possibility that some eating disorders were on the mood disorder “spectrum” was the observation that they sometimes respond to antidepressant medications. There is also some evidence that eating disorders run in families that have relatively high rates of depression. And the cognitive styles associated with some eating disorders are as distorted as those seen in depression. Should anorexia and/or bulimia be considered mood disorders?

Demonstrations / Activities Activity 8.1: Body Size Ratings The text discusses research by Fallon and Rosen (1985) in which participants were asked to use a picture scale to identify their current body, their ideal body, the ideal body type they envision for the opposite sex, and the ideal body type they expect the opposite sex to choose for members of their own sex. For men, the four ratings were about the same, but for women, their current figure was much heavier than their own ideal, which was heavier than the ideal they perceive held by men. In fact, men’s ideal figure for women was heavier than it was expected to be by women. It is a simple matter to project these figures using an overhead or PowerPoint projector and to secure the four ratings from every member of the class, being sure to get the respondent’s sex along with the ratings. These data can then be analyzed and presented to the class later as an exercise in research methods, or else the task can simply be used to help ensure student understanding of this somewhat difficult-to-describe study. The Body Image Ideals Questionnaire developed by Thomas Cash and Marcela Szymanski (1995) can also provide the basis for a class discussion (Journal of Personality Assessment, vol. 64, pp. 466–477). This measure evaluates attitudinal dimensions of the discrepancy between perceived and idealized physical characteristics. A multitude of physical characteristics is considered in addition to those that are weight related.

Activity 8.2: Measuring Body Image Distortion Students can be assigned the task of gathering and analyzing various methods of assessing body image distortions. An article by Thompson and Gray (1995) is a good starting point. Thompson and Gray found twenty-one different approaches to assessing body image distortions in eating disorders (Journal of Personality Assessment, vol. 64, pp. 258–269). Students can divide up these methods to present to the class, perhaps administering some to their fellow students and providing information for interpretation (viz. means and standard deviations). Once the different methods are presented in class, students can compare their strengths and weaknesses.

Activity 8.3: Focus on the Family A wide variety of psychological theories focus on family interactions of people with eating disorders.

For instance, Hilde Bruch proposed a psychodynamic theory of anorexia as an attempt to cope with feelings of powerlessness by taking control and gaining competence in the management of one’s own weight. The need to control this one area of life is created by parents who impose too much on their children, ignoring the child’s own needs in favor of their own apparently arbitrary regulations. From a more explicitly family systems point of view, Salvador Minuchin theorized that eating disorders exist to help families avoid conflicts over other things. Families of those with eating disorders are 164

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characteristically overly enmeshed, rigid, and protective. They are poor at conflict resolution, and communication is also very poor. Cognitive-behavioral theorists also focus on the family as a source of stress, in a diathesis-stress formulation, and as an important socializing influence in which preoccupation with weight can be established. For this activity, have students reflect on the way their families approached food and body image. Was food used as a reward? As a punishment? Was “comfort food” deployed to deal with negative emotions? Were students required to clean their plates? What other aspects of eating, exercise, and body image consciousness were taught in their families? How many of their current beliefs and practices have their origins in their family interactions? Do ideas about food, eating, and body image described by other class members sound strange? How resistant to change are these ideas? Handout 8.1 Activity 8.4: Bariatric Surgery Bariatric surgery has become increasingly common. As a result, most large hospitals offer the procedure. Inviting a surgeon or nurse who may be able to explain the procedure involved for those considering bariatric surgery would be very useful. Many students may be unaware of the presurgical education and the postsurgical lifestyle changes.

Activity 8.5: Medical Consequences of Eating Disorders Many college-aged people are quite uninformed about the medical consequences of eating disorders, viewing them as rather harmless strategies to cope with pressure to be thin. They are surprised to find that anorexia is frequently fatal and that bulimia also has a wide variety of medical consequences, some of which are permanent. An excellent way to make this point is to have students research these effects themselves or to invite a physician to present a lecture on the topic.

Activity 8.6: Local Prevention Efforts?

Ask students to explore the contents of the on-campus vending machines and food services. On most campuses, vending machines are filled with sodas, candy bars, and other high-calorie items. Many food services on campus provide pizza, burgers, fries, and cookies. Have students create their own lists of items to include in the vending machines and to have for sale at campus food services. Students could also attempt to interest the administration in making these changes.

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Web Links Web Link 8.1: http://www.obesity.org/ This site, sponsored by the American Obesity Association, provides current information on education, prevention, treatment, childhood obesity, discrimination, and disability due to obesity.

Web Link 8.2: http://www.anad.org National Association of Anorexia Nervosa and Associated Disorders provides “hotline counseling, a national network of free support groups, referrals to health care professionals, and education and prevention programs to promote self-acceptance and healthy lifestyles. All of our services are free of charge. ANAD also lobbies for state and national health insurance parity, undertakes and encourages research, fights dangerous advertising, and organizes advocacy campaigns to protect potential victims of eating disorders. ANAD stands with people and families and helps them win.”

Web Link 8.3: http://www.nationaleatingdisorders.org The National Eating Disorders Association Web site provides eating disorders information, referrals for groups, treatment centers, doctors, and therapists, as well as educational and promotional videos, books, and pamphlets.

Web Link 8.4: http://www.nichcy.org/organizations/Pages/Default.aspx?OrganizationID=1479 The Anorexia Nervosa and Related Eating Disorders Web site contains more than fifty pages of information about eating disorders. The information is written for a lay audience and covers warning signs, complications, causes, treatment and recovery, males and eating disorders, diabetes, pregnancy, the elderly, and myriad other lesser-known aspects of eating disorders.

Web Link 8.5: http://www.nedic.ca/ The National Eating Disorder Information Center provides information and resources on eating disorders and weight preoccupation. Their Web site provides an eating disorders glossary, a questionsand-answers section, recommended readings, and an excellent link list that has screen shots of its offerings.

Web Link 8.6: http://www.obesityaction.org/home/index.php The mission of the Obesity Action Coalition is to elevate and empower those affected by obesity through education, advocacy, and support. The site provides numerous resources including information, patient stories, comorbid conditions, and treatment options.

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Video Resources An Anorexic’s Tale: The Brief Life of Catharine. Princeton, NJ: Films for the Humanities and Social Sciences.

Anorexia and Bulimia. Princeton, NJ: Films for the Humanities and Social Sciences.

Anorexia Nervosa/Bulimia Client Interview (Kim)—#4 ABC News and Client Interviews. Allyn and Bacon Abnormal Psychology Video.

Beautiful Piggies. New York, NY: Filmmakers Library.

Belly: Overcoming Bulimia. New York, NY: Filmmakers Library.

Dying to Be Thin. Princeton, NJ: Films for the Humanities and Social Sciences.

Eating Disorders. Anxiety-Related Disorders: The Worried Well Video Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Eating Disorders: The Hunger Within. Princeton, NJ: Films for the Humanities and Social Sciences.

Eating Disorders: New Approaches to Treatment. Allyn and Bacon Video Library.

Eating Disorders: When Food Hurts. Boston, MA: Fanlight Productions.

Enigma of Anorexia Nervosa. New York, NY: Insight Media.

Fat Chance: The Big Prejudice. Oley, PA: Bullfrog Films.

Having Your Cake: Goodbye to Bulimia. Princeton, NJ: Films for the Humanities and Social Sciences.

The Human Body: Appearance, Shape, and Self-Image. Berkeley, CA: University of California Extension Center for Media and Independent Learning.

The Mind Awake and Asleep. Discovering Psychology Series. South Burlington, VT: Annenberg/CPB Multimedia Collection.

Self-Image and Eating Disorders: A Mirror for the Heart. Princeton, NJ: Films for the Humanities and Social Sciences.

The Silent Hunger: Anorexia and Bulimia. Princeton, NJ: Films for the Humanities and Social Sciences.

Thin At Any Cost: Treating Eating Disorders. Allyn and Bacon Video Library.

Wake Up, America: A Sleep Alert. Princeton, NJ: Films for the Humanities and Social Sciences.

When Food Is the Enemy: Eating Disorders. Allyn and Bacon Video Library.

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Handout 8.1 Food and Families

1.

In general, what are your recollections about how food and eating were approached in your family while you were growing up?

2.

Was food used as a reward? As a punishment?

3.

Did your family recognize “comfort foods” or in other ways tie food to either positive or negative emotions?

4.

Were you required to eat everything on your plate?

5.

Did your family comment on each other’s weight?

6.

Was the dinner table a frequent place for arguments and family conflict?

7.

How do you see your present attitudes about weight and eating connecting with your childhood family experiences?

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Handout 8.2 Eating Disorders in Men

1.

Does the DSM’s delineation of anorexia, bulimia, and binge-eating disorder give adequate coverage to the kinds of eating disorders to which men might be prone?

2.

What kinds of disordered eating are typical in men?

3.

What would be the diagnostic criteria for an eating disorder, or disorders, that would encompass the sorts of eating problems to which men are prone?

4.

More important than eating behaviors are the etiological factors behind the behavior. What are some of the cognitive, emotional, biological, and psychosocial factors behind men’s disordered eating?

5.

What are some of the media influences on men’s body image? How do they differ from women’s? Are there differences in the content of the messages to which men are exposed?

Differences in the pervasiveness of the message? More alternative messages available?

6.

Who is more anatomically implausible, Barbie or G. I. Joe? Is children’s attraction to these figures what makes them popular, or does their popularity influence children’s attraction to them? What is the role of early images like these in adult body images?

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Chapter 9 Personality Disorders

CHAPTER 9: Personality Disorders Chapter At-A-Glance Detailed Outline

Instructors’ Resources

Print Supplements

Media Supplements

Clinical Features of Personality Disorders

Teaching Objectives 9.1 Chapter Guide Lecture Launchers 9.5 Activities 9.1, 9.5 Web Links 9.1, 9.2, 9.4, 9.5

Test Bank Grade Aid Transparency T-89

CD-ROM PowerPoint

Difficulties Doing Research on Personality Disorders • Difficulties in Diagnosing Personality Disorders • Difficulties in Studying the Causes of Personality Disorders

Teaching Objectives 9.1 Chapter Guide Lecture Launchers 9.1, 9.3, 9.5 Activities 9.1, 9.2, 9.3, 9.5 Web Links 9.2, 9.3, 9.4

Test Bank Grade Aid Transparency T-89

CD-ROM PowerPoint

Cluster A Personality Disorders • Paranoid Personality Disorder • Schizoid Personality Disorder • Schizotypal Personality Disorder

Teaching Objectives 9.2–9.4 Chapter Guide Lecture Launchers 9.5 Activities 9.1, 9.3, 9.4 Web Links 9.1, 9.2, 9.3, 9.4, 9.5

Test Bank Grade Aid Transparency T-90

CD-ROM PowerPoint ABC Video Clip #7

Cluster B Personality Disorders • Histrionic Personality Disorder • Narcissistic Personality Disorder • Antisocial Personality Disorder • Borderline Personality Disorder

Teaching Objectives 9.2, 9.3, 9.5 Chapter Guide Lecture Launchers 9.2, 9.3 Activities 9.1, 9.2, 9.3, 9.4 Web Links 9.1, 9.2, 9.3, 9.4, 9.5

Test Bank Grade Aid Transparency T-90

CD-ROM PowerPoint ABC Video Clip #7

Cluster C Personality Disorders • Avoidant Personality Disorder • Dependent Personality Disorder • Obsessive-Compulsive Personality Disorder • General Sociocultural Causal Factors for Personality Disorders

Teaching Objectives 9.2, 9.3 Chapter Guide Lecture Launchers 9.1, 9.4 Activities 9.1, 9.3, 9.4 Web Links 9.1, 9.2, 9.3, 9.4, 9.5

Test Bank Grade Aid Transparency T-90

CD-ROM PowerPoint ABC Video Clip #7

Treatments and Outcomes for Personality Disorders • Adapting Therapeutic Techniques to Specific Personality Disorders • Treating Borderline Personality Disorder • Treating Other Personality Disorders

Teaching Objectives 9.6, 9.7 Chapter Guide Lecture Launchers 9.1, 9.2, 9.3, 9.4 Activities 9.1, 9.3, 9.5 Web Links 9.2, 9.4, 9.5

Test Bank Grade Aid

CD-ROM PowerPoint

Antisocial Personality Disorder and Psychopathy • Psychopathy and ASPD • The Clinical Picture in Psychopathy and Antisocial Personality Disorder • Causal Factors in Psychopathy and Antisocial Personality • A Developmental Perspective on Psychopathy and Antisocial Personality • Treatments and Outcomes in Psychopathic and Antisocial Personality • Prevention of Psychopathy and Antisocial Personality

Teaching Objectives 9.8 – 9.11 Chapter Guide Lecture Launchers 9.1 Activities 9.1, 9.2, 9.3 Web Links 9.2, 9.3, 9.4

Test Bank Grade Aid Transparency T-90

CD-ROM PowerPoint

Test Bank Grade Aid

CD-ROM PowerPoint

Unresolved Issues: Axis II of DSM-IVTR: Moving Toward a Dimensional System of Classification

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Teaching Objectives 9.1 Chapter Guide Lecture Launchers 9.1, 9.5 Activities 9.1, 9.3, 9.5 Web Links 9.2, 9.3, 9.4, 9.5

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Professor Notes

Chapter 9 Personality Disorders

Teaching Objectives 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

List the clinical features of the personality disorders and problems associated with diagnosis.

Compare and contrast the different types of personality disorders and identify the three clusters into which most personality disorders are grouped.

Summarize what is known about the biological, psychological, and sociocultural causal factors of personality disorders.

Argue whether schizoid and schizotypal personality disorders are simply variants of schizophrenia.

Differentiate between narcissistic personality disorder and histrionic personality disorder.

Discuss the difficulties of treating individuals with personality disorders and describe the approaches to treatment that have been tried.

Explain how changes in the family structure may have led to increasing rates of borderline personality disorder.

Compare and contrast the DSM-IV concept of antisocial personality and Cleckley’s concept of psychopathy.

List the clinical features of psychopathy and antisocial personality.

Summarize the biological, psychosocial, and sociocultural causal factors in psychopathy and antisocial personality and the integrated developmental perspective.

Explain why it is difficult to treat psychopathy and antisocial personality and describe the most promising of the as-yet-unproven approaches to treatment.

Chapter Overview / Summary Personality disorders appear to be inflexible and distorted behavioral patterns and traits that result in maladaptive ways of perceiving, thinking about, and relating to other people and the environment. Prevalence data is limited but one large epidemiological study estimated that about 13 percent of the population exhibits at least one personality disorder with 5.7% in Cluster A, 1.5% in Cluster B, and 6% in Cluster C. Difficulties in diagnosing personality disorders occur because even with structured interviews, the reliability of diagnosing personality disorders is less than ideal. Moreover, most researchers agree that a dimensional approach for assessing personality disorders would be preferable to the more categorical approach taken by the DSM system. The dimensional model that has been most influential is the five factor model (with each factor having six facets), which builds on the five factor model of normal personality. Difficulties in studying the causes of personality disorders occur because most people with one personality disorder have at least one more, making it difficult to disentangle the causes of one from the other.

Three general clusters of personality disorders have been described in DSM: • Cluster A includes paranoid, schizoid, and schizotypal personality disorders; individuals with these disorders seem odd or eccentric. Little is known about the causes of paranoid and schizoid disorders, but genetic factors are implicated in schizotypal personality disorder.

• Cluster B includes histrionic, narcissistic, antisocial, and borderline personality disorders; individuals with these disorders share a common tendency to be dramatic, emotional, and erratic. Little is yet known about the causes of histrionic and narcissistic disorders. Certain biological and psychosocial causal factors have been identified as increasing the likelihood of developing borderline personality disorder in those at risk because of high levels of impulsivity and affective instability.

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• Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders; individuals with these disorders show fearfulness or tension, as in anxiety-based disorders. Children with an inhibited temperament may be at heightened risk for avoidant personality disorder, and individuals high on neuroticism and agreeableness, with authoritarian or overprotective parents, may be at heightened risk for dependent personality disorder.

There is also relatively little research on treatments for most personality disorders. Treatment of the Cluster C disorders seems most promising, and treatment of Cluster A disorders is the most difficult.

A new form of behavior therapy (dialectical behavior therapy) shows considerable promise for treating borderline personality disorder, which is in Cluster B. Although the DSM diagnoses ASPD, many clinicians continue to use the diagnosis of psychopathy. A person with psychopathy is callous and unethical, without loyalty or close relationships, but often with superficial charm and intelligence. Individuals with a diagnosis of ASPD engage in an antisocial, impulsive, and socially deviant lifestyle. Genetic and constitutional, learning, and adverse environmental factors seem to be important in causing these disorders. There is some evidence that these may be distinct disorders with unique causal pathways. Psychopaths also show deficiencies in aversive emotional arousal, as well as more general emotional deficits. Treatment of ASPD and psychopaths is difficult in part because they rarely see any need for change and tend to blame other people for their problems.

Detailed Lecture Outline I.

II.

III.

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Clinical Features of Personality Disorders A. To be diagnosed with a personality disorder, a person’s enduring pattern of behavior must be pervasive, inflexible, stable, and of long duration. The pattern of behavior must lead to clinically significant distress or impairment in functioning and must be manifested in at least two areas.

B. Little evidence on prevalence; estimates are that about 13% of the population will meet the criteria for a personality disorder at some times in their lives C. Personality disorders are coded on Axis II of the DSM-IV-TR Difficulties Doing Research on Personality Disorders A. Difficulties in Diagnosing Personality Disorders 1.

Diagnostic criteria are not as sharply defined 2.

Diagnosis relies on inferred traits or consistent patterns of behavior rather than on more objective behavioral standards 3.

Although semi-structured interviews and self-report inventories have been developed, diagnostic reliability and validity is still low 4.

Diagnostic categories are not mutually exclusive 5.

Competing dimensional views; Five-Factor model has become the most influential model of normal personality B. Difficulties in Studying the Causes of Personality Disorders 1.

High levels of comorbidity among disorders 2.

Very little prospective research on disorders Cluster A Personality Disorders A. Paranoid Personality Disorder 1.

Typical symptoms are suspiciousness, rigidity, hypersensitivity, and argumentativeness 2.

The person is constantly “on guard” for attacks from others 3.

Causal factors .

Chapter 9 Personality Disorders

a. b. c.

IV.

Little is known Inconsistent findings on genetic transmission Modest genetic heritability through high levels of antagonism (low agreeableness) and neuroticism (angry-hostility) d.

Psychosocial factors suspected (parental neglect or abuse, exposure to violent adults) B. Schizoid Personality Disorder 1.

Central symptoms are an inability to form social relationships and an indifference toward developing them 2.

Causal factors a.

Early theorists believed this was a precursor to schizophrenia b.

Failure to establish strong hereditary basis or link to schizophrenia c.

Maladaptive underlying schemas with individual as self-sufficient loner and a view of others as intrusive (1) “I am basically alone” (2) “Relationships are messy (and) undesirable” C. Schizotypal Personality Disorder 1.

Extreme introversion, sensitivity, and eccentricity are the central features 2.

Oddities of thought, perception, and speech are also present and similar to schizophrenia 3.

2 percent in general population 4.

Causal factors: believed to be moderately heritable with a genetic and biological association with schizophrenia a.

Deficits in eye tracking b.

Attentional deficits c.

Deficits in working memory 5.

May be a second subtype unrelated to schizophrenia characterized by cognitive and perceptual deficits and linked to a history of child abuse and early trauma Cluster B Personality Disorders A. Histrionic Personality Disorder 1.

Excessive attention-seeking, emotionality, and self-dramatization are key features 2.

Interpersonal relationships are stormy 3.

Self-centered, vain, and overly concerned about approval 4.

Tendency to be seductive and to eroticize situations 5.

Prevalence in general population is 2–3% and occurs more often in women than men; sex difference most likely represents sex bias in diagnosing 6.

Causal factors a.

Possible genetic link with antisocial personality disorder b.

May be seen as extreme versions of neuroticism and extraversion c.

Maladaptive schemas involving need for attention to validate self-worth (1) “Unless I captivate people, I am nothing” (2) “If I can’t entertain people, they will abandon me” B. Narcissistic Personality Disorder 1.

An exaggerated sense of self-importance leading to a sense of entitlement, lack of empathy, and need for attention are found 2.

More common among men than women 3.

Fragile and unstable self-esteem underlies grandiosity 4.

May be hypercritical and retaliatory

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5.

V.

174

Five factor model would describe them as low agreeableness/high antagonism, low altruism, tough-mindedness, high levels of fantasy-proneness, and high levels of angry-hostility and self consciousness (facets of neuroticism) 6.

Relatively rare; about 1% of the population 7.

Causal factors a.

Psychoanalytic theory (1) Importance of mirroring infant grandiosity (2) Parental neglect, devaluation, lack of empathy b.

Social learning theory: unrealistic parental overvaluation C. Antisocial Personality Disorder (ASPD) 1.

Persons with this disorder violate the rights of others without remorse 2.

Intelligence and charm can be found in many antisocial personalities 3.

Impulsivity, irritability, and aggression are common features 4.

Must have symptoms of conduct disorder before the age of 15 D. Borderline Personality Disorder 1.

Common symptoms include impulsivity, anger, instability, and unpredictability 2.

These persons fail to complete the process of forming a stable self-identity 3.

Can have a history of stormy, intense relationships 4.

Mood is highly unstable 5.

Impulsive, self-destructive behavior such as gambling, binge eating, substance abuse, and reckless driving 6.

Suicide attempts are usually seen as manipulative 7.

75% experience relatively short or transient psychotic-like symptoms 8.

Comorbidity with other Axis I and Axis II disorders a.

Exists with disorders ranging from mood and anxiety disorders to substance abuse and eating disorders; overlap in symptomatology with depression b.

Comorbidity with other personality disorders especially histrionic, dependent, antisocial, and schizotypal 9.

Causal factors a.

Genetic factors play a significant role; personality traits of impulsivity and affective instability are partially heritable b.

Biological (1) Lowered functioning of the neurotransmitter serotonin may explain their impulsivity-aggression (2) Disturbances in regulation of noradrenergic transmitters may explain their hypersensitivity to environmental changes c.

Psychosocial (negative, even traumatic, childhood events) d.

Paris’s Multidimensional Diathesis-Stress model: high levels of impulsivity and affective instability combined with psychological risk such as trauma, loss, or parental failure Cluster C Personality Disorders A. Avoidant Personality Disorder 1.

These persons fear rejection and show extreme social inhibition, introversion, and hypersensitivity 2.

They desire affection and are lonely; desire interpersonal contact but avoid it out of fear of rejection 3.

Some hypothesize that avoidant personality disorder is a more extreme form of generalized social phobia .

Chapter 9 Personality Disorders

4.

B.

C.

D.

Causal factors a.

Inhibited temperament b.

Evidence that fear of being negatively evaluated is moderately heritable c.

Introversion and neuroticism are both elevated and moderately heritable d.

Emotional abuse and rejection from parents Dependent Personality Disorder 1.

Extreme dependency on others and panic when alone are central symptoms 2.

Self-confidence is lacking and will show clinging and submissive behavior 3.

They allow others to take over decision making 4.

An indiscriminate selection of mates can take place 5.

May accept abuse to remain in relationship 6.

Estimate 1.5% of population and more common in women 7.

Common to have comorbid diagnoses of mood and anxiety disorders 8.

Causal factors a.

Modest genetic influence b.

Traits of neuroticism and agreeableness partially heritable c.

Authoritarian and overprotective parents d.

Maladaptive schemas about weakness and competence and needing others to survive (1) “I am completely helpless” (2) “I can function only if I have access to somebody competent” Obsessive-Compulsive Personality Disorder 1.

Perfectionism and excessive concern with maintaining order and control are essential characteristics 2.

Mental and interpersonal control is maintained 3.

Repeatedly check work for mistakes 4.

Perfectionism is often dysfunctional in that they cannot finish tasks and become overly involved in details 5.

Leisure activities are sacrificed 6.

Rigidity and stubbornness is common 7.

Differences with obsessive-compulsive disorder a.

Intrusion of thoughts in OCD b.

Extreme anxiety in OCD due to thoughts and images 8.

Some overlap with narcissistic, antisocial, and schizoid personality disorders 9.

Causal factors a.

Dimensional approach—individuals have excessively high levels of conscientiousness, high level of assertiveness, and a low level of compliance b.

Modest genetic influence General Sociocultural Causal Factors for Personality Disorders 1.

The possible factors are poorly defined 2.

Less variance across cultures than within cultures 3.

Change in culture’s priorities and activities may influence the development of personality disorders a.

Narcissistic personality disorders more common in Western cultures b.

Histrionic less common in Asian cultures and more common in Hispanic cultures c.

Borderline is more common among Hispanic Americans than African Americans or Caucasians .

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Schizotypal personality disorder is more common among African Americans than among Caucasians Treatments and Outcomes A. In general, personality disorders are difficult to treat 1.

Personality disorders represent relatively enduring, pervasive, and inflexible patterns of behavior 2.

Different possible goals of therapy 3.

Many people with personality disorders only come to therapy at the request of someone else 4.

Many people with personality disorders (especially those with Cluster A or Cluster B diagnoses) will have difficulty forming a therapeutic relationship B. Adapting Therapeutic Techniques to Specific Personality Disorders 1.

May need to be careful not to encourage dependence 2.

Acting-out behavior may need to be constrained 3.

Specific therapeutic techniques are a central part of the cognitive approach to personality disorders; techniques include monitoring automatic thoughts, challenging faulty logic, and assigning behavioral tasks to challenge dysfunctional assumptions and beliefs C. Treating Borderline Personality Disorder 1.

Biological treatments a.

Controversial as using medications increases suicide risk b.

SSRIs for treating rapid mood shifts, anger, and anxiety c.

Low doses of antipsychotic drugs d.

Mood-stabilizing drugs may reduce irritability, suicidality, and impulsive aggressive behavior 2.

Psychosocial treatments a.

Traditional treatment involve variants of psychodynamic (1) Primary goal is strengthening weak egos (2) Focus is the defense mechanism of splitting b.

Linehan’s Dialectical Behavior Therapy (1) A promising new approach (2) A form of cognitive and behavioral treatment that is problemfocused and based on a clear hierarchy of five goals (a) Decreasing suicidal and other self-harming behavior (b) Decreasing behaviors that interfere with therapy (c) Decreasing escapist behaviors that interfere with a stable lifestyle (d) Increasing behavioral skills to regulate emotions, to increase interpersonal skills, and to increase tolerance of distress (e) Other goals the patient chooses D. Treating Other Personality Disorders 1.

Treating other Cluster A and B disorders a.

Antipsychotic medications only have modest success b.

Antidepressants from the SSRI category may be useful c.

No systemic studies exist for paranoid, schizoid, narcissistic, or histrionic disorders 2.

Treating Cluster C disorders a.

Active and confrontational short-term therapy shows improvement .

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VII.

b.

Significant gains with cognitive-behavioral treatment c.

Antidepressants and MAO inhibitors have been used Antisocial Personality Disorder and Psychopathy A. Psychopathy and ASPD 1.

Two dimensions of psychopathy a.

Affective and interpersonal core b.

Behavioral aspects of the disorder 2.

DSM focuses on behavioral factors 3.

Many use the Cleckley/Hare psychopathy diagnosis rather than the DSM-IV-TR ASPD diagnosis 4.

Diagnosis of psychopathy is the single best predictor of violence and recidivism 5.

ASPD may be omitting those who do not show violent behavior a.

Widom—advertisements b.

Experimental findings of possible biological differences between these two groups B. The Clinical Picture in Psychopathy and Antisocial Personality Disorder 1.

Inadequate conscience development 2.

Irresponsible and impulsive behavior a.

They take what they want b.

They are prone to thrill-seeking actions c.

High rates of alcohol and other substance abuse related to ASPD but not necessarily psychopathy d.

Likewise ASPD, but not psychopathy, is related to elevated rates of suicide attempts and completed suicides 3.

Ability to impress and exploit others a.

They are frequent liars b.

They understand and use the weaknesses of others c.

Rejection of authority d.

They can easily win “friends,” but seldom keep close friends e.

They can be violent toward “friends” and family C. Causal Factors in Psychopathy and Antisocial Personality 1.

Genetic influences a.

Moderate heritable for antisocial or criminal behavior b.

Genotype-environment interaction: Adopted away children of biological parents with ASPD were more likely to develop antisocial personalities if their adoptive parents exposed them to adverse environments (marital conflict or divorce, legal problems, parental psychopathology) c.

Monoamine oxidase-A gene—breakdown of neurotransmitters like norepinephrine, dopamine, and serotonin d.

Significant genetic involvement in comorbidity of alcoholism and ASPD 2.

The Low Fear Hypothesis and Conditioning a.

Lykken (1957)—deficient conditioning of anxiety to signals for punishment b.

This deficient conditioning of fear seems to stem from having a deficient behavioral inhibition system c.

Patrick, Bradley, and Lang (1993)—psychopaths show deficient fearpotentiated startle d.

Normal or hypernormal active avoidance of punishment (behavioral activation system) when actively threatened with it .

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e.

Dominant response set for reward More general emotional deficits a.

Reduced responsiveness to aversive visual images consistent with findings that they are low on empathy b.

Small startle responses when viewing unpleasant images might also be related to lack of empathy c.

Hare has suggested that these findings represent only a subset of a larger problem with processing and understanding the meaning of affective stimuli—“as if emotion is a second language” 4.

Early parental loss, parental rejection, and inconsistency a.

Studies pointed to early parental loss and emotional deprivation as causal agents b.

Parental rejection and inconsistency alone insufficient as causal agents A Developmental Perspective on Psychopathy and Antisocial Personality 1.

Begins in early childhood a.

The number of antisocial behaviors exhibited in childhood is the single best predictor of who develops an adult diagnosis of ASPD b.

The younger the symptoms develop, the higher the risk 2.

Oppositional defiant disorder a.

Early onset before 6 b.

Conduct disorder by 9 c.

Children who develop conduct disorder in adolescence do not typically develop ASPD 3.

Attention-Deficit/Hyperactivity Disorder (ADHD) a.

When ADHD occurs with conduct disorder, high likelihood of ASPD and even psychopathy b.

Lynam refers to these children as “fledgling psychopaths” 4.

Other psychosocial and sociocultural contextual variables also contribute: parents’ own antisocial behaviors, divorce, poverty, crowded inner-city neighborhoods, parental stress, poor and ineffective parenting skills 5.

Sociocultural causal factors and psychopathy a.

Disorder appears in various cultures: Inuit of Northern Alaska and Yoruba of Nigeria b.

Socialization forces have impact on expression of aggressive impulses c.

Distinguishing between individualistic and collectivist societies Treatments and Outcomes in Psychopathic and Antisocial Personality 1.

Traditional psychotherapeutic approaches are not effective 2.

Cognitive-behavioral treatments a.

Targets: increasing self-control, self-critical thinking, and socialperspective taking; victim awareness; anger management; changing antisocial attitudes; curing drug addiction b.

Interventions require a controlled situation c.

Even best programs show only modest improvements; psychopathy more difficult to treat than ASPD 3.

Many antisocial personalities show improvement as they age a.

They achieve insight into their self-defeating actions b.

Cumulative effect of social conditioning c.

Only ASPD changes with age; not psychopathy Prevention of Psychopathy and Antisocial Personality Disorder 3.

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1.

VIII.

Patterson and colleagues have developed programs for young children targeting family environment and teaching effective parental discipline and supervision 2.

FAST Track (Families and Schools Together) Intervention showed success in reducing conduct disorder (75%) and ADHD (53%) by focusing on improving social-cognitive and cognitive skills, friendships with peers, emotional awareness, and self-control Unresolved Issues: Axis II of DSM-IV-TR: Moving Toward a Dimensional System of Classification A. Axis II Diagnoses Are Often Unreliable 1.

The personality processes are dimensional in nature 2.

Arbitrary decisions are used to define the degree of a trait 3.

The diagnoses are not based upon mutually exclusive criteria B. Clearer Sets of Classification Rules Need to Be Formulated 1.

Adoption of a dimensional approach 2.

Possible use of the five-factor model

Key Terms antisocial personality disorder (ASPD) (p. 292, 302) avoidant personality disorder (p. 295) borderline personality disorder (BPD) (p. 293) dependent personality disorder (p. 297) dialectical behavior therapy (p. 300) histrionic personality disorder (p. 290) narcissistic personality disorder (p. 291)

obsessive-compulsive personality disorder (OCPD) (p. 298) paranoid personality disorder (p. 285) personality disorder (p. 282) psychopathy (p. 302) schizoid personality disorder (p. 286) schizotypal personality disorder (p. 287)

Lecture Examples / Discussion Topics Lecture Launcher 9.1: Adaptive Psychopathy DSM antisocial personality disorder overlaps with both classic descriptions of psychopathy and with criminality. Cleckley (1976), Lykken (1995), and Hare (1991) have all attempted to keep psychopathy separate from criminality and they have also emphasized certain psychopathic personality traits that may not necessarily be destructive in all cases. An especially telling example is the famous fighter-jet test pilot Chuck Yeager, whom Lykken describes as having many characteristics of a psychopath but without the antisocial tendencies that otherwise might make him a menace to society. For instance, Yeager’s apparent immunity from anxiety permitted him literally to have aircraft fall apart under him without causing him even to reconsider his line of work, much less prevent him from ever flying again—as might be the case for most of us. Given a different background, one might imagine a person like Yeager, insensitive to normal fear of negative consequences from rule-breaking, growing up to be a career criminal. What distinguishes fearless people who grow up to be criminals from those who grow up to be productive contributors to society? One factor might be the strong socializing force of institutions like the military, as in Yeager’s case. It is also possible that high IQ can permit some people to avoid legal trouble even though they have no reservations about breaking the law. A broader appreciation for psychopathic traits makes clear that these kinds of people exist in all walks of life, functioning well as business executives, politicians, lawyers, doctors, and the like, succeeding on the merits of their typically psychopathic superficial charm, lack of remorse, insincerity, and freedom from the distraction of a guilty conscience. That is why Cleckley’s book on the subject is entitled The Mask of .

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Sanity. Incidentally, Cleckley also coauthored The 3 Faces of Eve. Are there any advantages to being a psychopath?

Lecture Launcher 9.2: Narcissism: The Characteristic of Our Times Narcissism has been called the characteristic of our times. Unbridled self-absorption and entitlement, reflected in our society’s predisposition to litigate when we feel wronged, materialism, and the selfesteem movement are all taken as indicators of an inward focus not too dissimilar to narcissistic personality disorder. Unabashed image-consciousness is very nearly a literal narcissism, emulating the Greek hero’s love for his own reflection. Do students agree with this assessment of our times? What accounts for societal narcissism? Do modern child-rearing habits encourage narcissism? Are our children’s self-esteems overly emphasized? Or is it the opposite, as Kohut might have it? Are we so insecure and lacking in self-esteem that we have to construct elaborate and grandiose images of ourselves just to cope? Are we programmed by too much success or too little?

Lecture Launcher 9.3: Histrionics and Show Business Histrionic personality disorder is characterized by behavior that is overly dramatic and attentionseeking. Those diagnosed can be described as self-centered, overly concerned with physical appearance, and often quite shallow despite grand emotional displays. Sounds like Hollywood, doesn’t it? What better way to attract attention than to be a celebrity? Students can usually come up with quite a few names of successful histrionics. Marilyn Monroe and Liberace are classic older examples, while Madonna and Dennis Rodman are more contemporary ones. Are they mentally ill? Or does their ability to channel their histrionics into successful careers disqualify them? Are the private lives of celebrities in the news so often because the public is interested in them or because their histrionic characteristics motivate them to seek attention even outside the confines of their careers? Successful entertainers who are virtually unknown outside of their professional performances suggest that histrionics are not necessary for success, but the relative rarity of this type suggests celebrity tends to draw more generally histrionic types.

Lecture Launcher 9.4: Cognitive Style of the Obsessive-Compulsive Personality Students frequently struggle to separate obsessive-compulsive personality disorder from obsessivecompulsive disorder, per se, thinking that the personality disorder is just a milder version. Instead, it is important for them to understand that obsessive-compulsive personality disorder is characterized by perfectionism and a preoccupation with minute details, orderliness, rules, schedules, etc. Such people tend to be work-oriented and to require that things be done their way. Often serious, formal, and inflexible, they evidence poor interpersonal relationships. The cognitive inflexibility that is the hallmark of the disorder is well illustrated by the following example from Shapiro’s Neurotic Styles (1965, p. 25).

Perhaps students hear something familiar in this example.

K: L: K: L: K: L: K: L:

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So you think I shouldn’t buy it?

Never buy a house with a bad roof. It will cost you its price again in repairs before you’re finished.

But the builder I hired to look it over did say it was in good condition otherwise.

The roof is only the beginning. First it’s the roof and then comes the plumbing and then the heating and then the plaster.

Still, those things seem to be all right.

And, after the plaster, it will be the wiring.

But the wiring. . . [interrupts with calm assurance] It will cost you double the price before you’re finished. .

Chapter 9 Personality Disorders

Lecture Launcher 9.5: Personality Disorder as Exaggerated Personality Are all eccentrics actually schizotypic? Are all emotional people borderline? Are all self-centered people narcissistic? Clearly not, especially when distress and impairment are taken into consideration. The distinction between personality disorder and exaggerated personality can be explored two ways. First of all, each of the personality disorders can be discussed in its milder form as at the outset of this paragraph. Alternatively, various normal personalities can be discussed and extended into a pathological range. A good way to get this kind of discussion going is to ask students to describe characteristics they find very annoying in others. Then, DSM diagnoses based on these personality types can be constructed.

Students may find it interesting to learn that passive-aggressive personality used to be a DSM disorder but was later dropped.

Demonstrations / Activities Activity 9.1: Thrill Seekers When is extreme behavior normal? Should we consider obviously dangerous and thrill-seeking behavior as being abnormal? Students could interview people who are avid rock climbers, high-speed motorcyclists, and road racers to learn more about thrill-seeking experiences. Many would describe their motivations for thrill-seeking in personality terms. “I just like speed.” “I like being on the edge.” Would people who risk their lives be candidates for a personality disorder diagnosis or is it only when their extreme behavior bothers other people that it becomes diagnostic? A discussion of students’ own risktaking or sensation-seeking behavior could also support examination of the role of bothering others in formulating a distinction between extremes of personality and personality disorder.

Activity 9.2: Criminal Psychopaths Biographies of famous criminals hold an intrinsic fascination for students, though their study of them is often unfocused. For this activity, students can be asked to nominate candidate psychopaths from history or from the news and then to prepare a report on them that is focused on diagnostic issues. In particular, they will need to separate Cleckley/Hare-type psychopathy from DSM-type antisocial personality disorder. Among the more popular choices are Hitler, Stalin, Charles Manson, Jeffrey Dahmer, Ted Bundy, and John Hinckley. More contemporary choices might include Sadaam Hussein and Osama bin Laden.

Activity 9.3: Finding the Right Niche The question of where abnormality begins in the personality disorders is often a difficult one to answer.

Whether a person with a personality disorder will be viewed as abnormal or not depends on the circumstances in which the behavior is observed. Have students investigate this issue by selecting six or more careers or jobs and indicating how persons with the different personality disorders would perform in the different endeavors. Discussion could then revolve around how certain jobs have requirements that may actually fit certain traits found in the personality disorders. Which disorders do not fit well in almost any job? Which personality disorder has characteristic traits that would be useful in the largest number of careers? If a person’s traits fit a particular career, will he or she experience a satisfying life even with a personality disorder? Handout 9.2 Activity 9.4: Dramatic Characters Characters from movies, television, and theater need to be rather extreme to hold our interest. In fact, many would appear to qualify for diagnoses of personality disorder. Assign students the task of finding such characters and reporting on them to the class. In particular, it is crucial that students support their .

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selections by specifying exactly how their nominees manifest the necessary symptoms. Specific behavioral examples are especially helpful. It is also valuable to focus students on popular media, such as contemporary television shows, so their fellow students will know whom they are talking about. Soap operas are an especially ripe source of examples. Extra credit might be offered for students who are able to provide video clips of prototypic behavior.

Activity 9.5: Personality versus Personality Disorder?

There continues to be disagreement about whether personality disorders are distinct from each other and from normal personality. A student or group of students can be assigned the project of researching this issue for debate. The students can present the debate to the class whose members could vote on which point of view was presented most persuasively. An article by Livesley, Schroeder, Jackson, and Jang (1994, Journal of Abnormal Psychology, vol. 103, pp. 6–17) provides important historical information on this issue and could be a good first resource for the debating students. Handout 9.1

Web Links Web Link 9.1: http://similarminds.com/personality_disorder.html This is an online screening test for personality disorders. Answer fifty questions and click on the scoring button to get a summary of your score in relation to the personality disorders.

Web Link 9.2: http://counsellingresource.com/distress/personality-disorders/foundation/index.html Originally created and maintained by the Personality Disorders Foundation, this site has preserved the original materials designed to help people better understand what personality disorders are, how they are diagnosed, the impact they have on individuals and loved ones, educational resources, and clinical services. Bibliographies of research articles, practitioner articles, books, chapters, videotapes, and audiotapes related to personality disorders are also available on the site.

Web Link 9.3: http://psychcentral.com/resources/Personality/ This is the Personality section of PsychCentral, which gives hand-selected links to a variety of resources about personality disorders including disorder-specific sites, FAQs, and recommended readings.

Web Link 9.4: http://mentalhelp.net/poc/center_index.php?id=8 Mental Help Net includes an extensive section on personality disorders, encompassing diagnosis, treatment, organizations, book reviews, and links to other Web sites.

Web Link 9.5: http://mentalhealth.about.com/cs/personaltydisordrs/ About.com is an extensive collection of sites on various topics, each having an editor who chooses resources and writes about the topic of his or her expertise. This link takes you to the personality disorders section, edited by Leonard Holmes, Ph.D.

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Video Resources Between the Lines. Boston, MA: Fanlight Productions.

Beyond the Borderline. New York, NY: Filmmakers Library.

Borderline Personality Disorder, Client Interview, Janna—#6 ABC News and Client Interviews. Allyn and Bacon Abnormal Psychology Video.

Borderline Syndrome: Personality Disorder of Our Time. New York, NY: Insight Media.

Closet Narcissistic Disorders: The Masterson Approach with Dr. James F. Masterson. Assessment & Treatment of Psychological Disorders Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Cognitive Therapy for Borderline Personality Disorder. APA Psychotherapy Video Series II: Specific Treatments for Specific Populations. Washington, DC: American Psychological Association.

Don’t Be Shy, Mr. Sacks: Williams Syndrome. The Mind Traveller: Oliver Sacks Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Integrated Treatment of Borderline Personality Disorder: Pharmacotherapy and Psychotherapy.

Treatments of Psychiatric Disorders Videotape Series. Allyn and Bacon Video Library.

Interpersonal Reconstructive Therapy for Passive-Aggressive Personality Disorder. APA Psychotherapy Video Series II: Specific Treatments for Specific Populations. Washington, DC: American Psychological Association.

Mind of the Psychopath, Vol. 35. The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection.

Personality Disorders. New York, NY: Insight Media.

Personality Disorders. Differential Diagnosis in Psychiatry Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Personality Disorders. The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection.

The Psychopathic Mind. Allyn and Bacon Video Library.

Schizotypal Personality Disorder, Susan—Patient Interview Video for Abnormal Psychology (12th ed.).

Allyn and Bacon Video Library.

Treating Borderline Personality Disorder: The Dialectical Approach. Princeton, NJ: Films for the Humanities and Social Sciences.

Understanding Borderline Personality Disorder: The Dialectical Approach. New York, NY: Guilford Publications.

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Handout 9.1 Personality Disorder Debate

Personality Disorder

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Pros

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Cons

Chapter 9 Personality Disorders

Handout 9.2 Antisocial Actions

Consider a number of occupations that may attract people with antisocial characteristics. Then list careers that may encourage the development of antisocial behaviors.

“Antisocial” Occupations

“Antisocial” Influences

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CHAPTER 10: Substance-Related Disorders Chapter At-A-Glance Detailed Outline

Instructors’ Resources

Print Supplements

Media Supplements

Alcohol Abuse and Dependence • The Prevalence, Comorbidity, and Demographics of Alcohol Abuse and Dependence • The Clinical Picture of Alcohol Abuse and Dependence • Biological Causal Factors in the Abuse of, and Dependence on, Alcohol • Psychosocial Causal Factors in Alcohol Abuse and Dependence • Sociocultural Causal Factors • Treatment of AlcoholRelated Disorders

Teaching Objectives 10.1–10.4 Chapter Guide Lecture Launchers 10.2, 10.3, 10.4, 10.5 Activities 10.2, 10.3, 10.4, 10.5 Web Links 10.1, 10.2, 10.3, 10.4, 10.5, 10.6, 10.7

Test Bank Grade Aid Transparencies T-99 to T-102

CD-ROM PowerPoint ABC Video Clip #8

Drug Abuse and Dependence • Opium and Its Derivatives (Narcotics) • Cocaine and Amphetamines (Stimulants) • Methamphetamine • Barbiturates (Sedatives) • Hallucinogens: LSD and Related Drugs • Ecstasy • Marijuana • Stimulants: Caffeine and Nicotine

Teaching Objectives 10.5 Chapter Guide Lecture Launchers 10.5 Activities 10.1, 10.3, 10.4, 10.5 Web Links 10.1, 10.3, 10.4, 10.5, 10.7

Test Bank Grade Aid Transparencies T-103 to T-105

CD-ROM PowerPoint

Unresolved Issues: Exchanging Addictions —Is This an Effective Approach?

Teaching Objectives 10.6, 10.7 Chapter Guide Lecture Launchers 10.1, 10.4 Activities 10.1, 10.2 10.3 Web Links 10.1, 10.3, 10.4, 10.5, 10.7

Test Bank Grade Aid

CD-ROM PowerPoint

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Professor Notes

Chapter 10· Substance-Related Disorders

Teaching Objectives 1.

2.

3.

4.

5.

6.

7.

Outline the major divisions of psychoactive substance-related disorders, define alcohol abuse and alcohol dependence, summarize the many negative consequences of alcohol for both the individual and society, and indicate the prevalence and gender ratio of excessive drinking.

Describe the clinical picture of alcohol abuse including the biological and psychological effects of chronic consumption of alcohol.

Review the biological, psychosocial, and sociocultural contributors to alcohol abuse and dependence.

Summarize the research findings on the results of treatment and relapse prevention for alcohol-dependent persons.

List the specific drugs and their effects, summarize theories of causal factors, and review treatments for the following drugs of abuse: opium and its derivatives; cocaine and amphetamines; barbituates; LSD and other hallucinogens; marijuana; and caffeine and nicotine.

Discuss the controversy surrounding controlled drinking versus abstinence.

Summarize the pros and cons of including pathological gambling as an addictive behavior.

Chapter Overview / Summary Substance-related disorders — such as alcohol abuse, cocaine abuse, and nicotine dependence — are among the most widespread and intransigent mental health problems facing us today. Many problems of alcohol or drug use involve difficulties that stem solely from the intoxicating effects of the substances. Dependence occurs when an individual develops a tolerance for the substance or exhibits withdrawal symptoms when the substance is not available.

Lifetime prevalence for alcohol abuse in the United States is about 13 percent. Alcohol is associated with over 40% of the deaths suffered in automobile accidents each year and with about 40 to 50 percent of all murders. In the past, five times as many men than women developed problems with alcohol but this seems ratio appears to be changing as women’s drinking patterns change. At lower levels, alcohol stimulates certain brain cells and activates the brain’s pleasure areas, which release opium-like endogenous opioids. At higher levels, alcohol depresses brain functioning, inhibiting glutamate. Two psychoses related to alcoholism have been identified: alcohol withdrawal delirium and alcohol amnestic disorder.

Biological causal factors include the ability of most, if not all, addictive substances to activate areas of the brain that produce intrinsic pleasure and sometimes, immediate positive reward. Second, the person’s biological make-up including his or her genetic inheritance and the learning factors that enter into the need to seek mind-altering substance to an increasing need as use continues are important.

Particular psychosocial causal factors are involved in the psychological dependence that develops. Such psychosocial factors include: failures in parental guidance; psychological vulnerability; stress, tension reduction, and reinforcement; expectations of social success; and disturbed marital and other intimate relationships. Sociocultural factors such as religious sanctions and social customs are illustrated by Muslims, Mormons, and Jews whose incidence of alcoholism is minimal. Behavior that is manifested, such as aggressiveness, under the influence of alcohol also seems to be influenced by cultural factors The treatment of individuals who abuse alcohol or drugs is generally difficult and often fails.

Biological approaches include medications to reduce the cravings, to ease the detoxification process, and to treat co-occurring health and mental health problems that may underlie the drinking behavior.

Psychological therapies, such as group therapy, environmental intervention, and behavioral and .

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cognitive-behavioral therapy may be effective with some alcohol or drug-abusing individuals. Another source of help for alcohol abusers is Alcoholics Anonymous; however, the extent of successful outcomes with this program has not been sufficiently studied. Most treatment programs require abstinence; however, over the past twenty years, research has suggested that some alcohol abusers can learn to control their drinking while continuing to drink socially. Outcome research suggests that treatment is most likely to be effective when an individual realizes that she or he needs help, when adequate treatment facilities are available, when the individual attends treatment regularly, and when there is a positive relationship with the therapist. Finally, research with relapse prevention strategies has shown them to be effective in providing continuing improvement over time.

Other than alcohol, the psychoactive drugs most commonly associated with abuse and dependence are: narcotics such as opiates or opioids including opium and heroin, sedatives such as barbiturates, stimulants such as cocaine and amphetamines, anti-anxiety drugs such as benzodiazepines, pain medications such as OxyContin, hallucinogens such as LSD, and caffeine and nicotine. Drugabuse disorders may involve physiological dependence on substances, such as opiates—particularly heroin—or barbiturates; however, psychological dependence may also occur with any of the drugs that are commonly used today, for example, marijuana. The extent of drug abuse and dependence is probably underestimated because many abusers do not seek help. In a study of workers, illicit drug use was reported in 19% of those under 18, 10.3% of those 18-25, 7% of those 26-34, 7% of those 35-49, and 2.6% of those 50 and over in the month prior to the survey.

Morphine and heroin are commonly introduced into the body by smoking, snorting, eating, “skin popping”, or “mainlining.” Typically, the life of a person addicted to opiates becomes increasingly centered on obtaining and using drugs, so the addiction usually leads to maladaptive social behavior as the individual is forced to steal, lie, and associate with undesirable contacts to maintain a supply of drugs. Three most frequent cited reasons for beginning to use heroin were pleasure (81%), curiosity, and peer pressure. Pleasure seeking may be mediated through genetic and biological mechanisms. With time, most young addicts who join the drug culture become increasingly withdrawn, indifferent to their friends (except those in the drug culture), and apathetic about sexual activity. Methadone and buprenorphine also used to help combat the craving for heroin.

Stimulants such as cocaine and amphetamines speed up the central nervous system. In 2003, there were an estimated 2.3 million people using cocaine and over 600,000 people using crack cocaine.

Cocaine stimulates the cortex of the brain, inducing sleeplessness and excitement as well as stimulating and accentuating sexual feelings. Long-term use can lead to cognitive impairments and dependence.

Naltrexone has been used to reduce cravings and ensure treatment compliance. Amphetamines are used medically for curbing appetite and for treating narcolepsy and ADHD. In 2005, about 10% of drugrelated emergency room visits involved amphetamines or methamphetamine. Abrupt withdrawal from amphetamines can cause cramping, nausea, diarrhea, and even convulsions.

Methamphetamine, also known as “crystal” or “ice,” is a highly addictive stimulant drug that operates by increasing the level of dopamine in the brain. Prolonged use produces structural changes in the brain. Discontinuation of the drug once the person is addicted can cause learning, memory, and cognitive dysfunction as well as severe mental health problems such as paranoid thinking and hallucinations. Use doubled between 1989 and 1999 but mainly in the Southwest, West Coast and Hawaii near meth labs. Addicted users are highly resistant to treatment with high relapse rates.

Barbiturates were once widely prescribed as a sleep aid. Excessive use leads to physiological and psychological dependence; brain damage and personality deterioration may also occur. Combining barbiturates with alcohol can depress the central nervous system to such an extent that death occurs.

Withdrawal symptoms can be severe necessitating a slow approach of administering increasingly smaller doses of the barbiturate or a similar drug.

Hallucinogenic drugs such as LSD, mescaline, and psilocybin distort sensory images. Ecstasy, or MDMA, is both a hallucinogen and a stimulant. In one survey, nearly 5% of tenth and twelfth graders 188

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and about 2% of eight graders reported using the drug in the past month. Use has been associated with death, prolonged psychosis, memory impairment, and severe organic brain problems. Marijuana is considered a mild hallucinogen. In 2003, over 3.1 million people over 12 years of age reported using marijuana daily. In 2004, 34.9% of high school seniors reported using marijuana within the past 12 months. Psychological treatment approaches have been shown to be effective in reducing marijuana usage.

Although legal, people can also abuse and become dependent on caffeine and nicotine. Those who are addicted to caffeine may experience restless, nervousness, excitement, insomnia, muscle twitching, and gastrointestinal complaints. Caffeine withdrawal typically involves a headache. Nicotine reduces anxiety and may lead to dependence. Estimates suggest that 3.1 million adolescents and 25% of 17 to 18 year-olds are current smokers. Treatment of nicotine withdrawal may include social support groups, pharmacological agents, and psychological procedures such as behavioral or cognitivebehavioral interventions; most programs average a 20 to 25 percent success rate.

Detailed Lecture Outline I.

Alcohol Abuse and Dependence A. The Prevalence, Comorbidity, and Demographics of Alcohol Abuse and Dependence 1.

World Health Organization no longer recommends the term alcoholism but prefers the term alcohol dependence syndrome 2.

Beer first made in Egypt around 3000 B.C.; wine in Italy from 150 years before the birth of Christ; distillation about 800 A.D. in Arabia 3.

Lifetime prevalence of alcohol abuse is 13.4% in the U.S. 4.

Alcohol abuse is associated with organic impairment, accidents, violent crimes, and suicides 5.

Comorbidity with at least one other mental disorder, especially depression 6.

Alcohol abuse and dependency include all age, educational, occupational, and socioeconomic boundaries 7.

The course of alcoholism is erratic and fluctuating 8.

Five times more common in men than women; this ratio may be changing 9.

Marriage, higher levels of education, and being older are associated with lower levels of alcohol abuse B. The Clinical Picture of Alcohol Abuse and Dependence 1.

Alcohol’s effects on the brain a.

Several physiological effects are common (1) Decreased sexual inhibition (2) Lowered sexual performance (3) Lapses of memory (blackouts) (4) Hangover b.

Low levels of alcohol stimulate brain cells activating the brain’s pleasure areas c.

Higher levels depress brain functioning, inhibiting glutamate (leads to impaired learning, judgment, and self-control) d.

When the alcohol content of the bloodstream is .008, the person is intoxicated—decreased muscular coordination, impaired speech and vision, confused thought processes e.

When the blood alcohol level reaches .05, the entire neural balance is upset and the person loses consciousness; concentrations above .055 are usually lethal .

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f.

C.

Effects of alcohol vary for different drinkers depending on physical condition, amount of food in the stomach, tolerance, and duration of drinking 2.

Development of alcohol dependence a.

Progressive from early to middle to late stage b.

Fetal alcohol syndrome 3.

The physical effects of chronic alcohol use a.

Cirrhosis of the liver is found in 15–30% of heavy drinkers b.

The high caloric intake of alcohol can be detrimental as it reduces the consumption of other foods leading to malnutrition c.

Alcohol also interferes with the body’s ability to utilize nutrients; nutritional deficiency cannot be made up by vitamin pills 4.

Psychosocial effects of alcohol abuse and dependence a.

Chronic fatigue, oversensitivity, and depression b.

Excessive alcohol use results in impaired reasoning, poor judgment, loss of responsibility, lack of pride in appearance, neglect of family c.

Brain damage may occur 5.

Psychoses associated with severe alcohol abuse a.

Alcohol withdrawal delirium (delirium tremens) can occur during prolonged drinking or at withdrawal (1) Its symptoms can include disorientation, hallucinations, fear, extreme suggestibility, and marked tremors (2) It can last from three to six days; generally followed by a deep sleep (3) Death rates from convulsions, heart failure, and other complications have fallen from about 10% as a result of drugs such as chlordiazepoxide b.

Alcohol amnestic disorder (Korsakoff’s syndrome) (1) Memory defect is its main feature (2) Individuals with disorder may confabulate and appear disoriented and delusional (3) Other cognitive impairments, such as planning deficits, emotional deficits, and intellectual decline, also occur (4) Brain imaging studies document cortical lesions (5) Symptoms may be due to vitamin B (thiamine) deficiency Biological Causal Factors in the Abuse of and Dependence on Alcohol 1.

Two important factors in addiction: a.

Ability of addictive drugs to activate areas of the brain that produce intrinsic pleasure and immediate powerful reward b.

Person’s biological make-up including genetic inheritance and environmental influences (learning factors) 2.

The neurobiology of addiction a.

Routes of administration include oral, nasal, and intravenous b.

“Pleasure pathway”—mesocorticolimbic dopamine pathway c.

Alcohol, and other drugs, produces stimulation and euphoria d.

Exposure of the brain to an addictive drug alters its neurochemical structure, resulting in behavioral effects 3.

Genetic vulnerability a.

Almost one third of alcoholics had a parent with an alcohol problem .

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b.

D.

An alcohol-risk personality has been described as one who has an inherited predisposition toward alcohol abuse and who is impulsive, prefers taking high risks, and is emotionally unstable c.

Asians and Native Americans show an “alcohol flush reaction”— hypersensitive reaction that includes flushing of the skin, a drop in blood pressure, heart palpitations, and nausea following the ingestion of alcohol; found in about 50% and results from a mutant enzyme 4.

Genetics—The Whole Story a.

Exact role of genetics in alcoholism is unclear b.

Genetic transmission does not follow the hereditary pattern found in strictly genetic disorders 5.

Genetic influences and learning a.

There must be exposure to substance for addictive behavior to occur b.

Development of an alcohol-related problem involves living in an environment that promotes initial, as well as continuing, use of the substance c.

There are numerous social and intrinsic reinforcements Psychosocial Causal Factors in Alcohol Abuse and Dependence 1.

Failures in parental guidance a.

Stable family relationships lacking substance abuse b.

Exposure to negative models 2.

Psychological vulnerability a.

Many potential alcohol abusers tend to be emotionally immature (impulsive and aggressive), expect a great deal of the world, require an inordinate amount of praise and appreciation, react to failure with marked feelings of hurt and inferiority, have low frustration tolerance, and feel inadequate and unsure of their abilities to fulfill expected male or female roles b.

Depression, antisocial personality, and schizophrenia are disorders commonly associated with alcoholism 3.

Stress, tension reduction, and reinforcement a.

Tension reduction model cannot be sole explanation because there would be more alcohol abusers b.

Alcoholism may be a learned maladaptive response c.

Motivational models of alcohol use place responsibility on the individual 4.

Expectations of social success a.

Expect alcohol to lower tension and anxiety and increase sexual desire and pleasure in life b.

Reciprocal influences model 5.

Marital and other intimate relationships a.

Alcohol use may be related to crisis periods b.

Marital partners may behave toward each other in ways that promote or enable the spouse’s excessive drinking c.

Alcohol abuse is one of the most frequent causes of divorce d.

Six family relationship factors central to development of alcohol abuse: (1) Presence of an alcoholic father (2) Acute marital conflict (3) Lax maternal supervision and inconsistent discipline (4) Many family moves during early years .

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E.

F.

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(5) Lack of “attachment” to father (6) Lack of family cohesiveness Sociocultural Causal Factors 1.

Social drinking has reinforcing properties 2.

Cultural attitudes toward alcohol influence the incidence of alcoholism a.

Muslims b.

Mormons c.

Orthodox Jews d.

Europe and countries heavily influenced by European culture make up less than 20% of the world’s population yet consume 80% of the alcohol 3.

Behavior under the influence of alcohol also culturally influenced Treatment of Alcohol-Related Disorders 1.

Use of medications in treating alcoholics a.

Medications to block the desire to drink (1) Disulfiram (Antabuse) causes vomiting when alcohol is ingested and can disrupt the alcoholic cycle (2) Naltrexone reduces craving for alcohol b.

Medications to reduce the side effects of acute withdrawal (1) Valium (2) Maintenance doses of mild tranquilizers have given rise to concerns that this practice does not promote long-term recovery and may foster addiction to another substance 2.

Psychological treatment approaches a.

Group therapy (1) Face problems for first time (2) Family may be invited to group b.

Environmental interventions (1) Alleviate aversive life situation (2) Halfway houses may be important adjuncts c.

Behavior and cognitive behavioral therapy (1) Aversive conditioning methods employ noxious stimuli (2) Marlatt—skills training procedure typically aimed at younger drinkers (3) Self-control training techniques aimed at reducing alcohol intake but not necessarily abstaining d.

Controlled drinking versus abstinence (1) 15–18% of subjects are successful with controlled drinking (2) Controlled drinking more likely to be successful with people with less severe alcohol problems (3) Despite this evidence, this is still a highly controversial approach e.

Alcoholics Anonymous (1) Self-help group started in 1935 by two men who recovered from alcoholism through a “fundamental spiritual change” (2) AA has more than 51,000 groups in the U.S. and Canada (3) Basic belief is that one is an alcoholic for life (4) Rehabilitation lifts the burden of personal responsibility (5) Affiliated movements bring family members together (6) Reported success is primarily based on anecdotal evidence (7) Objective studies—few in number—report .

Chapter 10· Substance-Related Disorders

(a) (b) (c)

II.

Higher dropout rates in AA—about 50% Success with severe alcoholics severely limited Experimental participants assigned to AA subsequently encountered more life difficulties and drank more than people in other treatment groups (d) AA found to be better than no treatment f.

Outcome studies and issues in treatment (1) Low rates of success among hard-core substance abusers (2) Recovery rates of 70–90% with modern treatment and aftercare procedures (3) Favorable outcomes relate to personal motivation for change and a positive relationship with the therapist (4) Drinking Check-Up sessions during the early stages of therapy successful in reducing drinking (5) Project MATCH: matching patients to particular treatments did not appear to be important; all treatments used had equal outcomes g.

Relapse prevention necessary and effective (1) Recognizing indulgent behaviors (2) Recognizing abstinence violation effect (3) Clients taught to recognize apparently irrelevant decisions that serve as early warning signals of the possibility of relapse Drug Abuse and Dependence A. Estimated 28 Million People Worldwide Use Psychoactive Drugs 1.

Extent of abuse is probably underestimated 2.

One third quit without seeking help 3.

Drug abuse and dependence most common during adolescence and young adulthood 4.

More common among economically depressed minority communities 5.

Employment studies: a.

10.8% had illicit drugs in their system b.

55% of this figure tested positive for marijuana c.

36% of this figure tested positively for cocaine d.

28% of this figure tested positively for opiates B. Opium and Its Derivatives (Narcotics) 1.

Opium is a mixture of about eighteen chemical substances known as alkaloids a.

Alkaloid present in the largest amount (10–15%) is morphine b.

Morphine is a bitter tasting powder; serves as a powerful sedative and pain reliever c.

Hypodermic needle introduced in U.S. in 1856 2.

If morphine is treated with acetic anhydride, you get heroin a.

Pain relief b.

Acts more rapidly and intensely than morphine 3.

Harrison Act (1914) criminalized unauthorized sale and distribution of certain drugs 4.

Biological effects of morphine and heroin a.

Commonly smoked, snorted, eaten, “skin popped,” or “mainlined” b.

Mainlined or snorted heroin causes sixty-second euphoric spasm (rush) followed by a high and a subsequent lethargic, withdrawn state c.

Withdrawal occurs after extended use within eight hours of a dose .

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d.

C.

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Withdrawal symptoms vary; many withdraw without assistance; others experience runny nose, tearing eyes, perspiration, restlessness, increased respiration rate, and an intensified desire for the drug; more intense symptoms follow including chilliness alternating with flushing and sweating, cramps, vomiting, diarrhea, pain in the back and extremities, tremors, and insomnia e.

Symptoms of withdrawal decline by the fourth day 5.

Social effects of morphine and heroin a.

Life becomes centered on obtaining the drug b.

Leads to lying, stealing, and associating with those who supply the drugs c.

Disruption of the immune system d.

Nonsterile instruments can lead to contracting diseases including AIDS e.

No controls on strength and purity 6.

Causal factors in opiate abuse and dependence a.

No single causal pattern b.

Three most cited reasons for beginning to use heroin: pleasure, curiosity, and peer pressure c.

May be partially influenced by genetic factors 7.

Neural bases for physiological addiction a.

Repeated use of opiates results in changes in neurotransmitter systems b.

Endorphins are opium-like substances in the brain and are thought to be involved in pain responses; perhaps chronic underproduction of endorphins leads to a craving for narcotic drugs 8.

Addiction associated with psychopathology a.

Antisocial traits may be involved b.

Lack of capacity to delay gratification is a factor 9.

Drug use associated with sociocultural factors a.

Narcotics subculture b.

Isolation increases as addict’s sense of belonging to a group is bolstered 10.

Treatment and outcomes a.

Strategies are similar to those for alcoholism b.

Withdrawal does not remove the craving for the drug c.

Methadone treatment d.

Bupenorphine used as substitute with fewer side effects e.

Both Methadone and Bupenorphine work best when combined with behavior therapy Cocaine and Amphetamines (Stimulants) 1.

Cocaine a.

Due to expense, once considered the drug of the affluent b.

During 1980s and 1990s, prices fell and middle- to upper-income people increased use c.

“Crack” cocaine, processed from cocaine hydrochloride to a free base for smoking, is much cheaper d.

Cocaine may be ingested by sniffing, swallowing, or injecting e.

Creates a four- to six-hour euphoric state experienced as feelings of contentment and confidence f.

When cocaine is abused: acute toxic psychotic symptoms including visual, auditory, and tactile hallucinations may occur

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g.

D.

Cocaine stimulates the brain’s cortex inducing sleeplessness and excitement as well as stimulating and accentuating sexual experiences h.

Acute as well as chronic tolerance may be found i.

Physiological dependence does occur—cocaine withdrawal involves depression, fatigue, disturbed sleep, and increased dreaming j.

Follow-up studies show increased psychosocial problems over time k.

Cocaine use in pregnancy can cause fetal crack syndrome 2.

Treatment and outcomes a.

Use of medications such as desipramine and Naltrexone to reduce cravings b.

Use of psychological therapy to ensure treatment compliance c.

Must also address feelings of tension and depression d.

Factors associated with poorer outcome: severity of abuse, poorer psychiatric functioning, presence of concurrent alcoholism e.

Problem of “dropping out” f.

Some improve without treatment 3.

Amphetamines a.

Benzedrine (amphetamine sulfate) first synthesized in 1927 b.

Dexedrine and Methedrine (speed) introduced in the late 1930s c.

Initially used to ward off fatigue, especially during WWII, and to suppress appetite d.

Used today for appetite suppression, treating narcolepsy, and treating ADHD e.

Controlled Substance Act of 1970 classified amphetamines as Schedule II controlled substances 4.

Effects of amphetamine abuse a.

Psychologically and physically addictive b.

Body rapidly builds up a tolerance c.

Excessive dosage results in heightened blood pressure, enlarged pupils, unclear or rapid speech, profuse sweating, tremors, excitability, loss of appetite, confusion and sleeplessness d.

Chronic use can result in brain damage and psychopathology including amphetamine psychosis 5.

Treatments and outcomes a.

Withdrawal is usually painless physically b.

Withdrawal after chronic excessive use can result in cramping, nausea, diarrhea, and even convulsions c.

Depression is a psychological consequence of abrupt withdrawal Methamphetamine 1.

Highly addictive stimulant drug that can provide a quick and long-lasting high 2.

One of the most dangerous illegal drugs a.

Increases levels of dopamine; prolonged use produces structural changes in the brain b.

Discontinuation of the drug can cause problems in learning, memory, and cognitive dysfunction as well as severe mental health problems such as paranoid thinking and hallucinations 3.

In the United States, use is more common in the Southwest, West Coast and Hawaii nearest meth labs in Mexico, California, and Hawaii 4.

Some evidence that people become more quickly addicted to meth and require treatment sooner than those using cocaine .

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E.

F.

G.

H.

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5.

Highly resistant to treatment Barbiturates (Sedatives) 1.

Effects of barbiturates a.

Calms patients and induces sleep b.

Excessive use leads to tolerance and dependence; tolerance does not increase the amount needed to cause death c.

Brain damage and personality deterioration may occur from prolonged ingestion 2.

Causal factors in barbiturate abuse and dependence a.

Middle-aged and older persons are susceptible to dependency when used as “sleeping pills”; referred to as silent abusers b.

Alcohol is commonly used with the barbiturates 3.

Treatments and outcome a.

Must differentiate between barbiturate intoxication and withdrawal b.

Withdrawal symptoms can be dangerous and severe (1) Anxiety, apprehension, coarse tremors of hands and face, insomnia, weakness, nausea, vomiting, abdominal cramps, rapid heart rate, elevated blood pressure, loss of weight (2) Acute delirious psychosis may develop c.

Withdrawal symptoms may be limited by other medications Hallucinogens: LSD and Related Drugs 1.

LSD (lysergic acid diethylamide) a.

Chemically synthesized substance first discovered by the Swiss chemist Albert Hoffman in 1938 b.

Research has found it ineffective as a psychological treatment (1) “Trips” on the drug can be pleasant or extremely traumatic (2) Flashbacks are involuntary recurrences of hallucinations 2.

Mescaline and Psilocybin a.

Mescaline derived from the disc-like growths at the top of the peyote cactus b.

Psilocybin is obtained from a variety of Mexican mushrooms known as Psilocybe mexicana c.

Ceremonial uses among Indian groups d.

Perceptions are altered, reality distorted Ecstasy (MDMA) 1.

Both hallucinogen and stimulant 2.

Originally developed as a diet pill by Merck in 1913 3.

No value in drug for use in psychological treatment 4.

Increasingly popular as party drug 5.

Chemically similar to methamphetamine and to the hallucinogen mescaline 6.

Recreational use associated with impulsivity and poor judgment 7.

There are also negative psychological and health consequences (including death) Marijuana 1.

Classified as a mild hallucinogen 2.

Comes from the leaves and flowering tops of the hemp plant, Cannabis sativa 3.

Related to a stronger drug, hashish, derived from the resin exuded by the plant and made into a gummy powder 4.

Use is commonplace today; more than 3.1 million people over 12 years of age report daily use .

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5.

III.

Effects of Marijuana a.

Vary greatly depending on the quality and dosage, personality and mood of user, user’s past experiences with the drug, the social setting, and the user’s expectations b.

Mild euphoria is produced c.

Sensory inputs are intensified, with both pleasant and unpleasant experiences d.

Time distortions are often present e.

Depressant and hallucinogenic effects are found f.

Induces memory dysfunction and a slowing of information processing g.

Withdrawal symptoms including nervousness, tension, sleep problems, and appetite change reported h.

Psychological treatment methods effective I. Stimulants: Caffeine and Nicotine 1.

Caffeine a.

Available in many drinks and foods b.

Negative effects from excessive intake involve intoxication rather than withdrawal (mild headache only) c.

Caffeine induced organic mental disorder: restlessness, nervousness, excitement, insomnia, muscle twitching, and gastrointestinal complaints 2.

Nicotine a.

A poisonous alkaloid b.

Nicotine dependency syndrome c.

Nicotine withdrawal disorder d.

Treatment of nicotine withdrawal (1) Social support groups (2) Replace cigarette smoking with safer forms of nicotine (3) Self-directed change (4) Professional assistance (5) Nicotine replacement therapy (NRT) (6) All show about a 20 to 25% success rate (7) Higher rates of success among those hospitalized for cancer (63%), cardiovascular disease (57%), or pulmonary disease (46%) Unresolved Issues: Exchanging Addictions: Is This an Effective Approach?

A. Methadone as an aid to heroin addiction treatment 1.

Satisfies heroin craving without serious psychological impairment 2.

Facilitates psychological or social rehabilitation 3.

Addicts on methadone can function normally and hold jobs 4.

It is legal and quality controlled 5.

Negative physical (hepatitis, cognitive impairments) and social consequences (trading sex for drugs) sometimes associated 6.

Variations in methadone programs, such as use of additional drugs, aimed at keeping addicts in therapy B. Drug abstinence instead of Methadone maintenance?

1.

Methadone Transition Treatment a.

A 180-day course of treatment b.

Involves methadone and psychosocial intervention c.

Ends with 80 days of phase out

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Key Terms addictive behavior (p. 316) alcohol withdrawal delirium (p.321) alcoholic (p. 317) alcoholism (p. 317) amphetamine (p. 339) barbiturates (p. 340) caffeine (p. 344) cocaine (p. 337) delirium tremens (p. 321) Ecstasy (p. 342) endorphins (p. 336) flashback (p. 341) hallucinogens (p. 341) hashish (p. 343) heroin (p. 334)

LSD (p. 341) marijuana (p. 343) mesocorticolimbic dopamine pathway (MCLP) (p. 322) methadone (p. 337) morphine (p. 334) nicotine (p. 344) opium (p. 334) psychoactive substances (p. 316) substance abuse (p. 316) substance dependence (p. 317) tolerance (p. 317) toxicity (p. 316) withdrawal (p. 317)

Lecture Examples / Discussion Topics Lecture Launcher 10.1: Better Living through Chemistry It is difficult to attack specific substances or patterns of substance use and abuse when the culture is pervaded by others that can seem only arbitrarily different. Substances exist to regulate everything from our hair color and complexion to our sleep and bowel movements. We take pills for appetite, pain, disease, depression, anxiety, upset stomach, blood pressure, to wake us up and calm us down, and myriad other things. Ask students to help you list as many of these chemical regulators as possible. Once an extensive and easily generated list is available, point out that so much of our lives are regulated chemically, it is no wonder we think to ingest substances before we think of changing lifestyles. To what extent do students feel that the chemical culture makes lifestyle change the last resort instead of making alcohol and other drugs the last resort? Or do students see a sharp demarcation between these substances and the DSM substances of abuse and addiction? Handout 10.1 Lecture Launcher 10.2: Why Did Richard Feynman Quit Drinking?

One day as Nobel Prize–winning physicist Richard Feynman was walking along the beach enjoying a beautiful sunset and warm breeze off the ocean, and everything seemed perfect, the thought struck him that it would be nice to have a drink. At that moment he gave up drinking forever. Why might he have done that? Wouldn’t alcohol have made his experience “more perfect”? It appears that Feynman found his urge to drink scary, or perhaps pathetic, but at any rate it was a motivating reaction. Have students ever felt that way? Don’t most intrinsically exciting, moving, significant, enjoyable events involve alcohol? Why is that? Is that scary, or perhaps pathetic?

Lecture Launcher 10.3: Alcohol Myopia Will the true effects of alcohol please stand up? Does alcohol make you a miserable, “crying in your beer,” depressive or an elated, “dancing on the tables,” free spirit? Does alcohol make you a passive, bemused observer of life swirling around you or a hypervigilant, itching-for-a-fight, pumped-up combatant? Does it make you more or less talkative? More or less sexual? It seems to depend on the circumstances, doesn’t it? Steele and Josephs (1990) argue that the apparently diverse and contradictory effects of alcohol can be understood as being the product of “Alcohol Myopia,” which is the shortsightedness that occurs under the influence of alcohol. Once more remote cues influencing behavior are 198

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removed by alcohol (e.g., moral strictures, long-term plans, concern for one’s reputation), the immediate cues to action take over. If these immediate cues are depressing, and the antidepressant effects of a broader perspective are undermined by Alcohol Myopia, then one will be depressed. Conversely, if the immediate cues are to elation, and depressing concerns about relatively remote issues are diminished by alcohol, then one will be elated. A wide variety of examples of seemingly contradictory behavioral effects of alcohol are explained nicely within this model and are well summarized in Steele and Josephs’ American Psychologist article (1990, vol. 45, pp. 921–933).

Lecture Launcher 10.4: Is Alcoholism a Disease?

Whether or not alcoholism is a disease always provokes good debate. Typically, this debate centers on the proper definition of disease. The American Medical Association classified alcoholism as a disease in 1956. And of course, the disease model is the foundation of Alcoholics Anonymous. Interestingly, the Supreme Court has also weighed in on this question in Traynor v. Turnage [485 U.S. 535 (1988)]. The test case was of two military veterans who were denied extensions of their Veterans’ Administration educational benefits, extensions they requested on the basis of their inability to use them owing to alcoholism-related disability. The Supreme Court ruled against the plaintiffs, finding that alcoholism was not a disease. Instead, the Court described alcoholism as a “willfully caused handicap,” thereby worthy of benefit-extension denials of the sort made by the Veterans’ Administration. In support of this decision, the Court noted a variety of aspects of alcoholism that were inconsistent with it being a disease. Among these, there is no known biological defect, no clear separation from normality, loss of control is not automatic, drinking is subject to situational effects, and there are no physiological treatments. Shortly after this decision, the United States House of Representatives voted to overrule the Veterans’ Administration policy that had prompted the case in the first place.

Lecture Launcher 10.5: Expectancy Effects Alan Marlatt has performed interesting demonstrations with students he has drinking in a laboratory bar.

Ostensibly as a study of the effects of alcohol, he asks them to report on the symptoms, both physiological and psychological, that they experience as they ingest more and more alcohol. Once a fair number of stereotypic symptoms are reported (e.g., my face is flushing, I’m feeling a little light-headed, we are talking more and talking louder), he discloses the literally sobering fact that there has been no alcohol whatsoever in the pitchers of “beer” the students have been drinking. Most students are convinced that they themselves would not have been fooled the way the students in Marlatt’s bar were fooled, but that is exactly the message to be gotten from studies of expectancy effects on alcohol.

Demonstrations / Activities Activity 10.1: Develop a Better Drug Education Program It would be a rare student indeed who reached a course in Abnormal Psychology without having spent a considerable amount of time in drug education and prevention lectures and programs of various sorts.

Health classes, D.A.R.E. programs, televised public service announcements, and the like are pervasive.

Drug abuse and addiction is still far too common, though, so despite widespread promulgation of the relevant information, there are flaws in the system that are worth carefully examining. One approach to studying these flaws is to assign students to groups to examine their experiences. First of all, groups should discuss what is wrong with the programs they were exposed to and then they could be asked to develop alternatives. Often students will claim that they lack the expertise to make reasonable recommendations about something as complex as drug education and prevention programming, so it might help to suggest that the people who have the knowledge of program content are often out of touch with the target audience of young people. Typical college-age students therefore have some advantages over more typical program planners. Among the kinds of questions to be addressed in groups are the .

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following: What kinds of programs affected you most? What kinds of activities got your attention? What facts were most influential in your drug decision-making process? What is the best age group to target?

What kinds of things undermined the effectiveness of programs you were exposed to? How could you measure the effectiveness of these programs? How would you balance resources among education, interdiction, and treatment?

Activity 10.2: How to Reduce and Avoid Drinking Peer pressure to drink is intense at college campuses, where alcohol-free socializing opportunities are exceedingly rare. Over the course of the term, there will be ample opportunity for students to experiment with ways to attend alcohol-related social activities without drinking or at least without drinking very much. As an exercise in experiential learning, ask students to attend a party at which they would ordinarily drink, but to do so without drinking at all. In making this assignment, students can be asked to brainstorm ways to be unobtrusive about it. For instance, they can tell the other partygoers they do not feel well, that they are taking medications, or even that they are simply doing what a professor told them to try. It is also fairly simple to fill one’s glass with something nonalcoholic or to carry the same drink around all evening. Bartenders will tell you that it is not all that uncommon for patrons to secretly ask them for nonalcoholic versions of drinks they order in front of their friends. Most students resist the idea that they are pawns subject to the whims of peer pressure. They recognize, however, that this assignment will be difficult—not because they are alcoholic but because peer pressure is quite strong.

Activity 10.3: Mere Behavior Change Greater sympathy for the trouble other people have changing their behavior can be acquired through attempts to change one’s own behavior. To help make this point, the entire class can be assigned a simple behavior change they are highly likely to fail at. People tend to put on their pants the same way every time; that is, by putting in their left or their right foot first. Announce that at the next class meeting you will ask which leg goes first. Then, when everyone has identified their preference, they will be assigned the task of switching to the other foot. Surely, you can ask, it doesn’t really matter which leg goes in first? Then over the course of the next few weeks, you can request a show of hands for those people who have reverted to their old way of putting on their pants.

Activity 10.4: A Compendium of Alternatives to Substances For this exercise, students are asked to list all the reasons people might use and abuse substances. Ask what people get, and what do they avoid, by taking various substances. Then point out that it is unrealistic to ask people to give up their substances without providing another means to accomplish the same things. Therefore, they are to give an alternate means of getting, or avoiding, the items they previously listed as motivators of substance use and abuse. The only requirement is that the alternative they provide must be equally effective. Handout 10.2 Activity 10.5: Guest Speakers A variety of interesting speakers can enliven lectures on substance use and abuse. For instance, recovering alcoholics and addicts, AA and NA representatives, physicians specializing in detoxification and addiction treatment, and addictions counselors are often fairly readily available. Most yellow-page directories give resources for alcoholism and drug abuse information and treatment centers that can be consulted. It is more productive to schedule such visits for after the material has been covered in class so that students can pose informed questions of the visitors.

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Web Links Web Link 10.1: http://www.samhsa.gov/ SAMHSA is the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services. Browsing by topic allows you access to a wealth of information.

Web Link 10.2: http://www.addictioninfo.org/articles/337/1/Self-Scoring-Alcohol-Checkup/Page1.html This is a self-scoring alcohol check-up. As you answer sets of questions you get some brief interpretive statements about your drinking habits.

Web Link 10.3: http://www.habitsmart.com/ HabitSmart provides “alternative” theories of addictive behavior and change. It is offered as an alternative to 12-step programs. Overall, it is fairly cognitive-behavioral in its orientation.

Web Link 10.4: http://www.addictionresearch.com/index.cfm The America Foundation for Addiction Research seeks to fund research on addiction. Its site focuses on Internet and sex addiction.

Web Link 10.5: http://www.addictionsearch.com/addictionsearch/ This is an addictions search engine that limits search results to research-related sites.

Web Link 10.6: http://news.bbc.co.uk/1/hi/health/1872731.stm Interesting BBC article on the explosion of Internet gambling.

Web Link 10.7: http://www.apa.org/topics/topicaddict.html American Psychological Association Web page on addictions. It includes some of the most recent information from research studies.

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Video Resources AA and the Alcoholic. Center City, MN: Hazelden Foundation.

Addicted Brain—The Brain Video Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Addiction Caused by Mixing Medicines. Princeton, NJ: Films for the Humanities and Social Sciences.

Addiction: The Family in Crisis. Princeton, NJ: Films for the Humanities and Social Sciences.

Addictions and Mental Illness. Princeton, NJ: Films for the Humanities and Social Sciences.

A Dose of Death: Ecstasy, Homeostasis, and Substance Abuse. Princeton, NJ: Films for the Humanities and Social Sciences.

Advertising Alcohol: Calling the Shots, Second Edition. Cambridge, MA: Cambridge Documentary Films.

Alcohol Addiction. Princeton, NJ: Films for the Humanities and Social Sciences.

Alcohol Addiction: Hereditary Factors, Vol. 29. The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection.

Alcohol and the Family: Breaking the Chain. Princeton, NJ: Films for the Humanities and Social Sciences.

Altered States: A History of Drug Use in America. Princeton, NJ: Films for the Humanities and Social Sciences.

Animated Neuroscience and the Action of Nicotine, Cocaine, and Marijuana in the Brain. Princeton, NJ: Films for the Humanities and Social Sciences.

Behind the Smoke Screen: Facts about Tobacco Use. Allyn and Bacon Video Library.

Binge Drinking: The Right to Party? Princeton, NJ: Films for the Humanities and Social Sciences.

Bingo: You Betcha! New York, NY: The Cinema Guild.

Changing Lives. Moyers on Addiction: Close to Home. Princeton, NJ: Films for the Humanities and Social Sciences.

Cigarettes: Who Profits, Who Dies? Princeton, NJ: Films for the Humanities and Social Sciences.

Circle of Recovery: Healing the Wounds of Drugs and Alcohol. Princeton, NJ: Films for the Humanities and Social Sciences.

Cocaine: The End of the Line. Princeton, NJ: Films for the Humanities and Social Sciences.

Coping Mechanisms. Substance Abuse: Assessment and Intervention Series. Irvine, CA: Concept Media.

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The Cronkite Report: The Dice Are Loaded. Princeton, NJ: Films for the Humanities and Social Sciences.

Crystal. Princeton, NJ: Films for the Humanities and Social Sciences.

Cure or Wishful Thinking: Alcoholism—#7 ABC News and Client Interviews. Allyn and Bacon Abnormal Psychology Video.

Disorders Due to Psychoactive Substance Abuse. Differential Diagnosis in Psychiatry Series.

Princeton, NJ: Films for the Humanities and Social Sciences.

Drinking Apart: Families under the Influence. Allyn and Bacon Video Library.

Drinking: Are You in Control? Allyn and Bacon Video Library.

Drinking Responsibly, Module X. The Total Health Video Series. EMG / Allyn and Bacon Video Library.

Feelings, Alcohol, and Manhood. Men in Crisis Series. Irvine, CA: Concept Media.

Fetal Alcohol Syndrome and Other Drug Use During Pregnancy. Princeton, NJ: Films for the Humanities and Social Sciences.

Fetal Alcohol Syndrome: Life Sentence. Princeton, NJ: Films for the Humanities and Social Sciences.

Gambling: The Chance of a Lifetime. Allyn and Bacon Video Library.

Getting Help: Drugs: Profiles of Addiction and Recovery Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Getting Straight: New Hopes for Drug Treatment. Princeton, NJ: Films for the Humanities and Social Sciences.

Here’s to You, Sister: Women and Alcoholism. Princeton, NJ: Films for the Humanities and Social Sciences.

Heroin: The New High School High. Allyn and Bacon Video Library.

The Hijacked Brain. Moyers on Addiction Series: Close to Home. Princeton, NJ: Films for the Humanities and Social Sciences.

Hooked on Heroin: From Hollywood to Main Street. Princeton, NJ: Films for the Humanities and Social Sciences.

Inhalant Abuse: Breathing Easy. Princeton, NJ: Films for the Humanities and Social Sciences.

Inhalants. Drugs: Uses and Abuses. Princeton, NJ: Films for the Humanities and Social Sciences.

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LSD and Ergot. Princeton, NJ: Films for the Humanities and Social Sciences.

Last Call: Alcoholism and Co-Dependency. Princeton, NJ: Films for the Humanities and Social Sciences.

Making Choices. Drugs: Profiles of Addiction and Recovery Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Narcotics. Drugs: Uses and Abuses Series. Princeton, NJ: Films for the Humanities and Social Sciences.

The Next Generation. Moyers on Addiction Series: Close to Home. Princeton, NJ: Films for the Humanities and Social Sciences.

The Opium Poppy. Princeton, NJ: Films for the Humanities and Social Sciences.

PCP. Drugs: Uses and Abuses Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Place Your Bets. Princeton, NJ: Films for the Humanities and Social Sciences.

The Politics of Addiction. Moyers on Addiction Series: Close to Home. Princeton, NJ: Films for the Humanities and Social Sciences.

Portrait of Addiction. Moyers on Addiction Series: Close to Home. Princeton, NJ: Films for the Humanities and Social Sciences.

The Power of Addiction. Princeton, NJ: Films for the Humanities and Social Sciences.

Preventing Drug Abuse, Module XII. The Total Health Video Series. EMG / Allyn and Bacon Video Library.

Psychedelics and Hallucinogens. Drugs: Uses and Abuses Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Recovery and Prevention of Relapse. Substance Abuse: Assessment and Intervention Series. Irvine, CA: Concept Media.

The Science of Addiction. Risky Business: Teens and Addictive Behavior Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Smokeless Tobacco: A Wad of Trouble. Princeton, NJ: Films for the Humanities and Social Sciences.

Smoking: Time to Quit. Princeton, NJ: Films for the Humanities and Social Sciences.

Steroids. Drugs: Use and Abuse Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Stimulants. Drugs: Use and Abuse Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Straight Up Life. Boston, MA: Fanlight Productions.

Substance Abuse Among Latinos. Princeton, NJ: Films for the Humanities and Social Sciences.

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Substance Abuse Disorders. The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection.

Substance Abuse in the Elderly. Allyn and Bacon Video Library.

Substance Abuse, Panic Disorder with Agoraphobia, Kathy—Patient Interview Video for Abnormal Psychology (12th ed.). Allyn and Bacon Video Library.

The Substance in Question. Princeton, NJ: Films for the Humanities and Social Sciences.

Substance Misuse. Princeton, NJ: Films for the Humanities and Social Sciences.

THC. Drugs: Uses and Abuses Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Teen Gambling. Risky Business: Teens and Addictive Behavior Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Teens and Alcoholism. Princeton, NJ: Films for the Humanities and Social Sciences.

Thirsty Work. Alcohol: Breaking the Habit Series. Princeton, NJ: Films for the Humanities and Social Sciences.

This Buzz Is Not for You: Teenage Drinking. Princeton, NJ: Films for the Humanities and Social Sciences.

Tobacco Road: A Dead End. Princeton, NJ: Films for the Humanities and Social Sciences.

Treating Drug Addiction: A Behavioral Approach, Vol. 30. The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection.

The Two Brains. The Brain Series. South Burlington, VT: Annenberg/CPB Multimedia Collection.

Unborn Addicts. Allyn and Bacon Video Library.

Understanding Addiction. No More Shame: Understanding Schizophrenia, Depression, and Addiction Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Understanding the Risks of Tobacco and Caffeine, Module XI. The Total Health Video Series. EMG / Allyn and Bacon Video Library.

A Way Back: Redefining Masculinity. Men in Crisis Series. Irvine, CA: Concept Media.

Walking through the Fear: Women and Substance Abuse. Princeton, NJ: Films for the Humanities and Social Sciences.

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Handout 10.1 Drugs and Society

1.

How do drugs become outlawed in a society? What influences the selection of drugs to be regulated?

2.

What are the political factors influencing drug control and regulation?

3.

What are the religious factors affecting drug use and control?

4.

Once a drug has been regulated, does society accept its deregulation? Explain.

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Handout 10.2 Alternatives to Alcohol

Alcohol pervades much of our social lives.

1.

List some of the social occasions and events that commonly include alcohol.

2.

Why is there alcohol at these events?

3.

What would happen if there was no alcohol at these events?

4.

Why would a lack of alcohol have this effect?

5.

Are there alternatives to alcohol that could be provided to diminish the impact of not having alcohol?

6.

If it seems that alcohol must be available at these events, then is there a way that abstaining can be made easier? How could you help obscure the fact that some people are not drinking? What motivates people to pressure others to drink alcohol? How can this motive be reduced?

7.

What does it say about society that it is so hard even to reduce alcohol consumption?

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CHAPTER 11: Sexual Variants, Abuse, and Dysfunctions Chapter At-A-Glance Detailed Outline

Instructors’ Resources

Print Supplements

Media Supplements

Sociocultural Influences on Sexual Practices and Standards • Overview • Homosexuality and American Psychiatry

Teaching Objectives 13.1 Chapter Guide Lecture Launchers 13.1, 13.2, 13.4, 13.5 Activities 13.1, 13.2, 13.3 Web Links 13.1, 13.3, 13.4, 13.6

Test Bank Grade Aid

CD-ROM PowerPoint

Sexual and Gender Variants • The Paraphilias • Causal Factors and Treatments for Paraphilias • Gender Identity Disorders

Teaching Objectives 13.2–13.4 Chapter Guide Lecture Launchers 13.1, 13.2, 13.3, 13.4, 13.5 Activities 13.2 Web Links 13.7

Test Bank Grade Aid Transparencies T-84

CD-ROM PowerPoint ABC Video Clip # 9

Sexual Abuse • Childhood Sexual Abuse • Pedophilia • Incest • Rape • Treatment and Recidivism of Sex Offenders

Teaching Objectives 13.5–13.10 Chapter Guide Lecture Launchers 13.3, 13.5 Activities Web Links 13.1, 13.4, 13.5, 13.6

Test Bank Grade Aid Transparencies T-85 to T-88

CD-ROM PowerPoint

Sexual Dysfunctions • Sexual Desire Disorders • Sexual Arousal Disorders • Orgasmic Disorders • Sexual Pain Disorders

Teaching Objectives 13.11 Chapter Guide Lecture Launchers 13.1 Activities 13.1, 13.4 Web Links 13.2

Test Bank Grade Aid Transparencies T-81 to T-83

CD-ROM PowerPoint

Unresolved Issues: How Harmful Is Childhood Sexual Abuse?

Teaching Objectives 13.12 Chapter Guide Lecture Launchers Activities 13.5 Web Links 13.5

Test Bank Grade Aid

CD-ROM PowerPoint

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Professor Notes

Chapter 11: Sexual Variants, Abuse, and Dysfunctions

Teaching Objectives 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Describe the impact of sociocultural influences and cultural standards and values on the understanding of homosexuality.

Define, give examples of, and describe the clinical features of the following paraphilias: fetishism, transvestic fetishism, voyeurism, exhibitionism, sadism, and masochism.

Discuss the most effective treatments for paraphilias, and summarize causal factors implicated in their etiology.

Define and describe the clinical features and treatment of the gender identity disorders (gender identity disorder of childhood, transsexualism).

Review what is known about the frequency and nature of childhood sexual abuse.

Discuss the controversies surrounding both childhood testimony regarding sexual abuse and adult “recovered memories” of childhood sexual abuse.

Define pedophilia and summarize what is known about pedophiles.

Review what is known about the frequency and nature of incest.

Summarize what is known about rape and rapists and discuss issues regarding the frequency of rape and the motivation of rapists.

Describe attempts to treat sex offenders.

Define the sexual dysfunctions, describe their general features, review etiological theories, and summarize the major approaches to treatment.

Knowledgeably discuss the difficulty of deciding the extent of the harm caused by childhood sexual abuse.

Chapter Overview / Summary Defining boundaries between normality and psychopathology in the area of variant sexuality is very difficult, in part because sociocultural influences on what have been viewed as normal or aberrant sexual practices abound. Until rather recently, in many Western cultures homosexuality was viewed as either criminal behavior or as a form of mental illness. However, since 1974, homosexuality has been considered by mental health professionals to be a normal sexual variant.

Sexual deviations in the form of paraphilias involve persistent and recurrent patterns of sexual behavior and arousal, lasting at least six months, in which unusual objects, rituals, or situations are required for full sexual satisfaction. They almost always occur in males. The paraphilias include (1) fetishes, (2) transvestic fetishism, (3) voyeurism, (4) exhibitionism, (5) sadism, (6) masochism, and (7) pedophilia. Nearly all those with paraphilias are male and most typically have an onset at puberty or early adolescence. It has been suggested that male vulnerability to paraphilias is closely linked to their greater dependence on visual sexual imagery.

Gender identity disorders occur in children and adults. Childhood gender identity disorder occurs in children who have cross-gender identification and gender dysphoria. Most boys who have this disorder grow up to have a homosexual orientation; a few become transsexuals. Prospective studies of girls who have this disorder suggest that perhaps half of them develop a homosexual orientation and the other half may desire sex reassignment surgery.

Transsexualism is a very rare disorder in which the person believes that he or she is trapped in the body of the wrong sex. It is now recognized that there are two distinct types of transsexuals: homosexual transsexuals and autogynephilic transsexuals, each with different characteristics and developmental antecedents. The only known effective treatment for transsexuals is a sex-change operation. Although its use remains highly controversial, it does appear to have fairly high success rates when the people are carefully diagnosed and participate in a lengthy readjustment program

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There are three overlapping categories of sexual abuse: pedophilia, incest, and rape. All three kinds of abuse occur at alarming rates today. Controversies about the accuracy of children’s testimony and about the accuracy of recovered memories of sexual abuse that may often occur in psychotherapy have recently arisen.

Traditionally, sexual abuse has been seen as leading to both serious short-term and long-term consequences for its victims. Recent reassessments of the literature have revealed that the results of sexual abuse vary from person to person with some individuals showing little to no negative long-term consequences. What leads people to engage in sexual abuse is poorly understood at this time. The efficacy of treatment of sex offenders is controversial. Sex offenders with deviant sexual preferences (e.g., exhibitionists, severe sadists, and those who are most attracted to children) have particularly high rates of sexual recidivism. A recent study reported better overall success in a cognitive-behavioral treatment program for child molesters and exhibitionists than pedophiles and rapists. Surgical and chemical castration of offenders has been shown to reduce recidivism rates.

Sexual dysfunction involves impairment in the desire for sexual gratification or in the ability to achieve it, and can occur in the first three of the four phases of the human sexual response, which are the desire phase, the excitement phase, the orgasm phase, and the resolution phase.

Both men and women can experience hypoactive sexual desire disorder, in which they have little or no interest in sex. In more extreme cases, they may develop sexual aversion disorder, which involves disgust about sexual activity. Dysfunctions of the arousal phase include male erectile disorder and female arousal disorder. Dysfunctions of orgasm for men include premature ejaculation and male orgasmic disorder (retarded ejaculation), and, for women, female orgasmic disorder. There are also two sexual pain disorders: vaginismus, occurring in women, and dyspareunia (painful coitus), occurring in women and men.

In the past thirty-five years, remarkable progress has been made in the treatment of sexual dysfunctions. For desire disorders, no effective aphrodisiac exists but sensate focus and cognitive restructuring have been used effectively. Several medical treatments have been developed for male sexual arousal disorders such as medications to promote erections, injections of smooth-muscle relaxing drugs into the penile erection chambers, and a vacuum pump. Medications are not efficacious in treating female arousal disorder; psychological treatments prevail. For premature ejaculation, the pause-andsqueeze technique is effective; antidepressants may also be used for those not responding to this technique. Male and female orgasmic disorders respond best to psychological approaches that reduce anxiety and increase pleasurable stimulation. Vaginismus responds best to a combination of banning intercourse, training of the vaginal muscles, and gradual insertion of vaginal dilators while practicing relaxation exercises. Dyspareunia also responds best to cognitive-behavioral approaches similar to those with vaginismus.

Detailed Lecture Outline I.

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Sociocultural Influences on Sexual Practices and Standards A. Overview 1.

Some aspects of sexuality and mating, such as men’s greater emphasis on their partner’s attractiveness, are cross-culturally universal; others are quite variable.

2.

People tend to behave as though the sexual standards of their own time and place are obviously correct, and they tend to be intolerant of sexual nonconformity.

B. Homosexuality and American Psychiatry 1.

Homosexuality as a sickness a.

2003 U.S. Supreme Court struck down Texas state law banning sexual behavior between two people of the same sex

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b.

II.

Ellis and Hirschfield—homosexuality is natural and consistent with psychological normality 2.

Homosexuality as a nonpathological variation a.

Kinsey—homosexuality more common than previously thought b.

1960s—gay liberation movement c.

Openly gay psychiatrists and psychologists worked within field to have homosexuality removed from DSM d.

Removed from DSM by a vote of 5,854 to 3,810 Sexual and Gender Variants A. The Paraphilias 1.

Fetishism a.

Recurrent, intense sexually arousing fantasies, urges, and behaviors involving the use of an inanimate object for sexual gratification b.

Female cases are rare c.

Masturbation often accompanies the fetishistic behavior d.

Obtaining the inanimate object may lead to criminal acts e.

Classical conditioning and social learning can be involved in its development 2.

Transvestic fetishism a.

Recurrent, intense sexually arousing fantasies, urges, and behaviors involving cross-dressing for sexual gratification b.

Most common in men 3.

Voyeurism a.

Recurrent, intense sexually arousing fantasies, urges, and behaviors involving observation of unsuspecting persons who are undressing, or of couples engaged in sexual activity b.

Curiosity is satisfied in shy and inhibited youngsters through this behavior c.

Voyeurism meets individual’s needs while avoiding possible rejection d.

A sense of power maintains the behavior e.

Permissive pornography laws may provide alternatives for the voyeur 4.

Exhibitionism a.

Recurrent, intense sexually arousing fantasies, urges, and behaviors involving exposure of genitals for sexual gratification b.

Exposure is consistent in type of situation and victim c.

Usually begins in adolescence or young adulthood d.

A subtype with antisocial characteristics may be present e.

Considered a criminal offense 5.

Sadism a.

Recurrent, intense sexually arousing fantasies, urges, and behaviors involving inflicting psychological or physical pain on another individual for sexual gratification b.

“Bondage and discipline” is a closely related pattern a.

Sexual gratification can come from the sadistic practice alone b.

Occurs mainly in heterosexual men c.

Serial killers tend to be sexual sadists 6.

Masochism a.

Recurrent, intense sexually arousing fantasies, urges, and behaviors involving the act of being humiliated, beaten, or bound for sexual gratification .

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a.

Complementary relationships are formed b.

More common than sadism, occurring in both men and women c.

Autoerotic asphyxia—500 to 1,000 deaths per year in the U.S. B. Causal Factors and Treatments for Paraphilias 1.

Usually found in males 2.

Typically begin around puberty or early adolescence 3.

Typically more than one found in a person 4.

Money—suggested that male vulnerability to paraphilias is due to their greater dependence on visual sexual imagery 5.

Many believe paraphilias arise as a result of classical and operant conditioning and social learning 6.

Treatments for paraphilias a.

Most studies conducted with sex offenders b.

Non-sex offenders rarely seek treatment C. Gender Identity Disorders 1.

Gender identity disorder of childhood a.

Boys outnumber girls five to one for clinic-referred GID b.

Most common adult outcome of boys is homosexuality rather than transsexualism c.

Argument as to whether this should be seen as a disorder d.

Generally treated psychodynamically but there is a lack of outcome studies 2.

Transsexualism a.

Defined as adults with GID who desire to change their sex b.

Very rare c.

Homosexual male-to-female transsexual d.

Autogynephilic transsexual—a paraphilia in which the originally male individual is attracted to thoughts, images, or fantasies of himself as a woman e.

Treatment (1) Psychotherapy is usually ineffective (2) Surgery and hormone treatment are used (3) Trial periods are needed before surgery (4) Outcome studies show a success rate of 87% of 220 male-tofemale transsexuals and 97 % of 130 female-male transsexuals Sexual Abuse A. Childhood Sexual Abuse 1.

Increase in relevant research a.

Childhood sexual abuse is more common than once thought b.

Possible links between childhood sexual abuse and some disorders c.

Dramatic and well publicized cases have created controversy about the validity of childhood memories and the accuracy of recovered memories 2.

Prevalence of childhood sexual abuse a.

Depends on definition of abuse and childhood b.

Range from less than 5% to more than 30% 3.

Consequences of childhood sexual abuse a.

Short-term consequences include fears, PTSD, sexual inappropriateness, poor self-esteem; one third of abused children show no symptoms

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b.

B.

C.

D.

Long-term consequences include adult psychopathology and sexual symptoms 4.

Controversies concerning childhood sexual abuse a.

Children’s testimony (1) McMartin Preschool case (2) Accuracy of testimony a crucial issue as leading or coercive questioning methods were used b.

Recovered memories of sexual abuse (1) The cases of Eileen Franklin against her father and Patricia Burgus against two Chicago psychiatrists (2) Bass and Davis—Courage to Heal (3) Induction of false memories (4) Negative consequences of recovered memories Pedophilia 1.

Recurrent, intense sexually arousing fantasies, urges, and behaviors involving sexual activity with a prepubertal child 2.

The manipulation of the child’s genitals is usually involved 3.

Nearly all pedophiles are male; two thirds of victims are girls 4.

Studies using the penile phlethysmograph 5.

Pedophiles more likely to believe that children benefit from sexual contact and that children initiate sexual contact 6.

Cases of pedophilia among the Catholic clergy Incest 1.

Historical and biological considerations about incest are presented 2.

The incidence may be underreported in our society 3.

Brother-sister incest most common; father-daughter incest is second 4.

Multiple patterns of incest may exist within the same family 5.

Associated with pedophilia Rape 1.

Prevalence a.

Studies show wildly different estimates b.

Definitions are not consistent c.

Variability in the way information is gathered 2.

Is rape motivated by sex or aggression? a.

Traditionally classified as a sex crime b.

1970s—rape seen as motivated by the need to dominate, to exert power, and to humiliate rather than by sexual desire c.

Sexual motivation is often an important factor (1) Victims tend to be in their teens and early twenties (2) Rapists cite sexual motivations (3) Some rapists exhibit features associated with paraphilias and have multiple paraphilias 3.

Rape and its aftermath a.

Repetitive, planned activity rather than a single event b.

Acquaintance rapes account for two thirds of reported rapes c.

Physical trauma combines with psychological factors leading, in a substantial number of cases, to PTSD d.

Negative impact on victim’s intimate relationships

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e.

IV.

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Myth of victim-precipitated rape; rape shield laws began to appear in the 1970s 4.

Rapists and causal considerations a.

FBI statistics indicate that rape is a young man’s crime; 60% of all rapists are under 25 b.

Low end of socioeconomic ladder and commonly have a prior criminal record c.

Date rapists have a different profile: often middle- to upper-class young men d.

Both types of rapists may be characterized by promiscuity, hostile masculinity, and emotionally detached, predatory personalities e.

Some are afflicted by a paraphilia f.

Deficits in cognitive appraisal of women, social and communication skills, insensitivity to social cues or pressures, a lack of personally intimate relationships, quick loss of temper, and impulsivity g.

Conviction rates are low (50%); only two thirds serve any jail time E. Treatment and Recidivism of Sex Offenders 1.

Psychotherapies and their effectiveness a.

Therapies typically have one of four goals: (1) Modify patterns of sexual arousal typically with aversion therapy or covert sensitization; must replace deviant arousal patterns with arousal to acceptable stimuli (2) Modify cognitions and social skills through cognitive restructuring and social skills training (3) Change habits or behavior (4) Reduce sexual drive b.

Sexual offenders are difficult to treat successfully with many studies showing no differences between treated and untreated groups; recent meta-analysis showed that treated offenders were less likely to offend but effects were modest c.

Cognitive-behavioral techniques appeared to be most effective d.

Non-pedophile child molesters and exhibitionists also found to respond better to treatment than pedophiles and rapists 2.

Biological and surgical treatments a.

SSRIs have been found useful in reducing paraphilic desire and behavior but not with sex offenders b.

Controversial treatment of surgical and chemical castration 3.

Combining psychological and biological treatments a.

Lack of randomly assigned controls who are equally motivated for treatment b.

Research is further complicated by the fact that the outcome variable in most studies is whether the person is convicted of another sex offense; most sex offenses go unpunished (the offender is often never caught, let alone convicted) 4.

Summary Sexual Dysfunctions A. Human Sexual Response 1.

Desire phase 2.

Excitement phase .

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B.

A.

3.

Orgasm 4.

Resolution Sexual Desire Disorders 1.

Two disorders: Hypoactive sexual desire disorder and Sexual aversion disorder a.

Prior or current depression may contribute to these disorders b.

May be due to declining levels of testosterone with age c.

Other possible causes include: SSRIs, low relationship satisfaction, daily hassles/worries, increased disagreements and conflicts, low levels of feelings, and reduced cues of emotional bonding 2.

Hypoactive sexual desire disorder a.

Little or no sexual drive is present; most common female sexual dysfunction b.

What is “not enough” sexual interest is debatable c.

For many women, sexual desire is only experienced after sexual stimuli have led to subjective sexual arousal; linear sequence not accurate for women 3.

Treatment a.

Lower levels of testosterone may be involved; however, replacing testosterone does not typically help b.

Sustained use of bupropion improved sexual arousability and orgasm frequency in women c.

Therapists focus on education, communication training, cognitive restructuring, sexual fantasy training, and sensate focus training Sexual Arousal Disorders 1.

Male erectile disorder (or erectile insufficiency) a.

Barlow—cognitive distractions frequently associated with anxiety in dysfunctional people that seem to interfere with sexual arousal; preoccupation with negative thoughts b.

Occur in as many as 90% of men using antidepressants (especially SSRIs) c.

37% of men between 57 and 85 reported significant erectile dysfunction d.

Vascular disease most common cause of erectile problems in older men e.

Treatment (1) Cognitive-behavioral (2) Medications such as yohimbine (3) Injections of smooth-muscle-relaxing drugs into the penile erection chambers (4) Vacuum pump (5) Penile implants in extreme cases (6) Viagra (a) Works by making nitric oxide more available (b) Promotes erection only if some sexual excitement is present (c) Over 70% of men report improvement (d) Two similar drugs introduced: Cialis and Levitra (e) Improvements enhanced by cognitive-behavioral therapy 2.

Female sexual arousal disorder a.

This involves an absence of arousal and unresponsiveness to stimulation b.

Possible causes include early sexual traumatization, excessive and distorted socialization about the “evils” of sex, dislike or disgust with sexual partner, lowered tactile sensitivity .

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c.

B.

C.

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Biological casual factors include the use of SSRIs, certain medical illnesses, and decreases in estrogen levels occurring during and following menopause d.

Treatment: (1) Few controlled studies have been conducted (2) Vaginal lubricants are effective (3) Viagra, Cialis, and Levitra not useful for women Orgasmic Disorders 1.

Premature ejaculation a.

Exact definition of this condition is necessarily somewhat arbitrary b.

Most common male sexual dysfunction at least up to age 59 Explanations have ranged from increased anxiety to increased penile sensitivity to higher levels of arousal to sexual stimuli; no explanation has much empirical support c.

Treatment: (1) Behavioral therapy such as the pause-and-squeeze technique (2) Antidepressants such as Paxil and Zoloft can significantly prolong ejaculatory latency; work only as long as they are taken 2.

Male orgasmic disorder a.

Persistent inability to ejaculate during intercourse b.

Psychological treatments emphasize the reduction of performance anxiety in addition to increasing genital stimulation c.

Specific physical problems such as multiple sclerosis and certain medications (especially the SSRIs) may be involved 3.

Female orgasmic disorder a.

“Extra” stimulation is required for orgasm b.

No amount of stimulation can produce orgasm in lifelong orgasmic dysfunction; affects approximately 10–15% of women c.

Causal factors not well understood (1) Anxiety and tension (2) Feelings of inadequacy d.

Treatment requires distinction between lifelong and situational dysfunction (1) Instruction and guidance for lifelong dysfunction with high rates of success (2) Situational more difficult to treat than lifelong Sexual Pain Disorders 1.

Vaginismus a.

Defined as involuntary spasm of the muscles at the entrance to and outer third of the vagina b.

Questions about this definition; recommended that muscle spasms not be required, just persistent difficulty in allowing objects to be inserted c.

Some women also have sexual arousal disorder, possibly as a result of conditioned fears d.

Relatively rare e.

Treatment (1) Banning of intercourse (2) Training of vaginal muscles (3) Graduated self-insertion of vaginal dilators .

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2.

V.

Dyspareunia a.

Painful sexual intercourse is more common in females than males b.

Infections or structural pathology may be present c.

Some argue this should be reclassified as “pelvic pain disorder” d.

Treatment (1) Cognitive-behavioral techniques similar to those used in vaginismus (2) Techniques include: education about sexuality, identifying and correcting maladaptive cognitions, graduated vaginal dilation exercise to facilitate vaginal penetration, and progressive muscle relaxation Unresolved Issues: How Harmful Is Childhood Sexual Abuse?

A. Rind, Tromovitch, and Bauserman (1998) 1.

Correlations between childhood sexual abuse and later problems of small magnitude 2.

Family pathology, not abuse, may be involved 3.

Incest and forced sex associated with more problems 4.

Age at which CSA was experienced unrelated to adult outcome B. Controversy over study ignited by Dr. Laura Schlessinger 1.

Claims were socially dangerous: giving comfort to child molesters and being insensitive to victims of CSA 2.

U.S. House of Representatives condemned the study 3.

Study not scientifically strong enough to justify conclusions a.

Relied on college students; however, results confirmed with community samples b.

Statistical decisions and analyses were criticized; however, results did not change when analyzed differently C. Rind has extended discussion to adult-adolescent sexual relationships 1.

Reviews evidence that current views are driven by ideology and moral panic rather than by empirical research 2.

Evidence suggests that many teenage boys see perceived benefits from such relationships in regard to their sexual confidence and self-acceptance

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Key Terms autogynephilia (p. 362) cross-gender identification (p. 360) desire phase (p. 372) dyspareunia (p. 378) excitement (or arousal) phase (p. 372) exhibitionism (p. 357) female orgasmic disorder (p. 377) female sexual arousal disorder (p. 376) fetishism (p. 354) gender dysphoria (p. 360) gender identity disorder (p. 360) hypoactive sexual desire disorder (p. 372) incest (p. 367) male erectile disorder (p. 374) male orgasmic disorder (p. 377)

masochism (p. 358) orgasm (p. 372) paraphilias (p. 354) pedophilia (p. 366) premature ejaculation (p. 376) rape (p. 367) resolution (p. 372) sadism (p. 358) sexual abuse (p. 363) sexual aversion disorder (p. 374) sexual dysfunction (p. 372) transsexualism (p. 361) transvestic fetishism (p. 354) vaginismus (p. 378) voyeurism (p. 356)

Lecture Examples / Discussion Topics Lecture Launcher 11.1: Should Transvestism Be a Mental Disorder?

A classroom discussion of the status of transvestism as a mental disorder can draw out a variety of diagnostic issues, especially the significance of “harm” and “dysfunction” as well as the role of values in demarcating normal and abnormal. Male transvestism is unusual, but statistical infrequency in and of itself is insufficient to qualify it as a mental disorder. The DSM requires distress and impairment in order to make the diagnosis, but a recent study found transvestic men to be normal on a wide variety of measures of personality, sexual functioning, and personal distress (Brown et al., 1996, Journal of Nervous & Mental Disease, vol. 184, pp. 265–273). Most peoples’ immediate reaction to descriptions of the disorder involve pathologizing, making this an interesting disorder to discuss with respect to the boundaries of abnormality.

Lecture Launcher 11.2: Double Standards How would you know if a woman had a transvestic fetishism? In fact, DSM-IV-TR recognizes transvestism only in males. Do class members view women who dress in men’s clothing differently than they view men who dress in women’s clothing? What would a woman have to wear to unambiguously be in male attire—a tuxedo? More generally, how are feminine males perceived compared to masculine females? Why is the term sissy more pejorative than the term tomboy? Why can women stand closer to each other and have more intimate friendships with each other than men? We often speak of the narrow social constraints placed on female gender roles, but isn’t the opposite more the case?

Lecture Launcher 11.3: Why Are Paraphilias So Much More Common Among Men? The paraphilias are almost never diagnosed in females. Sexual masochism is the most common paraphilia found among women, but even masochism is diagnosed twenty times more frequently in men.

What might account for this enormous difference? Among the possible explanations is the fact that men are generally more likely to be arrested, and their sexual misbehaviors are therefore more likely to come to the attention of authorities. Anthropologically speaking, it may be that male external genitalia have become more sexually conditionable via evolutionary pressures. Similarly, lower male investment in gestation and nursing of offspring might confer reproductive advantages on promiscuity and sexual improvisation that would not have benefited females. Finally, as described in Lecture Launcher 13.2 218

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Double Standards, men may operate within narrower sex roles, pushing more activities outside accepted ranges. For instance, women are permitted to wear men’s clothing but not vice versa.

Lecture Launcher 11.4: Sex Change Operations Sex change operations are very complicated to get, with lengthy waiting periods, extensive psychological screening, and very high cost. Why? If someone wants a sex change operation why can’t they just get one? How does this procedure differ from any other medical procedure? Is it more like cosmetic surgery or the correction of a birth defect? Should insurance pay? How would you determine whether someone is a good candidate for the procedure? What kinds of scientific data would be necessary to set policies in this area? Would you want to see data on post-surgical adjustment to being a member of the opposite sex? How strong a predictor of post-surgical adjustment would be strong enough to serve as a basis for denying someone access to the surgery—even someone willing and able to pay?

Lecture Launcher 11.5: Self-Determination of Sexual Orientation How much choice do students in your class feel they exert over their sexual orientations? Beyond their sexual attraction to males and females, how much choice went into the kinds of material they find erotic? It is not necessary for students to disclose their sexual attractions to answer these questions. The questions are about the process of acquiring sexual desires and preferences, regardless of what they actually are. Does exposure to particular erotic stimuli enhance sexual attraction to them, or is it the prior attraction to such material that causes people to seek them out? What effect does ready availability of erotic and frankly pornographic material on the Internet have on people? Does it change peoples’ erotic preferences or enhance their pre-existing ones?

Demonstrations / Activities Activity 11.1: Kegel Exercises Kegel exercises are recommended by sex therapists working with clients experiencing a variety of sexual dysfunctions. The Kegel muscle is near the pelvic floor in both men and women. The muscles are attached to the pelvic bone and act like a hammock, holding in the pelvic organs. They are also the muscles that are used to interrupt the urine stream. Students can be asked to identify this muscle by the next class period and also to learn to flex the Kegel muscle directly. Kegel exercises then involve simply flexing the Kegel muscle a certain number of times every day. Kegel exercises are also recommended for pregnant women, to improve muscle tone prior to childbirth, and for incontinence. Some even advocate doing them regularly to enhance otherwise functional sexuality. Handout 11.1 Activity 11.2: Getting Good Sex Information This activity begins by asking students to jot down their questions and concerns about sex. These questions then can be collected and collated into a list that is distributed back to students to research on their own. The research part of the activity can be done in groups or individually. The list can be divided among the students/groups if it is lengthy, or else the research can be duplicated for comparison purposes. Class time can then be devoted to going through each question and the answers students found. An important aspect of this assignment is to have students carefully observe the wide variation in the quality and authority of the sources they find. It is especially instructive to consider the sources of contradictory answers. Alternatively, the instructor can answer the questions for the class or else the questions can be forwarded to a guest expert who will be visiting the class later. It is also instructive to process the discomfort this topic can produce and how that discomfort is often expressed with humor.

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Activity 11.3: Show Me Yours, and I’ll Show You Mine Men’s and women’s magazines are honed to interest largely one or the other gender. They are designed to appeal almost exclusively to ways men and women differ from each other. Interestingly, they both provide nearly constant coverage of sex, albeit from quite different perspectives. Awareness of the differences between the portrayals requires reading examples of magazines written for the other gender.

Therefore, this activity requires students to closely study sex articles in magazines written for the other sex. Men can read Cosmopolitan and Vogue or Women’s Day while women can read Maxim and GQ or Men’s Health. Bearing in mind that these articles were not written for them, ask students to reflect on how their own sex is being represented and how the material is different from what might appear in magazines written for them. Students who have not read such magazines at all before this exercise will need to investigate some from the other category to gain the comparative perspective upon which this assignment relies.

Activity 11.4: Is the Cure Worse than the Disease?

People taking medications for a number of medical conditions may experience sexual dysfunction as a side effect of their treatment. How does this affect the utilization of the medications and how does it influence the psychological adjustment of the patient? Notably, SSRI antidepressant medications frequently have sexual side effects. These can be interpreted as related to the depression itself when they are actually side effects of its treatment. Given the substantial role of cognitive processes such as “spectating” and performance concerns, is it wise to alert people taking antidepressant medications to the potential effects they might have on sexual functioning, or that might lead to a self-fulfilling prophecy or medication noncompliance?

Activity 11.5: Rape Reporting Procedures Many rapes go unreported out of fear for how the report will be handled. Have students investigate how rape reports are handled on campus. Are there any outreach programs to encourage reports of rape?

Does the campus have a mechanism to support rape victims? What services are called into action when a rape is reported on campus? Does the campus have a rumor-control service that may deal with inaccurate information following a sexual assault?

Activity 11.6: Reality TV = Voyeurism?

Does reality TV cater to viewers’ voyeuristic tendencies? What is the nature of its appeal? For this activity have students select two reality TV programs and provide examples of what may encourage voyeurism. Handout 11.2 Web Links Web Link 11.1: http://www.highbeam.com/library/docfree.asp?DOCID=1G1:53390357&ctrlInfo=Round18%3AMode 18c%3ADocG%3AResult&ao= This link is to an article written by Rind discussing the misrepresentation of cross-cultural examples of homosexuality in Human Sexuality textbooks. Rind presents a different view from many other experts in the field and one worth exploring.

Web Link 11.2: http://www.healthysex.com/ HealthySex.com is an educational site developed “to promote healthy sexuality—sex based on caring, respect, and safety.” It has information on sexual health, intimacy, communication, abuse, addiction recovery, sexual fantasy, and midlife sex.

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Web Link 11.3: http://www.aasect.org/ The American Association of Sex Educators, Counselors, and Therapists (AASECT) is a professional organization interested in the promotion of understanding human sexuality and healthy sexual behavior.

Their Web site has sex FAQs, links, and information about locating a therapist.

Web Link 11.4: http://www.sexscience.org/ The Society for the Scientific Study of Sexuality is an interdisciplinary society seeking to improve the quality of sex research and its clinical applications.

Web Link 11.5: http://www.indiana.edu/~kinsey/index.html This is the Web site of the Kinsey Institute at Indiana University – Bloomington.

Web Link 11.6: http://www.eeoc.gov/laws/types/sexual_harassment.cfm This site, sponsored by the U.S. Equal Employment Opportunity Commission, provides definitions, statistics, and links to regulations and other information about sexual harassment.

Web Link 11.7: http://www.emedicine.com/med/topic3127.htm This site provides a detailed article outlining describing paraphilias, diagnostic criteria, symptoms, causes, treatments, and medications.

Video Resources Adventures in the Gender Trade: A Case for Diversity. New York, NY: Filmmakers Library.

Anatomy of Desire. New York, NY: The Cinema Guild.

The Blank Point: What Is Transsexualism? New York, NY: The Cinema Guild.

Child Abuse: It Shouldn’t Hurt to Be a Kid. Boston, MA: Fanlight Productions.

Child Molestation: Sorting Out the Truth. Allyn and Bacon Video Library.

Child Sex Abusers. Princeton, NJ: Films for the Humanities and Social Sciences.

Child Sexual Abuse: The Clinical Interview. New York, NY: Insight Media.

Date Rape. Princeton, NJ: Films for the Humanities and Social Sciences.

Date Rape Drugs: An Alert. Allyn and Bacon Video Library.

Date Violence: A Young Woman’s Guide. Allyn and Bacon Video Library.

Fresh Talk. New York, NY: The Cinema Guild.

A Journey Back: From Rape to Healing. Allyn and Bacon Video Library.

Juvenile Sex Offenders: Voices Unheard. Princeton, NJ: Films for the Humanities and Social Sciences.

Love, Intimacy, and Sexuality. Growing Old in a New Age Series. South Burlington, VT: Annenberg/CPB Multimedia Collection. .

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Male Rape. Princeton, NJ: Films for the Humanities and Social Sciences.

Men, Women, and Sex Difference: Boys and Girls are Different. Princeton, NJ: Films for the Humanities and Social Sciences.

Multiple Genders: Mind and Body in Conflict. Princeton, NJ: Films for the Humanities and Social Sciences.

Pedophiles. Princeton, NJ: Films for the Humanities and Social Sciences.

Rape: An Act of Hate. Princeton, NJ: Films for the Humanities and Social Sciences.

Rape by Any Name. Boston, MA: Fanlight Productions.

The Remarkable Story of John/Joan. New York, NY: Filmmakers Library.

Sexual Brain—The Brain Video Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Sexual Disorders. The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection.

Transgendered Cops—#8 ABC News and Client Interviews. Allyn and Bacon Abnormal Psychology Video.

Viagra: A New Sexual Revolution? Princeton, NJ: Films for the Humanities and Social Sciences.

When a Kiss Is Not Just a Kiss. Boston, MA: Fanlight Productions.

You Don’t Know Dick. Berkeley, CA: University of California Extension Center for Media and Independent Learning.

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Handout 11.1 Kegel Exercises

Kegel exercises are recommended by sex therapists working with clients experiencing a variety of sexual dysfunctions.

The Kegel muscle is near the pelvic floor in both men and women.

The muscles are attached to the pelvic bone and act like a hammock, holding in the pelvic organs.

They are also the muscles that are used to interrupt the urine stream.

Next time you are urinating, identify your Kegel muscle by repeatedly interrupting the urine stream and memorizing the muscles you use to do so. Then learn to flex the Kegel muscle directly.

Kegel exercises simply involve flexing the Kegel muscle a certain number of times every day.

Kegel exercises are often recommended for pregnant women, to improve muscle tone prior to childbirth, and for incontinence.

Some people even advocate doing them regularly to enhance otherwise functional sexuality.

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Handout 11.2 Reality TV = Voyeurism?

Does reality TV encourage voyeurism? Select two reality programs and provide examples of what may encourage voyeurism.

Television Program

Premise of Program

1.

2.

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Voyeuristic Characteristics

CHAPTER 12: Schizophrenia and Other Psychotic Disorders Chapter At-A-Glance Detailed Outline

Instructors’ Resources

Print Supplements

Media Supplements

Schizophrenia • Origins of the Schizophrenia Construct • Epidemiology

Teaching Objectives 12.1, 12.2 Chapter Guide Lecture Launchers 12.1, 12.2, 12.4 Activities 12.1, 12.3, 12.4 Web Links 12.1, 12.2, 12.3, 12.4, 12.6

Test Bank Grade Aid Transparencies T-46 and T-47

CD-ROM PowerPoint

Clinical Picture • Delusions • Hallucinations • Disorganized Speech • Disorganized and Catatonic Behavior • Positive and Negative Symptoms • Subtypes of Schizophrenia • Other Psychotic Disorders

Teaching Objectives 12.3, 12.4, 12.5 Chapter Guide Lecture Launchers 12.2, 12.3, 12.5 Activities 12.2, 12.3, 12.4 Web Links 12.2, 12.3, 12.4, 12.6

Test Bank Grade Aid Transparency T-47

CD-ROM PowerPoint ABC Video Clip #10

Risk and Causal Factors • Genetic Factors • Prenatal Exposures • Genes and Environment in Schizophrenia: A Synthesis • A Neurodevelopmental Perspective • Other Biological Factors • Neurocognition • Psychosocial and Cultural Factors

Teaching Objectives 12.6 Chapter Guide Lecture Launchers 12.1, 12.4 Activities 12.2 Web Links 12.2, 12.3, 12.4, 12.6

Test Bank Grade Aid Transparencies T-48 to T-56

CD-ROM PowerPoint ABC Video Clip #10

Treatment and Outcomes • Pharmacological Approaches • Psychosocial Approaches

Teaching Objectives 12.7, 12.8 Chapter Guide Lecture Launchers 12.3, 12.4 Activities 12.5, 12.6 Web Links 12.1, 12.2, 12.4, 12.6

Test Bank Grade Aid Transparency T-57

CD-ROM PowerPoint

Unresolved Issues: Can Schizophrenia Be Prevented?

Teaching Objectives 12.9 Chapter Guide Lecture Launchers 12.1 Activities 12.6 Web Links 12.2, 12.5, 12.6

Test Bank Grade Aid Transparency T-52

CD-ROM PowerPoint

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Professor Notes

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Chapter 12: Schizophrenia and Other Psychotic Disorders

Teaching Objectives 1.

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Describe the typical person—age, gender, characteristics—who might develop schizophrenia.

Describe what is meant by the term schizophrenia and the evolution of diagnosing this disorder.

Describe and differentiate among positive, negative, and disorganized symptoms of schizophrenia. Explain why psychologists have grouped the symptoms in this manner.

Compare and contrast the subtypes of schizophrenia.

Describe the clinical features of other psychotic disorders.

Summarize the biological, psychosocial, and sociocultural causal influences in schizophrenia. Explain how these theories may be integrated.

Evaluate the various biological and psychosocial treatments for schizophrenia. Describe what might be seen as the most effective treatment approach for someone who is diagnosed with schizophrenia.

Discuss current issues in treating schizophrenia including limitations of antipsychotics and the need for expanded psychosocial intervention.

Differentiate among primary, secondary, and tertiary prevention and explain the difficulties associated with trying to prevent schizophrenia.

Chapter Overview / Summary Schizophrenia is the most severe form of mental illness. Kraepelin is credited with first describing a condition he called dementia praecox, what we now call schizophrenia. The term schizophrenia denotes a split within the intellect, between the intellect and emotion, and between the intellect and external reality. It is characterized by impairments in many domains and affects approximately one percent of the population.

High risk groups for developing schizophrenia include people whose fathers were older (aged 45-50 years or more) at the time of their birth, people of Afro-Caribbean origin living in the United Kingdom, those from western Ireland, and those from Croatia.

Most cases of schizophrenia begin in late adolescence or early adulthood. The disorder begins earlier in men than it does in women. Overall, the clinical symptoms of schizophrenia tend to be more severe in men than women. Women also have a better long-term outcome.

Characteristic symptoms of schizophrenia include hallucinations, delusions, disorganized speech, and disorganized and catatonic behavior. Symptoms can be classified as either positive (hallucinations and delusions) or negative (emotional flattening, poverty of speech, asociality, apathy, and anhedonia). A third pattern, disorganized symptoms, includes disorganized speech and behavior.

Subtypes of schizophrenia include paranoid, disorganized, catatonic, undifferentiated, and residual. Other psychotic disorders include schizoaffective disorder, schizophreniform disorder, delusional disorder, brief psychotic disorder, and shared psychotic disorder.

Genetic factors are clearly implicated in schizophrenia. Having a relative with the disorder significantly raises a person’s risk of developing schizophrenia. The overall

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pairwise concordance rate is 28% for monozygotic twins and 6% for dizygotic twins.

Other factors that have been implicated in the development of schizophrenia include variants of the COMT gene, prenatal exposure to the influenza virus (during the 4th to 7th month), rhesus incompatibility, early nutritional deficiencies, and perinatal birth complications impacting oxygen availability. Current thinking about schizophrenia emphasizes the interplay between genetic and environmental factors. Tienari and his colleagues illustrate this concept with their study of adopted children. Those children reared in dysfunctional families and had high genetic risk went on to develop schizophrenia-related disorders; children at high genetic risk reared in healthy family environments did not develop problems any more frequently than children at low genetic risk.

Even though schizophrenia begins in early adulthood, researchers believe that it is a neurodevelopmental disorder. A “silent lesion” in the brain is thought to lie dormant until normal developmental changes occur and expose the problems that result from this brain abnormality. Beginning with Walker’s studies of home movies, early precursors of schizophrenia have been identified including abnormal motor movements such as unusual hand movements, facial tics, blinking, or tongue thrusts; less positive and more negative facial emotions; delays in speech and motor development; and abnormalities in tasks measuring attention.

Many brain areas are abnormal in schizophrenia, although abnormalities are not found in all patients. Brain abnormalities that have been found include decreased brain volume, enlarged ventricles, frontal lobe dysfunction, reduced volume of the thalamus, and abnormalities in temporal lobe areas such as the hippocampus. The most important neurotransmitters implicated in schizophrenia are dopamine and glutamate.

Patients with schizophrenia have many problems in aspects of their neurocognitive functioning. They show a variety of attentional deficits (e.g., poor P50 suppression and deficits on the Continuous Performance Test). They also show eyetracking dysfunctions.

Patients with schizophrenia are more likely to relapse if their relatives are high in expressed emotion (EE). High EE environments may be stressful to patients and may trigger biological changes that cause dysregulations in the dopamine and glutamate systems. This could lead to a return of symptoms. Interestingly, both being reared in an urban environment and immigration have been shown to increase the risk of schizophrenia, perhaps through the effect of stress. People with schizophrenia are twice as likely to smoke cannabis; early cannabis use (prior to age 15) more than doubles a person’s risk of developing later schizophrenia by increasing the synthesis of dopamine.

For many patients, schizophrenia is a chronic disorder requiring long-term treatment or institutionalization. However, with therapy and medications, about 38 percent of patients show a reasonable recovery. Only about 16 percent of patients recover to the extent that they no longer need treatment.

Patients with schizophrenia are usually treated with antipsychotic (neuroleptic) medications. Second-generation antipsychotics cause fewer extrapyramidal (motor abnormality) side effects. Antipsychotic drugs work by blocking dopamine receptors.

Overall, patients taking second-generation antipsychotics do better than patients taking conventional antipsychotic drugs.

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Psychological treatments for patients with schizophrenia include cognitivebehavior therapy, cognitive remediation, social skills training, and other forms of individual treatment as well as case management. In addition, family therapy is also beneficial. Family therapy focuses on reducing EE and provides families with communication skills and other skills that are helpful in managing the illness.

Detailed Lecture Outline I.

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Schizophrenia A. Origins of the Schizophrenia Construct 1.

Kraepelin (1896)—careful description of what he called dementia praecox 2.

Bleuler (1911)—originated the term schizophrenia because he believed the disorder was primarily characterized by a disorganization of thought processes, a lack of coherence between thought and emotion, and an inward orientation away (split off) from reality B. Epidemiology 1.

Lifetime prevalence of about 1% 2.

Higher risk in certain groups: parent with schizophrenia, family with schizophrenia, older father (age 45–50) at time of birth, people of Afro-Caribbean origins living in the U.K. 3.

Vast majority of cases begin in later adolescence or early adulthood 4.

Males tend to have an earlier onset and a more severe form of the disorder; protective function of female hormones is suspected Clinical Picture A. Delusions 1.

Erroneous belief that is fixed and firmly held despite clear contradictory evidence 2.

Delusions are not exclusive to schizophrenia 3.

Certain delusions are common in schizophrenia: a.

Belief that one’s thoughts, feelings, or actions are being controlled by some outside agent b.

Thought broadcasting c.

Thought insertion d.

Some external agency has robbed one of one’s thoughts (thought withdrawal) e.

Delusions of reference f.

Delusions of bodily changes B. Hallucinations 1.

Sensory experience in the absence of any external perceptual stimulus 2.

Auditory are the most common — 75% of those with schizophrenia report auditory hallucinations

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3.

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Imaging studies show that hallucinating patients show increased activity in Broca’s area—area of the temporal lobe involved in speech production; suggests that auditory hallucinations occur when patients misinterpret their own self-generated and verbally mediated thoughts (inner speech or self-talk) as coming from another source Disorganized Speech 1.

Person fails to make sense, despite seeming to conform to the semantic and syntactic rules governing verbal communication; has been referred to as “cognitive slippage,” “derailment,” “loosening of associations,” and “incoherence” 2.

Neologisms Disorganized and Catatonic Behavior 1.

Impairment in goal-directed activity; deterioration from a previously mastered standard 2.

Deficits may appear in personal hygiene, disregard for personal safety and health, silliness or unusual dress, or a catatonic stupor Positive and Negative Symptoms 1.

Positive vs. Negative syndrome schizophrenia; disorganized symptom pattern now recognized 2.

Positive symptoms reflect an excess or distortion: delusions, hallucinations 3.

Negative symptoms reflects an absence or deficit: alogia, flat or blunted affect, avolition 4.

Research suggests that, even when flat or blunted, emotional expressiveness occurs; subjective reports of patients indicate they are experiencing plenty of emotion Subtypes of Schizophrenia 1.

Paranoid Type a.

Delusions of persecution and grandeur are common b.

Tend to function at a higher level and have more intact cognitive skills c.

Prognosis generally better 2.

Disorganized Type a.

Earlier, more gradual onset b.

This is a pattern of severe disorganization progressing into emotional indifference and infantile behavior c.

Hallucinations and delusions may be present but are not organized d.

Prognosis is poor 3.

Catatonic Type a.

Pronounced motor symptoms are apparent b.

Stupor and excitement phases can be seen; violent behavior can occur during excitement phase

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c.

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Some patients may automatically obey commands, imitate the actions of others (echopraxia), or mimic their phrases (echolalia) d.

Though common at one time, now uncommon except for less industrialized regions of the world e.

Stupor has been interpreted as patient’s way of coping or maintaining control 4.

Undifferentiated Type a.

“Wastebasket” category 5.

Residual type a.

Suffered at least one episode of schizophrenia but not currently exhibiting any prominent positive or disorganized symptoms b.

Prominent symptoms consist only of negative symptoms 6.

Other Psychotic Disorders a.

Schizoaffective disorder (1) Features of schizophrenia and a mood disorder (2) Bipolar and unipolar subtype possible (3) Prognosis better than for schizophrenia b.

Schizophreniform disorder (1) Schizophrenia-like psychoses that last at least one month but not as long as six months (2) Most often seen in an undifferentiated form (3) May or may not be related to subsequent psychiatric disorder (4) Prognosis better than for schizophrenia c.

Delusional disorder (1) Other than delusions, behave normally (2) Interesting subtype is erotomania d.

Brief psychotic disorder (1) Sudden onset of psychotic, grossly disorganized, or catatonic symptoms (2) Often lasting only days (3) Often triggered by stress e.

Shared psychotic disorder (folie a deux) (1) Diagnosed when a person in a close relationship with a psychotic individual begins to believe the same delusions (2) May spread to include an entire family Risk and Causal Factors A. Genetic Factors 1.

Twin studies a.

Higher concordance rate for schizophrenia in monozygotic twins b.

Torrey—MZ concordance rate is 28% and 6% in DZ

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Chapter 12· Schizophrenia and Other Psychotic Disorders

c.

2.

3.

4.

5.

Suggests that genes play a role but genes are not sufficient for explaining schizophrenia d.

Studies of discordant MZ twin pairs reveal that children of the “well” twin are at significantly higher risk of developing schizophrenia Adoption studies a.

Twin studies overestimate importance of genes by confounding environment and genes b.

Heston found higher rates of schizophrenia among adopted children of schizophrenic biological parents The quality of the adoptive family a.

Finnish Adoptive Family Study of Schizophrenia (1) Twenty-one-year follow-up (2) Children of biological parents with schizophrenia developed more schizophrenia and schizophreniarelated disorders than did the controls (3) The combination of genetic risk and high communication deviance was found to be problematic; children with genetic risk but low communication deviance families were healthier than the control children b.

Tienari and colleagues—recent evidence of geneenvironment interaction; only children with high genetic risk and adverse family environment went on to develop schizophrenia or schizophreniarelated disorders Molecular genetics a.

Schizophrenia probably involves multiple genes working together b.

Specific regions on chromosomes 1, 2, 6, 8, 11, 13, 15, 16, and 22 are being investigated c.

By using known genes (DNA markers) can predict where the genes for schizophrenia might be—this is called linkage analysis d.

Currently looking for candidate genes such as COMT gene: genes known to be involved in some of the processes that are thought to be problematic in schizophrenia such as genes involved in dopamine metabolism (1) People with a particular variant of the COMT gene are more likely to become schizophrenic if they use cannabis during adolescence Endophenotypes a.

Endophenotypes are discrete, stable, and measurable traits that are thought to be under genetic control b.

One example might be people who score high on perceptual aberrations and magical ideation

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c.

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By studying different Endophenotypes, researchers hope to identify specific genes involved in schizophrenia Prenatal Exposures 1.

Prenatal viral infection a.

In Northern hemisphere, more people with schizophrenia are born between January and March b.

1957 Flu epidemic in Finland—elevated rates of schizophrenia in children whose mothers had been in their second trimester 2.

Rhesus incompatibility a.

Associated with increased risk of schizophrenia b.

For males, raises risk of schizophrenia to 2.1% c.

Mechanism might involve oxygen deprivation 3.

Early nutritional deficiency a.

Dutch Hunger Winter b.

Children conceived during the height of the famine had a two-fold increase in their risk of later developing schizophrenia c.

Unclear whether problem is general lack of nutrition or of a specific nutrient 4.

Perinatal birth complications a.

Birth complications increase risk of schizophrenia Genes and Environment in Schizophrenia: a Synthesis 1.

Current expert thinking emphasizes the notion of a multiplicity of genes that must operate in concert in additive and interactive ways with environmental factors.

2.

Only people who had a parent with schizophrenia and who had birth complications later developed brain abnormalities such as enlarged ventricles; genetic liability predisposes person to suffer more damage from environmental insults A Neurodevelopmental Perspective 1.

Vulnerability to schizophrenia stems from a brain lesion that occurs very early in development, perhaps even before birth; lesion is dormant until normal maturation of the brain shows the problems 2.

Problem may be a result of neuronal migration 3.

Developmental precursors of schizophrenia a.

Walker—family home movies (1) Preschizophrenic children showed more motor abnormalities including unusual hand movements; less positive facial emotion and more negative facial emotion (2) Differences frequently present by age 2 b.

High-risk research

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Chapter 12· Schizophrenia and Other Psychotic Disorders

(1)

E.

Unique group as 89% of patients with schizophrenia have no first- or second-degree relatives with schizophrenia (2) Found to exhibit deficits in attention, social competence, and motor abnormalities Other Biological Factors 1.

Facilitated by the development of modern computer-dependent technologies such as PET and MRI 2.

Brain volume a.

Enlarged brain ventricles; average of 3% reduction in brain volume b.

Males more affected than females c.

Present only in a minority of those with schizophrenia and not specific to schizophrenia d.

Reductions in brain volume (cortical tissue loss) increase over time 3.

Specific brain areas a.

Evidence of problems in the frontal and temporal lobes as well as neighboring (medial temporal) areas such as the amygdala, hippocampus, and thalamus b.

Not specific to schizophrenia and not all patients with schizophrenia show these differences c.

Abnormally low frontal lobe activity (hypofrontality) shown when patients engage in mentally challenging tasks; associated with negative symptoms d.

Left temporal lobe abnormalities may be linked with positive symptoms e.

Reduced volume of thalamus may prevent filtering out of irrelevant sensory information 4.

Cytoarchitecture a.

If cells fail to migrate properly, the organizational structure (cytoarchitecture) will be abnormal b.

Organization could also be disrupted during synaptic pruning and programmed cell death c.

Documented differences in neurons in prefrontal cortex, cortex, and hippocampus d.

Inhibitory neurons may also be missing 5.

Neurochemistry a.

Mental changes associated with LSD prompted interest in biochemical basis of schizophrenia b.

Dopamine hypothesis (1) Pharmacological action of Thorazine (2) Amphetamine-induced psychosis (3) Giving patients drugs that increase dopamine may create psychotic symptoms

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c.

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Dysregulated dopamine may make us pay more attention to and give more significance to stimuli that are not relevant or important—aberrant salience d.

Numerous ways a functional excess of dopamine might be created, including receptor supersensitivity e.

Dopamine cannot be measured directly in the functioning brain; study of metabolite homovanillic acid (HVA) f.

Research has uncovered no strong evidence that patients with schizophrenia are producing more dopamine than controls g.

Focus on receptor sensitivity; more D2 receptors in the postmortem brains of schizophrenics than controls; drugs used to treat schizophrenia increase postsynaptic receptor supersensitivity h.

Despite some mixed results, PET scans of those with schizophrenia who have never been treated with neuroleptics show an increase, or super density, of D2 receptor sites i.

Glutamate, excitatory neurotransmitter, may be implicated (1) PCP and ketamine blocks glutamate receptors, induces positive and negative symptoms (2) Postmortem brains of patients with schizophrenia have lower levels of glutamate in both the prefrontal cortex and the hippocampus 6.

Neurocognition a.

Numerous problems including reaction time, attention to a series, working memory, eye-tracking dysfunctions b.

P50— two clicks heard in close succession, brain produces a positive electrical response to each click; response to second click is less intense in control subjects; poor P50 suppression may be linked to problems with specific receptors in the hippocampus of the medial temporal lobe Psychosocial and Cultural Factors 1.

Do bad families cause schizophrenia? a.

Popular theories in the past including “schizophrenogenic mothers” and “double bind” have not been supported by evidence b.

Adverse family environments and communication deviance probably have little pathological consequence for the child that has no genetic risk for schizophrenia 2.

Families and relapse a.

Brown—highly emotional family environments might be stressful to patients; went on to develop and refine the concept of expressed emotion b.

EE has three main elements: criticism, hostility, and emotional overinvolvement

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c. d.

IV.

EE predicts relapse; lower EE, decreased relapse Possible that when stressed, cortisol releases and then triggers dopamine activity and release of glutamate, leading to relapse 3.

Urban living a.

Being reared in an urban environment increases risk of schizophrenia (2.75 times more likely) b.

Suggests environmental causes of some types of schizophrenia 4.

Immigration a.

Recent migrants have much higher risk of developing schizophrenia b.

First-generation migrants have 2.7 times the risk; secondgeneration migrants 4.5 times the risk c.

No evidence that this can be explained by cultural misunderstandings d.

Migrants with darker skin have a much higher risk of developing schizophrenia than do migrants with lighter skin; suggests that experiences of being discriminated against could lead some migrants to develop a paranoid and suspicious outlook, setting the stage for the development of schizophrenia e.

Research has found that healthy people who feel discriminated against are more likely to develop psychotic symptoms than healthy people who do not feel discriminated against 5.

Cannabis abuse a.

People with schizophrenia are twice as likely as people in the general population to smoke cannabis b.

Young men who were heavy cannabis users by age 18 were 6 times more likely to develop schizophrenia 27 years later c.

10. 3% of those who used cannabis by age 15 were diagnosed with signs of schizophrenia by age 26 d.

Using cannabis more than doubles a person’s chances of developing schizophrenia at a later stage of life e.

People who carry a particular variant of the COMT gene are at increased risk of developing psychotic symptoms in adulthood if they used cannabis during adolescence f.

Cannabis is thought to increase the synthesis of dopamine g.

Cannabis may also accelerate the progression of brain changes that accompany schizophrenia Treatments and Outcomes A. Clinical Outcome 1.

15 to 25 years after developing schizophrenia, about 38% have a favorable outcome; does not mean a return to premorbid functioning

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B.

C.

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2.

16% recover to the extent that they no longer need treatment 3.

12% need long-term institutionalization 4.

One third show signs of continued negative symptoms 5.

Spontaneous improvements late in life sometimes occur Pharmacological Approaches 1.

First-generation antipsychotics a.

Thorazine and Haldol; referred to as neuroleptics b.

Block the action of dopamine, primarily by blocking D2 receptors c.

Work best for positive symptoms d.

Common side effects include drowsiness, dry mouth, weight gain, extrapyramidal side effects (involuntary movement abnormalities such as muscle spasms, rigidity, shaking) e.

African Americans and other minorities at increased risk for extrapyramidal side effects f.

Tardive dyskinesia involves involuntary movements of the lips and tongue; females more susceptible g.

Neuroleptic malignant syndrome involves high fever and extreme muscle rigidity that can be fatal 2.

Second-generation antipsychotics a.

1980s—Clozapine (Clozaril) was the first; others include Risperdal, Zyprexa, Seroquel, Geodon, and Abilify b.

Cause fewer extrapyramidal symptoms c.

Decrease in both positive and negative symptoms d.

Believed to block a wider array of receptors including D4 receptors e.

Side effects include drowsiness, weight gain, diabetes, agranulocytosis (life-threatening drop in white blood cells) Psychosocial Approaches 1.

Family therapy a.

Goal is to reduce EE b.

Involves education, improving coping and problem-solving skills, enhancing communications skills, and clarifying family communication 2.

Case management 3.

Social-skills training 4.

Cognitive remediation a.

Cognitive problems that accompany schizophrenia limit how well they can function in the community b.

This treatment focuses on improving these cognitive deficits c.

Effective with improving attention, memory, executive functioning skills, and social functioning 5.

Cognitive-behavioral therapy

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Chapter 12· Schizophrenia and Other Psychotic Disorders

a.

V.

Goal is to decrease intensity of positive symptoms, reduce relapse, decrease social disability b.

Results promising 6.

Individual treatment a.

Psychodynamic treatments made some patients worse b.

Hogarty—personal therapy focused on coping techniques and skills has been very effective in enhancing social adjustment and social role performance Unresolved Issues: Can Schizophrenia Be Prevented?

A. Aim of primary prevention is to prevent new cases 1.

Better prenatal care 2.

Decrease or eliminate cannabis abuse in adolescents B. Secondary prevention intervenes with high risk groups 1.

Problems in identifying high-risk groups 2.

Controversy over appropriate interventions C. Tertiary prevention involves early treatment for those who already have schizophrenia

Key Terms antipsychotics (neuroleptics) (p. 409) brief psychotic disorder (p. 391) candidate genes (p. 396) catatonic schizophrenia (p. 389) cognitive remediation (p. 412) delusion (p. 385) delusional disorder (p. 391) disorganized schizophrenia (p. 388) disorganized symptoms (p. 387) dopamine (p. 402) endophenotypes (p. 396) expressed emotion (EE) (p. 406)

glutamate (p. 404) hallucination (p. 385) linkage analysis (p. 396) negative symptoms (p. 387) paranoid schizophrenia (p. 388) positive symptoms (p. 387) prodromal (p. 400) psychosis (p. 383) residual schizophrenia (p. 389) schizoaffective disorder (p. 390) schizophreniform disorder (p. 390) shared psychotic disorder (folie à deux) (p. 391) undifferentiated schizophrenia (p. 389)

Lecture Examples / Discussion Topics Lecture Launcher 12.1: Schizophrenia in Historical Perspective Schizophrenia was not adequately described until 1809, after which it seems to have appeared all over the Western world and to have increased rapidly over the next hundred years. Did schizophrenia not exist until about 200 years ago? What might be the implications of this? Are there any interpretations that might be offered? What historical events or phenomena might account for this curiously late origin? Is there a genetic mutation? Or perhaps a new virus (like HIV)? Might schizophrenia be a consequence of industrialization?

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Lecture Launcher 12.2: The Delusion Border Members of some groups believe things that might be viewed as delusional by contemporary diagnostic standards. Have students nominate examples of these. Alien abductees, various cults and quasi-religious groups, antigovernment militia members, and practitioners of fringe health techniques are possibilities. Are these people delusional?

What makes them different from hospitalized psychotics? Should they be receiving treatment as well? What is the role of mass media in some of these “delusions”?

Handout 12.2 Lecture Launcher 12.3: The Three Christs of Ypsilanti: A Psychological Study In The Three Christs of Ypsilanti: A Psychological Study (1964), psychologist Milton Rokeach described three patients at the Ypsilanti State Hospital, in Ypsilanti, MI, each of whom had the delusion that he was Jesus Christ. In an effort to learn about identity development, Rokeach thought it would be useful to get the three Christs together, to see how they negotiated the challenge of meeting another person claiming to be them.

Verbatim session transcripts, especially of the initial meetings, vividly illustrate the tenacity of delusional beliefs. A side note to this fascinating work is the recent discovery of Rokeach’s notes and audiotapes of the original sessions. There was some interest in reexamining these data in light of modern conceptualizations of schizophrenia and to elaborate upon this classic of descriptive psychopathology. However, protection of human subjects’ concerns were raised when it was realized that the original participants—the three Christs—did not consent to this use of the data. It has been suggested that once the three Christs have all died there may be legal ways to legitimately continue the study.

Lecture Launcher 12.4: Better Third-World Country Outcomes The rate of schizophrenia is quite stable cross-culturally, but the outcomes vary considerably. Surprisingly, it appears that schizophrenics in Third-World countries fare better than their counterparts in the West. This is surprising because Western medicine would appear to offer enormous advantages in technology, training, treatment options, and resources over what is available to schizophrenics in less-developed nations. Why do Third-World countries have more positive outcomes? Is it because of cultural advantages? More stable families? Or is it related to EE, insofar as people in underdeveloped countries might be less critical and rejecting of people suffering from psychosis? Are there other environmental factors that might account for the difference?

Lecture Launcher 12.5: Jeffrey Dahmer and Andrea Yates Serial killer Jeffrey Dahmer was widely held to suffer from paranoid schizophrenia but his bid for a not-guilty-by-reason-of-insanity verdict failed. Essentially, the jury accepted that he was schizophrenic but that he was still culpable for his behavior. Similarly, Andrea Yates, who drowned her five children in the bathtub, was purported to be schizophrenic by one of the court’s examining psychiatrists. She, too, was held accountable for her actions, failing an NGRI bid. Does this make sense to students? How can somebody be schizophrenic and in sufficient command of their mental capacities to be culpable for their actions? Crucial to the Dahmer trial was his attempt to cover his crimes, indicating he knew what he was doing was wrong, and his interactions with

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police, which showed his conduct was under his control. In the Yates case, her failure to seek the approval of others was seen as an indicator she knew her plan was wrong, and her waiting until she was alone with the children demonstrated she could control her actions. Should anyone who is schizophrenic have an automatic pass to NGRI out of criminal offenses? The definition of insanity is clearly spelled out in the law, and it will be reviewed in detail in chapter 15. For now, it suffices to explain that legal and psychiatric definitions of insanity are not isomorphic.

Demonstrations / Activities Activity 12.1: Erroneous Diagnostic Ideas Students may have faulty impressions concerning the diagnosis of different mental illnesses such as schizophrenia. Have students conduct surveys of other students concerning their perception of how schizophrenia may be diagnosed. Students often hear about chemical imbalances as a cause of depression and schizophrenia. Do they believe that medical testing, such as blood tests, can be used in the diagnosis process of schizophrenia?

Activity 12.2: Perceptual Predispositions Students often enjoy taking brief questionnaires that relate to some topic of the course.

The Attitudes about Reality Scale (Journal of Personality Assessment, 1989, vol. 53, pp.

353–365) is a forty-item measure that samples four conceptual domains. The instrument has been found to be a consistent measure of the influences on a person’s perception of reality. A person’s epistemology has a pervasive and important effect on interpersonal consequences. People distort reality to fit existing belief structures. This scale can provide students with some first-hand information on the factors that influence their possible distortion of reality. More extensively researched instruments include the Perceptual Aberration Scale (Schizophrenia Bulletin, vol. 6, pp. 639–653) and the Social Anhedonia Scale (Journal of Personality Assessment, vol. 56, pp. 84–95).

Activity 12.3: “The Disordered Monologue” Osberg (1992, Teaching of Psychology, vol. 19, pp. 47–48) wrote “The Disordered Monologue” as a means of demonstrating the bizarre quality of language and thought occasionally observed in people with schizophrenia. He recommends memorizing it and delivering it without any prior warning: Okay class, we’ve finished our discussion of mood disorders. Before I go on I’d like to tell you about some personal experiences I’ve been having lately. You see I’ve [pause] been involved in highly abstract [pause] type of contract [pause] which I might try to distract [pause] from your gaze [pause] if it were a new craze [pause] but the sun god has put me into it [pause] the planet of the lost star [pause] is before you know [pause] and so you’d better not try to be as if you were one with him [pause] always fails because one and one makes three [pause] and that is the word for thee [pause] which must be like the tiger after his prey

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[pause] and the zommon is not common [pause] it is a zommon’s zommon. [pause] But really class, [holding your head and pausing] what do you think about what I am thinking about right now? You can hear my thoughts can’t you? I’m thinking I’m crazy and I know you [point to a student] put that thought in my mind. You put that thought there! Or could it be that the dentist did as I thought?

She did! I thought she put that radio transmitter into my brain when I had the Novocaine! She’s making me think this way and she’s stealing my thoughts!

Affect is an important part of the presentation. Blunted and inappropriate affect are easily demonstrated. Loose associations, neologisms (“zommon”), perseveration (“no one is one . . . and any one who tries to be one . . . fails because one and one . . .”), and clanging (“makes three and that is the word for thee”) are all included as are disorders of thought content, including thought broadcasting, thought withdrawal, and delusions of control.

Osberg puts the text on an overhead to aid in the analysis of this confusing monologue.

Activity 12.4: A Beautiful Mind and John Nash The major motion picture A Beautiful Mind tells the story of Nobel Prize–winner John Nash, who suffers from schizophrenia. It would be perhaps indulgent to watch the entire movie in class, but a selection of segments could be very worthwhile. Make sure that students are aware that the film is not an entirely accurate portrayal either of schizophrenia or of John Nash. In particular, the film’s message that schizophrenia can be overcome through sheer effort of will and that medications are a hindrance requires clarification. The film also implies that visual hallucinations are prominent when, in fact, they are not and are in fact more prominent in other conditions (e.g., acute toxicity and withdrawal).

Activity 12.5: Antipsychotic Side Effects Whether or not to treat a psychotic person against his or her will often depends on the costs-to-benefits ratio of doing so or not. To prevent psychotic patients being treated against their will, civil rights attorneys will often present an impressive litany of drug side effects that make treatment objections appear quite rational. Students can pretend that they are clerks working for an attorney trying to argue a patient’s right to refuse treatment before a judge. Have them research the side effects of a variety of antipsychotic medications. Handout 12.1 Activity 12.6: The Eden Express The Eden Express (1975) is an autobiographical account of by Mark Vonnegut’s schizophrenic breakdown. It is a classic case study of the etiology and treatment of schizophrenia. As noted by Gorman (1984, Teaching of Psychology, vol. 11, pp. 39–40), although Vonnegut himself attributes his illness to biomedical factors, there is also evidence of behavioral, humanistic, and psychoanalytic contributions. Students can be asked to write a wide variety of different kinds of book reports based on The Eden Express. For instance, they could focus on treatment, phenomenology, etiology, or symptoms.

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Web Links Web Link 12.1: http://www.rootsweb.com/~asylums/ This Web site is an attempt to catalog and present some of America’s historic state hospitals. The site is searchable by state. There are many photos and historical descriptions, some of which might be of local interest.

Web Link 12.2: http://www.nami.org This Web site is sponsored by the National Alliance for the Mentally Ill. NAMI is a very influential nonprofit, grassroots, self-help, support and advocacy organization of consumers, families, and friends of people with severe mental illnesses such as schizophrenia, major depression, bipolar disorder, obsessive-compulsive disorder, and anxiety disorders.

Web Link 12.3: http://www.nmha.org The National Mental Health Association is the country’s oldest and largest nonprofit mental health organization. NMHA works to improve the mental health of all Americans, especially those with mental disorders, through advocacy, education, research, and service. Their schizophrenia “fact sheet” is very useful.

Web Link 12.4: http://www.mhselfhelp.org/ National Mental Health Consumers’ Self-Help Clearinghouse is a consumer-run mental health consumer movement that seeks to disseminate self-help and advocacy resources.

They also offer expertise to self-help groups and other peer-run services for mental health consumers.

Web Link 12.5: http://www.narsad.org The National Alliance for Research on Schizophrenia and Depression raises and distributes funds for scientific research into the causes, cures, treatments, and prevention of brain disorders, primarily the schizophrenias, depressions, and bipolar disorders.

Web Link 12.6: http://www.nimh.nih.gov/publicat/schizoph.cfm This site, sponsored by the National Institute of Mental health, provides detailed information on schizophrenia including symptoms, causes, treatments, and how to get help.

Video Resources Causation. Schizophrenia Series. Irvine, CA: Concept Media.

Clozaril Case Management. East Hanover, NJ: Sandoz Pharmaceuticals Corporation.

Delusional Disorder, Joe—Patient Interview Video for Abnormal Psychology (12th Ed.).

Allyn and Bacon Video Library.

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Effective Psychoanalytic Therapy of Schizophrenia and Other Severe Disorders. APA Psychotherapy Videotape Series I: Systems of Psychotherapy. Washington, DC: American Psychological Association.

First Break. Boston, MA: Fanlight Productions.

Inside Schizophrenia. Boston, MA: Fanlight Productions.

Losing the Thread: The Experience of Psychosis. New York, NY: Insight Media.

Madness. The Brain Series. South Burlington, VT: Annenberg/CPB Multimedia Collection.

Paranoia. Berkeley, CA: University of California Extension Center for Media and Independent Learning.

Pharmacotherapy of Schizophrenia—Treatments of Psychiatric Disorders Videotape Series. Allyn and Bacon Video Library.

Preventing Relapse in Schizophrenia. Princeton, NJ: Films for the Humanities and Social Sciences.

Psychotic Disorders. New York, NY: Insight Media.

Psychotic Disorders—DSM-IV: New Diagnostic Issues Videotape Series. Allyn and Bacon Video Library.

Reintegration in Chronic Schizophrenia. East Hanover, NJ: Sandoz Pharmaceuticals Corporation.

Schizoaffective Disorder, Allen—Patient Interview Video for Abnormal Psychology (12th Ed.). Allyn and Bacon Video Library.

Schizophrenia. Boston, MA: Fanlight Productions.

Schizophrenia. Princeton, NJ: Films for the Humanities and Social Sciences.

The Schizophrenias. The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection.

Schizophrenia and Bipolar Disorders. Psychotropic Medications: Caring for Patients with Psychiatric Disorders. Irvine, CA: Concept Media.

Schizophrenia and Delusional Disorders. Differential Diagnosis in Psychiatry Series.

Princeton, NJ: Films for the Humanities and Social Sciences.

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Schizophrenia and Depression. Princeton, NJ: Films for the Humanities and Social Sciences.

Schizophrenia: Etiology. The Brain Teaching Modules Video Series. South Burlington, VT: Annenberg/CPB Collection.

Schizophrenia, John—Patient Interview Video for Abnormal Psychology (12th Ed.). Allyn and Bacon Video Library.

Schizophrenia: New Definitions, New Therapies. Allyn and Bacon Video Library.

Schizophrenia: Out of Mind. Princeton, NJ: Films for the Humanities and Social Sciences.

Schizophrenia: Pharmacological Treatment. The Brain Teaching Modules Video Series.

South Burlington, VT: Annenberg/CPB Collection.

Schizophrenia: Symptoms. The Brain Teaching Modules Video Series. South Burlington, VT: Annenberg/CPB Collection.

Schizophrenia: The Voices Within, the Community Without. Princeton, NJ: Films for the Humanities and Social Sciences.

Shattered Dreams. Man Alive Series. Boston, MA: Fanlight Productions.

Spinning Out. New York, NY: The Cinema Guild.

Symptomatology. Schizophrenia Series. Irvine, CA: Concept Media.

Through Madness. New York, NY: Filmmakers Library.

Torment of Schizophrenia. Allyn and Bacon Video Library.

Understanding Movement Disorders: Medication Issues in Mental Health Series. Irvine, CA: Concept Media.

Understanding Schizophrenia. No More Shame: Understanding Schizophrenia, Depression and Addiction Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Unlocking the Secrets of Schizophrenia. Allyn and Bacon Video Library.

The Voices Within: Schizophrenia—#9 ABC News and Client Interviews. Allyn and Bacon Abnormal Psychology Video.

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Handout 12.1 Drug Side Effects

Whether or not to treat a psychotic person against his or her will often depends on a costs-to-benefits ratio. To prevent psychotic patients being treated against their will, civil rights attorneys will often present an impressive litany of drug side effects that make treatment objections appear quite rational. Pretend that you are a clerk working for an attorney trying to argue a patient’s right to refuse treatment before a judge. You have been asked to research the side effects of a variety of antipsychotic medications.

Summarize your findings in the following table: Antipsychotic Medication

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Side Effects

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Probability

Chapter 12· Schizophrenia and Other Psychotic Disorders

Handout 12.2 What Is Delusional?

1.

Can it be difficult to determine when a belief is delusional? Give some examples.

2.

When does jealousy in a relationship become delusional? What are the signs?

3.

What strongly held beliefs could be considered delusional by nonbelievers?

4.

How can a belief system be tested to determine if it is a sign of abnormal behavior?

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CHAPTER 13: Cognitive Disorders Chapter At-A-Glance Detailed Outline

Instructors’ Resources

Print Supplements

Media Supplements

Brain Impairment in Adults • Clinical Signs of Brain Damage • Diffuse versus Focal Damage • The Neuropsychology/ Psychopathology Interaction

Teaching Objectives 13.1–13.4 Chapter Guide Lecture Launchers 13.5 Activities 13.3 Web Links 13.2

Test Bank Grade Aid Transparencies T-106 to T-108

CD-ROM PowerPoint

Delirium • Clinical Picture • Treatments and Outcomes

Teaching Objectives 13.5 Chapter Guide Lecture Launchers 13.2 Activities 13.3 Web Links 13.4

Test Bank Grade Aid Transparencies T-106 to T-109

CD-ROM PowerPoint

Dementia • Parkinson’s Disease • Huntington’s Disease • Alzheimer’s Disease • Dementia from HIV-1 Infection • Vascular Dementia

Teaching Objectives 13.6, 13.7 Chapter Guide Lecture Launchers 13.1–13.5 Activities 13.1, 13.2, 13.4, 13.5 Web Links 13.3–13.5

Test Bank Grade Aid Transparencies T-106 to T-108, T-110, T-111

CD-ROM PowerPoint ABC Video Clip #11

Amnestic Disorder

Teaching Objectives 13.7 Chapter Guide Lecture Launchers 13.4 Activities 13.3 Web Links 13.2

Test Bank Grade Aid Transparencies T-106 to T-108

CD-ROM PowerPoint

Disorders Involving Head Injury • Clinical Picture • Treatments and Outcomes

Teaching Objectives 13.8 Chapter Guide Lecture Launchers 13.2 Activities 13.5 Web Links 13.1–13.3

Test Bank Grade Aid Transparencies T-106 to T-108

CD-ROM PowerPoint

Unresolved Issues: Can Dietary Supplements Enhance Brain Functioning?

Teaching Objectives 13.9 Chapter Guide Lecture Launchers 13.4 Activities 13.5 Web Links 13.5, 13.6

Test Bank Grade Aid Transparency T-111

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Professor Notes

Chapter 13 · Cognitive Disorders

Teaching Objectives 1.

2.

3.

4.

5.

6.

7.

8.

9.

Explain why the DSM-IV dropped the terms functional mental disorders and organic mental disorders.

Discuss diagnostic issues and clinical signs of brain damage.

Explain diffuse versus focal damage as it relates to brain impairment.

Describe how neuropsychology and psychopathology interact.

Define delirium in terms of clinical presentation and discuss clinical treatments and outcomes.

Define dementia and the three disorders presented: Alzheimer’s, dementia from HIV-1 infection, and vascular dementia. Include in your description the clinical picture, prevalence, genetic or environmental aspects, treatment outcomes, and effects on caregivers.

Explain how the clinical picture in amnestic syndrome differs from that found in dementia.

Describe the possible results of traumatic brain injury (TBI) and how TBI can occur.

Explain why the long-term consequences of TBI are so difficult to predict.

Discuss the research on the benefits of dietary supplements on brain functioning.

Chapter Overview / Summary The DSM-IV recognizes various cognitive disorders including delirium, dementia, and amnestic disorder. Typically, these disorders result from transient or permanent damage to the brain. Chronic neuropsychological disorders involve permanent loss of neural cells.

The primary causes of brain tissue destruction are many and varied; common ones include certain infectious diseases (such as the HIV-1 virus), brain tumors, physical trauma (injuries and alcohol), degenerative processes (as in Alzheimer’s disease), and cerebrovascular arteriosclerosis, often manifested as vascular dementia. There is no simple relationship between the extent of brain damage and degree of impaired functioning. Some people who have severe damage develop no severe symptoms, while others with slight damage have extreme reactions. Although such inconsistencies are not completely understood, it appears that an individual’s premorbid personality and life situation are important in determining his or her reactions to brain damage. The APOE-4 genetic allele may also be important.

Delirium is a fluctuating condition common among the elderly. It involves a state of awareness between wakefulness and stupor or coma. It is treated with medications such as neuroleptics and benzodiazepines, environmental manipulations, and family support.

Dementia involves a loss of function of previously acquired skills. It has a slow onset and a deteriorating course. At least 50 different disorders are known to cause dementia including Huntington’s Disease, Parkinson’s disease, strokes, infectious diseases such as syphilis, meningitis, and AIDS, intracranial tumors and abscesses, certain dietary deficiencies (especially of the B vitamins), severe or repeated head injuries, anoxia, and the ingestion or inhalation of toxic substances such as lead or mercury. The most common cause of dementia is Alzheimer’s disease. Age is a major risk factor for Alzheimer’s disease as well as other forms of dementia, such as vascular dementia. Genes play a major role in creating susceptibility and risk for Alzheimer’s disease. Genetic mutations of the APP, presenilin 1 and presenilin 2 genes are implicated in early-onset AD. The APOE-4 allele of the APOE gene is also a risk factor for AD. Interestingly, substantial numbers of MZ twins are discordant for AD suggesting that genetic susceptibility interacts with environmental factors. Environmental factors include diet, being overweight, having Type II diabetes, not being physically active, depression, exposure to metals such as aluminum, and experiencing head trauma. .

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The characteristic neuropathology of Alzheimer’s disease involves cell loss, senile plaques, and neurofibrillary tangles. Plaques contain a sticky protein called beta amyloid. Neurofibrillary tangles contain abnormal tau protein. Alzheimer’s disease causes a destruction of cells that make acetylcholine, a neurotransmitter important for memory. Drug treatments for AD include cholinesterase inhibitors such as donepezil (Aricept). These drugs help stop ACh being broken down and so make more of it available to the brain. Newer drug treatments include Namenda that appears to regulate glutamate and Memantine that appears to provide patients some cognitive benefits. Caregivers are also at high levels of stress and benefit from counseling and supportive therapy.

Amnestic disorders involve severe memory loss. The most common cause of amnestic disorders is chronic alcohol abuse. Head injuries can cause amnesia as well as other cognitive impairments.

Traumatic brain injuries (TBI) affect more than 2 million people each year and commonly occur as a result of a motor vehicle accident. Around 15% of soldiers who have served in Iraq have experienced a traumatic brain injury. The three types of TBI are: closed head injury, penetrating head injury, and skull fracture. Retrograde amnesia is the ability to recall events before the accident. Anterograde amnesia is the inability to remember things since the accident. 24% of TBI patients develop post-trauma epilepsy. Prompt medical treatment may prevent further damage. Long-term treatment may be difficult and expensive requiring repeated neuropsychological assessment and the design of specific interventions to overcome the deficits that remain.TBI patients may also benefit from treatment with donepezil.

Detailed Lecture Outline I.

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Brain Impairment in Adults A. Clinical Signs of Brain Damage 1.

For most part, cell bodies and neural pathways do not regenerate 2.

Impairment may involve acquired and customary skills or capacity for realistic self-appraisal (anosognosia) 3.

Impairment depends on a.

Nature, location, and extent of neural damage b.

Premorbid competence and personality of the individual c.

Individual’s life situation d.

Amount of time since the first appearance of the condition B. Diffuse versus Focal Damage 1.

Attention is often impaired by mild to moderate diffuse damage, such as might be expected with moderate oxygen deprivation or the ingestion of toxic substances 2.

Focal brain lesions are circumscribed areas of abnormal change in the brain with a number of possible consequences 3.

Relationships between brain location and behavior can never be considered universally true, however: a.

Damage to frontal areas can result in one of two patterns (1) Behavioral inertia, passivity, apathy, and perserverative thought (2) Impulsiveness and distractibility b.

Damage to right parietal lobe may produce impairment of visual-motor coordination c.

Damage to left parietal area may impair language, including reading and writing, as well as arithmetical abilities d.

Damage to certain structures within temporal lobes disrupts memory storage; extensive bilateral temporal lobe damage can result in no new memories being able to be stored; damage to other structures within temporal lobe can lead to disturbances of eating, sexuality, and emotions .

Chapter 13 · Cognitive Disorders

e.

II.

III.

Occipital damage produces a variety of visual impairments and visual association deficits C. The Neuropsychology/Psychopathology Interaction 1.

Most people with a neuropsychological disorder do not have psychopathological symptoms 2.

Psychopathological symptoms not always predictable Delirium A. Clinical Picture 1.

Delirium is an acute confused state with a sudden onset and a fluctuating state of awareness 2.

Commonly find cognitive changes such as impaired information-processing, hallucinations, delusions, abnormal psychomotor activity (wild thrashing), disturbances of the sleep cycle 3.

May result from head injury, infection, drug intoxication, drug withdrawal, drug toxicity B. Treatments and Outcomes 1.

Medical emergency—must identify and treat underlying cause 2.

Most cases are reversible 3.

Treatment involves medications (neuroleptics or benzodiazepines for drug withdrawal), environmental manipulations such as orienting techniques (calendars, staff prompting, night lights), and family support Dementia A. Parkinson’s Disease 1.

Second most common neurogenerative disorder 2.

More common in men than women 3.

Characterized by motor symptoms such as tremors or rigid movements 4.

Underlying cause is loss of dopamine neurons in a certain area of the brain 5.

About 75% will develop dementia may develop later in the disease 6.

Those who smoke are less likely to develop Parkinson’s disease 7.

Symptoms temporarily relieved by medications B. Huntington’s Disease 1.

Rare degenerative disorder 2.

Mean age of onset is 40; affects men and women equally 3.

Characterized by a chronic, progressive chorea (involuntary and irregular movements that flow randomly from one area of the body to another) 4.

Eventually develop dementia 5.

Death typically occurs within 10 to 20 years of first symptoms 6.

Caused by an autosomal dominant gene on chromosome 4 A. Alzheimer’s Disease (AD) 1.

Clinical picture a.

Diagnosis based on clinical assessment but can only be confirmed after death b.

Usually begins after age 45 c.

Gradual and slow mental deterioration is seen with multiple cognitive deficits d.

First sign may be withdrawal from active engagement with life followed by more self-centered and child-like thoughts and activities including a preoccupation with functions of eating, digestion, and excretion; as symptoms become more severe may see impaired memory for recent .

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2.

3.

250

events, “empty” speech, messiness, impaired judgment, agitation, and periods of confusion e.

Delusions (paranoid and jealous) and a combative pattern occur in some patients f.

Death usually comes from lowered resistance to opportunistic infections Prevalence a.

1–2% of population between 65 and 74; about 30% of population over 85 b.

Problem grows in magnitude with increasing life span c.

Women have a slightly higher risk d.

Those who report loneliness have twice the risk of developing Alzheimer’s e.

Lower rates in Japan, Nigeria, and India suggesting role of high-fat, highcholesterol diet f.

High levels of an amino acid homocystine increases risk for AD and heart disease Causal Factors a.

Early-onset Alzheimer’s disease (1) Progression very rapid (2) Have identified three rare genetic mutations that can cause this (about 5% of cases) (a) Mutated APP gene on chromosome 21 (b) Mutated PS1 (presenilin 1) gene on chromosome 14 (c) Mutated PS2 (presenilin 2) gene on chromosome 1 b.

Late-onset Alzheimer’s disease (1) APOE (apolopoprotein) gene on chromosome 19 (a) Three alleles identified (b) APOE-E4 significantly enhances risk for late-onset AD (c) APOE-E2 protects against late-onset AD (d) APOE-E4 can be detected by blood test (e) Only 55% of those with two APOE-E4 alleles had developed AD by age 80 (2) Substantial numbers of MZ twins are discordant for AD (3) Genetic susceptibility thought to interact with environmental factors (4) Environmental factors include diet, being overweight, having Type II diabetes, depression, not being physically active, exposure to metals such as aluminum, and experiencing head trauma (5) Exposure to ibuprofen and engaging in mentally stimulating activities may be protective c.

Neuropathology (1) Amyloid plaques (a) Contain a sticky substance called beta amyloid (b) Believed that an accumulation of this substance causes plaques (c) Beta amyloid is neurotoxic (2) Neurofibrillary tangles (a) Webs of abnormal filaments within a nerve cell made up of a protein called tau (b) Tau may be caused by accumulation of beta amyloid .

Chapter 13 · Cognitive Disorders

(3)

IV.

Atrophy (a) Loss of cells (b) Leads to reduction in acetylcholine activity 4.

Treatment and outcome a.

No effective treatment exists b.

Behavioral techniques attempt to control wandering, incontinence, inappropriate sexual behavior, and poor self-care behaviors c.

Medications such as tacrine (Cognex) and donepezil (Aricept) that inhibit the production of acetylcholinesterase thereby increasing the availability of acetylcholine d.

Newest medication is Namenda that appears to regulate glutamate e.

Despite setbacks, continuing to work on developing vaccines f.

Prevention is needed 5.

Treating caregivers a.

Extremely stressful b.

Caregivers are at high risk for developing depression c.

Providing caregivers with counseling and support has proven effective B. Dementia from HIV-1 Infection 1.

Presence of the HIV-1 virus could itself result in the destruction of brain cells 2.

May lead to the emergence of psychotic phenomena 3.

Virus causes generalized atrophy, edema, inflammation, and patches of demyelination 4.

Damage may occur throughout brain but seems to be localized in subcortical regions, notably the white matter, the tissue surrounding the ventricles, and deeper gray matter structures such as the basal ganglia and thalamus 5.

With current antiretroviral treatment, the rate reduces to 10% C. Vascular Dementia (multi-infarct dementia) 1.

A similar clinical picture to Alzheimer’s exists, although a more varied early picture 2.

Series of circumscribed cerebral infarcts cumulatively destroy neurons over expanding brain regions 3.

Tends to occur after 50; more common in men 4.

Accounts for only about 19% of all dementia cases; patients are more vulnerable to sudden death from stroke or cardiovascular event 5.

Accompanying mood disorders more common than in AD 6.

Cerebral arteriosclerosis can be medically managed to some extent Amnestic Disorder A. Central feature is strikingly disturbed memory or amnesia 1.

Immediate recall and memory for remote events usually preserved 2.

Short-term memory typically very impaired 3.

Confabulation common B. Overall cognitive functioning may remain relatively intact C. Root cause of brain damage in Korsakoff’s syndrome typically chronic alcohol use with its associated deficiency in vitamin B1 D. Other causes include head trauma, stroke, surgery in the temporal lobe, hypoxia, brain infections E. Depending on cause, may abate wholly or partially

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V.

VI.

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Disorders Involving Head Injury A. Clinical Picture 1.

Occurs frequently, affecting more than 2 million people each year in the U.S. 2.

Most common cause is motor vehicle accidents followed by falls, violent assaults, and sports injuries 3.

Currently experiencing escalation of cases; 15% of soldiers who served in Iraq have experienced a traumatic brain injury 4.

Men aged 15–24 are at greatest risk 5.

Three types of injury are distinguished a.

Closed head b.

Penetrating c.

Skull fracture 6.

Immediate acute reactions such as unconsciousness and disruption of circulatory, metabolic, and neurotransmitter regulation 7.

Retrograde and anterograde amnesia are commonly seen 8.

Person typically passes through stupor and confusion on the way to recovering clear consciousness 9.

Coma may occur 10.

Presence of the APOE-E4 allele is a risk factor for increased problems after a brain injury 11.

Phineas Gage B. Treatments and Outcomes 1.

Prompt medical care is required 2.

The majority suffering mild concussion improve quickly 3.

24% of TBI cases develop post-traumatic epilepsy, presumably because of the growth of scar tissue in the brain 4.

In a minority of cases, dramatic personality change occurs 5.

Children with severe traumatic brain injury are more likely to be adversely affected the younger they are 6.

Severe injury cases have a poor prognosis 7.

Recent evidence suggests that patients with TBI may benefit from treatment with donepezil, an acetylcholinesterase inhibitor Unresolved Issues: Can Dietary Supplements Enhance Brain Functioning?

A. Gingko biloba (derived from the leaves of the gingko tree) widely used to improve memory 1.

Oken and colleagues (1998) found that AD patients who received gingko performed better cognitively than patients who took placebo; results similar to when patients took donepezil 2.

More recent study (2000) failed to find any effects 3.

Gold and colleagues (2002) support Oken’s study; however, gingko found to slow reaction times B. Other cognitive enhancers?

1.

Phosphatatidylserine (PS) has been recommended for memory but findings are inconsistent and minimal 2.

Those with higher levels of B12 has been associated with less brain atrophy in one study; too soon to know if this will translate into beneficial effect of taking more B12

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Chapter 13 · Cognitive Disorders

Key Terms Alzheimer’s Disease (p. 425) amnestic disorder (p. 431) amyloid plaques (p. 428) anterograde amnesia (p. 433) APOE-E4 allele (p. 427) delirium (p. 422) dementia (p. 423) early-onset Alzheimer’s disease (p. 427) functional mental disorders (p. 419) HIV-associated dementia (p. 430)

Huntington’s disease (p. 425) Korsakoff’s syndrome (p. 432) late-onset Alzheimer’s disease (p. 427) neurofibrillary tangles (p. 428) organic mental disorders (p. 419) Parkinson’s disease (p. 424) retrograde amnesia (p. 433) traumatic brain injury (TBI) (p. 432) vascular dementia (VAD) (p. 431)

Lecture Examples / Discussion Topics Lecture Launcher 13.1: Caregiver Strain To give a clear picture of the costs associated with Alzheimer’s disease, a lecture can be designed to show the various needs of the patients. An article by Albert, Sano, Merchant, and Stern (1998) provides a detailed account of the hours spent caring for Alzheimer’s disease patients (Gerontologist, vol. 38, pp.

704–714). A breakdown of formal and informal care required can be presented to the students. As the disease progresses, students can be shown the shift of services toward the formal type.

Lecture Launcher 13.2: Behavior Therapy Although cognitive disorders are often of organic etiology, there is still a substantial role for behavior therapies. A number of reports suggest that operant programs can be instituted to improve or maintain basic self-care, family interaction, and compliance with medical regimens. Dementia-related depression has also been shown to respond to behaviorally programmed pleasant event scheduling. Students benefit from learning about environmental approaches to treating essentially organic disorders. It combats the otherwise nihilistic view they can adopt toward what appears to be an irreversible condition.

Lecture Launcher 13.3: Would You Take the Test?

Presently, there is no diagnostic test for the presence of Alzheimer’s dementia, so it is quite futuristic to imagine a test that could predict Alzheimer’s disease, say via genetic assays. That makes what follows an entirely academic exercise, but where are academic exercises more appropriate than here? The question, and it actually could be raised in the context of many of the disorders covered in this class, concerns whether students would want to be tested for disorders they may later experience or whether they would prefer not to know. If students are slow to warm up to the discussion, they can be given some distance from the question by asking not what they would do but rather what are the arguments that could be made for and against getting the test(s). Alternatively, ask students to consider if they would want their unborn child tested for psychological disorders, allowing for the possibility of an abortion, if such testing was available.

Lecture Launcher 13.4: Life without Memories What would it be like to lose many or even all of your memories? This is a poignant question that in many ways gets to the heart of what it means to be who you are. Why doesn’t each day start completely fresh, a blank slate upon which you start from scratch, becoming someone new? How would you answer questions about who you are if not for your recollections about what you have done? Would it be better to lose all memory or just partial memories? Would awareness of the loss be as bad as the loss itself?

What would it be like to learn about an extensive episode from your life now, about which you have no memory whatsoever? How about meeting someone with whom it is clear you once had a close .

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relationship but of whom you have no recollection? If you had to rely on notes to yourself to remind you of who you are and what you are about as a person, what would you write down?

Lecture Launcher 13.5: Demographic Trends The fastest growing segment of society is the elderly, particularly people in their 80s and beyond. What are the consequences of this trend for society, the healthcare system, and family life? Should younger people undertake larger roles in caring for the elderly? How could that be accomplished? How can society adjust so that older people can become more of a resource than a drain on resources? How do other cultures handle this issue?

Demonstrations / Activities Activity 13.1: Living with People Who Have Alzheimer’s Students can be encouraged to share any personal experiences they have had with relatives who demonstrated disorders such as Alzheimer’s disease. How did the family deal with the disorientation and memory impairment of the older person? What major problems developed in the family when the disorder was obvious? Was institutionalized care called for? How did that affect the family? How was the decision made whether or not to institutionalize the person? How was the problem first evidenced?

What kinds of treatment were used? What effect did these treatments have? Handout 13.1 Activity 13.2: Mini-Mental Status Examination Students can be shown the Mini-Mental Status Examination, which was developed by Folstein, Folstein, and McHugh (1975, Journal of Psychiatric Research, vol. 12, pp. 186–198). This instrument is commonly used in the assessment of dementia. The examination can be demonstrated in class as a way to review the various impairments suffered by an Alzheimer’s disease victim.

Activity 13.3: Class Trip to Nursing Home Try to arrange a class trip to a nursing home that cares for people with organic brain syndrome.

Alternatively, students could serve as volunteers for at least one day to interact with the residents. What are the major problems that members of the nursing home staff have in caring for persons with such conditions as Alzheimer’s disease? Handout 13.2 Activity 13.4: Early Signs of Dementia Students may be surprised to learn that early intervention can influence the outcome of Alzheimer’s and other types of dementia. However, achieving these benefits requires early recognition of the signs of dementia. Rather than simply telling students what these signs are, assign them the task of researching them on their own. This assures that they will be able to effectively obtain high quality information at the time it becomes more relevant to them, perhaps as their parents age.

Activity 13.5: Memory Aids People with Alzheimer’s and other types of dementia benefit from using various memory aids. Ask students to research these and to report their findings to the class for discussion. Are memory aids for people with dementias designed specifically for the deficits characteristic of these disorders, or are they general purpose memory aids that address a variety of memory problems, not necessarily those characteristic of dementias? What specific memory problems ought to be addressed? What types of things, along the lines of the memory aids currently available, would be most relevant to those with dementias of various sorts? Is memory something that can be improved with use or weakened with disuse? You may also wish to ask students to consider memory aids that they use such as notes in class, various items on the refrigerator, clocks, PDAs, etc.

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Web Links Web Link 13.1: http://www.nichcy.org/pubs/factshe/fs18txt.htm This site, sponsored by the National Dissemination Center for Children with Disabilities (NICHCY), provides a brief case of a child with a TBI, answers to frequently asked questions about TBI, information about TBI for parents and teachers, and information about TBI organizations.

Web Link 13.2: http://www.neuroskills.com/index.shtml?main=/tbi/injury.html This information-packed site, sponsored by the Center for Neuro Skills, provides detailed information, useful maps of the brain, and even video clips of what happens to the brain during various events such as a concussive impact and coup-contra-coup injuries.

Web Link 13.3: http://www.neurologychannel.com/dementia/ A brief but informative summary of information about dementia including types, risk factors, causes, symptoms, diagnosis, and treatment.

Web Link 13.4: http://www.merck.com/pubs/mm_geriatrics/sec5/ch40.htm Overview and fact sheet on dementia from the Merck Medical Manual.

Web Link 13.5: http://www.alzheimers.asn.au/index.php Latest information on dementia, drug trials, research, support, and education.

Web Link 13.6: http://www.hsph.harvard.edu/nutritionsource/vitamins.html This site, created by the Harvard School of Public Health, provides current information on which vitamins our bodies need and how these vitamins are used by the body.

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Video Resources Advancements in Neurology and Neurosurgery. Allyn and Bacon Video Library.

Advancements in Traumatic Brain Injury. Princeton, NJ: Films for the Humanities and Social Sciences.

Alzheimer’s: A True Story. Allyn and Bacon Video Library.

Alzheimer’s: Effects on Patients and Their Families. Princeton, NJ: Films for the Humanities and Social Sciences.

Alzheimer’s: The Tangled Mind. Allyn and Bacon Video Library.

Alzheimer’s Disease. Boston, MA: Fanlight Productions.

Alzheimer’s Disease. The Brain Teaching Modules Video Series. South Burlington, VT: Annenberg/CPB Collection.

Alzheimer’s Disease: The Long Nightmare. Princeton, NJ: Films for the Humanities and Social Sciences.

Alzheimer’s Disease: How Families Cope. The Doctor Is in Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Alzheimer’s Mystery. Allyn and Bacon Video Library.

Characteristics and Behavior. The Cognitively Impaired Geriatric Patient Series. Irvine, CA: Concept Media.

Code Gray: Ethical Dilemmas in Nursing. Boston, MA: Fanlight Productions.

Dementia: Putting Together the Pieces of the Puzzle. Sherborn, MA: Aquarius Health Care Videos.

Early Alzheimer’s Disease—#10 ABC News and Client Interviews. Allyn and Bacon Abnormal Psychology Video.

Elderly Suicide. Princeton, NJ: Films for the Humanities and Social Sciences.

Forget Me Never. New York, NY: Filmmakers Library.

“He’s Doing This to Spite Me:” Emotional Conflicts in Dementia. Chicago, IL: Nova Films.

Impact of Disorders and Trauma on the Brain. Allyn and Bacon Video Library.

Intelligence. New York, NY: Insight Media.

IQ Testing and the School. New York, NY: Insight Media.

Lost in the Mind. Sherborn, MA: Aquarius Health Care Videos.

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Organic Disorders. Differential Diagnosis in Psychiatry Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Organic Mental Disorders. The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection.

A Prescription for Caregivers: Take Care of Yourself. Chicago, IL: Nova Films.

Recognizing and Responding to Emotion in Persons with Dementia. Chicago, IL: Nova Films.

Someone I Love Has Alzheimer’s Disease. Boston, MA: Fanlight Productions.

Something Should Be Done About Grandma Ruthie. Boston, MA: Fanlight Productions.

Understanding Alzheimer’s Disease—Vol. 19, The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection.

When the Mind Fails: A Guide to Alzheimer’s Disease. Allyn and Bacon Video Library.

You Must Remember This: Inside Alzheimer’s Disease. New York, NY: Filmmakers Library.

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Handout 13.1 Family and Alzheimer’s

Many people have had some experiences with a family member who developed Alzheimer’s disease.

Interview such a person to determine the impact of the disease on family members.

Relationship to the Patient:

Quality of Interactions:

Behaviors Observed:

Reactions of Immediate Family:

Reactions of Extended Family:

Reactions of Community:

Interactions with Medical Providers:

Interactions with Nursing Home Staff:

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Handout 13.2 Nursing Homes

From your visit to a nursing home, describe your reactions to the setting and to the services in the following categories:

Physical Characteristics:

Quality of the Environment:

Extent of Services Provided:

Characteristics of the Residents:

Personnel at the Facility:

Training Required for Employment:

Improvements Needed:

Activities for Residents:

Daily Routine for Residents:

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CHAPTER 14: Disorders of Childhood and Adolescence Chapter At-A-Glance Detailed Outline

Instructors’ Resources

Print Supplements

Media Supplements

Maladaptive Behavior in Different Life Periods • Varying Clinical Pictures • Special Psychological Vulnerabilities of Young Children • The Classification of Childhood and Adolescent Disorders

Teaching Objectives 14.1, 14.2 Chapter Guide Lecture Launchers 14.1, 14.2, 14.5 Activities 14.1, 14.5 Web Links 14.1, 14.3

Test Bank Grade Aid Transparency T-98

CD-ROM PowerPoint

Common Disorders of Childhood • Attention-Deficit/ Hyperactivity Disorder • Oppositional Defiant Disorder and Conduct Disorder

Teaching Objectives 14.3, 14.4 Chapter Guide Lecture Launchers 14.1, 14.2, 14.3, 14.4, 14.5 Activities 14.1, 14.3, 14.4, 14.5 Web Links 14.1, 14.3, 14.4, 14.5

Test Bank Grade Aid Transparencies T-91 to T-92, T97 to T-98

CD-ROM PowerPoint ABC Video Clip #12

Anxiety and Depression in Children and Adolescents • Anxiety Disorders of Childhood and Adolescence • Childhood Depression and Bipolar Disorder

Teaching Objectives 14.5, 14. 6 Chapter Guide Lecture Launchers 14.3, 14.4, 14.5 Activities 14.1, 14.5 Web Links 14.1, 14.2, 14.3, 14.4

Test Bank Grade Aid Transparencies T-91 to T-92, T97 to T-98

CD-ROM PowerPoint ABC Video Clip #12

Pervasive Developmental Disorders • Autism • Asperger’s Disorder

Teaching Objectives 14.7 Chapter Guide Lecture Launchers 14.3, 14.4, 14.5 Activities 14.1,14.5 Web Links 14.1, 14.3, 14.4, 14.6

Test Bank Grade Aid Transparencies T-91 to T-92, T97 to T-98

CD-ROM PowerPoint ABC Video Clip #12

Learning Disabilities and Mental Retardation • Learning Disabilities • Causal Factors in Learning Disabilities • Treatments and Outcomes • Mental Retardation • Causal Factors in Mental Retardation • Organic Retardation Syndromes • Treatments, Outcomes, and Prevention

Teaching Objectives 14.8– 14.10 Chapter Guide Lecture Launchers 14.3, 14.5 Activities 14.1 Web Links 14.3, 14.4

Test Bank Grade Aid Transparencies T-96 to T-98

CD-ROM PowerPoint

Planning Better Programs to Help Children and Adolescents • Special Factors Associated with Treatment of Children and Adolescents • Child Advocacy Programs

Teaching Objectives 14.11, 14.12 Chapter Guide Lecture Launchers 14.1, 14.2, 14.4, 14.5 Activities 14.1, 14.2 Web Links 14.1, 14.3

Test Bank Grade Aid Transparency T-98

CD-ROM PowerPoint

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Professor Notes

Chapter 14 · Disorders of Childhood and Adolescence Unresolved Issues: Can Society Deal with Delinquent Behavior?

Teaching Objectives 14.13 Chapter Guide Lecture Launchers 14.3 14.1 Activities 14.5 Web Links 14.1, 14.5

Test Bank Grade Aid Transparency T-98

CD-ROM PowerPoint

Teaching Objectives 1)

2) 3)

4)

5) 6)

7) 8) 9) 10) 11) 12) 13)

List special features of childhood disorders that make them different from adult disorders, and describe how young children are especially vulnerable to developing psychological problems.

Discuss general issues in the classification of childhood and adolescent disorders.

Describe the characteristic behaviors of a child with attention-deficit/hyperactivity disorder. Outline the best explanations as to what might cause this disorder and the most effective way to treat it.

Describe the characteristics of children with conduct disorder and oppositional defiant disorder. Explain how these disorders arise, why having oppositional defiant disorder may make a child more likely to develop conduct disorder, and what happens to these children in the long run.

Describe the characteristics of each of the anxiety disorders. Explain the causal factors identified for these disorders and the most effective treatments.

Describe the clinical features, causal factors, and treatment of childhood depression.

Describe the concerns you might have as a parent if your adolescent was prescribed antidepressants, such as an SSRI, for a depressed episode.

Describe the clinical features, causal factors, and treatment of autism.

Describe the clinical features, causal factors, and treatment of learning disabilities.

Explain the four levels of mental retardation and describe the functioning associated with each level.

List and explain mental retardation stemming from biological causes, especially Down syndrome, PKU, and cranial anomalies.

List and explain six special factors that must be considered in relation to treatment for children.

Describe the need for mental health services for children, and review the difficulties with recent efforts to increase the available resources.

Discuss delinquency as a major societal problem, summarize the many causal factors involved in delinquency, and describe different ways that society deals with delinquency.

Chapter Overview / Summary Children used to be viewed as “miniature adults.” It was not until the second half of the twentieth century that a diagnostic classification system focused clearly on the special problems of children. In this chapter, the DSM-IV-TR classification system is followed to provide clinical descriptions of a wide range of childhood behavior problems. A child’s behavior cannot be considered abnormal without determining whether the behavior in question is appropriate for the child’s age.

Attention-deficit/hyperactivity disorder is one of the more frequent behavior problems of childhood. In this disorder, children show impulsive, overactive behavior that interferes with their ability to accomplish tasks. The major approaches to treating hyperactive children have been medication and behavior therapy. Using medications such as amphetamines (Ritalin) with children reduces, in the shortterm, aggressive behavior, hyperactivity, and distractibility while increasing alertness. Newer

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medications include Pemoline that enhances cognitive processing and Strattera. Long-term studies of these medications are less positive with problematic side effects and as association with recreational use of stimulants. Behavior therapy, particularly cognitive-behavioral methods, has been shown to be effective in modifying the behavior of hyperactive children; combining the two approaches demonstrates efficacious results.

In oppositional defiant disorder, children repeatedly engage in negativistic, defiant, disobedient, and hostile behavior toward authority figures. Many children will progress to conduct disorder. In conduct disorder, a child engages in persistent aggressive or antisocial acts. A number of potential causes of conduct disorder or delinquent behavior have been determined, ranging from biological factors to personal pathology to social conditions. Children who develop conduct disorder at a young age are more likely to develop antisocial personality disorder. Punitive approaches to these disorders—the approaches most common in our society—seem to intensify rather than correct the behavior. Focusing on dysfunctional family patterns seems to hold more promise.

Children who suffer from anxiety disorders typically do not cause difficulty for others through their conduct. Rather, they are fearful, shy, withdrawn, insecure, and have difficulty adapting to outside demands. The anxiety disorders may be characterized by extreme anxiety, withdrawal, or avoidance behavior. Common anxiety disorders include separation anxiety disorder and selective mutism. A likely cause for these disorders is early family relationships that generate anxiety and prevent the child from developing more adaptive coping skills. Behavioral and cognitive-behavioral approaches have proven effective for treating anxiety disorders.

Childhood depression shares many of the same characteristics as adult depression although children may exhibit more irritability. Multiple factors, including biological and learning, may cause depression in children and adolescents. Treatment may include antidepressants or cognitive-behavioral therapy. Antidepressant use with children and adolescents remains controversial due to the reported side effects, only moderate efficacy, and the potential for increasing the chance for suicide.

Diagnoses of bipolar disorder in children and adolescents have been increasing in the United States.

Autism and Asperger’s disorder are classified as pervasive developmental disorders in the DSMIV-TR. In autistic children, extreme maladaptive behavior occurs during the early years and prevents affected children from developing psychologically. A precise cause for autism has not been identified but most investigators believe there is an inborn deficit in perceptual-cognitive functioning. Treatment with medications has not been able to normalize the behavior of autistic children. Newer instructional and behavior-modification techniques such as those documented by Lovaas have been found helpful in autism. In Asperger’s disorder, some of the same social impairments seen in autism are present but there is no language delay or delays in self-help skills and symptoms appear much later.

Specific learning disabilities are those in which failure of mastery is limited to circumscribed areas, chiefly involving academic skills such as reading; general cognitive ability may be normal or superior. Affected children are commonly described as learning disabled (LD). Some localized defect in brain development is often considered the primary cause of the disorder. Learning disorders create great turmoil and frustration in victims and their families, schools, and professional helpers. Most research is focused on subtle central nervous system impairments as the causal factors for learning disabilities. Few well designed treatment studies have been published.

Mental retardation is diagnosed when significant subaverage cognitive functioning is accompanied by deficits in adaptive functioning before the age of 18. Four levels of mental retardation are defined in the DSM-IV-TR: mild, moderate, severe, and profound. Relatively common forms of such mental retardation, which in these cases is normally at least moderate in severity, include Down syndrome, phenylketonuria (PKU), and certain cranial anomalies. This organic type of mental deficit accounts for only some 25 percent of all cases of mental retardation. Mental retardation diagnoses, regardless of the underlying origins of the deficit condition, are coded on Axis II of DSM-IV-TR. 262

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A number of potential causal factors were considered for the disorders of childhood and adolescence. Although genetic predisposition appears to be important in several disorders, parental psychopathology, family disruption, and stressful circumstances, such as parental death or desertion and child abuse, can have an important causal influence. Recent research has underscored the importance of multiple risk factors in the development of psychopathology.

There are special problems and special opportunities involved in treating childhood disorders.

The need for preventive and treatment programs for children is always growing, and in recent years, the concept of child advocacy has become a reality in some states. Unfortunately, the financing and resources necessary for such services are not always readily available, and the future of programs for improving psychological environments for children remains uncertain. Juvenile delinquency is a growing problem that impacts millions of children and their families each year.

Detailed Lecture Outline I.

Maladaptive Behavior in Different Life Periods A. Varying Clinical Pictures 1.

Childhood disorders differ from those in other life periods 2.

Some emotional disturbances in childhood are short-lived 3.

Results of one study found that those children who had been psychiatrically hospitalized (between 5 and 12) showed twice the mortality due to unnatural causes (suicide common) at follow-up four to fifteen years later B. Special Psychological Vulnerabilities of Younger Children 1.

Children have a limited capacity to understand problems 2.

More difficulty coping as cannot put problems into perspective of a past and future 3.

Use unrealistic concepts to explain things 4.

Children are dependent on others for help 5.

Lack of experience may make problems seem unmanageable C. The Classification of Childhood and Adolescent Disorders 1.

No formal classification system for children until the 1950s a.

Childhood schizophrenia b.

Adjustment reaction of childhood 2.

DSM-II (1968) added additional disorders but problems remained a.

Inadequacies stemmed from using adult models of pathology b.

The developmental level of a child was ignored c.

The influences of the environment were not discussed

II.

Common Disorders of Childhood A. Attention-Deficit/Hyperactivity Disorder 1.

The clinical picture in attention-deficit hyperactivity disorder a.

Difficulties that interfere with effective task-oriented behavior— impulsivity, excessive or exaggerated motor activity, sustaining attention b.

Usually 7 to 15 points lower in IQ c.

Social problems d.

Prevalence is thought to be 3–5% of school-aged children e.

Six to nine times more prevalent among preadolescent boys than girls 2.

Causal factors in attention-deficit/hyperactivity disorder a.

Considered to have multiple biological and psychological causes

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b.

B.

264

General agreement that there are processes operating in the brain that disinhibit the child’s behavior 3.

Treatment and Outcomes a.

Cerebral stimulants are widely used in treatment; Ritalin quite common b.

Newer drugs include Pemoline and Strattera c.

Long-term effects of these drugs are less well known; some concern has been raised about the development of psychotic symptoms and abuse potential d.

Behavior techniques using selective reinforcement, family therapy, positive reinforcement, and structuring of learning materials have been successful 4.

ADHD beyond adolescence a.

Development of aggressive behavior and substance abuse in some cases b.

25% of ADHD children never finish high school Oppositional Defiant Disorder and Conduct Disorder 1.

Clinical picture in oppositional disorders a.

Precursor of antisocial behavior b.

Recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures c.

Usually begins by age 8 d.

Developmental sequence from oppositional to conduct e.

Risk factors of family discord, socioeconomic disadvantage, and antisocial behavior in the parents 2.

The clinical picture in conduct disorders a.

Persistent repetitive violation of rules and a disregard for the rights of others; also show a deficit in social behavior b.

Frequently comorbid for substance abuse 3.

Causal factors in oppositional disorder and conduct disorder a.

A self-perpetuating cycle (1) Genetic predisposition leading to low verbal intelligence, mild neuropsychological problems, and difficult temperament set the stage (2) Difficult temperament leads to poor attachment; cognitive problems lead to school failure and social rejection (3) Because of difficulties child is placed with other delinquent children, leading child to adopt delinquent behaviors to be accepted b.

Age of onset and links to antisocial personality disorder (1) Early onset associated with later psychopathy (25–40%) (2) Link between conduct disorder and antisocial personality is stronger among lower socioeconomic-class children (3) 80% of boys with early-onset conduct disorder continue to have multiple problems of social dysfunction (4) Adolescent-onset cases do not share same risk factors or same long-term consequences c.

Environmental factors (1) Family and social context factors (2) Socially rejected children

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(3)

III.

Family setting characterized by ineffective parenting, rejection, harsh and inconsistent discipline, parental neglect (4) Low SES, poor neighborhoods, parental stress, and depression all increase risk 4.

Treatment and outcomes a.

Society tends to take a punitive- rather than a treatment-based approach b.

Focus of treatment is on dysfunctional family patterns, altering child’s aggressive or maladaptive behaviors c.

The cohesive family model (1) Family-group approach (2) Parent-child interactions are examined (3) Obtaining treatment cooperation from parents is difficult (4) If child is removed from home this is frequently interpreted as further rejection d.

Behavioral techniques (1) Teaching control techniques to parents (2) Parents may have difficulty carrying out treatment program Anxiety Disorders of Childhood and Adolescence A. Separation anxiety disorder 1.

Most common of the childhood anxiety disorders 2.

Characterized by excessive fears; excessive anxiety about separation from major attachment figures 3.

More common in girls 4.

Clear psychological stressors are usually identified B. Selective Mutism 1.

Persistent failure to speak in specific social situations 2.

Can speak and understands language 3.

Rare; most common at preschool age 4.

Genetic and learning factors involved a.

Specific deficiencies in auditory nerve activity b.

More common in families in which silent or uncommunicative behavior is prominent c.

Stress and family environmental factors 5.

Successfully treated by fluoxetine, moclobemide (MAO inhibitor), or familybased psychological treatment C. Causal factors in anxiety disorders 1.

Unusual constitutional sensitivity may be present 2.

Feelings of inadequacy may be due to trauma or illness 3.

Modeling of anxious parents 4.

An indifferent or detached parent may instill insecurity 5.

Social-environmental factors a.

Cultures that favor inhibition, compliance, and obedience increase the levels of fear reported b.

In the U.S., white children more likely to report with school refusal and African American children were more likely to report with PTSD symptoms c.

Strong association between exposure to violence and a reduced sense of security and psychological well-being 6.

Feelings of control over reinforcing events .

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D.

IV.

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Treatment and outcomes 1.

Success experiences alleviate anxiety 2.

Biologically based treatments a.

Medication usage becoming more common b.

Fluoxetine useful 3.

Psychological treatments a.

Behavior therapy focused on assertiveness training and desensitization is effective b.

Cognitive-behavioral therapy is effective Childhood Depression and Bipolar Disorder A. The clinical picture in childhood depression 1.

The depressive symptoms include withdrawal, crying, avoidance of eye contact, physical complaints, poor appetite, suicide, and perhaps aggressive behavior 2.

The depressive disorder increases in point prevalence over the age span (0.4– 2.5% for children and between 4 and 8.3% for adolescents) 3.

Rates are equal for boys and girls prior to adolescence; twice as common in girls during adolescence 4.

Adult criteria for depression are used in diagnosis (though irritability allowed for children) B. Increased Bipolar diagnoses in the United States C. Causal factors in childhood depression 1.

Biological factors a.

Genetic component assumed based on parental depression b.

Suicide attempt rate higher in children of depressed parents than offspring of control parents c.

Biological changes in neonate as a result of maternal alcohol consumption 2.

Learning factors a.

Maladaptive learning from negative parental behavior b.

Exposure to early traumatic events c.

Parent-child interaction in transmission of depressed affect d.

Depressive symptoms are positively correlated with the tendency to attribute positive events to external, specific, and unstable causes and negative events to internal, global, and stable causes; with fatalistic thinking; and with feelings of helplessness 3.

Treatment and outcomes a.

Effectiveness of antidepressants may, at best, be moderate, with the potential for many undesirable side effects b.

Suicide appraisal important; 7–10% of adolescents report at least one suicide attempt; SSRIs have been reported to increase suicide potential c.

Providing supportive environment important d.

Cognitive-behavioral treatments proven effective

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Chapter 14 · Disorders of Childhood and Adolescence

V.

Pervasive Developmental Disorders A. Group of severely disabling conditions that account for about 3.2% of clinic cases B. Autism 1.

The clinical picture in autistic disorder a.

First described by Kanner in 1943 b.

Autistic behavior such as lack of empathy, inattention to others, and inability to imitate is shown as early as 20 months of life c.

A social deficit (1) Do not show affection (2) Do not want physical contact (3) Sigman argues that autistic children lack social understanding (4) Lack of social interaction and spontaneous play d.

An absence of speech (1) Imitative defect (2) Speech is either absent or is rudimentary (says “yes” or engages in echolalia) e.

Self-stimulation (1) Usually takes the form of repetitive movements such as head banging, spinning, and rocking (2) Bizarre repetitive behaviors are typical (3) Will actively arrange environment to exclude or limit variety (4) Active aversion to auditory stimuli (not consistent) f.

Intellectual ability (1) Demonstrate marked impairment (2) Deficits in social reasoning but able to manipulate objects g.

Maintaining sameness (1) Many become preoccupied by or form attachments to unusual objects (rocks, light switches, film negatives, keys) (2) Violent temper tantrums result when object or environment is altered even slightly 2.

Causal factors in autism a.

Precise cause is unknown b.

Inborn defect that impairs perceptual-cognitive functioning c.

Best estimates are that in families with one autistic child, there is a 3 to 5% risk of a sibling being autistic as well 3.

Treatments and outcomes of autism a.

Medical treatment has not proven effective (1) If irritability and aggressiveness are present, medical management might involve use of medications (2) No currently available medication reduces the symptoms of autism enough to encourage its general use b.

Behavioral treatment has been used successfully (1) Institutional settings (a) Elimination of self-injurious behavior (b) Mastery of the fundamentals of social behavior (c) Development of language skills (2) Lovaas (a) Behavioral treatment approach

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(b)

VI.

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Highly positive results from a long-term experimental program (c) Intensive and conducted in homes with aid of parents (d) 47% achieved normal intellectual functioning (compared to 2% of untreated controls); 40% mildly retarded range (compared to 45% of untreated controls) c.

The Effectiveness of Treatment (1) Long-term effectiveness has been poor (2) Study of high-functioning autistic children (3) Poor transfer of learning outside of institution (4) Impact on family C. Asperger’s disorder 1.

Similar to autism in that there is social impairment, restricted interests, and repetitive behaviors 2.

Unlike autism in no language delay, no delays in self-help skills 3.

High rate of suicide during adolescence 4.

Often treated with medications and behavioral approaches Learning Disabilities and Mental Retardation A. Learning Disabilities 1.

Problems may be manifested in language, speech, mathematical, or motor skills 2.

Dyslexia manifested as problems in word recognition and reading comprehension; often markedly deficient in spelling 3.

Diagnosis is restricted to when there is clear impairment in school performance or daily living activities 4.

More common in boys 5.

Learning disability initially identified based on a disparity between expected and actual academic performance B. Causal Factors in Learning Disorders 1.

A subtle central nervous system immaturity, defect, or dysfunction is probably present 2.

Language-related LDs may be due to a defect in the brain’s normal laterality C. Treatments and outcomes 1.

Limited data on outcome 2.

Long-term follow-up suggests that problems continue into college D. Mental Retardation 1.

Definition requires: a.

Significantly subaverage general intellectual functioning b.

Significant limitations in adaptive functioning c.

Problems must have begun before the age of 18 2.

Levels of mental retardation a.

Mild mental retardation (1) The largest number of mentally retarded are in this level (2) Persons in this group are considered educable (3) Social adjustment is similar to adolescence b.

Moderate mental retardation (1) This group of individuals is considered trainable (2) Most in this group can achieve partial independent living c.

Severe mental retardation (1) This group is known as the “dependent retarded” .

Chapter 14 · Disorders of Childhood and Adolescence

(2) Institutionalization is usually required Profound mental retardation (1) This is the “life-support retarded” (2) Physical deformities are common in this group (3) This group can usually be diagnosed in infancy Causal Factors in Mental Retardation 1.

Genetic-chromosomal factors a.

Typically moderate to severe mental retardation b.

Down syndrome and Fragile X show the clear role of genetics c.

Chromosomal defects may influence metabolism, which affects the brain 2.

Infections and toxic agents a.

A number of infections, such as syphilis, HIV-1, German measles, genital herpes, and viral encephalitis can cause brain damage b.

Carbon monoxide, lead, alcohol, and incompatibility in blood types are toxic agents that cause brain damage 3.

Trauma (physical injury) a.

Difficulties in labor due to malposition of the fetus or other complications b.

Hypoxia can result from a number of factors 4.

Ionizing radiation a.

X-rays b.

Nuclear power leakages 5.

Malnutrition and other biological factors a.

Malnutrition affects mental development indirectly by altering a child’s responsiveness, curiosity, and motivation to learn b.

Some cases of severe and profound retardation are clearly associated with brain pathology but specific cause is unknown Organic Retardation Syndromes 1.

Down syndrome a.

Most common condition associated with moderate and severe conditions; 5.9 out of every 1000 births b.

Amniocentesis and chorionic villus sampling has reduced the incidence c.

Clinical Picture in Down Syndrome (1) Physical features usually are present in this syndrome (2) Life expectancy for Down children has risen dramatically; however, they experience accelerated aging process (3) Most learn self-help skills and acceptable social behaviors; skills decrease after age 40 (4) The greatest intellectual deficits are found in verbal and language skills (5) A trisomy of chromosome 21 is present in 94% of Down syndrome cases (6) Age of parent at conception critical: for a mother in her 20s, risk is 1 in 2000; by age 40, risk is 1 in 50; age of father also important 2.

Phenylketonuria (PKU) a.

A rare metabolic disorder where a missing liver enzyme prevents phenylalanine from being broken down; found in 1 of 12,000 births b.

To inherit PKU, both parents must carry the recessive gene c.

Severe to profound retardation is seen in untreated patients d.

Early detection can be achieved through urinalysis d.

E.

F.

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e.

G.

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Restriction of diet can prevent mental retardation; some children become mentally retarded in spite of treatment 3.

Cranial anomalies a.

Macrocephaly (large-headedness) (1) Increased size and weight of brain and skull (2) Visual impairments and convulsions also present b.

Microcephaly (small-headedness) (1) Circumference of head rarely exceeds 17 inches (normal is 22 inches) (2) Short stature, tendency for skull to be cone-shaped, with a receding chin and forehead (3) Moderate, severe, and profound mental retardation (4) The majority show little language development (5) The condition may be caused by intrauterine infection, pelvic irradiation, and possible genetic factors c.

Hydrocephaly (1) Relatively rare condition in which there is an accumulation of cerebrospinal fluid causing brain damage and enlargement of the skull (2) The clinical picture depends upon the extent of neural damage (3) Can be present at birth or begin after birth following the development of a brain tumor, subdural hematoma, meningitis, etc.

(4) Surgery is used in treatment; shunting devices inserted to drain cerebrospinal fluid Treatments, Outcomes, and Prevention 1.

Treatment facilities and methods a.

Institutionalization should be seen as last resort because it erodes self-care skills; institutionalized children fall into two groups: (1) Enter at early age due to severe mental retardation and accompanying physical impairment (2) Enter during adolescence with mild mental retardation, no physical impairments but difficulty adjusting, leading to delinquency or other behavioral problems b.

Community-oriented residential care has positives for adolescents c.

Many state institutions are overcrowded and have limited education programs d.

It is questionable whether the mentally retarded at any level receive adequate services e.

Public Law 94-142 requires education in the “least restrictive” environment f.

Group homes or halfway houses began to appear in the 1970s 2.

Education and inclusion programming a.

Typically involves mapping out target areas of improvement (personal grooming, social behavior, basic academic skills, simple occupational skills) b.

Specific skills divided into simple components that can be learned and reinforced c.

Children fare best when they attend regular classes for much of the day .

Chapter 14 · Disorders of Childhood and Adolescence

VII.

Planning Better Programs to Help Children and Adolescents A. Special Factors Associated with Treatment for Children and Adolescents 1.

The child’s inability to seek assistance a.

Child dependent on others to recognize problem and to take them for help b.

Law identifies four areas in which treatment without parental consent is permitted: (1) Mature minors (2) Emancipated minors (3) Emergency situations (4) Court-ordered treatment 2.

Vulnerabilities that place children at risk for developing emotional problems a.

Experience or are exposed to violence b.

Undesirable home environment including inadequate housing c.

Disruptive childhood experiences (deaths) d.

Parental substance abuse e.

High-risk behaviors such as engaging in sexual acts, delinquency, using alcohol or drugs f.

Abuse, parental divorce, family turbulence, homelessness 3.

Need for treating parents as well as children a.

Treatment program may focus on parent behaviors b.

Fathers are particularly difficult to engage in therapy c.

May be difficult to arrange with working parents d.

Poorer families lack money and transportation 4.

Possibility of using parents as change agents a.

Encouraging results have been obtained b.

Barriers to parental involvement: coming from a disadvantaged background, parents who were antisocial, parents under great stress 5.

Problem of placing a child outside the family a.

Four types of facilities are commonly used: (1) Foster homes (2) Private institutions such as group homes (3) County or state institutions (4) Homes of relatives b.

Quality of new home critical for child’s adjustment c.

Removing child from home results in child feeling rejected by parents, unwanted by new caretakers, rootless, constantly insecure, lonely, and bitter d.

Trend today is toward permanent planning 6.

Value of intervening before problems become acute a.

Identify and provide help to those at special risk b.

Double goal of reducing stressors in child’s life and strengthening the child’s coping mechanisms B. Child Advocacy Programs 1.

1989—UN Convention on the Rights of the Child 2.

Advocacy attempts to secure services for children in need 3.

Confusion, inconsistency, and uncertainty continues to hamper various advocacy groups 4.

Federal and state funding has been repeatedly cut

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VIII.

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Unresolved Issues: Can Society Deal with Delinquent Behavior?

A. Juvenile delinquency is a legal term and refers to illegal acts committed by individuals between the ages of 8 and 18 (depending on state law) B. Incidence difficult to determine 1.

More than 2 million go through juvenile court each year 2.

In 2004, over 2.2 million juveniles arrested in the United States 3.

Most juvenile crime committed by males; female rates are rising 4.

Both incidence and severity are higher for lower-class adolescents C. Causal Factors 1.

Personal Pathology a.

Genetic determinants: possible hereditary contributions in hyperactivity, impulsivity, and physiological reactivity b.

Brain damage and learning disability—probably less than 1% c.

Psychological disorders: hyperactivity, pervasive developmental disorders; 14% of cases have documented some type of psychological disorder d.

Antisocial traits e.

Drug abuse 2.

Pathogenic Family Patterns a.

Parental absence or family conflict b.

Parental rejection and faulty discipline D. Undesirable Peer Relationships 1.

Haney and Gold (1973)—two thirds of delinquent acts were committed in association with one or two other people; most of the remainder involved three or four others 2.

Interrelated factors that appear to be of key importance include alienation and rebellion, social rejection, and the psychological support afforded by membership in a gang 3.

32% of homeless youth join a gang E. Dealing with Delinquency 1.

Institutions and training schools; “boot camps” 2.

Harsh, punitive programs often fail as they do not reinforce alternative behaviors 3.

Behavior techniques have shown promise 4.

Counseling parents and related environmental changes are a vital concern 5.

Probation can be very effective 6.

Recidivism a.

Overall rates for those sent to training schools are high b.

Depends on type of offender and on the facility or procedures used c.

Factors predicting recidivism include type of offense, family problems, having delinquent peers, ineffective use of leisure time, conduct problems d.

Must provide a more positive peer culture

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Key Terms Asperger’s disorder (p. 454) attention-deficit/hyperactivity disorder (ADHD) (p. 442) autism (p. 454) conduct disorder (p. 445) developmental psychopathology (p. 440) Down syndrome (p. 462) dyslexia (p. 459) echolalia (p. 455) hydrocephaly (p. 465) juvenile delinquency (p. 445) learning disorders (p. 459) macrocephaly (p. 465)

mainstreaming (p. 467) mental retardation (p. 460) microcephaly (p. 465) oppositional defiant disorder (p. 445) Pemoline (p. 444) pervasive developmental disorders (PDD) (p. 454) phenylketonuria (PKU) (p. 464) Ritalin (p. 443) selective mutism (p. 449) separation anxiety disorder (p. 448) Strattera (p. 444)

Lecture Examples / Discussion Topics Lecture Launcher 14.1: Would Tom Sawyer or Pippi Longstocking Get Ritalin?

Ritalin/Concerta and a variety of newer medications, like Strattera, provide effective short-term treatment of some symptoms of attention-deficit/hyperactivity disorder. Lawrence Diller, a San Francisco pediatrician who has prescribed Ritalin for twenty-two years, began to question his actions after seeing more and more parents seeking the drug for preschoolers and for teens. “I wondered if Tom Sawyer or Pippi Longstocking would also leave with a Ritalin prescription,” Diller was quoted as saying in an Associated Press story. What do students in your class think? Do any believe that Tom Sawyer and Pippi Longstocking (or, maybe Junie B. Jones) would have benefited from medication?

Lecture Launcher 14.2: Short-Term vs. Long-Term Effects of Psychostimulants The effectiveness of psychostimulants in the short-term is fairly clear, but the long-term effectiveness is not. What evidence is available suggests there is no effect of psychostimulant treatment on academic performance, antisocial behavior, or peer relationships in the long run. Does it change student views on the benefits of medication for attention-deficit/hyperactivity disorder to recognize that they are only a short-term means of managing behavior with minimal demonstrable long-term benefits? Or are these short-term benefits themselves worth achieving pharmacologically?

Lecture Launcher 14.3: Whose Problem Is It Anyway?

How big a problem is hyperactivity in children? How about oppositional defiant disorder? Have the class discuss what they view as the symptoms of psychological disorder in children. Discuss how problems may change depending on who is making the evaluation, for instance the teacher, parent, or child. Students can work in groups to complete worksheets about the various perspectives on problems with children. Ask them to identify the kinds of things that would bother each stakeholder in children’s behavioral and emotional functioning. Handout 14.1 Lecture Launcher 14.4: Staying Together “For the Children” Should parents with marital problems stay together for the children? It is clear that a wide variety of child and adolescent problems are associated with marital discord and divorce. Would you stay together for the children if you were in a troubled marriage? Would it be better to divorce in order to insulate the .

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children from conflict? Would divorcing eliminate child exposure to conflict? Can children be insulated from conflict without divorcing? Or should the focus be on reducing conflict? Some states have considered making waiting periods to secure a divorce when there are minor children involved. Is that a good idea? Does the government have an interest in families that warrants such intrusive measures?

Lecture Launcher 14.5: Children as Involuntary “Patients” Children are usually involuntary patients when they are brought to a psychologist or psychiatrist for treatment. What are the ethical implications of forcing a child to receive treatment, especially when the child opposes treatment for principled, rational, and articulate reasons? What special problems might this produce for the therapist? At what age does a child have the right to refuse treatment? How about the converse—parents who defy medical advice and choose not to secure treatment for their minor children? Should authorities intervene in such cases? Is withholding treatment a form of child abuse?

What if it is done out of strong religious convictions?

Demonstrations / Activities Activity 14.1: You Can See a Lot Just by Looking Assign the class to observe children of different ages at play. Have the students categorize problem behaviors they might observe. Common categories include hostility, hyperactivity, distractibility, anxiousness, and shyness. What common problems were observed most frequently? What behaviors typically disappear as children age? Which behaviors appear to be the most long-lasting? How do other children react to those peers who evidence “problem” behaviors?

Activity 14.2: Inside a Child of Divorce Many of your students will have divorced parents, and those who don’t will have at least one close friend whose parents divorced. The purpose of this essay assignment is to gather reflections on the experience of being a child of divorce. It is also of interest to look at the experience of being a child of parents who experienced marital discord. Therefore, ask students whose parents divorced or whose parents experienced significant conflict but stayed together to write an essay about its effects on them.

Those who do not have first-hand experience of this sort can write about a close friend. As these essays can be quite personal in nature, it might be useful to gather them confidentially.

Activity 14.3: Bell and Pad Enuresis may be comorbid with many childhood disorders including ADHD, oppositional defiant disorder, and conduct disorder. The classic Bell-and-Pad approach to treating enuresis is quite effective and has been a popular treatment and self-help technique for decades. The actual device is inexpensive, and simple to operate and demonstrate to the class. They are also readily available in most department stores and make a nice visual aid. A common alternative to the bell-and-pad is imipramine (Tofranil), which is also used as an adult antidepressant. Adults taking imipramine for depression have reported as a side effect difficulty initiating a urine stream. It was then tried as a treatment for bed-wetting and subsequently received FDA approval for that purpose. What do students think of an adult antidepressant being used to treat childhood bed-wetting? It is a situation similar to the present in which SSRIs are being used for more and more things other than their original purpose as antidepressants (e.g., eating disorders, anxiety disorders, premature ejaculation, anger/aggression). What do students think of a drug being used to treat enuresis when behavioral treatments, with no side effects, have been shown to be just as effective, if not more so?

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Activity 14.4: Experiencing ADD The experience of attentional difficulty is easily demonstrated with exaggerated versions of common tests of attention. For instance, students can be asked to spell abnormal psychology backward, skipping every other letter. Or they can be asked to recite the “Pledge of Allegiance” backward or to count backward by 7s from some arbitrarily high number. Students can each try this in front of the class to enhance the experience or else they can break into groups or pairs to give it a try without the social anxiety caused by doing so in front of the whole class. You might point out that the task is not about intelligence, but that it taps attention pretty exclusively. During the task, someone could implore the person to “try harder” and to “pay attention” and “focus.” It is also worth imagining that it is a task you know others can do easily but that you struggle with. Many variations are possible, and it can be easily customized by substituting a local example, perhaps using the school fight song or spelling of the name of the university.

Activity 14.5: Media-Defined Normality Parents and children are often poor at estimating the proper behavior to expect at different ages. Some parents expect too much and place unrealistic demands on children. Others expect too little and fail to properly socialize children to their emerging responsibilities. If possible, the instructor may bring in paintings or drawings taken from classic texts depicting how children were at one time viewed as simply smaller versions of adults. A common source of expectations today is television. Some shows inaccurately portray children as miniature adults, speaking in complete sentences and paragraphs about worldly things out of the range of real children of the same age. Others feature whimsical portrayals of seriously deviant activity. Assign students the task of watching some television programs that have children and adolescents as major characters. Ask them to identify any main characters that show DSM mental disorders. For example, would Bart Simpson be diagnosable? How about any of the characters on South Park? Handout 14.2 Activity 14.6: Be Still, Be Quiet, Be Docile Students may be asked to read this classic article (Winett and Winkler, 1972) and then either take part in a small group discussion or debate, or complete an essay on this issue.

Web Links Web Link 14.1: http://www.nami.org/youth/ This is the Child and Adolescent Action Center on the Web site of the National Alliance for the Mentally Ill. It includes a broad range of information about many disorders of childhood and adolescence including research, treatment, advocacy, and various “fact sheets.”

Web Link 14.2: http://www.childanxiety.net/ This is a resource for parents, teachers, and healthcare professionals who work with children who have anxiety disorders. Maintains a list of suggested readings and a treatment provider database.

Web Link 14.3: http://www.mentalhealth.samhsa.gov/child/childhealth.asp This site, created by the United States Department of Health and Human Services Substance Abuse and Mental Health Services Administration, provides a wealth of information on child and adolescent mental health, resources for parents and families, and links to additional websites.

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Web Link 14.4: http://www.psychologyinfo.com/problems/children.html Childhood Disorders section of Psychology Information Online, links out to the most common disorders of childhood and adolescence.

Web Link 14.5: http://www.notmykid.org/media/12959/delinquency.pdf Very useful article written for parents and family members interested in learning more about juvenile delinquency. The articles include additional resources, tips on prevention, and differing definitions of delinquency.

Web Link 14.6 http://www.nami.org/Template.cfm?Section=20065&Template=/ContentManagement/ContentDisplay .cfm&ContentID=29868 Review of Susan Antonetta’s interesting book, A Mind Apart, that introduced the term neuroatypical to many. In this book, she argues that eradicating those who are atypical isn’t appropriate.

Video Resources A Is for Autism. Princeton, NJ: Films for the Humanities and Social Sciences.

ADHD in Adults. Boston, MA: Fanlight Productions.

ADHD: What Do We Know? New York, NY: Insight Media.

All about Attention Deficit Disorder. New York, NY: Insight Media.

American Adolescence. Princeton, NJ: Films for the Humanities and Social Sciences.

Around the Clock: Parenting the Delayed ADHD Child. New York, NY: Guilford Publications.

As I Am. Boston, MA: Fanlight Productions.

Asperger’s Syndrome: Autism and Obsessive Behavior. Princeton, NJ: Films for the Humanities and Social Sciences.

Assessing ADHD in the Schools. New York, NY: Guilford Publications.

Attention Deficit Disorder: Adults. The Doctor Is In Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Attention Deficit Disorder: Children. The Doctor Is In Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Autism. Princeton, NJ: Films for the Humanities and Social Sciences.

Autism: A Strange Silent World. New York, NY: Filmmakers Library.

Autism: A World Apart. Boston, MA: Fanlight Productions.

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Autism—The Brain Teaching Modules Video Series. South Burlington, VT: Annenberg/CPB Collection.

Autism: The Child Who Couldn’t Play. Allyn and Bacon Video Library.

Behavior Disorders of Childhood. The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection.

Breaking the Cycle. New York, NY: Filmmakers Library.

Breaking the Silence Barrier: Inside the World of Cognitive Disabilities. Princeton, NJ: Films for the Humanities and Social Sciences.

Breakthroughs: How to Reach Students with Autism. Boston, MA: Fanlight Productions.

Brother of Mine: Youth Violence and Society. Princeton, NJ: Films for the Humanities and Social Sciences.

Catching Them Early. In Search of Law and Order Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Childhood Depression. Princeton, NJ: Films for the Humanities and Social Sciences.

Children of Divorce. Allyn and Bacon Video Library.

Children with OCD. Allyn and Bacon Video Library.

A Child’s Grief. Sherborn, MA: Aquarius Health Care Videos.

The Child You Do Have: A New Approach to Autism. New York, NY: Filmmakers Library.

A Child’s View of Death. Death: A Personal Understanding Series. South Burlington, VT: Annenberg/CPB Multimedia Collection.

Choices: A Suicide Prevention Program. Sherborn, MA: Aquarius Health Care Videos.

Classroom Interventions for ADHD. New York, NY: Guilford Publications.

Coping with Attention Deficit Disorder: Taming the Turmoil. Princeton, NJ: Films for the Humanities and Social Sciences.

Day by Day: Raising the Child with Autism/PDD. New York, NY: Guilford Publications.

Domestic Violence and Children. Allyn and Bacon Video Library.

Down Syndrome: A Parent’s Perspective. Sherborn, MA: Aquarius Health Care Videos.

Dyslexia. The Doctor Is In Series. Princeton, NJ: Films for the Humanities and Social Sciences.

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Dyslexia in the Primary Classroom. Princeton, NJ: Films for the Humanities and Social Sciences.

Einstein and Me: Talking about Learning Disabilities. Boston, MA: Fanlight Productions.

Essentials of Play Therapy with Abused Children. New York, NY: Guilford Publications.

Eternal Scars: Physical and Emotional Child Abuse. Allyn and Bacon Video Library.

The Foolish Wise Ones: “Idiot Savants.” New York, NY: Filmmakers Library.

Girls in Gangs. Princeton, NJ: Films for the Humanities and Social Sciences.

In the House. New York, NY: The Cinema Guild.

John’s Not Mad: Tourette’s Syndrome. New York, NY: Filmmakers Library.

The Key to the World: A New Approach to Dyslexia. New York, NY: Filmmakers Library.

Kids and Crime. Princeton, NJ: Films for the Humanities and Social Sciences.

Kids and Crime: Keeping Kids Out of Trouble. Princeton, NJ: Films for the Humanities and Social Sciences.

Kids and Guns. Princeton, NJ: Films for the Humanities and Social Sciences.

The Last Taboo: Children Who Sexually Abuse. New York, NY: Filmmakers Library.

Learning Disabled. Princeton, NJ: Films for the Humanities and Social Sciences.

Lily: A Sequel. The Lily Videos: A Longitudinal View of Life with Down Syndrome Series. San Luis Obispo, CA: Davidson Films.

Lily: A Story About a Girl Like Me. The Lily Videos: A Longitudinal View of Life with Down Syndrome Series. San Luis Obispo, CA: Davidson Films.

Managing the Defiant Child: A Guide to Parent Training. New York, NY: Guilford Publications.

Maternal PKU: A New Crisis on the Horizon. Boston, MA: Fanlight Productions.

A New Look at ADHD: Inhibition, Time, and Self-Control. New York, NY: Guilford Publications.

Not Too Young To Die. New York, NY: Filmmakers Library.

One of Us: Four Stories of Inclusion. Boston, MA: Fanlight Productions.

Page Fright: Inside the World of the Learning Disabled. New York, NY: Filmmakers Library.

A Passion for Justice. Boston, MA: Fanlight Productions.

Pressure-Cooked Kids. Princeton, NJ: Films for the Humanities and Social Sciences.

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Psychotherapy of Children with Conduct Disorders Using Games and Stories. APA Psychotherapy Video Series II: Specific Treatments for Specific Populations. Washington, DC: American Psychological Association.

Rage for Order: Autism. Princeton, NJ: Films for the Humanities and Social Sciences.

Ritalin: Drug Treatment for Attention Deficit Disorder. Princeton, NJ: Films for the Humanities and Social Sciences.

Secret Shame: Bullied to Death. Princeton, NJ: Films for the Humanities and Social Sciences.

Shane: Tourette’s Syndrome. The Mind Traveler: Oliver Sacks Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Special Needs Students in Regular Classrooms? Sean’s Story. Princeton, NJ: Films for the Humanities and Social Sciences.

Stuttering. Allyn and Bacon Video Library.

Suicide: The Teenager’s Perspective. The Doctor Is In Series. Princeton, NJ: Films for the Humanities and Social Sciences.

Tackling ADHD—#11 ABC News and Client Interviews. Allyn and Bacon Abnormal Psychology Video.

Take This Heart. Berkeley, CA: University of California Extension Center for Media and Independent Learning.

Teen and Child Depression. Allyn and Bacon Video Library.

Teen Depression. Princeton, NJ: Films for the Humanities and Social Sciences.

Teen Killers: A Second Chance? Princeton, NJ: Films for the Humanities and Social Sciences.

Teenage Suicide. Princeton, NJ: Films for the Humanities and Social Sciences.

Teen Violence: Wot U Lookin’ At? Princeton, NJ: Films for the Humanities and Social Sciences.

The Trouble with Evan. New York, NY: Filmmakers Library.

Treating Tourette’s and Other Mental Illnesses. Princeton, NJ: Films for the Humanities and Social Sciences.

Twitch and Shout. Boston, MA: Fanlight Productions.

Understanding Attention Deficit Hyperactivity Disorder. Allyn and Bacon Video Library.

Understanding Autism. Boston, MA: Fanlight Productions.

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Understanding the Defiant Child. New York, NY: Guilford Publications.

When Parents Can’t Fix It: Living With a Child’s Disability. Boston, MA: Fanlight Productions.

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Handout 14.1 Defining Childhood Behavior Problems

What are defined as problem behaviors in children? Consider the question from these different points of view: Family:

Mother:

Father:

Siblings:

Extended Family Members

School:

Teachers

Administrators

Students

Community:

Neighbors

Service Agencies

What Problems Would the Child Identify?

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Handout 14.2 Media Defined Child Normality

A.

Critically examine television characters that portray child behavior that could be considered abnormal. Provide details about the behavior of interest including how other characters react to it and whether it strikes you as normal behavior being pathologized or abnormal behavior being normalized.

Television Program

B.

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Behavior of Character

Describe the positive or negative qualities of the portrayals of these children. Say whether stereotypes about abnormal behavior are being used deliberately by the producers or writers and what effect, if any, they are pursuing.

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CHAPTER 15: Contemporary and Legal Issues in Abnormal Psychology Chapter At-A-Glance Detailed Outline

Instructors’ Resources

Print Supplements

Media Supplements

Perspectives on Prevention • Universal Interventions • Selective Interventions • Indicated Interventions • The Mental Hospital as a Therapeutic Community • Deinstitutionalization

Teaching Objectives 15.1–15.4 Chapter Guide Activities 15.2, 15.5 Web Links 15.1

Test Bank Grade Aid Transparency T-113

CD-ROM PowerPoint

Controversial Legal Issues and the Mentally Disordered • Civil Commitment • Assessment of “Dangerousness” • The Insanity Defense

Teaching Objectives 15.5–15.7 Chapter Guide Lecture Launchers 15.1, 15.2, 15.3, 15.4, 15.5 Activities 15.1, 15.6 Web Links 15.2, 15.4

Test Bank Grade Aid

CD-ROM PowerPoint

Organized Efforts for Mental Health • U.S. Efforts for Mental Health • International Efforts for Mental Health

Teaching Objectives 15.8 Chapter Guide Activities 15.2, 15.4, 15.5 Web Links 15.3

Test Bank Grade Aid

CD-ROM PowerPoint

Challenges for the Future • The Need for Planning • The Individual’s Contribution

Teaching Objectives 15.9 Chapter Guide Activities 15.2, 15.5, 15.6 Web Links 15.4

Test Bank Grade Aid

CD-ROM PowerPoint

Unresolved Issues: The HMOs and Mental Health Care

Teaching Objectives 15.10 Chapter Guide Activities 15.2, 15.4, 15.5 Web Links 15.4

Test Bank Grade Aid

CD-ROM PowerPoint

Professor Notes

Teaching Objectives 1.

2.

3.

4.

5.

6.

Define universal intervention, and explain how universal intervention includes biological, psychosocial, and sociocultural efforts.

Define selective intervention, and describe and illustrate selective intervention programs, using the example of teen alcohol and drug abuse prevention.

Define indicated intervention and explain when it might be most likely used.

Describe what is meant by a therapeutic community. Compare and contrast the effectiveness of the three approaches to treating chronic hospitalized patients.

Outline the conditions necessary and the steps involved when considering involuntary commitment.

Discuss the problems of assessing and predicting “dangerousness” and explain the obligations of the clinician under the “duty-to-warn” legal doctrine. .

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7.

8.

9.

10.

Review the various legal rulings relevant to the insanity defense and discuss the problems and controversies associated with this concept.

Summarize U.S. and international efforts related to mental health.

Outline the three planning issues thought to be most pressing for the future. Explain how individuals can be of assistance in the mental health field.

Outline the advantages of the managed care revolution as it applies to mental health care.

Based on the evidence, what conclusions would you draw about the impact of managed care on the treatment of those with psychological disorders?

Chapter Overview / Summary Many mental health professionals are trying not only to cure mental health problems but also to prevent them, or at least reduce their effects. Prevention can be viewed as focusing on three levels: (1) universal interventions, which attempt to reduce the long-term consequences of having had a disorder; (2) selective interventions, which are aimed at reducing the possibility of disorder and fostering positive mental health efforts in subpopulations that are considered at special risk; and (3) indicated interventions, which attempt to reduce the impact or duration of a problem that has already occurred.

Over the past thirty years, with the advent of many new psychotropic medications and changing treatment philosophies, there has been a major effort to discharge psychiatric patients into the community. There has been a great deal of controversy over deinstitutionalization and the failure to provide adequate follow-up with these patients in the community. Some chronic patients were placed in circumstances that required more adaptive abilities than they possessed. Recent work in the area of aftercare for former mental patients has provided clearer guidelines for discharge and therapeutic follow-up.

Being “mentally ill” is not considered sufficient grounds for commitment. There must be, in addition, evidence that the individual is either dangerous to himself or herself or represents a danger to society. It is not an easy matter, even for trained professionals, to determine in advance whether a person is “dangerous” and likely to cause harm to others. Nevertheless, professionals must, at times, make such judgments. Recent court rulings have found professionals liable when patients they were treating caused harm to others. The Tarasoff decision held that a therapist has a duty to protect potential victims if his or her patient has threatened to kill them.

An important issue of forensic psychology involves the insanity plea for capital crimes. Many mental health and legal professionals, journalists, and laypersons have questioned the present use of the “not guilty by reason of insanity” (NGRI) defense. The original legal precedent, the M’Naghten Rule, held that, at the time of committing the act, the accused must have been laboring under such a defect of reason as to not know the nature and quality of the act or to not know that what he or she was doing was wrong. More recent extensions of the insanity plea, as in the American Law Institute standard, leave open the possibility of valid NGRI pleas by persons who are not diagnosed to be psychotic. This broadening of the insanity plea has led to its use in more and more cases, and decisions have often involved conflicting psychiatric testimony. The successful use of the NGRI defense by John Hinckley, who attempted assassination of President Reagan, set off a storm of protest, resulting ultimately in widespread tightening of insanity defense laws. One effective and widely adopted reform was to shift the burden of proof to the defense in such cases.

Federal agencies such as the National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) are devoted to promoting research, training, and service in the mental health community. Mental health programming in the United States is also the concern of several professional and mental health organizations, many corporations, and a number of voluntary mental health organizations. International

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organizations, such as the World Health Organization (WHO) and the World Federation for Mental Health, have contributed to mental health programs worldwide.

Detailed Lecture Outline I.

Perspectives on Prevention A. Universal Interventions are aimed at influencing the general population 1.

Perform two key tasks a.

Alter conditions that can cause or contribute to mental disorders b.

Establish conditions that can foster positive mental health 2.

Biological strategies a.

Promoting adaptive lifestyles b.

Good physical health as prevention 3.

Psychosocial strategies a.

Skills must be developed to problem-solve effectively, express emotions constructively, and engage in satisfying interpersonal relationships b.

Must acquire an adequate frame of reference upon which identity is built c.

Must be prepared to deal with the types of problems likely to be encountered during given life stages 4.

Sociocultural strategies a.

The relationship between the person and society is a reciprocal one b.

Social conditions can foster healthy development B. Selective Interventions are aimed at a specific subgroup considered at risk 1.

Attempts to effect psychologically desirable social change are also likely to have ideological and political repercussions that may inspire powerful opposition including opposition from government itself 2.

An illustration of selective prevention strategies a.

Ineffective government approaches have focused on (1) Interdicting and/or reducing the supply of drugs available (2) Providing treatment services for those who develop drug problems (3) Encouraging prevention (a) Typically not conducted long enough (b) Intervention effects not powerful (c) Strategy not well implemented b.

Recent effective prevention strategies: (1) School-based interventions (2) Intervention programs for high-risk teens (3) Parent education and family-based intervention programs (4) Extracurricular strategies (5) Comprehensive prevention strategies C. Indicated Interventions are directed at high-risk individuals who are identified as having minimal but detectable symptoms 1.

Emphasizes early detection and prompt treatment 2.

May involve immediate and brief intervention following a crisis D. The Mental Hospital as a Therapeutic Community 1.

The therapeutic community or “milieu therapy” a.

Staff expectations are clearly communicated to patients b.

Patients are involved in decisions c.

Patients belong to social groups encouraging group cohesiveness .

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2.

II.

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Social leaning programs a.

Effective in shaping acceptable behavior b.

Use learning principles and techniques such as token economies 3.

Aftercare programs a.

Smooth the transition to community life and can reduce relapses b.

Are a “halfway” period in which a released patient makes a gradual return to life outside the institution c.

Numerous problems with aftercare programs including relevant treatments not being available and failure of staff to provide a secure environment E. Deinstitutionalization 1.

Source of controversy a.

Between 1970 and 1992, the number of state hospitals dropped from 310 to 273 and the patient population was reduced by 73% b.

On one side are those who believe this is great and these former patients are fine in the community c.

On the other side are those who believe these patients have been abandoned, leading to increased homelessness, violent victimization, and suicide d.

Some of these changes have come about because of changes in the healthcare system e.

Recent indications of increased inpatient psychiatric hospitalization in the U.S. and U.K. 2.

Homelessness a.

Care outside of the hospitals has been inadequate b.

Vagrancy and crime found among discharged patients c.

Little follow-up data exists for this population Controversial Legal Issues and the Mentally Disordered A. Civil Commitment 1.

Persons who are a threat to themselves or others are candidates for confinement 2.

State law dictates the process 3.

Voluntary versus involuntary commitment 4.

Conditions necessary for involuntary commitment: a.

Dangerous to themselves or to others b.

Incapable of providing for their basic physical needs c.

Unable to make responsible decisions about hospitalization d.

In need of treatment or care in a hospital 5.

Steps in the commitment process a.

Filing a petition for a commitment hearing b.

Judge appoints two examiners for evaluation c.

Hearing held within fourteen days (can be extended for good cause) d.

Once committed, the hospital must report to the court within sixty days on whether the person needs to be confined longer e.

If there is no time for the court order, a physician must sign a statement saying that imminent danger exists and the patient can be held seventytwo hours B. Assessment of “Dangerousness” 1.

Most patients show no increased risk of violence; exceptions include those experiencing psychotic symptoms, schizophrenia, mania, personality disorder, substance abuse, organic brain injury, and Huntington’s disease .

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2.

III.

Attempts to predict dangerousness a.

Difficult to predict as violent acts are determined as much by situational factors as by an individual’s personality b.

Past history of violence is a significant predictor c.

Mental health professionals typically overpredict violence 3.

The duty to protect: Implications of the Tarasoff decision a.

Tarasoff v. Regents of the University of California, et al. (1976): duty to warn doctrine b.

Found liable for failing to warn the potential victim c.

Limits of confidentiality d.

Application and interpretation of this is confusing from state to state C. The Insanity Defense 1.

Not Guilty by Reason of Insanity (NGRI): a.

Most attempts to use this fail, e.g., Jeffrey Dahmer b.

Hinckley case successfully utilized NGRI c.

NGRI employed in less than 2% of capital crime cases in the U.S. d.

States differ widely in terms of how much time persons found NGRI are actually confined e.

Re-arrest rates for those found NGRI are as high as 50% 2.

Established legal precedents for the insanity defense a.

The M’Naghten rule (1843) b.

The irresistible impulse rule (1887) c.

Durham rule (1954) d.

American Law Institute (ALI) standard (1962) e.

Federal Insanity Defense Reform Act (IDRA) adopted in 1984 (1) Definition quite similar to M’Naghten (2) Mental disorder must be severe (3) Burden of proof is on the defense 3.

Most states and the District of Columbia subscribe to a version of either the ALI or the more restrictive M’Naghten standard 4.

NGRI most likely to be successful when there was a diagnosed mental disorder, a female defendant, violent crime other than murder, and prior mental hospitalizations 5.

Three states have essentially abolished insanity pleas (Idaho, Montana, and Utah) leading to an increase in the use of “incompetent to stand trial” 6.

Other states have adopted the plea/verdict of guilty but mentally ill (GBMI) Organized Efforts for Mental Health A. U.S. Efforts for Mental Health 1.

The federal government and mental health a.

The National Mental Health Act of 1946 b.

National Institute of Mental Health (NIMH): (1) Conducts and supports research (2) Supports the training of professional and paraprofessionals (3) Helps communities plan, establish, and maintain more effective mental health programs (4) Provides information 2.

Professional organizations and mental health a.

Standards and ethics promoted by these organizations b.

They encourage communication among professions .

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c.

IV.

V.

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Social problems are addressed especially through lobbying and acting as consultants 3.

The role of volunteer organizations and agencies a.

National Mental Health Association (1) Founded in 1909 by Clifford Beers (2) Improvement of services in community clinics and hospitals (3) Help recruit, train, and place volunteers (4) Works for enlightened mental health legislation (5) Special educational programs (6) Actively involved in many court decisions especially regarding rights of patients b.

Other groups include National Association for Retarded Citizens, Alcoholics Anonymous, National Alliance for the Mentally Ill (NAMI) 4.

Mental health resources in private industry a.

National Institute for Occupational Safety and Health recognizes psychological disorders as one of the ten leading work-related health problems b.

Americans with Disabilities Act—people with psychiatric problems cannot be discriminated against in the workplace c.

Although more work is needed, specific mental health risk factors in the work situation have been identified; employers are beginning to act on these through the development of employee assistance programs B. International Efforts for Mental Health 1.

The World Health Organization a.

Formed after WWII as part of the U.N. b.

International Classification of Disease—uniform set of diagnostic criteria 2.

The World Federation for Mental Health a.

Established in 1948 b.

Collects information on mental health conditions all over the world Challenges for the Future A. The Need for Planning 1.

There needs to be international cooperation 2.

Measures must reduce international conflict 3.

Progress in prolonging life has created new issues that must be resolved B. The Individual’s Contribution 1.

There are opportunities for both the professional and the nonprofessional 2.

The responsibility must be shared by everyone a.

Serving as a volunteer b.

Supporting realistic measures for ensuring comprehensive health services for all age groups c.

Working toward improved public education, responsible government, the alleviation of prejudice, and the establishment of a more sane and harmonious world Unresolved Issues: The HMOs and Mental Health Care A. Managed health care providers attempt to offer medical care at lower costs by 1.

Limiting traditional services 2.

Employing stringent review procedures 3.

Using lower-cost brief treatment options B. Mental Health Treatment—Who Decides What Kind and How Long? .

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1.

2.

C.

In one common approach, HMO seeks low bid for service HMO representative or gatekeeper is frequently a medical generalist or a business professional untrained in either psychiatric disorders or psychosocial interventions; conflicts inevitably develop 3.

Decisions about what treatments to provide are often based on business factors rather than treatment considerations Time-Limited Therapy 1.

Favoring of less expensive and less labor-intensive approaches 2.

Long-term therapy has been virtually eliminated 3.

Few, if any, of the decisions regarding the amount and type of services provided are directly guided by empirical criteria; guidelines appear arbitrary and capricious 4.

Critics of HMOs argue that there is no evidence that costs have been reduced; about a quarter of health care expenditures in the U.S. go for managed care administration 5.

Economics have limited mental health care to a.

Time-limited, symptom-focused services b.

Practitioners have experienced a reduction in income leading to less welltrained therapists taking on more work

Key Terms deinstitutionalization (p. 481) forensic psychology (forensic psychiatry) (p. 482) guilty but mentally ill (GBMI) (p. 488) health maintenance organization (HMO) (p. 492) indicated interventions (p. 474) insanity defense (p. 486)

managed health care (p. 493) milieu therapy (p. 479) NGRI plea (p. 486) residential treatment (p. 479) selective interventions (p. 474) social-learning programs (p. 480) Tarasoff decision (p. 485) universal interventions (p. 474)

Lecture Examples / Discussion Topics Lecture Launcher 15.1: Violence and the Mentally Ill Background checks on people trying to buy guns commonly focus on two things: (a) felony convictions and (b) history of mental illness. Why? Well, obviously, because these people are dangerous, right?

Although students may accuse you of wanting to arm the mentally ill, the presupposition behind a policy of denying people with a history of mental illness access to firearms is thought provoking and exposes a variety of issues raised in this chapter, namely, the prediction of dangerousness, stigma, and the rights of the mentally ill. The discussion can begin by simply asking students whether history of mental illness is a reasonable exclusion criterion for firearm sales. Then a wide variety of assumptions about the mentally ill can be exposed by asking why. Typically, students will say that mentally ill people are likely to harm others, that they are unpredictable, that their hallucinations will tell them to kill others, and that there are far too many cases of mentally unstable people perpetrating horrible crimes. These beliefs can be .

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challenged with data that suggest that past criminal behavior is a far better predictor of future criminality than is mental illness, and that for some categories of disorders there is evidence of reduced likelihood of violent offending. Finally, it can be pointed out that the issue concerns deprivation of constitutionally guaranteed rights based on what a person might do. If that is not sound policy for the public in general, what makes it good for the mentally ill?

Lecture Launcher 15.2: Not Guilty by Reason of Insanity The “not guilty by reason of insanity” verdict always makes for interesting class discussion. One approach to structuring the discussion is to separate the pros and cons, asking first what the pros are, and then asking what the cons are. To those who object to the idea entirely, it can be helpful to ask questions about the need to establish intent to secure conviction. Most would agree that accidental killing is not murder, but establishing a lack of intent requires examination of psychological factors such as the circumstances leading up to the act, the consequences following it, and whether these sufficiently account for the act. Once “intent” enters into the equation, though, the capacity of the actor to formulate intent becomes relevant and mental illness becomes germane.

Lecture Launcher 15.3: Perceptions of the Insanity Defense versus Reality It is instructive to ask students about their perceptions of the insanity defense. Is it common? When it is used, is it successful? If it is successful, do those acquitted avoid institutionalization? The reality is quite different from most people’s perceptions. The insanity defense is used in less than one percent of trials.

When used, it is successful about 26% of the time. Therefore, because 0.9% x 26.0% = .23%, it is accurate to say that .0023 of felony indictments end with insanity acquittals. And 80% of these successful insanity bids are agreed to in advance by the defense and prosecution. Therefore, indictments ending in disputed insanity acquittals is .0023 x .20 = . 00046. Data also show that insanity acquittees have not committed extraordinarily violent and bizarre crimes such as multiple murder, rape, or assassination. Many are charged with relatively minor and mundane offenses such as assault, drug use, shoplifting, and petty offenses—virtually identical to those who do not attempt an NGRI bid. These data come from Silver, Cirincione, and Steadman (1994, Law and Human Behavior, vol. 18, pp. 63–70).

Lecture Launcher 15.4: “Guilty but Mentally Ill” “Guilty but Mentally Ill” (GBMI) often strikes students as a healthy compromise between “Not Guilty

by Reason of Insanity” (NGRI), which they fear allows offenders to “get off scot-free,” and “Guilty,” which fails to appreciate the limits of responsibility associated with various psychiatric impairments.

More than thirteen states now provide for the GBMI verdict. In fact, Montana and Idaho only allow the GBMI option, having abolished NGRI entirely. Ideally, a plea of GBMI allows a person to be found guilty and to be incarcerated in a mental hospital rather than a prison. Unfortunately, GBMI does not work as well as most would expect. Fundamentally, it is a “Guilty” verdict. The rates at which those found GBMI get treated are astonishingly low. Most are simply incarcerated along with the other general “convicts,” at best receiving occasional counseling sessions but mostly getting virtually no special care at all. Where both pleas are available, GBMI does not even necessarily reduce NGRIs. In fact, in Michigan, there was no change at all in the rates of NGRI, following the introduction of GBMI and in Illinois, NGRIs actually increased following the addition of GBMI. In reality, GBMI is just another guilty verdict, though it is one that deceives the public and dupes juries into thinking it is something else. GBMIs are more likely than guilty defendants to (a) go to prison; (b) receive life sentences; (c) to receive longer sentences for the same crimes; and, astonishingly, (d) they are equally likely to receive mental healthcare.

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Lecture Launcher 15.5: Civil Commitment Civilly committed people can be held against their will as long as they pose a threat to themselves or to others. The textbook describes one problem with this situation as having to do with the terrible difficulty we have predicting “dangerousness.” Also of concern, however, are patients’ rights. Even if the likelihood of offending could be established, at what level of probability would it be reasonable to deprive someone of their freedom for acts they have not yet committed? If some arbitrary probability-ofoffending value could be established, and if it were possible to estimate such a probability in individual cases, would it apply only to people who were mentally ill? That is, what if someone who was not mentally ill had, for whatever reason, an equally high likelihood of offending. What would we do with that person? The answer is we wouldn’t do anything because preventive detention is not permitted in this country—unless you are mentally ill.

Demonstrations / Activities Activity 15.1: Psychiatric “Will” The justification for treating psychiatric patients against their will often centers on their inability to make good decisions on their own behalf. Even people with intact judgment, however, disagree about how they would prefer to be treated. This can sometimes cause those caring for people with emotional disorders to try to estimate what each patient would want were they not presently impaired. In such cases it would be extremely helpful to have some written guidance from the patient, prepared prior to their present difficulties. Sometimes called a “psychiatric will,” such a written document can be very instructive, if not binding, for students to prepare. Like a “living will,” such a document states one’s wishes about treatment in anticipation of the possibility they may one day be impaired by some form of mental illness. To animate the assignment some students can be asked to consider the following scenario: “In your lifetime, a new psychosurgery will appear that will be claimed to have good results. It treats a condition, however, that impairs people’s ability to formulate sound medical opinions. That is, by the time you could be a candidate for this surgery you will probably be too impaired to decide wisely.

Therefore, let’s take advantage of the fact that you are not currently impaired (relatively speaking) and have you write a ‛psychiatric will’ specifying the conditions (if at all) under which you would consent to such a procedure. If you would not want it under any circumstances, explain why. If you would require certain information/evidence to be weighed, specify what kinds and how it would influence the decision.”

Activity 15.2: Psychotherapy Insurance Policy It is easy to complain about a problem, but it is an entirely different matter to propose a better alternative. Complaints about health care policy, insurance, managed care, and medical parity are commonplace. But if you could start from scratch in the development of a third-party reimbursement system for psychotherapy, what would it look like? What restrictions would it carry on covered disorders? Would only certain professionals be eligible for payments? Would there be limits on the length of treatment or on the total number or frequency of sessions? Would only certain kinds of treatment be permitted? How would this insurance compare to other kinds of medical insurance? Would there be any built-in system of accountability? Would scientific studies of psychotherapies constrain care in any way?

Activity 15.3: Discharge Plans The issue of where discharged mentally ill patients should live after leaving the hospital continues to be highly controversial. If these patients are to live in the broader community should they be placed in “halfway houses” with supervision? Where should these “halfway house” residences be located? Should .

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members of a community have any say over the placement of these facilities? Currently, when sexual offenders are released from prison into the community, these individuals are frequently required to notify local law enforcement and their location is available to interested citizens. Is this an issue for discharged patients? Does the diagnosis of the patient matter? After placing students into small groups, inform the students that they are a local community group appointed by the mayor with the responsibility of developing a plan for discharging psychiatric patients into their community. What options would they consider and for what kinds of patients?

Activity 15.4: Buyer Beware Students are often surprised to learn that they need no special training, credential, or license to advertise themselves as therapists and to open an office and begin providing services for emotional problems.

They would only be breaking the law if they advertised themselves as psychologists, psychiatrists, or social workers, or if they engaged in practices such as diagnosis, assessment, or prescribing medications protected by state laws. Many entered the course not being quite clear on the difference between a psychologist and a psychiatrist, so it can be especially alarming to imagine how the general public secures access to professional care. The first place many go is to the Yellow Pages. For this activity, have students go to the Yellow Pages as if they were a person having various problems and search for possible providers. They will find a wide variety of counselors, therapists, support groups, outreach agencies, specialty trainers, and mental health workers under an impressive array of titles and headings.

If the local Yellow Pages directory is rather small, the same assignment can be undertaken using Internet Yellow Pages available through Yahoo.com and other comprehensive Web directories. The legal restriction on engaging in restricted practices is an interesting one to discuss, inasmuch as it can be viewed as the reason so many practitioners with dubious credentials gravitate to fringe and pseudoscientific treatments. When credible scientific practices are available only to properly credentialed providers, those without such credentials must avoid scientifically respectable methods.

Activity 15.5: Helping Communities What are the responsibilities of community members to help others in the surrounding area? Much of the debate over third-party payment of insurance, social program funding, volunteerism, and private underwriting of social services turns on people’s opinions about this question. Handout 15.1 guides students through some of the major issues surrounding this question. Handout 15.1 Activity 15.6: EDPs and Police Ride-Along Programs Deinstitutionalization of the mentally ill and the consequent increase in the number of homeless mentally ill, have made the police a frequent first point of contact for people in need of mental healthcare. Most police receive specialty training about how best to manage EDPs, that is, emotionally disturbed persons, and the local police department might be willing to send one of its officers to the class to talk about that training and to describe their personal experiences. Better yet would be to send groups of students to “ride-along” with police, particularly for part of an overnight shift. Most larger police departments have ride-along programs that are available for the public to gain a greater appreciation of the police. Even if students do not experience an EDP call, they will still have an extended opportunity to talk with the officers about how they handle potentially violent situations, how they cope with psychotic behavior, and what they think about the impact of the mentally ill on the corrections system. Handout 15.2

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Web Links Web Link 15.1: http://prevention.samhsa.gov/ The Center for Substance Abuse Prevention is a model federal program for funding and studying preventive efforts. The section on “Model Programs” gives a good indication of the state-of-the-art in this important area.

Web Link 15.2: http://www.ilppp.virginia.edu/ This University of Virginia teaching and research center conducts forensic evaluations, makes policy recommendations, and holds conferences for both mental health and justice professionals.

Web Link 15.3: http://www.who.int/en/ This is the link to the Web page for the World Health Organization. In addition to information about the organization itself, there is information provided by country and alphabetically by health topic.

Additional links provide publications and resource tools available.

Web Link 15.4: http://www.reidpsychiatry.com/ This is an interesting site run by a renowned forensic psychiatrist, William Reid. It gives an especially helpful FAQ for students and trainees (including a section entitled “CLASS PAPER or REPORT DUE TOMORROW?”).

Web Link 15.5: http://www.bazelon.org/ The Bazelon Center for Mental Health Law is an advocacy agency for people with mental illnesses. It specializes in the constitutional rights of people with mental illnesses and mental retardation, addressing itself to issues of abuse and neglect in state institutions and the exclusion of children with disabilities from public schools.

Video Resources An Ounce of Prevention. The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection.

Another First Step: From Institutions to Independence: A Family Saga. New York, NY: Filmmakers Library.

The Art of Intervention. Psychiatric Interventions and Care Series. Irvine, CA: Concept Media.

The Community’s Response. Schizophrenia Series. Irvine, CA: Concept Media.

Confidentiality. New York, NY: Insight Media.

Diverting the Mentally Ill from Jail. Allyn and Bacon Video Library.

Home, Heart, Hope: Community Living for the Severely Mentally Retarded. New York, NY: Filmmakers Library.

The Homeless Home Movie. Berkeley, CA: University of California Extension Center for Media and Independent Learning. .

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Institutionalized Interventions. One Voice, Domestic Violence Series. Irvine, CA: Concept Media.

Mistreating the Mentally Ill. Princeton, NJ: Films for the Humanities and Social Sciences.

Nerve. New York, NY: The Cinema Guild.

No Place to Go. New York, NY: Filmmakers Library.

Racial Profiling and Law Enforcement: America in Black and White. Allyn and Bacon Video Library.

The Right Future: Beyond Institutionalization. Princeton, NJ: Films for the Humanities and Social Sciences.

The Right to Decide. Boston, MA: Fanlight Productions.

Shadow Children. New York, NY: The Cinema Guild.

Turning Away: Life on the Streets. Princeton, NJ: Films for the Humanities and Social Sciences.

Welcome to Happy Valley. New York, NY: Public Broadcasting Service.

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Handout 15.1 Helping Communities

1.

What are the responsibilities of community members to help others in the surrounding area?

Should neighbors be aware of the mental health of other citizens?

2.

What can be done by individuals to enhance the mental health of their neighbors?

3.

Describe possible community involvement that would improve mental health conditions.

4.

Should individuals with mental disorder live in the community? What arrangements are necessary?

5.

Ask a neighbor if he or she feels some responsibility for the well-being of people he or she doesn’t know personally.

.

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Handout 15.2 “EDP” Ride-Along Police are a frequent first point of contact for people in need of mental healthcare. Most police receive specialty training about how best to manage EDPs, that is, emotionally disturbed persons. Answer the following questions based on your ride-along experience with the police.

1.

How do the police handle potentially violent situations with EDPs?

2.

How do police cope with other psychotic behavior?

3.

What do the police officers think about the impact of the mentally ill on the corrections system?

4.

What kind of training did the officers receive in handling EDPs? Do they view their training as sufficient?

5.

What were some of the more memorable experiences officers had with EDPs?

6.

What do you think about the corrections and mental health systems intersection that exists when police officers work with EDPs? What could improve the system? Is there a better way?

7.

What are your own reflections on the ride-along experience?

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