Abnormal Psychology The Science and Treatment of Psychological Disorders, 15th Edition, Ann M Kring,

Abnormal Psychology The Science and Treatment of Psychological Disorders, 15th Edition

By Ann M. Kring, Sheri L. Johnson

Email: Richard@qwconsultancy.com

Kring/Johnson, Abnormal Psychology 15th Edition

CHAPTER 1 INTRODUCTION AND HISTORICAL OVERVIEW

LEARNING GOALS 1. Explain the meaning of stigma as it applies to people with psychological disorders.

2. Understand the characteristics that define psychological disorder.

3. Understand how the causes and treatments of psychological disorders have changed over the course of history.

4. Describe the historical forces that have helped to shape our current view of psychological disorders, including biological and psychological views.

5. Understand what we have (and have not) learned from history.

6. Describe the different mental health professions, including the training involved and the expertise developed.

The Learning Goals are inherent in both the Lecture Launchers and Discussion Stimulators below. Please note the Discussion Questions at the end of this chapter.

INTRODUCTION TO THE DSM-5 This Instructor’s Manual provides instructors with a comprehensive overview of material contained in the text. Each chapter of the Instructor’s Manual contains a chapter synopsis, a review of the learning goals and key terms, a series of Lecture Launchers, a compilation of Discussion Stimulators, and a list of relevant instructional films. Additionally, the manual contains criteria for disorders contained in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

CHAPTER SYNOPSIS

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The study of psychopathology is a search for the reasons why people behave, think, and feel in unexpected, sometimes odd, and possibly self-defeating ways. The focus of this book will be on the description, causes, and treatments of a number of different mental disorders. It is important to note at the outset that the personal impact of our subject matter requires us to make a conscious, determined effort to remain objective. Stigma remains a central problem in the field of psychopathology. Stigma has four components that involve the labels for mental illness and their uses (see Figure 1.1).

1.

2.

3.

4.

Distinguishing label is applied.

Label refers to undesirable attributes.

People with the label are seen as different.

People with the label are discriminated against.

Even the use of everyday language terms such as crazy or schizo can contribute to the stigmatization of the mentally ill. Despite advances, many frontiers of discrimination persist.

Defining Mental Disorder A number of different definitions of mental disorder have been offered, but none can entirely account for the full range of disorders. The DSM-5 definition includes a variety of important characteristics (see Figure 1.2).

1. Personal Distress: Whether or not a behavior causes personal distress can be a characteristic of mental disorder. But not all behavior that we consider to be part of mental disorders causes distress.

2. Disability and Dysfunction: Behaviors that cause a disability or impair a person’s functioning at work, home, school, and/or in social situations can be considered part of mental disorder.

However, disability and dysfunction alone cannot account for mental disorders.

3. Violation of Social Norms: Behavior that violates social norms can also be considered part of a mental disorder. However, not all such behavior is considered part of a mental disorder, and some behaviors that are part of mental disorders do not necessarily violate social norms.

Taken together, each definition of mental disorder has something helpful to offer in the study of psychopathology. The DSM-5 definitions include all of these characteristics.

Early History of Psychopathology Since the beginning of scientific inquiry into mental illness, supernatural, biological, and psychological points of view have vied for attention. Early concepts of mental illness included demonology (possession by demons) but also biological approaches as evidenced by the ideas of Hippocrates, who believed that mental illness was caused by a disturbance of the humors—for example, that melancholy or depression was caused by excessive amounts of sticky thick black bile and that schizophrenia arose from too much cold mucus. During the Dark Ages, some people with mental illness were cared for in monasteries, but many simply roamed the countryside. Some were persecuted as witches, but this was relatively rare.

(Later analyses indicated that many of the people accused of being witches were not mentally ill.)

Treatments for people with mental illness have changed over time, though not always for the better.

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Exorcisms did not do much good. Treatments in asylums could also be cruel and unhelpful, but pioneering work by Pinel, Dix, and others made asylums more humane places for treatment, ushering in an era known for moral treatment. Unfortunately, their good ideas did not last, as the mental hospitals became overcrowded and understaffed.

For a more intensive history of how views of psychopathology have evolved over time, here is a link to a time link: http://www.zeepedia.com/read.php?psychopathology_in_historical_context_supernatural_model_biologi cal_model_abnormal_psychology&b=83&c=3.

The Evolution of Contemporary Thought: Biological and Psychological Approaches Early systems of classifying mental disorders led to a reemergence of the biological perspective in the eighteenth and nineteenth centuries. Developments outside the field of psychopathology, such as the germ theory of disease and the discovery of the cause of general paresis via syphilis, illustrated how the brain and behavior were linked. Early investigations into the genetics of mental illness led to a tragic emphasis on eugenics and the enforced sterilization of many thousands of people with mental illness. Such biological approaches to treatment as induced insulin coma, electroconvulsive therapy (ECT), and lobotomy eventually gave way to drug treatments.

Psychological approaches to psychopathology evolved from Mesmer’s manipulation of “animal magnetism” to treat hysteria (late 18th century) through Charcot’s interest in psychological aspects of hysteria and Breuer’s conceptualization of the cathartic method in his treatment of Anna O. (late 19th century) and culminated in Freud’s psychodynamic theories and treatment techniques (early 20th century). Freud’s theory posited a three-part psyche made up of the id, ego, and superego. He further emphasized stages of psychosexual development and the importance of unconscious processes, such as repression and defense mechanisms, with the suggestion that people can fixate at an early stage, and that all of this is traceable to early-childhood conflicts. Therapeutic interventions based on psychodynamic theory (psychoanalytic therapy) make use of techniques such as free association and the analysis of transference in attempting to overcome repressions so that patients can confront and understand their conflicts and find healthier ways of dealing with them.

Jung and Adler took Freud’s basic ideas in a variety of different directions. Those who developed ego analysis maintained that the ego has energies of its own that are just as important as id energies and that it is important to focus on a person’s current living situation as well as his or her social interactions. Freud’s theorizing, though often criticized, introduced a number of concepts that are still discussed today, including defense mechanisms and the importance of the early environment in the development of psychological problems.

Behaviorism began its ascendancy in the 1920s and continues to be an important part of various psychotherapies. John Watson built on the work of Ivan Pavlov in showing how some behaviors can be conditioned, with the conditioned stimulus (CS) coming to elicit the conditioned response, or CR, via its repeated pairing with an unconditioned stimulus (UCS). B. F. Skinner, building on the work of Edward Thorndike, emphasized the contingencies associated with behavior, showing how positive and negative Instructors Manual

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reinforcement could shape behavior. Research on modeling helped to explain how people can learn even when no obvious reinforcers are present. Early behavior therapy techniques included systematic desensitization, aversion therapy, and modeling. Behaviorism did not account for emotions and thoughts and consequently, cognitive approaches became prominent in the 1960s. Cognitive therapy was developed based on the ideas that people not only behave, but they also think and feel. Cognitive therapies focus on changing maladaptive thoughts so that they will act differently and feel better. Here is a definition from the National Association of Cognitive-Behavioral Therapists: http://www.nacbt.org/whatiscbt-htm/.

The Mental Health Professions There are a number of different mental health professions, including clinical and counseling psychologist (Ph.D., Psy.D.), psychiatrist (M.D.), psychiatric nurse (R.N., L.P.N.), social worker (M.S.W.), mental health counselor (L.P.C., L.C.S.W.), and marriage and family therapist (M.F.T., Ph.D.). Each involves different training programs of different lengths and with different emphasis on research, psychological assessment, psychotherapy, and psychopharmacology. Mental Health America lists 13 mental health professions with a brief description of each and the role the play in mental health: http://www.mentalhealthamerica.net/types-mental-health-professionals.

KEY TERMS anal stage

defense mechanism

id

analytical psychology

demonology

individual psychology

asylums

ego

interpretation

aversive conditioning

ego analysis

latency period

behaviorism

electroconvulsive therapy (ECT)

law of effect

behavior therapy cathartic method classical conditioning clinical psychologist collective unconscious conditioned response (CR) conditioned stimulus (CS) counseling psychologist

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exorcism extinction fixation free association general paresis genital stage harmful dysfunction

libido marriage and family therapist mental disorder modeling moral treatment negative reinforcement operant conditioning oral stage

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phallic stage

psychodynamic theory

superego

pleasure principle

psychopathology

systematic desensitization

positive reinforcement

psychotherapy

transference

psyche

reality principle

psychiatric nurse

repression

unconditioned response (UCR)

psychiatrist

shaping

psychoactive medications

social worker

psychoanalysis

stigma

unconditioned stimulus (UCS) unconscious

LECTURE LAUNCHERS 1. Careers in Mental Health Many students enroll in Abnormal Psychology classes because of an interest in entering the field or a curiosity about abnormal behavior. An interesting class discussion could focus on a more detailed review of the various mental health professions and work settings (e.g., psychology department, academic medical center, hospital, community clinic, forensic settings, etc.). Each profession can be listed on the board and compared on various dimensions, such as years of training required, difficulty of acceptance into training programs, criteria for acceptance (courses, grades, national exams, outside activities), focus of academic training, and career possibilities.

Students are also likely to be interested in comparisons such as opinions that each profession holds of each other, inter-professional conflicts, lines of authority and power structure, salaries (the $125+ hourly rate for highly trained professionals amazes most students), and similar “insider” information.

Current topics of interest in the mental health field might be discussed, such as: 1. Should clinical psychologists be allowed “admitting privileges” at psychiatric hospitals?

2. Which professionals should be eligible to receive Medicare payments for their services?

3. Should professionals other than psychiatrists be allowed to prescribe psychotropic medications? (see Discussion Stimulator) 4. Should training of clinical psychologists focus on clinical or research training, or both?

5. How are career goals affected by managed care?

An article in American Psychologist (Purdy, J. E., Reinehr, R. C., & Swarx, J. D., 1989, 44, 960–961) reported on results of a survey of 106 graduate programs in experimental, clinical, and counseling psychology regarding their admissions criteria. Students might be interested in hearing the conclusions: The ideal graduate school applicant has a high GRE combined score, strong letters of recommendation, some research experience (particularly for Ph.D. programs), and a high overall GPA (with particularly high grades for the final two Instructors Manual

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years). For applicants for a clinical or counseling program, previous clinical experience is desirable. Undergraduate coursework would include statistics, experimental methods, and at least some laboratory experience (e.g., directed study).

Since the publication of this article by Purdy, Reinehr and Swarx, later studies have confirmed their conclusions. See for example the article in the American Psychologist (Norcross, J. C., Kohout, J. L., & Wicherski, M. (2005). Graduate Study in Psychology: 1971-2004. American Psychologist, 60(9), 959– 975).

2. HANDOUT: Hypnosis Because of its central role in the development of psychogenic theories of psychopathology, hypnosis is worth considering in more detail. A good place to start is with the question what exactly is hypnosis? Given how often psychologists and psychiatrists use the term, it is sobering to realize how much controversy there is about its nature. Hilgard (1979) suggests the following characteristics: 1. Increased suggestibility. Hypnotized subjects seem much more open to suggestions from the hypnotist than they would be in a waking state.

2. Enhanced imagery and imagination. Hypnotized subjects are able to imagine vividly the sensory experiences suggested to them and also report that they are able to retrieve images, sometimes from childhood, with great clarity.

3. Disinclination to plan. The hypnotized subject loses initiative and instead looks to the hypnotist as a source of direction. Indeed, many hypnotized subjects become annoyed when asked to do some planning on their own.

4. Reduction in reality testing. Many hypnotized subjects readily accept all kinds of perceptual distortions that they would not tolerate when awake. Thus hypnotized subjects may accept suggestions that an animal is talking to them or that someone is present in the room when no one is actually there. The logic that operates during a hypnotic trance, allowing a person to perceive the world in a way remarkably different from how he or she regards it when awake, has been called “trance logic” (Orne, 1959).

These are what many mental health workers regard as characteristics of hypnotized subjects. As in all aspects of human behavior, not all people manifest all these characteristics in the same way, and it is indeed possible for subjects who otherwise appear to be deeply hypnotized not to give all these noticeable indications at any one time. An excellent review of the characteristics and therapeutic processes can be found in Varga, K., Józsa, E., & Kekecs, Z. (2014). Comparative analysis of phenomenological patterns of hypnotists and subjects: An interactional perspective. Psychology of Consciousness: Theory, Research, and Practice, 1(3), 308.

Our historical review mentions Mesmer’s therapy for hysterical disabilities and subsequent work

by Charcot, Janet, and Breuer. During the same period of time, surgeons were “mesmerizing” patients to block pain. For example, in 1842 a British physician, W. S. Ward, amputated the leg of a patient after hypnotizing him. Apparently the patient felt nothing during what would otherwise have been an excruciatingly painful operation. In 1849 a mesmeric infirmary was opened in

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London. Hundreds of apparently painless operations were performed while the patients were in hypnotic trances. In the same decade, however, ether was proved to produce insensibility to pain.

The term anesthesia had heretofore been applied to the numbness felt in hysterical states and paralysis. Oliver Wendell Holmes is credited with suggesting that it be applied to the effects of this new agent and others like it, and that the agents be called anesthetics. The availability of these chemicals for surgical operations discontinued the use of hypnosis as an alleviator of pain.

The person who coined the modern term hypnotism is usually considered to be James Braid (1795–1860), a British physician who was also hypnotizing people to reduce pain. However, unlike Mesmer, Braid did not break with his profession, describing what happened in terms that were more consistent with the Zeitgeist. He characterized the trance as a “nervous sleep,” from which came the name “neurohypnology,” later shortened to hypnotism. Braid rejected the mystical orientation of Mesmer and yet continued to experiment with the phenomenon as he saw it. He sought a physiological cause and felt he had found one in his discovery that trances could be readily induced by having people stare at a bright object located somewhat above the line of vision. The object was placed in front of a person in such a way that the levator muscles of the eyelids had to be strained in order to keep it in view. Braid suggested that the muscles were markedly affected by having them remain fixed in this position for a given period of time and that somehow this led to nervous sleep or hypnosis. He therefore placed the cause of the sleep inside the subject rather than external to him, as Mesmer had suggested with his concept of animal magnetism. In this way he was able to perform many public demonstrations without incurring the disapproval of his medical colleagues.

A fascinating workbook by Mark Jensen, Hypnosis for Chronic Pain Management, suggests that medicine does not always have the answers for chronic pain management. There are exercises to try in Jensen’s book. Jensen, M. Hypnosis for Chronic Pain Management, Oxford University Press, 2011.

As already indicated, the discovery of drugs for anesthesia discouraged the use of hypnosis in medicine. While drugs are clearly more reliable, they are more dangerous than hypnotic inductions. In clinical work many practitioners have employed hypnotic procedures for psychotherapeutic purposes, especially during World War II. From the Gulf War to the present conflicts in the Middle East, veterans have had hypnosis madeavailable to them for the treatment of a variety of issues: bodily pain, terror, physical illness, addictions and guilt. To relieve the combat exhaustion of frightened and sleepless soldiers, doctors hypnotized them and encouraged them to relive traumatic events in the imagination.

The scientific study of hypnosis had to await the development of relatively objective measures in the 1950s. Perhaps it was the principal device developed at Stanford University by Weitzenhoffer and Hilgard (1959) called the Stanford Hypnotic Susceptibility Scale and based on the 1938 scale by Friedlander and Sarbin. In the application of this scale, or scales, the subject is hypnotized and then asked to undertake a series of tasks. For example, the hypnotist may suggest to a subject that his right hand is so heavy that it is doubtful whether he can raise it. Then the hypnotist will ask the subject to try to lift the heavy hand, even though he probably will not be able to do so. The hypnotist oversees the degree to which the subject can or cannot raise the hand and gives a plus or minus score. After the subject has been observed at a number of tasks, he is given a score ranging from 0 to 12, and this score is regarded as a measure of how deeply hypnotized he is.

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Most of these scales, however, do not measure the more subjective aspects of hypnosis. For example, many hypnotized subjects, even though they have not been specifically told that it may happen, experience sensations such as floating or spinning. Many hypnotists consider such subjective experiences at least as important as the more observable performances tapped by the various scales. As we might expect, this divergence of interests contributes to the controversy within the field, with the more clinically oriented hypnotists rejecting the validity of such scales.

Instead, they content themselves with reports of their subjective reactions.

References: Hilgard, E. R. (1979). The Stanford hypnotic susceptibility scales as related to other measures of hypnotic responsiveness. American Journal of Clinical Hypnosis, 21, 68–83.

Orne, M. T. (1959). The nature of hypnosis: Artifact and essence. Journal of Abnormal and Social Psychology, 58, 277–299.

Weitzenhoffer, A. M. & Hilgard, E. R. (1959). Stanford hypnotic susceptibility scale, Forms A and B. Palo Alto, CA: Consulting Psychologists Press.

3. Law and Lunacy in the Middle Ages As discussed in the text, Neugebauer (1979, “Medieval and early modern theories of mental illness” Archives of General Psychiatry, 36, 477–483) reviewed English legal documents dating back to the 13th century, at a time when the Crown assumed the right and responsibility for caring for the property and person of the mentally disabled. Contrary to the popular view that demonology was the primary explanation for mental illness, Neugebauer found only one reference to demonological possession in all the cases he examined. Two groups of incompetents were distinguished: idiots, or natural fools, and lunatics. These terms seem to roughly correspond to our terms “mentally retarded” and “insane.” For instance, a 16th-century source defined idiot as: he that is a fool natural from his birth and knows not how to account or number 20 pence, nor cannot name his father or mother, nor of what age himself is, or such like easy and common matters; so that it appears he has no manner of understanding or reason, nor government of himself, what is for his profit or disprofit.

Commonsense explanations were offered for the person's disturbed state. Consider the following cases: In July, 1490, John Fitzwilliam was said to be mentally disabled starting when he was “gravely ill.” In 1502, John Norwick “lost his reason owing to a long and incurable infirmity” and on September 18, 1291, a jury declared Bartholomew de Sadewill mentally deranged and attributed that condition to “a blow received on the head.” Robert Barry's insanity was, in 1366, thought to have been “induced by fear of his father.” Similarly, a 1568 hearing found James Benok to have been “afflicted by reason of a fright on 20 October 1556 and has so continued from that time to the present.”

Interested students might also want to read the following: Brooks, Barbara (Ed.) (2001).'Unfortunate folk': Essays on mental health treatment, 1863–1992, Dunedin, New Zealand: University of Otago Press.

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Torrey, E. Filler and J. Miller. (2001). The invisible plague: The rise of mental illness from 1750 to the present. New Brunswick: Rutgers University Press.

4. Hysteria vs. Malingering and the Views of Thomas Szasz At this point in the course, a discussion of the problems of diagnosis and classification and the historical roots of the concept of mental illness could be presented. Thomas Szasz covers this topic in The Myth of Mental Illness (1961, New York: Harper and Bros.). Szasz reviews Charcot’s influence on psychiatry and on the public’s view of mental disorders. Before Charcot's time, hysteria was considered to be a form of malingering (faking real physical illness), and such counterfeiters were treated with anger and hostility by physicians who resented the deception. After Charcot had lent his expertise and authority to the problem of hysteria, it was elevated to the status of “illness.”

Szasz asserts that this shift has led to the present-day classification of all human conduct as falling within the purview of mental illness.

How did this shift take place? Szasz suggests that Charcot’s goal was to get hypnosis and hysteria accepted by the medical profession as respectable phenomena, worthy of study; further, he asserts that rather than use logical analysis or scientific investigation to understand hysteria, Charcot simply changed the rules of classification so that “malingering” became “illness.” Given that the new illness could nevertheless be considered counterfeit in the sense that it mimics a physiological dysfunction, medicine acquired the responsibility of distinguishing not only real from imitated physical illness, but conscious from unconscious faking. If the sufferer counterfeits unknowingly, he is not a malingerer, but a hysteric. While this change in label may have been humane in the sense that such sufferers were no longer shunned by physicians, Szasz argues that it has obscured our understanding both of true organic neurological disorders and of problems in living that may only look like physical disorders. Further confusion arises when, as is the case today, conscious malingering itself is seen as a form of mental illness; Szasz quotes Bleuler: “Those who simulate insanity with some cleverness are nearly all psychopaths and some are actually insane. Demonstration of simulation, therefore, does not at all prove that the patient is mentally sound and responsible for his actions” (p. 48).

Discussion might focus on the following questions: 1.

2.

3.

4.

5.

What are the consequences of labeling a phenomenon an “illness?”

How does such a label obscure or clarify that which it describes?

Should psychiatry be considered a branch of medicine?

What is the value of distinguishing “conscious” from “unconscious” malingering?

Would it be considered malingering if organically based symptoms are exaggerated by psychological factors?

6. How can such a distinction be made?

7. If hysteria had continued to be seen as simple malingering, would the psychogenic hypothesis of psychopathology have been advanced?

5. Asylums in Modern Times The text summarizes some recent work by Whitaker (2002) concerning asylums in modern times.

Another significant contribution to this area is Burton Blatt’s work exposing the condition of

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institutions for the mentally retarded as recently as the late 1970s. In Exodus from Pandemonium (1970, Boston: Allyn & Bacon), Blatt documents institutional care of the mentally retarded.

Discussion might be sparked by reading the following quotes from Blatt’s book, asking students to guess the year (or century!) they describe: The children's dormitories depressed me the most. Here, cribs were placed—as in the other dormitories—side by side and head to head. Very young children, one and two years of age, were lying in cribs without any contact with any adult, without playthings, without apparent stimulation. In one dormitory that had over 100 infants and was connected to nine other dormitories that totaled 1,000 infants, I experienced my deepest sadness. As I entered, I heard a muffled sound emanating from the “blind” side of a doorway. A young child was calling, “Come, come play with me. Touch me” (p. 18). . . . I found two young women in one cell, lying nude in the corner, their feces smeared on the walls, ceiling, and floor—two bodies huddled in the darkness, on a bare terrazzo floor . . . On the next floor was a girl who has been in a solitary cell for five years, never leaving—not for food or toileting or sleep. This cell—this concrete and tile cubicle, without furniture or mattress or washstand, is one human being’s total universe” (pp. 72–73).

The words describe institutions visited by Blatt in the 1960s.

Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (Goffman, E., 1961, Chicago: Aldine Publishing Company) offers a sociological perspective on life in institutions, researched during the 1950s. In the essay “On the Characteristics of Total Institutions,” Goffman discusses institutional life (with a particular focus on mental institutions) from the point of view of both the “inmates” and the staff. Discussion might focus on the loss of identity, personal possessions, meaningful work, and control over personal needs (asking permission to go to the bathroom, use the telephone, spend money, mail letters) that characterizes institutional life, as well as the perspective of the staff who must reconcile patients’ self-destructive behavior and the resulting need for measures which curtail their rights, incompatible standards for different patients (e.g., if the gates are left open for those patients with “town privileges,” patients who could otherwise have enjoyed the use of the grounds might have to be kept in locked wards), and the conflict between humane treatment and institutional efficiency (e.g., collective clothing is depersonalizing, yet much more efficient to clean and keep track of than personally owned clothing). Students might be encouraged to think about ways that institutional life could be improved, as well as whether it is possible to effect true reform without abandoning the institutional system altogether (foreshadowing the discussion of de-institutionalization in Chapter 18).

For those students who believe that our current enlightened recognition of the problem of institutionalization is sufficient to alleviate the conditions in institutions, it can be pointed out that the following quote first appeared in the Journal of Mental Science in 1856: Asylums . . . might justly be called manufactories of chronic insanity. If a case recovers, and few indeed are those that do recover within their walls, it is

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certainly the result of fortuitous circumstances, and not of any special treatment applied to it (Aldridge, p. 1979, British Journal of Psychiatry, 134, p. 333) Awareness and outrage, while starting points, seem to be insufficient motivators for change in institutional care when viewed from an historical perspective.

A classic experiment by David Rosenhan and colleagues between 1969 and 1972 demonstrated that it was difficult to distinguish sane from insane in hospitals. An expanded interview can be seen at: https://www.youtube.com/watch?v=D8OxdGV_7lo&feature=emb_logo. or watch Rosenhan talking about his experience here: www.youtube.com/watch?v=j6bmZ8cVB4o&feature=emb_logo This link is to David Rosenhan’s article, “On being sane in insane places”: http://www.bonkersinstitute.org/rosenhan.html.

They were admitted to psychiatric hospitals claiming they heard voices saying “empty, dull, thud” and then after admission claimed that they felt fine and had not more hallucinations. The ensuing experience was described by Rosenhan as dehumanizing. This is an excellent discussion starter.

6. Setting the Record Straight Skinner’s death in August of 1990 rekindled both recognition of his accomplishments in psychology and renewed criticism of his views. Many of his critics are journalists in the popular press who are both confused and inflamed by his social views as espoused in Walden Two and Beyond Freedom and Dignity. Since many of your students may have read one of these books (or, more likely, formed an opinion of Skinner without having read his books), discussion of some of the points raised by Dinsmoor in “Setting the record straight: The social views of Skinner” (1992, American Psychologist, 47, 1454–1463) may be helpful. The following points are especially illuminating: 1. While many misinterpreted Skinner as a totalitarian, interested only in controlling the behavior of humans, he may more accurately be seen as a libertarian. His point is that humans are already being controlled by their governments and other social institutions, and the important issue to address is what form that control should best take. One of Skinner's primary concerns, then, was to criticize the use of aversive control, or punishment, as oppressive and ineffective.

2. Dinsmoor believes that Skinner may have been too confident that what is reinforcing is also good for the person whose behavior is being reinforced; thus, he may have underestimated the possibility that positive reinforcement could be used for selfish purposes.

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

A second discussion may be about the “air-crib” or “heir conditioner” and Deborah Skinner Buzan.

Some claim that her father, B. F. Skinner, confined her to this device, rather than putting her into a regular crib, as some sort of research project. See the “air-crib” here:

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https://www.schoolforthedogs.com/being-the-baby-in-the-box-bf-skinners-daughter-dispels-themyths/

DISCUSSION STIMULATORS 1. Prescription Privileges for Psychologists As mentioned in the text, controversy has emerged in recent years over whether or not psychologists should be allowed to prescribe psychotropic drugs. Several recent articles discuss the pros and cons of such a change and might provoke interesting class discussions. For example, Brentar and McNamara (1991, “The right to prescribe medication: Considerations for professional psychology,” Professional Psychology: Research and Practice, 22, 179–187) present arguments in favor of prescription privileges for psychologists as well as impediments to such change. They argue that in rural areas in particular, there are too few psychiatrists to meet the communities' needs for psychotropic medications. Thus, such drugs are usually prescribed by general practitioners who have little or no psychiatric training (and may, in fact, already look to psychologists for help or consultation). In addition, it has been argued that prescription privileges will reduce health care costs since psychologists generally charge significantly less than psychiatrists.

Impediments to changes in the prescription laws include 1) a recent study by Crabtree in 2012 found strong objections from physicians (Dissertation Abstracts International: Section B: The Sciences and Engineering, Vol. 73(6-B). p. 3934. Publisher: ProQuest Information & Learning [Dissertation]), 2) psychologists’ theoretical foundation (some are concerned that prescription privileges would lead to a situation where “biological explanations of mental illnesses may be accepted without fully examining psychological determinants” [p. 182]), 3) the need to develop new psychopharmacological training programs for psychologists, 4) necessary changes in licensing laws and procedures for psychologists, and 5) increased malpractice liability for psychologists who wish to prescribe medication.

In “Prescription privileges for psychologists: The case against,” DeNelsky (1991, Professional Psychology: Research and Practice, 22, 188–193) raises the concern that prescription privileges would make psychology more a medical specialty than a predominantly behavioral field; he notes that psychiatry moved away from psychotherapy as it began to rely more on psychoactive medications. Students might be asked to read DeNelsky’s article with attention to the paradigmatic issues raised by consideration of such a major change in the role of psychologists. For example, DeNelsky discusses both the usefulness of non-biological interventions for conditions with a biological basis and the idea promoted by other writers that avoiding prescription privileges is a way of returning to the outdated notion of mind-body dualism.

A recent study examined the attitudes of psychology graduate students toward prescription privileges (Luschner, Corbin, Bernat, Calhoun, & McNair, 2002, Journal of Clinical Psychology, 58, 783–792). The findings indicated no consensus among graduate students regarding prescription privileges. One concern expressed in this study was that the course work needed to prepare for prescription privileges would considerably lengthen the time required to complete graduate

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training. Some of the possible issues mentioned in this study include difficulties with the medical profession, how to determine the best training method, increased malpractice insurance costs, whether psychologists could prescribe adequately, and the need for the field of clinical psychology to remain competitive.

In a special issue of the Journal of Clinical Psychology (2002, Vol. 58), some of the issues central to this debate were summarized by Helby: 1) The need of mental health care professionals to provide managed care and to collaborate more directly with primary care providers; 2) Whether prescription privileges represents an ongoing move to “medicalize” the field of psychology; 3) How training for prescription privileges will impact the entire graduate curriculum; 4) The cost of obtaining prescription privileges; 5) The impact of privileges on collaboration with physicians; and 6) Policy differences within the professional organizations toward prescription privileges.

Several states are allowing psychologists to have prescription privileges, the latest being Idaho in 2017. The states that do allow this privilege have stringent requirements: https://www.apaservices.org/practice/advocacy/authority/prescribing-psychologists.

2. Is It Really Abnormal?

The text discusses four “characteristics” of mental disorder: disability, distress, violation of social norms, and dysfunction. Discussion might focus on how each of these definitions could be misused. Examples: In a repressive society that values neighbors spying on neighbors, could those who do not spy on their neighbors be classified as having a mental disorder? The text discusses personal distress as another characteristic of mental disorder. In the above example, it is not difficult to imagine that one could become distressed either as an individual who spies on neighbors or as the spied-upon neighbor. Would either case be within the realm of Abnormal Psychology? In addition, some forms of mental disorder are more distressing to others than to the individual who presents for therapy. For example, children may be brought to a therapist because their behavior is distressing to the parents. How do we know that it is the child’s behavior that is abnormal rather than the parents’ lack of parenting skills?

3. Pre-Post Assessment of Students’ Views of Mental Disorder Name ___________________________

(circle one:) PRE or POST 1. How would you define “mental illness”?

2. Where do you think “mental illness” comes from? Do you think that the root of mental disorders is primarily physical/organic, early-childhood experiences, current environmental forces, or some other factor? Explain.

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3. How do you think people with mental illnesses should be treated? What treatment approach(es) do you think work best? How can we reduce stigma around mental illness?

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

4. Are You Satisfied with the Current Classification System for Mental Disorders?

Have students generate a list of behaviors they consider “odd” or “abnormal.” Then have them discuss whether each behavior meets the criteria for being a mental disorder. Are there behaviors that are concerning that don’t meet the criteria for being a mental disorder? Are there behaviors that are not concerning that do meet the criteria for being a mental disorder? Facilitate a class discussion that includes the students’ reactions to the classification system.

INSTRUCTIONAL FILMS 1. The Mind, No. 1—Search for Mind (PBS/ALS, 60 min., color video, 1988) Explores ways that science has looked into the mind throughout history, from psychoanalysis to neuroscience.

2. Hurry Tomorrow (Richard Cohen Films, 80 min., b&w, 1975) A documentary filmed in a Los Angeles psychiatric hospital that depicts the attitudes of staff and the treatment of patients. The film also illustrates how individuals struggle to maintain their dignity in what the film maker described as “a dehumanized environment.”

3. King of Hearts (MGM, 102 min., color video, 1966) This classic film stars Alan Bates as an English soldier sent to scout out a German-occupied French village, abandoned by all but members of the local insane asylum. The film focuses on what happens when these residents occupy the town. An excellent and humorous portrayal of normal and abnormal behavior.

4. Back from Madness: The Struggle for Sanity (FHS, 53 min., color, #BVL6299) “This program provides a view of the world of insanity that few ever see, following four psychiatric patients for one to two years, from the time they arrive at Harvard’s Massachusetts General Hospital, and contextualizing their present-day treatments with rare archival footage demonstrating how their conditions were treated in the past. On one level, the program examines what psychiatric treatment is like today at one of the world's most famous hospitals. Beyond this, the program is about the patients themselves, and the inner strength required of them as they search for some relief from the severe mental illnesses they are coping with: schizophrenia, manicdepression, obsessive-compulsive disorder, and suicidal depression. Caution: graphic images contained in this program may be objectionable to certain viewers. An HBO production.”

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5. Mistreating the Mentally Ill (FHS, 56 min., color, #BVL5069) “There are 250 million seriously mentally ill people the world over and no society—rich or poor— has devised a humane system of care. This program focuses on the United States, Japan, India, and Egypt, examining how each culture sees mental illness and treats the less accepted members of society. In general, Japan locks its patients up for long periods in predominantly for-profit institutions where they are often subjected to brutal treatment; the United States, with the best of intentions, casts many of its mentally ill out on the streets or into vast shelters with little hope of receiving care; India treats less than 10% of those who need care, with occasional oases of good community care contrasting with examples of inhumane conditions in psychiatric hospitals; while in Egypt, rural traditions that tolerate the mentally ill are being submerged in industrialization, and one of Cairo's largest private mental hospitals is run as a business by the president of the World Federation of Mental Health. The program concludes that the problem is not merely shortage of funds, but the indifference of society to the mentally ill.”

6. Committed in Error: The Mental Health System Gone Mad (FHS, 52 min., #BVL3997).

“This is the story of a man who spent 66 years incarcerated and forgotten in mental health institutions, although there was never anything wrong with him. This particular story takes place in Britain, but it could as easily have happened in the United States—people put away because they were hard of hearing, or their family didn’t want them—people whose lives were destroyed because the system went tragically wrong.”

7. Bellevue: Inside Out (FHS, 76 min., #BVL11870) “New York City's Bellevue Hospital has a renowned psychiatric emergency center that treats 7,000 men and women annually. This gritty program takes a daunting look at the daily operation of the center by focusing on a handful of people as they struggle with their illnesses. The entire experience is presented, from arrests of the criminally insane and admissions of new patients to long-term treatment and therapy groups. In addition to working with mental disorders, doctors and nurses also confront drug and alcohol addiction in an environment where 50% of their patients have substance abuse problems. An HBO production.”

8. How Mad Are You? (BBC Horizon, 108 min., color, video, 2008) “Around one in four people in the UK has been diagnosed with mental illness at some point in their lives. For many, simply being called "mentally ill" is a heavy burden, as it can bring profound social stigma, leaving some patients outcast all their lives. This two-part special for Horizon confronts this stigma and probes the fine line between mental illness and sanity. It asks: how mad are you? The program features 10 volunteers; half have psychiatric disorders; the other half do not—but who is who? Over five days, the group takes part in a life-changing experience as they are put through a series of challenges—from performing stand-up comedy to mucking out cows—to see who copes best with the tests put before them.” The events are designed to explore the character traits of mental illness and ask whether the symptoms might be within all of us. Horizon asks if you can tell who is who, and considers where the line between sanity and madness lies.

9.

The Marketing of Madness: Are We All Insane? (Topdocumentaryfilms.com, 2:58 hr.)

“The Marketing of Madness is the definitive documentary on the psychiatric drugging industry. Here is the real story of the high-income partnership between psychiatry and drug companies that has created an $80 billion psychotropic drug profit center. But appearances are

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deceiving. How valid are psychiatrists’ diagnoses—and how safe are their drugs? Digging deep beneath the corporate veneer, this three-part documentary exposes the truth behind the slick marketing schemes and scientific deceit that conceal dangerous and often deadly sales campaigns.” http://topdocumentaryfilms.com/marketing-of-madness-are-we-all-insane/.

10. Bedlam: The History of Bethlem Hospital (Topdocumentaryfilms.com,47 min.)

“The Bethlem Royal Hospital in London became infamous in the 1600s in regards to the inhumane and cruel treatment of its patients as revealed by psychiatric historians.

Bedlam: The History of Bethlem Hospital reveals why Bedlam came to stand for the very idea of madness itself.

It was satirized for centuries as both a human zoo and a university of madness and for 100 years was one of London's leading tourist attractions, as Madame Tussauds is today.

Britain's leading psychiatric historians discuss Bedlam and its inhabitants as we reveal the incredible history of one of UK's most notorious institutions.” http://topdocumentaryfilms.com/bedlam-the-history-of-bethlem-hospital/.

11. Inside Britain’s Highest Security Psychiatric Hospital (1:31 hr.)

“Patients that come here, they will have perpetrated often horrendous crimes but they are also victims and it’s very easy to see somebody as either the perpetrator or the victim. It’s much more difficult to understand that somebody might be both,’ Dr. Amlan Basu, Clinical Director.

Broadmoor, the most famous high secure hospital in the world, has allowed unprecedented access to television cameras for this new two-part ITV documentary. For the first time in its 150-year history, the viewing public will see the innermost parts of this iconic institution in this two-part series. The hospital in Berkshire, is often mistaken for a prison. It’s best known for its high profile patients such as Charles Bronson, Ronnie Kray, Peter Sutcliffe and Kenneth Erskine. Filmed over the course of a year, with extensive access to the hospital, the programmes paint a picture of life inside Broadmoor for both staff and patients. It’s the first time that patients have been allowed to tell their stories themselves and cameras follow patients while they meet psychiatrists, open up about their violent backgrounds, visit the hospital shop and participate in workshops.” https://www.dailymotion.com/video/x6rcxo5 (Part 1) https://www.dailymotion.com/video/x6s1nn6 (Part 2)

12. Children of Darkness (Topdocumentaryfilms.com, 57 min.)

“This is an Oscar nominated 1983 documentary film exploring the issue of mentally ill children and the institutions they lived in. The film not only exposed the abuse in mental institutions, but it also educated people that mental illness can happen to anyone.

Hundred and sixty mentally ill and emotionally disturbed children lived at the Eastern State School and Hospital (now closed) in Trevose, Pennsylvania.

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They were psychotic, schizophrenic; they suffered from organic brain damage and autism. Some were hyperactive, some totally withdrawn, some were suicidal. Many of the children at Eastern were chronically mentally ill and never saw what we see, heard what we hear, thought in ways we do. Eastern State was the largest children's state psychiatric hospital in America. Each child got food, medication, and a place to sleep.” https://topdocumentaryfilms.com/children-darkness/. https://topdocumentaryfilms.com/bulgaria-abandoned-children-revisited/

Discussion Questions These questions are based on the clinical case studies and other information found throughout the chapter.

Jack In reviewing Jack’s case, we see that he has been stigmatized by many of his family members and others in the community. In what ways can community strategies, policy and legislative strategies, and individual strategies help to illuminate or reduce the stigmatization of people with mental illnesses?

Felicia Felicia’s case history reflects the plight of many elementary school children. Because these children have a disorder that makes them appear different, they are singled out and stigmatized by their peers. How might school systems address this problem?

José In what ways does José’s behavior described in the case history fit the DSM definition of a psychological disorder? How could José benefit from treatment? How might cultural influences play a role in José’s clinical presentation?

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CHAPTER 2 CURRENT APPROACHES IN PSYCHOPATHOLOGY

LEARNING GOALS 1. Describe the essentials of the genetic, neuroscience, and cognitive behavioral influences on psychopathology.

2. Describe the essentials of socioemotional influences, including emotion, culture, ethnicity, stress, trauma, and interpersonal influences, on the study and treatment of psychopathology.

3. Recognize the importance of integration across many influences to understanding the causes and treatments for psychopathology.

The Learning Goals are inherent in both the Lecture Launchers and Discussion Stimulators below.

Please note the Discussion Questions at the end of this chapter.

CHAPTER SYNOPSIS Science is a human enterprise, and scientific inquiry is limited by scientists’ human limitations and by the limited state of our knowledge: people see only what they are able to see, and other phenomena go undetected because scientists can discover things only if they already have some general idea about them. This chapter reviews several types of influences that guide the study and treatment of psychopathology: genetic, neuroscience, cognitive behavioral, and socioemotional. All of these influences are important for a complete understanding of the phenomenology, etiology, and treatments of mental health disorders covered in the rest of the textbook. Importantly, no one influence is superior to the others. Rather, each provide important and complementary information.

Genetic Influences The field of genetics focuses on questions such as whether certain disorders are heritable and, if so, what is actually inherited. Heritability is a population statistic, not a metric of the likelihood a particular person will inherit a disorder. Environmental effects can be classified as shared and

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nonshared. Molecular genetics studies isolate particular genes and gene polymorphisms that may be involved in psychopathology.

Behavior genetics is the study of the degree to which genes and environmental factors influence behavior. The total genetic makeup of an individual, consisting of inherited genes, is referred to as the genotype (physical sequence of DNA); the genotype cannot be observed outwardly. In contrast, the totality of observable, behavioral characteristics, such as level of anxiety, is referred to as the phenotype.

Molecular genetics studies seek to find out what exactly is heritable by identifying particular genes and their functions. Different forms of the same gene are called alleles. A genetic polymorphism refers to a difference in DNA sequence on a gene that has occurred in a population. Research has emphasized the importance of gene-environment interactions. Genes do their work via the environment in most cases. Recent examples of genetic influence being manifested only under certain environmental conditions (e.g., poverty and IQ; early maltreatment and depression) make clear that we must not look just for the genes associated with mental illness, but also for the conditions under which these genes may be expressed.

Recent molecular genetics research has focused on identifying differences between people in the sequence and structure of their genes. For example, single nucleotide polymorphisms (SNPs) refer to differences between people in a single nucleotide. On the other hand, another area of interest is examining differences between people in their gene structure, such as identifying copy number variations (CNVs), which refers to an abnormal copy of one or more sections of DNA within a single gene or multiple genes.

Recent advances in genetic sequencing technology now have popularized genome-wide association studies (GWAS), which are a key method of examining SNPs and CNVs across thousands of genes in very large samples of individuals. This research has led to recent breakthroughs in our understanding of genetic influences on mental health (see Lecture Launchers below for more).

Recent advances in genetic research have also shown significant evidence of gene-environment interactions, where a person’s sensitivity to environmental context is influenced by their genetic makeup. However, the environment can also alter gene expression or function through epigenetic processes. Since a person can also choose to select certain environments to expose themselves to, a person’s behavior can also influence their gene expression. There is even evidence that epigenetic markers can be passed down through multiple generations, such as those related to the experience of adversity or trauma (Yehuda & Lehmer, 2018).

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Neuroscience Influences Neuroscience approaches are concerned with the ways in which the brain contributes to psychopathology. The cells that make up the brain and rest of the nervous system are called neurons.

Each neuron has four major parts: the cell body, dendrites, axons, and terminal buttons. The gap between adjacent neurons is called the synapse. Neurotransmitters such as serotonin, norepinephrine, dopamine, and gamma-aminobutyric acid (GABA) have been implicated in a number of disorders.

The cortex of the human brain is composed of two broad types of nervous tissue: (1) gray matter, which is the thin outer covering of the brain containing tightly packed neurons, and (2) white matter, which makes up much of the interior and is made up of large tracts of myelinated fibers that connect parts of the brain and spinal cord. Ventricles are fluid filled cavities deep within the brain which contain cerebrospinal fluid and connect to the spinal cord. The brain itself includes a variety of structures important for mental functioning that have been implicated in mental disorders, such as the prefrontal cortex, anterior cingulate, hippocampus, hypothalamus, and the amygdala. Earlier research on the brain and psychopathology focused on activity in discrete brain regions. However, more current research has focused not just on specific regions of the brain, but rather the connectivity between different brain regions. Brain regions do not operate in isolation, but across several brain networks.

The autonomic nervous system, which includes the sympathetic and parasympathetic nervous systems, is also implicated in the manifestations of some disorders. The sympathetic nervous system prepares us for sudden activity and stress. The parasympathetic helps us to calm down, though these distinctions are not always so clear-cut. As part of the neuroendocrine system, the HPA axis is responsible for the body’s response to stress and thus is relevant in several stress-related disorders.

The immune system has also shown to interact with stress and show associations with mental health disorders. For example, inflammation stimulates the release of proteins called cytokines, which help initiate bodily responses to infection, such as fatigue, inflammation, and activation of the HPA axis.

Some mental health disorders, such as depression and schizophrenia show elevated pro-inflammatory cytokines, which may explain why some mental health symptoms, such as fatigue or brain fog, may have some similarities to a viral infection.

Although biological treatments, primarily medications, are effective treatments for mental disorders, these treatments are not necessarily treating the cause of the problems. Although the brain plays an important role in our understanding of the causes of psychopathology, we must be careful to avoid reductionism.

Cognitive Behavioral Influences Cognitive and behavioral influences incorporate perspectives from behavior therapy and cognitive science.

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As reviewed in Ch. 1 the major figures on the behavioral side are John B. Watson, B.F. Skinner, and Albert Bandura, who considered mental illness as caused by maladaptive learning, conditioning, and modeling. Treatment techniques designed to alter the consequences or reinforcers of a behavior, such as in time-out or a token economy, are still used today. Behavioral activation (BA) therapy is one type of therapy based on behavioral principles of positive reinforcement used in treatment of depression. Similar principles can be used to reduce unwanted behavior, such as aggressive behavior in conduct disorder. Exposure is a key component to cognitive behavioral treatments of anxiety.

Cognitive science focuses on concepts such as schemas (a network of accumulated knowledge or set), attention, and memory, and these concepts are part of cognitive behavioral theories and treatments of psychopathology. Cognitive behavior therapy uses behavior therapy techniques and cognitive restructuring. Aaron Beck developed cognitive therapy for depression based on the idea that depressed mood is caused by distortions in the way a person perceives their life experiences (Beck, 1976). These distortions, or negative interpretations, can also be referred to as maladaptive mental schemas. Cognitive behavioral therapy incorporates both cognitive and behavioral components and can be effective for a variety of mental health disorders.

The work of Freud in developing psychoanalytic theory has been influential in understanding the importance of early life experiences and highlighting the importance of the unconscious. Much of human behavior has historically been presumed to be unconscious—meaning outside of an individual’s awareness. Modern cognitive psychologists and neuroscientists also study unconscious processes, such as implicit memories.

Socioemotional Influences Emotion plays a prominent role in many disorders, but the ways in which emotions can be disrupted vary quite a bit. Emotions guide our behavior and help us to respond to problems or challenges in our environment. It is important to distinguish among components of emotion that may be disrupted, including expression, experience, and physiology. In addition, mood can be distinguished from emotion. The concept of ideal affect points to important cultural differences in emotion that may be important for psychopathology. Psychological disorders have different types of emotion disturbances, and thus it is important to consider which of the emotion components are affected. In some disorders, all emotion components may be disrupted, whereas in others, just one might be problematic. Emotion is an important focus in the paradigms.

Sociocultural factors, including culture, ethnicity, gender, poverty, social support, and relationships are also important factors in the study of psychopathology. Some disorders appear to be universal across cultures, like schizophrenia or anxiety, yet their manifestations may differ somewhat and the ways in which society regards them may also differ. Other disorders, like eating disorders or hikikomori (which in Japanese culture refers to those who pull away from others and into themselves, seeking a life of extreme isolation and confinement—the recluses, loners, or hermits), may be specific to particular cultures. Some disorders are more frequently diagnosed in Instructors Manual

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some ethnic groups than in others. It is not clear whether this reflects a true difference in the presence of disorder or perhaps a bias on the part of diagnosticians. Research is also examining whether risk factors associated with various disorders differ for men and women. Sociocultural factors have recently become the focus of people working in neurobiological or cognitive domains, and this trend will continue.

Social relationships and other interpersonal influences can be important buffers against stress and have benefits for physical and mental health. Consequently, it is important that clinicians help clients build and maintain healthy social relationships. This goal is accomplished through a number of different approaches, including couples therapy, family therapy, and interpersonal therapy. Couples therapy and family therapy can be used to strengthen social relationships and improve healthy communication. Interpersonal therapy (IPT) is based on the idea that interpersonal problems can contribute to mental health issues, such as depression. IPT aims to help clients strengthen their interpersonal relationships by helping them identify feelings about their relationships and generate solutions to interpersonal problems.

KEY TERMS Allele

Cortisol

hippocampus

Amygdala

Cytokines

HPA axis

anterior cingulate

Dopamine

Hypothalamus

autonomic nervous system (ANS)

Emotion

interpersonal therapy (IPT)

Epigenetics

molecular genetics

Exposure

neuron

GABA

neurotransmitters

Gene

nonshared environment

gene expression

norepinephrine

gene-environment interaction

parasympathetic nervous system

GWAS

phenotype

Genotype

polygenic

gray matter

polymorphism

heritability

prefrontal cortex

behavior genetics brain stem BA therapy brain networks cognition cognitive behavior therapy (CBT) cognitive restructuring connectivity CNV

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pruning

shared environment

time-out

reuptake

SNP

ventricles

schema

sympathetic nervous system

white matter

serotonin

synapse

LECTURE LAUNCHERS 1. The Manufacture of a Human Chromosome For years, scientists have been able to create artificial chromosomes for very simple living organisms such as yeast. A mouse chromosome was created in the lab in 1996. But in 1997, the first artificial human chromosome was created at a lab at Case Western Reserve University in Cleveland (reported in Nature Genetics, April, 1997).

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

Eventually, a wide range of inherited or infectious diseases might be amenable to such gene therapy. Research in this area has grown considerably. A popular area for research is gene therapy for psychiatric disorders. In 2011, Thome, Hassler, and Zahariou in the World Journal of Biological Psychiatry point out that several developments in experimental neuroscience suggest that gene therapy may have an effect in animal models including addiction, affective disorders, and psychoses. However, it will take time for this to be applied to psychiatric patients (September 2011, Supplement, 12, 16–18). More recently, Gelfand and Kaplitt suggested that gene therapy has become of greater interest in neurosurgery and that clinical trials for Parkinson’s disease, Alzheimer’s disease, and pediatric genetic disorders have been completed (World Neurosurgery, September 2013, 80, S32.e11–S32.e18).

However, despite significant efforts, this research has failed to find that any mental health disorder is due to a single gene. Rather, it seems that complex patterns of genes may contribute to mental disorders (i.e., mental disorders are polygenic) and some genes may contribute to risk for more than one disorder. More recent research has focused on GWAS to examine thousands of genes in very large samples to find patterns of associations with mental health disorders. For example, Antilla, Bulik-Sullivan et al. (2018) and Smoller, Andreassen et Instructors Manual

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al. (2019) found in a large collaborative research effort that diverse disorders such as schizophrenia, bipolar disorder, major depressive disorder, ADHD and anxiety disorders share common genetic risk. Genes may also interact with environmental factors to contribute to risk, so it is not currently possible to predict whether or not someone will have a mental disorder based on their genetics.

Several websites of interest are 1.

2.

3.

4.

5.

The Institute for Genomic Research – http://www.tigr.org/ Genome Web – http://www.genomeweb.com/ National Center for Biotechnology Information – http://www.ncbi.nlm.nih.gov/ Genome Research – http://genome.cshlp.org/ National Human Genome Research Institute (NGGRI) – https://www.nih.gov/aboutnih/what-we-do/nih-almanac/national-human-genome-research-institute-nhgri.

2. Does Everything Come Down to Neurotransmitters?

As readers work their way through the textbook, they will notice that neurotransmitters like serotonin or dopamine feature prominently in etiological theories for many mental disorders.

For example, low levels of serotonin have been associated with everything from eating disorders, depression, and alcoholism to suicide and aggression.

On the other hand, animal studies have demonstrated repeatedly that environment plays a tremendously important role in serotonin levels. For example, Suomi and colleagues at the National Institute of Child, Health, and Human Development have found that childhood environments affect monkeys’ behavior and serotonin systems. Monkeys with low serotonin levels are markedly aggressive and impulsive, take physical risks, and, when provided access to alcohol, drink excessively. In the wild, such monkeys are rejected by their peers, fail at mating, and often die at an early age. Lest we assume that biological factors fully account for the monkeys’ behavior, however, consider the impact of environmental factors on serotonin levels. Monkeys raised without their mothers (with only peers for support) had low serotonin levels as early as 14 days of age and continuing into adulthood. Future research by this lab will include exploring whether ideal rearing environments can ameliorate the negative effects of low serotonin levels. Other research is being done on the role of serotonin and mental illness, such as the study by Uher who suggests that there is an interaction between gene and environment in severe mental illness that includes an interaction with the serotonin transporter gene and depressive disorder (Frontiers in Psychiatry, 5, May 15, 2014. ArtID: 48).

3. Are Neuroscience Approaches Superior?

The 1990s were proclaimed the “decade of the brain.” Much of the research conducted has helped to highlight the impact of neuroscience on our understanding of mental illness. With this in mind, students might expect that the discovery of biochemical causes for various

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mental disorders invalidates the psychological paradigms. If symptoms can be explained by neurochemical changes or a “chemical imbalance,” is there still a role for paradigms that emphasize talking, thinking, and behaving in the etiology and treatment of these same disorders?

Along these lines, one study in the early 1990s (Baxter et al., 1992) found both a medication (fluoxetine) and a form of behavior therapy (exposure and response prevention) resulted in the same changes in brain function on PET scans in patients who improved following treatment.

These findings illustrate an interconnection between biology and behavior, as a psychological treatment can be shown to have a direct impact on a biological process.

Another discussion of obsessive-compulsive disorder (OCD) highlights the role of psychodynamic therapy in a disorder believed to be mainly biologically caused. In “Psychodynamic psychiatry in the ‘Decade of the Brain,’” Gabbard (1992, American Journal of Psychiatry, 149, 991–998) emphasizes the way in which mind and brain interact in mental disorders. While noting the strong biological components of OCD and the lack of empirical evidence favoring psychodynamic therapy in the treatment of the disorder, Gabbard illustrates ways in which psychodynamic principles can nonetheless be valuable. Consider the following case, described by Gabbard: A 29-year-old man with OCD is so obsessed with avoiding contamination that he insists that his mother move in with him and care for him 24 hours a day; his father is not allowed in the house. His mother must follow a 58-step ritual in making dinner, and if one step is not followed, she must discard the meal and begin again. While the patient had been prescribed clomipramine, he stopped taking it after one dose and eventually was hospitalized by his parents. The following interchange occurred with his therapist: When he came to the hospital, I asked him why he was seeking treatment. He responded, “I'm determined to be dependent—I mean, independent.” I commented to him that he had first said “dependent,” and I inquired, “Is there perhaps a part of you that would like to be dependent?” Mr. A responded, “You mean on my mother?” I replied that I thought he would know better than I. Mr. A reflected a moment and said, “Well, she does take pretty good care of me.” Mr. A’s slip of the tongue provided a glimpse into the unconscious motivations for his resistance to treatment. Any kind of successful treatment threatened his dependent relationship with his mother. If clomipramine were likely to help him, then he would not take it. Mr. A reportedly improved during his stay in the hospital, discovering that the hospital setting had successfully reduced his anxiety about sexual feelings toward his mother. While this treating psychiatrist noted the importance of medication in the standard treatment of OCD, he used this case as an illustration of the role of psychodynamic principles, both in understanding the unconscious wishes accompanying the biologically driven symptoms, and in handling noncompliance with the biologically based intervention.

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4. The Gut-Brain Axis: A Missing Link?

The past few years have involved a growing interest in the potential link between the gut and mental health, as evidence from studies with rodents has shown that gut microbiota can have a dramatic impact on the behavior of rodents in ways that can mimic depressive or anxietylike behavior. Gut microbiota are the numerous bacterial organisms that inhabit the gut of humans and other animals. Research in humans has just begun to emerge suggesting that individuals with mental health disorders such as depression may have abnormalities in the structure or function of their gut bacteria. These abnormalities may lead to alterations in neural function and behavior. This work has the potential to lead to a better understanding of mechanisms underlying risk for depression and lead to novel interventions. For example, fecal transplants have already been used for patients with recurrent C. difficile colitis, a bacterial infection of the gut. Future research may lead to similar treatments for depression and other mental health disorders.

Cryan, J. F., O'Riordan, K. J., Cowan, C. S., Sandhu, K. V., Bastiaanssen, T. F., Boehme, M., ... & Dinan, T. G. (2019). The microbiota-gut-brain axis. Physiological Reviews, vol. 99, pp. 18772013.

Foster, J. A., Rinaman, L., & Cryan, J. F. (2017). Stress and the gut-brain axis: Regulation by the microbiome. Neurobiology of stress, 7, 124–136.

5. Integrating Multiple Influences on Mental Health: The RDoC Approach In recent years there has been a growing interest in transdiagnostic approaches to mental health, as neurobiological research has continued to uncover evidence that there are common risk factors across multiple mental health disorders. The National Institute of Mental Health has been a proponent of the Research Domain Criteria Initiative (RDoC), which focuses on mental health disorders that can be understand from research focusing on common domains from multiple levels of analysis (e.g., genetic, physiological, behavioral, self-report). The overall goal is to understand how biological, cognitive, and socioemotional influences contribute to mental health and illness. https://www.nimh.nih.gov/research/research-funded-by-nimh/rdoc/index.shtml

DISCUSSION STIMULATORS 1. “Medical Student’s Syndrome” Just as medical students often “diagnose” themselves as having many of the diseases they read about in such detail, Abnormal Psychology students frequently see themselves in the symptoms Instructors Manual

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of mental illness described in this course. A study by Hardy and Calhoun (1997, Teaching of Psychology, 24, 192–193) indicated that students who were going to major in psychology reported more worry about their psychological well-being than students majoring in another field. This study showed, however, that after completing a course in abnormal psychology, the same students were less concerned about the possibility that they might have a psychological disorder.

Because of the potential to diagnose family members as well as themselves, it is important to be sensitive in lecturing about various topics. It is good practice to give the class information about a student counseling center or other psychological services early on in the course. Still, be prepared during office hours to answer questions that are more personal than academic in nature, and have referral sources available for such times.

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

3. The Rise and Fall of Behaviorism?

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

19) makes the claim that behaviorism has lost favor in the scientific community, partially because “behavior theories were overly simplistic and inadequate, particularly as they applied to human beings.” The article concludes with the statement that while behavior modification has been “fruitful” it has lost growth in the clinical area to cognitive therapies.

It is unclear that behaviorism has “fallen” as the article asserts. Students might be stimulated to gather evidence over the course of the term to determine what the dominant paradigm might be. For example, the class might be divided into teams based on the paradigms described in the text. As the course progresses, each team gathers evidence in support of their paradigm as a “better” explanation for abnormal behavior. They could supplement the text with articles from professional journals and the popular media. At the end of the term, you might consider oral

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presentations, a poster session, or even a debate among the teams as they present the data to support their paradigm.

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

For the first exercise, have students sit in a circle (or several smaller circles).

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

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

Discuss students’ experiences with this exercise and differences observed between the two response modes.

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

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

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

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

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

Silence 1. “Silence is poison.” For this exercise, the group has to keep talking for 5 minutes and avoid any silence at all costs. They should be encouraged to interrupt and talk over each other.

Afterward, briefly discuss their reactions.

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

In discussing their reactions to this exercise, again consider what happens in the group and how the individuals feel about the different types of talking. “Poison” leads to talking faster, listening less, thinking less, and quieter students usually feel frustrated. “Golden” allows the talker more time and thought, and also provokes more anxiety. You might spend some time talking about how silence is used in psychotherapy Reflection While empathic reflection is one of the hallmarks of Rogerian therapy, all therapists use reflections to some extent in order to build rapport and help the client to feel understood. For this exercise, first review what a reflection is and demonstrate some reflective statements. Then have students pair up. One person talks about a topic of their choice and the other person responds using only reflections (no questions!). After five minutes, the partners switch roles. Alternatively, you might have the students remain in a group; you make statements that a client might make, and ask the students to take turns reflecting.

Students might be encouraged to try using reflections when talking to friends outside of class; first warn them to pick a time when they are prepared to listen, since this way of responding encourages people to continue talking! You could then discuss their experiences in a later class.

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

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

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5. Gene-environment interactions The book talks about gene-environment interactions, which refer to how an individual’s sensitivity to an environmental event may be influenced by genes. Life experiences may shape how our genes are expressed and our genes guide us in behaviors that lead to the selection of different experiences.

Imagine for a second, a college student named Mary. Mary is a second-semester college freshman at a highly competitive Ivy League school. She is a pre-med student who spends a great deal of time studying and worrying about her future. She recently did poorly on a series of important exams. Following these perceived failures, she began to display signs of depression including, depressed mood, lack of interest in previously enjoyed activities, increased sleep, weight gain, and thoughts about death. She visits the college counseling center and is diagnosed with major depressive disorder.

There are many things that may have contributed to Mary’s depression. Let’s think about these things for a moment.

• • • • • •

Did Mary seek out the stressful situations that triggered her onset of depression?

What genetic or neurobiological aspects might have been at play?

What type of early-childhood experiences might predispose a person to depression?

What personality traits might put a person at risk for developing depression?

What social and cultural influences might contribute to depression?

What do you think contributed to her depression?

INSTRUCTIONAL FILMS 1. How can brain imaging aid psychiatry?

“The most important lesson from 83,000 brain scans” TED Talk by Psychiatrist Dr. Daniel Amen. https://www.youtube.com/watch?v=esPRsT-lmw8 2. Videos that aid in understanding gene-environment interaction and epigenetics https://www.youtube.com/watch?v=sMyZO9YDlk8 https://www.youtube.com/watch?v=k50yMwEOWGU 3. The microbiome and mental health TED Talk by Dr. Erika Angle https://www.youtube.com/watch?v=B9RruLkAUm8

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Brain and Behavior Research Foundation https://www.youtube.com/watch?v=rt89_JdkwJo

CBT and IPT therapy techniques 1. Dr. Aaron Beck Overview of Cognitive Therapy https://www.youtube.com/watch?v=xrX43cCW6uE 2. Dr. Aaron Beck Describing how Cognitive Therapy Addresses Negative Core Beliefs 3. Beck Institute for Cognitive Behavioral Therapy https://www.youtube.com/watch?v=07JqktJGyyA&t=3s 4. CBT Therapy Session Example of Cognitive Therapy Modifying Automatic Thoughts in Anxiety https://www.youtube.com/watch?v=a0YyC1iS8Rc&t=461s 5. Dr. Myrna Weissman Overview of IPT https://www.youtube.com/watch?v=HrClyDVL43I 6. IPT Role Play of Therapy Session https://www.youtube.com/watch?v=WdWtfuPD4As&t=2s

Discussion Questions These questions are based on the clinical case studies and other information found throughout the chapter.

An Example of Beck’s Cognitive Therapy Discuss cognitive therapy from a critical standpoint. What are some examples of how negative schemas develop? What could be underlying mechanisms that sustain negatively biased thoughts?

An Example of Interpersonal Therapy Interpersonal therapy focuses on four types of interpersonal problems: unresolved grief, role transitions, role disputes, and interpersonal deficits. Can you think of an example of issues that fit in these four interpersonal problem areas? How do you think interpersonal therapy may address these?

Cognitive vs. Interpersonal Therapy Cognitive and interpersonal therapy have some common principles but also address problems in unique ways. Do you think there are some types of patients or presenting concerns that would work better for cognitive or interpersonal therapy and why?

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Clare Focusing on Clare’s family dynamics, how would Clare’s bipolar disorder affect and possibly change the way in which each member of the family relates to each other? What adjustments would have to be made to keep Clare safe from suicide? Is there any blaming? How might cognitive behavioral or interpersonal therapy inform your approach?

Arthur Considering Arthur’s case history, approach Arthur’s current problems from both cognitive behavioral therapy and interpersonal perspectives. What would be your strategy for Arthur’s current problems?

What technique would you use, and what triggers can you identify for Arthur’s drinking and negative thinking patterns?

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CHAPTER 3 DIAGNOSIS AND ASSESSMENT LEARNING GOALS 1. Describe the purposes of diagnosis and assessment.

2. Distinguish the different types of reliability and validity.

3. Identify the basic features, strengths, and weaknesses of the DSM and broader concerns about diagnosis.

4. Describe the goals, strengths, and weaknesses of psychological approaches to assessment.

5. Understand key approaches to neurobiological assessment.

6. Understand the ways in which culture and ethnicity impact diagnosis and assessment.

The Learning Goals are inherent in both the Lecture Launchers and Discussion Stimulators below. Please note the Discussion Questions at the end of this chapter.

CHAPTER SYNOPSIS Diagnoses and assessment are critical in the study and treatment of psychopathology. This chapter describes the official diagnostic system used by many mental health professionals, as well as the strengths and weaknesses of this system. It begins with an examination of the roles of reliability and validity in assessment. It also discusses the most widely used assessment techniques, including interviews, psychological assessment, and neurobiological assessment. It concludes with an examination of cultural bias in assessment.

Cornerstones in Diagnosis and Assessment: Reliability and Validity Reliability and validity are critical for any diagnostic or assessment measure. Without them, these tools are seriously limited in their usefulness.

Reliability refers to the consistency of a measure. There are several times of reliability. Inter-rater reliability refers to the degree to which two independent observers agree. Test-retest reliability measures the extent to which people score similarly when tested repeadly over time. Alternate-form reliability

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assesses the extent to which two forms of the same test show consistent results. Internal consistency reliability assesses whether items on a test are related to one another.

Validity is a complex concept related to whether a measure assesses what it is supposed to measure. The most common form, criterion validity, assesses whether scores on a measure are correlated with scores on other measures of the same dimension. Content validity refers to whether a measure adequately samples the domain of interest. Construct validity is more complex but generally refers to whether a measure assesses the construct is purported to measure when the construct is an inferred attribute that cannot be directly observed.

Diagnosis Diagnosis provides the first step in thinking about the causes of symptoms, so it is the first step in planning treatment. A diagnosis can help a person better understand their symptoms and enables clinicians and scientists to communicate accurately with one another about clinical cases or research.

Diagnostic systems for mental illness have changed a great deal in the past 100 years. Currently, the system in use in the United States is the Diagnostic and Statistical Manual, Fifth Edition (DSM-5). The DSM-IV-TR was a multiaxial, categorical classification system that included approximately 300 different diagnostic categories. Axes on the multiaxial classification system of DSM-IV-TR were: Axis I

Included all diagnostic categories except for the personality disorders and mental retardation.

Axis II

Included the personality disorders and mental retardation.

Axis III Specifies physical disorders or general medical conditions that might be relevant to the mental disorder.

Axis IV Included any psychosocial and environmental problems that might contribute to the disorder.

Axis V Used the Global Assessment of Functioning (GAF) scale as a determination of the individual's need for treatment.

Now that the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) is in use, it is important to discuss some of the major changes between the DSM- IV-TR and the DSM-5. Plans for the DSM-5 began in 1999.

Thirteen work groups were formed to review each set of diagnoses. These work groups focused on making research-based changes to the DSM-IV-TR and aimed to make the DSM-5 useful to clinicians. In addition to the work groups, a series of study groups considered issues that cut across diagnostic categories, such as lifespan developmental approaches, gender and cross-cultural issues, the psychiatric/general medical interface, impairment and disability, and diagnostic assessment instruments. These study groups conducted literature reviews and analyses and then gave feedback to the work groups on issues with specific diagnoses. The DSM-5 includes changes in personality disorder diagnoses, new clinical diagnoses, combined diagnoses, and clearer diagnostic criteria. Figures 3.1 and 3.3 show specific changes. The DSM-5

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uses a multiaxial categorical system, which is a major shift from the DSM-IV-TR’s five-axis classification system: Axis I

Psychiatric and Medical Diagnoses

Axis II Psychosocial and Environmental Problems Axis III Specific Rating Scales for Each Disorder The textbook provides detailed illustrations and discussions of the new DSM-5 categorical classification system and dimensional classification system (continuum of severity), and an introduction to the changes in personality disorder diagnoses in DSM-5. The text also discusses the newly proposed disorders, combined diagnoses, clarification of diagnostic criteria, and ethnic and cultural considerations in DSM-5.

The text also provides numerous examples of key elements of the new DSM-5, including an example of a possible severity rating scale for major depression (p. 72). The text points out that the new DSM-5 includes more accurate diagnostic criteria than the DSM-IV-TR. Kring provides the example of duration and intensity rules for some diagnoses, the revision of previous criteria based on new research information, and the rewording of some definitions for clarification.

Also of note is that the DSM-5 recognizes that mental illness is universal and must, therefore, take into consideration the cultural influence and differences in risk factors for mental illness. For example, social cohesion, poverty, access to drugs of abuse, stress, differences in types of symptoms experienced, willingness to seek help, and treatments available all play a role in mental illness and hence should play a role in the diagnostic process.

Ethnic and cultural considerations in diagnosing mental illnesses are universal. There is not a single culture in which people are free from mental illness. However, the way the definitions of disorders and the way in which disorders manifest themselves may vary from culture to culture. For example, rates of mental illness tend to be higher in the United States than in many other countries. Related to this, the DSM-IV-TR included 25 culture-found syndromes in the appendix, syndromes that are likely to be seen within specific regions. The DSM-5 appendix includes nine cultural concepts of distress used to describe syndromes that are observed within specific regions of the world or cultural groups: dhat syndrome, shenjing shuairuo, taijin kyofusho, khyâl cap, ataque de nervios, ghost sickness, and hikikomori.

The text mentions that the planning process for the DSM-5 included a study group dedicated to considering gender and cultural issues. Moreover, symptoms in some cultures are not considered abnormal and should not be included in the diagnosis of a disorder. They should be included only if the symptom is abnormal within the culture at hand.

Most consider the DSM a tremendous achievement. One of its most heartening features is its explicit rules for diagnosis. This clarity has improved reliability and provides a systematic foundation for studying whether each diagnosis is valid. The system guides clinicians in several different ways to be more sensitive to the role of culture and ethnicity in evaluating mental health.

DSM-5 focuses on how culture can shape the symptoms and expressions of a disorder. For example, in Japan there is a greater prevalence of the fear of offending others than in the United States. Specific cases Instructors Manual

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in the text are also highlighted to illustrate the difference in diagnoses between the DSM-IV-TR and DSM-5 (see Lola, p. 75). In the DSM-IV-TR, Lola would have been given the Axis I diagnosis of major depressive disorder; Axis II diagnosis of dependent personality disorder; no Axis III diagnosis; an Axis IV description of the problems with her primary support system and her social environment; and an Axis V GAF score of 25.

In the revised DSM-5, however, Lola would have received the diagnosis of major depressive disorder and personality disorder trait specified—traits of submissiveness and separation insecurity, as well as a Level of Functioning Score of 1.

Specific Criticisms of the DSM Despite the major improvements in the DSM, a number of problems remain. Some argue that there are too many diagnoses. One side effect of the huge number of diagnostic categories is a phenomenon called comorbidity, which refers to the presence of a second diagnosis. Others challenge the use of a categorical rather than a dimensional approach to diagnoses. Reliability is substantially higher than it was for DSM-II, but there is still some disagreement among clinicians regarding some symptoms and diagnoses. Reliability in everyday usage may be lower than what is seen in formal research studies. Finally, the field as a whole, faces a huge challenge; researchers are focused on validating this diagnostic system, by trying to identify the causal patterns, symptom patterns, and treatment that can be predicted by a given diagnosis. In sum, although the DSM is continually improving, it is far from perfect. We can expect more changes and refinements over the next several years. Regardless of the diagnostic system used, there are certain problems inherent in diagnosing people with mental illness; it is important to be aware of the potential stigma associated with diagnoses and the tendency to ignore a person’s strengths when focusing on diagnoses. APA recommends using phrases such as “person with schizophrenia” rather than “schizophrenic” as one way to be conscious that a person is much more than his or her diagnosis.

Two different dimensional approaches are currently being taken to improve current categorical diagnostic symptoms: the HiTOP model (Hierarchical Taxonomy of Psychopathology) and the National Institute of Mental Health’s Research Domain Criteria (RDoC).

In DSM-5, clinical diagnoses are based on categorical classification, while dimensional diagnostic systems describe the degree to which an entity (e.g., anxiety) is present). Categorical approaches are popular because they define a threshold for treatment and are consistent with medical diagnostic models, such as categorical approaches to defining hypertension. However, diagnostic categories often have validity and reliability issues in characterization of psychopathology and may not always be reliable in everyday practice.

Psychological Assessment A comprehensive psychological assessment draws on many different methods and tests. Clinicians often begin with a clinical interview, particularly to help form a diagnosis. These can be structured, with the questions predetermined and followed in a certain order, or may use an unstructured interview approach, to follow more closely what the client tells the interviewer. Structured interviews are more reliable.

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Rapport is important to establish regardless of the type of interview. Stress can be assessed via a checklist of life events, as in the Social Readjustment Rating Scale (SRRS), by assessing daily reports of thoughts and feelings, as with the Assessment of Daily Experience (ADE), but these tools are limited in coverage and validity. A better assessment of stress is the Life Events and Difficulties Schedule (LEDS) is a semistructured interview that captures the importance of any given life event in the context of a person’s life circumstances, as in a personality inventory.

In a personality inventory, the person is asked to complete a self-report questionnaire indicating whether statements assessing habitual tendencies apply to him or her. These tests are typically administered to many people in as part of the process of standardization. The Minnesota Multiphasic Personality Inventory (MMPI-2) is a standardized and objective personality inventory. The test has good reliability and validity and is widely used. Another highly influential model of personality focuses on five broad domains known as “the Big 5”: openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism. Two measures commonly used to assess the “Big 5” are the Big Five Inventory-2 (BFI-2) and the NEO Personality Inventory (NEO-PI).

Projective personality tests are psychological assessments presenting standard stimuli—inkblots or drawings—that are ambiguous enough to allow variation in responses. The assumption is that because the stimulus materials are ambiguous, the person’s responses are determined primarily by unconscious processes and will reveal true attitudes, motivations, thoughts, and behaviors. Examples of projective assessments are the Rorschach Inkblot Test and the Thematic Apperception Test. To take a sample of the Rorschach Inkblot Test try this link: http://theinkblot.com/. Another subjective test is the Thematic Appreception Test (TAT). For a practical sample of the test here is the link: http://www.utpsyc.org/TATintro/.

Intelligence tests have been used for a number of years and are quite reliable. The most commonly administered tests include the Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV), the Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV), the Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition (WPPSI-IV), and the Stanford-Binet, Fifth Edition SB5). As with any test, there are limits to what an IQ test can tell a clinician or researcher. Further, cultural bias is a salient issue with these tests, perhaps due to stereotypes about ethnicity and intelligence.

Direct observation of behavior can be very useful in assessment, though it can take more time than a selfreport inventory. Another useful assessment method for individuals to monitor their own behavior is Experience Sampling (also known as Ecological Momentary Assessment, EMA). Other self-report questionnaires can be used to assess a person’s internal experiences of emotion, thoughts about the self, past experiences, or symptoms.

All assessment instruments have advantages and disadvantages, including considerations of reliability, ease of administration and scoring, and relevance to the particular clinical problem.

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Neurobiological, Neuropsychological and Psychophysiological Assessment Advances in technology have allowed clinicians and researchers to “see” the living brain. Different imaging techniques, such as MRI (fMRI), PET scans, or SPECT have the potential to show brain areas that might not be working optimally. Direct assessment of neurotransmitters is rarely done. Rather, examinations of the metabolites of neurotransmitters provide a rough way to estimate how neurotransmitters are functioning.

Another approach is to administer drugs that increase or decrease the levels of a neurotransmitter.

Postmortem exams also allow measurement of neurotransmitters, particularly receptors. Brain stimulation approaches such as TMS and tDCS allow clinicians and researchers to stimulate different areas of the brain noninvasively to test hypotheses about brain-behavior relationships. These approaches may also have utility for treatment of treatment-resistant forms of psychopathology, such as treatmentresistant depression.

Neuropsychological tests have been developed to show how changes in behavior may reflect damage or disturbance in particular areas of the brain. Psychophysiological assessment methods such as electrocardiogram (EKG) or electrodermal responding can show how behaviors and cognitions are linked to changes in nervous system activity, such as heart rate, skin conductance, or brain activity. These methods are sometimes considered more scientific because they involve complicated instrumentation.

They have as many or more limitations as other assessment measures, and the key concepts of reliability and validity are just as relevant to neurobiological assessment as to other forms of assessment.

Cultural and Ethnic Diversity and Assessment Cultural and ethnic factors play a role in clinical assessment. Assessment techniques developed on the basis of research with Caucasian populations may be inaccurate when used with clients of differing ethnic or cultural backgrounds, for example. Clinicians can have biases when evaluating ethnic minority patients that can lead to minimizing or exaggerating a patient’s psychopathology. Clinicians use various methods to guard against the negative effects of cultural biases in assessment.

KEY TERMS alternate-form reliability

criterion validity

ataque de nervios

cultural concepts of distress

Big Five Inventory-2 (BFI-2)

diagnosis Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)

BOLD, categorical classification clinical interview comorbidity construct validity content validity

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DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) dimensional diagnostic system

ecological momentary assessment (EMA) electrocardiogram (EKG) electrodermal responding externalizing disorders functional magnetic resonance imaging (fMRI) hikikomori HiTOP model

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intelligence test internal consistency reliability internalizing disorders inter-rater reliability magnetic resonance imaging (MRI)

NEO Personality Inventory (NEO-PI) neuropsychological tests neuropsychologist personality inventory PET scan

SPECT standardization structured interview taijin kyofusho test-retest reliability

khyâl cap

reliability

transcranial direct current stimulation (tDCS)

Minnesota Multiphasic Personality Inventory (MMPI2-RF)

Research Domain Criteria (RDoC)

transcranial magnetic stimulation (TMS)

shenjing shuairuo

validity

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LECTURE LAUNCHERS 1. Diagnosis and Racial Bias “We ask a deceptively simple question in this article: 'Does the color of one's skin affect how one is diagnosed within an urban mental health system?'” (Pavkov, T. W., Lewis, D. A. & Lyons, J. S. “Psychiatric diagnosis and racial bias: An empirical investigation.” Professional Psychology: Research and Practice, 20, 1989, p. 367).

Pavkov et al. conducted diagnostic interviews with over 300 patients upon admission to urban mental hospitals and compared the resulting diagnoses with those assigned by the admitting clinician. Their investigation demonstrated that being Black predicted a diagnosis of schizophrenia, after taking into account other factors such as diagnosis according to the investigators' independent interview, age, sex, and prior hospitalization or use of professional help. Since almost all of the patients in the study, both Black and of other races, were very poor, social class was not a significant confound of the findings.

Students might be asked to consider the implications of the finding that Blacks are apparently more likely to be diagnosed incorrectly as schizophrenic. Issues raised in the article include: 1. Blacks may be more likely to be mistakenly treated with the powerful psychotropic drugs used to treat schizophrenia.

2. Once diagnosed with schizophrenia, the label can be very difficult to escape; this problem is particularly significant since clinicians frequently use past diagnostic history as a factor in making a current diagnosis.

3. Diagnosis with a serious mental illness can lead to difficulty finding employment, as potential employers may view such persons as unpredictable or dangerous.

4. The misdiagnosis of schizophrenia can lead to social isolation and the growth of the “underclass.”

In addition to those issues, students could be encouraged to examine the diagnostic criteria for schizophrenia and consider how being Black might lead to misdiagnosis. For example, if a young Black male believes that people are crossing the street to avoid passing him closely, or fears that the police are out to get him, are these “symptoms” paranoid delusions or a realistic appraisal of his situation? Also note the research by Arthur Whaley in the Journal of Black Psychology, 30(2), 2004, 167–186), which considers diagnostic bias in the psychiatric evaluations of African Americans. The bias has two forms, clinician bias and the failure to follow diagnostic criteria during evaluations, and cultural bias in which the symptoms are either overlooked or misinterpreted.

2. On Being Sane in Insane Places D. L. Rosenhan (1973, Science, 1979, 250–258) conducted one of the best-known and most controversial studies about the ability of mental health professionals to define abnormality.

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admitted to mental hospitals. During their screening interviews, all of the normal “pseudopatients” acted like themselves and simply reported on the events in their lives. They did, however, act atypically in two ways. First, they asked to be admitted to a psychiatric ward, something that most people who consider themselves well adjusted do quite rarely. Second, when asked by the admitting psychiatrist to describe their problems, the pseudo-patients claimed that they were hearing voices that said “empty,” “hollow,” or “thud.” Although they reported hearing voices, such complaints are not symptoms of any known mental disorder. Note the link in the Resource Manual, Chapter 1 and the links to his interviews.

In every instance in which they tried, the pseudo-patients got themselves admitted to the mental hospital, and in 11 out of 12 cases, they were diagnosed with schizophrenia. Following admission, all of the pseudo-patients immediately stopped complaining of their “symptom.”

None of the pseudo-patients was suspected of being a fake by the hospital staff. Rosenhan reported that several of the real patients, however, harbored these suspicions. In fact, the behavior of the pseudo-patients while they were “patients” on the psychiatric ward, as well as their accounts of their life experience, was often interpreted by the ward staff as being consistent with their “mental disorder.” Consider the following excerpt from a case summary of a pseudopatient’s report on his “normal” upbringing: This white 39-year-old male…manifests a long history of considerable ambivalence in close relationships, which begins in early childhood. A warm relationship with his mother cools during adolescence. A distant relationship with his father is described as becoming very intense. Affective stability is absent.

His attempts to control emotionality with his wife and children are punctuated by angry outbursts and, in the case of the children, spankings. And while he says that he has several good friends, one senses considerable ambivalence embedded in these relationships also.

This case summary raises several questions. Is it abnormal for a young man to get closer to his father and more distant from his mother as a teenager? Is it unusual sometimes to be angry with your spouse and children? Is it a symptom of mental disorder to spank your children? With conclusions that are based upon the premise that someone is “insane,” these observations become data in support of mental illness.

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

Rosenhan’s criticisms suggest that we should not attempt to classify a mental disorder, but whether or not his study suggests this conclusion is a matter of considerable debate. (See replies to the study, Science, 180, 1973, 1116–1122.) If I prove that it is possible to fool a physician into falsely believing that I am suffering from a physical disease, does that mean that physical illness does not exist? Did the pseudo-patients really behave normally? Would it not be the normal thing Instructors Manual

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to do never to try to be admitted to a mental hospital, or to try to get out immediately upon admission?

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

Michael Fontaine of Cornell University, in an article in Current Psychology: A Journal for Diverse Perspectives on Diverse Psychological Issues, 32(4), 2013, 348–365) write on Rosenhan’s experiment, “On being sane in an insane place—The Rosenhan experiment in the laboratory of Plautus’ Epidamnus offers two ethical reflections about diagnoses and validity of the medical model of insanity.”

3. False Positives and False Negatives Whenever decision rules are other than completely accurate, as is the case in clinical psychology and psychiatry, of necessity errors will be made. Given that errors will be made, the question arises as to what sort of bias in decision-making will be adopted. That is, will decisions be made in such a way as to minimize false positives—concluding that something is present when in fact it is not—or will there be a bias toward minimizing false negatives—concluding that something is not present when in fact it is? One of the many analyses of this important issue was conducted by Thomas Scheff (“Decision rules, types of error, and their consequences in medical diagnosis.” In R. Price and B. Denner [1973], The making of a mental patient, New York: Holt, Reinhart, and Winston). More recently in 2013, Schmidt and Rapp discuss three experiments they conducted to consider false positives and false negatives (Behavioral Interventions, 28(1), 2013, 58–81).

Consider the bias that exists in criminal law: The assumption is that a man is innocent until he is proven guilty. Furthermore, the maxim “Better a thousand guilty men go free than one innocent man be convicted” makes clear that the Western law wishes to minimize false positives at the expense of risking an increase in false negatives. In the Journal of Criminal Justice (42(1), 2014, 1– 9) the authors discuss false positive and false negative rates in self-reported intentions to offend.

They describe the gap between the participants’ predictions of being criminally free and the predictions of criminal involvement.

Other areas in which error exists in decision-making are not so clear on the biases that are adopted. What is the bias in medicine? A moment’s reflection suggests that, in most cases, it is the opposite of that adopted in law.

Physicians would seem to be more willing to tolerate false positives, offering treatment to a patient who in reality is healthy, than to risk false negatives, denying treatment to someone who in reality is ill. Such a posture seems prudent when the treatment carries a low risk (e.g., the

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prescription of antibiotics) but becomes more questionable as the risk involved in the treatment increases (e.g., major surgery).

What about the risk ratios in the specialties of psychiatry or clinical psychology? Scheff argues that a bias similar to medicine exists, but he suggests that the risk associated with the treatment for mental disorders may be higher than it first appears. Among his concerns are the potentially stigmatizing effects of labeling, the anxiety a diagnosis of mental disorder causes, and so on. While the consequences of various decision rules in psychiatry and psychology are open to debate (and should provoke a healthy discussion in class), a bias toward making false positives certainly fits with Rosenhan’s findings discussed above. In any regard, students will benefit from being introduced to the concepts of false positives and false negatives, and from considering these in relation to such topics as: • • •

What is best from the patient’s perspective?

How does the clinician’s financial reward influence decision-making?

How do we treat specific topics such as the prediction of dangerousness, parental fitness, and suicidal risk?

4. The Diagnoses of Autism and Schizophrenia: Examples of the False Positives/False Negatives Problem Comparing the diagnostic criteria for autism in DSM-III and DSM-III-R, Volkmar, Bregman, Cohen, and Cicchetti (1988, American Journal of Psychiatry, 145, 1404–1408) found that the DSM-III-R system was substantially broader than was DSM-III, leading to more false positives and fewer false negatives. The implications of this change provide interesting material on the differing standards for diagnosis depending on the purpose of the system in it is used. For example, the broader criteria may increase the number of people eligible for social services. In genetic research, including a broader range of individuals within the diagnosis of autism may cloud findings of genetic links. Finally, having differing systems in use makes it difficult to compare studies using differing criteria for diagnosis. Major changes were made in the criteria for the Pervasive Developmental Disorders in DSM-IV. It might be helpful to hand out the criteria from DSM-III, III-R, and IV, and have students discuss the changes over the years and their implications. Matson et al.

(Journal on Research in Autism Spectrum Disorders, 7(1), 2013, 17–22) discusses the Modified Checklist for Autism in Toddlers (M-CHAT) and the concern that it produces false positives and false negatives in the diagnoses of toddlers with autism.

In the area of schizophrenia, in contrast, changes made in the DSM led to a narrower definition of the disorder (Fenton, McGlashan, & Heinssen, 1988, American Journal of Psychiatry, 145, 1446– 1449). The impetus for such narrowing has been the hope that a specific biological cause will be found if a less heterogeneous group of patients is studied. However, as the authors note, a single etiology might result in multiple symptom patterns, and conversely, multiple etiologies may lead to the same set of symptoms.

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The use of the DSM for both clinical diagnosis and research means that different users of the manual may have different purposes for making diagnoses and, thus, different priorities concerning false positives and negatives.

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

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

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

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

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

6. Revising the DSM The text introduces the DSM as a scientific tool and discusses the manual in terms of coverage, reliability, and validity. While concerns can be raised about the manual in its scientific context,

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most professionals agree that recent revisions of the DSM are a dramatic improvement over their predecessors. It may be worthwhile, however, to spend some time discussing the political implications of the manual, as well as its scientific merit. Since the list of “mental disorders” in the manual becomes the operational definition of mental illness for insurance companies and other institutions, the manual does indeed have political implications. DSM-5 Prelude (http://www.dsm5.org/Pages/Default.aspx) is a research and outreach project designed as a clearinghouse for information about the revision of DSM. The report by Zimmerman and Spitzer (1989, American Journal of Psychiatry, 146, 20–28) on the process of revising the DSM-III criteria for the melancholic subtype of depression (Spitzer headed the committees to create both DSM-III and III-R, and was special advisor for DSM-IV) provides a fascinating look at the inner circle of professionals who decide the fate of the diagnoses of mental disorders. The steps taken to decide how to change the DSM-III version of the melancholia diagnosis included reviewing the remarkably limited number of research studies addressing questions of reliability and validity, and then suggesting and discussing specific changes that might be made and voting on which should be adopted. (The qualifications of the committee members for the job are unfortunately not described; interesting questions for students to discuss are who should be included on such committees and who should choose them.) Some excerpts from the article reveal the nature of the decision-making process: In the vote on the alternatives, one individual voted for retaining the DSM-III criteria, no one voted to adopt a symptom-based polythetic approach, six members voted to define melancholia on the basis of both symptom and non-symptom features, and four persons supported the proposal to eliminate melancholic subtyping and replace it with a severity distinction. (One of the committee members left the meeting early, thus leaving 11 votes.) (p. 24)

While students might object to the process of voting on diagnostic criteria, they should be encouraged to consider what alternative means of decision-making might be more appropriate and still feasible. They might also consider that while inadequate data may exist to make scientific decisions, a classification system is necessary in order to define groups to use in the research that will improve later systems (e.g., “The absence of stress was rejected [as a criterion for melancholia] because the group believed that it lacked empirical support as a treatment outcome predictor. [After the meeting, one of us reviewed this literature and found that the lack of precipitating stress has been a consistent predictor of favorable outcome.” p. 25]). The DSM-IV task force dictated that the systematic review of empirical data must be used to substantiate decisions about revisions to the diagnostic criteria.

See suggestions below for ways to encourage students to tackle the problem of devising classification systems themselves.

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

So begins Kirk and Kutchins’ The Selling of DSM: The Rhetoric of Science in Psychiatry (1992, New York: Walter de Gruyter, Inc.). This fascinating account of the political and social implications of the revisions of “the new bible” (DSM) includes a provocative discussion of uses for diagnosis other than the traditional ones such as planning treatment, discussed at more length in the textbook (in Kirk & Kutchins). Considering that clinicians using the DSM have considerable discretion in deciding on a particular diagnosis, the following purposes for diagnostic decisions may apply: 1. Regulating Client Flow. When agencies offer specialty services such as a “mood disorder clinic,” a bias could develop toward liberalized interpretation of the diagnostic criteria for Major Depression with potential clients. This would increase client flow. Since subjective judgment is required to make decisions such as whether a client has “diminished interest in all activities” or “psychomotor agitation,” such variations in diagnostic practice are easy to accomplish.

2. Protecting Clients from Harm. Many clinicians are concerned about the stigmatizing effects of certain diagnoses. When a patient is given the diagnosis of Borderline Personality Disorder, she frequently finds that some of her problems are dismissed as attempts to manipulate the clinician or health-care system. In many cases, the problem of stigmatization is handled by choosing the least harmful label that might apply to the client, even at the expense of accurate clinical decision-making. In one clinic, the present author heard a therapist tell a patient that she met criteria for Borderline Personality Disorder but that she should not tell anyone else that. The therapist reasoned that because of the bias against borderline patients, she should not jeopardize her chances of getting medical treatment when needed.

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

4. Rationalizing Decision-Making. There are cases in which diagnoses may be used to justify treatments after the fact. For example, a psychiatrist prescribes several medications until one works, and then bases the diagnosis on that successful treatment—e.g., if lithium works, the patient has bipolar disorder.

5. Advancing a Political Agenda. Political realities frequently shape decisions about the diagnoses included in the DSM. Homosexuality was dropped as a diagnosis after years of heat from gay activists; posttraumatic stress disorder was created under pressure from Vietnam veterans. Extensive lists of mental disorders help the mental health profession

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gain legitimacy, fund programs, and allocate research money, as more and more problems come under the purview of mental health.

8. Development of Theoretically Coherent Alternatives to the DSM-IV-TR A special section of the Journal of Consulting and Clinical Psychology (1996, 64) was devoted to the topic of developing theoretically coherent alternatives to the DSM-IV. While criticizing the DSM is relatively easy, coming up with a reasonable alternative is less so. Compare these thoughts with the development history of the DSM-5 in Chapter 1. Articles in this section include: •

Carson, R. C.: “Aristotle, Galileo, and the DSM taxonomy: The case of schizophrenia” (1133–1139).

Using the example of schizophrenia, Carson discusses the DSM system as an Aristotelian conception of mental disorders. This approach is contrasted with the Galileian mode of thought, “emphasizing the dynamic causal matrix in which behavior occurs.”

•

Wulfert, E., Greenway, D. E., & Dougher, M. J.: “A logical functional analysis or reinforcement-based disorders: Alcoholism and pedophilia” (1140–1151).

The authors argue for identifying homogeneous subgroups within diagnostic classes, basing these groupings on functional principles. Understanding the “motivational conditions, antecedents, consequences, and concomitant behavioral repertoires associated with a given disorder” informs the selection of intervention approaches.

•

Hayes, S. C., Wilson, K. G., Giford, E. V., Follette, V. M., & Strosahl, K.: “Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment” (1152–1168).

A review of research indicates support for a view of psychopathology as “unhealthy efforts to escape and avoid emotions, thoughts, memories, and other private experiences.”

Experiential avoidance is thus proposed as a functional diagnostic dimension that would integrate experimental and clinical data, leading to new approaches to analyzing and treating behavioral disorders.

•

Koerner, K., Kohlenberg, R. J., & Parker, C. R.: “Diagnosis of personality disorder: a radical behavioral alternative” (1169–1176).

The goal of a classification system should be to improve the outcome of intervention by enhancing the clinician's influence on processes associated with client change. Therefore, diagnostic classification should be based on knowledge and specification of processes of change.

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•

Scotti, J. R., Morris, T. L., McNeil, C. B., & Hawkins, R.P.: “DSM-IV and disorders of childhood and adolescence: Can structural criteria be functional?” (1177–1191).

As an alternative to structural, descriptive diagnosis, a system of functional analysis is proposed. This system would directly consider antecedent and consequent events, skills repertoires, response interrelations, and support systems, and could be integrated with a structural diagnostic system.

9. The History of the Inkblot: An Illustration of Changing Paradigms The history of the Rorschach Inkblot Test is an excellent illustration of the influence of paradigms on assessment approaches and the changes occurring in paradigms in the United States over the last 50 years. Exner (1995, The Rorschach: A Comprehensive System, Volume I. New York: John Wiley & Sons) reviews changes in the scoring and interpretation of the test since its early development, revealing influences of the psychoanalytic, behavioral, and cognitive paradigms.

Original Rorschach: When Hermann Rorschach began studying the inkblot test in the 1920s, he used empirical methods to develop the test as a diagnostic tool. He was particularly interested in determining how the responses of schizophrenics differed from those of non-schizophrenics.

Psychoanalytic Paradigm Influences: After Rorschach’s untimely death at the age of 37, numerous clinicians became interested in the inkblot test. In the United States, the strong influence of psychoanalytic theory in the 1930s and 1940s led to the practice of interpreting Rorschach responses for their symbolic content, and the “projective hypothesis” was born, suggesting that the examinee projects unconscious material onto the ambiguous stimulus of the inkblot. The psychoanalytic interpretations were based on analysis of content alone, and often involved inferential leaps (e.g., a person who sees a bird in a Rorschach card is described as “immature and inept sexually and [failing] to establish enduring heterosexual relationships” (1953, Phillips, L. & Smith, J. G., Rorschach interpretation: Advanced technique, New York: Grune & Stratton). By the 1950s, over 3,000 books and articles on the Rorschach had been published and numerous systems of scoring and interpretation were in use.

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

Cognitive Paradigm Influences: Most recently, the cognitive paradigm, gaining prominence in the 1970s and 1980s, has led to a view of the Rorschach as a cognitive-perceptual problem-solving task, rather than a stimulus to fantasy. Exner developed the “Comprehensive System,” widely taught in training programs today, which bases its scoring and interpretation on empirical data about the responses of different clinical groups (coming full circle, in fact, to Rorschach’s original work). The current system includes standardized administration and scoring methods and extensive normative data for use in interpretation.

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In spite of Exner’s work, many academic psychologists continue to challenge the use of the Rorschach, particularly when used for forensic purposes. One such article challenges the use of the Rorschach and other projective techniques to detect child sexual abuse (Garb, H. N., Wood, J. A., & Nezworski, M. T., 2000. Projective techniques and the detection of child sexual abuse. Child Maltreatment, 5, 161–168).

The authors reexamined the data from a meta-analytic study that claimed that projective techniques could discriminate between abused and non-abused children. Garb and his colleagues found that many of the original studies were flawed and that nonsignificant results were excluded from the analysis.

The Journal of Personality Assessment (2001, 77, 1) included a spirited exchange of articles between proponents and critics of the Rorschach Inkblot Method that provides additional insight into the current debate regarding the status of this technique.

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

10.

Integrated Assessment in Clinical Practice

Students usually are interested to learn how the several assessment approaches described in the text are integrated into clinical practice. The following steps may be outlined in class to give an overview of the clinical use of assessment.

Referral Question(s). A good assessment begins with a carefully formulated referral question.

Possible goals might be to diagnose a client, to recommend appropriate placement, to aid in treatment planning, or to provide baseline data at the beginning of a planned intervention.

Data Collection. The collection of information often begins with meeting with the referral source and examining the client’s file (if available) for relevant historical information, cultural background, and results of previous testing. In addition to an interview with the client, “significant others” such as teachers, parents, or individual therapists are often contacted to obtain additional information.

Finally, test materials are used to collect standardized data for comparison with normative groups.

This step may include personality testing, intelligence testing, neuropsychological evaluation, behavioral assessment, or, most often, some combination of approaches.

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

Recommendations. The assessment culminates in practical suggestions related to the referral question. Usually, a summary of the test results and recommendations is offered to the referral source, the client, and, if indicated, significant others such as teachers and parents. Feedback sessions are held to share test results and recommendations.

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11.

Assisting Coaches in Detecting Concussion

Simple neuropsychological assessment tools may be very useful in detecting mild concussions associated with youth sports. A report in the Journal of the American Academy of Neurology (Rosenberg et al., March, 1997) recommended that coaches use a brief test immediately following a head injury on the field. Previously, coaches and parents had been advised not to worry if a head injury did not result in loss of consciousness. The most recent evidence indicates that this advice is wrong and harmful. Guidelines have now been developed to identify Grade 1, 2, and 3 concussions and recommended responses. Kaiser Permanente has responded to the call by pledging to create laminated, pocket-size cards to assist coaches and trainers in making evaluations on the sidelines.

Your sports-minded students may be interested in the following guidelines: See handout on next page

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HANDOUT Guidelines for Responding to Concussions on the Field Symptoms

Recommended Response Grade 1 Concussion

•

• •

Transient confusion (inattention, inability to maintain a coherent stream of thought and carry out goal-directed movements).

No loss of consciousness.

Concussion symptoms of mental status abnormalities on examination resolve in less than 15 minutes.

• •

•

Remove from contest.

Examine immediately and at 5-minute intervals for the development of mental status abnormalities or post-concussive symptoms at rest and with exertion.

May return to contest if mental status abnormalities on exam resolve in less than 15 minutes.

Grade 2 Concussion • • •

Transient confusion.

No loss of consciousness.

Concussion symptoms or mental status abnormalities (including amnesia) on examination last more than 15 minutes.

• • • •

Remove from contest and disallow return that day.

Examine on-site frequently for signs of intracranial pathology.

A trained person should re-examine the athlete the next day.

Neurologic examination by a physician to clear the athlete for return to play after a full symptomatic week at rest and with exertion.

Grade 3 Concussion •

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Any loss of consciousness, either brief (lasting seconds) or prolonged (lasting minutes).

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•

•

A thorough neurological evaluation should be performed, including appropriate neuroimaging procedures.

Hospital admission is indicated if any signs of pathology are detected, or if the mental status of the remains abnormal.

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•

Transport the athlete from the field to the nearest emergency room by ambulance if still unconscious or if worrisome signs are detected.

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12.

The Barnum Effect

P. T. Barnum created circuses that had “a little something for everybody.” He also declared “there is a sucker born every minute.” Both of these quotes likely played a role in Paul Meehl’s honoring Barnum in naming a psychological phenomenon for him. The “Barnum effect” refers to the tendency for people to accept vague and generally applicable personality descriptions as characteristic of them personally; hence the popularity of horoscopes, handwriting analysis, and the like. Rather than recognizing that interpretations or predictions such as those in horoscope columns could apply to almost anyone, people tend to view these brief paragraphs as characterizing them in particular.

What are the characteristics of those people who are so gullible as to accept these general personality interpretations? Snyder, Shenkel, and Lowery (1977, Journal of Consulting and Clinical Psychology, 45, 104–114) reviewed the research on this topic and concluded that few such factors have been identified. However, characteristics of the testing situation that enhance acceptance of Barnum interpretations have been identified: (1) general, high-base-rate interpretations; (2) presenting the information as being specifically derived for the individual; (3) giving favorable feedback; and (4) using short, psychologically ambiguous procedures.

The identification of these enhancing variables helps to explain why and how palm readers and other “seers” remain in business. But what about psychological testing? Many of the above factors characterize the psychological test situation as well. A psychologist cannot, therefore, use a client’s feedback about her terrific testing insight as evidence of that insight, any more than a mystic can legitimately use a client’s belief in her powers as evidence for those powers. Once again, we see the difficulty in using self-report data as a measure of “truth.”

A demonstration to the class can vividly illustrate the Barnum effect. (See Discussion Stimulators for this chapter.) It is also likely, through embarrassment, to create some healthy skeptics among the class members.

13.

Ethnic Differences in Substance Abuse

As discussed in the text, cultural and ethnic differences affect not only testing and interview situations but also the kinds of diagnoses that are given. This bias can extend to referral questions as well.

In a recent study, Robbins and his colleagues looked at rates of comorbidity among Hispanic and African American adolescent substance abusers. The authors found that Hispanic youths had significantly higher rates of comorbid psychiatric symptoms than their African American counterparts. The authors stated that other differences exist between these two groups: for instance, when youths were referred from the criminal justice system, African Americans were more likely to be sent to detention or prison than Hispanic youths with the same level of problems.

Hispanics were more often given a “second chance” in community rehabilitation settings. They

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also suggest that treatment of substance abuse alone might not be sufficient with Hispanic youths, given the high rate of psychiatric comorbidity.

How might these findings be used to influence the criminal justice system? What differential factors might be influencing the higher rate of psychological symptoms found in Hispanic youths?

How might we use this information to improve treatment?

Robbins, M. S., Kumar, S., & Walker-Barnes, C. (2002). Ethnic differences in comorbidity among substance-abusing adolescents referred to outpatient therapy. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 394–401.

Saloner, B., Carson, N., Cook, B. (2014). Explaining racial/ethnic differences in adolescent substance abuse treatment completion in the United States: A decomposition analysis. Journal of Adolescent Health, 54, 646–653.

Guerrero, E. G., Marsh, J. C., Cao, D., Shim, H.-C., Andrews, C. (2014). Journal of Substance Abuse Treatment, 46, 584–591.

DISCUSSION STIMULATORS 1. On Being Sane in Insane Places Rosenhan’s article “On being sane in insane places” is engaging for students to read and can be counted on to provide material for classroom discussion (1973, Science, 179, 250–258). Replies to the article are also particularly valuable to assign, as they present a wide variety of viewpoints on the study (1973, Science, 180, 1116–1122). A few questions should be sufficient to sustain discussion on this controversial piece of research, such as: 1.

2.

3.

4.

Was Rosenhan setting up the psychiatrists?

Is insanity in the eye of the beholder?

What are the effects of the label “insane”?

Can medicine detect liars?

2. Cultural Formulation and the Development of the DSM What has been the process of transition between the DSM-IV and the DSM-5 in Cultural Formulation and Development?

An Appendix of DSM-IV-TR (pp. 897–898) includes an outline to assist clinicians in formulating the cultural aspects of psychopathology and diagnosis. While many clinicians ignore this appendix in making diagnoses, it actually provides an excellent formulation of cultural issues that are likely to impact diagnosis. Before presenting the outline to students, you might ask them to generate their own suggestions for how culture should be considered when making

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diagnoses of mental illness. The following handout, adapted from DSM-IV-TR, could then be passed round. Students might be encouraged to interview each other or a friend outside of class regarding the cultural identity questions.

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HANDOUT Outline for Cultural Formulation Note: The following material was adapted from DSM-IV-TR, pp. 897–898.

I. Cultural identity of the individual.

1. What is your ethnic background?

2. In what ways do you identify with your cultural group in your daily life? For example, what types of food do you eat, what style of clothing do you wear, and what rituals do you follow during the week and on holidays?

3. In what ways did your family of origin identify with your cultural group in your daily life growing up?

4. In what ways do you identify with mainstream American culture in your daily life?

5. What languages do you speak? Which did you speak growing up? Which do you prefer to use now and in what situations?

6. For immigrants: What kind of job did you have in your country of origin? What kind of job do you have now? What was the impact of immigration on your or your family's financial situation and professional status?

7. For immigrants: What were your (or your family's) reasons for immigrating?

What were the circumstances of the immigration? (Note any dangers involved.)

II. Cultural explanations of the individual's illness.

1. Note what words the person uses to describe their symptoms (“idioms for distress”).

2. What is the meaning of the symptoms in relation to norms of their cultural reference group?

3. How does the person’s family explain the person's symptoms?

4. What has been your past experience with mental health professionals?

5. What other kinds of help have you sought?

III. Cultural factors related to psychosocial environment and levels of functioning.

1.

2.

3.

4.

What kind of stressors has the person been experiencing?

What kinds of social support are available?

Explore religious or other support systems.

How do the symptoms impact the person's functioning?

IV. Cultural elements of the relationship between the individual and the clinician.

1. Note differences in the culture and social status of the client and the clinician.

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2. What problems might these differences cause in diagnosis and treatment? (e.g., difficulty communicating in the client’s first language; difficulty eliciting symptoms or understanding their cultural significance; difficulty in determining whether a behavior is normative or pathological.)

It is important to then compare the cultural elements of the DSM-IV to the DSM-5. Note the cultural issues in the DSM-5: Section I. Basics.

In the Introduction (p. 14, 15) there are sections on “Cultural Issues” and “Gender Differences.”

Section II. Diagnostic Criteria and Codes.

Some disorders have sections, “Cultural-Related Diagnostic Issues” and “Gender Related Diagnostic Issues.” Check pages 923 and 924.

Section III. Emerging Measures and Models A Cultural Formulation is on pages 749–759. This is enhanced from the DSM-IV to include a fuller description of cultural identity and Cultural Conceptions of Distress.”

Also included in the DSM-5 is the Cultural Formulation Interview (CFI) to guide interviewers in obtaining cultural information (see below).

Lastly, in “Cultural Concepts of Distress” is a replacement for the DSM-IV Glossary of CultureBound Syndromes. _______________________________________________________________________________

The DSM-5 Cultural Formulation Interview (CFI) and the Evolution of Cultural Assessment in Psychiatry This evidence-based tool is composed of a series of questionnaires that assist clinicians in making person-centered cultural assessments to inform diagnosis and treatment planning.

For a copy of the interview: https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_CulturalFormulation-Interview-Informant.pdf.

Further reading on the development of the CFI: Aggarwal, N. K., & Lewis-Fernández, R. (2015). An introduction to the cultural formulation interview. Focus, 13(4), 426–431.

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3. Developing Diagnostic Criteria To help students understand the task faced by the committee to revise the DSM, try presenting them with the diagnostic criteria for one of the disorders in DSM-I or DSM-II. Reproduced here are the criteria for obsessive compulsive reaction (DSM-I) and neurosis (DSM-II). Students could be divided into groups and asked to come up with better operational definitions of the criteria listed.

Following an attempt at group consensus in this exercise, give the students the DSM-IV-TR criteria for the same disorder; this will give them an opportunity to see how diagnostic classification has changed and to compare their attempts to those of the “experts.”

DSM-I Diagnostic Criteria for Obsessive Compulsive Reaction In this reaction, the anxiety is associated with the persistence of unwanted ideas and of repetitive impulses to perform acts which may be considered morbid by the patient. The patient himself may regard his ideas and behavior as unreasonable but is compelled to carry out his rituals.

The diagnosis will specify the symptomatic expression of such reactions, as touching, counting, ceremonials, hand-washing, or recurring thoughts (often accompanied by a compulsion to repetitive action). This category includes many cases formerly classified as “psychasthenia.”

DSM-II Diagnostic Criteria for Obsessive Compulsive Neurosis This disorder is characterized by the persistent intrusion of unwanted thoughts, urges, or actions that the patient is unable to stop. The thoughts may consist of single words or ideas, ruminations, or trains of thought often perceived by the patient as nonsensical. The actions vary from simple movements to complex rituals such as repeated hand-washing. Anxiety and distress are often present either if the patient is prevented from completing his compulsive ritual or if he is concerned about being unable to control it himself.

DSM-IV-TR Diagnostic Criteria for Obsessive Compulsive Disorder A. Either obsessions or compulsions:

Obsessions as defined by (1), (2), (3), and (4): 1. recurrent and persistent images, thoughts, or impulses that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress 2. the images, thoughts, or impulses are not excessive worries about real-life problems

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3. the person attempts to ignore or suppress such images, thoughts, or impulses or to neutralize them with some other thought or action 4. the person recognizes that the obsessional images, thoughts, or impulses are from his or her own mind and not imposed from without as in thought insertion

Compulsions as defined by (1) and (2): 1. repetitive behaviors (e.g., hand-washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly 2. the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.

C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day) or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.

D. If another Axis I disorder is present, the content of the obsession or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an eating disorder; hair pulling in the presence of Trichotillomania; concern about appearance in the presence of body dysmorphic disorder; preoccupation with drugs in the presence of a substance use disorder; preoccupation with sexual urges or fantasies in the presence of a paraphilia; or guilty ruminations in the presence of major depressive disorder).

E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

4. Diagnosis Discussing several of the diagnoses included in an appendix of DSM-IV is likely to generate lively controversy, as it did when the committee to revise the DSM-III-R considered including them in the body of the manual. Two disorders suggested for DSM-III-R and no longer on the list to be considered are self-defeating personality disorder and sadistic personality disorder; those disorders have been criticized as blaming abused women for their suffering (they are mentally ill for staying in the relationship) and then giving a legally acceptable mental defense—sadistic personality disorder—to their abusers. Other controversial diagnoses to discuss might include homosexuality (included as ego-dystonic homosexuality in DSM-III and then dropped altogether in DSM-III-R and IV, although “persistent and marked distress about one's sexual orientation” can be

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listed as a sexual disorder not otherwise specified) and learning disabilities (are these mental disorders?). Are there controversial diagnoses in the new DSM-5?

5. Case Vignettes The DSM-IV Training Guide (1995, Reid and Wise. New York: Brunner/ Routledge) provides brief case vignettes for practice in making DSM diagnoses. Brief discussions of the diagnoses suggested are included with each case. For practice in using the multiaxial system, students might be given the cases first, without the discussion, and asked to suggest diagnoses and ratings for each axis, this time using the DSM-5.

DSM-5 by Case Example: https://www.appi.org/Products/DSM-Library/Learning-DSM-5-by-Case-Example

6. Reliability and Chance Agreement The concept of accounting for chance agreement in evaluating reliability is an important idea to get across to students. Ask them this: Two psychiatrists are engaged in a study of the reliability of the diagnosis of schizophrenia. They are only making the diagnosis of schizophrenic or not schizophrenic, and each psychiatrist assigns the diagnosis of schizophrenic to 10% of the cases she sees. After seeing 1,000 cases the psychiatrists discover that they agreed on the diagnosis in 82% of the cases. Is this reasonable reliability? On the surface it does not sound too bad, but in reality the two diagnosticians would be agreeing at a purely chance level. (Given the base rates, this is exactly chance—draw a chi-square contingency table on the board for the students.) You can go on to discuss different statistical measures of reliability (e.g., kappa coefficient) or simply make the point that students should have a general idea of random joint probabilities when evaluating reliability statistics.

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

Wiederman (1999) offers a useful classroom demonstration of confirmatory bias that has been used with undergraduate psychology students. In this demonstration, the instructor orients the Instructors Manual

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class to the techniques and assumptions of projective instruments. Then, half of the class is given a description of the test subject that describes him as shy and reserved, recently becoming even more withdrawn. The other half of the class receives a description that describes the subject as outgoing and restless, becoming increasingly defiant in recent months. The students are then given hypothetical responses to Rorschach Card 3 and the Thematic Apperception Test Card 1 and asked for their observations. As you might expect, the students’ observations differed greatly based upon the information they received about the subject. Consult Wiederman’s study for specifics on how to apply this demonstration in your classroom.

Smith, D. & Dumont, F. (1995). A cautionary study: The unwarranted interpretations of the DrawA-Person Test. Professional Psychology: Research and Practice, 26, 298–303. Wiederman, M. (1999). A classroom demonstration of potential biases in the subjective interpretation of projective tests. Teaching of Psychology, 26, 37–39.

8. Improving Clinical Judgment A useful and well-written article, “Representative thinking in clinical judgment” (1986, Dawes, R. M., Clinical Psychology Review, 6, 425–441), demonstrates the common fallacy of basing clinical judgments (particularly probability estimates) on the degree to which characteristics are representative of our cognitive schemas while ignoring the rules of probability theory. For example, hand out the following question and have students write down their answer and the reasoning behind it before discussing the problem.

Linda is 31 years old, single, outspoken, and very bright. She majored in philosophy. As a student, she was deeply concerned about issues of discrimination and social justice, and also participated in anti-nuclear demonstrations. Which is a more likely description of Linda's current life?

1. Linda is a bank teller.

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

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

Both the Dawes article and another by Arkes (1981, Journal of Consulting and Clinical Psychology, 49, 323–330) conclude with suggestions for minimizing errors in clinical judgments. Students might discuss and practice such ideas as considering alternatives to one’s hypothesis, considering base

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rate information, and decreasing reliance on memory, using more examples selected from the articles.

For a thorough examination of judgment research, consult Studying the clinician: Judgment research and psychological assessment (1998. Garb, H. Washington, DC: American Psychological Association).

9. “Seeing” the Brain Several websites have excellent images of normal and diseased brains as well information on brain imaging: 1. The Whole Brain Atlas—This site combines clinical data with magnetic resonance (MR), Xray computed tomography (CT), and nuclear medicine images to show what goes in the brain. http://www.med.harvard.edu/AANLIB/home.html.

2. The Human Brain: A Learning Tool—An interactive site that identifies brain structures. http://www.getbodysmart.com/ap/nervoussystem/cns/brain/menu/menu.html.

3. The Human Brain: Dissections of the Real Brain—A very comprehensive site: http://www.scribd.com/doc/28155705/The-Human-Brain-Dissections-of-the-Real-Brain.

5. PET Brain Atlas—The PET Brain Atlas is an educational tool that teaches users how to read and interpret various types of PET brain studies. The authors state that over 100 actual patient cases are available for viewing the PET scans along reports and supporting MRI or CT images, when available. http://radiologytutorials.com/neuro-pet/neuro-pet.cgi.

10.

Rorschach Demonstration

The Rorschach (or inkblot test) is a type of projective test developed in 1921 by Hermann Rorschach used in psychoanalysis where a standard set of symmetrical ink blots of different shapes and colors are presented to a patient who is asked to describe what they suggest or resemble. As in other projective tests, the idea is that when a person is shown an ambiguous, meaningless image, the person will try to impose (project) their own meaning on it. It is thought that their interpretations can lead to psychological insights about the patient. It was originally developed to assess thought disorder but became more widely used as a measure of personality. However, the Rorschach is much less widely used today due to concerns about its validity and reliability, although some psychologists still argue that it can be useful when used properly in specific contexts in combination with other clinical assessment data. The scoring process is also very intensive and time consuming, but attempts have been made to improve the scoring system over time.

For more reading on the scientific basis and criticisms of the Rorschach: Garb, H. N., Wood, J. M., Lilienfeld, S. O., & Nezworski, M. T. (2005). Roots of the Rorschach controversy. Clinical Psychology Review, 25(1), 97–118.

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Meyer, G. J., & Archer, R. P. (2001). The hard science of Rorschach research: What do we know and where do we go?. Psychological assessment, 13(4), 486.

Viglione, D. J., & Hilsenroth, M. J. (2001). The Rorschach: Facts, fictions, and future. Psychological assessment, 13(4), 452.

Students are often interested in seeing Rorschach cards and trying their hand at answering and interpreting them. A demonstration might accompany a lecture on the influence of paradigms on Rorschach interpretation (see lecture material, above): Show several examples of inkblots similar to the Rorschach stimuli to the class, ask them, “What might this be?” and have them write down their associations. (Brave students might volunteer to have their responses written on the board, but have them wait until others have had a chance to respond in writing.) This exercise alone exposes students to the discomfort of responding to an ambiguous stimulus, as many will ask for more structure (Can I look at the card upside down? Can I give more than one answer? Am I supposed to use the whole thing? How did they make these?). An online test with inkblots can be viewed at: http://theinkblot.com/ or at http://oink.elrellano.com/desastre/rorschach_inkblot_test.html.

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

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

11.

Does Popularity Imply Utility?

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

12.

Diagnosing Using the DSM-IV-TR and the DSM-5

Although your students have not yet learned the diagnostic criteria for specific disorders, this exercise will allow them to think in terms of where groups of symptoms would be placed using both the DSM-IV-TR and the DSM-5 multiaxial system. Read the following scenario to the class and then have them discuss which symptoms would go on which axes.

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Neill is a 30-year-old man who has spent much of his adult life alone. He lives by himself and works from home programming computers. On average, he leaves his apartment once weekly to go grocery shopping, which he does at night because he is afraid of doing something “embarrassing” in front of large crowds of people. When asked about his social life, Neill reports that he has two friends that he met in internet chat-rooms. He has not met these individuals in-person, stating “If I meet them, they won’t like me. People always make fun of me.” His fears of being criticized are immense. These fears have kept him from applying for jobs outside of the home and from forming in-person social relationships. Neill has frequent headaches and stomach aches. He describes himself as being “functional but stressed.” On a scale of 1–10, with 1 being the least stress and 10 being the most stress, Neill ranks himself as a 7.

13.

Self-Monitoring Exercise

Self-monitoring is an interesting and easily used assessment technique that students can try themselves. You could mimeograph the attached materials and pass them out in the class before the session on assessment. Some smartphone apps may also provide an alternative format for selfmonitoring, such as https://daylio.net/.

In class, after the students have tried self-monitoring for a week, have them discuss their experiences. What was it like to monitor themselves? How faithfully did they keep records? Did they experience reactance? What are some advantages and disadvantages of self-monitoring as an assessment tool? How might students use the data they collected to change their behavior? More complicated records, such as (for someone trying to eat less) where food is eaten, with whom, and at what time, might help in developing a behavior-change plan.

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

A. Choose a behavior that occurs relatively frequently.

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

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

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

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

SELF-MONITORING RECORD TARGET BEHAVIOR: _________________________________________ ESTIMATED FREQUENCY OF BEHAVIOR BEFORE MONITORING: UNIT OF MEASUREMENT (e.g., number of cigarettes, hours of TV, etc.): FREQUENCY OF TARGET BEHAVIOR (Mark each time behavior occurs): Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 5

Day 6

Day 7

Day 1 Day 2

GRAPH (on a separate page, plot a graph of the frequency of behavior for each day of the week, using your own units on the frequency axis)

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14.

Considering Language in Assessment

The impact of language differences is an important aspect of the consideration of culture in psychological assessment. The Lecture Launcher on assessment of Hispanic-Americans addresses this issue. Students might consider broader questions regarding the role of language in the assessment process. One example for students to consider is whether a non-Spanish speaking psychologist should test a bilingual (Spanish/English) client for a learning disability? Should an English-only psychologist test a client who speaks no English? How might a translator affect the testing situation? Would there be any problem using a translator from the person’s family? Would it matter if the psychologist used the clinic secretary, who speaks fluent Spanish? What should the psychologist in question do if he or she cannot locate a Spanish-speaking psychologist to make a referral?

Or consider the following case: A college dean calls to consult with a monolingual (Englishspeaking) psychologist about a student from Japan who states that he is learning disabled and requests extra time on examinations. The dean notes that the student has provided a report from a psychologist in Japan who has diagnosed the student with a learning disability in reading.

However, the report is written in Japanese. The school rules require that learning-disabled students give the school documentation of their learning-disability diagnosis, with testing having been completed within three years. The student was tested within the past year, but the tests used are not those used in the United States, and the results are written in Japanese. Further, the student explains that part of his difficulty is with the Japanese characters; he has difficulty explaining to a person who does not read Japanese what the exact nature of the disability is. In interviewing the student, the psychologist finds that he has a history of reading difficulties throughout his schooling in Japan. However, the student has great difficulty expressing himself in English, and the psychologist is unable to get a clear picture of the impact of his difficulties on his current school requirements. What should the psychologist suggest to the dean? What should the school’s policy be? Should the student be allowed extra time on examinations, as provided to learning-disabled students at the school? Should he be required to take additional tests to demonstrate that he meets the learning-disability criteria of the school? If so, what tests should be administered? In what language?

In discussing these issues, it might be helpful to ask bilingual students to share their own experiences regarding the impact of language on their schooling.

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INSTRUCTIONAL FILMS 1. Challenge Cases for Differential Diagnosis (FHS, 35 min., #BVL7847, 1997) “This program, filmed in the UK, offers viewers a chance to watch interviews with four patients and then, based on their symptoms, come up with their own differential diagnoses.

The cases include a 22-year-old man who continually complains about body odor, when he does not have body odor; a 26-year-old man in a seemingly confused mental state; a 30-yearold woman with anxiety symptoms; and a seemingly normal young man who throws bricks through his neighbor’s window.” https://films.com/id/9817/Challenge_Cases_for_Differential_Diagnosis.htm.

2. Differential Diagnosis in Psychiatry (FHS, 8-part series, 25–46 min. each, #BVL7852, 1997) This series demonstrates a range of clinical disorders in the psychiatric field. Each program shows a doctor’s interviews with patients, preceded by a description of the characteristic features of the disorder and its related phenomenology. Similarities and differences with other disorders are noted to facilitate differential diagnosis. The series includes Organic Disorders, Disorders Due to Psychoactive Substance Abuse, Mood Disorders, and others. https://films.com/ecTitleDetail.aspx?TitleID=10249&r=SR. 3. The Mind Traveler: Oliver Sacks (FHS, 6-part series, 50 min. each #BVL8706, 1996) “World-renowned neurologist Oliver Sacks, author of Awakenings and The Man Who Mistook His Wife for a Hat, takes viewers on a compassionate voyage into the depths of the brain and nervous system. In this six-part series produced by the BBC, Dr. Sacks, who is as interested in the “who” as he is in the “what,” applies his broad cultural and scientific knowledge to a variety of individuals who, among them, suffer from congenital colorblindness, autism, Guam disease, and Tourette’s, Usher, and Williams syndromes.” https://www.youtube.com/watch?v=2J8YNyHIT64.

4. Intelligence, Creativity, and Thinking Styles (FHS, 29 min., color, #BVL9173, 1997) “How do multiple intelligences and different thinking styles relate to traditional IQ scores?

What role should teacher creativity and the family play in shaping student intelligence? In this interview by Phillip Harris, of Phi Delta Kappa, Robert Sternberg, IBM Professor of Psychology and Education at Yale University, answers questions about the IQ-based “single trait notion of intelligence,” the application and implementation of his triarchic theory of intelligence, and the implications of school reform on the future of public.” https://ffh.films.com/id/11085/Intelligence_Creativity_and_Thinking_Styles.htm.

5. Testing and Intelligence (CPB, 30 min.)

Psychological testing reveals how values are assigned to different abilities, behaviors, and personalities. Part of the Annenberg Corporation for Public Broadcasting series “Discovering

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Psychology.” https://www.learner.org/series/discovering-psychology/testing-and-intelligence/.

6. Clinical Interviewing Role Play Examples: https://www.youtube.com/watch?v=keSGvlBzQWg https://www.youtube.com/watch?v=ZB28gfSmz1Y

7. Using Clinical Science to Improve the Assessment and Treatment of Underrepresented Groups. SSCP Diversity Committee. https://www.youtube.com/watch?v=es344iIL1qA.

Discussion Questions These questions are based on the clinical case studies and other information found throughout the chapter.

Aaron Aaron is exhibiting symptoms that meet the criteria for schizophrenia based on DSM-5. What other possible disorders might his symptoms indicate? What would you rule out during the assessment process (differential diagnosis)?

Roxanne What are some of the symptoms of mania exemplified by Roxanne? People with bipolar disorder commonly encounter negative side effects of their medications or resist taking their medications as patients may miss some of the more positive aspects of mania or hypomania, such as the positive feelings or increased energy. They often later report that they feel better without the medications and discontinue their use, as exemplified in Roxanne’s case. What measures might be taken by friends and families of people diagnosed with bipolar disorder to ensure that medications are taken consistently?

Culture and Diversity Considerations Ask students to reflect on how their own cultural and ethnic background may influence their views on psychopathology or psychological treatment.

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CHAPTER 4 REASEARCH METHODS IN PSYCHOPATHOLOGY LEARNING GOALS 1. Describe issues in defining theory and hypothesis.

2. Discuss the advantages and disadvantages of case studies, correlational designs, and experimental designs, and identify common types of correlational and experimental designs.

3. Explain the standards and issues in conducting psychotherapy outcome research.

4. Describe the types of analogues that are most common in psychopathology research, and identify concerns about the use of analogues.

5. Discuss the current debate concerning replicability in science, and list the basic steps in conducting a meta-analysis.

The Learning Goals are inherent in both the Lecture Launchers and Discussion Stimulators below. Please note the Discussion Questions at the end of this chapter.

CHAPTER SYNOPSIS Science and Scientific Methods Science is the systematic pursuit of knowledge through observation. The first step of science is to define a theory and related hypotheses. A good theory is precise and could be disproven. A set of principles must be considered in testing a theory. It is important for researchers to replicate findings from a given study, which requires being precise about the methods used. Researchers must carefully choose their measures and research designs.

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Approaches to Research on Psychopathology Common methods for studying abnormal behavior include case studies, correlational methods, and experimental methods. Table 4.1 describes the strengths and weaknesses of each method for studying psychopathology.

The Case Study The case study is an excellent way of examining the behavior of a single person in rich detail and of generating hypotheses that can be evaluated by subsequent quantitative research. Some cases provide evidence that goes against a universal law or illustrate a rare disorder or technique. But findings from a case study may or may not be valid—they may be biased by the observer’s theories, and the patterns observed in one case may not apply to others. Furthermore, the case study cannot provide satisfactory evidence concerning cause–effect relationships because alternative hypotheses are not examined, and controlled conditions are not used.

The Correlational Method Studies using the correlational method allow a researcher to gather data about variables and to see if these variables covary or correlate (i.e., vary together with another variable, particularly in a way that may be predictive). No variables are manipulated; rather the researcher compares two variables and computes a correlation coefficient to determine whether a naturally occurring relationship is large enough to reach statistical significance. The strength of the relationships between the paired variables can be computed and is called the correlation coefficient, denoted by the symbol r. This statistic may take any value between −1.00 and +1.00, and measures both magnitude and direction of the relationship. The higher the absolute value of r, the stronger the relationship between the two variables. Beyond statistical significance, it is also important to consider clinical significance, which is defined by whether a relationship between variables is large enough to matter clinically. Psychopathologists are forced to make heavy use of the correlational method because there are many key variables, including diagnosis, genes, trauma, and neurobiological deficits, that they are not free to manipulate. But correlational findings are clouded by third-variable and the directionality problem, especially when cross-sectional designs rather than longitudinal designs are used, making correlational data unsuitable for drawing cause–effect conclusions. The high-risk method helps to overcome some of these issues by studying high-risk individuals before they are diagnosed with clinical disorders to better determine causality.

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A great resource for choosing a research method can be found here (pdf in left sidebar): https://explorable.com/different-research-methods.

Studies of epidemiology and behavioral genetics often use correlational designs. Researchers use epidemiological studies to assess how common disorders are (incidence and prevalence), and what variables are associated with them (correlates). Epidemiological studies avoid the sampling biases seen in studies of people drawn from undergraduate psychology classes or from treatment clinics. Behavior genetics research uses the family method, looking to see how the presence of a disorder varies by the number of genes shared by family members; the twin method, comparing monozygotic (MZ) and dizygotic (DZ) twins to see whether twins with more shared genes are at greater risk for developing a disorder (i.e., concordance). The starting point in such investigations is the recruitment of a sample of individuals with the diagnosis of interest, referred to as index cases or probands. The adoptees method and cross-fostering method are two designs to help separate gene and environmental effects.

The Experiment The experiment is the most powerful tool for examining causal relationships. It involves random assignment of participants to conditions, the manipulation of an independent variable (predictor), and measurement of a dependent variable (outcome). Differences between conditions on the dependent variable are called the experimental effect.

Internal validity refers to whether an effect can be confidently attributed to the independent variable. To have internal validity, a control group must be included. External validity refers to whether experimental effects can be generalized to situations and people outside of this specific study. Experimental designs can provide internal validity but external validity is sometimes of concern. Correlational studies can provide solid external validity, but poorer internal validity (see below Lecture Launcher #1 for threats).

Single-case experimental designs can also provide well controlled data with high internal validity, but they lack external validity since the manipulation of an independent variable is only examined in a single case. A reversal design or ABAB design is one type of single-case design where an individual’s behavior is carefully measured in a specific sequence.

Treatment outcome research is a common form of experimental research. This type of research is designed to address a simple question: does treatment work? At minimum, most researchers agree that a treatment study should include the following criteria:

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1.

2.

3.

4.

5.

6.

7.

A clear definition of the sample being studied.

A clear description of the treatment being offered.

Inclusion of a control of comparison treatment condition.

Random assignment of clients to treatment or comparison conditions.

Reliable and valid outcome measures.

Evaluation of outcomes by raters unaware of the patient’s treatment assignment.

A large enough sample size.

Studies involving clients being randomly assigned to receive active treatment or a comparison condition are called randomized controlled trials (RCTs). Placebo control groups are often used in treatment research, ordinarily using a double-blind procedure. The ultimate goal is to help develop empirically supported treatments (ESTs).

RCTs are designed to determine efficacy of a treatment under controlled conditions, but it is also important to determine effectiveness of a treatment in the real world. Dissemination is the process of facilitating the adoption of efficacious treatments in community settings.

An analogue experiment can be used to observe a related but less severe phenomenon in the laboratory to allow more intensive study.

Integrating the Findings of Multiple Studies In a successful replication, findings from one study will hold up when that study is repeated.

Replication is a core aspect of the scientific method, but many studies have not held up to replication, which has recently been spotlighted as a major issue in the field. Replicability may be overestimated when we rely on published articles since journals tend to prioritize new positive findings over null responds, an issue referred to as publication bias. Questionable research practices, such as p-hacking, also contribute to replication failures. Recent efforts have focused on improving replicability of psychopathology research.

Meta-analysis is an important tool for reaching general conclusions from a group of research studies. It entails putting the statistical comparisons from single studies into a common format— the effect size—so the results of many studies can be averaged. When researchers conduct a meta-analysis, they do the following: 1. The researcher defines which studies will be included.

2. The effect size within each study is calculated.

3. The average effect size across studies is calculated.

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KEY TERMS ABAB design

effectiveness

p-hacking

adoptees method

efficacy

placebo

analogue experiment

empirically supported treatments (ESTs)

placebo effect

case study

epidemiology

clinical significance

experiment

concordance

experimental effect

control group correlation correlation coefficient correlational method cross-fostering

random assignment

high-risk method

reversal design

hypothesis

single-subject experimental design

internal validity

directionality problem dissemination dizygotic (DZ) twins double-blind procedure

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family method

index case

dependent variable

publication bias

external validity

independent variable

cultural competence

proband

questionable research practices

incidence

cross-sectional design

prevalence

statistical significance theory third-variable problem

longitudinal design

treatment outcome research

meta-analysis

twin method

monozygotic (MZ) twins

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

1. History. Anything that has occurred to the subjects between Time 1 and Time 2 in addition to the independent variable may affect the dependent variable. For example, in addition to the psychotherapy treatment she received (the independent variable), a manic-depressive subject may see a television program on bipolar illness that influences her behavior.

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

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

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

5. Statistical Regression. Regression to the mean is expected of extreme scores from Time 1 to Time 2. This has nothing to do with the effect of the independent variable. For example, people who do extremely poorly on an IQ test at the first testing are likely to do somewhat better on the second test (and vice versa) because of imperfect test-retest reliability and the random component to the abilities tested.

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

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

2. Analogues and External Validity Students studying research methods in psychology often raise questions about the external validity of laboratory research: is the setting or the sample so artificial that it cannot apply to “real life”? In his essay “In Defense of External Invalidity” (1983, American Psychologist, 379–387), Mook points out that such questions are relevant only to certain types of experiments with certain purposes; it would be worthwhile discussing this issue with students. To summarize his point, many experimental studies seek to test theories; in such cases, predictions are made, based on the theory, about what ought to happen in the laboratory. For example, the tension-reduction theory asserts that alcoholics drink in order to relieve tension. A prediction derived from that theory is that subjects made anxious in the laboratory should drink more to release the tension. In a test of this prediction, subjects who were made anxious did not drink more (Cappell, H. & Herman, C. P., 1972, Quarterly Journal of Studies on Alcohol, 33, 33–64). This finding suggests that the theory needs to be qualified, even though the experimental conditions were not similar to real life. Indeed, another study by Steele et al. (Steele, C. M., Southwick, L., & Pagano, R., 1986, Journal of Abnormal Psychology, 95, 173–180) has begun to specify conditions under which alcohol might be used to reduce stress, thus advancing the theory through analogue research. Bradford, Shapiro, and Curtin have suggested that alcohol as a stress reducer has been inconsistently observed in the lab and raises questions about how this mechanism might work (Psychological Science, 24(12), 2013, 2541–2549). In an article in the Journal of Psychopharmacology, Hefner and Curtin suggest that alcohol use and stress response dampening (SRD) are interconnected, and that the selective SRDs produced by alcohol during uncertain threat exists (26(2), 2012, 232–244).

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In contrast, when researchers wish to describe what actually occurs in real life, external validity becomes a more potent issue; the following threats to external validity often arise in research designed to make generalizations about abnormal behavior: 1. Use of subject analogues, such as volunteer college students who score in the clinical range on questionnaires, to draw conclusions about how disordered individuals behave. Such subjects differ in important ways from diagnosed patients; for example, they have not sought professional help for their problems, despite scoring in the clinical range.

2. Use of therapist analogues, such as inexperienced graduate student therapists, to reach conclusions about the effectiveness of different types of therapy in the clinical setting. If no differences are found between types of therapies, this may relate to the lack of experience of the therapists; experienced therapists might, in fact, differ in their effectiveness depending on their theoretical orientation.

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

223).

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

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

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

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5. “Serendipity—the art of finding one thing while looking for something else” (p.

227). Instead of trying to find a way to keep rats at a constant level of food deprivation, Skinner discovered the phenomenon of fixed-ratio reinforcement.

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

Another interesting view on Skinner’s influence may be found in a 1937 issue of Life magazine, which featured pictures of a rat trained by Skinner through the method of successive approximation to pull a chain to release a marble, pick up the marble and carry it across the cage, then drop the marble in a slot to release a food pellet (“This Smart University of Minnesota Rat Works a Slot Machine for a Living,” Life, 1937, May 31).

For the industrious student, a special issue of American Psychologist devoted to Skinner's work would also be of interest (Volume 47, 1992).

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

Students might enjoy contrasting the perspective of Rogers with that of Skinner above.

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5. Meta-Analysis and Implications for “Significance” and Theory Building “What do data really mean?: Research findings, meta-analysis, and cumulative knowledge in psychology” (Schmidt, F. L., American Psychologist, 47, 1173–1181, 1992) discusses the role of meta-analysis in interpreting the findings of individual research studies. As the class is studying the different research methods used in psychology and the use of statistical significance tests to determine whether a particular finding occurred as a result of chance, it would be useful to introduce them at an elementary level to the use of meta-analysis and the meaning of Type I vs. Type II errors and power. Schmidt points out the erroneous conclusions that may be reached when a person studying the psychological literature assumes that research findings that do not reach statistical significance therefore disprove the researcher’s hypothesis. In fact, a small sample size may have prevented them from discovering a truth. Meta-analytic techniques enable the viewer to examine the results of numerous studies of a single phenomenon, pooling each study into a much larger sample.

In addition to accomplishing more accurate interpretations of a body of research data, meta-analysis leads to theory building, providing empirical building blocks by identifying consistent relationships between variables. Path analysis can then be used to help test the theories suggested by the meta-analysis.

The following example from Schmidt’s article may help students understand the role of meta-analysis in reviewing a set of studies, as compared to more traditional approaches of narrative literature review with which the students are probably more familiar. A large validity study (n = 1,428) examining the relationship between a clerical test and a measure of job performance was divided into 21 smaller studies, each with n = 68. The validity coefficient was statistically significant in only 38% of the smaller studies, although in the original large study, the correlation between the two measures was significant. Thus, a reviewer of the smaller studies would probably conclude that the test is valid in only 38% of the organizations, and invalid in most; in fact, such a conclusion would be false. In contrast, if the set of smaller studies was examined from a meta-analytic viewpoint, the correct conclusion would be reached: that is, the clerical test was a valid measure of job performance.

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

2.

3.

4.

5.

6.

7.

What was the independent variable?

What were the dependent variables?

What was the experimental hypothesis (if you have one)?

Is the study internally valid?

Externally valid?

Was this a double-blind study?

If you compare results for men and women, would this be a mixed design?

2. Critiquing Research A useful way to get students to utilize their knowledge about research design is to have them critique research. You could: 1. Assign a couple of research reports (Science is a good source for brief reports) and discuss them in class, or have students write a one-page evaluation including the following points: a. identify the type of research design, b. note what theoretical constructs were discussed and how they were operationalized, c. critique the report in terms of external and internal validity and the causal inferences made.

2. Have students locate their own “research reports” from sources such as Cosmopolitan, the National Enquirer, or the local newspaper. Having students critique media reports of psychological research will teach them to apply some of their newly learned concepts, make them a bit more skeptical about what

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they read, and introduce you to hundreds of new facts about diets, childhood experiences, and the effects of stress!

3. Reliability and ESP The concept of reliability of an experimental finding and the importance of this criterion can be easily demonstrated to the class by having them take part in an “ESP” experiment with you. You think of a number between 1 and 10 and ask the entire class to use ESP to divine the number. About 10% of the class will guess correctly, but after being amazed at the number of psychics in your class, you might begin to wonder if the finding is reliable.

Replications of the experiment will eventually eliminate all of the numbers of the first group of psychics and demonstrate why a finding must be reliable before the community of scientists accepts it.

4. Falsifiability Present the class with your “theory” of human behavior. Your theory goes like this: we each have an invisible little Martian sitting on our shoulder and whispering into our ears telling us what to do. Can the class disprove your theory? No—nor could you prove it. The students’ attempts to disprove your theory can be used to point out why theories, in order to be scientific, must be testable. This demonstration also illustrates why, in scientific research, the null hypothesis is that no effect is accepted until it is demonstrated. If I assert that schizophrenia can be cured by hemodialysis, that fluorescent lights cause hyperactivity, or that masturbation causes insanity, it is my obligation to prove the assertion to be true, not your obligation to prove me wrong. Ask the class to apply some of their newly learned rules of science to some of the theories discussed in Chapter 2.

5. Ethics in Research The ethics of doing research on human subjects is covered in the last chapter of the text, but discussion of the issues might begin now. Many students have probably served as subjects in psychology experiments to earn extra credit for courses. How do they feel about their experience? Were they deceived as a part of an experimental manipulation?

Past experiments such as Milgram’s obedience to authority studies can be discussed from an ethical perspective.

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

6. Designing a Research Study For this activity, have students divide up into groups of 4–5 students. Direct them to think about a problem in the field of abnormal psychology that they would like to study. Then instruct them to complete the following worksheet on next page.

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Designing a Research Study Topic

Study Hypothesis

Study Purpose (Why is this an important question to ask?)

Population (Who will be in the study? Why will they be in the study? How will they be selected for the study?)

How will you answer your study hypothesis? What will you do in your study?

List Independent Variable(s)—be sure to address how these variables will be measured:

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List Dependent Variable(s)—be sure to address how these variables will be measured:

What type of study will you conduct and why?

To whom will the results of your study apply?

Discussion Questions What method did you use for your study?

Why did you select this method?

What are the strengths of your study?

What are the weaknesses of your study?

What ethical issues might be important to consider?

Is there anything that you forgot to cover that should be addressed in this study?

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INSTRUCTIONAL FILMS 1. Experimental Methods in Psychological Research: https://www.youtube.com/watch?v=1MGTkf5eghQ.

2. Hans Rosling demonstrates how statistics work with world populations, health, and economy: https://www.ted.com/talks/hans_rosling_shows_the_best_stats_you_ve_ever_seen #t-609476. or in this longer version: https://www.bbc.com/future/story/20120528-the-best-stats-youve-ever-seen.

3. What is p-hacking: https://www.youtube.com/watch?v=Gx0fAjNHb1M.

4. John Oliver on p-hacking: https://www.youtube.com/watch?v=FLNeWgs2n_Q.

5. On the replication crisis in science (Ted Ed): https://www.youtube.com/watch?v=FpCrY7x5nEE.

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DISCUSSION QUESTIONS These questions are based information found throughout the chapter.

Correlational Studies In correlational studies, variables are measured as they exist in nature. What are the strengths and limitations of this method? What does the adage “correlation is not causation” mean? In what conditions would researchers choose this method of research over others?

Placebo Effect Mike took one of his wife’s antidepressant medications because he was feeling really down one day. He told his friend Jim that he felt so much better after only 20 minutes. Jim knew this could not be due to just one dose, because antidepressants need a couple of weeks of regular dosing to build up to a therapeutic level in the bloodstream in order to be effective. If it is not the medication, then what could be happening to make Mike feel better? Describe the conditions under which research results could reflect this phenomenon.

Case Studies vs. Experimental Model Compare and contrast the strengths and limitations of case studies and experimental studies.

What conditions would lead researchers to choose one method over the other?

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CHAPTER 5 MOOD DISORDERS LEARNING GOALS 1. Describe the symptoms of depression, the diagnostic criteria for depressive disorders, and the epidemiology of the depressive disorders.

2. Explain the symptoms of mania, the diagnostic criteria for bipolar disorders, and the epidemiology of bipolar disorders.

3. Discuss the genetic, neurobiological, social, and psychological influences that contribute to the mood disorders.

4. Describe the biological and psychological treatments of mood disorders as well as the current views of electroconvulsive therapy.

5. Explain the epidemiology of suicide, the risk factors for suicide, and methods for preventing suicide.

The Learning Goals are inherent in the Synopsis, Lecture Launchers, and Discussion Stimulators below.

CHAPTER SYNOPSIS Mood disorders involve disabling disturbances in emotion—from the extreme sadness and disengagement of depression to the extreme elation and irritability of mania. This chapter reviews the clinical descriptions and epidemiology of the different mood disorders and consider approaches to treatment. Finally, the chapter concludes with an examination of suicide, a common feature of mood disorders.

The DSM-5 recognizes two broad types of mood disorders: unipolar depressive disorders (no manic symptoms) and bipolar depressive disorders (with manic symptoms). See Table 5.1 for an overview of mood disorders included in the DSM-5.

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Clinical Descriptions and Epidemiology of Depressive Disorders The cardinal symptoms of depression include profound sadness (i.e., depressed mood) and/or an inability to experience pleasure (i.e., anhedonia). Most people experience some symptoms of depression during our lifetimes, but for most people these experiences do not meet the intensity or duration to qualify for a depressive episode. Physical symptoms are also common in depression and include fatigue, low energy, and physical aches and pains. Thoughts and movements may slow for some (i.e., psychomotor retardation), while others may not be able to sit still (i.e., psychomotor agitation).

Depression symptoms are quite varied and can manifest different ways in different people. Most people experiencing depression experience only a subset of symptoms, with over 1,000 different possible patterns.

Major depressive disorder (MDD) is an episodic disorder, meaning symptoms tend to be present for a specific period of time then improve. However, an untreated episode can still last for months or longer and tend to recur. On the other hand, persistent depressive disorder (formally known as dysthymia in DSM-IV), involves chronic depression more than half the time for at least 2 years.

MDD is one of the most common disorders: 16.2% of people in the United States met criteria for MDD at some point in their lifetime. Women are about twice as likely as men to experience MDD and persistent depressive disorder, and the prevalence of MDD seems to be increasing steadily across generations, while the age of onset for MDD has been decreasing. People from lower socioeconomic status are also more likely to experience depression. Prevalence rates vary considerably across countries and cultures.

Seasonal affective disorder, or depression associated with the winter, tends to be higher in areas farther from the equator.

Clinical Descriptions and Epidemiology of Bipolar Disorders Bipolar I Disorder (formerly known as manic-depressive disorder) involves at least one episode of mania during a person’s lifetime. Mania is a state of intense elation or irritability, along with abnormally increased activity and other symptoms, such as a flight of ideas (i.e., thoughts rapidly shifting from topic to topic). Mania can also lead to reckless behavior and risky decisions. While not required, individuals with this disorder also often experience depressive episodes as well. Bipolar II Disorder is defined by at least one hypomanic episode and at least one depressive episode during a person’s lifetime, where hypomania is a milder form of mania that tends not to result in the same level of serious problems as seen in mania. Cyclothymic disorder is a chronic mood disorder associated with frequent but mild depression symptoms alternating with mild manic symptoms.

Bipolar disorders are much rarer than MDD (0.6% lifetime prevalence across 11 countries), but are much more recurrent. Like depression, rates of bipolar disorders are also increasing, particularly among children and adolescents, with more than half of bipolar disorder diagnoses onsetting before age 25.

Bipolar I is among the most severe forms of psychological disorders.

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Etiology of Mood Disorders Bipolar disorder is highly heritable, and MDD is modestly heritable, suggesting the importance of genetic influences. Neurotransmitter models focus on serotonin, dopamine, and norepinephrine, which are also the target of many antidepressant medications. Dopamine may play a major role in the sensitivity of the reward system in the brain which guides pleasure, motivation, and energy in the pursuit of rewards. It appears that people with depression may be less sensitive to dopamine and those with mania may be more sensitive to dopamine.

Neuroimaging studies suggest that depression is associated with changes in regions of the brain that are involved in emotion and reward processing, including the anterior cingulate, the striatum, and the dorsolateral prefrontal cortex.

In terms of other neurobiological influences, MDD and bipolar disorders are also both related to cortisol dysregulation, as indicated by abnormalities in the cortisol awakening response (CAR). In further evidence of cortisol dysregulation in mood disorders, Cushing syndrome, which involves overly high levels of cortisol, is frequently associated with depression symptoms. Abnormalities in the immune response, such as increases in pro-inflammatory cytokines may also play a role in mood disorders.

In regard to psychosocial influences, research strongly supports the role of life events as a trigger for MDD, including childhood adversity, interpersonal difficulties, and other stressful life events. Families problems are another important interpersonal predictor of depression, including high levels of expressed emotion (EE) within families.

People do tend to experience high negative affect and low positive affect when depressed. Evidence suggests that neuroticism, which involves high negative effect, predicts the onset of depression.

Cognitive factors include a negative schema; negative beliefs about the self, world, and future (i.e., negative triad); information-processing biases to attend to and recall negative rather than positive information; stable, global, and internal attributions for stressors (i.e., attributional style); and a sense of hopelessness. Rumination (i.e., a tendency to focus on the nature of negative thoughts) may also increase risk for depression.

Less psychological research is available on bipolar disorders Nonetheless, many of the variables that predict MDD also appear to predict depression symptoms within bipolar disorder. For mania, one model suggests that mania may arise after life events involving reward sensitivity, goal attainment, and excess involvement in pursuing goals. Sleep deprivation has also been shown to increase risk for manic episodes.

Treatment of Mood Disorders Many different treatments are available for depression. Interpersonal psychotherapy (IPT), cognitive therapy, mindfulness-based cognitive therapy (MBCT), behavioral activation (BA), behavioral couples therapy, have received empirical support for treatment of depression. For bipolar disorders, psychoeducation, family focused therapy (FFT), and IPT have shown benefit. These treatments may be helpful as a supplement to medications for treatment of bipolar disorder and may be particularly helpful in improving adherence to medication and relieving depressive symptoms.

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Medications are the most common and best-research biological treatment for depressive and bipolar disorders. There are four main categories of antidepressants: Monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). SSRIs and SNRIs have become more popular and widely used because they have fewer side effects than MAOIs and tricyclics, although the effectiveness of all four classes is comparable. Although controversial, ECT is an effective last-resort treatment for treatment-resistant depression. rTMS is another biological treatment for treatment-resistant depression that has shown some efficacy and fewer side effects than ECT. Medication treatment is the first line of defense against bipolar disorder. Medications that reduce manic symptoms are referred to as mood-stabilizing medications and include medications such as lithium. Two classes of medications used besides lithium include anticonvulsants and antipsychotics which may be used for individuals who do not tolerate lithium well. While mood stabilizers may also reduce depressive symptoms, for some individuals still experiencing depressive symptoms, an antidepressant is also often added to help treat depressive symptoms.

Suicide Suicide rates may be underestimated as circumstances of many deaths may be ambiguous.

Epidemiology studies of suicide suggest that about 9% of people worldwide report suicidal ideation at least once in their lives and 2.5% have made at least one attempt. Men are more likely than women to kill themselves, while women are more likely to attempt.

The rate of suicide in the United States has increased most rapidly among White middle-aged men from a low level of education living in rural areas. Rates of suicide among adolescents and children in the United States are also increasing but remain lower than rates for adults.

As for mood disorders, risk factors for suicide are complex and multifaceted and include presence of a psychological disorder, as well as neurobiological and psychosocial influences. Most people who commit suicide meet diagnostic criteria for psychiatric disorders, with more than half experiencing depression.

The tendency to suicide is at least partially heritable, and neurobiological models focus on serotonin and overactivity in the hypothalamic-pituitary-adrenal axis (HPA). Dramatic changes in economic and/or social circumstances are common precedents to anomic suicide. Vulnerability may be tied to poor problem-solving, hopelessness, impulsivity, lack of reasons to live, and low life satisfaction.

Several approaches have been taken to prevention. For people with a mental illness, psychological treatments and medications to quell symptoms help reduce suicidality. Many people believe it is important to address suicidality more directly. Psychotherapy approaches such as DBT or CAMS may also target suicidality directly. Problem-solving therapy has shown promise in reducing suicidal behavior, but not all results have been positive. Suicide hotlines are found in most cities, but research demonstrating that these work has been hard to conduct. Means restriction is an important and effective strategy involving making lethal means less available, such as adding suicide barriers on bridges. Means restriction is effective as most suicidal urges are temporary and fleeting.

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Key Terms Anhedonia

hopelessness theory

anterior cingulate

hypomania

attribution

information-processing biases

attributional style behavioral couples therapy bipolar I disorder bipolar II disorder

major depressive disorder (MDD)

reward system

mania

Cushing’s syndrome

mindfulness-based cognitive therapy (MBCT)

episodic disorder expressed emotion (EE) flight of ideas

psychomotor agitation psychomotor retardation

means restrictions

dorsolateral prefrontal cortex

psychoeducation

lithium

cortisol awakening response (CAR)

cyclothymic disorder

persistent depressive disorder

monoamine oxidase inhibitors (MAOIs) mood disorders negative tiad neuroticism, nonsuicidal

rumination seasonal affective disorder selective serotonin reuptake inhibitors (SSRIs) serotonin-noreprinephrine reuptake inhibitors (SNRIs) serotonin transporter gene suicide suicide attempt tricyclic antidepressants

self-injury (NSSI)

LECTURE LAUNCHERS 1. I Expect to be Criticized, Therefore I Am Recent modifications of cognitive therapy recognize that the schemas of depressed individuals are not necessarily wrong, but rather that they are biased. That is, while normal people view the world through “rose-colored glasses,” those who are depressed see the depressing aspects of the world with painful accuracy. Recent evidence by Giesler, Josephs, and Swann (1996; Journal of Abnormal Psychology, 105, 358–368) suggests that this bias may be based on the tendency of depressed individuals to solicit feedback that confirms their negative self-views.

In this study, clinically diagnosed depressed individuals were compared with nondepressed people with either high or low self-esteem. After completing a series of personality questionnaires, participants were told that a graduate student was preparing an in-depth evaluation of their personality characteristics but that, because of a scheduling error, there would only be time for them to read one of the evaluations. Participants were then given two

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summaries, one containing positive (e.g., this person seems well adjusted, self-confident, happy, etc.) and one negative (e.g., this person seems unhappy, unconfident, uncomfortable around others, etc.) information. On the basis of the summaries, subjects were asked to choose which in-depth evaluation they would like to read. Further, participants rated each summary on its perceived accuracy and favorability.

The results indicated that, as predicted, 82% of depressed participants, 64% of low-self-esteem participants, and only 25% of the high-self-esteem participants chose to read the negative, rather than the positive, evaluation. Further analysis provided support for the author's selfverification theory; that is, the three groups’ desire for negative evaluation seem to be directly related to their perceptions of how self-confirming they found the negative summary to be.

People in all groups wanted to read the evaluation that they believed was most accurate.

Previous studies by Swann and colleagues have indicated that favorable feedback makes depressed individuals so uncomfortable that they prefer to be in a different experiment rather than interact with a favorable evaluator, and when they receive positive information about themselves, they intensify their search for negative feedback.

The authors speculate on ways striving for negative feedback interferes with the depressed person’s interactions with others. Research suggests that when depressed individuals find they are being viewed favorably; they intensify their negative interpersonal behavior by behaving in a hostile manner, self-disclosing inappropriately, or increasing their symptom expression.

“Because friends and relatives often attempt to cheer up newly depressed individuals by denying or disconfirming their negative self-views, such boomerang effects should be especially likely to occur early in depression” (p. 366).

What are the implications for cognitive therapy? On the one hand, one might guess that cognitive therapy would fail because depressed individuals would be so unwilling to hear, much less generate, positive self-statements. (Indeed, therapists working with depressed patients must guard against becoming swept up in the client’s overwhelmingly negative self-view.) On the other hand, Swann and colleagues contend that cognitive therapy may work by disrupting the self-verification process. That is, therapy seeks to decrease the certainty with which the depressed person holds their negative self-views, opening the door for positive feedback to filter in. A summary of the major interventions can be found in this link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1525059/.

A rapidly growing approach to treating mood disorders is Cognitive Bias Modification Therapy (CBMT). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4290215/. It is based on modifying cognitive processes and is a supplement to either or both medication or talk therapy. CBMT targets harmful thought patterns, is computer delivered and can be accomplished with or without clinical support. It is used for treatment of mood disorders and addiction. The object of treatment is to change mental habits, not just how one thinks and responds. Weisberg and Amir (2011) suggest that attention varies depending on the individual. If a person is looking for what makes them depressed or anxious, that is what they are more likely to find. The most common

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exercise is the computerized dot-probe task to train individuals to pay attention to or avoid negative and depressive stimuli or thoughts.

Thirty-six people with social anxiety disorder were tested for attention bias by Schmidt (2009).

In just two hours (which were broken up into 15-minute segments), 72% of the respondents no longer had the DSM-5 criteria for anxiety disorder, and the results lasted up to four months.

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

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

According to Watkins et al., each student should answer the following questions for each scene: 1.

2.

3.

4.

Was the scene real or imagined?

Was the student the maid character?

Using a 9-point Likert-like scale, was it vivid?

Using a 9-point Likert-like scale, was it pleasant or unpleasant?

Perhaps it would be interesting for each student to write a statement about their experience of unconscious memory bias.

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

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In each pair, the first word is the cue and the word after the hyphen is the target. For example, “adored” is the cue and “admired” is the target.

Set

Positive

Neutral

Negative

A

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

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

blamed-punished, bleakhopeless, criticizedjudged, discontentunsatisfied

B

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

animals-giraffe, colorsmagenta, fruits-peaches, fuels-propane

downcast-gloomy, empty-lonely, guiltyaccused, humiliatedashamed

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

3. NIMH Depression Awareness, Recognition, and Treatment Program The National Institute of Mental Health launched a program in May 1988 to educate the public about major depression, bipolar disorder, and dysthymic disorder (Regier, D. A. et al., 1988, American Journal of Psychiatry, 145, 1351–1357). Noting that although 80% to 90% of people with major depression can be treated successfully, only one in three sufferers seeks treatment, the goal of the NIMH Depression, Awareness, Recognition, and Treatment Program is to disseminate the message that depressive disorders are common, serious, and treatable.

Audiences targeted include primary care providers, mental health specialists, and the general public.

In the first phase of the project, grants were awarded to set up programs for training primary care physicians and mental health providers in the diagnosis and treatment of depressive disorders. The public education campaign includes surveying the public about their knowledge of depression and its treatment and preparing and disseminating print and electronic educational materials throughout the country. The basis for these materials includes: (1) Epidemiological studies indicate that 3% of the population has depression at any one time; the lifetime prevalence is 5.8%. Manic depression has a 0.8% prevalence rate, and dysthymia, 3.3%.

The rate of mood disorders in women is twice that in men; the highest risk is between the ages 22 and 44. (2) Highly effective treatments are available for the depressive disorders, including pharmacotherapy and other somatic treatments and psychotherapy.

4. Evidence for the Effectiveness of Beck’s Cognitive Therapy Dobson (1989, Journal of Consulting and Clinical Psychology, 57, 414–419) presents results from a meta-analysis of studies testing the effectiveness of Beck’s cognitive therapy for treating

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depression. The review covers all studies published from January 1976 to December 1987 involving an analysis of the efficacy of cognitive therapy that explicitly refer to Beck’s method, target depression as the focus of treatment, and use the Beck Depression Inventory as an outcome measure (resulting in a review of 28 studies). In comparing cognitive therapy groups with no-treatment or wait-list control groups, the average cognitive therapy client did better than 98% of the control subjects. (Mean effect size = −2.15, indicating the experimental groups showed decreases in depression scores over two standard deviations greater than control groups.) Compared to behavioral treatments, cognitive therapy also fared better (effect size = −0.46). In relation to nonbehavioral psychotherapy treatments (a varied category), cognitive therapy was also more effective (effect size = -0.54). Finally, cognitive therapy was shown to be superior to medication treatment (effect size = -0.53).

The length of treatment and proportion of women in the sample were not related to the change in depression in the cognitive therapy condition. (The average length of therapy was 14.9 weeks, indicating a fairly rapid effect of cognitive therapy.) There was a trend for younger clients to improve more with cognitive therapy than older clients; however, the samples were limited in their age range, making these findings tentative.

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

Depression occurs more often in women than in men. Research involving both patients in treatment and surveys of community residents consistently yields a 2:1 female:male ratio (Nolen-Hoeksems, 1987). Understanding the cause of this gender difference may yield some further clues to the etiology of depression.

Radloff (1975) speculates that the higher levels of depression among women are best explained as a consequence of learned helplessness. The feminist literature would agree (e.g., Bernard, 1973; Chesler, 1972), for it blames the greater incidence of mental problems among women on their lack of personal and political power. Feminists take the position that more women than men become depressed because their social roles do not encourage them to feel competent.

What women do does not seem to count compared with the greater power that men have in society. In fact, it may be that little girls are trained to be helpless (Broverman, Broverman, & Clarkson, 1970). Consistent with these speculations are data showing that girls’ behavior is less likely than boys’ to elicit consequences from both parents (Maccoby & Jacklin, 1974) and teachers (Dweck et al., 1978). Furthermore, girls are more likely to attribute success to luck or the favors of others (unstable) and failures to global and stable factors (Dweck, 1975).

In her research on factors influencing the duration of depressive episodes, Nolen-Hoeksema (1987, 1990) proposed an equally plausible account of these gender differences, referring to characteristic differences in the way men and women cope with stress. When responding to depression, men typically engage in activities that will distract them from their mood, for example, engaging in some physical activity or watching television. Women, on the other hand, are less active, tend to ruminate about their situation, and blame themselves for being

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depressed (e.g., Kleinke et al., 1982). This ruminative reaction is then seen as amplifying the state of depression and negative mood, perhaps by interfering with attempts to solve problems.

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

How does it come about that women have a more ruminative response style to stress and sadness than men? Nolen-Hoeksema seeks answers in sex-role learning that begins during childhood. It is part of the masculine stereotype to be active and coping rather than reflecting on one’s feelings and the reasons for them. Men learn to be less emotionally tuned in than women. Similarly, this sex-linked learning may teach women that they are more emotional by nature and therefore depressive episodes are natural and unavoidable.

A slightly different approach to why women have more depression than men comes from Neitzke, A. (2016). “There is considerable discourse surrounding the disproportionate diagnosis of women with depression as compared to men, often times cited at a rate around 2:1. While this disparity clearly draws attention to gender, a focus on gender tends to fall away in the study and treatment of depression in neuroscience and psychiatry, which largely understand its workings in mechanistic terms of brain chemistry and neurological processes. I first consider how this brain-centered biological model for depression came about. I then argue that the authoritative scientific models for disorder have serious consequences for those diagnosed.

Finally, I argue that mechanistic biological models of depression have the effect of silencing women and marginalizing or preventing the examination of social-structural causes of depression, like gender oppression, and therein contribute to the ideological reproduction of oppressive social relations. I argue that depression is best understood in terms of systems of power, including gender, and where a given individual is situated within such social relations.

The result is a model of depression that accounts for the influence of biological, psychological, and social factors. (PsycINFO Database Record (c) 2016 APA, all rights reserved).”

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

References:

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Broverman, J. K., Broverman, D. M., & Clarkson, F. E. (1970). Sexual stereotypes and clinical judgments of mental health. Journal of Consulting and Clinical Psychology, 34, 1–7.

Carver, C. S., Scheier, M. F., & Weintraub, J. K. (1989). Assessing coping strategies: Atheoretically based approach. Journal of Personality and Social Psychology, 56, 267–283.

Chesler, P. (1972). Women and Madness. Garden City, NY: Doubleday.

Dweck, C. S. (1975). The role of expectation and attributions in the alleviation of learned helplessness. Journal of Personality and Social Psychology, 31, 674–685.

Kleinke, C. L., Staneski, R. A., & Mason, J. K. (1982). Sex differences in coping with depression.

Sex Roles, 8, 877–889.

Maccoby, N., & Jacklin, C.N. (1974). The psychology of sex differences. Stanford, CA: Stanford University Press.

Morrow, J., & Nolen-Hoeksema, S. (1990). Effects of responses to depression on the remediation of depressive affect. Journal of Personality and Social Psychology, 58, 519–527.

Neitzke, A. (2016). An Illness of power: Gender and the social causes of depression. Culture, Medicine and Psychiatry, 40(1), 59–73.

Nolen-Hoeksema, S. (1987). Sex differences in unipolar depression: Evidence and theory.

Psychological Bulletin, 101, 259–282.

Nolen-Hoeksema, S. (1990). Sex differences in depression. Stanford, CA: Stanford University Press.

Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressive episodes. Journal of Abnormal Psychology, 100, 569–582.

Nolen-Hoeksema, S., & Morrow, J. (1991). A prospective study of depression and distress following a natural disaster: The 1989 Loma Prieta earthquake. Journal of Personality and Social Psychology, 61, 115–121.

Discussion Stimulators 1. Biochemical vs. Psychological Theories: An Either/Or? Students are often confused by the “levels of analysis” suggestion that neurochemical explanations of the mood disorders are not incompatible with psychological theories. In our reductionist world, we tend to discard more molar explanations for a phenomenon when more molecular theories are offered. Thus, when support is found for a neurochemical theory depression, a somatic treatment is the immediate (but not necessarily correct) conclusion.

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

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

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

3. These vehicles contain an energy-consuming device that generates the motion of the vehicle. Some vehicles contain larger or smaller devices in proportion to their total weight, and this influences the speed.

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

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

2. Relating Activity to Mood Lewinsohn and his colleagues have identified an important factor in depression: engagement in pleasant activities. While it is not clear which is cause and which is effect, the relationship between depression and a low level of pleasant activities is well documented. An exercise that students find both interesting and helpful is charting their engagement in pleasant activities and their mood over a one-week period; the following handout can be used to organize the exercise. Students can be asked to list the pleasant activities they engage in throughout the day, adding up the total number at the end of each day. The Pleasant Events Schedule may be passed out or read to give students an idea of the kinds of events to monitor (Lewinsohn, P. M. & MacPhillamy, D. J., 1972, Journal of Abnormal Psychology, 79, 291–295). In addition, students should rate their mood for that day on a scale from 1 to 10 (1 being extremely depressed, and 10 being elated). At the end of the week, students can chart their daily mood on one axis and the number of activities engaged in on the other. Most people find a strong association between the number of pleasant events they engage in and their mood—this can be a real eye-opener and have practical value, particularly for those students who feel depressed.

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Pleasant Events of the Week Keep this form with you during the day and record the pleasant activities below that you engage in each day. Then total the number of activities at the end of the day.

DAY

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TOTAL NUMBER

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Mood Ratings for the Week DAY

MOOD

Mood and Pleasant Events Graph After you have rated your mood and recorded your pleasant events for the week, complete the following graph. Place an “x” for each day at the spot corresponding to your mood rating and number of

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events for that day. (You will have seven “x”s plotted, one for each day.)

3. Acceptance and Commitment Therapy (ACT) Steven Hayes and his colleagues developed a form of behavior therapy known as acceptance and commitment therapy (ACT). ACT is based on the premise that it is unnecessary to change all negative feelings. In fact, it is psychologically unhealthy to do so. The central idea is that people often experience emotions as bigger than they really are and they try to avoid the unpleasant

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experience. Each avoidance strategy that is successful maintains the belief that unpleasant emotions should be avoided. ACT therapists ask patients to accept that unpleasant experiences are part and parcel of the human experience.

ACT raises interesting discussion questions: Is our society overly focused on eliminating all feelings or thoughts that we perceive are negative? Does the quest to feel good limit our experience as humans? The following is a sample ACT homework assignment that might be interesting for your students to complete. Discussion could focus on how our unsuccessful efforts to change may have made the situation more difficult.

4. What Hasn’t Worked?

1. Identify a problem, social, financial or personal.

2. Write down everything that your problem has cost you. Be as specific as possible.

3. Now write a list of everything you have done in an attempt to solve this problem. Be thorough and specific: You should be able to come up with several examples of strategies you have used in your attempts to solve it (for example, swearing you were going to stop, using your willpower, getting furious at yourself in order to spur yourself on, avoiding, criticizing, etc.) and many specific examples of where you have used these strategies.

4. Honestly evaluate how far each of these strategies has brought you toward solving the problem.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment Therapy. New York: Guilford.

5. Clinical, Ethical, and Philosophical Issues in Handling Suicide The topic of suicide is likely to raise personal issues in an abnormal psychology class. At least one student in your class has probably had personal experience with suicide: a friend’s or family member’s ideation or attempt, personal grappling with suicidal ideas, or the ubiquitous question among adolescents: “How would you do it?” Discussion of the issue in class might focus on debunking the myth that people who talk about suicide do not try it, and describing the practical steps that clinicians take to prevent suicide, including establishing a no-suicide contract, making oneself more available during times of stress, and even involuntary commitment to a psychiatric hospital.

Dubbed “Dr. Death” by the popular media, Jack Kevorkian (1928–2011) wrote in support of doctor-assisted suicide. Do students believe euthanasia is justified in any circumstances?

Kevorkian's views on the subject may be found in Prescription: Medicide: The goodness of planned death (1991, New York: Prometheus Books).

In an article on Oregon’s assisted suicide law, Abeles and Barlev (1999) examined end-of-life decisions and the role of mental health professionals. You might use the vignette below taken

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from Professor Abeles’ graduate clinical psychology ethics course to stimulate discussion of the role of therapists in end-of-life decisions. ln an article on Oregon’s assisted suicide law, Abeles and Barlev (1999) examined end-of-life decisions and the role of mental health professionals.

You might use the vignette below taken from Professor Abeles’ graduate clinical psychology ethics course to stimulate discussion of the role of therapists in end-of-life decisions: You are a psychology trainee (intern) in the gerontology section of a large hospital. Your task is to become familiar with the concerns and problems of the aged and to become more effective in various treatment modalities. One patient who suffers from numerous physical problems and who is taking considerable medications confides in you that he has an agreement with his treating physician to “let up on his medication so that he can die a natural death so that he will not be an excessive financial burden on his family.” The patient insists that you not discuss this with his physician. Your supervisor believes very strongly that individuals have the right to make these kinds of decisions about themselves and suggests you accept the statement of the patient as part of the therapy and deal with feelings involved. In checking the medical record, the trainee finds out that, indeed, the medications administered have decreased over the last week.

6. Psychological Autopsies: Suicide Notes Suicidologists have been interested for some time in studying the suicide notes left by successful suicides in hopes of discovering the motivations or other characteristics that might provide a basis for predicting and therefore preventing suicides. In the course of such studies, they discovered that suicide notes typically differ from the popular stereotype of what a suicide note should be. As discussed in the text, actual suicide notes and simulated ones (written by normal subjects asked to write a suicide note as if they were going to take their own lives) can be differentiated. Below are real and simulated suicide notes (cf. Shneidman, E., Farberow, N., & Litman, R. (Eds.), 1970, The psychology of suicide. New York: Science House. Chapters 9, 13, 14).

First read the notes in random order to the class and have them rate which they believe are real and which simulated.

REAL NOTES: 1. To whom it may concern: I live at 400 Oak Drive, Cincinnati, Ohio. You will find on the kitchen table a letter with instructions to my wife on the disposition of my estate. Please notify all of my friends. Do not mourn me. H. Smith.

2. Dear Susan, Please take care of your mother and your brother. They won't be able to get along without you. I've made a list of things that have to be done and bills to be paid. See if you can take care of things for me. I want you to be sure I'm cremated and my ashes scattered over the ocean. Daddy.

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

SIMULATED NOTES: 1. To whom it may concern: I have looked and found that life is not worth living. What meaning is there anyway? Better this way. H. Smith.

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

3. I thought things would work out between us, but now I see that they won’t. I thought you were the only one for me, but now I see differently. Couldn’t you have understood my unhappiness? Why didn’t you care? Perhaps we’ll meet together in the next world. Bill.

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

INSTRUCTIONAL FILMS 1. Understanding Depression (from the series No More Shame: Understanding Schizophrenia, Depression, and Addiction) (FHS, 21 min., color, #BVL5828) “Depression affects over 4% of the population of the United States—over 10 million people— annually. It is a condition that will affect one in five Americans over the course of their lifetime.

A depressive illness can be devastating not only for those afflicted, but also for family and friends. This program focuses on current research into depression explaining the medications and psychosocial therapies that can help to eliminate the symptoms of the disease. The program profiles a woman with clinical depression and examines how her life and that of her family have been affected by the disease.”

2. Understanding Depression: Through the Darkness (FHS, 24 min., color, #BVL6066) “Explores clinical depression, explaining the symptoms, treatment options, and the need to erase the stigma that this illness carries. Features three patients with clinical depression, examining the effect of the illness on them, how they have dealt with the social stigma, the roles of their families and friends during the illness, and how they have fared in their treatment programs.

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Psychiatrists discuss the symptoms of depression, the importance of seeking help, and the need for society to accept clinical depression just as they would other illnesses.” https://www.films.com/id/8361.

3. Viktor Frankl's Choice (FHS, 58 min., color, #BVL30732) “A Holocaust survivor, the author of Man's Search for Meaning, and the founder of logotherapy, Viktor Frankl combined an inquisitive nature and a courageous zest for life with wisdom and humility. This captivating program hosted by Richard Dreyfuss and Kathleen Chalfant examines the life of the renowned psychiatrist, his contributions to science and philosophy, and the application of his theories, specifically in the area of palliative care. Rare archival lecture and interview footage, readings from his autobiography Recollections, and other works are featured, as are interviews with members of the Frankl family.” https://www.amazon.com/Frankls-Choice-Richard-Dreyfuss/dp/B00EKWTMMQ. 4. Men Get Depression (PBS, 60 min, color, ASIN:B0013MOLPO) “Men Get Depression is a 1-hour documentary that explores the corrosive effect of depression on the self, relationships and careers through the intimate profiles of real men including a former NFL Quarterback, a Fortune 100 CEO, an Iraq War veteran and others. It features revealing scenes of psychotherapy, interviews with therapists, and offers commentary by leading medical authorities on the causes, symptoms and treatments of depression.” https://www.amazon.com/Men-Get-Depression-by-PBS/dp/B00UGQ79E8.

5. Key Redfield Jamison, a psychiatrist with personal experience with bipolar disorder talks about her experiences. https://www.youtube.com/watch?v=eAC6jC4giu0.

6. The cloud of depression documentary. https://www.youtube.com/watch?v=zkxa4xgYSRA. 7. Student suicide real stories documentary. https://www.youtube.com/watch?v=wJ4BMrxflLA.

8. Psychiatric interviews for teaching: Mania

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https://www.youtube.com/watch?v=zA-fqvC02oM&ab_channel=UniversityofNottingham 9. CBT for depression https://www.youtube.com/watch?v=GrV3dR-_BVw. 10. Kay Redfield Jamison talks about treatment for bipolar disorder https://www.youtube.com/watch?v=ZsLKEhF__LA. 11. Here One Day by Kathy Leighter (Two Suns Media) about living with bipolar disorder https://vimeo.com/ondemand/hereondayindividual.

12. Out of the Shadows—PBS Documentary on depression Out of the Shadows–confusing! This one, with “Shadows” plural, is about depression https://www.pbs.org/wgbh/takeonestep/depression/

13. Major movies, a small sample of movies that portray depression: 1. Girl Interrupted 2. Sylvia 3. Helen 4. Prozac Nation 5. The Hours 6. Revolutionary Road 7. 29. The Virgin Suicides 8. A Single Man 9. 21.The Fisher King

DISCUSSION QUESTIONS These questions are based on the clinical case studies and other information found in boxes throughout the chapter.

Mary It is widely accepted that the incidence of depression is higher in women than men. Considering Mary’s case, what influences (environmental, biological, and psychological) might have contributed to Mary’s depression? Why is gender a vulnerability?

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Treatment Decisions for Mary According to the outcome of Mary’s cognitive therapy, she received help for and relief from many of her symptoms of depression. What other types of treatment could have helped in place of cognitive therapy or as adjunctive to cognitive therapy?

Challenging a Negative Thought in Cognitive Therapy Children of parent(s) who have been diagnosed with major depression can have an underlying genetic predisposition for depression. What are some examples of how parents could use techniques they have learned in cognitive therapy to help their children challenge negative thoughts about themselves?

Steven In the case of Steven, friends and family were surprised by his suicide. Usually there are signs that a person is thinking of suicide, or has decided to commit suicide, as a way out of pain and suffering. What are some risk factors for suicide (psychological, biological/genetics, behavioral and social), and what measures can you take to prevent or avert an impending attempt? Why do you think the mortality rate increases after a celebrity suicide?

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Pause and Ponder Activity: Depression The following questions reference the case studies published in Oltmanns and Martin, Case Studies in Abnormal Psychology, 11th Edition, John Wiley & Sons, 2019.

Part I: Pause What would you think if…? …a woman cannot get out of bed to eat or shower because she feels that she is being held back by something she is not strong enough to fight off? …a woman hates herself so much she decides to cut herself.

Consider how much you agree with the following statement: I can see this woman’s perspective and understand how she would feel if I were in her shoes.

Part II: Learn Now that you have considered the statement, watch the case study video on Nick and Moirama’s experiences with depression and answer the questions.

Question type Essay 1. Describe Nick and Moirama’s experiences with depression.

Question type Multiple Choice 2. Which of the following is not one of the cardinal symptoms of depression? a) Inability to experience pleasure b) Psychosis c) Sadness d) All of these are cardinal symptoms Answer: b

3. Moirama says that during her episode of major depression, she was unable to get out of bed, and did not eat or shower. Which of the following characteristics of a mental disorder best describes this aspect of major depressive disorder?

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a) Disability b) Distress c) Dysfunction d) Violation of social norms Answer: a

4. Which of the following is not one of the common treatments for depression? a) Antidepressant medication, such as SSRIs b) Behavioral activation therapy c) Cognitive behavioral therapy d) Mood stabilizer medication, such as lithium Answer: c

5. The rate at which women experience depression is ________ that of men. a) half b) the same as c) twice d) three times Answer: d 6. In the United States, what ratio of women will experience depression at some time in their lives? a) 1 out of 1 b) 1 out of 5 c) 1 out of 10 d) 1 out of 20 Answer: c

7. A list of diagnostic criteria for mood episodes is shown below. Select all of the diagnostic criteria for a major depressive episode.

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a) Decreased need for sleep b) Depressed mood most of the day, nearly every day c) Diminished ability to think or concentrate, or indecisiveness d) Distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week e) Excessive involvement in pleasurable activities that have a high potential for painful consequences f) Fatigue or loss of energy g) Feelings of worthlessness or excessive or inappropriate guilt e) Flight of ideas f) Increase in goal-directed activity g) Inflated self-esteem or grandiosity k) Markedly diminished interest or pleasure in all or almost all activities l) More talkative than usual

Answer 1: b Answer 2: c Answer 3: e Answer 4: f Answer 5: g Answer 6: l

Pause and Ponder Activity: Bipolar Disorder The following questions reference the case studies published in Oltmanns and Martin, Case Studies in Abnormal Psychology, 11th Edition, John Wiley & Sons, 2019.

Part I: Pause What would you think if…? …a woman feels as if her head will explode if she does not run around and yell in order release energy?

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…a man cannot get out of bed and go out with his friends because he is too sad? …a 35-year-old man does not work and lives with his mother because he is too sad to get out of bed every day and go to work?

Consider how much you agree with the following statement: I can see these people’s perspectives and understand how they would feel if I were in their shoes.

Part II: Learn Now that you have considered the statement, watch the case video about Doug and answer the questions.

Question type Multiple Choice 1. a) b) c) d)

When Trisch is running around and yelling, she is in the midst of a ________ episode. manic depressive anxious irritable

Answer: a

2. a) b) c) d)

Bipolar Disorder has also been referred to as ________. depression manic depression psychosis schizophrenia

Answer: b

3. Bipolar Disorder must include episodes of ________, but may also include episodes of ________. a) depression; mania b) mania; psychosis c) mania; depression d) depression; psychosis Answer: c 4. Doug refers to times when he is “back in the molasses.” What type of episode involved in bipolar disorder is he referring to? a) Mania

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b) Depression c) Anxiety d) Rapid cycling Answer: b 5. When Doug mentions going “up and down,” he is referring to the manic and depressive episodes involved in bipolar disorder. This recurring change from one episode to another is referred to as ________. a) switching b) transitioning c) cycling d) rotating Answer: c

6. Claire, Doug’s mom, explains that Doug is unable to work because he is not able to get out of bed every day as a work schedule would require him to do. Which of the following characteristics of a mental disorder best describes this aspect of bipolar disorder? a) Disability b) Distress c) Dysfunction d) Violation of social norms Answer: a

7. Doug states, “I can’t do anything when it comes to real life.” Which of the following characteristics of a mental disorder best describes Doug’s statement? a) Disablity b) Distress c) Violation of norms d) Both disability and distress Answer: d

8. Claire, Doug’s mother, mentions the pressure that bipolar disorder places on a person’s relationships. She is referring to the impacts on what type of functioning? a) Occupational b) Economic c) Educational d) Social

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Answer: d

9. a) b) c) d)

Which of the following treatments are not commonly used for bipolar disorder?

Lithium Mood stabilizers Psychotherapy alone Medication and psychotherapy combined

Answer: c

10. Dr. Andrew Stoll describes a state in which a person has a deep dark mood, low energy, cannot sleep, and cannot eat. He is referring to what type of episode involved in bipolar disorder? a) Manic b) Depressive c) Low d) High Answer: b

11. A list of diagnostic criteria for mood episodes is shown below. Select all of the diagnostic criteria for a manic episode. a) Decreased need for sleep b) Depressed mood most of the day, nearly every day c) Diminished ability to think or concentrate, or indecisiveness d) Distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week e) Excessive involvement in pleasurable activities that have a high potential for painful consequences f) Fatigue or loss of energy g) Feelings of worthlessness or excessive or inappropriate guilt e) Flight of ideas f) Increase in goal-directed activity g) Inflated self-esteem or grandiosity h) Markedly diminished interest or pleasure in all or almost all activities i) More talkative than usual Answer 1: a Answer 2: d Answer 3: e Answer 4: g Answer 5: h Instructors Manual

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Answer 6: j

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CHAPTER 6 ANXIETY DISORDERS LEARNING GOALS 1. Describe the emotions of anxiety and fear and their adaptive benefits.

2. Describe the clinical features of the anxiety disorders, the prevalence of the anxiety disorders, and how the anxiety disorders co-occur with each other.

3. Discuss how gender and culture influence the prevalence of anxiety disorders.

4. Explain commonalities in etiology across the anxiety disorders.

5. Describe the influences on the expression of specific anxiety disorders.

6. Discuss psychological and medication treatment approaches that are common across the anxiety disorders and how psychological treatment approaches are modified for the specific anxiety disorders.

The Learning Goals are inherent in both the Lecture Launchers and Discussion Stimulators below.

CHAPTER SYNOPSIS Anxiety is defined as apprehension over an anticipated problem, while fear is defined as a reaction to immediate danger. Both anxiety and fear can be symptoms of anxiety disorders. Anxiety is common to all the anxiety disorders, but phobias and panic also involve fear as a clinical feature. As a group, anxiety disorders are the most common type of mental illness. The major anxiety disorders included in DSM-5 are: specific phobia, social anxiety disorder, panic disorder, agoraphobia, and generalized anxiety disorder.

The following resources are found throughout this chapter: • • • • •

Table 6.1: Overview of the Major Anxiety Disorders Table 6.2: Percent of Adults Ages 18-64 in the General Population Who Meet Diagnostic Criteria for Anxiety Disorders in the Past Year and in Their Lifetime Defining Symptoms of Specific Phobia Table 6.3: Types of Specific Phobias Defining Symptoms of Social Anxiety Disorder

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• • • • •

Defining Symptoms of Panic Disorder Defining Symptoms of Agoraphobia Defining Symptoms of Generalized Anxiety Disorder Table 6.4: Factors That Increase General Risk for Anxiety Disorders Table 6.5: Techniques for Provoking Somatic Symptoms During Exposure Treatment for Panic Disorder

Clinical Descriptions of the Anxiety Disorders The specific DSM-5 anxiety disorders are each defined by a different type of key symptom, summarized in Table 6.1. Specific phobia is defined by an intense fear of an object or situation, social anxiety disorder by an intense fear of strangers or social scrutiny, panic disorder by anxiety about recurrent panic attacks, agoraphobia by anxiety of being in places where escaping would be difficult if anxiety were present, and generalized anxiety disorder by uncontrollable worry.

1.

Specific Phobias are intense, unreasonable fears that interfere with functioning. Specific phobias commonly include fears of flying; animals; heights; enclosed spaces; and blood, injury, or injections.

2.

Social anxiety disorder is defined by intense fear of unknown people or social scrutiny. The DSM-5 outlines the following criteria for Social Anxiety Disorder: a. Marked and disproportionate fear consistently triggered by exposure to potential scrutiny b. Exposure to the trigger leads to intense anxiety about being humiliated, embarrassed, rejected or about causing offense c. Trigger situations are avoided or else endured with anxiety d. Symptoms persist for at least 6 months

3.

Panic disorder involves recurrent attacks of intense fear that occur out of the blue. Panic attacks alone are not sufficient for the diagnosis; a person must be worried about the potential of having another attack. The DSM-5 outlines the following criteria for Panic Disorder: a. Recurrent uncued panic attacks b. At least 1 month of concern about the possibility of more attacks, worry about the consequences of an attack, or behavioral changes because of the attacks

4.

Agoraphobia is defined by fear and avoidance of being in places from which escape would be hard if panic symptoms were to occur. The DSM-5 outlines the following criteria for Agoraphobia: 1. Disproportionate and marked fear or anxiety about at least 2 situations where it would be difficult to escape or receive help in the event of incapacitation or panic-like symptoms.

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2. These situations consistently provoke fear or anxiety 3. These situations are avoided, require the presence of a companion, or are endured with intense fear or anxiety.

4. Symptoms last at least 6 months.

5.

Generalized anxiety disorder is characterized by virtually constant tension, apprehension, and worry which lasts for at least 6 months. The DSM-5 outlines the following criteria for Generalized Anxiety Disorder: a. Excessive anxiety and worry at least 50 percent of days about at least two life domains (e.g., family, health, finances, work, and school) b. The anxiety and worry are associated with at least three of the following: 1. Restlessness or feeling keyed up or on edge 2. Being easily frustrated 3. Difficulty concentrating or mind going blank 4. Irritability 5. Muscle tension 6. Sleep disturbance c. The anxiety and worry are associated with marked avoidance of situations in which negative outcomes could occur, marked time and effort preparing for situations that might have a negative outcome, marked procrastination, difficulty making decisions due to worries, or repeatedly seeking reassurance due to worries.

Comorbidity in Anxiety Disorders More than half of people with one anxiety disorder meet the criteria for another anxiety disorder during their lifetime. This comorbidity among anxiety disorders arises because of symptom overlap and shared risk factors between among anxiety disorders. There is also substantial comorbidity with other disorders: three-quarters of people with an anxiety disorder will meet diagnostic criteria for at least one other psychological disorder. For example, major depression and obsessive compulsive disorders commonly cooccur with anxiety disorders.

Gender and Sociocultural Factors in the Anxiety Disorders Women are much more likely than men to be diagnosed with an anxiety disorder. Culture also influences the focus of fears, the ways that symptoms are expressed, and even the prevalence of different anxiety disorders. Another important difference across countries is the level of income inequality, such that higher levels of income inequality (such as in the United States and Europe) have higher numbers of anxiety disorders.

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Common Influences Across the Anxiety Disorders Cultural and cross-national factors such as exposure to war, persecution, and income inequality contribute to different rates of anxiety disorders. Behavioral conditioning (classical and operant conditioning) is another factor that may increase the risk for more than one anxiety disorder. Genes increase risk for a broad range of anxiety disorders. Neurobiological research on anxiety focuses on elevated levels of activity in the brain regions that include the amygdala, the medial prefrontal cortex and other brain regions involved in the processing of fear and emotion. Anxiety disorders also appear to involve poor functioning of the GABA and serotonin systems, and high levels of norepinephrine. Other research has focused on abnormalities in the HPA-Axis, such as increased cortisol awakening response (CAR). The personality traits of behavioral inhibition and neuroticism are both related to the development of anxiety disorders. From the cognitive perspective, anxiety disorders are associated with beliefs that life is uncontrollable and because the tendency to pay closer attention to signs of potential danger.

Etiology of Specific Anxiety Disorders Behavioral perspectives on specific and social phobias are based on a Mowrer’s two-factor model of anxiety disorders (classical conditioning followed by operant conditioning). The first stage involves classical conditioning, in which a formerly innocuous object is paired with a feared object. This can occur through direct exposure, modeling, or cognition. The second stage involves avoidance, which is reinforced because it reduces anxiety. Because not all people with negative experiences develop phobias, diatheses must be important. Prepared learning refers to the fact that people are likely to sustain conditioned responses to fear stimuli that have some evolutionary significance.

Neurobiological research demonstrates high levels of activity in the locus coeruleus, which is a brain region responsible for norepinephrine release and is also associated with panic attacks. Behavioral models emphasize the possibility that people could become classically conditioned to experience panic attacks in response to external situations or internal somatic signs of anxiety. Conditioning to somatic signs is called interoceptive conditioning. Cognitive perspectives focus on a lack of perceived control and on catastrophic misinterpretations of somatic symptoms Cognitive behavioral theories hold that GAD results from distorted cognitive processes. One cognitive behavioral model emphasizes that worry helps people avoid more intense emotions. Generalized anxiety disorder (GAD) has been related to deficits in the GABA system.

Treatments of the Anxiety Disorders Most people who seek treatment for anxiety disorders will only see a family doctor and will be given a prescription for antianxiety medication (anxiolytics). The most common class of medications used for treatment anxiety are benzodiazepines, a type of anxiolytic. Antidepressants such as SSRIs are also sometimes used in treatment for anxiety disorders and may be preferred because they are less likely to become addictive or lead to severe withdrawal symptoms when a person stops taking them.

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Psychotherapy approaches can also be very effective in treatment of anxiety disorders. Effective psychological treatment for anxiety disorders all share exposure as a common focus, that that people must face what they are afraid of to overcome their fear. The behavioral view of exposure is that it works by extinguishing the conditioned fear response. For example, for a specific phobia this would involve systematic exposure to a feared stimulus. For panic disorder, this may involve exposure to physical sensations that elicit fear. Exposures can be in real life (in vivo), imaginal, or elicited using virtual reality (VR). Relaxation strategies may also be helpful for GAD, which are a type of behavioral strategy. For some anxiety disorders, cognitive components may also be helpful in therapy. Cognitive approaches may also work together with exposure treatment to help individuals correct their mistaken beliefs that they are unable to cope with the feared stimulus.

KEY TERMS Agoraphobia

fear

Anxiety

fear circuit

anxiety disorders

fear-of-fear hypothesis

Anxiety Sensitivity Index

generalized anxiety disorder (GAD)

Anxiolytics behavioral inhibition benzodiazepines contract avoidance model depersonalization derealization

in vivo exposure interoceptive conditioning locus coeruleus medial prefrontal cortex

neutral predictable unpredictable (NPU) threat task panic attack panic disorder prepared learning safety behaviors ocial anxietuy disorder specific phobia

Mowrer’s two-factor model

LECTURE LAUNCHERS 1. Virtual Reality in Phobia Treatment Virtual-reality technology has been used in the treatment of phobias, especially when in vivo exposure is not practical. In a controlled study (2002; Maltby, Kirsch, Mayers, &Allen, Journal of Consulting and Clinical Psychology, 70, 1112-1118), virtual-reality exposure was compared to an attention-placebo control group. Forty-five participants who refused to fly were randomly assigned to either virtual-reality exposure (VRE) or the attention-placebo control group treatment

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(GT). Both groups received five treatment sessions. The VRE group was taught relaxation skills and then exposed in a graduated manner to flight environments, including stormy and turbulent flight conditions. The GT participants were given five sessions that included education about flying but no behavioral or stress management techniques. Each participant in the GT group told about their own fear of flying and was encouraged to comment on their peers’ experiences. After the five sessions, 65% of the VRE group and 57% of the GT group flew during a test flight. Both groups scored significantly lower on a self-report measures of anxiety, with the VRE group scoring better on 4 of 5 measures. Interestingly, though, at six-month follow-up, group differences disappeared and the VRE group was better than the GT group on only 1 of 5 measures.

There have been numerous studies in the last ten years that have shown virtual reality to be successful in treating a variety of phobias. Virtual-reality-assisted treatment has been used for flight phobia (2007, Wallach, and Bar Zvi, Israel Journal of Psychiatry and Related Sciences, Vol 44(1), pp. 29-32); (2010, Brinkman, van der Mast, Sandino, Gunawan, and Emmelkamp, Interacting with Computers, Vol 22(4), pp. 299-310); nature phobias (2003, Davidson, and Smith, Sociology of Health and Illness, Vol 25(6), Special Issue: Health and Media: An overview, pp. 644661); and even driving phobia, in the fear of driving research by Wiederhold, B and Wiederhold M., Virtual-reality therapy for anxiety disorders: Advances in evaluation and treatment, US: American Psychological Association, pp. 147-155, viii. [Chapter].

A comprehensive overview of the use of virtual reality in the treatment of anxiety disorders can be found in Wiederhold and Bouchard’s Ebook, Advances in virtual reality and anxiety disorders, 2014, New York, Springer. (ISBN: 9781489980236). The ebook includes the efficacy and methodological lessons from outcome trials, lessons learned from treatment process, the use of virtual reality with a variety of phobias and anxiety disorders, and includes a discussion of a case and the future of Virtual Realty in the treatment of Anxiety Disorders.

2. Treating Social Phobia Social phobia involves both behavioral problems (avoiding contact with other people) and cognitive distortions (fear of being evaluated negatively, for example), making it particularly suited to cognitive-behavioral approaches to treatment. In a special issue of Clinical Psychology Review devoted to social phobia, Butler (1989, 9, 91-106) describes the application of cognitive-behavioral therapy to social phobia. The wealth of clinical examples and practical guidance included in the article make it clear how cognitive and behavioral principles can be combined in clinical practice.

As presented by Butler, the first steps of treatment include specifying the situations in which anxiety occurs, identifying available resources in the client’s life, and agreeing on goals of treatment. As with other types of phobias, the primary behavioral intervention is exposure to the feared stimulus. In the case of social phobia, this approach takes on added complexity because of the difficulty of predicting how a dynamic stimulus like social interaction will unfold. Unlike the case of a simple dog or snake phobia, it may be difficult to decide what exposure tasks are appropriate. “In order to meet someone of the opposite sex at a disco, should you offer them a

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drink, ask them to dance, or first go and buy some new clothes?” (p. 97). Role-playing may be an especially effective behavioral technique for social phobia, allowing the client to try out new behavior in the safety of the office first.

While exposing the client to the feared situations is an essential part of treatment, Butler points out that the cognitive aspects of social phobia, such as the fear of being evaluated negatively, often do not subside with exposure alone. Thus, cognitive techniques are often combined with behavioral tasks to dispute maladaptive beliefs. For example, a person who remembers only the negative social events that have occurred might be asked to monitor and write down instances of positive social exchange at the end of each day. A particularly valuable technique is encouraging people to test out their pessimistic or self-conscious expectations. A client who was afraid everyone would notice and critically evaluate him when he entered a room (making him afraid to enter a lecture hall) was given the assignment of purposely dropping his books on entry to class and then taking note of people’s reactions. When he found that most people took little notice of his behavior, he became less self-conscious.

A review of research on cognitive and behavioral treatments in the same issue of Clinical Psychology Review (Heimberg, R. G., pp. 107-128) documents the effectiveness of these techniques in relieving social phobia. For other reviews and comprehensive information on social phobia, see Social Phobia (1995; Heimberg, R.G., Liebowitz., M. R., Hope, D. A., & Schneier, F. R. New York: Guilford Press). A study was done in 2014 on the “One session treatment of cognitive and behavioral therapy and virtual reality for social and specific phobias. Preliminary results from a randomized clinical trial”, by Modovan, and David, Journal of Evidence-Based Psychotherapies, Vol 14(1), pp. 67-83.

Another approach is imagery rescripting, which aims to change the meaning and impact of unpleasant memories (Frets, and others, Journal of Behavior Therapy and Experimental Psychiatry, Vol 45(1), pp. 160-169.).

3. HANDOUT: Little Hans A classic case of phobia, reported by Freud in 1909, was that of a five-year-old boy, Little Hans, who was afraid of horses and thus would not venture out of his home. Many psychoanalytic scholars attest to the importance of this case. Ernest Jones, Freud’s famous biographer, calls it “the brilliant success of child analysis” (1955, p.289), and Glover, a respected scholar, terms it “a remarkable achievement . . . [constituting] one of the most valued records in psychoanalytic archives” (1956, p. 76).

Freud’s analysis of Little Hans was based on information reported in letters written to Freud by the boy’s father; Freud actually saw the child only once. Two years before the development of his phobia, when he was three, Hans was reported to have “a quite peculiarly lively interest in the part of his body which he used to describe as his widdler.” When he was three and a half his mother caught him with his hand on his penis and threatened to cut it off if he continued “doing that.” At age four and a half, while on summer vacation, Hans is described as having tried to Instructors Manual

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“seduce” his mother. As his mother was powdering around his penis one day, taking care not to touch it, Hans said, “Why don't you put your finger there?” His mother answered, “Because that would be piggish.” Hans replied, “What's that? Piggish? Why?” Mother: “Because it's not proper.”

Hans, laughing: “But it's great fun.” These events were taken by Freud as proof that Hans had strong sexual urges, that they were directed toward his mother, and that they were repressed for fear of castration. According to Freud’s first theory of anxiety, this sexual privation would ultimately be transformed into neurotic anxiety.

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

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

There are many other details in the case study, which occupies 140 pages in Freud's Collected Papers. In our brief account, we have attempted to convey the flavor of the theorizing. We agree with Wolpe and Rachman (1960) that Freud made large inferential leaps from the data of the case.

First, the evidence for Hans’s wanting sexual contact with his mother is minimal, making it debatable that Hans wanted to possess his mother sexually and replace his father. Second, there is little evidence that Hans hated or feared his father, and, in the original case report, it is stated that Hans directly denied any symbolic connection between horses and his father. This denial was interpreted as evidence for the connection, however. Third, there is no evidence, or any reason to believe, that sexual excitement was somehow translated into anxiety. Indeed, the fact that Hans became afraid of horses after being frightened by an accident involving a horse may be more parsimoniously explained by the classical conditioning model, although this interpretation has its own problems.

4. Whatever Happened to Little Albert?

An interesting aside to Watson and Rayner’s famous experiment with Little Albert is the misinterpretations and distortions found in subsequent accounts of the study (1979, Harris, B., American Psychologist, 84, 151-160). Textbook reports of the study have made such simple errors as misspelling Rayner, getting Albert’s age wrong, and substituting a rabbit for a rat. More serious errors include falsely reporting that Albert’s fear of the white rat generalized to a fur pelt, a man’s

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beard, a cat, a teddy bear, all white furry things, his aunt who wore fur, and his mother’s fur coat.

Some accounts managed to conflate Watson and Rayner’s study with Mary Cover Jones’ report of deconditioning a child’s fear of a rabbit, giving Little Albert’s story a happy ending.

In fact, the experiment with Little Albert was not nearly as successful as it has been portrayed. It has been difficult to replicate, it did not contain proper controls, and the extent to which the fear generalized to other objects is not clear. This does not mean, however, that Watson and Rayner were wrong; it does suggest that they were not necessarily right. Given the historical significance that the case of Little Albert has taken on, the elements of persuasion that are a part of the pursuit of science are evident once again.

Whatever happened to Little Albert? There are some accounts that suggest that he was never deconditioned by Watson and Rayner and was not treated by Mary Cover Jones. In recent years there have been attempts to discover who Little Albert really was. Beck, Levinson, and Irons suggested in 2009 that he was Douglas Merritte, the son of Arvilla Merritte, a wet nurse at Harriet Lane home, and that he died at the age of 6 of hydrocephalus (Beck, Levinson, Irons, “Finding Little Albert: A journey to John B. Watson’s infant laboratory. American Psychologist, Vol 64(7), 605614). A 2012 article suggests that Little Albert was neurologically impaired to begin with and some see evidence of that in the Watson videos (Gridlund, Beck, Goldie, and Irons, History of Psychology. Doc:10.1037/a0026720). Russ Powell and Nancy Digdon from MacEwan University suggest that he was William Barger who died at 87 in 2007’ a niece who was close to him described his lifelong fear of dogs.

Here is a link to a short clip of the original study: https://www.youtube.com/watch?v=9hBfnXACsOI

The final fate of Little Albert can be read at this location: https://www.youtube.com/watch?v=9hBfnXACsOI.

Sadly, Douglas Merritte (little Albert) passed away at the age of 6 because of acquired hydrocephaly.

5. Wolpe on the Etiology of Panic Disorder In a clear and compelling presentation of their theory of the etiology of panic disorder, Wolpe and Rowan (1988, Behavior Research and Therapy, 26, 441-450) argue that, while first panic attacks have a variety of causes, recurring attacks are the result of classical conditioning. First panic attacks may be caused by organic or psychological factors. Organic causes may be direct (as in the case of panic induced by amphetamines, cocaine, or other drugs) or indirect (as when a person experiencing non-pathological heart palpitations or intermittent tachycardia perceives the Instructors Manual

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symptoms as dangerous). The psychological pathway to a first panic attack involves the following steps: (1) the person is habitually anxious and oversensitive, and is also going through a stressful period, (2) this person finds herself in a particularly stressful circumstance, (3) the anxiety and stress precipitates hyperventilation (a common consequence of anxiety), (4) the hyperventilation is accompanied by physical symptoms such as dizziness, shortness of breath, and tingling in the extremities, and (5) the physical symptoms escalate into a panic attack. The person may interpret the attack as impending death or insanity, leading to a misattribution; however, such misattributions do not cause panic attacks, according to Wolpe and Rowan, but rather follow them. In a pilot study involving interviews with panic disordered patients, they found that in the first panic attack, the physical symptoms always preceded the panic, and if misattributions occurred, they followed the attack.

While numerous experiences may cause a person to have their first panic attack, Wolpe and Rowan assert that recurrent attacks, or panic disorder, have a single cause: classical conditioning.

According to their model, the first panic attack is an unconditioned response to the physical symptoms caused by hyperventilation. Contiguous stimuli, both endogenous (bodily sensations) and exogenous (sunlight, driving in a car, being away from home), become conditioned stimuli for panic, as they are associated with the first attack. These stimuli thus become triggers for recurring attacks.

The classical-conditioning model leads directly to a treatment technique that Wolpe describes: (1) The person is taught to prevent hyperventilation through breathing retraining (holding the mouth shut and breathing through the nose is remarkably effective). (2) The next step is to extinguish the anxiety response to the physiological effects of hyperventilation. This is done by exposing the person to these physical symptoms by inducing hyperventilation (through breathing CO2) in the office. Repeated exposure to the symptoms extinguishes the anxiety response: hyperventilation no longer leads to panic. (3) Finally, it is necessary to eliminate the maladaptive anxiety response habits that the person has developed, through systematic desensitization or cognitive restructuring.

DISCUSSION STIMULATORS 1. Trying Out Behavioral Techniques If time allows, you might do an exercise teaching the class the basics of systematic desensitization.

Have students pair up, pass out the following instructions, and have them take turns acting as behavior therapist and client. To make the exercise briefer, tell students to assume they have been taught how to relax in previous sessions and are ready for the desensitization procedure.

Following the exercise, bring the group back together to discuss their experiences: How did it feel, from both the client’s perspective and the therapist's perspective? What problems arose in constructing the hierarchy or visualizing the scenes? Do students feel this technique would be helpful? Be sure to highlight the differences between this exercise and use of technique in a real-

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life therapy situation (in which you would spend more time, build a relationship, proceed more slowly through the hierarchy, use in vivo exposure, etc.). The instructions, which follow, are adapted from Goldfried and Davison's Clinical Behavior Therapy (Expanded Edition) (1994, New York: Wiley).

SYSTEMATIC DESENSITIZATION “CLIENT” INSTRUCTIONS Choose a situation that actually makes you anxious, or make up a situation. Examples might include fear of driving on the freeway, fear of speaking in class, test-taking anxiety, fear of being in closed spaces, fear of talking to strangers, or fear of dogs.

Work with your “behavior therapist” to construct a hierarchy from the least anxiety-provoking situation to the most feared situation. Think of your anxiety as a large balloon filled with stimuli, each of which is associated with a given amount of anxiety. In constructing your hierarchy, you will choose examples from this balloon, which represent all its elements, sampling items of varying degrees of aversiveness. Make your examples as concrete as possible, so your “therapist” can help you imagine them vividly. You will be asked to sit comfortably in your chair, imagine that you are very relaxed, and visualize the scenes that your “therapist” will describe for you, signaling him or her when you feel any anxiety.

SYSTEMATIC DESENSITIZATION “BEHAVIOR THERAPIST” INSTRUCTIONS 1. Interview. Begin with a brief interview of your “client” to determine what is making him or her anxious. (We are assuming that anxiety is the presenting problem.) As well as making the person feel comfortable during the interview, find out as much detail as you can about the specific situations which make him/her anxious: time of day, other people present, where it occurs, how long it lasts, and (briefly) how they have tried to overcome it in the past. These details are essential for use in the next step, constructing a hierarchy of anxiety-producing situations. Take notes to help you remember the details.

2. Construct hierarchy. Together with your “client,” come up with a list of anxiety-producing situations (related to the particular problem they described in the interview) and order them from least to most anxiety producing. You should help your “client” come up with 10-12 situations, and collect enough information about them so that you will be able to help your “client” visualize them as if they are actually occurring.

3. Systematic desensitization procedure. Instruct your client to relax (you might ask them to rate on a scale from 1 to 100 how relaxed they feel, with 1 being extremely relaxed, and 100 being extremely tense). Tell them to signal you by raising a finger whenever they feel at all anxious.

When the client appears relaxed or reports feeling relaxed, begin describing the least anxietyproducing situation from the hierarchy. Describe it briefly, and then pause to let the person imagine it. After about 10 seconds, ask them to stop visualizing the situation and simply relax

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again. If the person has not signaled any anxiety, proceed to the next scene, in the same manner. Continue up the hierarchy, describing each scene in turn, giving the client time to visualize them, and pausing to relax in between.

At any point that the person signals anxiety, instruct them to stop visualizing the scene and relax.

They might choose a relaxing scene to imagine, such as lying on the beach, instead of the anxietyproducing one. When the person reports feeling relaxed again, try having them visualize a scene lower on the hierarchy, that is, one that will be less anxiety producing. If it is difficult to find a scene that does not provoke anxiety, you have made the hierarchy too difficult; you need to come up with smaller steps.

2. Case Studies in Abnormal Psychology Oltmanns, Neale, and Davison have written a book of illustrative cases that provides interesting examples of the various disorders, as well as offering supplementary material on most of the psychological problems presented in the text. Students really appreciate the way a case can bring material alive, and Case Studies in Abnormal Psychology is something to seriously consider as a supplement to the text.

3. Anxiety in All of Us As an introduction to the concept that we all experience anxiety, start your class off with a “pop quiz.” Write the following on a PowerPoint slide or on the board so that students can view the instructions as they walk in the door.

Unannounced Quiz 1. Take out a pen and paper.

2. Write the 3-5 main points from the assigned readings for today’s class.

3. You will be graded on content, not length. Please be concise in your answers.

Your students are bound to start feeling anxiety immediately and will want to ask you questions about the assignment to lower their anxiety. In order to not reduce their anxiety, simply answer their questions with “the instructions are on the board.” After giving the students 3-5 minutes to complete the “pop quiz,.” tell them that their time is up and then collect their papers. After you’ve collected the papers, inform the students that this was an activity on anxiety and that the quizzes will not be graded. You may want to actually trash the papers in front of them to drive home this point. At this point, watch how your class visibly relaxes. Now you can facilitate a discussion on the following: • •

The symptoms of anxiety that they experienced The severity of symptoms that they experienced

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• • • •

The duration of symptoms that they experienced The cause of the symptoms that they experienced Their current feeling state The difference between this type of anxiety and clinically diagnosable anxiety disorders

INSTRUCTIONAL FILMS 1. Anxiety: The Endless Crisis (IU, 59 min., 1975, #EC1415) Examines a wide range of anxiety-producing situations, from fleeting anxiety to anxiety that ultimately leads to death. Discusses state and trait views of anxiety.

2. Anxiety Disorders (IU, 60 min., 1992, #BVL160471) Part of the “World of Abnormal Psychology Series.” This film focuses on treatment of panic disorder with agoraphobia and generalized anxiety disorder. Now available online for purchase (streaming): https://www.films.com/ecTitleDetail.aspx?TitleID=163003 3. The Anxiety Disorders (CPB, 60 min., 1992, color, ISBN: 1-55946-679-0) “Even in the best of times, we all experience some anxiety. But millions of Americans suffer from major anxiety disorders. This program examines two of the most common-panic with agoraphobia and generalized anxiety disorder – and shows how psychologists are making headway in treating them (The World of Abnormal Psychology series).” Also available online appears to also be available online: https://www.learner.org/series/the-world-of-abnormal-psychology/the-anxiety-disorders/ 4. Coping with Phobias (FHS, 29 min., color, #BVL4385) “This program explains why people have phobias and how they can usually be overcome. It focuses on fear of flying, explaining how to understand what is happening on the plane and within oneself and thereby become more comfortable with flying. The only phobia more common than fear of flying is fear of public speaking; the program visits a speech class to explain the dynamics of this phobia and provide specific suggestions on overcoming the fears involved.”

5. Don't Panic: The Promise of Intensive Exposure Therapy (FHS, 17 min., color, #BVL9237) Can confronting one's own worst nightmare really destroy the paralyzing power it commands? In this program, ABC News anchors Diane Sawyer and Sam Donaldson and correspondent Jay Schadler document a young woman’s struggle to overcome the feelings of fear that have reduced her world to the narrow confines of her own home. Through intensive exposure therapy, an alternative to medication and psychotherapy for treating panic attacks complicated by agoraphobia, many patients return to normal living within mere days. Although the long-term benefits of the therapy are still being researched, the results are nothing short of miraculous.

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6. Panic Attack: Causes and Treatments (FHS, 29 min., color, #BVL7327) “You are in a cold, clammy sweat, and pervaded by fear. These are two symptoms of a panic attack, a debilitating mental disorder that affects thousands of people worldwide. This program explores the possible causes of the condition and examines treatments, particularly cognitive therapy. Three patients talk about their lives lived under the pall of panic attacks. One patient, whose first occurrence was on a train trip, takes a short train journey as part of her liberating therapy. A BBC Production.” Available online at: https://ffh.films.com/id/9368/Panic_Attack_Causes_and_Treatments.htm.

7. Social Anxiety Documentary: Afraid of People (2011) https://www.youtube.com/watch?v=gmEJEfy5f50.

Discussion Questions These questions are based on the clinical case studies and other information found in boxes throughout the chapter.

Jenny According to Jenny’s case history, she developed panic disorder during rounds at the hospital. How does the “fight-or-flight” response become maladaptive when someone experiences it in the workplace?

Jan In reviewing Jan’s case, it seems she has developed a specific phobia of snakes. She stated that she goes to great lengths to avoid coming into contact with them. Is her avoidant behavior helping to reduce her anxiety, or is it maintaining her disorder, and why?

Maureen Discuss the ways in which cognitive behavioral therapy could address Maureen’s social anxiety disorder.

What are some specific cognitive behavioral approaches that may help Maureen and why might they be effective?

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Joe Discuss which symptoms Joe exhibited during his initial interview with his therapist that would meet criteria for generalized anxiety disorder (GAD). In what ways is GAD distinguished from other anxiety disorders?

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CHAPTER 7 OBSESSIVE-COMPULSIVE RELATED AND TRAUMA-RELATED DISORDERS

LEARNING GOALS 1. Explain the symptoms and epidemiology of the obsessive-compulsive and related disorders.

2. Describe the commonalities in the etiology of obsessive-compulsive and related disorders, as well as the influences that shape the expression of the specific disorders within this cluster.

3. Discuss the medication and psychological treatments for the obsessive-compulsive and related disorders.

4. Define the symptoms and outcomes of the trauma-related disorders: acute stress disorder and posttraumatic stress disorder.

5. Summarize how the nature and severity of trauma, as well as biological and psychological influences, contribute to whether trauma-related disorders develop.

6. Describe the medication and psychological treatments for trauma-related disorders.

The Learning Goals are inherent in both the Lecture Launchers and Discussion Stimulators below.

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CHAPTER SYNOPSIS This chapter focuses on obsessive-compulsive (and related disorders) and trauma-related disorders. Obsessive-compulsive and related disorders are characterized by repetitive thoughts and behaviors that interfere with daily life. Trauma-related disorders are triggered by exposure to severely traumatic events. People with these disorders also often report feeling anxious or have comorbid anxiety disorders. However, these disorders also have some features that are distinct from anxiety disorders. This chapter reviews the clinical features of these disorders, research on their epidemiology and etiology and provides and overview of treatment approaches.

Clinical Descriptions of the Obsessive-Compulsive and Related Disorders The specific obsessive-compulsive and related disorders are each defined by a different type of key symptom (see Table 7.1).

1. Previously placed in the anxiety disorders section of the DSM-IV-TR, obsessive-compulsive disorder (OCD) is now placed in the obsessive-compulsive and related disorders section of the DSM-5. People with obsessive-compulsive disorder have intrusive, unwanted thoughts (i.e., obsessions) and feel pressured to engage in rituals to avoid overwhelming anxiety (i.e., compulsions).

2. Previously placed in the Somatoform Disorder section of the DSM-IV-TR, body dysmorphic disorder (BDD) is now placed in the obsessive-compulsive and related disorders section of the DSM-5. People with body dysmorphic disorder experience distress and impairment over their imagined or exaggerated imperfections or physical flaws, and perform repetitive behaviors or mental acts in response to their appearance concerns.

3. Hoarding disorder is a new diagnosis for the DSM-5. People with hoarding disorder acquire an excessive number of objects and have an inability to part with these objects, and consequently have accumulated a large number of possessions that clutter living areas of the home or workplace.

Etiology of Obsessive-Compulsive and Related Disorders OCD, BDD, and hoarding disorder share some overlap in etiology related to genetic and neurobiological influences and all involve fronto-striatal circuits in the brain. OCD is characterized by higher activity in these circuits, including the orbitofrontal cortex, the caudate nucleus, and the

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anterior cingulate. Similarly, people with body dysmorphic disorder display hyperactivity in the orbitofrontal cortex and the caudate nucleus.

Behavioral models of compulsions focus on the relief provided by performing these acts, which could act as a reinforcer. Cognitive models of obsessions focus on the contribution of beliefs known as thought-action fusion and increased tendencies to engage in thought suppression as contributing factors.

In hoarding disorder, an evolutionary perspective considers the behavioral pattern of hoarding to have been adaptive and wise in our distant past as human beings. The cognitive behavioral model suggests that hoarding is related to poor organizational abilities, unusual beliefs about possessions, and avoidance behaviors.

BDD is often comorbid with OCD, and these two disorders may be related to some of the same genetic and neurobiological influences. Similarly, up to a quarter of people with hoarding disorder will meet diagnostic criteria for OCD.

Treatment of Obsessive-Compulsive and Related Disorders Treatments that work for OCD, BDD, and hoarding disorder are similar. Each of these disorders responds to SSRIs. The major psychological approach to treatment is exposure and response prevention (ERP). Cognitive approaches to obsessive-compulsive disorder focus on challenging a person’s beliefs about what will happen if they do not engage in rituals. For BDD, cognitive techniques that are highly parallel with those used to treat OCD are helpful in conjunction with behavioral treatments. Brain stimulation may also be used for treatment-resistant OCD using dTMS or DBS.

Clinical Description and Epidemiology of the Trauma-Related Disorders The trauma-related disorders (i.e., posttraumatic stress disorder and acute stress disorder) are both severe reactions to trauma, but acute stress disorder occurs 2 days to 4 weeks after a trauma while posttraumatic stress disorder lasts for more than 4 weeks after a trauma.

1. Posttraumatic stress disorder (PTSD) is only diagnosed after a traumatic event. It is marked by symptom clusters of reexperiencing the trauma, arousal, and avoidance or emotional numbing.

2. Acute stress disorder (ASD) is defined by similar symptoms, but lasts more than 3 days but less than one month.

Etiology of Trauma-Related Disorders

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Posttraumatic stress disorder can be diagnosed only in people who have experienced a severe trauma. Even among people who have been traumatized, though, the likelihood that a person will develop posttraumatic stress disorder depends on the severity and type of trauma. In terms of neurobiological influences, PTSD appears to be related to genetic risk for anxiety disorders, high levels of activity in areas of the fear circuit such as the amygdala, childhood exposure to trauma, and tendencies to attend selectively to cues of threat. Neurobiological research has found people with small hippocampal volume are more likely to develop posttraumatic stress disorder. Other neurobiological research has found that posttraumatic stress disorder is associated with elevated sensitivity to the stress hormone cortisol. Studies from the cognitive perspective indicate that people who are able to maintain some sense of control during the trauma are less likely to develop PTSD. After exposure to trauma, people who rely on dissociation as a form of coping (i.e., feeling removed from one’s body or emotions or unable to remember the event) seem more likely to develop PTSD than people who rely on other strategies. The behavioral perspective focuses on the same two-factor model used to explain phobias: classical conditioning of fear followed by operant conditioning of avoidant behavior that prevents the fear from extinguishing. Less is known about the etiology of ASD. However, the presence of ASD does predict a higher risk of developing PTSD within 2 years.

PTSD tends to be highly comorbid with other conditions, including anxiety disorders, major depression, substance abuse, and conduct disorder. Approximately two-thirds of people who develop PTSD have a history of another anxiety disorder.

Treatment of Trauma-Related Disorders Medications, specifically antidepressants (i.e., SSRIs) have received strong support as a treatment for posttraumatic stress disorder. However, relapse is common if mediations are discontinued.

Exposure therapy techniques, such as imaginal exposure, are frequently used with people experiencing posttraumatic stress disorder because evidence indicates that exposure treatments that focus on trauma-related events are more effective than treating posttraumatic stress disorder with medication or supportive unstructured psychotherapy. Cognitive processing therapy (CPT), a treatment designed to help victims of rape and childhood sexual abuse to dispute tendencies towards self-blame, has also received empirical support.

For acute stress disorder, short-term cognitive behavioral approaches that include exposure appear to reduce the symptoms of an individual developing posttraumatic stress disorder. The positive effects of these interventions appear to last for years. Exposure treatment appears to be more effective than cognitive restructuring in preventing the development of posttraumatic stress disorder.

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KEY TERMS acute stress disorder (ASD) body dysmorphic disorder (BDD)

exposure and response prevention (ERP)

obsessions, obsessivecompulsive disorder (OCD)

fronto-striatal circuits

posttraumatic stress disorder (PTSD)

caudate nucleus

hoarding disorder

compulsions

imaginal exposure

thought-action fusion thought suppression

dissociation

LECTURE LAUNCHERS 1. PTSD in the War Zone Feinstein, acting as psychiatric medical officer for a counterinsurgency unit on active patrol, writes an interesting account of symptoms of posttraumatic stress disorder on the battlefield (1989, American Journal of Psychiatry, 146, 665–666). Following an ambush involving intense and prolonged crossfire and casualties on both sides, Feinstein decided to monitor the soldiers for symptoms of PTSD. He found that all the DSM-III criteria were frequently reported one week after the ambush, including, for example, hyper-alertness, recurrent and intrusive recollections of the event, sleep disturbance, and guilt about surviving. The men would have fit a DSM-III diagnosis of PTSD, although they continued to function efficiently in their duties (all but one soldier, who had to be evacuated because of the severity of his symptoms), and most symptoms subsided within a few weeks.

The author concludes that periods of distress are normal following traumatic life events, and supports the changes made in the DSM-III-R PTSD criteria, which introduced a minimum duration of one month as a criterion for labeling such distress a disorder; this criterion had been maintained in DSM-IV, and similar symptoms with shorter duration were now listed as acute stress disorder.

On the other hand, evidence exists that exposure to combat can have long-term impact on adult psychosocial adjustment. A follow-up study of over 2,000 Vietnam veterans (Barrett, Resnick, Foy, Dansky, Flanders, & Stroup; 1996, Journal of Abnormal Psychology, 105, 575– 581) found that veterans who had been exposed to high levels of combat later exhibited markedly more antisocial behavior in adulthood than those exposed to no or low levels of

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combat. Many of the combat-exposed veterans met criteria for antisocial personality disorder.

The authors note that exposure to traumatic events during late adolescence or early adulthood predisposes people to multiple adjustment problems later in life. The implication is that treatment needs to focus on more than the direct effects of the trauma.

Soldiers sometimes question their personal “moral injury,” which is perceived as a clash between what happens on the battlefield and their values. The authors suggest that moral injury goes beyond psychopathological views of reactions such as PTSD and creates existential conflicts as well as psychopathological responses (2014, International Forum for Logotherapy, 37, 26–31).

Here is an intriguing article on the DSM-5 and PTSD including those affected by war: http://www.traumatheory.com/whats-going-on-with-dsm-5/.

2. Survivor’s Syndrome: Long-term Consequences of the Holocaust The term “survivor’s syndrome” was coined following World War II to describe the problems afflicting survivors of the Holocaust. Reports by Nadler and Ben-Shushan (1989, Journal of Consulting and Clinical Psychology, 57, 287–293) and Solomon, Kotler, and Mikulincer (1988, American Journal of Psychiatry, 145, 865–868) confirm the long-lasting and far-reaching consequences of such massive traumatization.

Nadler and Ben-Shushan present results from a 40-year follow-up study comparing Holocaust survivors (now in their 60s) and a control group of similar age and cultural background who had not been victims of the Holocaust. None of the subjects had received psychiatric treatment. Structured personality inventories revealed that survivors had significantly lower psychological well-being, poorer interpersonal functioning, and more psychopathological symptoms than the controls. Interviews with the survivors revealed considerable problems with anxiety; almost all reported frequent nightmares, insomnia, and frequent anxieties and fears, even 40 years after the trauma.

Not only have Holocaust survivors shown lasting effects of the traumatization, but their children, who were not directly exposed, also have been found to react with severe anxiety when under stress, as well as experiencing survival guilt and conflict about the expression of aggression. Solomon and colleagues compared Israeli combat stress casualties from the 1982 Lebanon War, whose parents were Holocaust survivors, with a control group of casualties without such family history. None of the subjects had evidenced psychiatric problems before serving in the Lebanon War. The authors found that soldiers whose parents had been Holocaust survivors had significantly higher rates of posttraumatic stress disorder than the controls. Several alternative explanations are offered for the results: (1) survivors’ children may be particularly vulnerable to stress reactions; (2) failure to continue in combat may be seen as particularly shameful to survivors’ children, who see themselves as guardians and protectors of their parents; or (3) the survivor parents may be more Instructors Manual

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protective and reluctant to have their children return to war, leading to secondary gains for PTSD symptoms. Regardless of the interpretation, these studies reveal the far-reaching psychological consequences of massive traumatization.

Another study in 2007 by Sadavoy suggests that survivor syndromes persist for a long time, even into old age. He found that elderly patients who experienced early serious trauma, such as surviving the Holocaust or being a veteran of World War II, Korea, or Vietnam, had symptoms that lasted into old age. Some of these symptoms manifested as sleep disruptions, memories, lack of trust, avoidance of any stress-provoking event, and greater vulnerability to retraumatization (2007, Modern terrorism and psychological trauma (pp.

167–189). Gordian Knot Books, 242).

3. Effects of War on Children UNICEF statistics indicate that far more civilians are killed in armed conflict in recent wars than in the early decades of the 20th century; for example, in Lebanon, 9 out of 10 people killed because of the war have been civilians, particularly women and children. Two recent articles address the issue of children’s responses to chronic exposure to wartime stresses.

Jensen and Shaw (1993, Journal of the American Academy of Child and Adolescent Psychiatry, 32, 697–708) review current knowledge about children as victims of war. They note the changing nature of war in the latter part of the 20th century, as armed conflicts have increasingly become low intensity and episodic, with greater victimization of civilian populations. While children have been found to exhibit symptoms very similar to posttraumatic stress disorder in adults, Jensen and Shaw also focus on the broader responses of children to wartime trauma.

In an empirical study of children exposed to war stress in Croatia, Zivcic (1993, Journal of the American Academy of Child and Adolescent Psychiatry, 32, 709–713) compared children who were evacuated from war-torn areas with local children who were less directly exposed to violence. Children in all groups showed more symptoms of depression than did children who were assessed before the war. In addition, the displaced children reported more negative emotions (particularly sadness and fear) than their local peers did.

Interestingly, far greater negative mood was reported by the children themselves than in their parents’ and teachers’ estimates of the children’s mood states. This suggests that significant adults may not be aware of the degree of stress being experienced by children and the impact on their internal states.

A two-generation Northern Ugandan study by Olema et al. entitled “The Hidden effects of child maltreatment in a war region: Correlates of psychopathology in two generations living in Northern Uganda” suggested that children living in refugee camps with both parents exhibited both war and child maltreatment trauma as well as PTSD, anxiety, depression, and suicide ideation (2014, Journal of Traumatic Stress, 27, 35–41). Both generations were severely affected by both traumas and correlated with psychological disorders.

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This link provides a breakdown of the issues confronting children as a result of war: https://www.melissainstitute.org/documents/effectsofwar.pdf.

4. Seriousness of Hoarding Disorder Hoarding disorder is a pattern of behavior characterized by the excessive collection of and inability or unwillingness to get rid of large quantities of things that cover the living areas of the home and cause significant distress or impairment. In the reality series about hoarding, the hoarders have a difficult time even moving about their own homes because of the inordinate amount of what they have collected, which covers virtually every bit of floor space and is piled toward the ceiling.

Since hoarding disorder is a relatively new diagnosis, very little is known about the lives of people who engage in hoarding behavior. One study (Samuelsa, Bienvenua, Gradosa, Cullena, Riddlea, Liangb, et al., 2008) found that nearly 4% of the general population engaged in hoarding behaviors. These behaviors were found more frequently in older than younger age groups and were more common in men than women. People who engaged in hoarding behaviors also tended to experience “alcohol dependence; paranoid, schizotypal, avoidant, and obsessive-compulsive personality disorder traits; insecurity from home break-ins and excessive physical discipline before 16 years of age; and parental psychopathology” (p. 1). The psychological distress of individuals dealing with hoarding behaviors is quite evident.

A recent study, “The role of adult attachment and social support in hoarding disorder,” showed that hoarders had significantly higher levels of attachment anxiety and avoidance and lower levels of social support than the control groups (Behavioural and Cognitive Psychotherapy, 42, 2014, 629–633).

Three other recent articles on hoarding are: Ayers, C. R. et al. (2014). Hoarding severity predicts functional disability in late-life hoarding disorder patients. International Journal of Geriatric Psychiatry, 29, 741–746.

Ayers, C. R. et al. (2014). Behavioral and experiential avoidance in patients with hoarding disorder. Journal of Behavior Therapy and Experimental Psychiatry, 45, 408–414.

Morein-Azmir, S. et al. (2014). The profile of executive function in OCD hoarders and hoarding disorder. Psychiatry Research, 215, 659–667.

DISCUSSION STIMULATORS 1. Superstitious Behavior and Compulsions Skinner drew an analogy between what he described as “superstitious behavior” resulting from chance reinforcement and compulsions. We all engage in a certain amount of superstitious behavior; students might be encouraged to consider ritualistic superstitions they Instructors Manual

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may hold—professional athletes are prime examples of this. What similarities or differences are there between these behaviors and compulsions?

2. “White Elephants” and the Paradoxical Effects of Thought Suppression The way thought avoidance usually leads to thought exacerbation is easily demonstrated in class, using the following script or your own variations: In a minute, when I say ‘go’, I want you to avoid thinking about white elephants. No matter what you do, I want you to try your hardest to avoid thinking about how white they are, how large, how much you like elephants, how they walk, or anything else about them. No matter what, do not think about white elephants. Ready? Go.” After 30 seconds, stop the clock and ask who was able to do it. Ask what people tried to do, then focus the discussion on people who successfully avoided the thoughts. Usually, those who strive to suppress thoughts find they are unable to do so.

3. Stress and the War in Iraq The American Psychological Association and the Kent State University Applied Psychology Center Task Force on War-Related Stress formed a task force during the first Persian Gulf War. This group developed strategies and guidelines for public policymakers, mental health professionals, and persons directly affected by the war. As a class exercise, students could be divided into “task forces” and, from their readings on PTSD in the text, devise guidelines regarding the current war in Iraq (or another traumatic event) in the following areas: 1.

2.

3.

4.

5.

6.

Who is most likely to be at risk for experiencing stress regarding the traumatic event?

What common stress reactions would be expected?

What reactions would indicate more serious disorder such as PTSD? What coping strategies should affected individuals be encouraged to use?

What role can psychologists take in helping alleviate stress following the traumatic event?

What can be done specifically to help children cope with the traumatic event?

Hobfoll, S. E., Spielberger, C. D., Breznitz, S., Figley, C., Folkman, S., Lepper-Green, B., Meichenbaum, D., Milgram, N. A., Sandler, I., Sarason, I., & van der Kolk, B. (1991). Warrelated stress: Addressing the stress of war and other traumatic events. American Psychologist, 46, 848–855.

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4. Traumatic Response to 9/11 In the wake of the attack on the World Trade Center, hundreds of therapists responded to offer support and treatment to the survivors and the emergency service workers. A review of the literature revealed that therapists from many different perspectives published their accounts. Students might conduct a review of the literature on the traumatic response to emergencies such as the Boston Marathon bombing, the Sandy Hook Elementary school shooting, a tornado, or 9/11, and present the articles they find for discussion.

5. Disorders on Television At the risk of letting your students know that you occasionally do something as mundane as watching television, you can help to illustrate some of the disorders (and what does not constitute a disorder) discussed in this and subsequent chapters by “diagnosing” various characters from TV, movies, and novels. As an alternative, have the class go to see virtually any of Woody Allen’s earlier movies. Play It Again Sam and Manhattan are particularly good examples of his creative neurosis, as well as a series of irrational beliefs. A good portrait of an individual with OCD can be found in As Good as It Gets with Jack Nicholson. Although the show tends to present extreme cases, a good portrait of individuals with hoarding disorder is the television show Hoarding: Buried Alive.

INSTRUCTIONAL FILMS 1. Pediatric OCD https://www.youtube.com/watch?v=3lvbcShuz14.

2. Understanding the OCD Brain (3-part series) https://www.youtube.com/watch?v=YpCOAqxbfpA. https://www.youtube.com/watch?v=A2zY12k1m2E. https://www.youtube.com/watch?v=txvVZxScCL8.

3. Living with OCD: https://www.youtube.com/watch?v=dSZNnz9SM4g 4. CBT for OCD by Amelia Aldao, Ph.D. https://www.youtube.com/watch?v=v71ictMKvgQ.

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5. Body Dysmorphic Disorder Patients See Faces Differently. ABC Science. https://www.youtube.com/watch?v=vf4Sigud3Pw.

6. The four-part British series, Hoarding, 2006. https://www.youtube.com/watch?v=gQ-ZBvZrf1o. https://www.youtube.com/watch?v=iqVekHHObLg. https://www.youtube.com/watch?v=MMQ1o4eJDww. https://www.youtube.com/watch?v=xoDD-5bktCY.

7. For a another glimpse into hoarding: https://www.youtube.com/watch?v=CMEWT1AWhq0.

8.

TED talk by Ceci Garrett, Hoarding as a Mental Health Issue https://www.youtube.com/watch?v=L0c33pemjLw.

9. Post-Traumatic Stress Disorder (FHS, 15 min., color, #BVL6791) “This program examines the disorder associated with anxiety symptoms experienced following the witnessing of a traumatic event. One man who witnessed the deaths of his two teenage daughters and another man shot in an IRA ambush, give highly personal accounts of the behavioral changes experienced as a result of the traumas. An expert from a hospital traumatic stress unit tells why she supports the view that the condition does, indeed, exist.” https://www.films.com/ecTitleDetail.aspx?TitleID=8899.

10. The Psychology of PTSD. Ted Lessons: https://www.youtube.com/watch?v=b_n9qegR7C4.

11. Invisible Wounds. Documentary on Veterans’ Experiences with War Trauma https://www.youtube.com/watch?v=vBX-1pAyXnI. 12. Understanding PTSD https://www.youtube.com/watch?v=nZLD9z6_bFI.

13. Several major motion pictures have focused on OCD including:

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What About Bob Matchstick Men The Aviator As Good as It Gets

DISCUSSION QUESTIONS These questions are based on the clinical case studies and other information found in boxes throughout the chapter.

Jacob Some movies paint a main character with obsessive-compulsive disorder as having strange but amusing behavior. Do you think that such films undervalue the seriousness and suffering of OCD patients? Should films depict such characters more realistically by showing the anxiety, pain, and frustration that they suffer instead of portraying them as comical characters?

Paul What role does gender play in which physical features a person develops a strong aversion to in themselves? In reviewing Paul’s case, how might his symptoms be different from what is usually the physical focus of men with body dysmorphic disorder?

CBT Treatment for Paul Discuss why identifying the automatic thoughts and underlying core beliefs about Paul’s perceived “ugly” nose is the most important part of his treatment.

Dena Discuss the various current treatment for hoarding. Which treatment has seen the most success and why? How does this compare to popular media portrayals of hoarding?

Ashley In thinking about Ashley’s posttraumatic stress disorder, how does context and severity determine what situations will cause PTSD and what situations will not?

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Pause and Ponder Activity: Obsessive-Compulsive Disorder The following questions reference the case studies published in Oltmanns and Martin, Case Studies in Abnormal Psychology, 11th Edition, John Wiley & Sons, 2019.

Part I: Pause What would you think if...? ...a man has to turn around and go back the way he came because if he crosses a line in the sidewalk he will panic? ...every time a man scratches the left side of his face for an itch, he must scratch the right side too, or he will be distressed? ...a man needs to wash his hands every time he touches something, or he will become anxious?

Consider how much you agree with the following statement: I can see this man's perspective and understand how he would feel if I were in his shoes.

Question type Multiple Choice 1. When Bill refers to his "overwhelming sense of doom and fear," he is describing the experience of __________. a. anxiety b. fear c. irrationality d. stress Answer: a

2. Gavin discusses his repeated scratching behavior. When discussing OCD, what would this behavior be called? a. obsession b. compulsion c. ritual d. grooming Answer: b

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3. Gavin describes how he must scratch both the left side and the right side of his face. Next, since he already scratched the left side first, now he must scratch the right side of his face and then the left side. This is an example of “evenness,” which is a common focus of obsessions and compulsions in OCD. This theme is typically referred to as _____. a. symmetry b. regularity c. asymmetry d. inclusion Answer: a

4. Gavin states that he often does behaviors in fours, or four times four. It is common for individuals with OCD to focus on certain numbers they believe are “safe.” This type of compulsion is typically referred to as _____. a. counting b. addition c. ordering d. checking Answer: a

5. Dr. Robin Zasio describes the relationship between obsessions and compulsions. Which of the following statements is true of obsessions and compulsions in OCD? a) Obsessions produce anxiety b) Obsessions temporarily eliminate compulsions c) Compulsions temporarily relieve anxiety associated with obsessions d) Obsessions and compulsions are not related in most individuals with OCD

Answer 1: a Answer 2: c

Question type Essay

6. Kelly, Bill’s wife states that when Bill’s OCD was at its worst, she wanted to shake him and say, “snap out of it.” Explain why this statement would not be helpful to Bill. Be sure to discuss the nature of obsessions and compulsions in your explanation. ___________________________

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Question type Multiple Choice 7. Bill states that when his OCD was at its worst, he was unable to work. Dr. Robin Zasio also explains that a significant amount of time is taken up by compulsive behavior and obsessions.

Which of the following characteristics of a mental disorder best describes these aspects of OCD? a. disability b. distress c. dysfunction d. violation of social norms Answer: a

8. Gavin states that his obsessions and compulsions bother him all the time, and he cannot really go for a period of time without noticing them. Which of the following characteristics of a mental disorder best describes Gavin’s statement?

a. b. c. d.

disability distress dysfunction violation of social norms

Answer: d

Question type Essay

9. Name and explain the key features of the treatment for OCD described by Dr. Robin Zasio.

Question type Multiple Choice 10. Bill states that the medication he was prescribed to treat his OCD worked in which of the following ways? a) The medication allowed him to control his anxiety so other psychological treatments could be effectively used. b) The medication alone was a completely effective treatment for his OCD. c) The medication was not useful and he quit taking it. d) Bill did not take medication to treat his OCD. Answer: a

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11. A list of diagnostic criteria for anxiety disorders is shown below. Select all of the diagnostic criteria for obsessive-compulsive disorder. a. Exaggerated startle response b. Hypervigilance c. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anitipation of a specific object or situation d. Recurrent and intrusive distressing recollections of a traumatic event e. Recurrent or persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate and cause anxiety or distress.

Answer: d

Ponder Part III: Ponder Reflect upon the changes in your empathy that came about during this activity.

Question type Essay

1. Consider how much you agree with the following statement: I can see these men's perspectives and understand how they would feel if I were in their shoes.

__________________________________

Pause and Ponder Activity: PTSD The following questions reference the case studies published in Oltmanns and Martin, Case Studies in Abnormal Psychology, 11th Edition, John Wiley & Sons, 2019.

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Part I: Pause What would you think if...? ...a man left his wife and children because he felt it was more important to try and save the world? ...a woman cannot go to the grocery store when it is busy without feeling like she will wig out?

Consider how much you agree with the following statement: I can see these people's perspectives and understand how they would feel if I were in their shoes.

Part II: Learn Now that you have considered the statement, watch the case video on Jennifer and answer the questions.

Question type Multiple Choice 1. In order to be diagnosed with PTSD, the individual must experience or witness an event that ____. a. involved actual or threatened death b. involved serious injury c. involved a threat to the physical integrity of self or others d. Any of the above

Answer: d

Question type Essay 2. Describe the traumatic experiences that led to Jennifer’s PTSD. ________________________

3. Describe the traumatic experiences that led to Ken’s PTSD. _______________________

Question type Multiple Choice

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4. Ken says left his wife and family because he was dissatisfied and “drawn to something else—there was something else I had to be doing, and staying with the marriage wasn’t it.”

Which symptom of PTSD may account for this behavior? a. Feeling of detachment or estrangement from others b. Inability to recall an important aspect of the trauma c. Restricted range of affect d. Sense of a foreshortened future Answer: a

Question type Essay 5. Describe the traumatic experiences that led to Ken’s PTSD and his description of PTSD. _________________________

6. Two symptoms of PTSD are: 1) intense psychological distress, and 2) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. Discuss the experiences that Jennifer describes with these symptoms. __________________________

Question type Multiple Choice 7. a. b. c. d.

Which of the following treatments is most effective in treating PTSD? exposure therapy medication unstructured psychotherapy All of the above are effective.

Answer: a

8. Jennifer says she avoids situations in films and media that will get her worked up because of their similarity to the traumatic events she experienced. These experiences are grouped into which of the major categories of PTSD symptoms? a. Acute b. Avoidance c. Increased arousal d. Reexperiencing Answer: d

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9. Jennifer says she avoids situations in films and media that will get her worked up because of their similarity to the traumatic events she experienced. These experiences are grouped into which of the major categories of PTSD symptoms? a. Acute b. Avoidance c. Increased arousal d. Reexperiencing Answer: b

10. Jennifer says she will watch something upsetting and know she is getting worked up but be unable to calm down. These experiences are grouped into which of the major categories of PTSD symptoms? a. Acute b. Avoidance c. Increased arousal d. Reexperiencing Answer: d

Question type Multiple Selextion 11. A list of diagnostic criteria for anxiety disorders is shown below. Select all of the diagnostic criteria for posttraumatic stress disorder. a. Acting or feeling as if the traumatic event was recurring b. Difficulty falling or staying asleep c. Efforts to avoid activities, places, or people that arouse recollections of the trauma d. Exaggerated startle response e. Hypervigilance f. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation g. Recurrent and intrusive distressing recollections of a traumatic event h. Recurrent distressing dreams of the traumatic event i. Recurrent panic attacks j. Repetitive behaviors or mental acts that the person feels driven to perform or according to rules that must be applied rigidly and are aimed at reduced distress k. Sense of a foreshortened future

Answer 1: a Answer 2: b Answer 3: c

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Answer 4: d Answer5: e Answer 6: g Answer 7: h Answer 8: l

Ponder Part III: Ponder Question type Essay Reflect upon the changes in your empathy that came during this activity.

1. Consider how much you agree with the following statement: I can see this woman's perspective and understand how she would feel if I were in her shoes. ____________________

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CHAPTER 8 DISSOCIATIVE DISORDERS AND SOMATIC SYMPTOM DISORDERS LEARNING GOALS 1.

2.

3.

4.

5.

6.

Summarize the symptoms and epidemiology of the three major dissociative disorders.

Discuss the current debate regarding the etiology of dissociative identity disorder.

Describe the available treatments for dissociative identity disorder.

Define the symptoms of the somatic symptom and related disorders.

Explain the etiological models of the somatic symptom-related disorders.

Describe the available treatments for somatic symptom and related disorders.

The Learning Goals are inherent in both the Lecture Launchers and Discussion Stimulators below.

CHAPTER SYNOPSIS Dissociative disorders and somatic symptom and related disorders are covered together in this chapter because the onset of disorders of both classes is hypothesized to be related to some stressful experience, yet symptoms do not involve direct expressions of anxiety. They also tend to be comorbid with each other. In the dissociative disorders, the person experiences disruptions of consciousness— he or she loses track of self-awareness, memory, and identity. In the somatic symptom disorders, the person complains of bodily symptoms that suggest a physical defect or dysfunction—sometimes dramatic in nature—for which no physiological basis can be found.

Clinical Descriptions and Epidemiology of Dissociative Disorders The DSM-5 includes three major dissociative disorders: depersonalization/derealization disorder, dissociative amnesia, and dissociative identity disorder (DID) (see Table 8.1). Dissociation is the core feature of each of these disorders, which involves some aspect of emotion, memory or experience

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being consciously inaccessible. Dissociative experiences are common, but dissociative disorders involve much more severe forms that cause impairment or distress. Psychodynamic and cognitive theories consider this to be an avoidance response to protect the person from the conscious experience of stressful or traumatic events.

In depersonalization/derealization disorder, the person’s perception of the self is altered; he or she may experience being outside the body or perceive changes in the size of body parts. Dissociative amnesia involves the inability to recall important personal information, usually about a traumatic experience. The fugue subtype of dissociative amnesia involves loss of memory for one’s entire past or identity (usually temporary). Dissociative identity disorder (DID) (formerly known as multiple personality disorder) involves a disrupted sense of identity in which a person experiences at least two separate personality states or experiences of possession (i.e., different modes of being, thinking and acting that exist independently of one another and emerge at different times that may lack awareness or memory of the other states).

It is unknown exactly how prevalent dissociative disorders are, but in one small community study in New York found that 0.8% met diagnostic criteria for depersonalization/derealization disorder, 1.8% dissociative amnesia, and 1.5% DID, which were much higher than previously assumed rates. Reports of DID increased markedly in the 1970s, particularly in the United States and Canada, possibly due to popular media portrayals. Prevalence rates may vary with cultural and professional attention to these conditions.

Etiology of Dissociative Disorders Little research is available concerning the causes of these disorders, particularly for dissociative amnesia. The etiology of depersonalization/derealization disorder may relate to the way in which the brain integrates information from different sensory and bodily sources, creating a mismatch in sensory experiences.

Considerable debate exists about the causes of DID. Two etiological models have been proposed: the posttraumatic model and the sociocognitive model. The posttraumatic model suggests that dissociative identity disorder is the result of extreme abuse, an unpredictable home environment, war or natural disasters, coupled with a tendency to use dissociation as a coping strategy. Almost all patients with DID report severe childhood abuse, and there is also evidence that children who are abused are at risk for developing dissociative symptoms. The sociocognitive model suggests that dissociative identity disorder is caused by role-playing of symptoms among patients with a history of abuse and a deep need to satisfy authority figures like therapists, meaning that DID could be iatrogentic (i.e., created within treatment). In tests of explicit memory (i.e., consciously remembered) and implicit memory (i.e., automatic performance related memory), it has been found that while individuals with DID often deny explicit memories associated with a different personality, implicit memories are shared.

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Treatment of Dissociative Identity Disorder There are currently no empirically supported treatments for DID. In general, many clinicians agree that therapy for DID should include an empathic and gentle stance, with the goal of helping the client function as one wholly integrated person. Given that DID is conceptualized as a way of escaping severe stress, treatment can involve helping the person find more effective ways to cope and regulate their emotions. Psychoeducation can also help a person understand their symptoms and identify triggers for dissociation. Psychodynamic treatment is perhaps the most commonly used treatment for dissociative disorders, but some of the techniques involved, such as hypnosis and age regression, may make symptoms worse.

Clinical Descriptions of Somatic Symptom and Related Disorders The somatic symptom and related disorders are defined by excessive concerns about physical symptoms or health. These disorders are associated with the tendency to seek frequent medical treatment, leading to thousands of dollars per year in medical expense. The DSM-5 includes three major disorders in this category (see Table 8.2): somatic symptom disorder, illness anxiety disorder, and conversion disorder. Many people may use the term hypochondriasis to describe chronic worries about developing a serious medical illness, which is not a DSM-5 diagnosis but overlap with somatic symptom disorder and illness anxiety disorder, as both of these involve distress and energy expenditures around health concerns. Conversion disorder involves the development of sudden neurological symptoms such as blindness or paralysis where no medical cause can be found.

However, concerns about somatic symptoms are relatively common in the general population (80% report having concern about a somatic symptom in the past week), and these diagnoses can be stigmatizing. This has led to some criticism of these diagnostic categories.

Etiology of Somatic Symptom and Related Disorders Neurobiological models emphasize that brain regions activated by unpleasant body sensations may be hyperactive for those with somatic symptom disorders. Cognitive behavioral models of somatoform disorders focus on cognitive beliefs that promote negative responses to bodily sensations and appearance. Psychodynamic perspectives on conversion disorder focus on the role of the unconscious.

Neuroscience approaches also support the idea that perceptual processing often operates outside conscious awareness. However, research findings are mixed. Social and cultural factors may also influence symptoms of conversion disorder, as this disorder is more common among people from rural areas and lower-SES background. Conversion disorder may also be related to the phenomenon of “mass hysteria” in which a group in close contact suddenly develops inexplicable medical symptoms at the same time.

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Treatment of Somatic Symptom and Related Disorders One problem in treating somatic symptom and related disorders is that few people want to see a mental health provider for their physical symptoms. Nonetheless, cognitive behavioral techniques have been found helpful, including strategies to help people address emotions more directly, change their cognitive responses to physical symptoms, and shift from assuming the sick role. Behavioral or family based approaches may also be helpful for some patients where family members reinforce the patient’s sick role. Acceptance and commitment therapy (ACT) has also shown to be helpful for symptoms involving pain.

KEY TERMS conversion disorder

dissociative identity disorder (DID)

depersonalization

explicit memory

depersonalization/dere alization disorder

factitious disorder

dissociation

fugue subtype

dissociative amnesia

iatrogenic

dissociative disorders

illness anxiety disorder

implicit memory malingering posttraumatic model sociocognitive model somatic symptom disorders

LECTURE LAUNCHERS 1. Conversion Disorders in Children The text discusses variations in the prevalence of conversion disorders in different time periods and cultural groups. A recent study of hysteria in a child inpatient population in India sheds further light on this issue (1993, Srinath, S., Bharat, S., Girimaji, S., Seshadri, S. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 822–825). While conversion disorders in children are very rare in modern Western societies, the authors note that hysteria is the most prevalent psychiatric condition among children and adolescents in India. Their study examined the rates, correlates, and clinical outcome of childhood hysteria in an inpatient sample. Over 30% of the sample of children and adolescents in inpatient psychiatry wards received a diagnosis of hysteria. The most common clinical presentation was pseudoseizures, or “hysterical fits.” As the authors described: “A typical pseudoseizure generally would be characterized by the child slumping down to the ground and making irregular, non-rhythmic, bizarre movements, throwing the limbs around, or writhing on the

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ground. . . . Among these inpatients, a recurring pattern of pseudoseizures was notable for the dramatic nature of the symptom, repeated attacks sometimes lasting from 30 minutes to 1 hour, and the presence of additional conversion symptoms, such as general muscle weakness, inability to walk without support, and 'hysterical gait'” (p. 823).

Most patients had a recent onset of the disorder and a relatively short inpatient stay (usually less than 30 days). The majority of the children reported stressors in connection with the disorder, such as academic difficulties or having a punitive parent, and many recognized the connection between the stressor and their symptoms. Most of the children recovered rapidly.

Consistent with material on hysteria discussed in the text, the authors note that the higher rates of the disorder in India may suggest that “in this culture, having a ‘medical’ illness is the most acceptable means of seeking help or expressing psychological distress” (p. 824).

Sherick, in the article “Hysterical identification in an eleven-year-old girl,” suggests that “hysteria” and its dynamics are not being used in treatment, and it is time to reconsider the merits of bringing it back (2014, Psychoanalytic Review, 101, 675–700).

This link is to an extensive review of pediatric conversion disorder: http://emedicine.medscape.com/article/917864-overview.

2. Hypochondriasis and Functional Somatic Symptoms Hypochondriasis and various functional somatic symptoms are important public health phenomena. Various estimates suggest that somewhere between 20% and 84% of the patients who consult medical practitioners fit into either hypochondriasis or other somatic symptoms, and the prevalence of hypochondriasis is between 3% and 13% of the population.

A review of the topic provides some additional interesting information on the disorders (Kellner, R., 1985, Archives of General Psychiatry, 42, 821–829). Other data shows that between 60% and 80% of healthy people experience somatic symptoms in any one week.

Between 10% and 20% of a random sample worry intermittently about being ill (Kellner, R., JAMA. 1987, Nov 20, 258(19): 2718.22).

Anxiety and depression are two complaints commonly associated with hypochondriasis, to such an extent that some investigators suggest that hypochondriasis is not a separate entity.

Most experts on the topic suggest, however, that there is a subgroup of patients for whom the physical symptoms constitute the major complaint. Fear of death commonly accompanies hypochondriasis, a fear that can intensify to the extent that it is properly considered a phobia.

Particular hypochondriacal complaints tend to run in families, and the disorders are more common among lower-SES (socioeconomic status) patients who complain less about psychological symptoms and more about physical ones. Life stressors—particularly bereavement or witnessing illness or death—often appear to precipitate hypochondriasis, and symptoms can mimic those of an illness that the patient recently read about. Finally, it has been noted in several investigations that hypochondriacal patients are generally more sensitive to their physiological functioning.

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Little in the way of controlled research has been conducted on the treatment of functional somatic symptoms and hypochondriasis. Several investigators have suggested that the presence of hypochondriasis is an indication of poor prognosis in therapy, but treatment successes have also been reported using cognitive behavioral treatment to reduce excessive attention to bodily sensations, challenging negative thoughts about those sensations, and discouraging them from seeking reassurance from doctors. Behavioral components of the treatment focus on keeping people from repetitively checking on their health, increasing their engagement in healthy activities, and decreasing their focus on seeking treatment.

Antidepressant and anti-anxiety medications are also useful, and it has also been noted that simple reassurance is often sufficient. Perhaps what is most surprising is the relative neglect of a topic that presents an important challenge to both medical and mental health professionals.

3. Amnesia in the Laboratory Systematic research of dissociative amnesia has been limited because of both the rarity of the condition and the problems associated with retrospective recall. A study by Barnier (“Posthypnotic amnesia for autobiographical episodes: A laboratory model of functional amnesia” (2002, Psychological Science, 13, 232–237)) examined these problems using posthypnotic amnesia (PHA). In this method, hypnotized persons receive suggestions that they will not be able to recall specific material until they receive a “reversibility cue.” Findings indicate that highly hypnotizable subjects experience profound forgetfulness but lowhypnotizable subjects do not.

Typically, PHA experiments use simple, impersonal material to test the hypothesis rather than the type of autobiographical material that is not remembered in dissociative amnesia. Barnier divided the participants into high- and low-hypnotizable groups and elicited both recent and distant autobiographical memories from each individual. They were then hypnotized and half the participants were told they would not be able to recall their distant autobiographical memory while the other half were told they would not be able to recall their recent autobiographical memory. Participants were then brought out of hypnosis and asked to recall the autobiographical memory. Finally, the reversibility cue was given and participants were again asked to recall the autobiographical memory.

The findings indicate that recall of autobiographical information was signiicantly impaired for high-hypnotizable subjects compared to low-hypnotizable subjects. The study also found that recall of the distant memory was more affected than recall for the recent memory.

How might this research shape future investigations of the dissociative disorders?

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4. Issues in Conceptualizations of DID (Formerly Known as Multiple Personality Disorder) Kluft (1987, Hospital and Community Psychiatry, 38, 363–373) reviews a range of issues involved in multiple personality disorder, including controversy over its prevalence and phenomenology, etiology, diagnostic criteria and differential diagnosis, and treatment: Prevalence. An exchange of letters in the American Journal of Psychiatry (Ludolph, 1985, 142, 1526–1527; Bliss, 1985, 142, 1527; Kluft, 1986, 143, 802–803; Chodoff, 1987, 144, 124; and Kluft, 1987, 144, 124–125) explores the controversy surrounding the prevalence of multiple personality. One group of clinicians asserts that the disorder is rare or nonexistent. They suggest that the recent increase in reported cases is due to loose diagnostic criteria, the overenthusiasm of a few diagnosticians, or even the creation of the disorder through hypnosis treatments, and they conceptualize the disorder as maintained and perhaps created by secondary gains. Those who believe that the prevalence of the disorder is much higher than previously believed conceptualize it as a child’s attempt to cope with trauma through inward flight; a child who cannot physically escape extreme abuse, for example, may find that dissociation provides an inner escape. However, Dorahy and others believe that DID affects approximately 1% of the general population (2014, Australian and New Zealand Journal of Psychiatry, 48, 402–417).

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

Treatment. As described in the text, most treatment methods involve attempting to integrate the split personalities. In addition, Kluft points out the importance of teaching the client new ways of coping with stress, to replace the previously ingrained dissociation pattern. Thus, after integration has been achieved, coping skills such as relaxation and assertion training and new interpersonal skills become an important aspect of treatment to prevent relapse. Interestingly, Braun (1984, Psychiatric Annals, 14, 3440) reports that integration may result in physiological changes; patients report changes in allergies, color blindness, eyeglass prescription, and insulin requirements (in diabetics) following integration. A survey of 36 experts who have treated DID suggest that there be a carefully staged treatment of three phases. In the first place is skill building in development and maintenance of safety about self and others and avoidance of high-risk behaviors, emotion regulation as well as impulse control, interpersonal effectiveness, grounding and containment of whatever may intrude into the process are

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equally important. The recommendation is a specific trauma-focused cognitive therapy, which leads to unification of self (Brand, B. L., Myrick, A. C., Loewenstein, R. J., Classen, C. C., Lanius, R., McNary, S. W., ... & Putnam, F. W. (2012). A survey of practices and recommended treatment interventions among expert therapists treating patients with dissociative identity disorder and dissociative disorder not otherwise specified. Psychological Trauma: Theory, Research, Practice, and Policy, 4(5), 490).

Another interesting article concerning treatment is that by Brand (2014, Psychiatry: Interpersonal and Biological Processes, 77,169–189). The title, “Dispelling myths about dissociative identity disorder treatment: An empirically based approach,” is an indication of the confusion surrounding treatment in which some experts claim that treatment is harmful and others suggest that psychotherapy is helpful.

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

At around the time of the trial, a research team (Spanos, Weekes, & Bertrand, 1985) highly skeptical of the reality of DID conducted an ingenious experiment that added a new perspective to the testimony of Kenneth Bianchi, the man accused of these murders. This study supports the possibility that a person may adopt another personality just to avoid punishment. The experimental manipulations were derived from an actual interview with Bianchi while he was supposedly under hypnosis during a pretrial meeting with a mental health professional to determine his legal responsibility for his crimes. The interviewer (I) asked for a second personality to come forward.

I: I've talked a bit to Ken but I think that perhaps there might be another part of Ken

that I haven’t talked to. And I would like to communicate with that other part.

And I would like that other part to come to talk with me…And when you're here, lift the left hand off the chair to signal me that you are here. Would you please come, Part, so I can talk to you? Part, would you come and lift Ken’s hand to indicate to me that you are here?…Would you talk to me, Part, by saying “I’m here”? (Schwarz, 1981, pp. 142–143).

Bianchi (B) answered “yes” to the last question, and then he and the interviewer had the following conversation.

I: Part, are you the same as Ken or are you different in any way? …

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B: I'm not him.

I: You're not him. Who are you? Do you have a name?

B: I'm not Ken. I: You're not him? Okay. Who are you? Tell me about yourself. Do you have a name I can call you by?

B: Steve. You can call me Steve. (pp. 139–140)

While speaking as Steve, Bianchi stated that he hated Ken because Ken was nice and that he, Steve, with the help of his cousin, had murdered a number of women. Bianchi’s plea in the case became not guilty by reason of insanity; he claimed that he suffered from dissociative identity disorder.

In the Spanos study, undergraduates were told that they would play the role of an accused murderer and that despite much evidence of guilt, a plea of not guilty had been entered. They were also told that they were to participate in a simulated psychiatric interview that might involve hypnosis. Then the students were taken to another room and introduced to the psychiatrist, actually an experimental assistant. After a number of standard questions, the interview diverged for students assigned to one of three experimental conditions. Those in the Bianchi condition were given a rudimentary hypnotic induction and were then instructed to let a second personality come forward, just as Bianchi’s interviewer had done. Students in the Hidden Part condition were also hypnotized and given information suggesting that they may have walled off parts of themselves, but these instructions were less explicit than those given for the first condition. Students in a final condition were not hypnotized and were given even less explicit information about the possible existence of a hidden part.

After the experimental manipulation, the possible existence of a second personality was probed directly by the “psychiatrist.” In addition, students were asked questions about the facts of the murders. Finally, in a second session those who had acknowledged the presence of another personality were asked to take two personality tests twice—once for each of their two personalities. Eighty-one percent of the students in the Bianchi condition adopted a new name, and many of these admitted guilt for the murders. Even the personality test scores of the two personalities differed considerably. Clearly, when the situation demands, people can adopt a second personality. Spanos et al. suggest that some people who present as multiple personalities may have a rich fantasy life and considerable practice imagining that they are other people, especially when, like Bianchi, they find themselves in a situation in which there are inducements and cues to behave as though a previous bad act had been committed by another personality. We should remember, however, that this demonstration illustrates only that such role-playing is possible; it in no way demonstrates that all cases of multiple personality have such origins.

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The Spanos study does give us pause. Some professionals still consider dissociative identity disorder nothing more than role-playing. Others consider it a real, though rare, disorder. How can this dispute be resolved? The main method has been to compare cases of multiple personality with people asked to role-play or who are tested while hypnotized or deeply relaxed. The key comparisons are those of the main personality with the alters, and the reality of DID is taken to be reflected by greater differences across the personalities for the clinical cases than for the role players. Physiological measures are frequently used as dependent variables because they are regarded as less subject to conscious control.

Using this type of research strategy, Putnam, Zahn, and Post (1990) found greater differences in autonomic nervous system activity across personalities for the cases of DID than for controls, and Miller (1989) found more differences in visual functioning. Do these data unequivocally indicate that DID is more than mere role-playing? Not necessarily. They are interesting, but we must remember that the role players in these studies were considerably less practiced than were the clinical cases in enacting their different personalities. Perhaps with greater practice the differences would lessen.

Returning to the actual trial, Bianchi was found guilty. His insanity plea did not hold up, in part because evidence indicated that his role enactment differed in important ways from how true multiple personalities and deeply hypnotized subjects act (Orne et al., 1984).

6. Strategies for Coping with Pain An important role for psychologists working in behavioral medicine is assisting medical patients to cope with pain. Many pain intervention strategies stress an avoidant approach, in which patients are taught distraction techniques to divert their attention from the pain. An interesting study by Holmes and Stevenson (1990, Health Psychology, 9, 577–584) suggested that different coping strategies may be effective depending on the type of pain experienced.

Comparing acute and chronic pain patients with benign, intractable pain caused by injury, the researchers found that avoidant strategies (such as denial and distraction) led to better adaptation (i.e., less anxiety and depression, higher activity levels) in acute pain patients, whereas attentional strategies (seeking more information, reinterpreting the pain) were associated with better adaptation in chronic pain patients. Thus, the authors concluded that intervention strategies should be tailored to the type of pain experienced. In more recent years, there has been development in psychotherapeutic approaches to chronic pain, including the use of acceptance and commitment therapy (ACT). See recent papers below for more: Hughes, L. S., Clark, J., Colclough, J. A., Dale, E., & McMillan, D. (2017). Acceptance and commitment therapy (ACT) for chronic pain. The Clinical Journal of Pain, 33(6), 552–568.

Feliu-Soler, A., Montesinos, F., Gutiérrez-Martínez, O., Scott, W., McCracken, L. M., & Luciano, J. V. (2018). Current status of acceptance and commitment therapy for chronic pain: a narrative review. Journal of Pain Research, 11, 21–45.

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DISCUSSION STIMULATORS 1. Distinguishing DID and Schizophrenia As discussed in the text, students (and the popular media) frequently confuse the concepts of multiple personality and schizophrenia. It is worthwhile to spend some time at this point in the course explaining the difference. Pointing out the derivation of the term “schizophrenia” will help to clarify the source of confusion: “Schizo” means split and “phrenia” means mind, thus the interpretation that schizophrenia means split personality. The term was coined by Bleuler, however, and indicates his view that the central problem in schizophrenia is the “breaking of associative threads” or the loss of connections between thoughts. In fact, schizophrenia and dissociative identity disorder are two very different disorders.

2. Demonstrating Hypnotic Suggestibility Many theorists and researchers have reported that individuals with dissociative identity disorder are more susceptible to hypnosis, making them more likely to dissociate as a means of coping with trauma. Hypnotic suggestibility may have other, less pernicious, associations with creativity, imagination, and the ability to relax. People who are able to vividly imagine may be better candidates for systematic desensitization. Try the following demonstration with the class, for students may be interested in finding out how susceptible to hypnosis they are.

Hadley, J., & Staudacher, C. (1985). Hypnosis for change (pp. 22–23). Oakland, CA: New Harbinger Press.

Make sure you are completely comfortable. Stretch your legs, your arms and now begin to relax. Close your eyes and take a deep breath . . . and exhale . . . and relax. Completely relax. Relax your legs, lower back, relax your shoulders. Relax your shoulders, your arms, your neck, your face. Relax your whole body, just relax. Take another deep breath. . . and exhale . . . let go, and relax. Become aware of the rhythm of your breathing. Begin to flow with the rhythm of your breathing, and as you inhale, relax your breathing and begin to feel your body drift and float into relaxation. The sounds around you are unimportant, let them go, and relax. Let every muscle in your body completely relax from the top of your head to the tips of your toes. As you inhale gently, relax. As you exhale, release any tension, any stress from any part of your body, mind, and thoughts.

Now stretch your arms in front of you at a level even with your shoulders.

Imagine you are holding a bucket in each hand. Curl your fingers around the handles of the buckets, hold onto those two buckets. The bucket in your left hand is made of paper, it is made of paper. It is empty and feels very light.

The bucket in your left hand feels very, very light. The bucket in your left hand is very, very light because it is made of paper. You hold that light

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bucket in your left hand. The bucket in your right hand is made of iron. It is made of iron. It is made of heavy, heavy iron, and the bucket has a few rocks in it. As you hold the heavy iron bucket, more and more rocks are dropped into the bucket until the bucket is completely full of heavy rocks. The bucket is completely full of heavy rocks, the rocks are piled up to the top of the bucket. The bucket is so very heavy; it is pulling your right arm down. The bucket of rocks pulls your arm down and your arm goes down because the heavy iron bucket is so heavy, so very heavy.

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

3. Experiencing Dissociation Crystal is a college student who sometimes dissociates. She has been diagnosed with depersonalization/derealization disorder. When talking with her therapist, Crystal explains that she is feeling spacey. That everything looks and feels different. She says that she feels disconnected from herself, almost as if she is physically outside of her body watching herself talking with her therapist. It is hard to focus her eyes and her visual perspective changes—it seems as if her therapist is much further away from her than he truly is. She feels disconnected from her body and feels as if her body is not real.

What might it feel like to experience this type of disconnection and dissociation? What might you be thinking and feeling? What would you want to do or say to communicate your experience? What would it be like to be with another person while having this sort of internal experience?

INSTRUCTIONAL FILMS 1. 60 Minutes Interview with woman showing symptoms of DID https://www.youtube.com/watch?v=2c8xpiCKtHQ. 2. Oprah Winfrey interview of woman with DID describing treatment approach https://www.youtube.com/watch?v=n2atzoaA2NI. 3. Multiple Personality Disorder, a documentary (59 min.) http://topdocumentaryfilms.com/multiple-personalities/.

4. Conversion Disorder clinical case example https://www.youtube.com/watch?v=Ja8ccfhCrE0.

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5. Documentary film on life with depersonalization disorder https://www.youtube.com/watch?v=Lx3iPmDVEms. 6. Counseling session vignette illustrating symptoms of illness anxiety disorder https://www.youtube.com/watch?v=q4x4KHDiJAs. Popular films showing examples of DID: 7. http://traumadissociation.com/did-osdd/top-10-multiple-personality-did-movies.html

DISCUSSION QUESTIONS These Questions are based on the clinical case studies and other information found in boxes throughout the chapter.

Gina Dissociative identity disorder (DID) is most often diagnosed in women. There is one probable reason for this. Men tend to be more aggressive and may end up being processed through the justice system, whereas women are usually processed through the therapeutic system. If this is correct, then what measures could be implemented by forensic psychologists to spot possible DID cases in the incarcerated male population?

Mrs. A Which did Mrs. A suffer from, depersonalization, derealization, or both? How would you differentiate depersonalization and derealization disorders?

Hannah Discuss the case of Hannah. What do you think was the cause of her disappearance?

Maria In reviewing Maria’s case, what are possible underlying reasons for her disorder to have developed when she was a child? Consider the psychodynamic approach, the neurobiological model, and the cognitive model.

Anna O What could be the underlying cause of Anna’s paralysis that was cued by seeing objects shaped like snakes? Consider the psychodynamic approach, the neurobiological model, and the cognitive model.

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Louis In reviewing Louis’ case outline the underlying reasons for his concern about his health. What is it about health that sometimes makes a person like Louis obsessive about it? What model do you think was used in treating Louis?

Pause and Ponder Activity: Dissociative Identity Disorder (DID) The following questions reference the case studies published in Oltmanns and Martin, Case Studies in Abnormal Psychology, 11th Edition, John Wiley & Sons, 2019.

Part I: Pause What would you think if...? ...a woman says she has several different people living within her? ...a woman says that one of the several people living inside her is a 4-year-old boy?

Consider how much you agree with the following statement: I can see this woman's perspective and understand how she would feel if I were in her shoes.

Part II: Learn Now that you have considered the statement, watch the case video on Melissa and answer the questions.

Question type Multiple Choice 1. Tomi explains that dissociative identity disorder involves: a. Fragments of a core personality b. Multiple personalities within one consciousness c. Variable mood d. None of the above Answer: b

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2. Which of the following is the central cause of dissociative identity disorder, according to Andrea Chilton, MFT? a. Anxiety b. Fragmentation c. Trauma d. Witnessing violence Answer: c

3. The separate personalities involved in dissociative identity disorder would be correctly referred to as: a. Alters b. Fragments c. Others d. All of the above Answer: a

4. The separate personalities involved in dissociative identity disorder would be correctly referred to as: a. Alternate personality disorder b. Dissociative personality disorder c. Multiple personality disorder d. Multiple alter disorder Answer: c 5. Melissa, Tomi’s partner, was able to record four of her alters. These alters vary in:

a. b. c. d.

Age Gender Tone of voice All of the above

Answer: d

6. The name of the core personality of the individual shown in the video is…? a. Beth b. Mimi c. Richi d. Tomi

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Answer: d

7. The goal of therapy for dissociative identity disorder is: a. Helping the client function as a wholly integrated person b. Showing the client that splitting into different personalities is no longer necessary to deal with trauma c. Teaching the client to better cope with present stressors d. All of the above Answer: d

8. Tomi argues that current treatment methods are controversial and that alters see the treatment as: a. A waste of time b. Contributing to greater fragmentation c. Their death sentence d. Unnecessary Answer: c

9. A list of diagnostic criteria for dissociative disorders is shown below. Select all of the diagnostic criteria for dissociative identity disorder. a. Confusion about personal identity b. Different personalities that take control of a person's behavior c. Episodes of inability to recall important personal information d. Presence of two or more distinct personalities e. Sudden, unexpected travel away from home Answer1: b Answer2: d

Ponder Part III: Ponder Reflect upon the changes in your empathy that came about during this activity.

1. Consider how much you agree with the following statement: I can see this woman's perspective and understand how she would feel if I were in her shoes.

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Pause and Ponder Activity: Illness Anxiety Disorder The following questions reference the case studies published in Oltmanns and Martin, Case Studies in Abnormal Psychology, 11th Edition, John Wiley & Sons, 2019.

Chapter 8 Pause and Ponder Activity: Illness Anxiety Disorder Pause Part I: Pause What would you think if...? ...a woman has to check her pulse 10 times a day because she is afraid she is having a heart attack? ...a woman goes to the emergency room because she is afraid her headache means she has a brain tumor?

Consider how much you agree with the following statement: I can see this woman's perspective and understand how they would feel if I were in her shoes.

Part II: Learn Now that you have considered the statement, watch the case video on Lisa and answer the questions.

Question type Multiple Choice 1. Which of the following is not a category of disorder that often co-occurs with illness anxiety disorder? a. anxiety disorders b. eating disorders c. mood disorders d. all of the above are co-occuring disorders Answer b

Question type Essay

2. How does Dr. Stephen Friedkin describe illness anxiety disorder?

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3. Describe Lisa’s first experience of worry about a serious illness, as well as her current worries.

Question type Multiple Choice 4. Lisa has migraines. However, she went to the emergency room because one of her headaches was not like her usual migraines, and she was concerned that she had _____. a. a brain tumor b. a hematoma c. encephalitis d. lupus Answer a

5. If a doctor were to tell Lisa or another individual with illness anxiety disorder that there was nothing physically wrong, what would the outcome be? a. The individual would believe the doctor and be relieved. b. The individual would believe the doctor, but the concern would continue to a small degree. c. The individual would not believe the doctor. d. The individual would need to hear this from at least two doctors before it would be believed.

Answer c

6. Lisa says that the part of illness anxiety disorder that is debilitating is the _____. a. attacks b. depression c. fear d. headaches Answer c

7. Cognitive behavioral treatment for illness anxiety disorder does not include which of components? a. challenging negative thoughts about bodily sensations b. discouraging seeking of reassurance from doctors c. extensive medical testing d. reducing excessive attention to bodily sensation Answer c

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8. Lisa’s treatments include all of the following except ____? a. medical testing b. medication c. therapy d. all of the above are included in Lisa's treatment Answer a

9. Carolyn, Lisa’s partner, advises those who are close to someone with illness anxiety disorder to have all but which of the following? a. compassion b. fear c. patience d. understanding Answer b

10. A list of diagnostic criteria for somatoform disorders is shown below. Select all of the diagnostic criteria for illness anxiety disorder. a. Many physical complaints beginning before age 30 that occur over a period of several years that are not intentionally produced and cannot be explained by a known general medical condition b. Preoccupation with an imagined defect in appearance c. Preoccupation with fears of having, or the idea that one has, a serious disease despite appropriate medical evaluation and reassurance d. One or more symptoms or deficits affecting voluntary motor or sensory function that is not intentionally produced and cannot be explained by a general medical condition Answer c

Ponder Part III: Ponder Reflect upon the challenges in our empathy that came about during this activity.

1. Comment on the following statement: I can see how this woman's perspective and understand how she would feel if I were in her shoes.

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CHAPTER 9 SCHIZOPHRENIA LEARNING GOALS 1. Describe the clinical symptoms of schizophrenia, including positive, negative, and disorganized symptoms.

2. Differentiate the genetic influences, both behavioral and molecular, in the etiology of schizophrenia.

3. Understand the psychological influences in schizophrenia, including sociocultural, familial, and developmental influences.

1. 4. Distinguish the medication treatments and psychological treatments for schizophrenia.

The Learning Goals are inherent in both the Lecture Launchers and Discussion Stimulators below. Please note the Discussion Questions at the end of this chapter.

CHAPTER SYNOPSIS Schizophrenia is a disorder characterized by disorganized thinking, faulty perception and attention, a lack of emotional expessiveness, and disturbances in behavior. Schizophrenia is a highly stigmatized disorder and is associated with widespread disruption in every aspect of a person’s life. This chapter reviews the clinical symptoms, genetic and psychological influences, and treatments of schizophrenia.

Clinical Descriptions of Schizophrenia Schizophrenia is a very heterogeneous disorder. The lifetime prevalence of schizophrenia is around 1%. It affects men slightly more than women and typically begins in late adolescence or early adulthood.

Symptoms can be distinguished as positive, negative, and disorganized (see Table 9.1). Positive symptoms include excesses and distortions, such as hallucinations and delusions. Negative symptoms include deficits such as avolition, asociality, anhedonia (including deficits in

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consummatory and anticipatory pleasure), blunted affect, and alogia. Disorganized symptoms include disorganized speech (such as loose associations, or derailment) and disorganized behavior (including catatonia). For a diagnosis of schizophrenia, symptoms must last at least 6 months.

The DSM-5 also describes several other schizophrenia spectrum disorders that do not meet full criteria for a schizophrenia diagnosis, including schizophreniform disorder (i.e., symptoms of schizophrenia lasting only 1 to 6 months), brief psychotic disorder (i.e., symptoms lasting 1 day to 1 month), schizoaffective disorder (i.e., involving a mixture of mood episodes and schizophrenia symptoms), and delusional disorder (i.e., involving only persistent delusions).

Etiology of Schizophrenia Given its complexity, a number of influences are likely to contribute to schizophrenia. The evidence for genetic influences is strong (heritability estimate of .77), with much of the evidence coming from family, twin, and adoption studies. Familial high-risk studies are one type of family study design involving examining the children of a biological parent with schizophrenia longitudinally.

Understanding the specific genetic influences on schizophrenia remains a challenge for molecular genetics research. Linkage studies have focused on identifying specific candidate genes associated with aspects of schizophrenia. One such candidate gene is DRD2 which encodes a specific type of dopamine receptor (D2). However, evidence for other candidate genes has not replicated well. GWAS techniques allow researchers to identify rare mutations, such as CNVs, rather than just focus on known gene loci. Overall conclusions from GWAS findings are that observed mutations are rare, only some people with these rare mutations have schizophrenia, and the identified mutations are not specific to schizophrenia.

Neurotransmitters play a role in schizophrenia. For years, dopamine was the focus of study, but later findings led investigators to conclude that this one neurotransmitter could not fully account for schizophrenia. Other neurotransmitters are also the focus of study, such as serotonin, GABA, and glutamate.

A number of different brain areas have been implicated in schizophrenia in terms of both brain structure and function. One of the most widely replicated findings is of enlarged ventricles.

Other research supports the role of the prefrontal cortex, particularly reduced activation of this area, in schizophrenia. More recent research has identified abnormalities in the temporal cortex and subcortical grain regions. Some of these structural abnormalities could result from maternal viral infection during the second trimester of pregnancy or from damage sustained during a difficult birth. More recent research has focused on connectivity among brain regions and has found that people with schizophrenia generally have less connectivity in frontal and temporal cortices.

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Identified sociocultural influences on schizophrenia include poverty, history of trauma, urbanicity, migration, and family factors such as high levels of expressed emotion (EE). Developmental research has also focused on identifying problems that exist prior to the onset of schizophrenia.

For example, clinical high-risk studies have identified young people exhibiting mild symptoms of schizophrenia who are at high clinical risk for developing schizophrenia spectrum disorders.

Treatment of Schizophrenia Treatment of schizophrenia most often includes a combination of short-term hospital stays (during the acute phases of the illness), medication, and psychosocial treatment. The most promising approaches to treatment today emphasize the importance of both pharmacological and psychosocial interventions. Unfortunately, such integrated treatments are not widely available.

Antipsychotic drugs (also known as neuroleptics), especially the phenothiazines, have been widely used to treat schizophrenia since the 1950s. Second-generation antipsychotic drugs, such as clozapine, olanzapine, and risperidone, are also effective and produce fewer motoric side effects, though they have their own set of side effects. Drugs alone are not a completely effective treatment, though, as people with schizophrenia need to be (re)taught ways of dealing with the challenges of everyday life.

Effective psychological treatments for schizophrenia include social skills training, family therapies (often aimed at reducing high levels of expressed emotion) psychoeducation, and cognitive behavioral therapy (CBT).

Residential treatment homes are sometimes good alternatives for people who do not need to be in the hospital but are not quite well enough to live on their own or with family.

KEY TERMS Alogia anhedonia anticipatory pleasure antipsychotic drugs asociality avolition blunted affect brief psychotic disorder catatonia clinical high-risk study

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consummatory pleasure delusional disorder delusions disorganized behavior disorganized speech disorganized symptoms expressed emotion (EE) familial high-risk study hallucinations loose associations

(derailment) negative symptoms positive symptoms schizoaffective disorder schizophrenia schizophreniform disorder second-generation antipsychotic drugs social skills training

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LECTURE LAUNCHERS 1. Delusions in Schizophrenia vs. Other Disorders Students are often interested in the “positive symptoms” of schizophrenia, including florid hallucinations and bizarre delusions. However, delusions are also present in other disorders, particularly manic episodes, which may be difficult to distinguish from schizophrenia. In an effort to narrow the earlier broad definition of schizophrenia (discussed in the text), DSM-IV separates the diagnoses of mood disorders and schizoaffective disorder from that of schizophrenia. An early study by Junginger, Barker, and Coe (1992, Journal of Abnormal Psychology, 101, 287–292) proposed a method of distinguishing these disorders by examining the type of delusions reported by patients.

They compared the delusions of 83 patients and 55 patients with chronic disorders other than schizophrenia (including bipolar disorder, major depression, and schizoaffective disorder). They found that the delusions that distinguished people with schizophrenia were the Schneiderian ones, such as thought broadcasting, withdrawal, and thought insertion. Schneiderian delusions, also called First-rank symptoms, include auditory hallucination, passivity experiences, and delusional perception. In contrast, grandiose delusions were more common in patients without schizophrenia. In addition, their finding that the delusions of people without schizophrenia were more likely to contain a mood theme (either manic or depressive) supports the current diagnostic approach of distinguishing mood-congruent from mood-incongruent delusions.

An October 2013 article discusses the diagnosis and evaluation of hallucinations and delusions in children and adolescents (Sikich, Linmarie, Child and Adolescent Psychiatric Clinics of North America, 22(4), 2013, 655–673). It suggests that it is important to recognize positive psychotic symptoms in youth and that it is challenging to diagnose appropriately. An older work attempted to identify the core parameters that discriminate different types of delusions utilizing the three parameters that were thought to be of value: “base rate or the real world incidence of the event described in the delusion; physical possibility or the degree to which the event or situation is physically possible; and consensus potential or the degree to which the delusional belief is open to public scrutiny”(Cohen, Alex S., Schizophrenia Research, 83(2–3), 2006, 293– 295).

2. A First-Person Account: Problems of Living with Schizophrenia The following is an anonymous account of the personal problems of living with schizophrenia. The article appeared in the Schizophrenia Bulletin (1981, 7, 196–197). It is a good piece to read to students at the beginning or end of the lecture(s) on schizophrenia as it reviews many of the issues outlined in the chapter from a very human perspective.

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Living with schizophrenia creates problems for me that are not obvious or easy to explain. I am not entirely comfortable with the label “schizophrenia” because it implies that I am different in some basic way from other people, when I feel I am not. The label has helped me, though, to feel less guilt about my inability to “conquer” my problems, and to learn to make some allowances for my difficulties in handling situations. Unfortunately, other people often do not recognize the difficulties I face or make any attempt to make allowances for me.

The largest problem I face—I think the basic one—is the intensity and variety of my feelings, and my low threshold for handling other people’s intense feelings, especially negative ones. I have quite often experienced a euphoric “high” that is much like being in contact with some greater reality or meaning to life—accompanied by a kind of added brightness or extra dimension to everyday things around me.

The other side of the coin, though, is a very intense anxiety from nowhere that typically hits me quite suddenly after a short period of time without medication. The two feelings are opposite, yet somehow connected.

Feelings are “the stuff life is made of,” and I do not regret a lot of what I have experienced, but the terrible feelings are bad enough to make me opt for the medication—at least an adequate amount to give me control, even with some remaining discomfort. I have been taking one of the phenothiazines for almost 7 years, and I am concerned about the many potential problems with long-term use, particularly tardive dyskinesia. However, I feel there is no effective alternative to the drug, particularly if I am to maintain my normal lifestyle, with a husband and 9-year-old son.

My son—our son—is a very healthy, active boy, with a “take things in stride” disposition and an interest in many things, among them fossils, reading, the weather, swimming, soccer, and drawing. He is doing very well in school too. He has a sensitive nature, yet is quite self-sufficient.

My husband is supportive of me, but in many ways I am supportive of him too. We talk well together; he spends many hours listening to me philosophize, or talk about my problems.

I am convinced that my normal “façade" arises mainly when other people expect me to become emotionally involved with them. I find emotions tremendously complex, and I am quite acutely aware of the many over- and undertones of things people say and the way they say

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them. Generally, I like direct, honest, kind people, and I have difficulty handling social situations that require me to be artificial or too careful.

Another problem I have to deal with to a greater or lesser degree is my “runaway thinking.” I “free associate” rather easily, and sometimes forget what I was saying because other ideas are in my mind. If I concentrate, however, this can be an advantage, because I have a ready supply of new ideas—I don't bore myself. Concentrating, though, is sometimes easier said than done.

Intimacy is an interesting problem in my life. In a way, I am capable of the deepest spiritual intimacy with people, yet I am less capable than most people of handling the demands of relationships. I cannot share negative feelings other people have, because I am too sensitive to them; yet I can give a great deal of love and concern when I am protected against feelings like anger and cynicism.

I used to think a great deal about unlikely, unreal things, like being watched or filmed and events being orchestrated around me by other people or outside forces, or being literally an alien, since I felt so different and basically unattached to the world. I still have similar feelings and thoughts, but less so than before. In any case, they come and go and don't affect me greatly. The only pervading feeling that is a problem sometimes—on too little medication—is a general one of unreality or being unattached. The particular ideas that stem from the feeling are not the problem for me.

Overall, I feel I have a good life, and I am, in spite of my frequent doubts, a success in many areas. I have good people as friends, and a fine family, and I am not forced into a position of taking on too much independence or of being too dependent. I am a unique and interesting person; I don’t always quite fit in with the world, but I think I add something to it.

Another fascinating narrative can be found at: http://www.cnn.com/2012/08/12/opinion/saks-mental-illness/index.html

3. More First-Person Accounts Many students enjoy reading first-person accounts of the experience of mental illness, such as that quoted above. Each issue of Schizophrenia Bulletin contains a first-person account from an individual with schizophrenia or a parent or other concerned layperson.

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The following poem, written by Lynne Morris, a woman with schizophrenia, appeared in a compilation of first-person accounts in the 1988 issue of the journal.

I am the rear tire of a bicycle, not trusted enough to be a front tire, expected to go round and round in one narrow rut, never going very far, ignored except when I break down.

Then I get lots of frightening, angry attention and I am put into a garage, sometimes for months, where I forget my function

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and I become afraid to function and all functions seem useless.

Next time out I think I will be an off-ramp from a freeway.

4. Nobel Laureate John Nash and Schizophrenia When he was 21 years old, John Nash wrote a 27-page dissertation titled “NonCooperative Games.” In 1994 he was given a Nobel Prize in Economics for his work that heavily influenced the application of game theory to economics. Nine years after that paper, while a tenured professor at MIT, Nash began suffering debilitating delusions and hallucinations. He was frequently hospitalized over the years and spent time traveling through Europe hoping to gain refugee status. He returned to Princeton University where he was referred to as the “Phantom of Fine Hall.”

Nash’s struggle with his disease is chronicled in the biography A Beautiful Mind, by Sylvia Nasar, and the film of the same name directed by Ron Howard (see listing in Instructional Films section). In addition, students might enjoy The Essential John Nash by Nash (Nasar and Kuhn, Eds., Princeton University Press). A link to “One on One—John Nash” can be found in the Instructional Films section below. Here is a 29 min. interview

by Nobel Prize.com: http://www.nobelprize.org/mediaplayer/index.php?id=429.

5. Childhood Schizophrenia 40 Years Later In a rare and ambitious undertaking, German scientists Eggers and Bunk (1997; Schizophrenia Bulletin, 23, 105–117) followed 44 patients with childhood-onset schizophrenia for 42 years. The study sample comes from inpatients hospitalized for childhood schizophrenia (ages 6 to 14 years) between 1925 and 1961. The first followup was conducted in the 1960s and the second in 1994. To ensure accurate initial diagnoses, DSM-III-R criteria were applied to retrospective chart reviews. For the followup, patients and their relatives were interviewed, and patients who had died were evaluated using chart reviews and interviews with relatives.

First, some descriptive information: Most of the subjects were from the lower socioeconomic class (based on the father’s occupation), which is different from the distribution of social class in Germany (evidence for the sociogenic hypothesis?). The Instructors Manual

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peak age of onset for psychotic symptoms was around age 13. For children younger than age 12 at diagnosis, the onset was more likely to be insidious, whereas onset after age 12 was usually acute.

Outcome was assessed for communication deficit/social withdrawal, working behavior, interest in work and occupation, interests/need for information, and global social adaptation. Using these variables, subjects were rated as on a six-point scale ranging from complete remission through moderate to poor social remission to severe residual disease. Over 40 years after original inpatient admission, 25% of patients were in complete remission, 25% were in partial remission, and 50% were in poor remission and had developed a severe residual syndrome or were chronically psychotic.

Remission was related to type and age of onset: 1) none of the subjects with chronicinsidious onset showed a complete remission; 2) Early-onset disease carried a worse prognosis than later-onset disease.

Remschmidt and Theisen’s research on early-onset schizophrenia found that, when beginning in childhood or adolescence, schizophrenia psychosis before the age of 13 has a poor prognosis, and that the disease can be diagnosed with the same criteria that are used for adults. They also found that schizophrenia of acute onset with hallucinations and delusions has a better prognosis than insidious onset. The prognosis seemed better for those who had no family history of schizophrenia and whose families cooperate in treatment. A review of the few available studies confirms the suggestion that schizophrenia beginning in childhood and early adolescence is much worse than adultonset schizophrenia. The suicide rate over a 42-year study was higher than for patients of adult-onset schizophrenia (Neuropsychobiology, 66(1), 2012. Special Issue: 100 years of schizophrenia: Symposium ‘100 Years of Schizophrenia’, Marburg, May 21, 2011, pp.

63–69).

For a more recent update: Driver, D. I., Thomas, S., Gogtay, N., & Rapoport, J. L. (2020). Childhood-Onset schizophrenia and early-onset schizophrenia spectrum disorders: An update. Child and Adolescent Psychiatric Clinics, 29(1), 71–90.

6. Efficient Treatment of Schizophrenia As discussed in the text, several controlled studies have demonstrated that family therapy is highly effective in reducing the relapse rates of people with schizophrenia, particularly when this treatment succeeds in reducing the expressed emotion (EE) of high-EE relatives. Indeed, educational or behavioral family therapy in conjunction with neuroleptic medication is becoming the treatment of choice in the schizophrenia literature. Over the past couple of decades, efforts have been made to discover what components are necessary to improve the relapse rates of people with schizophrenia.

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Regular family therapy sessions, often held in the patient’s home, require a great deal of professional time. Is there a more efficient way of accomplishing the same result?

This question was addressed in a study by Leff, Berkowitz, Shavit, Strachan, Glass, and Vaughn (1989, British Journal of Psychiatry, 154, 58–66). Subjects in the study were people with schizophrenia with at least one relative rated as high in expressed emotion and having at least 35 hours per week of face-to-face contact with the patient. The 23 subjects who met these criteria were randomly assigned to two groups; one group received family therapy twice monthly, conducted in the patient’s home, and families in the other group were invited to attend a twice- monthly relatives group led by a professional, outside of the home. All subjects also received antipsychotic medication, and all families received two sessions of education about schizophrenia, conducted in their homes, without the patient present. The primary aim of the study was to determine whether the relatives group, which required much less professional time, was as effective as family therapy in reducing relapse.

The results suggested that when families complied with the treatment offered, family therapy and the relatives group were equally effective in reducing relapse. Relapse rates were 8% for the family therapy group and 17% for those who complied with the relatives group (a non-significant difference). (A control group receiving standard individual supportive treatment and medication had a 50% relapse rate, consistent with findings from other studies.) However, the families assigned to the relatives group were much less likely to comply with the treatment. While 11 out of 12 families complied with family therapy, 5 out of 11 of the relatives group failed to attend a single session. Those subjects who did not comply with the treatment had a 60% relapse rate, comparable to the control group.

The authors conclude that for those families who are willing and able to attend a relatives group, this form of treatment provides an effective and more efficient means of preventing relapse. Since many families do not comply with this treatment, however, alternative treatments should be available. Previous research by the same authors suggested that one or two sessions of family therapy in the home by the professional who leads the relatives group is sufficient to ensure that most families will subsequently attend the group. For those families who cannot or will not attend a group outside their home, family therapy remains an effective option.

Weisman de Mamani et al. say, “Research strongly suggests that family interventions can benefit patients with schizophrenia,” but that these interventions fail from a cultural and spiritual context (Weisman de Mamani, Weintraub, Gurak, and Maura, Journal of Family Psychology, October 6, 2014). They have developed a family focused program, culturally informed treatment (CIT-S), and conducted a study of 46 families to see if CITS would perform better than PSY-ED. In a quantitative study there were significantly fewer severe psychiatric symptoms at the end of treatment regardless of cultural orientation.

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An illuminating article, “Psychosocial treatments in schizophrenia: Update and future directions,” reviews the various interventions. Psychoeducational and family therapy, cognitive behavioral therapy, social competence and cognitive remediation are examined for their effectiveness (Schmidt, and Roder, Minerva Psichiatrica, 53(3), 2012, 217–231).

Another more recent update: Kuipers, E., Yesufu-Udechuku, A., Taylor, C., & Kendall, T. (2014). Management of psychosis and schizophrenia in adults: Summary of updated NICE guidance. BMJ, 348.

DISCUSSION STIMULATORS 1. Biographies of Mental Illness It may be useful to assign a biography for the class to read in order to give a better feel for the phenomenology of and social reactions to serious mental disorders. Sylvia Plath’s The Bell Jar and Mark Vonnegut’s The Eden Express are two excellent accounts. You may also want students to render a diagnosis after reading the biography. It has been suggested that the cases of “schizophrenia” that are portrayed in such popular literature are really misdiagnoses, and that this leads to undue optimism about the possibility of recovery from schizophrenia. See North and Cadoret (1981, Archives of General Psychiatry, 38, 133–137) for a detailed discussion of the appropriate diagnoses for the characters portrayed in the two books mentioned above, as well as other biographies.

Mental Hospitals Have any of the class members ever been in or worked in a mental hospital or behavioral health inpatient unit? What were their experiences like? What was the physical layout of the ward and how did this affect patient behavior? Was there much contact between the patients and the professional staff? What would it be like to be a patient there?

Mental hospitals occasionally permit visits from students and instructors studying mental illnesses, including schizophrenia. If there is a hospital in the area perhaps it would be worthwhile to inquire about visiting the facility.

2. Patient, Ex-Patient, Client, Consumer, Survivor?

Write these words on the board, and ask the class what associations each has. Explore feelings associated with sayings such as: “Label jars, not people,” “Nothing about me without me,” and “I am not a case, and you are not my manager.” In The Mental Health

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System: Experiences from Both Sides of the Locked Doors, Bassman explores changing views of psychiatric survivors from his perspective as a former hospitalized mental “patient” and now clinical psychologist (Professional Psychology: Research and Practice, 28, 238–242). He explores issues related to terminology used to talk about people with mental illness, liberation and empowerment of psychiatric survivors, goals for treatment in people with serious mental illness (quality of life over symptom reduction), and concerns about involuntary hospitalization. The following anecdote is particularly poignant: Edward Knight, a highly regarded sociologist and former homeless consumer/survivor who has organized, researched, and advocated for hundreds of self-help groups in New York, spoke candidly of his patient experience (Lipman, 1995). Hoping to be released from a psychiatric hospital, he had to convince his treatment team that he had realistic goals. Knight was a research sociologist and told the team he wanted to do research on schizophrenia. The treatment team told him that this was a delusion of grandeur. He then said he would like to start self-help and advocacy groups. Again he was told it was a delusion of grandeur; he must accept where he is in life right now, a mental institution. A few weeks later, he went back to the staff and told them he hoped to become a filing clerk. This goal was acceptable for discharge. Shortly after the meeting, a psychologist from the treatment team took him aside privately behind closed doors in the nursing station and encouraged him, “Don't give up your delusions of grandeur. Those are your goals.” (p. 241)

3. The Right to Refuse Treatment While discussed in the text in Chapter 16, the issue of the right to refuse treatment, particularly antipsychotic medication, often arises in the treatment of schizophrenia.

Appelbaum (1988, American Journal of Psychiatry, 145, 413–419) reviewed and discussed court decisions on the right to refuse antipsychotic medications. While the right of voluntarily committed inpatients to refuse medication has been accepted easily, the issue becomes more complicated with involuntary patients: Why commit a patient because they are judged to need treatment, and then allow them to refuse that treatment? Changes in the commitment laws in the 1970s led to a criterion of dangerousness (to self or others), rather than need for treatment, as the rationale for involuntary commitment. This change made the right to refuse treatment less illogical (dangerous behavior could be controlled by hospitalization without medication).

Since the Supreme Court has never decided the issue, state laws vary, though all have established some degree of right to refuse treatment. Treatment-driven approaches to Instructors Manual

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the issue limit patients’ interests to the receipt of appropriate care. If a person is involuntarily committed, the physician’s judgment determines what treatment is given, regardless of the patient’s wishes. In some variants of this approach, an independent clinical review must support the physician’s decision before a patient's refusal can be overridden. The treatment-driven model is generally favored by clinicians and administrators and opposed by patients’ rights advocates.

The rights-driven approach emphasizes the right of competent patients to control the treatment they receive. In different variations of the model, the determination of competence may be made by clinical review, or by a judge, either during the commitment hearing or after commitment. In general, the latter variation is most palatable to patients’ rights groups but raises concern among clinicians that patients will not receive needed treatment (and that clinicians’ judgments of appropriate treatment are being distrusted).

After presenting these models for addressing the issue (and possibly assigning the above article, plus a first-person account by a parent upset by her daughter’s successful refusal of treatment [Slater, 1986, Schizophrenia Bulletin, 12, 291–292]), you might set up an inclass debate among four principals: (1) a patients’ rights advocate, (2) a concerned clinician, (3) a parent of a young adult with schizophrenia who has refused treatment, and (4) a patient with schizophrenia who has refused to take antipsychotic medication.

Students not participating in the debate could be asked to serve as high court judges and reach a decision on the issue. The descriptions in numbers 5 and 6 below could be used as handouts to aid in setting up the debate.

Lewis, in “Right to refuse treatment,” presents case studies of the rights of patients to refuse treatment for psychiatric conditions (Landmark cases in forensic psychiatry. Ford, E. (Ed.); Rotter, M. (Ed.); 2014. 54–58). This is an excellent resource that discusses treatment and law.

A patient’s right to refuse treatment has been questioned for the last three decades and still is under question. “Regulatory oversight: Do psychiatric patients have the right to refuse treatment?” discusses the moral complexities faced by professionals in their attempt to balance patients’ rights to autonomy and the regulatory demands of the federal government (Hannon-Engle, Archives of Psychiatric Nursing, 25(1), 2011, 21–23).

4. Whose Reality Is it Anyway?

As mentioned above, psychologist Ronald Bassman was diagnosed with and treated for schizophrenia. He has written extensively about his personal experiences in the mental health system. His narrative of his experience and a criticism of the mental health system appeared in the Journal of Humanistic Psychology (Bassman, R. 2001. “Whose reality is it anyway? Consumers/survivors/ex-patients can speak for themselves.” 41, 11– 35). Dr. Bassman is a member of the APA task force on serious mental illness, a faculty

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member of the Center for the Study of Issues in Public Mental Health, and past president of National Association for Rights Protection and Advocacy.

Dr. Bassman published a brief account in Psychology Today, February 2001. The following material is condensed from that article with the permission of Psychology Today:

Overcoming the Impossible: My Journey Through Schizophrenia The seclusion room was empty except for a mattress covered in black rubber on the concrete floor. They lowered me onto the mattress and turned me on my side. I fought their grip on my ankles and wrists, but they were too strong and experienced. I quit struggling and stared at the wire-encased ceiling light. I couldn’t see the nurse when she came in and said, “Get him ready.” They quickly pulled my pants and underwear down to my knees. I winced at the violent thrust of the needle. I tried to prepare myself to fight the onslaught of the thought-dulling, body-numbing Thorazine.

They waited for the drug to take effect before they stripped me of my clothes. I was left naked in the seclusion room, and no explanations were given. They did not tell me how long I would stay there.

Three decades have passed since I've had any kind of psychiatric treatment, yet the memories remain. Even after more than 20 years of work as a licensed psychologist, the nightmares have not disappeared. The dreams of endless wanderings through gauzeshrouded hospital corridors, the disembodied screams, and the smothering restraints and seclusion were not overcome by my successes. Those haunting memories only ended when I was finally able to use all of my experiences, when I was able to stop hiding my psychiatric history, and when I could speak publicly about my own treatment and transformation. Now I understand the importance of sharing what I learned from living and working on both sides of the locked door.

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I am just one of many who have suffered psychiatric torments from an inadequate and often destructive mental health system. The journey that brought me to this place of credibility enables me to offer my experience not only to those who have the power to bring about change, but also to those who feel powerless and need inspiration. My good fortune allows me to challenge the prevailing psychiatric model. When you become a mental patient, you are no longer regarded as a whole person with an individual mix of strengths and weaknesses.

When I was discharged from the hospital I was told I had an incurable disease called schizophrenia. The doctor told my family that my chances of being rehospitalized were very high. The medical orders were directed at my parents, not me, and stated with an absolute authority that discouraged any challenge. He predicted a lifetime in the back ward of a state hospital if his orders were not followed.

“He will need to take medication for the rest of his life. For now, you need to bring him to the hospital weekly for outpatient treatment and he must not see any of his old friends.” I was devastated.

The hospital doctor put me into a coma five days a week for eight weeks by injecting me with insulin. Those 40 insulin treatments combined with electroshock blasted huge holes in my memory, parts of which have never returned. I ballooned from 140 to 170 pounds. I appeared the clown in clothes that no longer fit. My already damaged self-image had plummeted to an unrecognizable depth, and the heavy doses of Thorazine and Stelazine made me feel like I was walking in slow-motion under water.

Was the doctor joking? Not say my old friends? How was I going to face them and explain what had become of me? Did anyone really think that I was capable of making new friends? I was sure that they would have nothing to do with me. But the most disturbing of all the orders was to hear him say that I would never be free of the hospital's control.

My best friends were once locked up in mental hospitals and fought their way back. We are psychiatric survivors. Some believe that psychiatric survivors defy the odds. Or maybe we were never really mentally ill, just misdiagnosed.

After all, they say schizophrenia is a lifelong disease. Such reasoning makes my peers and me look like exceptions. Among our large group of closeted expatients are lawyers, teachers, mechanics, doctors, carpenters, plumbers and psychologists. We are your neighbors, ministers and friends, living and working in your communities. Many thousands choose not to reveal their past.

For the past five years I have presented psychiatric survivor concerns at lectures and symposiums at the American Psychological Association’s annual

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convention. I have tried to connect with other psychologists who have been diagnosed and treated for major mental illness. At the annual conventions, I hold a meeting for psychologists who have psychiatric histories as well as those who are interested in serious mental illness. I have tried to make it a safe place for people to meet without feeling that they are at risk of being exposed. They can choose to participate as an interested psychologist if they feel uncomfortable about revealing their experiences.

Over the years, psychologists have come to our meetings and talked about their experiences as mental patients. Some disclosed their past for the first time. But in this organization comprising more than 130,000 members, with an annual convention that draws between 20,000 and 30,000 psychologists, only 15 have felt safe enough to reveal their histories.

Do we recover or are we transformed by our experiences?

Some of us think of ourselves as recovering or recovered. Others, like myself, see it as a process of transformation. Like other psychiatric survivors, I feel duty-bound to share what helped and hurt me so that we may eliminate the ineffective treatments and abuses of the mental health system and help make our communities more supportive and inclusive.

Yet how does one climb from the depths? Research from around the world documents high rates of complete recovery from schizophrenia. The most extensive study, known as the Vermont Longitudinal Study, followed patients for an average of 32 years. Lead researcher Courtenay Harding of the University of Colorado studied the most “hopeless” patients diagnosed with schizophrenia: the feces-smearing patients who barely dressed themselves and had forgotten how to tell time. Harding reported that 30 percent of these patients had fully recovered. These ex-patients were symptom-free, employed, had a social life, and did not take medication.

During my own struggles it would have been extremely helpful to have known of this optimistic research. Yet even with such remarkable findings, the common belief remains: Recovery is rare or impossible. In forums and presentations, I’ve shared these research findings and found that most people are surprised by the results.

Another study conducted by the United Nations through the World Health Organization found that people diagnosed with schizophrenia in Third World countries have higher rates of recovery than those who live in First World nations. Why is this? The thinking has been that families in underdeveloped countries need each member to be productive. Therefore, there may be

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greater tolerance for people who look and act differently. These people are necessary to their families and community. They have value.

What makes recovery and transformation possible? Unlike the research on recovery rates, there is little quantitative research on what promotes recovery.

To determine what is helpful, we are guided by qualitative research gathered from people willing to share their stories.

In the Vermont study, Harding asked people, “What really made the difference in your recovery?” Many of them answered similarly. They looked down at their feet, shuffled around and said something about a person who told them that they have a chance to get better. Having someone believe in them translated into hope. Without hope, death can establish a foothold. Hope fights fear and nurtures courage. It inspires vision and the work required to realize the unattainable.

Deep in the recesses of our being there are safe sanctuaries, secure hiding places for salvageable dreams. Anger sustains our stubborn refusal to accept others' dire predictions. Anger protects our hopes and dreams.

Author and international lecturer Judi Chamberlin writes proudly and sardonically about having been a noncompliant patient. “Noncompliant patients receive the worst and potentially most harmful treatments. We have been locked in seclusion, placed in restraints, chemically and physically straitjacketed, lobotomized, shocked and beaten because we protested too much. If we were lucky enough to escape permanent damage, anger helped us. It helped us fight for our rights and shun the role of lifelong mental patient.”

Anne Krauss, a psychiatric survivor working in the mental health field in New York, tells an illuminating story of the effects of suppressing anger. She worked as a peer advocate in a state psychiatric hospital, and on one occasion she was in the ward talking with a patient for whom she was an advocate. Knowing that her complaints were legitimate, Anne listened respectfully to the woman as she angrily complained about not getting what she wanted. At the time, a psychiatrist assigned to the ward who knew both Anne and the patient walked over and placed himself between the two women. He faced Anne and said, “You know, some people just don't know that they should not be angry with people who are trying to help them. They would get along much better if they showed more respect.” After he walked away, Anne resumed the conversation. The woman was no longer lucid. She ignored Anne, and began talking to the voices only she could hear. Anne was stunned by this example of the price paid when you are forced to bury your anger.

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Darby Penney is director of the Bureau of Recipient Affairs for the New York State Office of Mental Health. In her cabinet-level position, she supervises a staff of 14 and reports directly to the commissioner of the world's largest mental health system. Darby tries to infuse her work with survival lessons she learned during her stay in psychiatric hospitals. In the hospital you are asked to talk about your feelings, but when that emotion is actually felt and expressed, you suffer the staff-imposed consequences. If you cry, you are considered suicidal. If you are angry, you are aggressive and dangerous. And if you are laughing too happily, you are manic and need to be sedated.

When people who have been diagnosed and treated for serious mental illness work and play side by side with others, they will be seen and valued for who they are with all their strengths, weaknesses and foibles. By demystifying madness, we can begin to appreciate the beautiful gifts that diversity offers to everyone.

5. Schizophrenia and the Death Penalty James Colburn is a 42-year-old convicted murderer who has been diagnosed with paranoid schizophrenia. The Supreme Court issued a stay of execution in November 2002 blocking his execution after earlier refusing to grant a stay. Colburn was given antipsychotic medications that caused him to be heavily sedated and his lawyers claim that to execute him in that state constituted cruel and unusual punishment. The Supreme Court has also ruled to halt the execution of mentally retarded defendants on the same grounds.

Many questions come to mind for classroom discussion. Is it cruel and unusual to execute a person who is in an active psychotic state? If not, can the person be executed when medication controls his or her psychosis? Is it cruel and unusual punishment to force a person to take medications in order to be executed? Is it cruel and unusual punishment to allow the person to suffer through a psychotic episode without medication?

This case in Texas is one of several recent cases in which execution has been stayed on grounds of mental illness. “UPDATE: The U.S. Court of Appeals overturned the stay of execution and Green was executed on October 10. Earlier: Jonathan Green was scheduled for execution in Texas on October 10, but a federal judge issued a stay because the state did not afford him due process in examining his mental competency. U.S. District Court Judge Nancy Atlas said, “It is clear from the record that, at a minimum, the trial court prevented Green from presenting testimony by treating mental health professionals, relied on an order solicited from and drafted by the state to which Green had no opportunity to object, and applied at least one incorrect legal Instructors Manual

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standard.” Green's lawyers argued that the Texas competency hearing was so abrupt that medical personnel from the Texas Department of Criminal Justice, who had treated Green, were not available to testify. James Rytting, one of Green’s defense attorneys, said, “Mr. Green is seriously mentally ill; he suffers from schizophrenia and constant hallucinations.” Rytting added that Green’s condition has worsened while on death row because of lack of adequate treatment.” (M. Hennessy-Fiske, “Texas judge stays execution of man who raped, killed 12-year-old,” Los Angeles Times, October 8, 2012).

6. Patients’ Rights Advocate You are a patients’ rights advocate, working to protect the rights of chronically ill clients in mental hospitals. Prepare a defense for this patient with schizophrenia who has refused medication has been brought to your attention. You are to argue for a rightsdriven approach to treatment in hospital settings. According to your view, a patient admitted to a mental hospital has the right to refuse treatment if they may reasonably be judged to be competent to make such a decision. In this case, a 34-year-old man with schizophrenia, Mr. Johns, was admitted to the hospital involuntarily at his parents’ request. He wants to be released from the hospital, but a judge denied his request upon recommendation of the psychiatrist in charge. Mr. Johns has been refusing to take antipsychotic medication, and the hospital wants to force him to take the medication by restraining him and administering it via injection.

7. Concerned Family Member You are a family member of a person with schizophrenia. Your family member was recently diagnosed with schizophrenia. The first line of treatment for schizophrenia often involves the use of antipsychotic medications. These medications are used to gradually decrease mental confusion, hallucinations, and delusions, as well as other symptoms of schizophrenia. However, these medications are known to have many side effects, including drowsiness, constipation, cotton mouth, tremors, muscular rigidity, and impaired coordination. Given these side effects, you and your family member are left to make difficult decisions regarding treatment. What decision will you make?

8. Concerned Clinician You are a psychiatrist working in a state mental hospital with indigent clients. Your patient, Mr. Johns, was first diagnosed with paranoid schizophrenia at age 19; he is now 34 years old. Mr. Johns was admitted to the hospital involuntarily after his parents contacted the police. He had been living with them for several years following his last hospitalization, and they had supported him financially since he was unable to work.

However, two weeks prior to the hospitalization, Mr. Johns disappeared from the family home while his parents were at work. After searching for him for several days, his father found him wandering in the streets. He was disheveled and dirty, and he was sleeping

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on benches in a dangerous part of town. When his father approached him to try to encourage him to return home, Mr. Johns began yelling that his mother was trying to poison him and his father was listening to his thoughts while he was sleeping.

As the psychiatrist on the case, you have prescribed an antipsychotic medication to control Mr. Johns' paranoid delusions. Given his past history of successful treatment with this medication, it is your professional opinion that Mr. Johns’ florid symptoms could be controlled and he could be released from the hospital into his parents’ care if he complied with the medication plan. However, Mr. Johns has refused to take the medication, claiming that the hospital staff is trying to poison him. No improvement in his symptoms has been observed following the behavioral milieu treatment provided in the hospital ward.

You are arguing for a treatment-driven approach, in which Mr. Johns will be forced to take the prescribed medication in an effort to manage his delusions and enable him to function more autonomously and independently than his current hospitalization allows.

9. Parent of Schizophrenia Patient You are the concerned mother of Mr. Johns, a 34-year-old man diagnosed with paranoid schizophrenia since the age of 19. You have provided a home and financial security for your son since he has been unable to work or care for his personal needs such as cooking. When last hospitalized two years previously, your son was prescribed an antipsychotic medication that resulted in dramatic improvement. While still displaying “negative symptoms” of schizophrenia (particularly apathy, flat affect, and poverty of speech), Mr. Johns no longer exhibited florid delusions when he was taking his medication. However, about a month before the hospitalization, Mr. Johns came down with the flu and as a result, vomited frequently and could not keep his medication down. After several days without medication, Mr. Johns became extremely paranoid.

He claimed that his mother was trying to poison him, and that this was causing the vomiting he was experiencing. Further, he believed that his father was reading his mind when he tried to sleep, and thus he spent nights wandering the halls trying to keep himself from falling asleep when his father was home.

Two weeks prior to the hospitalization, Mr. Johns disappeared from the family home.

After searching for him for several days, his father found him wandering in the streets.

He was disheveled and dirty, and he was sleeping on benches in a dangerous part of town. When his father approached him to try to encourage him to return home, your son began shouting his paranoid ideas and ran away. You decided to call the police and have him committed involuntarily, to keep him from getting hurt and to enroll him in the treatment program that had been so successful in the past.

Your son is now refusing to comply with the medication plan set up by the psychiatrist, and he is showing no improvement. You are arguing that he should be forced to take

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the medication, since you are convinced that once it takes effect and his delusions are under control, he will be able to be released from the hospital and resume the relatively comfortable and autonomous lifestyle that he could manage before he stopped taking the medication.

10.

Schizophrenia Patient

You are Mr. Johns, a 34-year-old man diagnosed with paranoid schizophrenia. You were first diagnosed at age 19, and have been hospitalized several times over the past 15 years. In between hospitalizations, you have lived with your parents, who have supported you financially and provided for your basic needs. While you recognize that you are unable to work and care for yourself, you also feel that your parents are overly controlling and you desperately want to be able to live independently.

Currently, you are enraged at being hospitalized against your will. As you see it, you decided to move out of your parents’ home because your mother was trying to give you drugs in your food that would make you follow her wishes. In addition, whenever you fall asleep at home, your father comes into your room and reads your mind, using your thoughts against you the next day. Naturally, you have been unable to sleep or eat under these conditions, and so decided to move out on your own. However, when your father saw you walking in the street, he began trying to force you into his car and bring you back home. When you refused to return, he called the police and had you admitted to the hospital.

You are adamant in your opinion that you have the right to decide how to live your life. If you want to live on the streets or sleep on park benches, that is your right. You have been refusing to take medication because you know that it only poisons your mind and keeps you from thinking clearly.

INSTRUCTIONAL FILMS 1. Imagining Robert: My Brother, Madness, and Survival (FHS, 56 min., color, #BVL30304) “For 17 million Americans, severe, long-term mental illness is a fact of life—a fact little understood by the majority of their fellow citizens. In an effort to raise public awareness of the day-to-day impact mental illness has on families, this intimate documentary profiles Robert Neugeboren and his brother, Jay, as decade after decade they cope with Robert’s schizophrenia and bipolar disorder. Drawing on Jay's heartrending yet uplifting family memoir of the same title, the program deftly reveals the engaging personality of Robert while expressing Jay’s considerable frustration in dealing with the mental health Instructors Manual

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establishment. As instructive as it is insightful, “Imagining Robert” is ideal for opening a sympathetic dialogue on the treatment and impact of mental disorders. A Study Guide and other resources are located online at: www.imaginingrobert.org.”

2. One on One—John Nash (23 min.) Two parts https://www.youtube.com/watch?v=UiWBWwCa1E0. https://www.youtube.com/watch?v=ufKIgW9XrCE.

3. Paranoid schizophrenia with Allie Burke, Vide Video https://video.vice.com/en_us/video/paranoid-schizophrenia-what-its-like-life-mentalhealth/5d1b911ebe40773a707a49e1.

4. Ellen Saks discussing stigma: https://www.ted.com/talks/elyn_saks_a_tale_of_mental_illness_from_the_inside.

5. Schizophrenia symptoms: https://www.youtube.com/watch?v=AVAbNL8mrgk. https://www.youtube.com/watch?v=ESNpR8jgRSU.

6. Schizophrenia cognitive behavioral treatment workshop https://www.youtube.com/watch?v=4edinfIt5QM.

7. Out of the Shadow—2004 film about a woman with schizophrenia https://outoftheshadow.com.

8. Examples of Schizophrenia in Popular Films: • A Beautiful Mind • Angel Baby • Clean Shaven

Discussion Questions

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These questions are based on the clinical case studies and other information found throughout the chapter.

A Woman with Schizophrenia From the case history, trace the young woman’s deterioration into schizophrenia. Consider the positive symptoms that she exhibits. How are these reflected in her narrative?

Can A Mind Be Sick?

Read the following article: https://www.mentalhelp.net/articles/can-a-mind-be-sick-a-discussion-of-schizophrenia/.

Respond to the question—“Is it possible for a mind to be sick?”

Pause and Ponder Activity: Schizophrenia The following questions reference the case studies published in Oltmanns and Martin, Case Studies in Abnormal Psychology, 11th Edition, John Wiley & Sons, 2019.Part I:

Pause What would you think if...? ...a man took off his clothes in the middle of downtown? ...a man said he was hearing voices that told him to "kill your mother and join the club"? ...a woman would not give her father her address because she was afraid he would become intrusive in her life?

Consider how much you agree with the following statement: I can see these people's perspectives and understand how they would feel if I were in their shoes.

Part II: Learn Now that you have considered the statement, watch the case video on Mark and answer the questions.

1. The voice Mark heard that told him to “kill your mother and join the club” is an example of what symptom of schizophrenia?

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a. b. c. d.

delusional hallucination paranoia perseveration

Answer: b

Question type Essay 2. Describe Mark’s most painful day with schizophrenia.

Question type Multiple Choice 3. According to Ann Kring, Ph.D., how likely is it that people with schizophrenia will be violent toward others? a. Very likely. Most people with schizophrenia are violent. b. No more likely than those without schizophrenia. c. People with schizophrenia are never violent. d. It depends on the person.

Answer: b

Question type Essay 4. What combination of treatments works well for Mark? Which of these treatments is an essential part of treatment for schizophrenia?

Question type Multiple Choice 5. Delaney's mother left her father Richard, who has schizophrenia, shortly after she was born because he often was _____. a. anxious b. depressed c. psychotic d. unemployed Answer: с

6. Delaney's parents were evicted five times in the year her mother was pregnant with her.

This is an example of the effects of a disorder on what type of functioning?

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a. b. c. d.

economic educational housing occupational

Answer: с

Question type Essay 7. Describe the effects of Richard's schizophrenia on his relationship with his daughter Delaney.

Question type Multiple Selection 8. A list of diagnostic criteria is listed below. Select all of the diagnostic criteria for schizophrenia. a. Delusions b. Delusion develops in an individual in the context of a close relationship with another person who already has an established delusion c. Disorganized speech (incoherence) d. Grossly disorganized or catatonic behavior e. Hallucinations f. Negative symptoms (i.e., loss of speech, inability to initiate goal-directed activity) g. Nonbizzare delusions (i.e., involving situations that could occur in real life such as being followed or deceived by a spouse or lover) Answer1: a Answer2: c Answer3: d Answer4: e Answer5: f

Ponder

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Part III: Ponder Reflect upon the changes in your empathy that acme about during this activity.

Question type Essay

1.

Consider how much you agree with the following statement: I can see these people's perspectives and understand how they would feel if I were in their shoes.

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CHAPTER 10 SUBSTANCE USE DISORDERS LEARNING GOALS 1. Describe substance use disorder and its symptoms.

2. Describe the epidemiology and symptoms associated with alcohol, tobacco, and marijuana use disorders.

3. Describe the epidemiology and symptoms associated with opioid, stimulant, and other drug use disorders.

4. Understand the major causal influences for substance use disorders, including genetic, neurobiological, psychological, and sociocultural influences.

5. Describe the approaches to treating substance use disorders, including psychological treatments, medications, and drug substitution treatments.

6. Describe the major approaches to preventing substance use disorders.

The Learning Goals are inherent in both the Lecture Launchers and Discussion Stimulators below.

CHAPTER SYNOPSIS For centuries, people have used various substances in the hope of reducing physical pain or altering states of consciousness for centuries. The United States is a drug culture with many Americans relying on drugs common to wake up, stay alert, or reduce pain. The widespread availability and frequent use of drugs sets the stage for their potential abuse. This chapter focuses on substance use disorders, including clinical descriptions, epidemiology, causal influences, and major approaches to treatment.

Substance Use Disorders Alcohol and drug use is common in the United States: In 2018, nearly 32 million people over age 12 in the United States reported having used an illicit drug in the past month, with marijuana being the most common drug reported. Alcohol remains the most used substance, with more than 139.6 million Americans over age 12 reporting alcohol use in the past month. Alcohol and substance use disorders are

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among the most stigmatized of psychological disorders. In 2018, 19.3 million people in the United States met DSM-5 criteria for a substance use disorder (14.4 million had alcohol use disorder).

Two symptoms that are often part of a substance use disorder are tolerance and withdrawal, which are indicators of dependence. Other defining symptoms of substance use disorder based on DSM-5 include failing to meet obligations, using a substance even if it is dangerous to do so, ongoing interpersonal problems, continued use despite problems associated with use, failed efforts to reduce or control substance use, spending a lot of time trying to get the substance, giving up time spent on other activities, and cravings.

Alcohol is the most commonly used substance. In relatively rare cases, withdrawal from alcohol can involve hallucinations and delirium tremens. Alcohol use disorders are comorbid with several personality disorders, mood disorders, schizophrenia, and anxiety disorders. People who abuse or are dependent on alcohol are also likely to use other drugs, particularly nicotine. This very high comorbidity may occur because alcohol and nicotine are cross-tolerant; that is, nicotine can induce tolerance for the rewarding effects of alcohol and vice versa. Alcohol dependence can have a quite variable course. Alcohol use is particularly high among college students. Men are more likely to drink alcohol than women, and differences in use, abuse, and dependence by ethnicity have been observed. Even light or moderate drinking during pregnancy can be associated with later problems in learning for the child (fetal alcohol syndrome, FAS).

Smoking remains prevalent, though it has been on the decline. Nicotine is the addicting agent of tobacco. Cigarette smoking causes a number of illnesses, including several cancers, heart disease, emphysema, and other lung diseases. Although more men smoke than women, the rates are the same among adolescent boys and girls. The ill effects of tobacco are greater for African Americans.

Secondhand smoke, also called environmental tobacco smoke, also is linked to a number of serious health problems. Although cigarette smoking has continued to decline, the use of e-cigarettes (or vape) has been on the rise, particularly among high school and college students.

Marijuana consists of dried and crushed leaves and flowering tops of the hemp plant, Cannabis sativa.

Hashish is much stronger than marijuana and is produced by drying the resin exudate of the tops of cannabis plants. Marijuana is the most frequently used illegal drug. Marijuana makes people feel relaxed and sociable, but it can also interfere with attention, memory, and thinking. In addition, it has been linked to cardiovascular and lung-related problems. It remains among the most prevalent drugs, particularly among younger people. Men use it more than women. Users can develop tolerance to marijuana. It is not clear whether withdrawal symptoms occur after users stop smoking it. Marijuana also has therapeutic benefits, particularly for those suffering from the side-effects of chemotherapy and for patients with AIDS. Many states have begun to legalize marijuana for medicinal and recreational use.

Opiates include opium and its derivatives morphine, heroin and other pain medications like codeine, hydrocodone, and oxycodone that can be legally prescribed. Abuse of prescription pain medications has risen dramatically, and overdoses are common. Initial effects of opiates include euphoria; later, users experience a letdown. Death by overdose from opiates is a severe problem. Other problems include exposure to HIV and other infectious agents through the use of needles. Synthetic sedatives are

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prescribed less than they used to be. They relax the muscles, reduce anxiety, and can produce a mildly euphoric state. Large doses can be fatal. Withdrawal is severe for opiates and synthetic sedatives.

Barbiturates have been implicated in both intentional and accidental suicides; they are particularly lethal when taken with alcohol.

Stimulants act on the brain and the sympathetic nervous system to increase alertness and motor activity.

Amphetamines are stimulants that produce wakefulness, alertness, and euphoria. Men and women use these equally. Tolerance develops quickly and withdrawal symptoms are common. Methamphetamine is a synthesized amphetamine whose use has increased dramatically since the 1990s. Men use it more than women and whites more than other ethnic groups. Methamphetamine can damage the brain, including the hippocampus, and is responsible for severe weight loss, dental decay, and skin sores. Cocaine and crack remain serious problems. Cocaine can increase sexual desire, feelings of wellbeing, and alertness, but chronic use is associated with problems in relationships, paranoia, and trouble sleeping, among other things. The faster crack or cocaine is absorbed, the more quickly and intensely the person becomes high.

Hallucinogens include drugs such as LSD, psilocybin, and mescaline. LSD was a popular hallucinogen in the 1960s and 1970s, often billed as a mind-expanding drug. Hallucinogens can cause flashbacks, which are recurrences of perceptual experiences after the physical effects of the drug have worn off.

Ecstasy and PCP are hallucinogen-like substances. The mind-expanding drug of the 1990s was Ecstasy, which is made from MDMA and acts on the serotonin transmitter system. PCP (phencyclidine, or angel dust) can cause serious negative reactions, such as severe paranoia and violence, and chronic use can lead to neuropsychological deficits. Although these drugs do not typically elicit withdrawal symptoms, tolerance can develop. There is some evidence that use of Ecstasy and PCP may be on the decline.

Etiology of Substance Use Disorders A number of etiological factors have been proposed to account for alcohol and drug dependence, and some have more support than others. Generally speaking, becoming substance dependent is a developmental process. The person must first have a positive attitude toward the substance, then begin to experiment with using it, then begin using it regularly, then use it heavily, and finally abuse or become dependent on it (see Figure 10.6). The general idea is that after prolonged heavy use, some people become ensnared by the biological effects of tolerance and withdrawal.

Genetic influences play a role in substance use disorders with heritability estimates ranging from .40 to .60. The ability to tolerate alcohol and metabolize nicotine may be what is passed on in the genes. Genes that are important for the operation of the dopamine system may be an important factor in explaining how genes influence substance dependence, although more research is needed. The most-studied neurobiological influences are brain systems associated with dopamine pathways—the major reward pathways in the brain. The incentive-sensitization theory describes brain pathways involved in liking (i.e., consuming) drugs and wanting (i.e., cravings) drugs. Other neurobiological models focus on how people at risk for substance abuse tend to value the short term over the long term and engage in more risky decision.

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Psychological influences that have been identified include deficits in emotion regulation, expectancy effects (i.e., how one expects to feel after using a substance), and personality factors (e.g., neuroticism).

Sociocultural factors play a role, including the culture, availability of a substance, family factors, social settings and networks, and advertising.

Treatment of Substance Use Disorders Inpatient hospital treatment for alcohol use disorder is not as common today as in earlier years, primarily due to the cost. Detoxification (aka “detox”) is usually the first step in treatment for drug use disorders. While detoxification from alcohol often takes place in hospitals, treatment after this is more commonly done in outpatient settings.

Alcoholics Anonymous (AA) is the most common form of treatment for alcohol dependence. It is a group-based self-help treatment that instills the notion of alcohol dependence as a disease. Though not widely studied, available research suggests that AA is an effective treatment. While AA emphasizes the importance of completely abstaining from drinking, the concept of controlled drinking (i.e., moderation in drinking) was introduced by Sobell and Sobell in 1993 in a treatment approach called guided selfchange that helps individuals gain more control over their drinking. Other effective psychological treatment approaches include behavioral couples therapy, motivational interventions, and cognitive behavioral therapy.

Medications for alcohol dependence treatment include antabuse, naltrexone and naloxone, and acamprosate. Antabuse is not an effective treatment in the long run, and noncompliance is a big problem, with around 80% dropping out of treatment. It is not clear that other medications are effective on their own, but they do seem to be beneficial in combination with psychotherapy. Evidence from several studies suggests that acamprosate is an effective medication. It may also reduce the chance for relapse after quitting drinking.

Nicotine replacement therapy (NRT) substitutes a different delivery system for nicotine in the form of gum, patches, inhalers, or e-cigarettes to allay cravings while dosages are gradually reduced, with the goal of eliminating nicotine dependence. NRT shows some effectiveness, but abstinence rates are less than 50% in 12-month follow-ups. Although e-cigarettes may help some people to quit smoking, they also increase risk of smoking among young people. Medications such as bupropion (Wellbutrin) and varenicline (Chantix) have also shown some efficacy for reducing smoking.

CBT, motivational Interviewing (MI), and contingency management behavioral techniques may be effective psychological treatment approaches for drug abuse. The use of heroin substitutes, such as methadone and buprenorphine, are effective treatments for heroin dependence. Methadone can only be administered in a special clinic, and there is stigma associated with this type of treatment.

Buprenorphine can be taken at home.

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Prevention of Substance Use Disorders Since it is far easier never to begin using drugs than to stop using them, considerable effort has been expended in recent years to prevent substance abuse by implementing educational and social programs to equip young people to develop their lives without a reliance on drugs. Recent efforts have used multimedia initiatives and school programs.

KEY TERMS Amphetamines

Flashbacks

opiates

Antabuse

Hallucinogen

oxycodone

Caffeine

Hashish

PCP

Cocaine

Heroin

Psilocybin

controlled drinking

hydrocodone, LSD

secondhand smoke

crack

marijuana

stimulants

delirium tremens (DTs)

MDMA

substance use disorder

detoxification

Methamphetamine

tolerance

Ecstasy fetal alcohol syndrome (FAS)

Nicotine

withdrawal

nitrous oxide

LECTURE LAUNCHERS 1. The Self-Medication Hypothesis of Addiction Khantzian has elaborated on an intriguing hypothesis concerning the etiology of substance use disorders (1985, American Journal of Psychiatry, 142, 1259–1264). He argues that commonly held notions about the cause of substance use (peer group pressure, escape, or self-destruction) are simplistic in their formulation. He suggests instead that there is considerable psychopathology associated with the heavy reliance on and continuous use of illicit drugs.

Moreover, he proposes that the choice of dependence on a given illicit drug is not random. He sees drug choice as a form of self-medication. A drug is selected based on the underlying psychopathology that has caused the substance abuse in the first place. Narcotic addiction, for example, is thought by Khantzian to be an attempt to repress feelings of aggression and rage. He argues that many of the narcotics addicts that he has treated come from backgrounds

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characterized by extreme forms of violence, and he suggests that narcotic drugs effectively combat feelings of rage and violence. Khantzian offers the following vignette as an example of clinical evidence for this hypothesis: A successful 35-year-old physician described how defensive and disdainful he had become since his early adulthood as a consequence of his mother’s insensitivity and his father’s cruel and depriving attitude toward him and his family, despite their significant affluence. He said he became dependent on opiates when his defense of self-sufficiency began to fail him in a context of disappointing relationships with women and much distress and frustration working with severely ill patients.

More than anything else, he became aware of the calming effects of these drugs on his bitter resentment and mounting rage. He stressed how this effect of the drugs helped him to feel better about himself and, paradoxically, helped him to remain energized and active in his work.

As a contrast to his hypothesizing about opiate addiction, Khantzian suggests that cocaine addiction may be an attempt to combat depression. Based on this hypothesis, he reports the successful treatment of some cocaine addicts by prescribing a stable, long-acting amphetamine.

While there is little data available on the self-medication hypothesis, it provides for some interesting speculation on substance use and drug selection.

Since the study by Khantzian, several other researchers have addressed the self-medication hypothesis. An excellent overview is the article by Gottdiener in Journal of the American Psychoanalytic Association (58(5), 2010, 1028–1032). This is a review of Khantzian’s book Understanding addiction as self-medication: Finding hope behind the pain (2008). The hypothesis was applied to different addictive disorders including excessive sexual activity and gambling.

Khantzian reaffirms his hypothesis in a 2013 article (Addiction, 108(4), 2013, 668–669). He states that he remains convinced that SMH (self-medicating hypothesis) continues to be important clinically. Anna Lembke from Stanford University says it is “Time to abandon the self-medication hypothesis in patients with psychiatric disorders” (American Journal of Drug and Alcohol Abuse, 38(6), 2012, 524–529). She goes on to say that the SMH does notprovide, as originally intended, a “useful rationale” for guiding treatment and has actually led to underrecognition and undertreatment of substance use disorders.

2. Binge Drinking and Illegal Substance Use Among College Students Jones and her colleagues (“Binge drinking among undergraduate college students in the United States: Implications for other substance use”, Journal of the American College Health, 50(1), 2001, 33–38) conducted a study among undergraduates questioning the relationship between binge drinking and substance use. Over 4,800 students from 148 institutions completed a 96-item questionnaire that focused on drinking patterns over the previous 30 days. Students were also asked about their use of cigarettes, marijuana, cocaine, heroin, and several other drugs.

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The authors found that 41.5% of the respondents reported binge drinking, five or more drinks in a row within a couple of hours, during the previous month. Men were more likely to binge than women and White students more likely than Black or Hispanic students. In addition, students who reported binge drinking were significantly more likely to smoke cigarettes, marijuana, cocaine, and other illegal substances.

How does this compare with students’ beliefs about college drinking and drug use? The authors suggest that most college students overestimate the extent to which their peers use alcohol and other substances.

3. “Designer Drugs” A recently evolving drug problem is the development of new “designer drugs”—synthetic analogs of organically found drugs, prepared by underground chemists to mimic the effects of other drugs (1986, U.S. Department of Health and Human Services, Public Health Service memo).

Up to 3,000 times stronger than the drugs they mimic, designer drugs are less expensive to manufacture and, until recently, were legal because they were not structurally identical to their parent compounds. A heroin analog, Fentanyl, became widely available in 1979 and caused numerous overdose deaths. Another narcotic analog, MPPP, has been found to contain an impurity (MPTP), a potent neurotoxin that has caused irreversible brain damage, similar to Parkinson’s disease, in several individuals.

Given its widespread use on college campuses, students may be familiar with MDA or MDMA, amphetamine analogs known as “Ecstasy” (see text p. 380). Psychological difficulties associated with MDMA include confusion, depression, anxiety, and paranoia; physical symptoms include muscle tension, nausea, blurred vision, chills or sweating, and increased heart rate and blood pressure. Research has demonstrated that this drug destroys serotonin-producing neurons in animals, neurons that regulate aggression, mood, sexual activity, sleep, and sensitivity to pain. In addition, recent evidence indicates degeneration of dopamine following chronic use (or even a single high dose). Although immediate impairment may not be noticeable, researchers hypothesize that with aging and exposure to other toxic elements, Parkinsonian symptoms will develop (1985, ADAMHA News, 11 (6), p. 8). One particularly serious problem with designer drugs is their potential for overdose: “In animal studies, the doses of MDMA which produce neurotoxicity are only two to three times more than the minimum dose needed to produce a psychotropic response” (1986, U.S. Department of Health and Human Services).

A case study of a 22-year-old soldier exhibited many of the symptoms listed for MDA, showing agitation, confusion, and tachycardia from snorting 1 g of Cristalius (Lenz et al., Military Medicine, 178(7), 2013, e893–e895). This is part of the new wave of designer drugs marketed as plant food and bath salts.

The National Institute on Drug Abuse (NIDA) sponsors a website with comprehensive information about designer drugs and the club scene (http://www.clubdrugs.org/).This is a useful resource with links to scientific data on drugs that are currently popular in dance clubs.

A guidebook of inhalants, steroids, and designer drugs was written by Pandina and Hildbrandt (Addictions: A comprehensive guidebook (2nd ed., pp. 285–308) Oxford University Press, 2013).

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One of these drugs, Rohypnol (flunitrazepam–“Roofies”), belongs to the class of benzodiazepines such as Valium. Although it is not approved for prescription use in the United States, it is available in Europe and is used as a treatment for insomnia, as a sedative, and as a presurgery anesthetic. Rohypnol is tasteless, odorless and dissolves easily in drinks. This drug can cause severe amnesia and has been used in several sexual assaults. Typically, the victim remembers little if anything, whence the street name “forget-me-not pill.” Combined with alcohol, Rohypnol can be lethal.

4. Not an Upper or a Downer but an Inside-Outer In 1956 Parke Davis and Company, a large pharmaceutical firm, synthesized a new anesthetic.

Although effective in large doses, it was found to cause agitation and disorientation as a patient regained consciousness. When administered in smaller doses, it induced a psychotic-like state. In 1965 this new drug, phencyclidine (PCP), was taken off the market, and by 1978 its legal manufacture was discontinued in the United States.

PCP was first seen in illegal use in Los Angeles in 1965. It soon turned up in the Haight-Ashbury district of San Francisco under the name “PeaCe Pill” and was sold as a psychedelic, but it quickly gained a bad reputation because many users had negative reactions. In the late 1960s and early 1970s the drug spread to other parts of the country and, by 1979, it had turned up in most states.

Its prevalence declined sharply in the 1980s.

On the street PCP is known by dozens of names, among them angel dust, elephant tranquilizer, cadillac, cozmos, Detroit Pink, embalming fluid, Killerweed, horse crystal, PeaCe Pill, wac, and zombie, and has been marketed falsely as LSD, psilocybin, cocaine, and other drugs. It is available in many forms and degrees of purity and in most colors. In granular form it contains between 50 and 100 percent phencyclidine. The most popular ways of taking PCP are in mint- or parsleyflavored joints and in commercial cigarettes that have been dipped in liquid PCP or had a string dipped in liquid PCP passed through them. But the drug can also be injected intravenously, swallowed, put in the eyes as drops, snorted like cocaine, and smoked in a pipe.

The effects of PCP depend largely on the dosage. The user generally has jerky eye movements (nystagmus) alternating with a blank stare, is unable to walk heel-to-toe in a straight line (gait ataxia), and has great rigidity of the muscles. Some also experience hallucinations and delusions.

All sensory systems become overly sensitive so that users are extremely susceptible to any stimulation and are best left alone. When touched, they are likely to flail and become so agitated and combative that it takes several people to restrain them. Their incoherence and lack of communicativeness do not allow them to be talked down from their high. Very high dosages— actually, as little as a single gram—usually result in a deep and prolonged coma, seizures, apnea or periods of no breathing, sustained high blood pressure, and sometimes even death from heart and lung failure or from ruptured blood vessels in the brain. No medication to reverse the effects of PCP has yet been found. People seldom remember afterward what happened while they were on the drug.

Phencyclidine is not an upper or a downer, nor is it a psychedelic. Some workers refer to it as an inside-outer, a term that to some extent conveys the bizarre and extreme nature of its effects.

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How long do the effects of PCP last? The way in which it is ingested and the dosage seems to play a role. Onset is usually between 1 and 5 minutes after smoking a treated cigarette; effects peak after about half an hour and then do not dissipate for up to two days. Since PCP remains in the body for several days, it can accumulate if ingested repeatedly. Chronic users who have taken the drug several times a week for six months experience cognitive distortions and disorientation for several months afterward, even for as long as two years after use has ceased. In addition, personality often changes. There can be memory loss, and the user may experience severe anxiety, depression, and aggressive urges (Aniline & Pitts, 1982). The addictiveness and other consequences are difficult to determine because most PCP users take other drugs, such as alcohol, as well.

More than 100 deaths from ingesting PCP were reported in Los Angeles County in 1978 alone.

These fatalities were caused in a number of ways. One man, who was swimming, drowned because he lost his spatial orientation; others died because of severe respiratory depression or an uncontrollable increase in body temperature.

Those who use PCP tend to be very young, averaging 15 years of age. Abusers tend to be arrested more often for substance-related offenses than those taking the other drugs discussed in this chapter, and they tend to have overdosed on more occasions as well. The PCP user, then, seems to be more socially deviant, perhaps more often psychopathic, than abusers of other illicit substances.

In light of how terrifying and dangerous the drug is, it is not surprising that its popularity declined in the 1980s. More surprising, perhaps, is that it enjoyed a resurgence in the 1990s.

PCP has been blamed by the police in several violent murders, one in particular. In 2012, ABC News reported that authorities in New Jersey are cracking down on PCP, a hallucinogenic drug that has been involved in two grisly murders of children in less than two weeks in the crimeridden city of Camden, NJ. The Camden County Prosecutor’s Office and the Camden Police Department say they are concerned “with the use of the drug in the city” and are “taking steps to curb the market for this exceedingly dangerous and destructive drug.” “Violent behavior with PCP, that's nothing new,” Police Chief Scott Thomson said. “It’s happening on a daily basis in Philadelphia and urban centers all over the country. But what has us concerned is the attacks on small children ... Is something being added [to the PCP]?"

5. Matching Patient to Treatment: Project MATCH For many years, both practitioners and researchers have assumed that it is important to use treatments that are suitable for particular patients. But Project MATCH, a large, 8-year, multisite study on alcohol abuse (Project MATCH Research Group, 1997), has become controversial in professional circles because of its failure to find what it was looking for—namely, a way to match particular kinds of alcohol-dependent patients with specific interventions.

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(referred to as “psychiatric severity”), and support from one’s social milieu for drinking, and sociopathic tendencies. There were three treatments: 1. Twelve-step facilitation treatment (TSF) was designed to convert patients to the AA view of alcoholism as an incurable but manageable disease and to encourage their involvement in AA. 2. Motivational-enhancement therapy (MET), based on William Miller’s motivational interviewing approach (Miller et al., 1992), attempted to mobilize the person’s own resources to reduce drinking. Part of this intervention involved highlighting for the person the ways in which current maladaptive behavior was interfering with the attainment of goals.

3. Cognitive behavioral coping-skills therapy (CBT) presented to patients the idea that drinking is functionally related to problems in a person’s life; this treatment taught patients skills for coping with situations that trigger drinking or for preventing relapse.

The researchers predicted that drinkers under heavy pressure to stop would do best with the TSF, that those with psychological problems would do best with CBT, and that those with low motivation to change would do best with MET. All treatments were carefully administered in individual sessions by trained therapists over a 12week period, following treatment manuals prepared for this study. Patients could not be dependent on other drugs and otherwise had to have reasonably stable lives. As in other efficacy studies, internal validity was quite good, but external validity—the generalizability of the findings to therapy as actually practiced—was apparently low.

The principal outcomes measured were percentage of days abstinent and drinks per drinking day during a 1-year post-treatment assessment period.

Significant within-group improvement was observed—all treatments were very helpful on average, consistent with a subsequent study (Ouimette et al., 1997). But as noted at the outset of this discussion, predictions about which patients would benefit most from which therapy were not confirmed, except that patients in better psychological shape had more abstinent days after TSF than did patients who received CBT. However, patients in worse psychological condition did not fare differently across the three treatments. And even this one significant finding did not hold up at the one-year follow-up (Fuller & Allen, 2000). It seems that we have a long way to go before we can make statements with confidence about the kinds of patients who will benefit from particular treatments.

DISCUSSION STIMULATORS 1. Pre-Test on Alcohol Expectations Before the students read the chapter, discuss their impressions about the effects of alcohol and other drugs on aggression, sex, and anxiety, or have them write out answers on a questionnaire

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and compile the results. After reading the chapter, these impressions can be discussed in terms of the impact of expectations about drug effects on the behavior of those under the influence of a drug. How might expectancies influence other responses to alcohol or to other drugs? What are the expectancies about the effects of cigarette smoking, marijuana use, or psychedelics?

2. Effects of Alcohol Discussion questions to ask the class when introducing the lecture on substance use disorders to assess prior views about alcohol and substance use.

1. How does alcohol affect aggression? Does drinking make people less aggressive, more aggressive, or have no effect on aggressiveness? Why do you think this occurs?

2. How does alcohol affect sexual responsiveness and arousal? Why do you think these effects occur?

3. How does alcohol affect anxiety? Why do you think these effects occur?

4. What other short-term effects does alcohol have?

3. Controlled Drinking vs. Abstinence Organizations like Alcoholics Anonymous assert that the only way to ensure that a substance will not be abused in the future is to never again partake of the substance. Is it true that once you are an alcoholic, you always are an alcoholic? Is one drink sufficient to begin binge drinking? Can alcoholics be taught to become social drinkers? What are the consequences of AA’s stance and what are the consequences of challenging that stance? While these appear to be straightforward questions, scientific evidence regarding their answers is equivocal and certainly controversial, as discussed in the text.

4. Personal Experiences with Smoking How did the smokers in the class get started? Do their parents smoke? Did they begin smoking with friends? Was it “cool” to smoke? How did the nonsmokers resist peer pressure? You might break the class into groups, including both smokers and nonsmokers in each group, and ask them to come up with a smoking prevention program based on their own experiences. The following questions could be addressed: 1. What age group should be targeted?

2. In what setting(s) should the program be implemented?

3. Who should convey the message to the target group (mental health professionals, paraprofessionals, ex-smokers, peers, and parents)?

4. How could the mass media be used to help in the prevention program?

5. Drug Use and the Law What are the social consequences of making a drug illegal when there is a continuing market for the drug despite the possibility of prosecution? At least three examples can be discussed in

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connection with this question. First is the experiment with the prohibition of alcohol in the United States in the 1920s, which resulted in prevalent law breaking, a rise in gangsterism, and eventual repeal of the constitutional amendment. Second is the continuing illegality of marijuana, which, at least in the 1960s, may have alienated young marijuana users from the law.

However, marijuana state laws are changing at a rapid pace, with many states now having legalized marijuana for medicinal and/or recreational use. A discussion topic with the class could be the pros and cons of marijuana legalization and what effects this may have on marijuana use and abuse in society.

Current status of marijuana legalization: https://disa.com/map-of-marijuana-legality-by-state.

Third is the different status of heroin in the United States, where it is illegal, and Britain, where heroin can be obtained in clinical settings. Some have argued that the British treatment of the drug has greatly reduced the profit available to underworld heroin dealers, and thus explains the lesser incidence of heroin addiction in Britain as compared to the United States.

In a similar vein, students might debate the pros and cons of making sterilized needles easily available to IV drug users to prevent the spread of AIDS. While many people have expressed concern that such a practice would increase drug use and make it appear that the government is condoning illegal activity, research indicates that IV drug use has actually declined when sterile needles have been made more available.

6. Drug Testing Recent concern about drug abuse has led to widespread drug testing, at work, in athletics, and even within the home, as parents test their children. What do students think of this approach to the drug problem? Ask students to discuss the following case: You are a counselor in a mental health clinic connected with a hospital. A man brings his 15-year-old son to see you because he suspects him of using drugs.

The father insists that you arrange for drug testing, to confirm his suspicion.

The son denies using drugs and insists that his only problems occur in relation to his father. He has refused to comply with his father's requests to take a drug test. What would you do? Would you agree to the father's request? If so, how would you get the son to comply with the plan? What would you propose as a treatment plan?

A related issue is the inconsistency with employee drug testing policy and recent changes in the legal status of marijuana. For example, even in states where marijuana has been legalized, federal employees still have to follow federal law, which still considers marijuana and illicit substance. Even for non-federal jobs, some employers still test for marijuana use in their employees, which can lead to consequences even if the use was legal.

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7. Which Treatment is Best for Substance and Alcohol Use Problems?

For this activity, you will divide your class in half the day prior to this activity. Half of the class will be assigned to defend the argument “abstinence from all substances should be the primary treatment goal for individuals with drug and alcohol problems” and half of the class will be designed to defend the argument “moderate and responsible use of substances (i.e., moderation management) should be the primary treatment goal for individuals with drug and alcohol problems.” The two teams should be given 20 minutes on the day before the class debate to prepare their arguments and to assign out parts of the debate. For example, one person may research statistics about who is affected by drug and alcohol abuse; one person may research the negative effects of drug and alcohol use; several people may research the effectiveness of the assigned treatment, etc. On the following day, an in-class debate will take place following the outline on the handout on the next page. Before beginning the debate, give students 10–15 minutes to prepare the order of who will be speaking and who will say what.

Students tend to get very invested in this activity and it may take an entire class to do, but it’s well worth the time investment. See relevant exercise below.

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Exercise: In-Class Debate What Should Be the Primary Treatment Goal for Individuals with Drug and Alcohol Problems?

1. You are assigned to the debate team circled below: a. TEAM A asserts that abstinence from all substances should be the primary treatment goal for individuals with drug and alcohol problems. b. TEAM B asserts that moderate and responsible use of substances should be the primary treatment goal for individuals with drug and alcohol problems.

2. In order to receive credit for the debate you must come to class prepared with: a. two scholarly articles that support your team’s stance—these articles should be empirical research studies. b. typed notes for each of these two articles. c. a typed list of 3–5 main points that outline the conclusions of your articles. Be sure to include WHERE you obtained the information.

3. The three items listed above will be reviewed and counted for class credit.

Debate Format 1. TEAM A: 6–8-minute opening argument that presents the team’s rationale for believing that abstinence from all substances should be the primary treatment goal for individuals with drug and alcohol problems.

2. TEAM B: 6–8-minute opening argument that presents the team’s rationale for believing that moderate and responsible use of substances should be the primary treatment goal for individuals with drug and alcohol problems.

3. JUDGES’ QUESTION PERIOD: Judges (students chosen from the class) will ask several questions of each team, and each team will have an opportunity to respond to the questions [20–30 minutes].

4. TEAM QUESTION PERIOD: Each team will be allowed to ask several questions of the other team, and each team will be given ample time to respond [20–30 minutes].

5. CLOSING: At the end of class, we will evaluate the debate experience and will discuss students’ thoughts about ethical and professional issues related to treatment options for drug and alcohol problems.

Evaluating Team Debate 1 [Needs Improvement] * 2 [Fair] * 3 [Average] * 4 [Good/Above Average] * 5 [Outstanding/Superior] Organization and Strategy Information is presented in a structured & logical way that is easy to understand.

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Opening Argument

Judges Questions

Team Questions

Team A

Team A

Team A

Team B

Team B

Team B

Professional Evidence Use of facts, statistics, research & case examples.

Opening Argument

Judges Questions

Team Questions

Team A

Team A

Team A

Team B

Team B

Team B

Debate Procedure Adherence to debate structure while maintaining focus on debate issues. Team remains respectful and answers questions clearly.

Opening Argument

Judges Questions

Team Questions

Team A

Team A

Team A

Team B

Team B

Team B

Persuasion Overall ability to provide a convincing & compelling argument.

Opening Argument

Judges Questions

Team Questions

Team A

Team A

Team A

Team B

Team B

Team B

TOTAL SCORE: Team A

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Judge’s Decision The debate should be won by the team that bests supports its stance through the use of logical arguments based on theory, research, case examples, statistics, and current findings of professional organizations.

This debate has been won by • •

TEAM A: asserting that abstinence should be the primary treatment goal for individuals with drug and alcohol problems.

TEAM B: asserting that moderate and responsible use should be the primary treatment goal for individuals with drug and alcohol problems.

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INSTRUCTIONAL FILMS 1. On recovering from cocaine addiction by Carrie Fiorillo: https://youtu.be/gPdzpRvAOvg’ 2. Chasing the Dragon (49 min.)

“Produced by the Federal Bureau of Investigation, Chasing the Dragon is a wrenching portrait of the escalating opioid epidemic told through the frank testimonies of young addicts and their family members.” http://topdocumentaryfilms.com/chasing-dragon/.

3. Ben: Diary of a Heroin Addict (50 min.)

“As a bright schoolboy from a loving, middle-class family Ben Rogers was expected to make a success of his life. Raised in a quiet, picturesque village Ben was a Boy Scout, loved cricket, played in the school orchestra and looked forward to the annual family holiday. But despite his privileged start in life Ben found himself on the road to ruin, injecting heroin up to four times a day.” http://topdocumentaryfilms.com/ben-diary-heroin-addict/.

4. Last Call: Alcoholism and Co-dependency (FHS, 25 min., color, #BVL6056, 1993) “Alcoholism affects not only the person suffering from the disease but the alcoholic’s family as well. This program takes an in-depth look at the effects of alcoholism on both the individual and the family, contrasting an urban and a rural home linked by the common problem of alcoholism. From the alcoholic to his or her spouse and their children, everyone is affected. As other family members seek to cope and prevent the destruction of the family, unhealthy behavioral patterns often emerge: spouses face frustration, shame, and a feeling of helplessness, and children try to hide the problem, creating stresses they can carry with them for the rest of their lives. The program provides a broad insight into alcoholism and how it affects those on its periphery.” https://www.films.com/id/8352/Last_Call_Alcoholism_and_Codependency.htm

5. Heroin: The New High School High (FHS, 42 min., color, #BVL7660, 1997) “ABC News Turning Point examines the increasing prevalence of heroin among today's teenagers and its devastating effects on users, their families, and their communities. Focusing on youths in Orlando, Florida, the program follows the lives of two teenage friends, both heroin addicts. One, an honor student, dies of a heroin overdose. Drug counselors discuss the difficulties in treating addicts because of the extreme euphoria produced by the drug.

Families of addicts reveal how the drug destroys family life. Failure to stem the tide of heroin sale and use among teenagers is discussed by frustrated law enforcement officials.”

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https://paulearley.net/film-audio/film/heroin-high-school-high.

6. Adult Children of Alcoholics: A Family Secret (FHS, 52 min., color, #BVL2629, 1990) “In this program, famous adult children of alcoholics speak out about childhood nightmares and adult behavior that continues to reflect the problem of a parent’s alcoholism: some chose alcoholic partners, and others developed drug, gambling, or other addictions. All speak of the difficulties of coping with the damage inflicted by an alcohol-centered childhood” (recommended by Addiction and Recovery). https://cambridge.films.com/PreviewClip.aspx?id=3706. https://www.films.com/id/3706.

7. Small Town Ecstasy: Getting High with Dad (FHS, 86 min., color, #BVL31357, 2002) “This cautionary program pulls no punches as it tracks the downward spiral of a successful suburban husband and father who, at 40, becomes addicted to the drug Ecstasy and ruins his family and his marriage. A powerfully unsettling firsthand account of middle-class drug abuse, the program documents Scott’s dive into the rave scene, where he encourages his teenage children to do drugs with him; his acrimonious divorce and custody battle; his arrest on drug charges; and his children’s fruitless attempt to help him get straight. The emotional devastation and brain damage resulting from drug abuse are emphasized. Viewer discretion is advised. An HBO Production.” https://www.films.com/id/5429/Small_Town_Ecstasy_Getting_High_with_Dad.htm.

8. Ted Talk on Alcohol and Drug Abuse in Teens that Helps Address Stigma. https://www.youtube.com/watch?v=ISMLIAXENFc. 9. David with Fetal Alcohol Syndrome (FHS, 45 min., color, #BVL6554, 1996) “David Vandenbrink seems like a normal, bright, articulate 21-year-old man. There is little to suggest, on the surface, that while in his mother's womb he suffered permanent brain damage. David suffers from fetal alcohol syndrome or FAS, a condition that went undiagnosed for the first 18 years of his life, causing confusion, anger, and pain for him and his adoptive family. The damage from FAS can be subtle or severe, resulting in a wide range of symptoms from slowed growth or disfigurement to behavioral problems including impulsiveness, aggression, and the inability to grasp the consequences of one's actions. This program provides a unique personal look at what it’s like to grow up and live with the effects of FAS, through the words and experiences of a victim and his family.” https://ffh.films.com/id/8759/ecTitleDetail.aspx?TitleID=8759&r=David_with_Fetal_Alcohol_S yndrome.htm.

10. Terri’s Story on Her Struggles with Smoking and Nicotine Dependence. https://www.cdc.gov/tobacco/campaign/tips/stories/terrie.html

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11. Hooked on Heroin: From Hollywood to Main Street (FHS, 52 min., color, #BVL5149) “Heroin isn’t a drug only for the rich and famous. Like cocaine in the 1980s, heroin is now attacking the middle class. This ABC News Turning Point program examines why some of the unlikeliest people have become junkies, like the all-American Boy Scout who ‘just wanted to try it’ and the housewife who was ‘just going to try it one time.’ ABC News correspondent Meredith Vieira talks with Steven Tyler, lead singer of Aerosmith, who describes what it was like to be down and to come back up and recover. She also speaks with DEA officers, who warn of the growing epidemic of heroin addiction, and to a drug dealer who explains that snorting heroin is gaining popularity because there is no danger of AIDS from dirty needles. The program also explains why the Colombia drug cartels are finding heroin so much more profitable than cocaine. Some of the addicts in this program have recovered, others are recovering, and others still feed their habit while assuring the world they'll recover sometime. The message of this program is clear: heroin is so addictive that you can’t just try it. If you can’t say no, you’ll forever be saying yes.” https://paulearley.net/film-audio/film/hooked-fromhollywood-to-main-street.

12. Circle of Recovery: Healing the Wounds of Drugs and Alcohol (FHS, 60 min., color, #BVL6749, 1991) “In this program, Bill Moyers provides a candid portrait of seven African-American men—all recovering from drug and alcohol addiction—and their efforts to heal through a voluntary recovery group they formed. Each week, members of the group meet and openly discuss issues involving family, love, sex, racism, and work, which are interwoven with their struggles and achievements as they strive to rebuild their broken lives. We see how the support each man draws from the other group members contributes to his recovery in the healing circle.” https://www.films.com/id/88

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DISCUSSION QUESTIONS These questions are based on the clinical case studies and other information found in boxes throughout the chapter.

Alice Discuss why it is not solely a moral impairment or personal choice that substance use disorders develop. What other factors interact to bring about this disorder?

Brandon Discuss the underlying addiction issues and causes. What was the progression of substance use for Brandon?

James Discuss how James could have been helped by the implementation of substance abuse programs, which have been developed to find and treat individuals like James in earlier stages before addiction sets in.

Anton Describe methamphetamine abuse, withdrawal and tolerance symptoms. What are negative consequences of methamphetamine use?

Tamara Tamara had a positive experience with ecstasy the first time she took it at a rave. She expected to have the same euphoric feelings as she did the first time. How was her experience different the second time? How big a part does drug expectation play in deciding to experiment with drugs?

Pause and Ponder Activity: Alcohol Dependence The following questions reference the case studies published in Oltmanns and Martin, Case Studies in Abnormal Psychology, 11th Edition, John Wiley & Sons, 2019.

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Part I: Pause What would you think if...? ...a woman says she drinks not a couple glasses of wine, but two bottles of wine? ...a woman says she drinks to pass out, wakes up in the middle of the night, and drinks to pass out again?

Consider how much you agree with the following statement: I can see this woman's perspective and understand how she would feel if I were in her shoes.

Part II: Learn Now that you have considered the statement, watch the case video about Laurie and answer the questions.

Question type Multiple Choice 1. a. b. c. d.

How many adults in the United States have an alcohol use problem?

1 out of 5 1 out of 12 1 out of 20 1 out of 40

Answer: c

2. Laurie says that after college, she started drinking more and more. A need for increased amounts of a substance in order to achieve intoxication is knowns as: a. Recreational use b. Social use c. Tolerance d. Withdrawal Answer: c

3.

Robert H. Hopcke, MFT, says that once a person hits tolerance and withdrawal, or depends on a substance physiologically and psychologically, he would call that alcoholism. What is the best diagnostic term for this? a. Substance abuse b. Substance dependence c. Substance intoxication

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d. Substance use Answer: b

4. Robert H. Hopcke, MFT, states that in his opinion, the success of 12-step programs, such as Alcoholics Anonymous (AA) is due largely to: a. Anonymity b. Availability of social support c. Spirituality focus d. All of the above Answer: b

5. a. b. c. d.

Other treatments that are mentioned for alcohol use disorders include: Cognitive behavioral therapy Medications Psychodynamic therapy A and B only

Answer: d

6. A list of diagnostic criteria for substance use disorders is shown below. Select all of the diagnostic criteria for substance dependence. a. Great deal of time spent to obtain or use the substance, or recover from its effects b. Persistent desire or unsuccessful efforts to cut down or control substance use c. Recurrent substance-related legal problems d. Recurrent use in situations in which it is physically hazardous e. Substance is taken in larger amounts and over a longer period than was intended f. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused by or exacerbated by the substance g. Tolerance h. Withdrawal Answer1: a Answer2: b Answer3: e Answer4: f Answer5: g

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Answer6: h

Ponder Part III: Ponder Reflect upon the changes in your empathy that came about during this activity.

1. Consider how much you agree with the following statement: I can see this woman's perspective and understand how she would feel if I were in her shoes. ____________________________

Pause and Ponder Activity: Substance Dependence The following questions reference the case studies published in Oltmanns and Martin, Case Studies in Abnormal Psychology, 11th Edition, John Wiley & Sons, 2019.

What would you think if...? ...a woman sells herself on the streets in order to buy crack? ...a man's marriage ended because he could not control his heroin use? ...a woman lost her children because she could not stop using drugs?

Consider how much you agree with the following statement: I can see these people's perspectives and understand how they would feel if I were in their shoes.

Part II: Learn Now that you have considered the statement, watch the case video on Julie and John and answer the questions.

Question type Multiple Choice 1. a. b. c.

A common word used to in place of the term “substance dependence” is _____. addiction intoxication tolerance

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d. withdrawal Answer: a

Question type Essay 2. Summarize Julie’s description of what she has given up because of her substance dependence.

Question type Multiple Choice 3. Both Julie and John are experiencing dependence to a substance in which of the following categories? a. alcohol b. amphetamines c. hallucinogens d. opioids Answer: d

4. As Patricia Craven, MFT explains, substance dependence, or addiction, involves a _____ component. a. biological b. cognitive c. physiological d. psychological Answer: c 5. As Patricia Craven, MFT explains, substance dependence, or addiction, involves a _____ component. a. occupational b. economic c. educational d. social Answer: a 6. a. b. c.

John states that the one thing that is routine for him every day is ______. eating sleeping thinking about how to get drugs

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d. working Answer: c

7. a. b. c. d.

John states that the one thing that is routine for him every day is ______. cognitive behavioral treatment detoxification group therapy in a 12-step program medication

Answer: c

8. A list of diagnostic criteria for substance use disorders is shown below. Select all of the diagnostic criteria for substance dependence. a. Great deal of time spent to obtain or use the substance, or recover from its effects b. Persistent desire or unsuccessful efforts to cut down or control substance use c. Recurrent substance-related legal problems d. Recurrent use in situations in which it is physically hazardous e. Substance is taken in larger amounts and over a longer period than was intended f. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused by or exacerbated by the substance g. Tolerance h. Withdrawal Answer 1: a Answer 2: b Answer 3: e Answer 4: f Answer 5: g Answer 6: h

Question type Essay

Ponder Part III: Ponder Reflect upon the changes in your empathy that came about during this activity.

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1. Consider how much you agree with the following statement: I can see these people's perspectives and understand how they would feel if I were in their shoes.

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CHAPTER 11 EATING DISORDERS

LEARNING GOALS 1. Distinguish the symptoms associated with anorexia, bulimia, and binge eating disorder and distinguish among the different eating disorders.

2. Describe the neurobiological, sociocultural, and psychological influences implicated in the etiology of eating disorders.

3. Discuss the issues surrounding the growing epidemic of obesity in the United States.

4. Describe the treatments for eating disorders and the evidence supporting their effectiveness.

The Learning Goals are inherent in both the Lecture Launchers and Discussion Stimulators below.

Please note the Discussion Questions at the end of this chapter.

CHAPTER SYNOPSIS Many cultures, including the United States, are preoccupied with food. Dieting to lose weight is common and there are many societal pressures to be thinner. As many other psychological disorders, eating disorders are also likely to be stigmatized. This chapter reviews clinical descriptions of eating disorders; neurobiological, sociocultural and psychological influences implicated in the etiology of these disorders; and empirically supported treatments.

Clinical Descriptions of Eating Disorders The DSM-5 eating disorders include: anorexia nervosa, bulimia nervosa, and binge eating disorder. The DSM-5 also includes specific disorders of early childhood, including pica, rumination disorder, and avoidant/restrictive food intake disorder.

Anorexia nervosa has the following characteristics:

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1. Restriction of behaviors that promote a healthy body weight e.g., a body mass index (BMI) or less than 18.5 for an adult.

2. Strong fear of gaining weight or behavior that interferes with gaining weight.

3. Distorted body image or sense of body shape.

Anorexia usually begins in the early teen years and is more common in women than men. Bodily changes that can occur after severe weight loss can be serious and life threatening. About 70% of women with anorexia eventually recover, but it can take many years.

Bulimia nervosa involves both binging and purging. Binging is defined by the intake of a substantially large amount of food within a 2-hour time period. This amount of food is more than an average person would eat within the same period of time in the same situation. When people binge they feel powerless to control their eating and are overwhelmed by the need to consume food. Binging often involves sweet foods and is more likely to occur when someone is alone, after a negative social encounter, and in the morning or afternoon. Purging encapsulates the behaviors that people use in order to compensate for the large amount of food that they have eaten during a binge. Individuals who purge may vomit, abuse laxatives, engage in over-exercising, or fast for a distinct period of time in order to compensate for the food they have eaten during a binge.

One striking difference between anorexia and bulimia is weight loss: people with anorexia nervosa lose a tremendous amount of weight, whereas people with bulimia nervosa do not. People with bulimia nervosa are likely to be of average weight. Bulimia typically begins in late adolescence and is more common in women than men. Depression often co-occurs with bulimia, and each condition appears to be a risk factor for the other. Dangerous changes to the body can also occur as a result of bulimia, such as menstrual problems, tearing in the stomach and throat, swelling of the salivary glands and even gum disease and tooth enamel erosion.

In the DSM-5, Bulimia Nervosa has three characteristics: 1. Repeated episodes of binge eating 2. Repeated compensatory behaviors to prevent weight gain (e.g., vomiting) 3. Body shape and weight are extremely important for self-evaluation

Binge eating disorder is typically characterized by several binges, and most (but not all) people are obese (i.e., having a BMI greater than 30). Not all obese people meet criteria for binge eating disorder— only those who have binge episodes and report feeling a loss of control over their eating qualify. Binge eating disorder is more common than anorexia and bulimia and is more common in women than men, though the gender difference is not as great as in anorexia and bulimia. Unlike bulimia nervosa, individuals with binge eating disorder do not engage in compensatory behaviors.

Defining symptoms of binge eating disorder:

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1. Repeated episodes of binge eating 2. Binge eating episodes that include several features: a. eating fast b. eating even if not hungry c. eating past feeling full d. feeling bad about eating so much

Etiology of Eating Disorders Genetic influences appear to play a role in eating disorders, as these disorders run in families. Serotonin, which is involved in mediating hunger and satiety, has been implicated in eating disorders, although evidence of a causal relationship is limited. Dopamine has also been implicated, given its involvement in the reward aspects of eating, but the causal relationship is also unclear.

Cognitive-behavioral theories focus on body dissatisfaction and preoccupation with thinness.

Interpersonal theories focus on how interpersonal problems contribute to the patient’s distorted eating behaviors and body image.

Sociocultural factors, including society’s preoccupation with thinness, have contributed to an increase in frequency of eating disorders. This preoccupation is linked to dieting efforts, and dieting precedes the development of eating disorders among many people. In addition, the preoccupation with thinness, as well as media portrayals of thin models, predicts an increase in body dissatisfaction, which also precedes the development of eating disorders. Stigma associated with being overweight also contributes. Women are more likely to have eating disorders than men, and the ways in which women’s bodies are objectified may lead some women to see their bodies as others do (self-objectify), which in turn may increase body dissatisfaction and eating pathology. Anorexia appears to occur in many cultures; bulimia appears to be more common in industrialized and Westernized societies. Eating disorders are more common in women than men and are slightly more common among White women than women of color, with the difference being most pronounced in college student samples. Eating disorders used to be more common among women of higher socioeconomic status, but this is less true today.

Research on personality characteristics has found that perfectionism may play a role. Other personality characteristics that predicted disordered eating across 3 years include body dissatisfaction, the extent to which people can distinguish different biological states of their bodies, and a propensity to experience negative emotions.

Troubled family relationships are fairly common among people with eating disorders, but this could be a result of the eating disorder and not necessarily a cause of it. High rates of sexual and physical abuse are found among people with eating disorders, but these are not risk factors specific to the development of eating disorders.

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Treatment and Preventive Interventions for Eating Disorders Antidepressant medications have shown some benefit for the treatment of bulimia but not anorexia or binge eating disorder. However, people with bulimia are more likely to discontinue the medication than therapy. Psychological treatment of anorexia must first focus on weight gain and may require hospitalization to reduce medical complications for severe cases. Family therapy is the principal treatment for anorexia, but studies are needed to demonstrate whether this is effective. Interpersonal Psychotherapy (IPT) involves addressing interpersonal problems (e.g., conflicts, grief, transitions, skill deficits) so that interpersonal functioning improves, and in turn, eating disordered behaviors subside.

IPT is effective for all eating disorders although the therapeutic process lasts longer in IPT than in CBT. One of the most effective psychological treatments for bulimia is CBT, which involves changing a patient’s beliefs and thinking about thinness, being overweight, dieting, and restriction of food, with the overall goal being to reestablish normal eating patterns. Exposure plus ritual prevention is one CBT component that is effective early in treatment. CBT alone is more effective than medication treatment, though antidepressants can help lessen comorbid depression. CBT also shows promise as an effective treatment for binge eating disorder.

Intervening with children or adolescents before the onset of eating disorders may help prevent these disorders from ever developing, particularly those programs that include girls age 15 or older, involve more than one session, and are interactive rather than didactic (i.e., lecture format). Outcomes appear promising up to 3 years after the prevention programs are instituted. Broadly speaking, three different types of preventive interventions have been developed and implemented: a) psychoeducation, b) deemphasizing sociocultural influence, and c) risk factor approach. The Body Project is one such intervention that has shown some effectiveness.

Link for NEDA: https://www.nationaleatingdisorders.org//.

KEY TERMS anorexia nervosa

body mass index (BMI)

binge eating disorder

bulimia nervosa

obese

LECTURE LAUNCHERS 1. First-Person Accounts of Anorexia and Bulimia The following first-person accounts by adolescents with eating disorders appeared in Ms.Magazine (March/April 1993, Berman, N., “Disappearing acts,” 42–43; reprinted by permission of Ms. Magazine, (c) 1993). The author interviewed the girls during a three week

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visit to the Eating Disorders Unit of Highland Park Hospital in Illinois. The names used are pseudonyms.

Cait, Age 17 I was going to make myself perfect. I thought I had control of it. I didn’t think I had a problem. I thought I was happy, but I can't really figure out what happy is.

I ate every couple of days. Or I would have a rice cake. I was convinced that an orange was too much. I got to the point where everything was too much. I restricted everything. After a while you don’t feel the hunger pains anymore. And you don’t know when you’re hungry. I started restricting more and more, and then after a while I was craving food and that's when the binging started.

In the beginning I was throwing up healthy food, broccoli, carrots, apples. And then I thought, if I’m going to do this, I might as well binge on what I like. I left a party early because I had to have a binge. I told my boyfriend I was tired, got in my car, and went to McDonald’s. God, it was scary while I was doing it. I ate a Big Mac, a large fries, an apple pie, a hot fudge sundae with nuts, and I wasn’t done. There was a grocery store right there. I got, like, a thing of Ben & Jerry’s ice cream, a couple of candy bars, a big, like, 2-lb bag of Peanut M&Ms. I ate at McDonald’s, I ate in my car, and I ate the rest of it at home.

I felt good after because it was gone. But in the end it was not so much the binging, it was not eating at all. I wouldn’t drink pop, not even diet pop. My logic was: why? I don’t need it. It was something extra. I knew there were no calories, but I thought there had to be something in the pop.

I didn't want anybody to find out. I would make food, Spaghetti Os, and give it to my dog. My boyfriend has never seen me eat. I would say, “Oh, I just ate,” or “I’m not hungry.” I didn’t want him to think that I was a cow or a pig or something. Like, if we were out and other girls were eating, I would get satisfaction out of the fact that I wasn’t. It made me feel better than them.

I make people tired. I'm constantly on the go. I was doing a thousand and one things. It was easier to go a thousand miles an hour than to deal with anything. I think I wasn’t really happy with the image I was living, but I didn't know what to do.

I practice being gentle. I practice in front of the mirror saying hello. I want to present myself in the best possible way, and if I can present myself better, or happier, as more energetic, then I want to know how to do it.

I want so badly to just be me. I want to get out of this person, this perfectionist that everyone admires.

Nicole, Age 16

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It’s like a huge feeling that I’m not right. That I could be better. I feel like I am a heavy person.

You know how really, really fat people must feel? That's how I feel. I could not tell you how I look in jeans. I always had to go shopping with my mom so she could tell me how they looked. I honestly don't know what I’m supposed to look like.

It started the spring of sophomore year. People said I had a good body all the time, a nice butt. I would turn my head away and blush. I got compliments up until the time I came into the hospital. Guys said I looked hot and I was wearing children’s size 14 jeans.

I hated the curves. I've got to get rid of the curves. I think my legs are fat. And this muscle here. I never sit with my legs crossed. I always look in the mirror sideways.

I used to spit out my food instead of throwing up. Tootsie Rolls, peanut butter, M&Ms, Starburst. I had Jane Fonda’s Workout, Kathy Smith’s Fat Burning Workout. They’re addicting. I watched them in the basement. I did butt exercises, sit-ups, stretches. I was never too thin. I never had a goal weight; it was always just not yet.

My boyfriend couldn’t bear to touch me. He stopped sleeping with me because he said I was just bones. I tried to get thinner to look better and win him back, but it just repulsed him. I thought I could be more appealing to him because all of the most beautiful women, the sexiest, are the thinnest. All the women men desire are thin. In the movies, the desired women are thin.

Magazines, I would look through them at night: Vogue, Mademoiselle, Seventeen, Cosmopolitan, Elle, Harper’s Bazaar.

I based how I felt about myself on the way a guy felt about me. I would try to be a good girlfriend and when I did get hurt, it was a big blow.

I was readmitted because I tried to kill myself. In my car, in the garage. It was the most real attempt. Everyone said I was doing so good, and then when I wasn’t, when they build it up, I get sick.

A lot of it has to do with my relationship with my father. I was taught to be quiet. Girls should be quiet. I should not express myself. I’ve always wanted a father that I know I can never have. For 16 years, I've wanted a father that I can never have.

Sometimes I still wish I could fit into my old jeans. And that empty feeling—on top of the world, like you could conquer anything. I loved it.

More first-person stories can be found at this link: https://www.healthyplace.com/eating-disorders/articles/eating-disorder-first-handstories/.

2. The Longitudinal Course of Disordered Eating While a very small percentage of people meet criteria for a diagnosis of eating disorder, disordered patterns of eating that do not constitute full-blown disorders are quite common.

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Studying the course of eating patterns over time may assist in the understanding of eating disorders, while also exploring less pathological forms of disordered eating.

A study by Heatherton et al. does just that (1997, Journal of Abnormal Psychology, 106, 117– 125). In a collaborative effort between several universities, Heatherton and colleagues studied a cohort of 715 men and women who were teenagers in the late 1970s and early 1980s, a period when dieting and eating disorders were quite prevalent. The participants were studied during their college years and surveyed again 10 years later.

Results indicated that for women, body dissatisfaction, chronic dieting, and eating disorder symptoms generally diminished in the 10 years following college. Particularly dramatic declines were found for eating disorders and the prevalence of binge eating and purging. The authors note that “maturing into adulthood and getting away from the enormous social influences that emphasize thinness (such as being on a college campus) help most of the women to escape from chronic dieting and abnormal eating” (p. 123). On the other hand, many of the women who were dissatisfied with their bodies in college continued dieting and disordered eating patterns ten years later.

The pattern was different for men. Half of them gained at least 10 lbs during the ten years after college, and concerns about body weight and dieting behavior increased accordingly.

While the authors argue that maturational changes and changes in role status explain the lessening of eating problems for women as they age, an alternative explanation is that there is a general social trend toward less pathological eating behavior. Media messages may have informed women about the risks of eating disorders and changing ideals regarding thinness.

A similar study by Slane et al. showed essentially the same elements for 745 females between ages 11 and 25. It did show an increase in disordered eating from early to late adolescence and confirmed the three symptoms of disordered eating, body dissatisfaction, and weight preoccupation (International Journal of Eating Disorders, July 4, 2014).

The Discussion Stimulator on dieting could be used in conjunction with this lecture material.

3. Predictors of Recovery Following Treatment for Anorexia As discussed in the text, eating disorders are notoriously difficult to treat. A study by Herzog, Schellberg, and Deter (1997, Journal of Consulting and Clinical Psychology, 65, 169–177) followed a group of 69 patients for 12 years in Germany who had undergone inpatient treatment for anorexia nervosa. The treatment consisted of a 3-month hospital stay combining behavioral and psychodynamic approaches. Even with this intensive treatment (not likely to be available in the United States considering changes in insurance coverage for psychiatric hospital stays), 50% of the anorexic patients did not show improvement for 6 years.

The study did reveal some factors that predicted recovery. Patients likely to recover sooner were those with restrictor-type anorexia and with low serum creatinine levels (high serum creatinine levels are a biological marker of poor renal function suggestive of frequent vomiting).

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Purging behavior, particularly in combination with social disturbances, predicted poor probability of recovery. The social disturbances measured included low integration with a peer group, disturbed communication with family, exaggerated dependence on the family of origin (Minuchin’s concept of enmeshment), no steady relationship, no founding of a family of her own, and no professional integration.

Implications of the study include the long course of the illness, with recovery unlikely after one episode of treatment. It would seem that treatment planning should consider the stage of illness and the need for follow-up and aftercare services. Further, it appears that treatment needs to address social functioning in addition to symptom change. This suggestion would fit with the finding (cited in the text) that Interpersonal Therapy had an effect on bulimia even without addressing symptom change.

A more recent study (2013) suggests that for adolescents, achieving a body weight of 95.2% of expected body weight is the best predictor of recovery for anorexia nervosa. The research included both adolescents and adults with slightly different indicators but with essentially the same results (Lock, Agras, Le Grange, Couturier, Safer, and Bryson, International Journal of Eating Disorders, 46(8), 2013, 771–778).

4. Athletes with Eating Disorders: An Overview In a sense, eating disorders are diets and fitness or sports programs gone horribly wrong. A person wants to lose weight, get fit, and excel in his or her sport, but then loses control and ends up with body and spirit ravaged by starvation, binge eating, purging, and frantic compulsive exercise. What may have begun as a solution to problems of low self-esteem has now become an even bigger problem in its own right.

Several studies suggest that participants in sports that emphasize appearance and a lean body are at higher risk for developing an eating disorder than non-athletes or people involved in sports that require muscle mass and bulk. Eating disorders are significant problems in the worlds of ballet and other dance, figure skating, gymnastics, running, swimming, rowing, horse racing, ski jumping, and riding. Wrestlers, usually thought of as strong and massive, may binge eat before a match to carbohydrate load and then purge to make weight in a lower class.

One study of 695 male and female athletes found many examples of bulimic attitudes and behavior. A third of the group was preoccupied with food. About a quarter binged at least once a week. Fifteen percent thought they were overweight when they were not. About 12% feared losing control, or actually did lose control, when they ate. More than 5% ate until they were gorged and nauseated. In this study, 5.5% vomited to feel better after a binge and to control weight. Almost 4% abused laxatives. Twelve percent fasted for 24 hours or more after a binge, and about 1.5% used enemas to purge.

Another research project done by the NCAA looked at the number of student athletes who had experienced an eating disorder in the previous two years. Ninety-three percent of the reported problems were in women’s sports. The sports with the most participants with eating disorders, in descending order, were women’s cross country, women’s gymnastics, women’s swimming, Instructors Manual

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and women’s track and field events. The male sports with the highest number of participants with eating disorders were wrestling and cross country.

Male and Female Athletes: Different Risk Factors The female athlete is doubly at risk for the development of an eating disorder. She is subject to the constant social pressure to be thin that affects all females in Western countries, and she also finds herself in a sports milieu that may overvalue performance, low body fat, and an idealized, unrealistic body shape, size, and weight. Constant exposure to the demands of the athletic subculture added to those bombarding her daily on TV, in movies, in magazines, and transmitted by peers, may make her especially vulnerable to the lures of weight loss and unhealthy ways of achieving that loss.

Males also develop eating disorders but at a much-reduced incidence (approximately 90% female; 10% male). Males may be protected somewhat by their basic biology and different cultural expectations.

Many sports demand low percentages of body fat. In general, men have more lean muscle tissue and less fatty tissue than women. Males also tend to have higher metabolic rates than females because muscle burns more calories faster than fat does. So women, who in general carry more body fat than men and have slower metabolisms and smaller frames, require fewer calories than men.

All these factors mean that women gain weight more easily than men, and have a harder time losing weight and keeping it off than men. In addition, women have been taught to value being thin. Men, on the other hand, usually want to be big, powerful, and strong. Therefore, men are under less pressure to diet than women are—and dieting is one of the primary risk factors for the development of an eating disorder.

Special Concerns: Wrestlers and Quick Weight Loss Everyone who uses drastic and unhealthy methods of weight loss is at risk of dying or developing serious health problems, but the deaths of three college wrestlers in the latter part of 1997 triggered re-examination of the extreme weight-loss efforts common in that sport.

Athletes in other sports have died too; runners and gymnasts seem to be at particular high risk.

The deaths of three young wrestlers in different parts of the United States in the late 1990s put the problem once again before the public. News reports say that the three were going to school in North Carolina, Wisconsin, and Michigan. Authorities believe they were trying to lose too much weight too rapidly so they could compete in lower weight classes. The wrestling coach at Iowa State University has been quoted as saying, “When you have deaths like this, it calls into question what’s wrong with the sport. Wrestlers believe that, foremost, it’s their responsibility to make weight, and that mind-set may come from the fact that they find themselves Instructors Manual

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invincible.” They share that mind-set with others who use dangerous methods of weight loss, both athletes and non-athletes. Two of the young men were wearing rubber sweat suits while they worked out in hot rooms. One died from kidney failure and heart malfunction. The other succumbed to cardiac arrest after he worked out on an exercise bike and refused to drink liquids to replenish those he lost by sweating. One was trying to lose 4 lbs, the other 6.

Wrestlers share a mentality with people who have eating disorders. They push themselves constantly to improve, to be more fit, to weigh less, and to excel. They drive themselves beyond fatigue. One coach reports that “wrestlers consider themselves the best-conditioned athletes that exist, and they like the fact they can go where no one’s gone before. The instilled attitude among these kids is that if they push and push, it’ll pay off with a victory.” No one expects to die as a consequence of weight loss, but it happens.

When a clamor arose for the NCAA to do something, to make rules prohibiting drastic methods of weight loss, a representative said, “We could make every rule in the book, but we can’t legislate ethics. That's where the wrestlers and coaches have to put the onus on themselves.”

What is the price of victory? It takes wisdom indeed to realize that in some circumstances the price is too high.

Information used with permission of ANRED: Anorexia Nervosa and Related Eating Disorders, Inc. http://www.anred.com.

5. Treatment of Binge Eating Disorder Data are starting to come in regarding binge eating disorder and its treatment. As discussed briefly in the text, the disorder refers to a pattern of binge eating similar to that seen in bulimia, but without accompanying purging, fasting, or excessive exercise. The syndrome is complex both psychologically and medically, since it usually combines disordered eating (with its comorbid psychopathology) and frank obesity (with its medical complications).

Agras and colleagues treated and followed 75 obese women with binge eating disorder (1997, Journal of Consulting and Clinical Psychology, 65, 343–347). The treatment involved 30 sessions of group therapy using a manualized treatment. The first 12 sessions involved cognitive behavior therapy for binge eating, and the subsequent 18 sessions focused on weight loss. The cognitivebehavioral interventions included reducing the intervals between meals or snacks, decreasing avoidance of feared foods and coping with the precipitants of binge episodes, and relapse prevention strategies. The weight-loss sessions stressed gradual weight loss with caloric restriction achieved mainly by reduced fat intake.

Like other studies of weight loss in general and binge eating disorder in particular, most participants gained weight in the year following treatment. However, important differences emerged with implications for design of future treatment studies. Patients who were able to abstain from binge eating by the end of the CBT treatment were able to then lose a small amount of weight during the weight loss portion of treatment, and maintain the weight loss

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over the next year. In contrast, both those who never learned to abstain and those who abstained after the treatment was over gained weight over the next year.

These findings suggest that treatment may need to be longer and include more relapse prevention in order to make a meaningful impact. Only 41% of participants were able to abstain from binge eating after the 12-week CBT program; perhaps a longer period focusing on binge eating would improve outcome. In addition, most of the weight loss of the 1-year study period occurred during the weight-loss therapy part of the treatment program; subsequent to stopping treatment, patients who continued to abstain from binge eating were able to maintain their small weight losses, but not continue to lose more. Thus, it may be that extended group contact, with attention to resumption of binges as well as weight-loss strategies, needs to be implemented.

In another study, Wilfley and her colleagues looked at the treatment of 162 overweight people with binge eating disorder (2002, Archives of General Psychiatry, 59, 713–721). Their study investigated the effectiveness of CBT group treatment and IPT group treatment for people with binge eating disorder. Participants in both treatment groups received 20 weekly 90-minute group therapy sessions and three individual therapy sessions that assessed their goals and progress at the beginning, middle, and end of treatment. The CBT treatment had three stages.

First, participants learned to recognize when they were over-restricting or under-restricting their food intake. Second, participants learned how to combat the negative self-talk that often leads to binge eating. Third, participants learned how to cope with setbacks, maintain the changes they had made, and how to avoid relapse. The IPT treatment also had three stages.

First, participants identified interpersonal problem (e.g., grief, interpersonal role disputes, role transitions, and interpersonal deficits) that contributed to the onset and maintenance of their eating disorder. A plan for addressing these deficits was then developed. Second, participants learned and implemented new strategies to deal with interpersonal deficits. Third, participants discuss progress, maintenance plans, and additional work that needs to be done.

The study found that IPT and CBT have similar recovery rates for people with binge eating disorder both immediately after treatment (CBT = 79% recovery rate; IPT = 73% recovery rate) and one year after treatment (CBT = 59% recovery rate; IPT = 62% recovery rate). Results indicate that group IPT is comparable to group CBT and should be considered as a first- line treatment for people with binge eating disorder.

The article “Treatment of binge eating disorder in racially and ethnically diverse obese patients in primary care: Randomized placebo-controlled clinical trial of self-help and medication” compares the effectiveness of self-help cognitive-behavioral therapy with or without an antiobesity medication. It was determined that pure self-help CBT and the medication did not show long-term effectiveness in weight loss. The medication had significantly greater acute weight loss (Crilo et al., Behaviour Research and Therapy, 58, 2014, 1–9).

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6. Manualized Family Therapy for Anorexia Observing master clinicians at work, or reading descriptions of their clinical approach, impresses most clinicians. However, many are left with the question, “How can I do that?” The recent trend toward developing manualized treatment approaches has extended to a clearer explication of family therapy approaches as well.

Behavioral family systems therapy (BFST) was developed to address the gap between clinical lore and empirical support. Originally growing from Patterson’s work with under-controlled children, the model has been extended to other clinical populations, including adolescents with anorexia nervosa. A chapter by Robin et al. in E. D. Hibbs and P. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (Washington, DC: American Psychological Association, 1996) carefully outlines the application of BFST to anorexia. Students may be interested in hearing the steps involved in this approach to treatment. The approach involves working with the parents and the adolescent with anorexia, and typically takes about a year to complete.

I. Assessment. The therapist works with an interdisciplinary team, including pediatrician and dietitian, to determine whether immediate hospitalization is necessary. If the disease is not yet life threatening, the therapist proceeds with the assessment phase. Over several sessions, the therapist engages the family in treatment, obtains information about the adolescent’s weight, menstruation, eating habits, exercise, mood, medical changes, development, school, peer relations, and family interactions.

II. Control Rationale. Once the assessment is completed, the therapist instructs the parents in taking control (temporarily, until normal weight is achieved) of their child’s eating. The parents are assigned the responsibility for planning, purchasing, and preparing food, making sure their child eats, recording food consumption, and making sure they do not vomit or exercise after eating. Usually, both parents and adolescent strongly object to this plan. One explanation the therapist uses is that the adolescent is in a state of starvation and thus is unable to think clearly.

Further, the therapist maintains a non-defensive, empathic stance to the family’s concern, while emphasizing that food is the “medicine” the adolescent needs and thus it is the parents’ responsibility to make sure the child gets it. This phase brings to the fore any parental conflicts that prevent them from working together to carry out their assigned task. The beginning of compliance with the weight gain strategies is a pivotal point in treatment.

III. Weight Gain. This phase involves continued parental control of eating, closing off “loopholes” to ensure that the adolescent does gain weight, and beginning to explore other issues, such as cognitive distortions and family structure problems.

IV. Weight Maintenance. Once normal weight has been achieved, the therapist not only begins to shift control overeating and weight from the parents to the adolescent, but also encourages normal adolescent autonomy and individuation. The marital couple becomes stronger (and may begin to address some of their own issues) as the adolescent moves out of the marital relationship and into her own peer relationship issues. During this phase, the therapist may spend time in sessions with the couple alone and with the adolescent alone.

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DISCUSSION STIMULATORS 1. Bulimia on Campus Eating disorders are likely quite common among students in your class. Some estimates suggest that as many as 20% of college females engage in some form of binge eating and purging.

Among some, it is the “perfect diet” and almost has a faddish quality. Instructors have found it useful to ask students to talk about bulimia in their social context. This can lead into a discussion of feminism and what women value. Instructors have found it useful to ask students about dieting behaviors, binging, and purging within their social contexts. Encourage students to discuss both individual examples and trends they have noticed, including personal and societal pressures and expectations. Be sure to remind students not to identify friends, acquaintances, and family members by name or direct relationship.

2. Dieting Survey Taking a survey of your students could illuminate societal pressures to diet and sex differences in dieting, and lead to a discussion of changing social trends. Pass round the survey on the next page(adapted from Polivy and Herman’s Restraint Scale discussed in the text). In addition to having students complete the questionnaire, you might ask them to have their parents complete it. This would provide some perspective about dieting issues in people from another generation, and lead to a discussion of age-related vs. cohort effects. Such a discussion could parallel the Lecture Launcher above on Heatherton et al.’s longitudinal study of disordered eating. After students have completed the dieting survey, be sure to supply relevant referral sources for students who may be dealing with eating disordered thoughts or behaviors. Your college counseling center is a good place to refer students for assistance.

3. Practical Application Megan is a high-school junior who has been diagnosed with anorexia nervosa. She is 5′6″ and weighs 75 lb. Her physician and her therapist are worried about her extremely low weight.

Megan does not appear to be concerned and neither do her parents. Megan’s physician says that Megan’s pulse is low and she is at risk for developing osteoporosis and having a heart attack. As Megan’s therapist, what would you do? How would you talk to Megan? How would you talk to her parents? If her parents continued to be in denial of the severity of her symptoms, what would you to and who would you turn to? Presenting students with a case like this allows them to practice their own critical thinking skills. It also provides the instructor with a way to introduce ethical concepts such as beneficence, non-maleficence justice, fidelity, and autonomy.

Dieting Survey

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Gender: _____ female _____ male 1. How often are you dieting? (Circle one) never

rarely

sometimes

often

always

2. At what age did you first start dieting? _______

3. What is the maximum amount of weight (in lbs) you have ever lost in one month?

0–4

5–9

10–14 15–19 20+

4. What is your maximum weight gain within a week?

0–1

1.1–2

2.1–3

3.1–5

5.1+

5. Would a weight fluctuation of 5 lbs affects the way you live your life?

Not at all

slightly

moderately

very much

6. Do you eat sensibly in front of others and splurge alone?

Never

rarely

often

always

7. How conscious are you of what you are eating?

Not at all

slightly

moderately

extremely

8. How many lbss over your desired weight are you now?

0–1

1–5

6–10

11–20

21+

4. Comparison of Two Approaches to Treating Anorexia In the previous Lecture Launcher on family therapy treatment of anorexia, the behavioral family systems therapy is explained in some detail. Next, you might present an alternative and very different approach to treating anorexia: “ego-oriented individual therapy.” In stark contrast to the BFST model, ego-oriented individual therapy involves working with the adolescent in

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individual sessions and asking the parents not to involve themselves at all in the adolescent’s eating behavior. Weekly individual sessions address the adolescent’s ego strength, coping skills, individuation from the family, identity confusion, and other interpersonal issues. These issues are related to eating, weight, and body image. The therapist does not direct the adolescent to gain weight, but rather tries to help her choose to be healthy. Collateral sessions with the parents help them to understand normal adolescent development and prepare for having a more assertive and demanding adolescent.

Before presenting findings from Robin et al.’s (1997) study (reference in Lecture Launcher above), you might encourage the class to discuss likely outcomes.

1. Which treatment approach do they think would work best?

2. Which fits with theories of etiology outlined in the text?

3. Are there variables in the adolescent or in the family that might predict success in one or the other treatment?

The outcome study examined the effectiveness of the two therapy approaches outlined above.

Therapists for both models followed written manuals, and adherence to the treatment was monitored through analyses of audiotapes.

Preliminary analyses indicate that the two treatments are essentially equivalent. Assuming they continue to remain equally effective when the study is completed, what implications can the class derive? If the treatments are equal, what client/family characteristics would they use to decide which treatment to apply to a particular client? The authors note that the family therapy approach requires a great deal of parental involvement, which makes it unworkable in some families. What other factors might limit treatment for each of the approaches?

INSTRUCTIONAL FILMS 1. A first-person account of binge eating disorder: https://youtu.be/NPgHu2Lup94.

2. Dying to Be Thin (FHS, 18 min., color, #BVL5370) This program profiles a young woman obsessed with the desire to be thin. It has taken her four hospitalizations and years of outpatient therapy to help her overcome her problem. Doctors in this program discuss the characteristics of anorexia nervosa and bulimia and identify those most likely to be affected by these disorders. Self-starvation combined with binge eating and purging can lead to cardiac problems and a cessation of the menstrual cycle. And although great efforts have been made to educate people about eating disorders, they continue to represent a nationwide problem. https://www.youtube.com/watch?v=2-uBZk89qM0.

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3. Thin (NTSC, 60 min., ASIN: B000HEVZA8) This is a 2008 HBO presentation. “A compelling film that delves into the lives of young women with eating disorders.” This film follows the lives of four between the ages of 15 and 30 as they attempt to heal in a recovery facility. http://topdocumentaryfilms.com/thin/

4. Several popular movies that feature eating disorders • The Karen Carpenter Story • The Best Little Girl in the World • When Friendship Kills • Girl Interrupted • Kate’s Secret

Discussion Question These questions are based on the clinical case studies and other information found throughout the chapter.

Lynne In reviewing Lynne’s case, why do you think she held such a strong belief that her abdomen and buttocks were too large, even though she weighed 78 lbs?

Jill Jill, and other girls and boys like her, sometimes develop bulimia due to their desire to stay within the right weight range to continue in sports. In Jill’s case, what part, if any, do you think her mother played in the development of Jill’s eating disorder?

Amy Discuss how psychological, social, and genetic factors interact to produce binge eating disorder.

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Pause and Ponder Activity: Anorexia The following questions reference the case studies published in Oltmanns and Martin, Case Studies in Abnormal Psychology, 11th Edition, John Wiley & Sons, 2019.

Part I: Pause What would you think if...? ...a woman has lost 2 lbs since yesterday and is not concerned about it? ...a woman is having heart palpitations due to extreme weight loss but feels like it would be safe to lose another 5 lbs?

Consider how much you agree with the following statement: I can see this woman's perspective and understand how she would feel if I were in her shoes.

Part II: Learn Now that you have considered the statement, watch the case video about Ashley and answer the questions.

Question type Multiple Choice 1. a. b. c. d.

Which of the following is a central symptom of anorexia nervosa? frequent eating judging others' body size distorted image of one's own body frequent exercise

Answer: c 2. a. b. c. d.

Individuals with anorexia nervosa often keep close track of what? what others are eating their own weight physical diagnostic criteria the weight of others

Answer: b 3. a. b. c. d.

The images of Ashley's body clearly show which symptom of anorexia nervosa?

Amenorrhea Disturbance in the way body weight or shape is experienced Intense fear of gaining weight Refusal to maintain body weight at or above normal weight for age and height

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Answer: d

4. Which of the following is not a physical symptom associated with anorexia nervosa that Ashley mentions experiencing? a. brittle nails b. headache c. dizziness d. heart palpitations Answer: a

5. Leisa, Ashley’s sister, describes how Ashley would not leave her house or room for days. Patricia Craven, MFT also mentions that withdrawal is associated with anorexia. Which of the following characteristics of a mental disorder best describes this aspect of anorexia nervosa? a. disability b. distress c. dysfunction d. violation of social norms Answer: a

6. Which of the following is not one of the dangers associated with anorexia nervosa mentioned by Patricia Craven, MFT? a. heart failure b. kidney failure c. starvation d. suicide Answer: d

Question type Essay 7. 7.Describe Ashley’s description of her experience with anorexia nervosa, including her perceptions of the understanding of herself and others of her disorder.

Question type Multiple Choice 8. The difference between the self and the cultural ideal is associated with all except this aspect of anorexia nervosa. a. amenorrhea

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b. body dissatisfaction c. fear of gaining weight or becoming fat d. preoccupation with being thin Answer: a

Question type Multiple Choice 9. a) b) c) d)

Which of the following treatments are not commonly used for anorexia nervosa? cognitive behavior therapy family therapy hospitalization medication

Answer: d

10. Patricia Craven, MFT believes that which type of treatment is most important in the treatment of anorexia nervosa? a) cognitive behavior therapy b) family therapy c) hospitalization d) medication Answer: b

11. A list of diagnostic criteria for eating disorders is shown below. Select all of the diagnostic criteria for anorexia nervosa. a) Absence of at least three consecutive menstrual cycles b) Binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months c) Disturbance in the way one's body weight or shape is experienced d) Eating, in a discrete time, an amount of food that is definitely larger than most people would eat during a similar period of time, accompanied by a sense of lack of control overeating e) Intense fear of gaining weight, even though underweight f) Refusal to maintain body weight at or above normal weight for age and height Answer1: a Answer2: c Answer3: e

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Answer4: f

Ponder Part II: Ponder Reflect upon the changes in your empathy that came about during this activity.

Question type Essay 1. Consider how much you agree with the following statement: I can see this woman's perspective and understand how she would feel if I were in her shoes.

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CHAPTER 12 SEXUAL DISORDERS LEARNING GOALS 1. Describe the influence of culture and gender on sexual norms and some of the research methods and issues in sexuality research.

2. Explain the symptoms of the DSM-5 sexual dysfunction disorders, and the prevalence of sexual dysfunctions.

3. Discuss the biological and psychosocial influences on sexual dysfunctions.

4. Describe psychological and medication treatments for sexual dysfunctions.

5. Discuss the symptoms of the paraphilic disorders and debates about these diagnoses.

6. Explain the risk factors for paraphilic disorders and the limits in the knowledge concerning these risk factors.

7. Discuss common psychological and medication treatments for the paraphilic disorders, the current state of evidence about treatment efficacy, and the debates about community prevention programs.

The Learning Goals are inherent in both the Lecture Launchers and Discussion Stimulators below.

CHAPTER SYNOPSIS Every individual has their own sexual preferences which can vary greatly across individuals and these preferences can be unusual or surprising at times. When sexual fantasies or desires begin to affect us or others in unwanted or harmful ways they can be considered psychological disorders. This chapter briefly describes healthy sexual behavior and norms. Then the two forms of sexual problems considered: sexual dysfunctions and paraphilias. Sexual dysfunctions are defined by (1) persistent disruptions in the ability to experience sexual arousal, desire, or orgasm, or by (2) pain associated with intercourse. Paraphilias are defined by persistent and troubling attractions to unusual sexual activities or objects.

Sexual Norms and Behavior It is important to consider that definitions of what is normal or desirable in human behavior vary with time and place. More recent historical changes have influenced people’s attitudes about sexuality. Similarly, sexuality is profoundly shaped by culture and experience (age, gender, ethnicity, SES, and other key characteristics). Therefore, it is important to be aware of cultural norms and subjective biases in thinking

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about diagnoses. Research methods aimed at understanding normative sexual behavior has gone through a series of revolutions. Important insights have been gained by directly measuring physiological sexual responses using tools such as the penile plethysmograph or vaginal plethysmograph which have been used to better understand the relationship of sexual interest, subjective arousal, and biological arousal for men versus women. Gender shapes sexuality in various ways and sexual disorders in many ways.

Sexual Dysfunctions The DSM-5 divides sexual dysfunction into three categories: those involving sexual desire, arousal and interest; orgasmic disorders; and sexual pain disorders. See Table 12.3. The following sexual disorders are included in the DSM-5: Sexual interest, desire and arousal • Sexual interest/arousal disorder in women • Hypoactive sexual desire disorder in men • Male erectile disorder Orgasmic disorders • Female orgasmic disorder • Male early ejaculation • Male delayed ejaculation Sexual pain • Genito-pelvic pain/penetration disorder in women Although there are no good estimates of how many people meet formal diagnostic criteria for sexual dysfunctions, in one major survey, 43% of women and 31% of men reported at least some symptoms of sexual dysfunction. People who experience one sexual dysfunction disorder often experience a comorbid sexual dysfunction disorder; for example, a man who is experiencing premature ejaculation may develop hypoactive sexual desire disorder. Before diagnosing sexual dysfunction, it is important to rule out medical explanations for a symptom.

The etiology of sexual dysfunctions involves both biological and psychosocial influences. Medical causes of sexual dysfunctions or alcohol/substance abuse should first be ruled out. Biological influences may be specific to certain sexual dysfunctions. For example, in premature ejaculation, one possible cause is an overly sensitive penis. Psychosocial influences involved in sexual dysfunctions include previous sexual abuse, relationship problems, lack of sexual knowledge, other psychological disorders (e.g., depression, anxiety), low arousal and exhaustion, and negative cognitions and attitudes about sexuality.

Psychological treatments for sexual dysfunction include techniques to reduce anxiety, to increase knowledge and awareness of the body (psychoeducation), to reduce negative thoughts about sexuality, to improve couples communication (couples therapy), cognitive interventions to challenge self-demanding perfectionistic thoughts, and sensate focus exercises.

Medical treatments are increasingly popular, despite some criticism. Medications such as Viagra and Cialis are often used to treat erectile dysfunction. Antidepressant drugs can be helpful in the treatment of

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premature ejaculation. However, medication treatment for female sexual dysfunction is quite limited. The only approved medication for female sexual dysfunction is Addyi for premenopausal women with low sexual desire, but it has shown limited efficacy.

The Paraphilias Paraphilias are defined by recurrent sexual attraction to an unusual sexual object or activity that lasts at least six months and causes significant distress or impairment. The DSM-5 diagnostic criteria for paraphilias are distinguished based on the object of sexual attraction. The following paraphilias are included in the DSM-5: • • • • • • • •

Fetishistic disorder Transvestic disorder Pedophilic disorder Voyeuristic disorder Exhibitionist disorder Frotteuristic disorder Sexual sadism disorder Sexual masochism disorder

The etiology of paraphilias also involves neurobiological and psychosocial influences. Researchers do not know the prevalence of these disorders, nor is much research available on the causes of paraphilias.

Neurobiological influences that have been speculated to contribute to paraphilias include excess levels of male hormones such as androgens like testosterone which regulate sexual desires. However, men with paraphilias do not appear to have abnormally high levels of androgens.

Childhood sexual abuse may be an important etiological factor in the paraphilias. 40–66% of adult sexual offenders report a history of sexual abuse, but sexual abuse is not the whole story.

Psychological influences can include negative mood where sexual activity is used to escape negative affect, problems with emotion regulation, impulsivity, hostile attitudes toward women, lack of empathy toward sexual targets, poor judgment of emotional expressions of sexual targets, and neurocognitive deficits.

Although there are many approaches to treatment and community prevention, the research evidence regarding treatments for paraphilias is limited. Strategies to enhance motivation may be helpful to increase motivation and insight into an individual’s problems. Cognitive behavioral approaches include various versions of aversion therapy, including covert sensitization and satiation. Cognitive techniques are used to challenge distorted beliefs about the consequences of sexual behaviors. Cognitive behavioral therapists also use techniques to improve social skills, to help people control impulses, to increase empathy for potential victims, and to identify potential high-risk situations for the return of symptoms.

Prevention programs try to reach out to at risk offenders to intervene prior to their acting out on their impulses through community advertisements. These efforts have shown some success. Laws have been

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passed that allow the public to access information about where sexual offenders live, but civil liberties groups are opposed to some aspects of these laws.

The most common medication treatments involve antidepressants or medications that reduce male hormone (androgen) levels such as Depo-Provera, typically used with sex offenders.

KEY TERMS biological arousal delayed ejaculation disorder erectile disorder exhibitionistic disorder female orgasmic disorder female sexual interest/arousal disorder frotteuristic disorder

genito-pelvic pain/ penetration disorder incest male hypoactive sexual desire disorder orgasm paraphilic disorders pedophilic disorder penile plethysmograph

premature (early) ejaculation sexual dysfunctions sexual interest sexual masochism disorder sexual sadism disorder subjective arousal vaginal plethysmograph voyeuristic disorder

LECTURE LAUNCHERS 1. Transsexual Surgery at Age 74 Docter (1985, Archives of Sexual Behavior, 14, 271–277) presents an interesting case report of a man who underwent transsexual surgery at age 74. While “Marty/Mary Ann” reported lifelong weak fantasies of being a woman, he had only occasionally cross-dressed (in private) and was happily married for 37 years. Ten years after his wife’s death, Marty realized that he could experiment with his fantasies of being a woman without hurting his wife, and he contacted a club for transsexuals. Finding others who felt as he did, Marty became more comfortable crossdressing, and in fact began speaking to college classes about transvestism. After becoming friends with a female-to-male transsexual, Marty (now Mary Ann) lived for a year as a woman (a requirement in preparing for transsexual surgery) and underwent surgery at the age of 74. For the remaining three years of his life, he reportedly enjoyed a more active and satisfying social life than he had experienced as an isolated widower, and was treated as somewhat of a celebrity in the neighborhood he had lived in for 20 years.

The number of gender reassignment procedures conducted in the United States each year is estimated at between 100 and 500. The number worldwide is estimated to be two to five times

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larger. A new book, Hung Jury: Testimonies of Genital Surgery by Transsexual Men by Cotton, reviews the narratives of 14 men and their experiences with their partners. Overwhelmingly they report satisfaction and rarely regret undergoing surgery (Cotton, Trystan T. (Ed.). (2012), Transgress Press, Oakland, CA).

Historically is the story of Renee Richards, a professional tennis player: http://www.bbc.com/news/magazine-33062241.

2. Sex-Reassignment Surgery in Adolescence At the other end of the age spectrum, clinicians now recognize that in select cases, sexreassignment surgery may be an appropriate intervention for transsexual adolescents. Given the identity issues common to many adolescents, clinicians have been reluctant to agree to medical procedures related to gender dysphoria in this age group. The chance of making the wrong diagnosis (identifying someone as a transsexual when in fact they are going through a more transient phase of gender dysphoria) leads to a high level of concern about the risk of postoperative regret if sex-reassignment surgery is agreed to. On the other hand, most researchers agree that transsexualism begins in childhood, and that, around puberty, concerns about gender dysphoria can create other problems in development. In such cases, early identification and treatment might prevent unnecessary suffering.

A recent case of a South Carolina family’s experience with the reassignment of their child at the age of one has become a lawsuit. The child was born intersexed, had surgery to remove the male genitalia, and was reared as a girl for the first eight years. But now he identifies as a boy. See the link for more information: http://www.huffingtonpost.com/2013/09/12/north-carolina-genderreassignment-lawsuit-_n_3915532.html.

The most famous case is that of a boy, David Reimer. His parents were counseled to raise him as a girl after the loss of his penis during a circumcision at birth. He was never comfortable as a girl and after being told about the circumstances and then choosing to live as a male, even marrying and having adopted children, he committed suicide. The link has the interesting story: http://www.singlesexschools.org/reimer.html.

The physical aspects of sex reassignment are also easier in adolescence, particularly in male-tofemale patients. That is, if surgery is completed earlier, the transsexual will not have the deep voice and facial scarring which make it difficult for many male-to-female patients to successfully “pass” as women.

At the Utrecht University Hospital in the Netherlands, Cohen-Kettenis and Van Goozen have implemented sex-reassignment surgery with a select group of adolescents (ages 16 to 18) (1997; Journal of the American Academy of Child and Adolescent Psychiatry, 36, 263–271). The treatment begins with a thorough assessment of gender dysphoria that may take several weeks to several years. Patients are referred for the second phase of assessment, a “real-life diagnostic test,” if they demonstrate a lifelong extreme and complete cross-gender identity/role. The feelings must have intensified with puberty, and the patients must be psychologically stable and function socially without problems. The next phase includes partial hormone treatment (which blocks the action of sex steroids in a reversible way) and living full-time in the desired gender role. After one to one

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and a half years in the real-life test, successful patients are allowed to continue and have sexreassignment surgery.

The authors conducted a follow-up study of 22 patients who had undergone their last surgery at least one year prior to the study. Follow-up assessment included questionnaires and interviews with a person not involved in the diagnosis or treatment of transsexuals at the hospital. Results indicate very positive outcomes in these adolescents who had had sex-reassignment surgery.

Gender dysphoria was greatly reduced and within the normal range at follow-up. None expressed feelings of regret about their decision. All of the male-to-female transsexuals and most of the female-to-male transsexuals were satisfied with their general appearance. Of those who had stable sexual partners (36%),71% reported satisfaction with their sex life, 14% were neutral, and 14% were dissatisfied. It should be noted in this context that the female-to-male patients did not have a penis, since this aspect of surgery was postponed given that surgical techniques were felt to be steadily improving. The majority of subjects (89%) felt accepted and supported in their new gender role by everyone they knew. None had been harassed, and most had been approached in a flirtatious manner.

In terms of concurrent psychological functioning, there was a significant increase in extroversion, dominance, and self-esteem, and a significant decrease in inadequacy following treatment. All but three of the patients reported being satisfied or very satisfied with their lives in general, and, of the three dissatisfied patients, two were unemployed and had difficulties related to this situation.

When compared to studies of adult Dutch transsexuals who had undergone sex-reassignment surgery, the adolescents in this study were functioning better psychologically, had fewer social problems, and received more support from family and friends. Of course, the adolescent sample was pre-selected to be well adjusted; transsexuals with concomitant psychological problems were denied the opportunity for surgery. Clearly adults who undergo surgery after a long history of trying to live in the biological gender may have stronger ties to that role (e.g., as husbands, fathers, colleagues) that make the change more challenging.

3. Characteristics of College Men Who Are Aggressive Against Women The text discusses the view that rape is considered to be a violent act more than a sexual act, and that high levels of hostility toward women are found in men who rape. Since over 27% of collegeage men report having engaged in some form of physical aggression against their partners over the previous year, understanding the high rates of aggression against women in this age group is critical. 43% of college men admit using coercive behavior to have sex, including physical aggression and restraint.

4. Sexual Dysfunction The text reports that many people meet formal diagnostic criteria for sexual dysfunction disorders.

In one major survey, 43% of women and 31% of men reported at least some symptoms of sexual dysfunction. Since a large percentage of people have experienced sexual dysfunction, it is important to understand the causes and treatments for various sexual dysfunctions.

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5. Relapse Prevention with Sex Offenders Recidividism is high in sex offenders, and current beliefs about these paraphilics is that the most effective treatment involves several components. Since most offenders are not voluntary treatment participants, it is important to attempt to motivate them to participate in treatment.

Typically, initial therapy groups focus on motivating the offender to take responsibility for his offense, recognizing thinking errors, and beginning to write a sexual history. The sexual history is important to identify patterns of sexual behavior and identify any additional paraphilias that have not yet been disclosed. This is an extremely stressful part of treatment; the patient must pass a comprehensive polygraph examination based on this history that will be used for arousal management planning. Treatment now focuses on managing deviant arousal and identifying the behavioral chain that leads each man to reoffending.

Arousal management utilizes behavioral techniques that are designed to both decrease deviant arousal and increase appropriate adult arousal. In covert sensitization the patient writes a script of his offending behavior and a script of the most dire consequences he can imagine. Typically, the consequences involve arrest, public humiliation to himself and his family, and assault by other prisoners. The patient reads the offending script aloud followed by the aversive script repeatedly to increase the association between offending and adverse consequences. Patients are encouraged to replay the aversive script in their mind when they have deviant thoughts. Another arousal management technique, olfactory aversion, requires the offender to inhale ammonia immediately following a deviant thought. Appropriate arousal is reinforced when the patient reads an appropriate sexual script while masturbating to climax. Although these techniques have been shown to manage deviant arousal, they do not eliminate it.

The behavioral chain is a frame-by-frame account of the sexual offense. Patients identify some precipitating event and trace the links of thoughts, feelings, and behaviors that lead to the offense. They are then taught to identify the weak links in the chain and generate multiple alternatives for each. For example, if the patient isolated after a personal loss, he might alternatively call friends or coworkers to discuss his feelings.

When the offender has learned how to manage arousal and identify his dysfunctional behavioral chain, he develops a relapse prevention plan. This plan identifies risky situations, environmental restrictions, alternate behaviors, and plans to reduce his vulnerability to future offending.

Frequently, patients role play risky situations and learn to generate effective solutions to novel problems.

6. Case Study of Hypoactive Sexual Desire Disorder Students often enjoy hearing case studies, and the following example of hypoactive sexual desire, adapted from McCabe, M. P. (1992) Psychotherapy, 29, 288–296, provides an interesting description of integrated treatment of this disorder. A 47-year-old man, married 28 years, was seen for therapy because of loss of interest in sex and in sexual fantasies. He had intercourse once or twice in the past year, and reported sexual inhibition from an early age. He came from a very religious family and had never developed intimate relationships. His relationship with his wife was

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characterized by avoidance of discussion of personal matters and emotional distance. The following treatment was described: Communication Exercises: The first task of therapy was to establish a pattern of trusting communication between the client and his partner . . . This was a difficult demand for the client because he had never revealed any vulnerabilities to his partner. If uncertain about his ability to master a particular situation he would avoid pursuing either that or similar situations.

Sensate Focus Exercises: Previous sexual encounters involved little foreplay or preparation for intercourse. The approach to intercourse was cognitive and task oriented. The aim of the sensate focus program was to remove the emphasis from the goal of intercourse and to develop and encourage enjoyment of the body’s response to various sensual and sexual acts. The sensate focus exercises were designed to encourage physical responses to body stimulation, to foster a self-acceptance and enjoyment of these sensations, and eventually to achieve a situation where these behaviors were actively sought out and initiated by the client. These exercises also allowed both partners to discover and communicate to one another those sexual activities they enjoyed and those that they did not find pleasurable.

Fantasy: The client had used graphic sexual fantasies in the past to enhance his sexual performance. In fact, these fantasies distracted him from his participation in the sexual act and allowed him to depersonalize from the experience, act as a spectator, and still achieve the goal of orgasm. This strategy had become less effective in recent years. The use of graphic fantasies would appear to be counterproductive with this client. Such fantasies would simply encourage the return to depersonalized, goal-oriented sex.

Fantasies that were employed in the therapy sessions addressed the sensual capacities of the client. The two fantasies that were employed in the first two therapy sessions involved a reawakening of all the senses and the response of the senses to everyday events. During the third therapy session, when the sensate focus program was introduced, a massage fantasy was experienced. A male masseur gives a woman a massage, then she massages him. The setting is described (relaxed room, soft lights, soft cloths, incense, perfumed oils). Sensual and sexual feelings arise, but the activities stop short of overt sexual behavior. The client was instructed to use this fantasy in exploring his own reaction to body massage in the coming week.

The remaining fantasies complemented the sensate focus program, with an emphasis on the sensual as well as sexual reaction to the stimulation. The first of these was a composite story of extracts from a romantic historical novel. The remaining fantasies were extracts from modern erotic short stories by Anais Nin. The goal of these fantasies was to widen the sexual repertoire and model communication about sexual activities and feelings. They were designed to enhance the client's sensual and sexual response to all stages of lovemaking (p. 293).

DISCUSSION STIMULATORS

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1. “Tomboys” and “Sissies” The terms “tomboy” and “sissy” denote similar concepts: children of one sex who engage in behaviors that are stereotyped as being appropriate for the opposite sex. Interestingly, however, the two terms have very different connotations. A sissy is much more likely to be viewed negatively than a tomboy. What does this tell us about our social attitudes toward sex roles? We often think of females as having the more narrowly defined cultural sex-role, but is that really the case?

2. Demonstration of Sex-Conditioning An effective demonstration of sex-conditioning, homophobia, and proxemics (the study of personal space) can be done as follows: Ask two men to come to the front of the class. Position them to face each other at opposite sides of the room and ask them to walk toward each other and stop when they feel comfortable. Note the distance, and then ask them to approach each other as closely as they are able. Question them about how comfortable they feel. Ask them to hug each other. Have them sit down, then repeat the procedure with two women and then a man and a woman. Even though the class will anticipate your purpose during the first demonstration, the subsequent demonstrations should still work. Point out to the class how reluctant the males were to get close to each other, but how easily the females and mixed pair were able to do so.

3. Sex Survey If the class is large enough, a survey of students taken and tabulated before the lecture can provide an interesting backdrop and a springboard for discussion. Obviously, special efforts to ensure anonymity need to be made and its completion should be entirely optional. Survey is on the next page.

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Anonymous Sex Survey Sex: M F O 1. How often do you (does your male partner) ejaculate before it is desired? (circle one) never

rarely

occasionally

often

always

not applicable

2. How often do you (does your female partner) not have an orgasm during sexual relations? (circle one) never

rarely

occasionally

often

always

not applicable

3. How often do you (does your male partner) have difficulties achieving or maintaining an erection when wanted? (circle one) never

rarely

occasionally

often

always

not applicable

4. How often do you (does your female partner) have difficulty becoming sexually aroused when it is desired? (circle one) never

rarely

occasionally

often

always

not applicable

5. How long should intercourse last?

6. How often should two people with a normal level of sexual desire have intercourse (assuming they have an available partner)?

7. Should both partners reach orgasm at the same time?

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4. Sensate Focus Exercise To help students “get a feel” for what sex therapy techniques are like, you might suggest they try a simple sensate focus exercise outside of class, the “hand, face, foot caress.”

Students will need to ask a friend to participate in the exercise. They will take turns caressing their partner’s hand, face, or foot, moving very slowly and gently. The person doing the caressing is to focus only on the sensation of touching, experimenting with different kinds of touches, not thinking about what the partner is experiencing. The person being caressed should likewise focus on the experience of being touched. As an exercise in communication, the person being caressed can try telling the partner what feels especially good, including what type of touch, how light or hard, how fast or slow. After the exercise, partners can talk with each other about what it felt like to caress and to be caressed.

5.

Self-Help Books on Sexuality Many popular books are available in bookstores that can be helpful to men and women who are interested in their sexuality. Students might be encouraged to read one of these in conjunction with this chapter of the text. Exploring Human Sexuality: Making Healthy Decisions (McAnulty, R. D. and Burnette, M. M., 2000, Boston: Allyn & Bacon) and Sex Matters for Women: A Complete Guide to Taking Care of Your Sexual Self (Foley, S., Kope, S., & Sugrue, D., 2002, New York: Guilford Press) are two recommendations. There are many self-help books on sexuality, with titles that address virtually every sexual issue. The buyer needs to be discriminatory in the selection of books that may be useful.

5. Case Studies Helen Singer Kaplan’s Disorders of Sexual Desire (1979, New York: Brunner/Mazel) contains numerous case examples of inhibited sexual desire and other sexual dysfunctions, complete with descriptions of therapeutic approaches and complex problems that sometimes develop during treatment. You might want to pass out copies of one or two cases and have the class discuss Kaplan’s analysis of the problem and treatment approach.

6. Adolescent Sexuality An article by Brooks-Gunn and Furstenberg in American Psychologist (1989, 44, 249–257) raises many topics about adolescent sexuality that may provoke interesting discussion in class: Age at first intercourse. Dramatic changes in the age at first intercourse have occurred in the last 50 years. Approximately 7% of white females had intercourse by age 16 in the 1940s and 1950s; by 1982, the figure had risen to 44%. Recently, the figure has fallen some. Interestingly, similar data for boys have not been collected, suggesting that our society sees fertility control as a female, not a male issue. What age do students think is appropriate for first intercourse?

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What factors affect their decision? What do they see as the most important factors determining when a person becomes sexually active: Parents’ values? Peer behavior? Religious beliefs? Statistics about when youth begin sexual intercourse: http://www.webmd.com/sexrelationships/news/20120816/when-do-us-youths-start-oral-sex-intercourse#1.

Antecedents to sexual experiences in adolescence. Research indicates that most adolescents do not consciously plan to become sexually active. Important antecedent factors identified include hormonal changes associated with puberty, contextual effects (what is considered normal sexual behavior in the peer group), development of secondary sexual characteristics, parental influences, including communication and supervision, and school functioning (teens who are not doing well in school are more likely to begin sexual activity during adolescence).

Contraceptive use. About one half of all teenagers do not use contraceptives when they first engage in sexual relations, and many continue to have unprotected intercourse for years. Why do students think this problem exists? Research indicates that teenagers put off coming to a family planning clinic because of procrastination, ambivalence about their sexual behavior, and fear of their parents finding out. What would make adolescents more likely to use contraception? Factors found to be associated with irregular contraceptive use include lower social class, nonattendance of college, fundamentalist Protestant affiliation, lack of a steady partner, never having been pregnant, infrequent intercourse, and no access to free, confidential family planning. In addition, teenagers who have little communication or have conflict with their parents, and those who do not know about their parents’ contraceptive experience, are less likely to use birth control. Again, these findings all concern girls; very little is known about male contraceptive use.

Students might be asked to design a program for increasing the use of contraception among sexually active adolescents. What approaches would they recommend? What age group would they target? How might approaches differ for boys vs. girls? How would they present their ideas to parents? What problems do they foresee with implementing such a program?

Effective birth control for teens https://www.healthychildren.org/English/agesstages/teen/dating-sex/Pages/Birth-Control-for-Sexually-Active-Teens.aspx.

INSTRUCTIONAL FILMS 1. Male sexual dysfunction https://www.youtube.com/watch?v=h6PQaWySHrY. 2. Female sexual dysfunction https://www.youtube.com/watch?v=Z6mC16Q0ZL8.

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3. Paraphilic disorders https://www.youtube.com/watch?v=YOV61lKxqxY. 4. Ted Talk on Healing Adult Survivors of Childhood Sexual Abuse https://www.youtube.com/watch?v=5viOYkM4CRE. 5. Gender dysphoria https://www.youtube.com/watch?v=YTR-22LC4_Y. 6. The Genderbread Person—a useful tool to illustrate gender identity, gender expression and biological sex https://www.youtube.com/watch?v=89Az3m-qJeU. https://www.youtube.com/watch?v=-cdsGFnNp6Q. 7. Many movies have been made about sexual abuse and the tragic stories they tell. Here is a link that describes several: http://annex.wikia.com/wiki/List_of_films_portraying_paedophilia_or_sexual_abuse_of _minors.

DISCUSSION QUESTIONS These questions are based on the clinical case studies and other information found in boxes throughout the chapter.

Anne Clearly Anne’s traumatic experience with her brother affected her ability to fully enjoy sexual relationships. What other factors might interfere with normal sexual experience?

Robert Given Robert’s stated lack of interest in sex with his fiancé or with any women, can this couple be helped? How might the therapist help Robert resolve his lack of interest in se so they can move forward to marriage? What possible interventions and suggestions can be made to help Robert?

Bill Discuss what may have caused Bill’s performance anxiety. How was this resolved?

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William (and Nancy) In reviewing the case of William and Nancy, what factors led up to his voyeuristic behavior? How was this resolved?

Carol Discuss the issues for Carol that were inhibitory in being sexual with her husband?

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CHAPTER 13 DISORDERS OF CHILDHOOD

LEARNING GOALS 1. Describe the issues in the diagnosis of psychopathology in children.

2. Discuss the description, etiology, and treatments for externalizing problems, including ADHD and conduct disorder.

3. Discuss the description, etiology, and treatments for internalizing problems, including depression and anxiety disorders.

4. Understand the description, etiology, and treatments for intellectual disability.

5. Describe the symptoms, causes, and treatments for autism spectrum disorder.

The Learning Goals are inherent in both the Lecture Launchers and Discussion Stimulators below.

CHAPTER SYNOPSIS This chapter discusses several disorders that are most likely to arise in childhood or adolescence. First, disorders involving inattention, impulsivity, and disruptive behavior are discussed, followed by depressive and anxiety disorders. Finally, we discuss disorders involving problems in the acquisition of cognitive, language, motor, or social skills, including specific learning disorder, intellectual disability, and autism spectrum disorder (ASD). Rates of childhood psychological disorders have increased dramatically in the past three decades. Like adult disorder, childhood disorders also involve a combination of genetic, neurobiological, behavioral, and social influences in their etiology and treatment.

Classification and Diagnosis of Childhood Disorders The field of developmental psychopathology often organizes childhood disorders into two domains: externalizing disorders and internalizing disorders. Externalizing disorders are characterized by more outward-directed behaviors, such as aggressiveness, noncompliance, overactivity, and impulsiveness; they include attention-deficit/hyperactivity disorder, conduct disorder, and oppositional defiant disorder.

Internalizing disorders are characterized by more inward-focused experiences and behaviors such as depression, social withdrawal, and anxiety, and include childhood anxiety and mood disorders.

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Externalizing Disorders: Attention-Deficit/Hyperactivity Disorder and Conduct Disorder Attention-deficit/hyperactivity disorder (ADHD) is a persistent pattern of inattention and/or hyperactivity and impulsivity that is more frequent and more severe than what is typically observed in children of a given age. Conduct disorder is sometimes a precursor to antisocial personality disorder in adulthood, though many children carrying the diagnosis do not progress to that extreme. It is characterized by high and widespread levels of aggression, lying, theft, vandalism, cruelty to other people and to animals, and other acts that violate laws and social norms. Both disorders are more common in boys than girls, though research has begun to examine externalizing problems in girls. These disorders appear across cultures, although there are also differences in the manifestation of externalizing symptoms in different cultures.

A number of factors work together to influence risk for ADHD and conduct disorder. Genetic influences play a particularly important role in ADHD but are also implicated in conduct disorder. Neurobiological research has implicated areas of the brain and neurotransmitters such as dopamine in ADHD. Neuropsychological deficits are seen in both disorders. Other risk factors for ADHD include low birth weight and maternal smoking. Family factors such as parenting practices and peer influences are also important factors to consider, especially in how they interact with genetic vulnerabilities.

The most effective treatment for ADHD is a combination of stimulant medication (e.g., Adderall, Ritalin), and behavioral therapy. For conduct disorder, family-based treatments are effective, such as parent management training (PMT), as are treatments that include multiple points for intervention (family, school, and peers), as in multisystemic treatment (MST). Some more recent work has focused on prevention programs, such as the FAST Track program, to prevent conduct disorder before it becomes problematic.

Internalizing Disorders: Depression and Anxiety Disorders Depression and anxiety disorders often first begin in childhood and adolescents and continue into adulthood. Rates are often higher among minority youth. These disorders are also often comorbid, as in adults. Depression in childhood and adolescence looks similar to depression in adulthood, although there are notable differences. In childhood, depression affects boys and girls equally, but in adolescence girls are affected twice as often as boys (15.9 vs. 7.7%). About 3–5% of children and adolescents are diagnosed as having an anxiety disorder. Anxiety and fear are typical in childhood. When fears interfere with functioning, such as keeping a child from school, intervention is warranted.

Separation anxiety disorder is a particular anxiety disorder associated with childhood characterized by constant worry that some harm will befall the child’s parent(s) or other caregivers. This can often lead to problems such as school refusal.

Etiological risk factors for mood and anxiety disorders are similar to those for adults and include interactions of genetic and environmental influences. Particular childhood stressors such as abuse, neglect, or bullying are also important influential factors. Cognitive factors, such as attributional styles, also play a role in adolescent depression.

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CBT is effective for pediatric mood and anxiety disorders, and interpersonal therapy is also effective for depression in adolescents. Medication can also be effective for treatment of depression in adolescents, particularly in combination with CBT, but its use is controversial. For pediatric OCD, a combination of CBT and an SSRI (sertraline) was found to be effective.

Specific Learning Disorder and Intellectual Disability A specific learning disorder is a condition in which a child shows a problem in a particular area of academic, language, speech, or motor schools that is not due to intellectual disability or deficient educational opportunities. DSM-5 includes several disorders in areas of learning, communication, and motor development (see Table 13.3). These disorders are often identified and treated within the school system rather than through mental health clinics.

Dyslexia is not named as a distinct disorder in DSM-5, but is included as one type of specific learning disorder as a specifier involving impairment in reading that affects 5–15% of school-age children, with rates higher in boys than girls. Other specific learning disorders include dyscalculia (i.e., impairment in math) and dysgraphia (i.e., impairment in written expression).

The DSM-5 uses the term intellectual disability rather than mental retardation, and emphasizes the importance of assessing intellectual ability and adaptive functioning with a person’s cultural group. The approach of the American Association on Intellectual and Developmental Disabilities (AAIDD) stresses the importance of identifying an individual’s strengths and weaknesses. This shift in emphasis is associated with increased efforts to design psychological and educational interventions that make the most of individuals’ abilities. In line with the AAIDD, categories in the DSM-5 are no longer to be based solely on IQ scores, although intellectual assessment is an important component.

There are a number of known causes of intellectual disability, including genetic abnormalities (i.e., Down syndrome or Trisomy 21, fragile X syndrome, phenylketonuria or PKU), infections (e.g., HIV, rubella, syphilis), and toxins. Many children with intellectual disability who would formerly have been institutionalized are now being educated in the public schools under the provisions of Public Law 94–142 (Education for All Handicapped Children Act, 1975). In addition, using applied behavioral analysis, selfinstructional training, and modeling, behavior therapists have been able to successfully treat many of the behavioral problems of individuals with intellectual disability and to improve their intellectual functioning.

One type of behavioral intervention is called functional communication training (FCT).

Autism Spectrum Disorder (ASD) Autism spectrum disorder begins early in life, and the number of children with these diagnoses has risen in recent years. Current prevalence rates of ASD estimate that it affects about 1 in 54 children and is found across all SES, ethnic and racial groups. It is also a very stable diagnosis. The major symptoms are a failure to relate to other people; communication problems, consisting of either a failure to learn any language or speech irregularities, such as echolalia and pronoun reversal; and theory of mind problems. Children with

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ASD often have trouble with making eye contact and their gaze may have an unusual quality, often referred to as a problem in joint attention.

A number of genetic and neurobiological influences have been identified as contributing to ASD. Family and twin studies give compelling evidence of a genetic predisposition in autism spectrum disorder.

Abnormalities have been found in the brains of children with autism spectrum disorder, including an overgrowth of the brain by age 2 and abnormalities in the cerebellum.

The most promising treatments for ASD involve intensive behavioral interventions and work with parents.

Medications have been used to treat problem behaviors associated with ASD, such as antipsychotic medications, but these have proven less effective than behavioral interventions and can involve serious side effects.

KEY TERMS attention-deficit/hyperactivity disorder (ADHD) autism spectrum disorder conduct disorder developmental psychopathology Down syndrome (trisomy 21)

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Dyslexia

joint attention

externalizing disorders

multisystemic treatment

fragile X syndrome

parental management training (PMT)

functional communication training (FCT)

phenylketonuria (PKU)

intellectual disability

separation anxiety disorder

internalizing disorders

specific learning disorder

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LECTURE LAUNCHERS 1. One Child’s View of Being Hyperactive The following are quotes from taped therapy sessions with a 9-year-old boy who had what would now be called ADHD. The quotes are taken from the Ross and Ross book, Hyperactivity (1982, New York: Wiley).

“ . . . The very first day Mrs. K. (teacher) says, ‘Oh, you're David J.,’ and right in front of everyone she says when do I take my pills.”

“ . . . then the new girl says, ‘Is your brother MR?' and Sal (sister) says that I got minimal brain dysfunction and the other girl says, ‘That’s MR.’”

“Chrissie Wilson had her Reckless Robert Robot in science class and it got started and wouldn’t stop and Randy said, ‘Man that robot’s hyper just like Davey! Give it a pill, Davey,’ and everyone laughed.”

“The doctor says I'll be OK when I'm 14. Well, I'm only nine. He acts like 14 is next week.”

“Dad started telling the Rec Leader about me and he just laughed and says, ‘No problem, Mr. J., I was too and so was Tom Edison and two of my buddies who are in think tanks now’ . . . and when he told who were the new ones that day all he said was, ‘Glad to have you, Dave, I know your brother’ . . . just like I’m like the other kids.”

“ . . . when it’s special like a party I have to go to the sitter’s . . . I heard my Mom say, ‘If only we could send him away to school.’”

“ . . . and then she (mother) gives Dad one of those looks and he like reads it and then he says, ‘Maybe just Sal and Peter (brother) should go this time.’ They think I'm really stupid. I know I never get picked to go . . . Every time is this time.”

“ . . . Sal has to take me places like I’m a dog and when we go to the Safeway where all the boys are Sal goes like, ‘Mom, do I have to take Davey?’ and she’s

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practically crying. So when we get to the park I say, ‘Sal, can I swing?’ and she gets me on the way back.”

“I don't get them (pills) weekends so I can grow and it’s scary because I'm one of the smallest in my class now and how can I catch up on only growing two days a week?”

“. . . medications is like in a big thick space suit with ear muffs and things get real fuzzy like far off.”

“I got no friends coz I don't play good and when they call me Dope Freak and David Dopey I cry, I just can’t help it.”

“ . . . in my best one (daydream) I pretend I’m Richard Dean and it’s the city playoff the next day and Mr. Simpson (P.E. teacher) looks at me and say, ‘We really need you tomorrow, Rich.’”

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2. The NIMH Multimodal Treatment for ADHD On the one hand, ADHD treatment is an optimistic field; many interventions have been carefully studied, and many of them work. On the other, very little data is available to tell us which treatments, in which combinations, or for which children, in which areas of functioning, actually work. Longer-term effects of treatment are also unknown.

The good news is that the National Institute of Mental Health, with co-sponsor U.S. Department of Education, has decided to answer these questions through a multi-site study of multimodal treatment of ADHD. At each of six sites, 96 children are randomly assigned to one of four groups: 1. Medication alone 2. Psychosocial treatment alone (including parent training, school consultation, intensive summer camp, and 12 weeks of assistance from a paraprofessional classroom aide) 3. Both (1) and (2) in combination 4. Community treatments of the family's own choosing A full description of the study design can be found in Richters, Arnold, Jensen, Abikoff, Conners, Greenhill, Hechtman, Hinshaw, Pelham, & Swanson (1995; Journal of the American Academy of Child and Adolescent Psychiatry, 34, 987–1000).

Mona Redja of the Wright Institute conducted a study “ADHD assessment and treatment by pediatricians: A study of the implementation of the American Academy Of Pediatrics and American Academy of Child and Adolescent Psychiatry ADHD guidelines” (Dissertation Abstracts International: Section B: The Sciences and Engineering, 74(12–B), 2014). ADHD is primarily treated by physicians. The study sampled 41 pediatricians and discovered that 67% did not obtain evidence of functional impairment across more than one setting for a diagnosis of ADHD. Forty-nine percent will give a diagnosis of ADHD solely based on a behavioral rating scale. The majority, at 73%, do not conduct assessments of comorbid conditions. And 95% of physicians recommend pharmacotherapy. Wolraich surveyed four school districts across two states and discovered a large portion of the children in the study were medicated (Journal of Attention Disorders, 18(7), 2014, 563–575).

3. Learning Disabilities in Adulthood It is likely that at least one student in your class has a learning disability, given the current recognition that these disorders persist into adulthood. A special issue of the Journal of Learning Disabilities (1992, 25) is devoted to “Learning disabilities: The challenges of adulthood.” Some highlights: Brinckerhoff, Shaw, & McGuire (Learning disabilities: The challenges of adulthood. Patton, J. (Ed.); Polloway, E. A. (Ed.); Austin, TX: PRO-ED; 1996. 71–92) focus on service delivery for learning-disabled college students. Students may be interested in learning that, just as P.L. 94– 142 protects the rights of children to a free, appropriate education, Section 504 of the Rehabilitation Act of 1974 requires that persons with disabilities be ensured program accessibility, provided that they meet the academic standards of an educational program. For college students with learning disabilities, this means that colleges may need to modify academic

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requirements (such as by allowing extra time on tests) in order to afford an equal opportunity to succeed in school.

Vogel & Adelman (Journal of Learning Disabilities, 25(7), 1992, 430–441) present a study comparing the educational success of LD and non-LD college students, matched on ACT scores.

The study was conducted at a school that provides extensive support and counseling for LD students. Interestingly, there was no correlation between the ACT scores and GPA upon exit from college for the LD group, and the correlation was also quite small for the non-LD group. The LD group was found to have higher GPAs upon leaving college than the non-LD group. The authors hypothesize that this finding is explained by the services offered to LD students at this particular college, including advisement regarding dropping courses rather than risk failing grades, determining a manageable course load, and identifying instructors who are sensitive to the needs of LD students. Based on their findings, the authors recommend that admissions officers weigh high school preparation and performance more highly than admissions test scores.

Encouraging LD students to take a lighter course load and not expect to complete a B.A. in four years is also recommended.

4. First-Person Perspectives on Being Learning Disabled The poignancy and determination of adults who have struggled with learning disabilities are captured in Polloway, Schewel, and Patton's compilation of first-person accounts (Journal of Learning Disabilities, 25, 520–522). Some excerpts: I get very defensive still . . . and am afraid to ask questions in fear that I will be wrong. Every teacher should remember their worst class when they were in school and realize that that’s how LD kids feel all the time.

I faked my way through school because I was very bright. I resent most that no one picked up on my weaknesses. . . A blow to my self-esteem when I was in school was that I could not write a poem or a story . . . I could not write with a pen or pencil. The computer has changed my life. I do everything on my computer. It acts as my memory. I use it to structure my life and for all of my writing since my handwriting and written expression have always been so poor.

I had a tutor for 8 years who helped me reach my fullest potential. . . . My tutor built my self-confidence . . . concentrated on what I could do. I had ideas but couldn’t write them so she taped them and then I listened and wrote them.

5. Community-Based Instruction Community-based instruction (CBI) is teaching that is undertaken in community settings. Usually, this is coordinated with schools and extends the learning experience into a natural setting. As mentioned in the text (p. 500), mild and moderately retarded individuals are able to function in varying degrees in the community. With CBI, they learn skills to adapt to unique situations. One

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of the problems associated with CBI is how to manage inappropriate student behavior in the community. One of the most common behavioral techniques is timeout; however, secluding an individual in the middle of a community outing is difficult.

In a recent study (2002), moderately retarded students were given a contingency ribbon and taught that when they were wearing the ribbon, they would be able to receive tokens for appropriate behavior. Students could use the tokens to purchase dessert, choose their own seat partner on the bus, or purchase extra privileges.

One student in this study regularly touched himself inappropriately while on outings. The teacher explained to that student that when he touched himself, she would remove the ribbon (an athletic sweatband) and that he was to stand next to the teacher for a 5-minute period without the possibility of earning tokens (non-seclusionary timeout). When the timeout period was completed, the ribbon was returned and the student could then earn tokens for prosocial behavior.

Using an ABAB design, the baseline frequency was established, then the timeout procedure implemented. At baseline, the mean frequency of the student's inappropriate behavior was 11.8.

When the timeout procedure was implemented, the frequency of inappropriate behaviors dropped significantly (mean = 3.6). When the intervention was withdrawn, the inappropriate behaviors returned to the baseline level. During the second intervention, his inappropriate behaviors dropped to zero and remained there when reinforcement was thinned.

The study confirmed that instruction in the community could be conducted in a non-invasive manner. The ribbon acquired stimulus control properties; the student verbalized that he could not get tokens for ice cream when the ribbon was removed. This procedure allowed the teachers to continue the outing and work effectively with the other students.

Alberto, P., Heflin, L. J., & Andres, D. (2002). Use of the timeout ribbon procedure during community-based instruction. Behavior Modification, 26, 297–311.

6. What Is Intelligence?

While traditional IQ tests have demonstrated their validity for predicting success in school (at least in Western societies), critics have argued that such a criterion does not capture the full meaning of the word “intelligence.” Howard Gardner, in particular, has proposed a theory of “multiple intelligences” to encompass a broader vision of the nature of the mind (1983, Frames of Mind, New York: Basic Books). His prerequisites for an area of skill to be called intelligence include: 1. it must enable the individual to resolve genuine problems or difficulties and create (where appropriate) an effective product and 2. it must include the potential for finding or creating problems. In other words, the skill must be useful in some way, although the value of particular abilities can vary across cultures and time frames. The navigational skills of an Indian sailor, the musical prowess of a Mozart, the language ability of a Dostoyevsky, all may be seen as useful within the

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individual’s culture (though perhaps not in another culture). In addition, Gardner has outlined a number of criteria or “signs” that most often signal the presence of a separate intelligence: a. potential isolation by brain damage, b. the existence of idiots savants, prodigies, and other exceptional individuals within the domain of ability, c. an identifiable core operation or set of operations, d. a distinctive developmental history and definable set of “end-state” performances, e. an evolutionary history and evolutionary plausibility, f. support from experimental psychological tasks, g. support from psychometric findings, and h. susceptibility to encoding in a symbol system.

Finally, Gardner presents his provisional compilation of eight domains that qualify as separate intelligences: linguistic, musical, logical-mathematical, spatial, bodily-kinesthetic, naturalistic, intrapersonal and interpersonal (the latter two intelligences include the ability to access one’s own feeling life and the ability to notice and make distinctions among other individuals, particularly their moods, temperaments, motivations, etc.). Students might be encouraged to evaluate this set of candidates for intelligence, arguing for the exclusion of any of the domains, the inclusion of other domains not listed, and the value of considering multiple areas of intelligence vs. the traditional conception of intelligence favored in our society. See Gardner’s 2000 book Intelligences Reframed: Multiple Intelligences for the 21st Century, Basic Books. Here is a link to a printable MI Inventory: http://schoolofeducators.com/tag/multiple-intelligence-test-printable/.

7. Home Videos and the Early Recognition of Children with Autism The very early development of children with autism is a mystery. Most autistic children are not diagnosed until around age 4 and, after diagnosis, retrospective reports of early development may be contaminated by later observations. An innovative strategy to address this problem involves examination of home videotapes of children’s first birthday parties (Osterling & Dawson, 1994; Journal of Autism and Developmental Disorders, 24, 247–257). Home videos of 11 children with autism and 11 normally developing children were collected and coded. The coding system focused on social, affective, joint attention, and communicative behaviors, as well as specific autistic behaviors such as self-stimulatory behavior and staring blankly.

Variables that distinguished between groups included joint attention behaviors such as pointing and showing and social behaviors including looking at the face of another, seeking contact, and imitating. In addition, children with autism were much less likely to orient to their name being called. Using a stepwise discriminate analysis, 91% of the subjects were correctly classified based on the coding system. In addition, the variable of “looking at the face of another” correctly classified 77% of the children.

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The authors note that given the results of this study, efforts should be made to identify and intervene with autistic children at much younger ages than is currently the norm in the field.

8. Controversy and the Lovaas Findings on Treatment of Autism The landmark Lovaas (1987) study described in the text reports that nearly half of the autistic children given the intensive experimental treatment achieved “normal functioning” by the end of the program. Normal functioning in this study was defined as an IQ above 80 and successful participation in a mainstream public-school classroom. These dramatic and unusual results have generated considerable controversy, as researchers challenge the methodology and conclusions of the study. Students may benefit from reading the comments in Journal of Counseling and Clinical Psychology (1989, 57, 162–167) by Schopler, Short, and Mesibov, and the rejoinder by Lovaas and colleagues. But first, students could be asked to meet in groups and come up with a proposal for a treatment outcome study of autism, including how they would choose subjects, how subjects would be assigned to treatment groups, and what outcome measures they would use. This exercise will alert them to the issues that arise in designing treatment outcome research and increase their appreciation of the points raised in the Lovaas controversy.

Schopler et al. challenge the Lovaas study on three points: 1. The usual outcome measures, such as standard assessments of social, behavioral, and communication functioning before and after treatment, were not used. The classroom placement criterion used by Lovaas may be influenced more by school policies regarding special-needs children and advocacy by parents and treatment staff than by actual changes in the children. IQ changes may reflect increased compliance rather than improvement in cognitive functioning.

2. Schopler et al. assert that the method of subject selection was biased, resulting in a relatively high-functioning subject group.

3. The control group in the Lovaas study was criticized as inadequate; control subjects were not assigned to the group randomly and may have been those whose parents were less involved, and the control treatment involved less time and energy, so that greater improvements in the experimental group may have been the result of greater attention rather than the specific (and costly) behavioral techniques employed.

In their reply, Lovaas, Smith, and McEachin address each of the points raised by Schopler et al., defending their choice of outcome measures as clinically relevant, challenging the assertion that their subjects were higher functioning than other groups of autistic children, and noting that an attention control group would not be expected to achieve a favorable outcome, based on the failure of dedicated and attentive parents and teachers to cure the disorder.

9. A First-Person Account of an Adult Autistic Man Excerpted below, with some punctuation and spelling corrections made by the professionals who published the account (Volkmar & Cohen, 1985), is a first-person report by a 22-year-old man

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who had been treated for autism as a very young child at the Yale Child Study Center and who had returned to gain access to his records. In the course of many meetings with the staff, he decided to write an account of his experience as an autistic child and now as a young adult. This depiction is unusual because autistic children seldom acquire enough cognitive and linguistic abilities to communicate in this way.

“Tony” had been described by his parents as, from the first weeks of life, avoiding human contact, never smiling responsively to others, and being preoccupied with his hands and with spinning objects. When examined at 26 months of age at the Yale Center, he did not speak, exhibited bizarre and highly stereotyped behavior, and showed no interest in others. After treatment at the center, he was able to enter a special education program in a public school and was even able to attend a private high school until the tenth grade. His WAIS IQ at the time he wrote his autobiographical account was 94 Verbal, 92 Performance, and 93 Full Scale, which placed him just a little below the average and was described as “a testament to his intellectual abilities” (Volkmar & Cohen, 1985, p. 48). When he contacted the center, he was employed as an assembler in a local industry.

Tony’s account of his life contains features that are often found in people with autistic disorder, such as his sense of social isolation, inability to empathize with others, unusual sensory experiences, and pervasive anxiety (and occasional abuse of alcohol in attempts to diminish it).

Less typical of such individuals are the anger and aggressive tendencies he reports, and perhaps also his desire to be considered normal and his interest in the opposite sex. The reader should note that Tony succeeded in obtaining a driver’s license and enlisting in the army.

“Autism: The Disease of Abomination” Tony W. I was living in a world of daydreaming and Fear revolving about myself I had no care about Human feelings or other people. I was afraid of everything! I was terrified to go in the water swimming, (and of) loud noises; in the dark I had severe, repetitive Nightmares and occasionally hearing electronic noises with nightmares. I would wake up so terrified and disoriented I wasn't able to Find my way out of the room for a few minutes. It felt like I was being dragged to Hell. I was afraid of simple things such as going into the shower, getting my nails clipped, soap in my eyes . . . I remember Yale Child Study Ctr. I ignored the doctors and did my own thing such as make something and played or idolize it not caring that anybody was in the room. I was also very hat(e)full and sneakey. I struggled and breathed hard because I wanted to kill the guinea pig; as soon as the examiner turned her back I killed it. I hated my mother because she try to stop me from being in my world and doing what I liked; so I stopped and as soon as she turn her back I went at it again. I was very Rebellious and sneaky and destructive . . . I also (had) a very warp sense of humor and learn(ed) perveted thing(s) very quickly. I used to lash out of control and repeat sick, perverted Phrases as well as telling people violent, wild, untrue things to impress them . . . I like mechanical Battery Power toys or electronic toys.

Regular toys such as toy trucks, cars that wernt battery powered didn’t turn me on at all.

I was terrified to learn to ride the bicycle. One thing I loved that not even the Fear could stop was Airplanes. I saw an air show the planes-f4s-were loud. I was allway(s) impressed

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by airplanes. I drew pictures and I had several Airplane models. The Test came when we went to D.C. I was so Anxious and Hyper to go on the plane I drove my Parents nuts. The only peace they had is when I heard the turbines reving at the end of the runway. Then I knew we were taking off. Soon as the plane took off I was amazed. I started to yell y(a)h HO! I loved every minuit of it. I allways loved Hi tech thing(s)-Planes, Rockets . . . I dont or didnt trust anybody but my self-that still (is) a problem today. And (I) was and still (am) verry insucure! I was very cold Hearted too. I(t) was impossible for me to Give or Receive love from anybody. I often Repulse it by turning people off. Thats is still a problem today and relating to other people . . . I would hear electronic Noises and have quick siezious (seizures) in bed and many other ph(y)sical problems. Often I have to be Force to get things done and (was) verry uncordinated. And was verry Nervious about everything. And Feared People and Social Activity Greatly . . . I lived with my father and the(n) saw the so call(ed) normal, sick teenage world. I was 14. I set my will (to) be normal like everybody else. (I) look(ed) up to people in school and did what they did to be accepted and put (up) more of a show to hide the problems and be Normal. I forced(d) myself to Know all the top rock groups, smoke pot, and drink and (tried to) have a girlfriend. This was the 9th grade and 10th. I constantly got in trouble in school and did som(e) real crazy things to be cool. Like everybody else I thought I was all normal. Most of it was a failure. More people hated me then ever . . . I went into the army and got in lots of Fights with people.

So I got dicarged [discharged] . . . I worked a few more Jobs and hung around w/some Crazy people I knew from school and got drunk a lot and did distructive [destructive] things. Magnified Fears and Peronia on pot. I never got Fired from a job. My problems havn't [haven’t] changed at ALL from early childhood. I was Just able to Function. And it still (is) the same today-1983 (Volkmar & Cohen, 1985, pp. 49–52).

Volkmar, F., & Cohen, D. J. (1985). The experience of infantile autism: A first-person account by Tony W. Journal of Autism and Developmental Disorders, 15, 47–54.

10.

Behavioral Treatment of Autism: Case Example

Clara Park (1987, Growing Out of Autism. In E. Schopler & G. B. Mesibov (Eds.), Autism in adolescents and adults. New York: Plenum), mother of an autistic child grown up, writes of her discovery of an innovative behavioral program to teach her daughter essential social skills.

There is a sense in which the most important thing Jessy ever learned was to smile and say hello.

How did she learn to do this? Certainly a cheerful household contributed. But it was by no means enough . . . However we coaxed and encouraged, she did not in fact learn to greet another human being until she was 14 years old. She learned it not through imitation or osmosis, but through a behavior-modification program. . . . Jessy learned to say “Hello, Mrs. Jones” via an ordinary, score-keeping golf counter, available at any sporting goods store. “Hello” earned her one point; eye contact, another; the proper name, a third. “Hello, Mrs. Jones” . . . and people at school began to report their astonishment. Jessy was suddenly so much more friendly. Of course they were all smiles, greeted for the first time after Jessy had so long ignored them. Social

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reinforcement could hardly have been stronger or more naturally delivered. It was some time before they noticed the click-click-click of Jessy’s counter.

This was only one of the many behaviors that could gain or lose points. Jessy kept track of them all, with autistic literalness. Autistic people don't cheat. We had stumbled onto the system by accident: Jessy had seen the counter on a visiting child, been fascinated with an instrument that combined two of her strongest interests, clicks and numbers, and decided she wanted one of her own. Only slowly did we discover how to use it, to utilize her strength—her exactitude and thoroughness, her grasp of numbers—to address her weaknesses. . . . We watched in amazement as Jessy . . . rapidly acquired a large repertoire of new behaviors and eliminated others we had assumed we must live with forever, spurred on by something no more concrete than a rising tally. (Years later, she was to watch with the same satisfaction the rising balance in her bank account.) (pp. 291–292)

11.

Treatments That Do not Work

We are fortunate to have the case of treatments for enuresis to teach an historical lesson about the pitfalls of our current enthusiasm for empirically supported treatments. The treatment of enuresis has a long and very colorful history dating as far back as 1550 b.c. In West Africa, children who wet the bed were “treated” by attaching a large frog to their waist, and this apparently frightened them into being dry. Among the Navaho tribe, one preferred treatment was a ritual that required enuretic children to stand naked over a burning bird’s nest. This was believed to produce a cure of bedwetting because birds did not soil their nests. We may snicker at these practices of the past, but the laugh is really on us. These practices worked, and they worked on a variable interval schedule of reinforcement because they were occasionally followed by the spontaneous cessation of bedwetting, something that happens for about 16 out of every 100 children within a 12-month period. It is no wonder, then, that so many peculiar treatments have been tried, and so many odd practices have persisted. In some ways what we really need to know about treatments for bedwetting is what treatments definitely do not work.

12.

Enuresis Treatment and the Health Care System

The available evidence that we have regarding what treatments children receive for bedwetting suggests that the front-line service providers, pediatricians, and family physicians, have traditionally favored medication treatments and have only rarely recommended urine alarm treatment. Although we do not have more recent direct surveys of medical practitioners, there is every reason to believe that the situation has gotten worse. This has been due to massive advertising by the pharmaceutical industry, to typical procedures of managed care organizations, and to the failure of health care professionals actually to practice evidence-based health care.

Over the past 10 years, millions of dollars have been spent promoting synthetic vasopressin (DDAVP) as a treatment for bedwetting. First approved in the United States in 1989, this treatment quickly replaced the leading medication treatment for bedwetting, imipramine, because DDAVP had fewer side effects and did not carry the mortality risk due to cardiac failure associated with imipramine. When it was first introduced, DDAVP was available as a nasal spray.

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That delivery system was required because the synthesis of the drug was said to be too costly to be affordable in oral tablets, a route of administration that required wasting a lot of the compound to achieve adequate blood levels. In the past three years, the drug has been made available in tablet form.

The monthly cost of treating a child with DDAVP is approximately $150. What should be remembered is that DDAVP rarely stops bedwetting, and when the child stops taking the medication, the child reliably reverts to wetting (Moffatt, Harlos, Kirshen, & Burd, 1993). Given the mechanism by which DDAVP works, one should expect complete relapse once the medication is withdrawn.

In order to maintain a child on DDAVP for one year, the cost would be approximately $1800. This should be compared to a 12-week course of urine alarm treatment that included all supporting materials and regular consultations with a doctoral-level psychologist for a total cost of only $500. In other words, maintaining a child on ineffective drug treatment for a year costs over three times what it costs to cure bedwetting. Why then do most children still receive some type of pharmaceutical treatment when even leading medical authorities (Moffat, 1997) have clearly recommended urine alarm treatment as the treatment of choice based on current outcome evidence?

At the present time, third-party payers such as insurance companies and managed care organizations, along with medical professionals, determine what happens to the majority of bedwetting children. Most insurance policies provide benefits according to what is determined to be medically necessary by a physician, and those insurance policies also typically have different reimbursement policies for providers of psychological services, the type of providers who are most likely competent to deliver or supervise urine alarm treatments. A medical doctor may judge that urine alarm treatment is medically necessary, but the treatment may not be reimbursable because of limitations of the policy on non-medical providers. Similar scenarios can and do occur in managed care organizations where enrollee children are restricted to certain provider lists, and many of those organizations relegate mental health services to master’s level providers without psychological training in how to use the urine alarm protocol. What is also very common is that managed care organizations do not know about treatment outcome evidence in the case of bedwetting, despite the fact that they are interested in reducing costs and providing evidence-based treatments. What happens as a result of these processes is that children who are diagnosed with functional nocturnal enuresis are treated with what is reimbursable and what is familiar, namely medications.

In addition to not having any easy channel of referral for urine alarm treatment, most pediatricians and family physicians are visited regularly by representatives of the various pharmaceutical companies that manufacture and advertise medication treatments for bedwetting. The culture of professional medicine and the culture of many parents support medication solutions to children's problems. As someone who has followed these cultures surrounding the problem of enuresis for the past 20 years, I am not surprised that urine alarm treatment remains so underutilized. Perhaps it will take another 20 years for a treatment that was devised over 60 years ago finally to be provided on a routine basis to the almost 7 million children affected by enuresis in the United States.

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Houts, A. C. (2000). Commentary: Treatments for enuresis: Criteria, mechanisms, and health care policy. Journal of Pediatric Psychology, 25, 219–224.

In a study of urotherapy 70% of the children improved. Urotherapy keeps a bladder diary and regulates the intake of liquids before bedtime (Robson & Leung, Urotherapy recommendations for bedwetting. Journal of the National Medical Association, 94(7), 2002, 577–580). Some experts agree that urotherapy should precede all other treatment measures.

13.

Cognitions, Life Events, Learned Helplessness, and Depression in Children Evidence suggests that the reformulated learned helplessness model of depression is applicable to children as well. A study by Nolen-Hoeksema, Girgus, and Seligman (1992, Journal of Abnormal Psychology, 101, 405–422) used a longitudinal design to explore the relationship among depressive symptoms, negative life events, explanatory cognitive styles, and helplessness behaviors in elementary school children. The following measures were administered every 6 months over a 5-year period: The children’s depression rating scale (CDRS-R) by Poznanski and Mokros for ages 6–12 which includes a semi-structured interview (Isa et al., Journal of Child and Adolescent Psychopharacology, 24(6), 2014, 318–324), the children’s depression inventory (CDI2), or Beck’s depression inventory for children, a life events questionnaire, and a student behavior checklist filled out by teachers to assess helplessness behaviors in social and achievement situations.

The longitudinal design of the study enabled exploration of both correlates and predictors of depression in children. The results indicated that depressive symptoms were correlated with a more pessimistic explanatory style (viewing bad events as having internal, stable, global causes), more negative life events, and higher levels of helplessness in social and achievement settings.

Elevated depression scores at one time were the best predictor of later depression. In addition, bad life events in the younger children, and explanatory style (alone or in interaction with bad life events) in the older children predicted later depression.

Some aspects of learned helplessness theory were not supported in the study, as children showing more helpless behaviors were not more likely to develop depressive symptoms. On the other hand, helpless behaviors may be of concern separately from depression, in terms of leading to lower school achievement.

The authors also tested the “scar hypothesis,” which asserts that a period of depression leads to a stable explanatory style, which will predispose the child to later periods of depression. This hypothesis was supported by the data, as even when children’s depression lifted, their pessimistic explanatory style remained stable. The authors speculate that the experience of depression early in life, when explanatory styles are being developed, may lead to development of a pessimistic style since “pessimistic cognitions are highly accessible and salient” during a depressive episode.

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DISCUSSION STIMULATORS 1. Personal Experiences with Divorce and Research Findings Divorce is a prevalent event in contemporary American family life. It is estimated that more than one-third of White children and three-fourths of Black children will experience a parental divorce by the time they are 16. It is certain that a number of students in your class will have experienced a parental divorce. The following handout can be used to gather information regarding your students’ perspectives on divorce. The results could be tabulated and compared to the findings from a meta-analysis of the effects of divorce on children (1991, Amato, P. R.& Keith, B., Psychological Bulletin, 110, 26–46).

Students might be encouraged to generate ways to test hypotheses about which theory of the effects of divorce is most accurate. After the results of the survey have been tabulated, students might be interested to hear the results of Amato and Keith’s meta-analysis or to read the article themselves. Amato and Keith found, based on a meta-analysis of 93 studies involving over 13,000 children, that there is strongest support for the family conflict model of the effects of divorce.

In examining hypotheses regarding why divorce is bad for children, there was some support for the parental absence theory, particularly for boys; boys who have a stepfather added to the family following divorce, and boys who maintain close contact with the noncustodial parent have better adjustment. However, the parental absence theory was not supported by findings that children who lose a parent through death (also experiencing parental absence) generally show better adjustment than those experiencing divorce.

Regarding the economic disadvantage argument, little support was found. There were conflicting findings regarding whether differences between children of divorced and intact families remain after socioeconomic status is controlled. The family conflict hypothesis received strong support; children in intact high conflict families have even lower adjustment than children from divorced families. Further, differences between children from divorced and intact families become less pronounced over time, suggesting that as the conflict of separation subsides, children’s adjustment improves.

Questionnaire: Effects of Divorce on Children

1. Your gender:

male / female

2. Have you experienced divorce in your family?

no / yes

3. If yes, with which parent did you live following divorce?

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4. Did your custodial parent remarry? no / yes

5. Does divorce have a major impact on children's adjustment?

6. If yes, what kind of impact is most likely? (Explain your answer)

7. What aspect of divorce is most difficult for children? a. parental absence (having only one parent to live with; not having two role models; not having the emotional support and supervision/guidance from two parents) b. economic disadvantage (having a lower standard of living after divorce) c. family conflict (experiencing high levels of conflict prior to and after the separation) d. other (explain)

8. Below, please explain more fully why you chose the answer you did in the previous question.

2. Should Learning Disabilities Be Classified as Mental Disorders?

The DSM manual itself questions the inclusion of learning disorders within a classification of mental disorders, since many learning-disabled children show no signs of emotional disturbance.

Students might be asked to discuss the advantages, disadvantages, and implications of such a classification.

3. Down Syndrome Babies A 2000 study addressed attitudes of health care workers and mothers of Down syndrome babies in Israel. The authors stated that in the past, health care workers tended to “protect mothers during the delivery of a child with Down syndrome, helping to place the infant in an institution, sometimes without even letting the mother see the newborn infant.” The results indicated that close to 25% of these infants were institutionalized during the time period studied. This represented a decrease from a similar time period approximately 20 years earlier.

What is the practice in the United States? What ethical issues need to be considered? Is it more important to protect the child or the family? Have laws changed the way we treat these children?

4. Treatment of Self-Injurious Behavior There are times when psychologists and other mental health workers employ aversive means for controlling self-injurious behavior (SIB), particularly with retarded and autistic children. In a

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manner similar to the work of the Association for the Advancement of Behavior Therapy task force, students might be asked to debate the ethical issues surrounding the use of aversive procedures for reducing SIB and come up with guidelines to govern the use of such techniques.

They should consider in their discussion the conditions under which aversive punishment might be appropriate, alternatives to the use of aversives, the cost of not employing an effective though controversial treatment, the concerns of parents and other advocates for the rights of retarded individuals, and ways to evaluate the effectiveness of the procedures.

5. Literature on Autism and Asperger Syndrome (now considered part of Autism Spectrum Disorder) Several popular books are available for students who are interested in reading more about autism and Asperger syndrome. Without reason: A family copes with two generations of autism (1989, Hart, C., NY: Harper & Row) explores the experiences of the author, whose brother and son both had autism. A book of journal entries chronicles the experiences of a family with an autistic son (There’s a boy in here, 2002, Barron, J. & Barron, S., Arlington, TX: Future Horizons).

Others include: Freaks, geeks, and Asperger syndrome: A user guide to adolescence (Jackson, L. & Atwood, T., 2002, London: Jessica Kingsley Publishers) and Pretending to be normal (Willey, L. H. & Attwood, T., 1999, London: Jessica Kingsley Publishers). And several others, such as The Asperkid’s (secret) book of social rules: The handbook of not-so-obvious social guidelines for tweens and teens with Asperger syndrome (paperback 2012, Jessica Kingsley Publishers) Asperger’s: Parenting a child with Asperger syndrome: signs, symptoms, and treatments (Autism Spectrum Disorders Book 2, 2014), by Grace Child. Many more have been published in the last several years that provide information for both parents and child; frequently these books also have personal stories.

Online resources: • • • • •

Autism Society of America Center for the Study of Autism, http://www.autism.org Autism Resources, http://www.autism-resources.com/ Asperger Syndrome Coalition of the United States, http://www.cehn.org/asperger_syndrome_coalition_united_states_inc Asperger’s Disorder Homepage—;http://www.aspergers.com/

6. Are Medications for Attention-Deficit/Hyperactivity Disorder OverPrescribed to Youth?

For this activity, you will divide your class in half the day prior to this activity. Half of the class will be assigned to defend the argument “stimulant medications are over-prescribed to youth” and half of the class will be designed to defend the argument “stimulant medications are not overprescribed to youth.” The two teams should be given 20 minutes on the day before the class debate to prepare their arguments and to assign out parts of the debate. For example, one person may research statistics about who is diagnosed with ADHD; one person may research how

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frequently stimulant medications are prescribed; one person may research the negative effects of stimulant medications; several people may research the misuse of stimulant medications, etc.

On the following day, an in-class debate will take place following the outline on the handout on the next page. Before beginning the debate, give students 10–15 minutes to prepare the order of who will be speaking and who will say what. Students tend to get very invested in this activity and it may take an entire class to do, but it is well worth the time investment.

In-Class Debate: Are Medications for Attention-Deficit/Hyperactivity Disorder Over-Prescribed to Youth?

You are assigned to the debate team circled below: 1. TEAM A asserts that stimulant medications are over-prescribed to youth.

2. TEAM B asserts that stimulant medications are not over-prescribed to youth.

In order to receive credit for the debate you must come to class prepared with: 1. Two scholarly articles that support your team’s stance—these articles should be empirical research studies.

2. Typed noted for each of these two articles.

3. A typed list of 3-5 main points that outline the conclusions of your articles. Be sure to include WHERE you obtained the information.

The three items listed above will be reviewed and counted for class credit.

Debate Format • •

TEAM A: 6–8-minute opening argument that presents the team’s rationale for believing that stimulant medications are over-prescribed to youth.

TEAM B: 6–8-minute opening argument that presents the team’s rationale for believing that stimulant medications are not over-prescribed to youth.

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• • •

JUDGES’ QUESTION PERIOD: Judges will ask several questions of each team and teams will be given 3–5 minutes to respond to these questions.

TEAM QUESTION PERIOD: Each team will be allowed to ask one question of the other team.

Teams will be given 3–5 minutes to respond to the opposing team’s question.

CLOSING: At the end of class, we will evaluate the debate experience and will discuss students’ thoughts about ethical and professional issues related to the use of stimulant medications for youth diagnosed with ADHD.

Evaluating Team Debate 1 [Needs Improvement] * 2 [Fair] * 3 [Average] * 4 [Good/Above Average] * 5 [Outstanding/Superior]

Organization and Strategy Information is presented in a structured & logical way that is easy to understand.

Opening Argument

Judges Questions

Team Questions

Team A

Team A

Team A

Team B

Team B

Team B

Professional Evidence Use of facts, statistics, research & case examples.

Opening Argument

Judges Questions

Team Questions

Team A

Team A

Team A

Team B

Team B

Team B

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Debate Procedure Adherence to debate structure while maintaining focus on debate issues. Team remains respectful and answers questions clearly.

Opening Argument

Judges Questions

Team Questions

Team A

Team A

Team A

Team B

Team B

Team B

Persuasion Overall ability to provide a convincing & compelling argument.

Opening Argument

Judges Questions

Team Questions

Team A

Team A

Team A

Team B

Team B

Team B

TOTAL SCORE: Team A

Team B

Judge’s Decision The debate should be won by the team that bests supports its stance through the use of logical arguments based on theory, research, case examples, statistics, and current findings of professional organizations.

This debate has been won by

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TEAM A: asserting that abstinence should be the primary treatment goal for individuals with drug and alcohol problems.

TEAM B: asserting that moderate and responsible use should be the primary treatment goal for individuals with drug and alcohol problems.

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INSTRUCTIONAL FILMS 1. I have Autism (MTV, 2007) https://www.mtv.com/episodes/gnc82y/true-life-i-have-autism-season-2007-ep-8.

2. Living with ADHD (BBC, 2013) https://www.youtube.com/watch?v=5lrcxmOolB8.

3. Pediatric Depression, Mayo Clinic Radio (2017) https://www.youtube.com/watch?v=6b4VOygrZ74.

4. Clinical interview with child with separation anxiety disorder (UT Health, San Antonio, 2017) https://www.youtube.com/watch?v=VknusdiF4kM.

DISCUSSION QUESTIONS These questions are based on the clinical case studies and other information found in boxes throughout the chapter.

Eric Do you think more children today are being over-diagnosed with ADHD by doctors who are reacting to parents’ complaints? Are parents just too tired and stressed at the end of a day to deal with the normally active child? Or do you feel that the psychiatric community has become better educated on ADHD, and therefore better able to recognize it more often?

Sharon Depression in children like Sharon is increasing today, while the age of onset is decreasing. Discuss the possible reasons for the decreasing age of onset for depression in children. What could be some reasons for the increase in prevalence rates?

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Marcus Do you think that a significant number of students, such as Marcus, are not being assessed for their learning disorders until college? How might this be addressed earlier?

Pause and Ponder Activities The following questions reference the case studies published in Oltmanns and Martin, Case Studies in Abnormal Psychology, 11th Edition, John Wiley & Sons, 2019.

Pause and Ponder Activity: ADHD Part I: Pause What would you think if...? ...a 7-year-old boy disassembled his toys beyond repair and didn't say when asked? ...a 7-year-old boy raised his hand to answer a question at school but when called upon had to tell the teacher he had forgotten his answer? ...a 7-year-old boy had to take a medication in order to sleep every night or he would be up for 2 or 3 days?

Consider how much you agree with the following statement: I can see this boy's perspective and understand how he would feel if I was in his shoes.

Part II: Learn Now that you have considered the statement, watch the case video about Kenzie and answer the questions.

Question type Multiple Choice 1. Kenzie's teacher told Ashleigh, Kenzie's mother, that she does not expect as much out of Kenzie in class because he has ADHD. This is an example of what? a. Classroom management b. Empathy c. Stigma d. Teaching training Answer: c

Question type Essay

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2. How does Ashleigh, Kenzie's mother, describe his behavior when he is not taking medication? ________________________________________________________________________________ ____________________________________________________________________

3. Ashleigh, Kenzie’s mother, says that Kenzie needs structure, guidance, reminders, and coaching to get through what he is trying to do. This is best explained by what component of ADHD? a. cognitive development b. hyperactivity c. impulsivity d. inattention Answer: d

4. Kenzie states that he was about to give an answer in class, but had to tell his teacher he had forgotten the answer. This is best explained by which component of ADHD? a. cognitive development b. impulsivity c. hyperactivity d. inattention Answer: d

5. Which of the following is not a common treatment for ADHD? a. classroom management b. parent training c. punishment d. stimulant medication Answer: c

6. Kenzie takes three medications—Adderall, Restoril, and Ritalin. Which of these medications is not a stimulant medication? a. Adderall b. Restoril c. Ritalin d. All are stimulant medications.

Answer: b

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7. A list of diagnostic criteria for Attention-Deficit and Disruptive Behavior Disorders is shown below.

Select all of the diagnostic criteria for ADHD. a. b. c. d. e. f. g. h. i. j. k.

Has been physically cruel to people or animals Has deliberately engaged in fire setting Often actively defies or refuses to comply with requests or rules Often angry, resentful, spiteful, or vindictive Often blurts out answers or interrupts Often bullies, threatens, or intimidates others Often fails to give close attention to detail or has difficulty sustaining attention Often fidgets or squirms in seat j) Often has difficulty awaiting turn k) Often lies to obtain goods or favors l) Often loses temper or argues

Answer1: e Answer2: g Answer3: h Answer4: j

Ponder Part III: Ponder Reflect upon the changes in your empathy that came about during this activity.

Question type Essay 8. Consider how much you agree with the following statement: I can see this boy's perspective and understand how he would feel if I were in his shoes.

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Pause and Ponder Activity: Autism Pause Part I: Pause What would you do if...? ...a 2 1/2-year-old boy did not speak to his parents? ...an 11-year-old boy communicated by making clicking noises? ...an 11-year-old boy ran around flapping his arms and hands frequently?

Consider how much you agree with the following statement: I can see these boys' perspectives and understand how they would feel if I were in their shoes.

Part II: Learn Now that you have considered the statement, watch the case video about Axel and answer the questions.

Question type Multiple Choice 1. Herbert Schreier, M.D., lists all of the following symptoms of autism except __________? a. Abnormal preoccupation with objects b. Impairment in social interactions and communication c. Language differences d. Ritualistic behavior Answer: a

Question type Multiple Choice 2. Jeff, Axel's father, states that autism is a part of what larger diagnostic category? a. Attention-deficit and disruptive behavior disorders b. Communication disorders c. Learning disorders d. Pervasive development disorders Answer: d

3. Which of the following is not one of the symptoms of autism that Jeff, Axel's father, sees in retrospect? a. Delay in language

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b. Impairment in eye contact c. Stereotyped mannerisms d. All of the above were mentioned Answer: c

4. Which of the following is not an effective treatment for autism? a. Behavioral intervention b. Medication c. Psychological treatment d. All of the above are effective Answer: b

Question type Essay 5. Describe the method used to communicate concepts to children with autism in behavioral intervention. ________________________

Question type Multiple Choice 6. During behavioral intervention, Axel is shown flapping his hands and arms. This is an example of which symptom of autism? a. Delays in imaginative play b. Impairment in body language c. Lack of developmentally appropriate play d. Stereotyped mannerisms Answer: d

7. A list of diagnostic criteria for pervasive developmental disorders is shown below. Select all of the diagnostic criteria for autism. a. Clinically significant loss of bowel or bladder control before age 10 b. Deceleration of head growth between ages 5 and 48 months c. Delay in, or total lack of, the development of spoken language d. Encompassing preoccupation with one or more stereotyped and restricted patterns of interest e. Lack of social or emotional reciprocity

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f. g. h. i.

Loss of previously acquired purposeful hand skills between ages 5 and 30 months Marked impairment in use of multiple nonverbal behaviors Stereotyped and repetitive motor mannerisms Stereotyped and repetitive use of language or idiosyncratic language

Answer1: c Answer2: d Answer3: e Answer4: g Answer5: h Answer6: j

Ponder Part III: Ponder Reflect upon the changes in your empathy that came about during this activity.

Question type Essay 8. Consider how much you agree with the following statement: I can see this boy's perspective and understand how he would feel if I were in his shoes.

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Pause and Ponder Activity: Dyslexia Part I: Pause What would you think if...? ...a student could not understand what he was reading because the parts of the words kept disappearing? ...a classmate had to read aloud in class but had difficulty because the words kept moving off the page?

Consider how much you agree with the following statement: I can see these students' perspective and understand how they would feel if I were in their shoes.

Part II: Learn Now that you have considered the statement, watch the case video on Dyslexia in school children and answer the questions.

Question type Multiple Choice 1. Children with a learning disability are usually: a. Of average or above average intelligence b. Of below average intelligence c. There is no pattern of intelligence associated with learning disabilities.

Answer: a

2. According to Ian Jordan, optical specialist, learning disabilities typically result in underachievement in school. This would be an example of: a. disability b. distress c. dysfunction d. violation of social norms Answer: a

3. According to the video, dyslexia is present in what percent of school aged children? a. 1–2% b. 3–4% c. 5–10% d. 15% Instructors Manual

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Answer: c

4. Ian Jordan, optical specialist, states that dyslexia involves visual processing problems. He states that this leads to difficulty in which of the following activities? a. Comprehension b. Reading c. Writing d. All of the above Answer: d

5. Since competence and success in school are measured primarily by examinations that involve reading and writing, students with dyslexia often: a. are allowed to focus primarily on mathematics b. are exempt from examinations c. are exempt from formal schooling d. underachieve in school Answer: d

6. What is NOT one of the types of "false information" that Ian Jordan, optical specialist, refers to when discussing the experiences of those individuals with dyslexia? a. letters changing to numbers b. text shape c. extra words or letters d. multiple images Answer: a 7. Instead of waiting for noticeable problems with achievement, all children should be screened for dyslexia by what age? a. 3 years b. 5 years c. 7 years d. 9 years Answer: c

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8. The children in the video discuss feeling scared, having a knotted stomach, and having low selfconfidence because they must read aloud in class and experience difficulties due to their dyslexia.

This is an example of: a. Disability b. Distress c. Dysfunction d. Violation of norms Answer: b

9. Techniques used to help children with dyslexia include: a. Alternative schools b. Education focused on the arts c. Learning with several senses d. Reading only with pictures Answer: c

Ponder Part III: Ponder Reflect upon the change in your empathy that came about during this activity.

1. Consider how much you agree with the following statement: I can see these students' perspectives and understand how they would feel if I were in their shoes.

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CHAPTER 14 LATE LIFE AND NEUROCOGNITIVE DISORDERS LEARNING GOALS 1. Differentiate common misconceptions from established findings about age-related changes, and discuss methodological issues involved in conducting research on aging.

2. Describe the prevalence of psychological disorders in the elderly and issues involved in estimating the prevalence.

3. Discuss the symptoms, etiology, and treatment of differing forms of dementia.

4. List the symptoms, etiology, and treatment of delirium.

The Learning Goals are inherent in both the Lecture Launchers and Discussion Stimulators below.

CHAPTER SYNOPSIS This chapter focuses on psychological disorders in late life, with a focus on dementia and delirium. First, the chapter reviews general topics relevant to understanding late life, including common myths about aging, as well as some challenges and strengths associated with growing older. Methodological issues in conducting aging research are also discussed, including implications for prevalence estimates. While rates of psychological disorders generally decline as people age, rates of dementia and delirium increase.

Dementia is defined as a gradual deterioration of cognitive abilities, while delirium is an acute state of mental confusion and inability to focus attention.

Aging: Myths, Problems, and Methods As the number of older people in the United States burgeons, more and more mental health professionals are working with this population. Unfortunately, even mental health professionals tend to hold certain stereotypes about late life. It is important to recognize that as they age, most people tend to become more effective at regulating emotions, to remain invested in sexuality, to downplay medical symptoms, and to focus on core relationships over superficial social acquaintances and activities (i.e., social

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selectivity). On the other hand, poverty, stigma, and physical disease are common challenges for people as they age. The challenges of late life also include insomnia and declining health for many people. As increasing numbers of chronic health problems emerge, polypharmacy becomes an issue for many.

Compounding the hazards of polypharmacy, people become more sensitive to medication side effects and toxicity as they age.

Since chronological age may influence research findings, caution must be taken in attributing differences between age groups solely to the effects on aging. In research on aging, it is difficult to disentangle age effects, cohort effects, and time-of-measurement effects. Cross-sectional studies do not help distinguish age and cohort effects. Longitudinal studies provide more clarity about age and cohort effects, but the validity of findings can be challenged by attrition. One form of attrition, selective mortality, is particularly important to consider in studies of aging.

Psychological Disorders in Late Life The prevalence of psychological disorders is lower among older adults than for any other age group (Table 14.3). The psychological disorders that are present during late life usually represent a recurrence or continuation of symptoms that first emerged earlier in life. Some have argued that the low rates of mental illness could be an artifact of less disclosure among older people, could be a cohort effect, or could reflect selective mortality. Most researchers, though, believe that increased coping abilities might help explain the lower rates of disorder as people age. When psychological symptoms are present, it is important to screen for medical causes.

Certain issues should be considered in thinking about specific psychological disorders in late life. For example, cognitive symptoms may be a prominent symptom of depression during late life, so that differential diagnosis with dementia is important. Late-life depression may also be related to cardiovascular conditions. Aggressive depression treatment is particularly important among people with a history of myocardial infarction. Although the base rates of depression are low, suicide rates are high among older men, in part because suicide attempts made by older people are likely to be lethal. Aside from cognitive disorders, anxiety disorders are the most common mental health problem faced in late life and may often be tied to the stresses involved in aging.

Unfortunately, benzodiazepines are widely prescribed for the elderly despite clear evidence of potentially serious and dangerous side effects. Symptoms of paranoia become more common as people age and may be triggered by sensory loss, dementia, or social isolation. Alcohol and substance abuse are rare, but inappropriate use of prescription or over-the-counter medications is a concern. Treatment for most conditions parallels the treatment used with younger adults, but some innovations have been made, such as offering treatment in the home or through primary care.

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Adjusting Treatment with Older Adults Contrary to stereotypes, older people tend to benefit a great deal from psychological treatments. Many of the treatments shown to help most psychological disorders in adulthood appear to be helpful for late-life disorders. For example, cognitive behavioral psychotherapy is effective for depression and for anxiety.

Psychological treatments may need to be tailored to the needs of older people. Clinicians should sometimes be active and directive, providing information and seeking out the agencies that give the social services needed by their clients. Therapists will often need to examine their own attitudes and feelings about aging.

Dementia Dementia is a broad term to capture cognitive decline, most commonly a decline in memory for recent events. As cognitive deficits become more widespread and profound, social and occupational functioning becomes more and more disturbed. Dementia affects approximately 1–2% of people in their 60s but more than 20% of people over the age of 80. There are many types of dementia (see Table 14.2), including Alzheimer’s disease, behavioral variant frontal-temporal dementia (FTD), vascular dementia, dementia with Lewy bodies (DLB), and Huntington’s disease. Most dementias develop slowly over a period of years, but subtle cognitive and behavioral deficits often emerge much earlier. These early signs of decline which are mild and do not cause functional impairment are known as mild cognitive impairment (MCI).

The most prominent symptom of Alzheimer’s disease is memory loss. As the disorder progresses, problems with language skills and word finding intensify and visual-spatial abilities decline, which can manifest in disorientation. The neurobiology of Alzheimer’s disease is characterized by plaques and neurofibrillary tangles in the brain. In terms of genetic influences, Alzheimer’s disease has been related to the APOE-4 allele. The expression of genetic vulnerability, though, is influenced by environmental and psychological events, such as depression, head injury, and baseline cognitive ability and activity.

In regard to treatment, the FDA has approved acetylcholinesterase inhibitors and memantine (Namenda) for the treatment of Alzheimer’s disease, which acts on glutamate neurotransmitters involved in memory function, but these medications offer modest effects. Psychoeducation may be helpful for some patients during the early stages of Alzheimer’s but is not helpful as the dementia symptoms become more profound. Exercise appears to improve cognitive functioning for people with MCI as well as those with Alzheimer’s disease. Caregivers of people with Alzheimer’s are at high risk of depression and anxiety.

Multimodal interventions that address a range of caregiver issues, including even periods of respite from caretaking, offer some protection against psychological symptoms.

Frontal-temporal dementia (FTD) is characterized by neuronal deterioration in the amygdala, frontal, and temporal lobes. Pick’s disease is one form of FTD. The primary manifestation of FTD is marked changes in social and emotional behavior, including problems with empathy, executive function, disinhibition, compulsive behavior, hyperorality, and apathy. Multiple genetic pathways appear to be involved in FTD.

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Vascular dementia is caused by cerebrovascular disease, such as a stroke or blood clot. Other lifestyle and biological influences include high blood pressure, elevated cholesterol, and cigarette smoking. Risk factors are similar as those for cardiovascular disease.

Dementia with Lewy bodies (DLB) is characterized by visual hallucinations, fluctuations in cognitive functioning, supersensitivity to side effects of antipsychotic medications, and intense dreams during which the person moves and talks. It is common among people diagnosed with Parkinson’s disease. The cholinesterase inhibitors and Memantine that block NMDA receptors are the major medical treatments for dementia, but these medications offer modest effects. Exercise appears to improve cognitive functioning for people with mild cognitive impairment as well as those with Alzheimer’s disease.

Antidepressants and behavioral treatments can help relieve comorbid symptoms of depression.

Antipsychotic medications can reduce agitation for those with dementia but can also increase the risk of death; behavioral treatments can be used to safely reduce agitation. Multimodal interventions that address a range of caregiver issues, including even periods of respite from caregiving, offer some protection against psychological symptoms.

Huntington’s disease is a neurocognitive disorder involving problems with memory and other cognitive symptoms, similar to Alzheimer’s. The distinguishing feature of Huntington’s is the presence of symptoms of chorea, (i.e., involuntary jerky or writhing movements and problems with voluntary movements due to muscle rigidity or contractions). These symptoms can interfere with a person’s gait and speech.

Huntington’s is an autosomal dominant disorder caused by a defect in a single gene.

Dementia Delirium is a cognitive disorder characterized by clouded consciousness. The person can seem unaware of and unable to attend to their environment. Mood and symptoms tend to vary throughout the day.

Delirium is most likely to affect children and older adults; among the elderly, it is particularly common in hospitals and nursing homes.

By definition, delirium is secondary to an underlying medical condition. Etiological influences include overmedication, infection of brain tissue, high fevers, malnutrition, dehydration, endocrine disorders, head trauma, cerebrovascular problems, and surgery. If the underlying medical condition is treated, full recovery from delirium can be expected. Delirium is often not detected, though, and the risk of further cognitive decline and even death is quite high when symptoms are not addressed.

KEY TERMS age effects

cognitive reserve

dementia

Alzheimer’s disease

cohort effects

chorea

delirium

dementia with Lewy bodies (DLB)

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disorientation

mild cognitive impairment (MCI)

frontal-temporal dementia (FTD)

neurofibrillary tangles

Huntington’s disease

plaques

social selectivity time-of-measurement effects traumatic brain injury vascular dementia

selective mortality

LECTURE LAUNCHERS 1. What Leads to Successful Aging?

A prospective longitudinal study conducted by Vaillant and Vaillant (1990, American Journal of Psychiatry, 147, 31–37) involved assessment of a sample of white men at the age of 65. The men had been followed since age 18 using questionnaires, interviews, questionnaires completed by wives, and demographic information. The sample was originally selected in college for good physical health and high academic achievement. Psychosocial adjustment measures were developed based on compilations of measures, covering the areas of “ability to work” (continued employment and sustained job success), “ability to play” (job/retirement satisfaction and taking three or more weeks of vacation), and “ability to love” (marital satisfaction and recreation with others), as well as global measures of psychosocial adjustment, physical health, observer-rated life satisfaction, and subject-rated life satisfaction. In addition, physical health at age 65 was rated by an internist based on a physical examination.

The results? The most significant predictor of both physical and mental ill health at age 65 was psychoactive substance use (usually tranquilizers) before age 50.

Childhood strengths, including the cohesiveness of the home, positive relationships with mother and father, and closeness to siblings, were related to physical health at age 65. Of the men who remained in excellent physical health at age 65, the following variables were usually present: warmth of childhood, longevity of ancestors, low blood pressure in college or regular exercise in college. Interestingly, childhood socioeconomic status, childhood emotional problems, and college scholastic aptitude were not related to older adult outcome, either physical or psychosocial.

“Maturity of ego defenses” rated before age 50 was strongly related to later psychosocial adjustment.

2. Cerebrovascular Diseases—Stroke and Its Aftermath The blood vessels supplying the brain are subject to several types of malfunction. In atherosclerosis, deposits of fatty material narrow the lumen, or inner passageway, of the arteries of the body. When those in the brain are affected, some areas may not receive enough blood and hence insufficient oxygen and glucose. If the shortage is prolonged, the brain tissue, which is particularly dependent on receiving adequate supplies, softens, degenerates, and is even destroyed. The effects of cerebral atherosclerosis vary widely, depending on what area of the

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brain has clogged arteries and whether it is also supplied by unaffected blood vessels. About 3 m Americans are presently incapacitated in some way by cerebral atherosclerosis.

In cerebral thrombosis, a blood clot forms at a site narrowed by atherosclerosis and blocks circulation. Carbon dioxide builds up and damages the neural tissues. The loss of consciousness and control is referred to as apoplexy or stroke. The patient may suffer paralysis or decreased sensation on one side of the body or in an arm or leg, lose other motor and sensory functions, or die. The impairments of patients who survive may disappear spontaneously, or they may be lessened through therapy and determined effort. Usually there is some residual damage. When only a small vessel is suddenly blocked, the patient suffers transient confusion and unsteadiness. A succession of these small strokes, however, brings cumulative damage.

In cerebral hemorrhage a blood vessel ruptures because of a weakness in its wall, damaging the brain tissue on which the blood spills. Cerebral hemorrhages are frequently associated with hypertension. The psychological disturbance produced depends on the size of the vessel that has ruptured and on the extent and the location of the damage. Often the person suffering a cerebral hemorrhage is overtaken suddenly and rapidly loses consciousness. When a large vessel ruptures, the person suffers a major stroke. All functions of the brain are generally disturbed—speech, memory, reasoning, orientation, and balance. The person usually lapses into a coma, sometimes with convulsions, and may die within two to 14 days. If the person survives, he or she will probably have some paralysis and difficulties with speech and memory, although in some cases appropriate rehabilitation restores nearly normal functioning.

A frequent impairment is aphasia, a disturbance of the ability to use words. The cause of this damage may be a clot in the middle cerebral artery supplying the parietotemporal region, usually of the dominant cerebral hemisphere. A right-handed person depends on the parietotemporal region in the left hemisphere for language skills; a left-handed person may depend on this region in the right hemisphere or in the left.

The following case illustrates the human impact of a stroke and efforts that can be made to restore some semblance of normalcy: At age sixty-eight, Mr. H., a retired small businessman, was active in community affairs and with his hobby of woodworking. He had high blood pressure that was well controlled on medication and had had diabetes for several years, which was controlled with insulin.

Mr. H. was accustomed to being independent and in charge of things, and this was acceptable to his wife of forty-five years. Mr. H. believed that any reduction of his independent status would be a sign of weakness. He was generally even-tempered but would become angry when he was hindered from completing a task he had set out to do . ..

Mrs. H. was active in her church group and had frequent visitors. She was in good health but had only moderate physical strength. She prepared well-balanced meals for both of them, including the special diet required for Mr. H. because of his diabetes and high blood pressure. They had two children, both of whom were married and living out of state but who visited at holiday times.

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One morning Mrs. H. entered her husband’s workshop and found him sitting in a chair and unable to speak. The right side of his face drooped and he was unable to move his right arm or leg. He did not seem to see her when she approached him from his right but could see her when she moved to his left side. He made a few attempts to speak but was unsuccessful. Mrs. H. called their physician, who arranged for ambulance transportation to the hospital. Detailed examination and testing revealed that Mr. H. had sustained a stroke due to the occlusion [the complete blockage] of an artery supplying the left side of his brain. After receiving acute care including that necessary to prevent complications and reaching a stabilized condition, Mr. H. was transferred to a comprehensive medical rehabilitation center . . . .

Mrs. H. found that she would be part of the rehabilitation process, that the staff would work closely with her, and that she would receive training necessary to help in her husband's care when he returned home. She would also receive counseling to aid her in coping skills and help her adapt to this change in their life situation . . . As Mr. H. progressed in the program, they taught him how to inject his insulin with his left hand and taught his wife how to draw up the proper amount in the syringe.

Mr. H. began to regain some communication ability, and his function was carefully evaluated by the speech pathologist, who aided him in improving general communication abilities. She informed Mrs. H. and the rehabilitation team members how best to communicate with Mr. H. Speech therapy was also used to improve the volume and clarity of his speech.

As communication abilities improved, a psychologist evaluated Mr. H.’s mental status and cognitive skills and helped him to adapt to the frustration of his disability and his feelings of [not] being in control. The psychologist also helped Mr. H. direct his anger in a more productive manner rather than diffusely taking out frustrations on the staff or his wife.

The physical therapist gradually helped Mr. H. improve his bed mobility and transfers, and eventually he progressed to the point where he was ambulating, first with a broad-based four-pointed cane and maximum assistance, and ultimately with a straight cane with his wife standing by. The occupational therapist worked on teaching Mr. H. to use his nondominant hand while he was also working to improve function in the weak right hand.

He was taught to feed himself, to dress himself, and to perform the basic activities of daily living. He was also given exercises and training that would [allow him to pursue] his woodworking hobby, to a limited degree.

The recreational therapist helped Mr. H. to reach some self-fulfillment during his leisure time. His leisure activities were geared to those he had previously enjoyed, adapted to his disability. An occupational therapist went to the house to evaluate the existence of architectural barriers and make recommendations for safety.

During this course of events, the rehabilitation team met weekly to discuss the problems that Mr. H. was experiencing, to compare ideas on solving those problems, and to plan the treatment approach for the forthcoming week. After about a month of this treatment Mr. H. was able to return home with his wife at a semi-independent level, with plans to return

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for outpatient treatment in order to further increase his strength, mobility, self-care, and communication skills (Zarit, S. H., 1980, Aging and mental disorders: Psychological approaches to assessment and treatment (pp. 179–180). New York: Free Press).

3.

Detecting Dementia Early Many family members ignore early signs of dementia in their spouses or parents, perhaps because they prefer not to hear a definitive (and depressing) diagnosis. The Discussion Stimulator below explores the issue of telling vs. not telling patients a diagnosis of Alzheimer’s. However, physicians and psychologists find cause for alarm in the recent finding that one in five family members did not recognize symptoms of dementia in a relative and, of those who did, half did not seek medical evaluation (Ross et al., 1997, Journal of the American Medical Association). The study looked at 191 Japanese-American men, ages 71 to 93, in a larger research project called the Honolulu-Asia Aging Study. Family members were interviewed before the diagnosis of dementia; many apparently assume nothing can be done for dementia and so avoid pursuing a diagnosis and medical assessment.

In fact, as readers of the text should know, many causes of dementia are reversible or preventable. Even in cases such as Alzheimer’s, early recognition can help families prepare for the future, understand their family member’s difficulties, and create a safe environment for care.

In light of this information, students might be interested in knowing early signs of dementia: • • • • • • • •

repeating comments misplacing items difficulty finding names for familiar objects getting lost on familiar routes personality changes becoming physically passive losing interest in activities once enjoyed inability to recall recent events

3. Hot Flashes Cooled by Cognitive-Behavior Therapy Fifty-two menopausal women experiencing frequent hot flashes were treated with an 8-week treatment of either cognitive-behavior therapy (CBT), hormone replacement therapy, or a notreatment control (Hunter & Liao; 1996. British Journal of Health Psychology, 1, 113–125). While both hormones and CBT reduced hot flashes, CBT had the added benefit of reductions in anxiety and depressed mood and perceptions of hot flashes as less problematic in everyday life. Selfratings of overall improvement occurred in 90% of the CBT group and only 50% of the hormone group.

Allen reported two cases of women treated with CBT for menopausal hot flashes. Both women had substantial improvements in the reduction of hot flashes and quality of life. It was hypothesized that CBT reduced hot flashes by reducing central sympathetic activation, perceptions of stress, and self-critical thoughts (Maturitas, 54(1), 2006, 95–99).

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4. Mortality and Bereavement The expression “to die of a broken heart” is more popular among writers than scientists, but research shows that it may indeed hold a certain truth. One of the best studies of mortality subsequent to bereavement is that of Rees and Lutkins (1967, British Medical Journal, 4, 13–16).

They studied a small Welsh town whose 2,350 people were all served by the same doctor for many years. First, a list was compiled from county records of the names of all town residents who had died in a six-year period, and each of the deceased was matched with a living resident of the same age, sex, and marital status. Then, using that register and a nurse’s memory, lists of all close relatives (spouses, parents, children, siblings) of both groups were compiled. Mortality rates between the two groups of relatives after the date of the deceased’s death constitute the data of the study.

In the five years following the date of death, 2–3% of the control families each year experienced the death of a close member, whereas among the bereaved families, almost 12% experienced another death in the first year, 5% in the second year, and 3%, 2%, and .1% in the third, fourth, and fifth years, respectively. Statistical tests showed that the spouses, children, and siblings of the bereaved were all significantly more likely to die in the first year following bereavement than were control relatives. The increased risk was most clearly elevated for widows.

It has been suggested that relatives may die in quick succession for reasons other than the emotional impact of the loss. For instance, a husband and wife may be infected by the same disease or may have lived the same unhealthy lifestyle. Contrary to this prediction, Rees and Lutkins found that of families where the deceased died at home, 7.1% experienced another death within the year. In contrast, in families where the deceased died suddenly when away from home, 37.6% experienced another death that year. In this sample, all such deaths were unexpected, thus they likely were more traumatic for the survivors.

Finally, it should be noted that death following bereavement was largely confined to the elderly.

The youngest relative to die within a year of bereavement was 44; most were over 70.

Can people die of a broken heart? That question was studied by Domelas, who suggested that people have long recognized that emotions seem to be felt by the heart and that human behaviors also seem to indicate that the heart is somehow linked to emotional intensity (Dornelas, E. A. Psychotherapy with cardiac patients: Behavioral cardiology in practice. Washington, DC: American Psychological Association: 2008. 39–47).

5. Ageism and Physical Function How do stereotypes affect the way we perceive ourselves? Are the changes all psychological? A study was conducted to determine whether ageist stereotypes would cause changes in an older person’s walking gait. As people age, walking speed tends to slow, but how much of the slowing is the result of aging vs. psychological factors?

Forty-seven healthy men and women between the ages of 60 and 90 were recruited and told they would be playing a video game. After random assignment, both groups played a computer game

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that required them to identify a flash on the screen by pushing an up or down arrow. The flash was actually a priming word that was displayed so briefly that none of the subjects were able to identify it as a word. The words for one group were negative primes such as “senile,” dependent,” and “diseased.” The words shown to the other group consisted of positive primes such as “wise,” “astute,” and “accomplished.”

Before playing the game, each subject had to walk down a long corridor and his or her walking gait was recorded to determine average gait speed. After the game, all the subjects made the same walk and the speeds were calculated again. There were no age or gender differences in the two groups and the average gait speed was the same before the experimental manipulation.

The authors found that the people who saw the positive prime words increased their walking speed significantly. The group that saw the negative words did not show a change in speed.

How can these findings be used to benefit older individuals?

Hausdorff, J. M., Levy, B. R., & Wei, J. Y. (1999). The power of ageism on physical function of older persons: Reversibility of age-related gait changes. Journal of the American Geriatrics Society, 47, 1346–1349.

DISCUSSION STIMULATORS 1. Ageism Consider the following scenes: 1.

2.

3.

4.

A 60-year-old man is asked his age as he registers at a hotel, so that he may receive the proper deference by hotel staff.

A dress shop has clothing arranged according to age groups, with clothing appropriate for older people grouped together.

A 55-year-old employee of a large company is asked to retire.

The eldest son and his wife are expected to care for the elderly father, while the youngest son bears no responsibility.

These situations describe typical treatment of the elderly in Japan, a country we associate with respectful and positive views of old age. Do they represent ageism?

Kimmel (1988, American Psychologist, 43, 175–178) says yes. But what is wrong with treating people differently based on their age? Kimmel asserts that both positive and negative stereotypes about the elderly have powerful effects on older persons’ views of themselves and on public policy. One study found that elderly nursing-home residents had ageist beliefs themselves; when given plausible alternative explanations for their behavior and symptoms (floors are slippery because they must be kept clean, and even young people slip on them) instead of attributions to aging or personal failure, the residents improved in their participation and sociability. In public

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policy, ageism is evident in mandatory retirement at a specific age and in entitlement programs based solely on age.

You might ask students to debate whether “ageism,” defined as discrimination of individuals based on age, is always wrong. What do they think of mandatory retirement? Of senior citizen discounts? Of special deference for the aged in Japan?

The 2011 book Agewise: Fighting the new ageism in America asks the reader to shift perspective to a view of the sanctity of the older folk (Gullette, M. M. University of Chicago Press: Chicago, IL, 294 pp.). The author attempts to deconstruct the narrative that suggests that “peppy, silverhaired, athletic people are the poster images of ageing and reconstructs the ageing image with heritage and the whole spectrum of aging with a strong respect for the life we have at all of its stages.” A chapter in the Myers and Shannonhouse book Combating ageism: Advocacy for older persons discusses the demographic changes in the aging population in the United States and suggests some strategies and actions for counselors for advocacy and empowerment for older individuals (Lee, C. C. (Ed.). Multicultural issues in counseling: New approaches to diversity (4th ed.), Alexandria, VA, US: American Counseling Association, 2013, 151–170). Included is a case study that demonstrates how these suggestions would work with an older client.

2. Disclosing the Diagnosis of Alzheimer’s: To Tell or Not to Tell?

Many families who bring their relatives for evaluation of Alzheimer’s disease plead with professionals not to disclose the diagnosis to the patient. Unlike in the area of cancer, where consensus is strong that patients should be told their diagnosis, the case is less clear for Alzheimer’s. Students might be asked to debate the two sides of the issue; a sounding board piece in the New England Journal of Medicine (Drickamer, M. A., & Lachs, M. S., April, 1992) presents arguments for and against disclosure.

A study in 2005 suggests that attitudes towards patients with Alzheimer’s disease have changed in recent years. In a survey of family members in Taiwan, an overwhelming 93% of subject families given the Attitude Questionnaire on AD Disclosure favored disclosure of the diagnosis if, hypothetically, they personally were affected by AD. However, only 76% favored disclosure for a current AD patient (Lin et al., International Psychogeriatrics, 17(4), 2005, 679–688).

The Case for Not Telling 1.

2.

3.

4.

5.

The diagnosis of Alzheimer’s disease cannot be made with certainty prior to autopsy.

The prognosis of the disease course and life expectancy of patients is quite variable.

Therapeutic options are limited.

Patients with Alzheimer’s have deteriorating cognitive functions; it can be difficult to find a time to disclose the diagnosis when the diagnosis can be made reliably, but the patient is still well enough to understand it.

Diagnostic labeling may lead to stigmatization by insurers, health professionals, and others in society.

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6.

7.

Stress (such as learning one's diagnosis) may exacerbate the symptoms of Alzheimer’s and lead to depression.

Little evidence exists to determine whether patients with Alzheimer’s would want to know their diagnosis.

The Case for Telling 1.

2.

3.

4.

5.

6.

Our culture believes that medical decision-making should maximize patient autonomy.

Patients cannot make informed choices about whether to accept or forego treatments without knowing the truth.

Persons with a progressive illness should be given the opportunity to make decisions about their future while they are still competent to make these decisions.

Knowing one’s diagnosis might lead to having a voice in subsequent care decisions (by making one’s wishes known to the person who will make decisions after the patient is incompetent) and being able to do advance planning in the areas of financial arrangements, seeking other medical advice, personal plans, etc.

Uninformed patients cannot make decisions regarding whether or not to participate in research projects related to the disease.

Patients may prefer to express their thoughts and fears before they are unable to.

3. Differential Diagnosis: Dementia vs. Delirium The successful differentiation of dementia and delirium is an extremely important task for those working with the elderly. Since delirium is very often reversible while dementia is often not, it is essential to recognize the difference between the two. For example, it is not uncommon for factors such as malnutrition, unintentional overmedication, or surgery involving general anesthesia to create a state of delirium in an older person that may be misinterpreted as dementia by family members who then believe there is nothing they can do to correct the symptoms.

Present the following cases to your class for practice in distinguishing the two problems.

CASE A Fred White is a 72-year-old man who was brought to the clinic accompanied by his wife and children.

While Fred denied having any memory problems, his wife reported that he had been forgetting where he put things around the house, and then would accuse the housekeeper of taking them. He also could not remember social engagements and recently failed to recognize a couple of friends at a party. His wife, Lilly, reported that these problems had been occurring for some time, perhaps as long as two years. At that time she noticed he was having trouble finding his keys, but she did not think anything was wrong since he had always misplaced a few things around the house. When he started accusing the housekeeper of stealing items, about one year ago, she started to think something was wrong, especially since he had always liked the housekeeper. Fred made five errors on the Kahn

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mental status test. He did not know the name of the clinic or its address. He did not know the date or month, and could not remember the President before Reagan. Fred denied feeling depressed and was not overly concerned when he made errors on the mental status test.

CASE B June West is a 79-year-old woman who was brought to the clinic by her neighbor, who noted a sudden change in her behavior. According to the neighbor, Sam Spade, June had always dressed immaculately and had been fairly reserved and polite. In the last week, however, she had begun appearing somewhat disheveled, and also made some overt sexual overtures to Sam (e.g., “Hey, big boy, looking for some action?”). While she had previously walked her dog only during the daytime, Sam now observed that June went out walking with the dog at random hours, including late at night. June's apartment, which had always been immaculate, was now in disarray, and Sam had noted that there was no food in the refrigerator. When asked how she was doing, June denied having any problems or having made any overtures to Sam. June made four errors on the mental status test. She incorrectly identified the clinic as a hotel and giggled when she said it. She did not know the date or month or the President before Reagan (she said “Kennedy”). She also thought she knew the interviewer from a nightclub and thought he might be the maitre d’. She denied feeling depressed and appeared to be in good spirits.

The following factors are among those that should be considered in distinguishing dementia from delirium: Onset: The onset of dementia is usually gradual and insidious, whereas that of delirium is usually abrupt and obvious.

Symptoms: Early symptoms of dementia include failing attention, memory loss, and declining mathematical ability; the person may also make errors of judgment, show irritability, personality changes, or loss of a sense of humor. Symptoms of delirium include restlessness, fluctuating alertness, confusion, decrease in amount of sleep with day-night reversal, and sexual acting-out.

Both dementia and delirium patients may deny their symptoms.

Responses to test questions: While both patients with dementia and those with delirium may make the same errors on a mental status exam, the quality of their responses is likely to differ: those with dementia commonly make denotative errors, whereas delirium patients often give connotative, symbolic responses.

After presenting this information, it should be easy for students to identify Case A as dementia, and Case B as delirium.

4. Aging in Literature There are at least two well-written and absorbing novels that provide excellent windows into the life of the elderly. You might refer your students to these books as a means of helping them understand and consider the issues involved in growing older. May Sarton’s As We Are Now tells

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the story of a 76-year-old woman who has suffered a heart attack and been committed to an old people’s home. The first-person account offers a searing insight into the hope, despair, anger, and compassion of her experiences there. The Diary of a Good Neighbour, by Doris Lessing, depicts the developing relationship between a fashionable, successful middle-aged woman and a fierce, vulnerable 80-year-old woman after they meet by chance in the local pharmacy.

5. Mini Mental State Exam The Mini Mental State Exam (MMSE) can be used as a way of assessing gross neurocognitive functioning in adults. Have your class practice giving the Mini Mental State Exam to one another.

Visit https://www.heartandstroke.ca/-/media/pdf-files/canada/clinical-update/allen-huangcognitive-screening-toolkit.ashx for a free copy of the Mini Mental State Exam. After they have administered the structured exam to one another, discuss how the various components of the exam relate to symptoms and diagnostic criteria for DSM neurocognitive disorders.

INSTRUCTIONAL FILMS 1. Films about Alzheimer’s from Alzforum: Networking for a Cure https://www.alzforum.org/films-about-alzheimers

2. The Unspooling Mind (https://topdocumentaryfilms.com/unspooling-mind/) 3. “The Unspooling Mind is a documentary about the human toll of dementia, heart-wrenching decisions for families, the desperate search for care for those who can no longer care for themselves, and seeking help in a place with no return in a country far from home”.

4. Terry Pratchett: Choosing to Die. In a frank and personal documentary, author Sir Terry Pratchett considers how he might choose to end his life. Diagnosed with Alzheimer’s in 2008, Terry wants to know whether he might be able to end his life before his disease takes over. Traveling to the Dignitas Clinic in Switzerland, Terry witnesses at first hand the procedures set out for assisted death, and confronts the point at which he would have to take the lethal drug. https://topdocumentaryfilms.com/terry-pratchett-choosing-to-die/ .

5. Alzheimer’s: A True Story (FHS, 75 min., color, #BVL10002, 1999) “Alzheimer’s is a disease that affects not only the patient, but all who love and care for that person as well. This poignant program allows a rare glimpse into one couple's experience with the fatal illness that tore their life apart, tracking the mental deterioration of Malcolm Pointon— husband, father, Cambridge professor, and gifted pianist, diagnosed at only 51 years of age. The documentary sympathetically yet unflinchingly chronicles Malcolm’s descent into dementia and

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his wife Barbara’s unyielding commitment to be there ‘in sickness and in health.’ Some content may be objectionable.” https://www.films.com/id/1.

DISCUSSION QUESTIONS These questions are based on the clinical case studies and other information found in boxes throughout the chapter.

Henry Discuss the case of Henry. What factors interacted to cause Henry’s delirium?

Mrs. J Delineate the symptoms of Mrs. J’s disorder. What factors seem to have caused her problem?

Mary Ellen Mary Ellen shows many symptoms of dementia of the Alzheimer’s type. How can you tell if Mary Ellen’s dementia is Alzheimer’s type or vascular dementia? How are the ways in which Mary Ellen sees her life different from the ways in which others see it? How can psychosocial interventions help her and others who suffer from dementia?

Bob Bob was diagnosed with behavioral variant frontotemporal dementia. How does this form of dementia compare to other more typical forms of dementia, such as Alzeheimer’s disease or vascular dementia?

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Pause and Ponder Activity: Dementia The following questions reference the case studies published in Oltmanns and Martin, Case Studies in Abnormal Psychology, 11th Edition, John Wiley & Sons, 2019.

Part I: Pause What would you think if...? ...a man cannot remember what town he is currently in? ...a man needs his daughter to help him shave, bathe, and get dressed everyday? ...a woman says that it is not possible to be fully sane while living with her father? ...a woman says her father is like a child trapped in a man's body?

Consider how much you agree with the following statement: I can see these people's perspectives and understand how they would feel if I were in their shoes.

Part II: Learn Now that you have considered the statement, watch the case video on Herb and answer the questions.

Question type Multiple Choice 1. Which of the following is the most common type of dementia? a. Dementia of the Alzheimer's type b. Dementia due to other General Medical Conditions c. Substance-Induced Persisting Dementia d. Vascular Dementia Answer: a

2. Dementia involves disturbances in ____________. a. cognition b. consciousness c. mood d. temperament Answer: a

3. Herb Winokur's inability to remember the town he is in now reflects this prominent cognitive deficit in dementia.

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a. b. c. d.

aphasia apraxia agnosia memory impairment

Answer: d 4. Julie Winokur, Herb's daughter, states that some days he rambles incoherently. This is an example of what symptom of dementia? a. aphasia b. apraxia c. agnoscia d. memory impairment Answer: a

5. Julie Winokur, Herb’s daughter, discusses the medications he takes for his dementia. The medication is intended to _____ the symptoms. a. cure b. eliminate c. plateau d. reverse Answer: c

Question type Essay 6. Describe the experience Julie Winokur and her family had while taking care of her father Herb. ________________________________

Question type Multiple Choice 7. a. b. c. d.

Cazeaux Nordstrum, M.A. LMFT states that the individuals who often suffer most are the ______. hired caregivers immediate family caregivers individual with dementia medical professionals

Answer: b

Question type Essay

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8. Summarize Cazeauz Nordstrum’s discussion of the relationship between memory impairment and feelings. _______________________________

Question type Multiple Choice 9. A list of diagnostic criteria for cognitive disorders is shown below. Select all of the diagnostic criteria for dementia of the Alzheimer’s Type. a. agnosia (failure to recognize objects) b. aphasia (language disturbance) c. apraxia (impaired ability to carry out motor activities) d. course characterized by gradual onset and continuing cognitive decline e. disturbance develops over a short period of time (hours to days) and tends to fluctuate during the course of the day f. disturbances in executive functioning (planning, organizing, abstracting) g. disturbance of consciousness h. memory impairment i. perceptual disturbance Answer1: a Answer2: b Answer3: c Answer4: d Answer5: f Answer6: h

Ponder Part III: Ponder Reflect upon the changes in your empathy that came about during this activity.

Question type Multiple Choice 10. Consider how much you agree with the following statement: I can see this man's perspective and understand how he would feel if I were in his shoes. _________________

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CHAPTER 15 PERSONALITY DISORDERS LEARNING GOALS 1. Explain the DSM-5 approach to classifying personality disorders, and identify key concerns with this approach.

2. Describe the DSM-5 alternative approach to personality diagnosis.

3. Discuss commonalities in etiology across the personality disorders.

4. Define the key features of each of the personality disorders in the odd/eccentric cluster, as well as biological and social influences on schizotypal personality disorder.

5. Describe the key features and etiology of each of the personality disorders in the dramatic/erratic cluster.

6. Define the key features and etiology of the personality disorders in the anxious/fearful cluster.

7. Describe the available psychological treatments for the DSM-5 personality disorders.

The Learning Goals are inherent in both the Lecture Launchers and Discussion Stimulators below.

CHAPTER SYNOPSIS This chapter begins by explaining classification approaches for personality disorders, including the DSM-5 approach and an alternative approach. Next, etiological factors are discussed, as well as key features specific to particular personality disorder clusters. Finally, an overview of treatment approaches for personality disorders is provided.

Classifying Personality Disorders Personality disorders are defined by long-standing and pervasive ways of being that cause distress and impairment through their influence on cognition, emotions, relationships, and impulse control. Most people with personality disorders experience comorbid conditions, including mood, anxiety, substance abuse, and other personality disorders. The DSM-IV-TR included 10 personality disorders classified in three clusters, reflecting the idea that these disorders are characterized by odd or eccentric behavior (cluster A), dramatic, emotional, or erratic behavior (cluster B), or anxious or fearful behavior (cluster C). The DSM-5 includes only six personality disorder types: schizotypal, antisocial, borderline, narcissistic, avoidant, and obsessive-compulsive personality disorder. Interrater reliability of personality disorder Instructors Manual

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diagnoses, particularly when clinicians use structured interviews, is strong. But despite the idea that personality disorders are long-standing, test-retest reliability is only modest. Concerns have also been raised about gender bias in diagnoses. In response to the DSM-IV-TR, some have argued that we should be measuring personality traits as dimensions rather than attempting to classify people with personality disorders.

The DSM-5 also includes a dimensional system for evaluating personality traits and more specific facets.

The changes were made to address concerns about high levels of comorbidity between the different personality types; low prevalence of some personality disorder types and correspondingly limited research; heterogeneity among those diagnosed with a given personality disorder type; generally low stability of personality disorders over time; and evidence that personality traits can correlate with psychological disorders, interpersonal functioning and treatment outcome, even after considering the role of personality disorders. The DSM-5 system includes four types of personality ratings: levels of personality functioning, personality disorder types, personality trait and facet ratings, and personality disorder criteria. The DSM-5 personality disorders are diagnosed using a prototype approach. The DSM-5 personality trait domains and facets largely overlap with the Five Factor Model personality dimensions, but some changes were made to ensure that the DSM-5 system relates well to psychological disorders.

People with obsessive-compulsive personality disorder are meticulous perfectionists who desire order and control to an excessive degree. Although the personality disorder can be distinguished from obsessive-compulsive disorder in that obsessions and compulsions are not present, the two conditions do tend to co-occur. Obsessive-compulsive personality disorder is modestly heritable and there is some research that suggests that the genetic vulnerability may be related to obsessive-compulsive disorder.

People with narcissistic personality disorder overtly demonstrate a highly inflated self-esteem but also harbor a deep need for admiration. According to the self-psychology theory of narcissistic personality disorder, parents who are inconsistent and focused on their own worth fail to help the child develop a stable sense of self-worth. Social-cognitive theory proposes that the behavior of the person with narcissistic personality disorder is shaped by the goal of maintaining specialness and the belief that the purpose of interpersonal interactions is to bolster self-esteem.

People with schizotypal personality disorder are eccentric in their thoughts and behavior. Genetic and neurobiological studies indicate that schizotypal personality disorder and schizophrenia are related.

People with avoidant personality disorder are extremely uncomfortable in social situations because of fears that they will be perceived negatively. They struggle with feeling inadequate, and as a consequence, will avoid main interpersonal situations. This disorder often co-occurs with social anxiety disorder and some have even argued that it is a more severe variant of social anxiety disorder.

Antisocial personality disorder is defined by violation of rules and a disregard for others’ feelings and social norms. Psychopathy is related to antisocial personality disorder but is not defined in the DSM. Psychopathy criteria focus on internal experience. The DSM-5 definition of antisocial personality disorder is more aligned with psychopathy criteria than the DSM-IV-TR definition. Antisocial personality disorder and psychopathy are both highly heritable. Beyond genes, family environment and poverty seem to play a role in the development of this disorder.

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The key features of borderline personality disorder (BPD) include intense emotionality, unstable identity, and impulsivity. There is evidence that BPD is inherited, and that serotonin function is diminished. Other biological risk factors seem particularly related to emotional dysregulation and impulsivity. Consistent with the greater emotionality, people with BDP have also been found to demonstrate increased activity in the amygdala, and high rates of mood disorders among first-degree relatives have been found. Consistent with symptoms of impulsivity, research indicates diminished activity in the prefrontal cortex among people with BPD, and high rates of disorders involving impulsivity among first-degree relatives. People with BPD report elevated rates of abuse. Linehan’s model builds on the high rates of abuse reported by people with BPD and also emphasizes the biological diathesis for emotional dysregulation; it focuses on emotional dysregulation coupled with parental invalidation.

Treatment of Personality Disorders Personality disorders are usually comorbid with other disorders such as depression and anxiety disorders, and they tend to predict poorer outcomes for these disorders. Most of the treatment research has focused on BPD. There is some support for the utility of dialectical behavior therapy (DBT) as well as psychodynamic approaches such as transference-focused therapy and mentalization therapy for treating BPD. Medications may be used to supplement psychotherapy for BPD, although support for medication use for treatment of personality disorders is mixed. Antipsychotic medication may be helpful for schizotypal personality disorder, and antidepressants may be helpful for avoidant personality disorder.

KEY TERMS antisocial personality disorder

obsessive-compulsive personality disorder

avoidant personality disorder

personality disorders

borderline personality disorder

personality trait domains

dependent personality disorder

personality trait facet

dialectical behavior therapy (DBT)

psychopathy

histrionic personality disorder

schizoid personality disorder

mentalization therapy

schizotypal personality disorder

narcissistic personality disorder

transference-focused therapy

LECTURE LAUNCHERS

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1. Childhood Sexual Trauma and Borderline Personality Disorder The diagnosis of borderline personality disorder carries a heavy burden of stigma; insurance carriers do not often cover treatment for the disorder because it is thought to be a lifelong condition, and therapists often share the pessimistic view that individuals with borderline personality are not amenable to treatment. An article by Landecker (1992, Psychotherapy, 29, 234–242) addresses the close relationship between symptoms of borderline personality disorder and those of posttraumatic stress disorder (PTSD), suggesting that the frequent finding of child abuse (particularly sexual abuse) in the history of individuals diagnosed as borderline may make PTSD a more useful formulation of the person's treatment needs. Neither diagnosis adequately describes the full symptom picture of people with a history of sexual abuse trauma, leading to PTSD-like symptoms, and with the presence of specific personality styles. However, viewing the symptoms in the context of trauma, as a PTSD diagnosis encourages, has important implications for treatment. For example, borderline symptoms such as use of primitive defenses and selfmutilation might be viewed as once-adaptive responses to abuse. Students might be encouraged to consider the implications of choosing one diagnosis over another in terms of varied degrees of stigma associated with one diagnosis vs. another, insurance coverage, treatment implications, and the patient’s own view of the etiology and prognosis of their symptoms.

Goodman and Yehuda’s research found that individuals with borderline personality disorder have significantly greater rates of childhood sexual abuse than non-BPD patients, often exhibiting features related to childhood trauma such as impulsive aggressive behaviors, dissociation, identity disturbance, and affective instability (Psychiatric Annals, 32(6), 2002, 337–345).

2. The True Experience of Borderline Personality Disorder In Lost in the Mirror: An Inside Look at Borderline Personality Disorder (1996), Moskovitz reports, “The extreme emotions of the person with BPR are matched by her extreme behaviors. She may deprive herself to the point of starvation or may indulge in dramatic excess. These shifting compulsions contribute to the discontinuity of her identity, leaving a chameleon-like impression.

The arena of behavior covers the range of human appetites and may include food, sex, and aggression, as well as acquiring possessions, using alcohol and drugs, and the excitement of taking risks. Someone with borderline personality disorder is likely to indulge in more than one of these areas. They may become interchangeable so that measures to suppress one kind of behavior results in the prompt emergence of another” (p. 63). In an exercise on empathy, students might be encouraged to consider how it would feel to be out-of-control and to experience such dramatic shifts in behaviors with the goal of ultimately regulating one’s emotional state.

Here are two links, one about a personal story of BPD: http://www.psychforums.com/borderline-personality/topic125446.html, and one Central: https://www.bpdcentral.com/.

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3. Personality Disorders and the Ego Defenses Vaillant and Drake have presented data on a subject infrequently subjected to empirical study— the use of ego defense mechanisms (1985, Archives of General Psychiatry, 42, 597–601). In a longitudinal follow-up evaluation of the Glueck’s delinquency sample, these two investigators provide information on the relationship among ego defenses, personality disorder, and health functioning. They also analyze early predictors of adult functioning.

It is important to understand Vaillant’s classification of the ego defenses in order to comprehend the data obtained in this investigation. Defenses are classified into three groups: mature, intermediate, and immature. Mature defenses include suppression (postponement of impulse gratification without repression), altruism, mature humor, sublimation, and anticipation (affective rehearsal of future stressful events). Intermediate defenses are those that are typically associated with neurosis in psychoanalytic theory, including reaction formation, isolation, displacement, and repression. Finally, immature defenses are thought to be associated with personality disorder and include hypochondriasis (magnifying somatic complaints), dissociation (the denial of inner feelings), autistic schizoid fantasy, projection, and acting out.

In this investigation, ego defense diagnoses were made from independent ratings of a two-hour semi-structured interview. Data obtained in this investigation revealed a strong association between defensive maturity and DSM-III diagnoses of personality disorder. Sixty-seven percent of the men in the sample who used immature defenses were judged to have a personality disorder as compared to 15% of the intermediate group and 0% of the mature group. Defensive maturity was also strongly associated with ratings on the Health-Sickness Rating Scale, with socioeconomic status, and with stage of adjustment according to Erikson's psychosocial model. Defensive maturity was not predicted by childhood family environment, contrary to what might be expected based on psychoanalytic theory, but was related to earlier ratings of emotional problems, to grades in school, and to IQ measures.

Vaillant and Drake offer several conclusions based on their investigation. First, they suggest that the correspondence between defensive maturity and personality disorder is so great that it is justifiable to replace the former classification with the latter. Nevertheless, they do argue for a routine assessment of the ego defenses in psychiatric diagnosis. Second, they suggest that others who have studied the ego defenses may have found primarily negative results because they have focused on the wrong defenses. In general, the intermediate defenses were not found to be strongly related to other measures, but these “neurotic” defenses have received the greatest attention among psychodynamic investigators. More primitive defenses were found to have considerably greater predictive power in this study. Finally, the authors note the lack of association obtained between ego defense maturity and childhood experience. They suggest that ego defense style, however it is produced, may be a stable characteristic of the “invulnerable” child.

In an interesting study of male inpatients, it was found by using the Defense Style Questionnaire (DSQ) that the defense style appears to have the potential to inform assessment and measure change in this group of offenders (Defense styles in a sample of forensic patients with personality disorder (Personality and Mental Health, 8(3), 2014, 238–249).

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4. Does Treatment Success Predict Lower Recidivism?

In most therapies, good treatment behavior is expected to predict favorable outcomes. Therapists tend to believe that patients who work well in group sessions, complete good homework assignments, and appear motivated for change will have a greater chance of succeeding outside of the treatment setting. As discussed in the text, psychopaths might be an exception.

Seto and Barbaree (1999) looked at treatment behaviors of sex offenders who also had high scores on psychopathy. They found that men who scored high on Hare’s measure of psychopathy and behaved well in treatment were “much more likely to commit a new serious offense.” The authors proposed two possible reasons for this outcome. First, those who performed well in treatment were more adept at manipulation and exploitation. They were able to identify the behaviors that improved their chances of a favorable rating. Once in the community, these same skills might improve their chances of getting close to a potential victim. The alternate explanation is that these men actually learn the behaviors in treatment that will make them more adept at offending.

Seto, M. C. and Barbaree, H. E. (1999). Psychopathy, treatment behavior, and sex offender recidivism. Journal of Interpersonal Violence, 14, 1235–1248.

5. Clinical Strategies with Borderline Patients Linehan’s book Cognitive-Behavioral Treatment of Borderline Personality Disorder (1993) is full of clinical examples to illustrate the principles of dialectical behavior therapy. Some examples of treatment strategies:

1. Using metaphor. “Therapy, for the patient, is like climbing out of hell on a red-hot aluminum ladder with no gloves or shoes. Continually jumping off or letting go is therapy-interfering behavior by the patient. Holding a blowtorch on the patient's feet to get her to climb faster is therapy-interfering behavior by the therapist. The bottom of hell is usually hotter even than the ladder, so that after a while the patient always gets up, gets back on the ladder, and has to climb again” (p. 210) 2. Entering the paradox. Comfort with paradox and ambiguity is essential for the dialectical behavior therapist. The therapist needs to continually stress that things can be both true and not true at the same time. For example, when borderline patients become obsessed with who is right and who is wrong in a particular disagreement, the therapist maintains a stance that both (or neither) are right. For example, in the therapeutic relationship, the patient's need or desire is validated at the same time that the therapist maintains the limit they have set. An example of a paradoxical statement that requires the patient to think differently: “If I didn’t care for you, I would try to save you” (p. 207).

3. The Devil’s Advocate technique. Similar to the use of paradox, the therapist takes the extreme position to encourage the argumentative patient to adopt a more moderate stance. For example, at the beginning of treatment, the therapist may argue against change and commitment to Instructors Manual

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therapy, since it will be too difficult and painful. This stance leads the patient to argue in favor of change.

4. Extending. In this technique, the therapist takes the patient more seriously than the patient is taking herself. For example, when a client is threatening suicide in a manipulative manner (e.g., “If you don't schedule an extra session with me, I will kill myself”), the therapist refuses to go on with any other topics of discussion until the matter is resolved. By taking the consequences of suicide extremely seriously, the patient who did not actually plan to kill herself begins persuading the therapist that she is not, in fact, suicidal. For example, the therapist may say, “We’ve got to do something immediately if you are so distressed that you might kill yourself. What about hospitalization? Maybe that is needed. How can we discuss such a mundane topic as session scheduling when your life is in danger? Surely, this threat to your life must be dealt with first. How are you planning to kill yourself?”(p. 213)

5. Dialectical Assessment A unique aspect of dialectical behavior therapy is its attention to all the systems impacting a patient's current behavior. For example, the feeling of the borderline patient that they do not “fit in” is viewed, not necessarily as evidence that they need to change in order to fit in better, but as requiring assessment of the social context which may be wrong. This openness to exploring and analyzing the environment extends to looking at double-binds caused by sex-role, religious, social class, and racial expectations placed on the individual, as well as examining the therapy relationship itself.

DISCUSSION STIMULATORS 1. Personality Disorders: Mental Disorders?

If personality disorders are maladaptive personality traits that interfere with functioning, should they be considered to be “mental disorders”? Are they disorders in the same sense as agoraphobia or bipolar disorder? Or are they just the individual’s personality? Does calling such behavior a disorder excuse it and allow the individual not to take responsibility for their behavior?

What trait, if it was maladaptive and interfered with functioning, would not qualify as a personality disorder?

2. Evaluating and Refining Diagnoses To expose students to the finer points of attempting to devise reliable and consistent diagnostic criteria, try presenting them with the diagnostic criteria for one of the personality disorders in DSM-I or DSM-II. Reproduced below are the criteria for schizoid personality. Students could be divided into groups and asked to come up with better operational definitions of the criteria listed.

Following an attempt at group consensus in this exercise, give the students the DSM-IV criteria for the same disorder; this will let them see how diagnostic classification has changed and compare their attempts to those of the “experts.”

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DSM-I Diagnostic Criteria for Schizoid Personality Inherent traits in such personalities are (1) avoidance of close relations with others, (2) inability to express directly hostility or vent ordinary aggressive feelings, and (3) autistic thinking. These qualities result early in coldness, aloofness, emotional detachment, fearfulness, avoidance of competition, and daydreams revolving around the need for omnipotence. As children, they are usually quiet, shy, obedient, sensitive, and retiring. At puberty, they frequently become more withdrawn, then manifesting the aggregate of personality traits known as introversion, namely, quietness, seclusiveness, “shut-in-ness,” and unsociability, often with eccentricity.

DSM-II Diagnostic Criteria for Schizoid Personality This behavior pattern manifests shyness, over-sensitivity, seclusiveness, avoidance of close or competitive relationships, and often eccentricity. Autistic thinking without loss of capacity to recognize reality is common, as is daydreaming and the inability to express hostility and ordinary aggressive feelings. These patients react to disturbing experiences and conflicts with apparent detachment.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 1st ed.: 1952; 2nd ed.: 1968. Washington, DC: American Psychiatric Association.

DSM-IV Diagnostic Criteria for Schizoid Personality Disorder A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1.

2.

3.

4.

5.

6.

7.

neither desires nor enjoys close relationships, including being part of a family almost always chooses solitary activities has little, if any, interest in having sexual experiences with another person takes pleasure in few, if any, activities lacks close friends or confidants other than first-degree relatives appears indifferent to the praise or criticism of others shows emotional coldness, detachment, or flattened affectivity

B. Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder, or a pervasive developmental disorder and is not due to the direct physiological effects of a general medical condition.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g., “schizoid personality disorder (premorbid).”

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American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders.

4th ed. Washington, DC: American Psychiatric Association.

3. Psychopaths and Society Given that psychopaths are, by definition, people who repeatedly engage in antisocial behavior, and given also that they do not seem to learn from experience or respond to therapy, how should society treat psychopaths? Should they be punished like other lawbreakers? Would students consider the death penalty for psychopaths more appropriate (given that rehabilitation may be less likely) or less appropriate (given that they have a mental disorder) than for other criminals?

Should they be considered insane and committed to treatment?

4. Criminal Justice What is the purpose of the criminal justice system? Is it our society’s responsibility to rehabilitate those who break the law, or is punishment the only goal that we need to concern ourselves with?

The issue is complicated by the fact that many criminals, particularly younger ones, are not psychopaths but are people who, in some senses, seem to be victims of poverty or other unfortunate life experiences. It is complicated further by the observation that, in fact, the system does not do much of a job of rehabilitating; if anything, the criminal justice system seems to produce criminals. This observation is so keen that some have suggested that the best thing the criminal justice system can do in order to facilitate rehabilitation is to keep offenders out of the system—divert them into restitution programs, community service, or some form of therapy.

INSTRUCTIONAL FILMS 1. What it is like to have BPD (2019): https://youtu.be/acGcQQ1X74M 2. Dialectical Behavioral Therapy for BPD (2015): https://youtu.be/Stz--d17ID4 3. Back From the Edge (48 min., 2012) Back From the Edge offers guidance on treating borderline personality disorder. Borderline personality disorder (BPD) is a relative newcomer in the field of diagnosable psychiatric illnesses.

The individual with the disorder and his or her family usually find themselves in need of multiple support systems due to the complexities of the diagnosis. http://topdocumentaryfilms.com/back-edge/.

4. I, Psychopath (83 min, 2009) Instructors Manual

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In this intriguing documentary, Sam Vaknin, a self-proclaimed psychopath, goes in search of a diagnosis. In a scientific first, he allows himself to undergo testing to find out if he was born without a conscience. He knows he is narcissistic and cannot empathize with others. By his own admission, he’s pompous, grandiose, repulsive and contradictory, bad person. What he is is indifferent...he couldn’t care less. Unless, of course, the topic is himself. http://topdocumentaryfilms.com/i-psychopath/.

DISCUSSION QUESTIONS These questions are based on the clinical case studies and other information found in boxes throughout the chapter.

Emily As her therapist what would you suggest for Emily? Would you consider more socialization?

Alec In reviewing Alec’s case history, do you feel that he should be diagnosed with antisocial personality disorder, psychopathy, or both? Although not mentioned in his case file, what possible comorbid disorder(s) would Alec most likely struggle with?

Bob In discussing Bob’s history of behaviors and thought patterns, what would be the most likely diagnosis?

What behavior(s) would be best to target for therapeutic intervention in order to help Bob develop better interactions with others?

Leon In reviewing the case on Leon, what would be the most likely personality disorder diagnosis? What would be the most beneficial treatment targets for Leo?

Sarah In reviewing Sarah’s case, what personality disorder do her symptoms indicate? From the cognitive behavioral perspective, what maladaptive cognitions is Sarah probably having as evidenced by her difficulty at her new job?

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Pause and Ponder Activity: Borderline Personality Disorder The following questions reference the case studies published in Oltmanns and Martin, Case Studies in Abnormal Psychology, 11th Edition, John Wiley & Sons, 2019.

Part I: Pause What would you do if...? ...a woman goes clubbing every weekend, and brings home a different man each time? ...this woman takes pictures of each man that she brings home with her while he is still sleeping?

Consider how much you agree with the following statement: I can see these people's perspectives and understand how they would feel if I were in their shoes.

Part II: Learn Now that you have considered the statement, watch the case video on borderline personality disorder and answer the questions.

Question type Multiple Choice 1. Which of the following is a central symptom of borderline personality disorder, according to Andrea Chilton, MFT? a. Instability b. Inconsistency c. Irrationality d. Irritability Answer: a

2. a. b. c. d.

With borderline personality disorder, instability is often seen in which of the following area(s)?

Identity Occupation Relationships Both a and c

Answer: d

3. a. b. c.

The impulsive behaviors associated with borderline personality disorder are often...

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d. None of the above Answer: c

4. Borderline personality disorder is... a) More common in males than females b) More common in females than males c) Diagnosed equally in males and females d) Diagnosed only in females Answer: b

5. According to Andrea Chilton, MFT, borderline personality disorder is often combined with... a) Anxiety disorders b) Eating disorders c) Substance use disorders d) None of the above Answer: c

6. According to Dr. John Matthews, therapy for borderline personality disorder can be effective, but the therapist must devote significant time to what? a) Allowing the client to be impulsive in sessions b) Building trust and faith that will not collapse c) Identifying all components of the personality d) All of the above Answer: b

7. The piece of information that Emily gives us that most suggests that her year of therapy has produced some success in the treatment of her borderline personality is... a) She has discovered the meaning of life. b) She sees how colorful the world is. c) She has a stable relationship with her boyfriend.

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d) All of the above are suggestive of success.

Answer: c

8. A list of diagnostic criteria for personality disorders is shown below. Select all of the diagnostic criteria for borderline personality disorder. a) Affective instability due to reactive mood b) Chronic feelings of emptiness c) Efforts to avoid abandonment d) Envious of others e) Exploits others f) Impulsivity in self-damaging areas g) Inappropriate, intense anger h) Instability in self-image j) Lacks empathy k) Requires excessive admiration l) Suggestible and easily influenced by others m) Suicidal behavior or gestures, or self-mutilating behavior n) Uncomfortable when not the center of attention o) Unstable and intense relationships p) Uses physical appearance to draw attention to self

Answer 1: a Answer 2: b Answer 3: c Answer 4: f Answer 5: g Answer 6: h Answer 7: m Answer 8: o Instructors Manual

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Ponder Part III: Ponder Reflect upon the changes in your empathy that came about during this activity.

Question Type Essay 1. Consider how much you agree with the following statement: I can see this woman's perspective and understand how she would feel if I were in her shoes.

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CHAPTER 16 LEGAL AND ETHICAL ISSUES

LEARNING GOALS 1.

2.

3.

4.

Differentiate the legal concepts of insanity and the various standards for the insanity defense.

Describe the issues surrounding competency to stand trial.

Describe the conditions under which a person can be committed to a hospital under civil law.

Discuss the difficulties associated with predicting dangerousness and the issues surrounding the rights to receive and refuse treatment.

5. Describe the ethics surrounding psychological research and therapy.

The Learning Goals are inherent in both the Lecture Launchers and Discussion Stimulators below.

CHAPTER SYNOPSIS With the best of intentions, judges, governing boards of hospitals, legal associations, and professional mental health groups have worked over the years to balance the need to protect individual constitutional rights with the need to protect society at large from the actions of people with a psychological disorder who are considered dangerous to themselves or to others. This balance is not always easy to achieve, as illustrated in the cases throughout this chapter (see discussion questions below).

The two procedures of primary interest in this chapter are criminal commitment, which is undertaken when a crime is alleged to have occurred, and civil commitment, which is undertaken to prevent crime. Beyond these two legal procedures, important ethical issues involving treatment and research are discussed.

Criminal Commitment Insanity is a legal term, not a psychological one. Meeting the legal definition is not necessarily the same thing as having a diagnosable mental illness and vice versa. A person can be diagnosed as mentally ill and yet be deemed sane enough both to stand trial and to be found guilty of a crime. The insanity defense is the legal argument that a defendant should not be held responsible for an illegal Instructors Manual

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act if it is attributable to mental illness that interferes with rationality or that results from some other excusing circumstance, such as not knowing right from wrong; the not guilty by reason of insanity (NGRI) plea signifies that an accused person should not be held responsible for the crime due to his or her mental illness. The guilty but mentally ill (GBMI) plea signifies that an accused person is legally guilty of a crime but can then, in theory, be committed to a prison hospital or other suitable facility for psychiatric treatment rather than to a regular prison for punishment.

The concept of irresistible impulse suggested that an impulse or drive that the person could not control compelled that person to commit the criminal act. The M’Naghten rule specified that a person could not distinguish right from wrong at the time of the crime because of the person’s mental illness.

The Durham Test ruled that a person is not responsible for a crime if it was “the product of mental disease or mental defect.” However, given that this concept was so vague, only one state continues to use it today. The first part of the American Law Institute guidelines combines the M’Naghten rule and the concept of irresistible impulse. The second concerns those who are repeatedly in trouble with the law; they are not to be deemed mentally ill only because they keep committing crimes. The Insanity Defense Reform Act shifted the burden of proof from the prosecution to the defense, removed the irresistible impulse component, changed wording of substantial capacity, and specified that mental illness must be severe. A table in the chapter gives brief summaries of these landmark cases and laws.

The Jones case illustrates a number of the complexities associated with the insanity defense.

The legal standard for competency to stand trial requires that the accused understand the charges against him or her and can assist his or her attorney in the defense. Someone who is judged incompetent to stand trial receives treatment to restore competence and then returns to face the charges. The Jackson case specified that the pre-trial period can be no longer than it takes to determine whether a person will ever become competent to stand trial. Medication can be used to restore competency to stand trial in limited circumstances.

Recent cases such as the Oscar Pistorius and Jody Arias trials, in which both defendants have had psychiatric evaluations to determine whether or not there would be an insanity plea, are examples of how the court works with mental health professionals.

The U.S. Supreme Court has ruled that it is unconstitutional (a violation of the Eighth Amendment, which prohibits cruel and unusual punishment) to execute people who are deemed legally insane or mentally retarded. Individual states can determine what constitutes mental retardation and insanity.

Civil Commitment A person can be civilly committed to a hospital against his or her wishes if the person is mentally ill and a danger to self or others. Formal commitment requires a court order; informal commitment does not. People with mental illness who are not substance abusers are not necessarily more likely to engage in violence than are non-mentally ill people who are not substance abusers.

Early studies on the prediction of dangerousness had a number of flaws. Later research has shown that repeated acts of violence, a single serious violent act, being on the brink of violence, and

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medication noncompliance can maximize accuracy in predictions. Outpatient commitment, or assisted outpatient treatment (AOT) is one way of increasing medication compliance.

Court cases have tried to balance people’s rights with rights of society to be protected. The least restrictive alternative to freedom is to be provided when treating people with mental disorders and protecting them from harming themselves and others. Court rulings have affirmed that people with mental illness have the right to written notification, to counsel, to a jury decision concerning their commitment, and to Fifth Amendment protection against self-incrimination. A series of court cases have also generally supported the notion that those people committed to a hospital have the right to receive treatment. Patients have the right to refuse treatment as well, except when doing so poses a danger to self or others.

Beginning in the 1950s, large numbers of patients were released from hospitals in what has been called deinstitutionalization. Unfortunately, there are not enough treatment options available in the community. Jails and prisons are now the new “hospitals” for people with mental illness. Thus, transinstitutionalization may be a more appropriate term. Police officers are called on to do the work once reserved for mental health professionals. Partnerships between police, courts, and community mental health providers are promising for helping people with mental illness, such as crisis intervention teams (CIT).

Ethical Dilemmas in Therapy and Research Ethical restraints on research are necessary to avoid the abuses that have occurred in the past. Since the Nuremberg Codes of 1947, a number of ethical codes regarding psychological research have been developed. Research must be approved for safety and ethics by an institutional review board.

Universities and other research institutions, as well as federal grant- Funding agencies, require that researchers receive specialized training and certification in research ethics, on the basis of special coursework and examinations, to make it less likely that research participants will be put at risk.

Special precautions must be taken to ensure that research participants with mental illness fully understand the risks and benefits of any research they are asked to participate in and that particular care be taken to make certain that they can decline or withdraw from research without feeling coerced. Informed consent procedures must include enough information about the research so that participants know about the risks and feel free to withdraw without penalty.

In therapy sessions, patients have the right to have what is discussed kept confidential (cannot be disclosed to a third party), and this discussion is considered a privileged communication (information in confidential relationship protected by law). However, confidentiality and the privileged communication can be broken if an individual is a danger to self or others, is suing a therapist for malpractice, is a child under 16 who has been the victim of a crime or abuse, or is trying to evade the law for a crime committed or planned.

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KEY TERMS American Law Institute guidelines AOT civil commitment competency to stand trial

confidentiality

least restrictive alternative

GBMI

M’Naghten rule

in absentia

NGRI

informed consent

privileged communication

insanity defense

criminal commitment

irresistible impulse

LECTURE LAUNCHERS 1. Diminished Responsibility When the insanity defense is used, the facts of the crime are generally not in dispute. It is acknowledged that the defendant committed an act against the law, so what is at issue is whether the defendant should be held responsible for his or her behavior. The insanity plea pits two extreme views of the defendant in opposition: either he is sane, hence blameworthy and guilty, or insane, and innocent. Some scholars and lawyers have tried to chart a middle course by allowing that certain circumstances may mitigate blameworthiness without altogether eliminating guilt. Again, reference is made to the Oscar Pistorius case. What this means operationally is that the charge and sentence for a given act would vary according to circumstances. Which circumstances is a matter of debate.

The least radical and best-known version of what is known as the doctrine of diminished responsibility takes into account the context of the crime. Common examples of such mitigating circumstances are those where the person acted in self-defense, in response to provocation, in the heat of passion, or while intoxicated. As formulated in the model penal code, the issue is whether the act was “committed under the influence of an extreme mental or emotional disturbance for which there is reasonable excuse.” Whether there is reasonable excuse for the disturbance is to be judged by how a normal person “in the [defendant’s] situation under the circumstances as he believed them to be” would have felt. In essence, the relevant factors are situational, as opposed to personal variables; what matters is not how the defendant actually felt but how the situation would have made most people feel. It is common in most states for such factors to influence both the charge and the sentence for an illegal act.

A second, more radical version of diminished responsibility takes into account personal variables related to the “capacity of the accused to form the specific intent essential to constitute a crime” (People v. Wells, cited in Stone, 1975, Mental health and law: A system in transition. Rockville, MD: National Institute of Mental Health). For instance, first-degree Instructors Manual

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murder may be defined as a deliberate, premeditated killing; if it can be shown that the defendant lacked the intellectual capacity to plan the murder, or was so lacking in impulse control that premeditation was very unlikely, how others would respond to the circumstances of the crime is less important than how the defendant, by virtue of his or her capacities, could respond to it.

The third version of diminished responsibility proposes that the crime be judged in the complete context of the defendant’s life, person, and circumstances. Responsibility would be reduced if the person was predisposed by upbringing in a deviant family or subculture to commit criminal acts, or if the person was generally unable to control his behavior or recognize the wrongfulness of his acts, or if the situation was a provocative one, etc. This highly flexible standard is not currently in use. If pursued to its logical extreme, it seems to present the dilemma of why, given a determinist position, should anyone be held blameworthy for their acts? This may be why the courts shied away from the notion of diminished responsibility in the first place. As Stone notes, the free-will premise of the legal system is most viable if the exceptions to the rule are sharply defined.

Mason in 2011 (The insanity defense and diminished responsibility, Mental health ethics: The human context. Barker, Phil (Ed.); New York, NY: Routledge/Taylor & Francis Group; 317–324) suggests that one constant theme is that since records began, people considered to be insane and who have committed an offense should be treated differently from those offenders who are not considered to be insane.

2. Joint Statement of the American Medical Association and the American Psychiatric Association Regarding the Insanity Defense Below are excerpts from a joint statement on the insanity defense adopted by the American Medical Association and the American Psychiatric Association in April 1985. As is made clear in the first paragraph, the two organizations adopted differing policies in regard to the defense, thus necessitating the statement. The complete statement and a commentary on it can be found in American Journal of Psychiatry, 1985, 142, 1135–1136.

In the past two years the American Medical Association and the American Psychiatric Association have adopted position statements on the insanity defense. The APA took the position that the defense should be maintained but restricted to cognitive (as distinguished from volitional) matters that affect a defendant’s behavior. The AMA, by contrast, urged that the defense be abolished and that the issue of a defendant's mental status be relevant only to the issue of criminal intent, which is that element of all major crimes referred to in legal terms of mens rea, and to the questions of appropriate disposition following trial. This difference in approach has led to considerable discussion and constructive debate within and outside of both associations . . .

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It is the firm belief of the representatives of both the AMA and the APA, who met to discuss these matters, that further information is likely to lead to a consensus on whether there should be an insanity defense and, if so, how it should be structured.

This belief is buttressed by the fact that the motivating concern and basic judgments of both associations in this area essentially are the same. Both start from the proposition that, as a matter of sound public policy, the criminal justice system must seek to assure a reasonable balance between the public’s legitimate interest in protection from potentially violent offenders, and the mentally disordered defendant’s entitlement to fair and humane treatment. Thus, both associations agree that mental impairment should exonerate criminal behavior in only a narrow class of cases, and that defendants so exculpated should not suffer punishment or hardship as a result. Beyond that paramount concern, there are two other matters directly affected by the insanity defense that are of special importance to the medical profession: 1) assurance of proper medical and psychiatric treatment to disordered criminal offenders; and 2) establishment of an appropriate role for physicians who testify in legal proceedings.

The first concern has been an active one for both the AMA and the APA. There are many criminal offenders who, whether or not they successfully plead the insanity defense, are simply not receiving adequate psychiatric treatment . . . While there is no established correlation between mental illness and crime, the persistence of mental illness in a convicted offender can only impede the effective reduction of future criminal behavior by that offender.

There is also a shared concern on the part of the AMA and the APA over the role of medical testimony in the legal system. While this concern is by no means limited to the use of psychiatric testimony in criminal trials, that use is nevertheless one of high public visibility. In general, the adversary system does not facilitate lay comprehension of reasoned medical judgment. To the contrary, the adversary system, by its nature, tends to polarize expressions of medical opinion and to highlight the differences even when a large degree of agreement is present . . . It is especially important that the law not seek to mask basic policy decisions in the guise of medical expertise. To be sure, medical knowledge is often critical to effective policy analysis, but the need for clear lines as to where medical expertise ends and value judgments begin is essential.

This admonition is equally applicable to physicians who are called upon or choose to testify. While it is perhaps understandable that some physicians may become caught up in the combat of litigation, it is necessary that they

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do not stretch their medical opinions beyond legitimate, established scientific and clinical knowledge. When physicians do overreach, they may make it easier for the side that they support in a case, but they bring disrepute on themselves and their profession. Society will not, and in our view should not, tolerate the misuse of medical expertise to serve unrelated legal ends…

3. Psychologists in the Courtroom Psychologists and psychiatrists play three basic roles in the legal system: expert witness, consultant, and observer. As expert witnesses, one major type of testimony they are asked for is psychological information about a person involved in the case. Two familiar examples are cases involving the insanity defense, in which the court wants information about the person’s psychological state at the time of the crime, and competency to stand trial hearings, where it wants information about the present capacities of the accused. Similar information may be requested in child custody hearings where the psychologist is asked to provide information about the future best interests of the child. Evaluations of the child’s and parents’ mental health may well be included in such reports. In many states, a marriage can be annulled if it can be shown that one of the partners entered the contract unaware that the other had intentionally concealed a severe mental disability, a determination that might well require expert opinion. The propriety of special class placements of school children depends on the intellectual, emotional, and behavioral functioning of the child and these matters, too, can come to court. A family or social agency may ask a court to declare a person incompetent to manage his or her own affairs; this usually requires a psychiatrist’s statement. Finally, disability and compensation judgments can rest on experts’ opinions of the extent of emotional and intellectual impairment brought on by accident or disease.

A second capacity in which the psychologist or psychiatrist can be called on to testify is as an expert in some aspect of human behavior. For instance, the question may be, are reports obtained through hypnosis reliable? Can polygraphs detect lies? What are the odds that an eyewitness to a crime has a mistaken recollection of particular details? Is it possible for a person to be led into criminal behavior through watching television? These questions involve the expert’s opinion not of the person accused, but of the scientific evidence bearing on a point of importance to the court.

A second role is that of consultant to a party in a dispute. Here the behavioral expert advises the lawyer on how psychology may serve his ends. For instance, the consultant may advise the lawyer on how to attack an opposing psychologist’s testimony. A very controversial practice is that of aiding attorneys in the jury selection process. Each side can challenge, or block, the seating of a certain number of candidates for the jury and can therefore influence to some extent the composition of the jury. The claim of some psychologists is that they can shift the odds of acquittal by eliminating particular jurors on the basis of demographic and attitudinal variables (see Saks, M. J. & Hastie, R., 1978, Social psychology in court. New York: Van Nostrand Reinhold).

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The third role is that of observer. Here behavioral scientists study the psychology of the legal process. For instance, a great deal of work has been done using mock trials to determine the legally irrelevant determinants of conviction and innocence. For example, does the physical appearance of a witness influence the credibility of his or her testimony? The hope, at least, is that such studies will eventually help produce a more just judicial system.

4. Criminalizing Mental Disorder Are mentally ill persons being shunted into the criminal justice system in the wake of deinstitutionalization? Is jail to become the poor person's mental health facility? As inpatient services are used less and community services are inadequate, many mentally disordered individuals live in the community without treatment and become a more visible presence.

Some have hypothesized that the bureaucratic and legal impediments to initiating mental health referrals make criminal arrests a less cumbersome means of removing a disordered person from the community; research by Teplin (1984, American Psychologist, 39, 794–803) indicates that this “criminalization of mental disorder” is indeed occurring.

Teplin conducted a large-scale observational study of the ongoing police activity of 283 police officers (randomly selected) over a 14-month period. Quantitative data collected included coding of concrete behaviors relevant to the police officer's handling of all police-citizen encounters. Qualitative data included more impressionistic data about the officer's behavior and the reasoning underlying his or her judgments in handling situations.

Results indicated that, overall, 5.9% of suspects encountered were rated as severely mentally disordered by the field workers. The probability of being arrested was 20% greater for suspects exhibiting signs of mental disorder than for those who apparently were not mentally ill; 14 of the 30 mentally disordered suspects were arrested (46.7%), as opposed to only 27.9% (133 of 476) of the suspects without signs of mental disorder. This difference was statistically significant. In addition, the findings indicated that the difference in arrest rates was not due to the mentally ill persons committing more serious offenses; in almost every category of offense, those with signs of mental illness were more likely to be arrested than those without.

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The propensity to arrest mentally disordered persons may be due in part to officers’ lack of knowledge of the symptoms of severe mental disorder, as there was no significant difference in the arrest rates in terms of police officers’ perception of their mental status. It may be that symptoms of mental disorder that are not violations of the law (verbal abuse, belligerence, disrespect) provoke a harsher response from police officers.

In addition, qualitative data indicated that police officers commonly obtained signed complaints in instances where they were going to seek psychiatric hospitalization for the suspect. In this way, arrest could be used as a backup if hospital admission could not be arranged. Ironically, many hospitals refuse to accept patients they view as dangerous, although this is one of the few criteria by which involuntary admission can be made, and since persons with mixed symptomatology, particularly a combination of drug or alcohol abuse and other mental disorder, are especially difficult to place; the only alternative to the police may be arrest.

Teplin makes the following recommendations based on her results: (1) police officers should receive training in recognizing and handling the mentally ill, and no-decline agreements should be established with hospitals; (2) the least restrictive alternative should be utilized where possible; (3) treatment systems must be designed to accommodate those individuals not fitting into a neat category of mental illness; (4) modes of care other than hospitalization must be available as alternatives for police referral of mentally disordered persons.

Huxter supports this thinking in “Prisons: The psychiatric institution of last resort?” To quote, “One of the more disparate and outrageous examples of inequities in public health has been an insidious trend towards criminalizing mental illness, and the largely unjust treatment of many mentally ill persons” (Journal of Psychiatric and Mental Health Nursing, 20(8), 2013, 735–743).

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5. Ethical Abuses in Private Psychiatric Hospitals Charges of serious ethical abuses, driven by concerns for falling profits, have been made against several large chains of for-profit mental hospitals in the United States (Moffat, S., February 2, 1992. “Healing patients, or profits?” Los Angeles Times, A1, A24, A25). A woman, feeling very depressed one night, called an 800 number shown on a television ad offering free counseling. Given an address to go to, she arrived at a private psychiatric hospital where, after it was determined that her insurance coverage would pay for psychiatric hospitalization, she was dragged away by some attendants and committed against her will—without even seeing a mental health professional. It took frenzied phone calls to her lawyer to get her released the following day, but not until she had spent a night against her will on a locked ward, for which she received a bill for $1,700 (which included a fee for a doctor she did not see)!

Other hustles are marketed to the parents of teenagers who are untidy, get drunk from time to time, and are disobedient. Some ads portray such behaviors as signs of serious mental illness and encourage parents to commit their adolescents for treatment. Highly skilled salespeople working for some private hospitals sell inpatient stays to potential consumers—all of whom have private insurance. A parent in upstate New York saw an ad with an 800 number encouraging worried parents to call. He phoned because he wanted to get his children away from stormy divorce proceedings and was told, on the basis of a short phone conversation with a salesperson, that his children could be enrolled in a “youth program” in California, which would include such things as trips to Disneyland and shopping malls. The outfit would even buy plane tickets for his two children. Unknown to him or to his youngsters until they arrived in California, he had agreed to commit them to a mental hospital. It took him two weeks to get them released, and he claimed that, during that time, they were not even seen by a professional for evaluation.

These horror stories are different from the accounts of what Pinel saw in La Bicetre, different from the snake pit portrayed in the movie Amadeus, and different still from Ken Kesey’s One Flew Over the Cuckoo’s Nest. One key dissimilarity is that the earlier abuses took place in public hospitals, in which financial expense to either the patient or family was not an issue.

What is happening in some private hospitals today is that empty beds have to be filled to make ends meet and that most private insurance carriers cover inpatient treatment— sometimes more completely than less expensive outpatient care. At stake is an $8-billion-ayear industry, where the pursuit of available yet shrinking private insurance dollars leads some hospitals not only to egregious abuses like the above but also to more subtle perversions like making diagnoses on the basis of what insurance will cover rather than only on the basis of informed professional judgment; providing unnecessary treatments; and extending hospital stays longer than actually needed. Furthermore, all of this is happening when tens of thousands of uninsured people, many of them living on the streets, do not have access to what can be up-to-date care.

An April 29, 1992 article by Peter Kerr of the New York Times News Service

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“WASHINGTON—A federal government review of private psychiatric hospital cases— most of them teen-agers and young children of military families—has found that in 64 percent of the cases, patients never should have been admitted or were kept longer than necessary or their hospitals could not justify treatment with their medical records. The abuses may have cost U.S. taxpayers hundreds of millions of dollars.”

The study by the Defense Department of more than 500 patients admitted to psychiatric hospitals around the nation in 1990 under a federal insurance program for military families also found that many of the programs appeared to provide poor or dangerously deficient care.

Many of the hospitals charged hundreds of dollars a day. Not a pretty picture.

6. Civil Commitment of Sex Offenders In 1990, Washington State enacted legislation that provides for the indeterminate commitment of “any person who has been convicted of a sexually violent offense and who suffers from a mental abnormality or personality disorder which makes the person likely to engage in predatory acts of sexual violence” (WASH. REV. CODE §71.09.010). This statute has been the template for similar legislation in over 20 states. Since that time, many challenges have been mounted to the constitutionality of these laws, but to date, they have been upheld by the Supreme Court. In some states these people are referred to as sexual predators, sexual psychopaths, and sexually violent persons (SVP).

In 1997, Arizona committed its first SVP. Today, there are approximately 80 men in treatment and an additional 30 awaiting disposition by the courts. Arizona’s program differs from that in the other states because of a special program called the Less Restrictive Alternative (LRA). In most states, men are in medium to maximum secure facilities and have no contact with the community. Arizona’s LRA program allows graduated contact with the community under supervision of clinical staff and surveillance officers. Each man wears a GPS monitor when he is in the community and makes detailed reports of his activities. Some drive themselves to work or school, while a few have moved into the community and return to the center for treatment. Through graduated access to the community, these men can handle unique problems that did not exist when they went to prison 10–20 years prior. They can work through challenges with the help of their peers and group facilitators.

Relieving someone of his civil liberties for an indefinite period is a serious matter. Students could take the pro and con side of this issue for a classroom discussion.

Fitch, W. L. (1998). Sex offender commitment in the United States. The Journal of Forensic Psychiatry, 9, 237–240.

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7. Ethics in Domestic Violence Research One of the main concerns of researchers in domestic violence is the safety of the participants.

Ellsberg and Heise (2002) developed guidelines for domestic violence researchers (see below) based upon the World Health Organization Multi-Country Study on Women’s Health and Domestic Violence against Women. Because much of the authors’ research takes place in underdeveloped countries, there are many risks and special challenges that might not occur to most of us. They related the story of a research team in Chiapas, Mexico who learned that three women who responded to the survey were beaten by their partners. In one case, they interviewed women washing clothes in a river in Zimbabwe in order to preserve their privacy.

Ellsberg, M., & Heise, L. (2002). Bearing witness: Ethics in domestic violence research. Lancet, 359, 1599–1565.

• • • • • •

• • • •

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Minimize harm—respondents might be vulnerable to physical harm if a partner finds out that she participated in the research.

Ensure participant safety—interview only one woman in the household to avoid alerting others who might tell the potential abuser.

Protect privacy and confidentiality—complete privacy might require interviews in the field as the women work.

Minimize participant distress—interviewers should be trained to deal with strong emotional reactions when the victims retell stories of the violence.

Referrals for care and support—women should be asked if it would be safe for them to receive pamphlets with referral sources.

Minimize harm to the research team—researchers have been assaulted by angry men who disliked the study. They also have emotional risks in hearing the many stories of violence.

Assure scientific soundness—an unsound study exposes subjects to risk or inconvenience while achieving no benefit.

Interview as intervention—many women who have suffered domestic violence did not know they had alternatives.

Use study results for social change—involve advocacy and direct service groups in the project.

Informed consent—some researchers believe that women should be informed in advance that there will be questions about violence, while others believe that this may discourage participation.

Mandatory reporting—researchers should respect the woman’s autonomy but should report instances of child abuse.

8. Ethical Issues in Psychotherapy Research Conducting research on psychotherapy raises difficult ethical issues that differ from those issues common to all research with human subjects. In a thought-provoking article, Imber and colleagues (1986, American Psychologist, 41, 137–146) discuss these issues in the context of the NIMH Treatment of Depression Collaborative Research Program’s handling of ethical dilemmas. The Instructors Manual

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NIMH depression study is described in Chapter 18 of the text. Since students will be familiar with the project, they might be first asked to identify ethical issues which may arise in the project and ways to resolve those issues, before the following material from the Imber et al. article is presented.

In determining whether a patient was admitted to or withdrawn from the study, the research investigator, rather than the patient’s therapist, had ultimate authority in this study. Does this policy provide the best care to the patient? The study addressed this issue by basing guidelines for eligibility and withdrawal on clinical care considerations as well as research purposes, weighing the patient’s preference and therapist’s recommendations heavily, and preserving patients’ right to drop out unilaterally.

In a controlled trial such as this one, treatment regimens were standardized rather than based on the flexible clinical judgment that is used more often in non-research psychotherapy settings. This issue was addressed by standardizing broad guidelines and suggestions for treatment rather than rigid directives.

Treatment assignments were made randomly, rather than being based on patient preferences or evaluation findings about the patient. Do patients adequately understand the random nature of treatment assignment, and feel they would have access to alternative treatment if they refused the research protocol? To address this issue, the NIMH project instructed researchers not to exert pressure on potential candidates, to provide adequate referrals if the research protocol was refused, and to let patients drop out if they preferred an alternative treatment to the one they were assigned (which 10% of patients did).

One of the treatment conditions in this study was a pill-placebo control. Should patients be assigned to an inactive treatment when effective interventions are available? Safeguards implemented to address this problem included screening out subjects who were imminently suicidal, providing regular contact with a pharmacotherapist, periodic independent evaluations, and a clear mechanism for patient withdrawal and referral to appropriate treatment.

Long delays may occur (in this study about 3 weeks) between the time a potential subject requests treatment, and the time treatment actually begins, due to screening procedures and scheduling problems. Are patients in acute distress put at unnecessary risk by this waiting period? In this study, the waiting period was used for several clinically relevant tasks, such as evaluating the patient condition and “washing-out” drugs which would interact adversely with imipramine. When immediate treatment was deemed compelling, patients were withdrawn from the study and treatment was arranged elsewhere.

Following treatment, informing patients of the treatment condition they were in and referring for further care where indicated, while good ethical practice, may confound the results of the followup assessments. To balance research purposes with patient care, this study referred patients who had not improved for further treatment but asked those who had improved to put off further treatment; the latter were seen later for an appointment to re-evaluate their request for a referral. For ethical reasons, patients on pill-placebo were told of their treatment status at termination, despite the fact that this might contaminate their follow-up evaluations.

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In any psychotherapy study, some patients will withdraw from treatment, despite considerable energy having been expended in their care. Will the resulting frustration for researchers preclude their following up these patients who may remain at risk? In the NIMH study, careful efforts were made to maintain contact with dropouts for the duration of the study and refer them for appropriate treatment.

DISCUSSION STIMULATORS 1. Commitment Decisions Show students the following matrix:

The matrix represents the possibilities open to the diagnostician faced with an individual who is either “sick” or well. He can commit him to a hospital or not commit him. In the case of physical illness, decision A represents proper medical procedure (treating someone who is sick); decision B, conservative medicine (better to err on the side of caution); decision D illustrates diagnostic acumen; and decision C is what physicians try to avoid (not treating someone who really needs treatment). Thus, physicians would prefer to err in making decision B than in making decision C. In cases of uncertainty, the rule is to diagnose illness, unless the treatment itself is quite dangerous.

In the case of psychiatric disorder, the outcome of decisional errors is vastly different.

Committing someone who is really well (B) deprives him of constitutionally guaranteed civil liberties, and unlike a diagnosis of physical illness, stigmatizes the individual for life. Not committing someone who is really “sick” (C) rarely results in death and, in fact, may not even result in further deterioration (cf. R. B. Stuart, 1970, Trick or treatment. Champaign, IL: Research Press). Diagnosis is further complicated by the apparent tendency of many clinicians to see mental disorder whenever an individual is so labeled by himself or others (recall the Rosenhan study).

2. Community Protection vs. Civil Rights: Megan’s Law Named “Megan’s Law” after the 7-year-old New Jersey girl who was sexually assaulted and murdered, community notification laws require child molesters on probation to register and be made known to the communities they live in. The idea is to protect people from neighbors who are known sex offenders. Critics contend that the laws do not prevent a convicted child molester from going to another community to offend again; in fact, that is what many

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molesters do. Further, ex-convicts who are trying to make a good-faith effort at rehabilitation are stigmatized and ostracized.

3. Ethics Role-Play: Confidentiality This role-play exercise will help students grapple with ethical issues involved in providing mental health services. There are four roles to be assigned; the rest of the class can observe the debate and give their opinions about the issues afterward. The following information might be photocopied and distributed to the class before asking for volunteers for the parts.

When the role-play is complete, you could tell students that the law in many states now allows minors to seek therapy for certain reasons (including drug use and sexuality/pregnancy decisions) without parental consent.

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EXERCISE: Ethics Role-Play A walk-in clinic for teenagers within a large children’s hospital in Hollywood has been providing counseling for adolescents who walk in on their own asking for help with various medical and psychological problems. Some of these adolescents are “street children” who do not have contact with their parents; others are adolescents who live at home but, for various reasons, choose to seek therapy on their own. The clinic has had a policy of keeping information about such issues as drug use and teenage sexual behavior confidential; they assure their clients that discussions about these issues will not be disclosed to parents or juvenile justice personnel. Recently, some parents and juvenile justice system workers (probation officers) have criticized the clinic for keeping this information confidential. You are meeting to discuss the issues and determine whether the clinic should be limiting their assurances of confidentiality to their clients.

ROLES: Dr. Clout: You are a psychologist who runs the clinic in question. You strongly believe that therapy can be effective only if the client knows that everything she/he says during therapy will be kept in the strictest of confidence. Without this guarantee, the client will be unable to trust the therapist and unable to disclose his/her innermost fears and secrets. Furthermore, you are certain that most of the clients the clinic serves would not come to the clinic if they knew that their illicit behavior would be reported to their parents or to the probation officers. Therefore, if confidentiality was limited, the important services being provided by the clinic (such as information about safe sex, drug abuse counseling, referrals to human service resources) would not reach the community most in need.

Mr./Ms. Wright: You are a parent working for a parents’ rights group and are also involved in a Tough Love program for keeping kids off drugs. You represent a group of parents who are seriously concerned about the clinic’s policy of keeping information confidential which could harm children. Recently, an adolescent girl who had been seen at the clinic was found dead of a drug overdose in Hollywood. Her parents feel that if the clinic had notified them of her drug use, they might have been able to prevent this tragedy. Furthermore, you feel that since the clients of the clinic are minors, their parents should be asked for consent before they are offered treatment of any kind.

Mr./Ms. Strict: You are a juvenile justice worker who is frustrated by your inability to significantly limit gang activity and drug use in the community. You feel that the clinic, which has contact with many of the adolescents you are concerned about controlling, should be working with the juvenile justice system to help monitor and limit drug use.

Mr./Ms. Young: You are a teenager who has been a client at the clinic and have volunteered to offer your opinion about this matter. You have consulted with other clients at the center in order to better represent their position. You feel strongly that

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the clinic should be allowed to keep information about drug use and sexual behavior confidential. In fact, you are certain that most, if not all, of the adolescents who use the clinic would never set foot in the door again if their secrets were going to be exposed. In fact, since this inquiry has begun, the number of clients using the clinic has dropped dramatically.

4. Confidentiality and HIV Diagnosis A recent issue regarding confidentiality vs. Tarasoff duties has arisen in the area of HIV diagnosis. Present the following vignette for class discussion: You are a counselor working in an HIV/AIDS clinic. The clinic offers confidential testing for HIV, and your job is to present the results of HIV tests to clients and discuss their reactions to the diagnosis. One day, a couple comes to the clinic to hear the results of their HIV tests. You are to meet with the man to go over his results, and another counselor will be meeting with his girlfriend.

It turns out that the man (your client) is determined to be HIV positive. When you meet with the man and disclose his diagnosis, you discuss the modes of transmission of the virus and the importance of safe sex. You also encourage him to disclose the diagnosis to any former and current sexual partners, and he assures you that he will do so.

As the man leaves your office, you observe him greeting his girlfriend in the waiting room. His girlfriend hugs him and says, “Thank God, I'm negative.” Your client responds, “That’s great; so am I!” They walk off arm in arm.

Discussion could involve what the counselor should do, and whether the man’s confidentiality is more important than the duty to warn the girlfriend that she may be in danger. Most of your class will undoubtedly identify with the girlfriend and feel that the counselor should break confidentiality. To counter this stance, the following arguments might be offered: 1. If people are not guaranteed confidentiality, they will not get tested for HIV, and this will increase the risk of transmission and delay treatment.

2. Given that information about safe sex is widely available, people involved in sexual relationships have a responsibility to protect themselves regardless of their knowledge of a person’s HIV status.

How might these same issues also apply to COVID-19 infection? What if a patient tells a therapist they are COVID-positive and are attending large gatherings withing masking or social distancing?

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5. Ethics in Marital Therapy Who is the client in marital therapy? What if one partner’s goals are at odds with those of the other? Margolin (1982, American Psychologist, 37, 788–801) raises several other ethical issues related to marital therapy that might be discussed in class. One of particular interest involves confidentiality. Imagine that Mr. and Mrs. Crack are being seen in marital therapy, and Mr. Crack requests an individual appointment with the therapist. During this session, he discloses that he is having an affair, and asks the therapist to keep this information confidential. What should the therapist do? Should the information be disclosed? Should the therapist have granted an individual interview? Should the therapist have implied that she would keep information from the spouse?

These questions are hotly debated by marital therapists, who reach very different conclusions.

Some therapists will not see the spouses individually. Others will consent to individual appointments but inform the couple in advance that information disclosed there might not be kept confidential (thus giving the client the chance to decide whether to share the information or not). Other therapists agree to keep disclosures confidential and may even encourage the sharing of “secrets.” To make the issue even more complicated, what if marital therapy is initiated after a client has been seen in individual therapy? Information obtained during the earlier individual sessions cannot ethically be disclosed to the spouse without the client's permission. If the client gives permission for confidentiality to be broken, does she actually remember all that she has disclosed individually? Would she have responded differently if she knew before the fact that the information might be disclosed to her spouse? While a consensus has not been reached on these issues, an overriding ethical principle is to inform clients of the limits of confidentiality, so that they know before disclosing information whether the therapist has promised to keep it private or not.

6. Ethical Dilemmas: Should vs. Would Not surprisingly, mental health practitioners report that they have more rigorous standards for what they should do in ethical situations than for what they feel they would do in handling a particular dilemma (Smith, McGuire, Abbott, & Blau, 1991. Professional Psychology: Research and Practice, 22, 235–239). While clinicians apparently use codified ethical and legal guidelines in deciding what they should do, they cite other factors, including personal values (e.g., it feels right, upholding personal morals/standards) and practical considerations (e.g., fear of verbal/social reprisal by supervisor, colleague, or client: financial need) when deciding what they would do. To understand the complex issues involved, students might be asked to consider what they “should” and “would” do in handling the following ethical dilemmas.

7. Ethical Dilemmas Child Abuse: To Report or Not to Report?

You are seeing a nine-year-old girl, “Sherri,” diagnosed with Oppositional Disorder, in individual therapy. After six months of treatment and a number of parent sessions, your impression of her mother is that she is a caring, thoughtful parent. A primary focus of therapy

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has been helping Sherri’s mother learn to set appropriate, firm limits, rather than letting her daughter avoid consequences for misbehavior. Today, you meet with her mother first, and she reports that she has been trying hard to stick to her decision to not allow her daughter to watch TV for the week, as a consequence for Sherri's lying about her homework. She says that Sherri has been very upset about this consequence and has been yelling at her mother, crying, and threatening to run away to her best friend’s house.

When you meet with Sherri alone, she reports that her mother has been mean to her all week by not letting her watch TV. She asks you what would happen if she told you that her mother had hit her. In particular, she wonders if children are taken away from their parents for this, and if she might be sent to live with her best friend, whose mother she feels is more understanding. She then tells you that her mother hit her with a belt several days before, and it left a bruise and red marks. You ask to see the place on her leg where she was hit, and she shows it to you. There is no mark there now. Knowing the law that mental health practitioners are mandated to report suspected child abuse, what should you do in this situation? Would you file a report? Why or why not?

8. Ambiguous Diagnosis You are a psychologist working at a private psychiatric hospital. Most of your work involves referrals from psychiatrists for psychological evaluations, including your opinion regarding diagnosis of the patients. A psychiatrist, Dr. Bard, has referred a number of patients to you in the past, and you find him a competent and caring mental health professional. He is also one of two primary referral sources in your private practice and a personal friend. He refers a patient to you, Todd, a 15-year-old boy who was recently hospitalized for psychiatric treatment. Dr. Bard tells you that the boy is depressed, and his diagnosis is listed in the chart as “atypical depression.” In your assessment of Todd, you find that his symptoms most closely fit the diagnosis of conduct disorder. While he does show some symptoms of major depression (irritable mood, anhedonia, and difficulty concentrating), he does not meet all the criteria for the disorder. You know that his insurance company will not pay for psychiatric hospitalization for conduct disorder, but they will pay for treatment of depression.

What should you write in your evaluation? What would you do in this situation? Explain your reasoning.

9. Ethics in Research Students have probably participated in various psychological experiments in your psychology department. What were they told about the experiments, and what sort of informed consent procedure did they go through? Did they feel free to withdraw at any time? Perhaps you could review your department’s human subjects guidelines with the class.

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10.

Psychology and the Internet

Each edition of this manual utilizes the Internet more and more. The obvious uses are literature searches, downloading articles of interest, online purchases or reference materials, etc. But two other uses are becoming more and more popular: electronic communication with patients and conducting online research.

What ways do students think email could benefit the therapeutic relationship? What might be some of the pitfalls? What about texting or use of apps?

For a discussion of issues related to e-mailing patients: Hatcher, S. (2001). Using email with your patients. Australasian Psychiatry, 9(3), 207– 209.

For a more recent discussion of telecommunication in psychotherapy: Vincent, C., Barnett, M., Killpack, L., Sehgal, A., & Swinden, P. (2017). Advancing telecommunication technology and its impact on psychotherapy in private practice. British Journal of Psychotherapy, 33(1), 63–76.

Online or text-based psychotherapy considerations: Fang, L., Tarshis, S., McInroy, L., & Mishna, F. (2018). Undergraduate student experiences with text-based online counseling. The British Journal of Social Work, 48(6), 1774–1790.

Stoll, J., Müller, J. A., & Trachsel, M. (2020). Ethical issues in online psychotherapy: A narrative review. Frontiers in Psychiatry, 10, 993.

11.

The Rise of Telehealth

Telehealth (or Telepsychiatry) has become increasingly popular in recent years, especially during the COVID-19 pandemic. Many providers or patients may have been resistant to Telehealth previously were forced to adapt during the pandemic to ensure continuity of care for their patients. Ask students for their thoughts on the pros and cons of Telehealth for assessment, psychotherapy or medication management and how they think Telehealth services may be better or worse in comparison to in-person services. What might be some ethical, privacy, or safety challenges that providers may face when using Telehealth to treat patients with mental health disorders?

12.

Reactions to the Tarasoff Case

In the Tarasoff case. Prosenjit Poddar, a graduate student from India studying at the University of California at Berkeley, met and become infatuated with Tatiana Tarasoff. Prosenjit expressed his affection for Tatiana but Tatiana did not reciprocate. Prosenjit became depressed as a result of this and started seeing a psychologist at the campus health service.

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When Tatiana returned from Brazil after a summer trip, Prosenjit informed his psychologist that he planned to purchase a gun and he discontinued therapy. The psychologist notified campus police, both orally and in writing, that Prosenjit was dangerous and should be taken to a community mental health center for psychiatric commitment. The campus police interviewed Prosenjit, who seemed rational and promised to stay away from Tatiana. They released him, notified the health service, and no further efforts at commitment were made. In fact, the supervising psychologist requested that the letter to the police and specific therapy records be destroyed. On October 27, Prosenjit went to Tatiana’s house with a pellet gun and a kitchen knife. He shot her with the pellet gun and repeatedly and fatally stabbed her.

Under the privileged communication statue of California, the counseling center psychologist properly breached the confidentiality of the professional relationship and took steps to have Poddar civilly committed. What the psychologist did not do, and what the court decided he should have done, was warn the likely victim, Tatiana Tarasoff, that her former friend had bought a gun and might use it against her. The Tarasoff ruling requires clinicians, in deciding when to violate confidentiality, to use the very imperfect skill of predicting dangerousness.

The Tarasoff case in California was one of the seminal moments in legal history: “The famous Tarasoff v. Regents of the University of California decision by the California Supreme Court, decided in 1976, created a new duty for therapists when they are treating certain patients in the state of California. Specifically, the court held that ‘[w]hen a therapist determines, or pursuant to the standards of his profession should determine, that his patient presents a serious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim against such danger.’ While this case has come to be known as the case that established a ‘duty to warn,’ it is more accurate to state that the duty created by Tarasoff is a ‘duty to take reasonable care to protect the intended victim’” (Richard Leslie, The California Therapist, Mar–Apr, 1990).

How do the students in your class react to this ruling? Do they agree or disagree? What is the rationale behind their thinking? Do they believe that mental health clinicians can predict dangerousness? What are their thoughts on confidentiality? Do they believe that the psychologist was at fault for Tatiana’s murder? What might they do if placed in a similar situation?

INSTRUCTIONAL FILMS 1. By Reason of Insanity (44 min.), By George Lavoo: https://www.youtube.com/watch?v=kjdYNZJ7JFw 2. The Case if the Hillside Strangler (1999, 1 hour 35 min.)

TV Movie Documentary about a serial killer: https://www.youtube.com/watch?v=eAGwWphSj38

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3. Insanity in the Courtroom: Mental Illness and the Search for Justice (23 min.)

“If a person is deemed mentally unfit to stand trial for a capital crime, should the state be allowed to administer drugs, so the person is healthy enough to be tried and sentenced to death? In this program, ABC News correspondent Chris Bury reports on this legal paradox in the case of Russell Weston, a paranoid schizophrenic who allegedly killed two policemen in 1998 and whose lawyers have kept him from medication. The issue is debated by a panel of experts including retired circuit court judge Vincent Femia, forensic psychologist Barbara Kirwin, George Mason University legal scholar Paul Stavis, former federal prosecutor Christopher Tayback, and the defense attorney for Long Island Railroad shooter Colin Ferguson, Ron Kuby (23 minutes).” https://films.com/id/1798/Insanity_in_the_Courtroom_Mental_Illness_and_the_Search_for_J ustice.htm 4. Mistreating the Mentally Ill (56 min., 1987) “There are 250 million seriously mentally ill people in the world and no society—rich or poor— has devised a humane system of care. This program focuses on the United States, Japan, India, and Egypt, examining how each culture sees mental illness and treats the less accepted members of society. In general, Japan locks its patients up for long periods in predominantly for-profit institutions where they are often subject to brutal treatment; the United States, with the best of intentions, casts many of its mentally ill out on the streets, or into vast shelters with little hope of receiving care; India treats less than 10% of those who need care, with occasional oases of good community care contrasting with examples of inhumane conditions in psychiatric hospitals; while in Egypt, rural traditions which tolerate the mentally ill are being submerged in industrialization, and one of Cairo’s largest private mental hospitals is run as a business by the president of the World Federation of Mental Health. The program concludes that the problem is not merely shortage of funds, but the indifference of society to the mentally ill.” https://www.films.com/id/7698 5. Genes on Trial: Genetics, Behavior, and the Law (58 min., 2003) “Could genetic research stigmatize people who carry a “bad” gene? Could their behavior actually be determined by that gene? If so, then just how free is free will? Moderated by Harvard Law School's Charles Ogletree, this Fred Friendly Seminar scrutinizes social, ethical, and legal issues involving genetic research into undesirable traits such as addiction to alcohol by exploring the relationship between the genetic basis for addiction and the limits of personal responsibility. Panelists include U.S. Supreme Court Justice Stephen Breyer; journalist Gwen Ifill, managing editor of Washington Week in Review; high-profile attorney Johnnie Cochran, Jr.; Alan McGowan, president of the Gene Media Forum; Patricia King, Carmack Waterhouse Professor of Law, Medicine, Ethics, and Public Policy at the Georgetown University Law Center; and David Goldman, chief of the Laboratory of Neurogenetics at the National Institute on Alcohol Abuse and Alcoholism.” https://films.com/ecTitleDetail.aspx?TitleID=5169

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6. Discussions in Bioethics (National Film Board, Canada, 106 min., 1986) “A series of eight short, open-ended dramas designed to stimulate discussion of values and ethics in relation to modern medical technology. They deal with some of the most vital issues faced by doctors, lawyers, the church and society as a whole. Each drama is based on a documented case.” http://onf-nfb.gc.ca/en/our-collection/?idfilm=16771 7. Science and Ethics (23 min.) (#5625) “Ethical problems have been crowding in on scientists since the atomic bomb. Should scientists be responsible for what they develop? Is there a limit to where science should tread? How can privacy be maintained in the face of computers that increasingly invade our lives? These and other questions are raised in this program, including the very delicate questions raised by the new field of biotechnology.” https://www.madisonartshop.com/general-science-methods.html 8. Psychopath (50 min., 2000) “There are many psychopaths in society whom we virtually know nothing about. These are the psychopaths who do not necessarily commit homicide, commit serious violence, or even come to the attention of the police. They may be successful businessmen. They may be successful politicians. They may be successful academics. They may be successful priests. They exist in all areas of society. There is a growing awareness that psychopathic behavior is around us in all walks of life.” http://topdocumentaryfilms.com/psychopath/.

9. Interview with a Cannibal (34 min., 2011) Sagawa was declared insane and unfit for trial and was institutionalized in Paris. His incarceration was to be short, however, as the French public soon grew weary of their hardearned euros going to support this evil woman-eater, and Issei was promptly deported. Herein followed a bizarre and seemingly too convenient set of legal loopholes and psychiatric reports that led doctors in Japan declaring him “sane, but evil.” On August 12, 1986, Sagawa checked himself out of Tokyo's Matsuzawa Psychiatric hospital, and has been a free man ever since.

10. Milgram’s Research Milgram's famous obedience to authority studies created considerable controversy regarding the protection of human subjects in psychological experimentation. The film of these studies, Obedience, is certain to provoke reactions from the students regarding this issue. The link to the original study can also be found here: https://www.youtube.com/watch?v=eTX42lVDwA4.

DISCUSSION QUESTIONS These questions are based on the clinical case studies and other information found in boxes throughout the chapter.

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Jeremy Jeremy’s case is an example of being found NGRI, which led to his treatment in a psychiatric hospital for 7 years. When his providers petitioned for his release after successful treatment, the judge ordered that this was premature and ordered he be evaluated again in a year. What are some of the challenges associated with this approach to committing individuals to forensic hospitals after a successful NGRI defense? Did the judge do the right thing to refuse to release Jeremy because of the potential for his dangerous behavior to return if he chose to stop taking his medication upon release?

When would be the appropriate time to release Jeremy from the forensic hospital and how should this be determined?

David As seen in David’s case and many others, do you feel that the forced medication of mentally ill persons—who have been dangerous when not medicated in the past—should be legalized? If so. How would that be operationalized?

Yolanda In reviewing the case of Yolanda, do you feel she should have been legally charged with theft because she was later deemed capable to stand trial and admitted to stealing the donuts? Do you think the judgment was correct in her case?

Descriptions of Real Legal Cases:

Michael Jones In the case of Michael Jones, he was found NGRI but served a far lengthier sentence (28 years) than he would have if he had pled guilty to petty theft (1 year). Due to the legal interpretation of violence and his reassessment of paranoid schizophrenia, he had to continue his sentence. Do you think there should be legal changes to the interpretation of the violence that, in part, lead to his incarceration for 28 years? What would have to change to reflect a fair judgment in this case?

Horace Kelly and Scott Panetti Considering the case of Horace Kelly and Scott Panetti, among other similar cases, do you feel that individuals with mental illness should be executed if they are competent to stand trial and understand their charge? Should part of their eventual release be a forced medication regimen to prevent them from re-offending? What measures should be taken to keep the public safe from the mentally ill who are released from prison or forensic hospitals?

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