Essentials of Abnormal Psychology, Fourth Canadian Edition, 4E Jeffrey S Nevid Solution Manual

INSTRUCTOR’S MANUAL Barinder Mohini Eastern Iowa Community Colleges, IA

Essentials of Abnormal Psychology in a Changing World Fourth Canadian Edition Jeffrey S. Nevid St. John’s University

Beverly Green St. John’s University

Linda J. Knight John Abbott College

Paul A. Johnson Steven Taylor University of British Columbia

Table of Contents Ch. 1

What Is Abnormal Psychology? .............................................................................. 1.1

Ch. 2

Assessment, Classification, and Treatment of Abnormal Behaviour ...................... 2.1

Ch. 3

Anxiety, Obsessive-Compulsive, and Trauma- and Stressor-Related Disorders .... 3.1

Ch. 4

Depressive Disorders, Bipolar and Related Disorders, and Suicide ....................... 4.1

Ch. 5

Dissociative Disorders and Somatic Symptom and Related Disorders ................... 5.1

Ch. 6

Personality Disorders .............................................................................................. 6.1

Ch. 7

Substance-Related and Addictive Disorders ........................................................... 7.1

Ch. 8

Feeding and Eating Disorders and Sleep–Wake Disorders ..................................... 8.1

Ch. 9

Gender Dysphoria, Paraphilic Disorders, and Sexual Dysfunctions ....................... 9.1

Ch. 10 Schizophrenia Spectrum and Other Psychotic Disorders ...................................... 10.1 Ch. 11 Abnormal Behaviour across the Lifespan ............................................................. 11.1

Chapter 2 Assessment, Classification, and Treatment of Abnormal Behaviour Chapter Overview: Methods of Assessment The Clinical Interview The most widely used method of assessment, the clinical interview, involves the use of a set of questions designed to elicit relevant information from people seeking treatment. Clinicians generally use a structured interview, which consists of a fairly standard series of questions to gather a wide range of information concerning presenting problems or complaints, present circumstances, and history.

Psychological Tests of Intelligence and Personality Psychological tests are structured methods of assessment that are used to evaluate reasonably stable traits such as intelligence and personality.

Tests of intelligence, like the Stanford‐Binet and the Wechsler scales, are used for various purposes in clinical assessment, including determining evidence of mental retardation or cognitive impairment, and assessing strengths and weaknesses. Intelligence is expressed in the form of an intelligence quotient (IQ).

Self‐report personality inventories, like the MMPI, use structured items to measure various personality traits, such as anxiety, depression, and masculinity‐ femininity. These tests are considered objective in the sense that they make use of a limited range of possible responses to items and an empirical, or objective, method of test construction.

Projective personality tests such as the Rorschach and TAT, ask subjects to interpret ambiguous stimuli in the belief that their answers may shed light on the unconscious processes. Concerns persist about the validity of these tests, however.

Neuropsychological Assessment Methods of neuropsychological assessment help determine organic bases for impaired behaviour and psychological functioning. For example, the Luria‐Nebraska Neuropsychological Battery is a sophisticated battery of tests measuring various perceptual, intellectual, and motor skills and performance.

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Behavioural Assessment In behavioural assessment, test responses are taken as samples of behaviour rather than as signs of underlying traits or dispositions. The behavioural examiner may conduct a functional assessment, which relates the problem behaviour to its antecedents and consequences.

Methods of behavioural assessment include behavioural interviewing, self‐monitoring, use of analogue or contrived measures, direct observation, and behavioural rating scales.

Cognitive Assessment Cognitive assessment focuses on the measurement of thoughts, beliefs, and attitudes in order to help identity distorted thinking patterns. Specific methods of assessment include the use of a thought record or diary and the use of rating scales such as the Automatic Thoughts Questionnaire (ATQ‐30).

Physiological Measurement Measures of physiological function include heart rate, blood pressure, galvanic skin response (GSR), muscle tension, and brain wave activity.

Probing the Workings of the Brain Brain‐imaging techniques such as electroencephalograph (EEG), computerized tomography (CT scan), positron emission tomography (the PET scan), magnetic resonance imaging (MRI), functional magnetic resonance imaging (fMRI), brain electrical activity mapping (BEAM) and magnetoencephalography (MEG) probe the inner workings and structures of the brain without the need for surgery.

Sociocultural Factors in Psychological Assessment Researchers and clinicians must keep sociocultural and ethnic factors of clients in mind when assessing personality traits and psychological disorders. Clinicians also need to recognize that assessment techniques that may be reliable and valid in one culture may not be in another, even when they are translated accurately. Other factors to be considered when assessing clients is to be keep the assessment bias‐free, not be influenced by cultural stereotypes, and consider language preferences of the clients,

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Classification of Abnormal Behaviour Systems of Classification The Diagnostic and Statistical Manual of Mental Disorders (DSM), is the most widely accepted diagnostic system, now in its fifth edition. Another widely used system is the International Classification of Diseases (ICD) published by the World Health Organization. Now, in its tenth edition, and with Canadian enhancements and modifications, the system is known as the ICD‐ 10‐CA, which has been adopted as the Canadian standard for coding, reporting, and tracking health information.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) The DSM uses specific diagnostic criteria to group patterns of abnormal behaviours that share common clinical features. Strengths of the DSM include its use of specified diagnostic criteria to provide a picture of the person’s disorder. Weaknesses include questions about reliability and validity, and about the medical model framework. Additionally, there has been criticism regarding its use of a categorical approach to the diagnosis of disorders which has been addressed in the new DSM‐5, published in 2013.

DSM‐5 The DSM‐5 classifies abnormal behaviour patterns, or mental disorders, according to developmental models. This allows relevant lifespan information to be included in decisions regarding clinical diagnoses. Moreover, DSM‐5 deliberately employs dimensions rather than categories in evaluating abnormal behaviour. When a diagnosis of mental disorder is made, other pertinent details are gathered from the individual, such as the psychosocial and environmental conditions which influence the persistence of the disorder. The impacts the disorder has on areas of the individual’s life are also documented. For example, a diagnosis of depression may have a significant influence on a student’s ability to fulfill his or her typical role functions.

The DSM‐5 has undergone structural changes such as the elimination of the five‐level multiaxial system. A major reorganization and regrouping of disorders also occurred. New disorders were added including Disruptive Mood Dysregulation Disorder (DMDD), Premenstrual Dysphoric Disorder (PMDD), and Hoarding Disorder. Asperger Syndrome was eliminated in favour of the broader category named Autism Spectrum Disorder.

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Methods of Treatment Types of Mental Health Professionals in Canada The majority of licensed mental health professionals in Canada are clinical psychologists, psychiatrists, and social workers. In the cluster formed of psychotherapists and counsellors, there remains a lack of common pan‐Canadian titles and clearly defined scopes of practice, with regulations varying among provinces.

Biological Therapies Biological approaches include drug therapy, electroconvulsive shock therapy (Ed), and psychosurgery. Minor tranquilizers such as Valium may relieve short‐ term anxiety but do not directly help people solve their problems. Neuroleptics help relieve flagrant psychotic features, but regular use of most antipsychotic drugs has been associated with a risk of disabling side effects. Antidepressants have been shown to be effective in treating depressive disorders, and lithium has been shown to be effective in treating bipolar disorder. ECT is often associated with dramatic relief from severe depression, but questions remain about side effects. Psychosurgery is conducted only rarely because of adverse consequences. Deep brain stimulation involves implanting electrodes within the part of the brain that affects mood.

Psychodynamic Therapies Psychodynamic therapies originated with psychoanalysis, the approach to treatment developed

by Freud. Psychoanalysts use techniques such as free association and dream analysis to help people gain insight into their unconscious conflicts and work them through in the light of theft adult personalities. More recent psychoanalytic therapies are generally briefer and less intensive.

Behaviour Therapy Behaviour therapy applies principles of learning to help people make adaptive behavioural changes. Behaviour therapy techniques include systematic desensitization, gradual exposure, modeling, aversive conditioning, operant conditioning approaches, social skills training, and self‐ control techniques.

Humanistic‐Existential Therapies Humanistic approaches focus on the client’s subjective, conscious experience in the here and now. Rogers’s person‐centered therapy helps people increase theft awareness and acceptance of inner feelings that had met with social condemnation and been disowned. The effective person‐centered therapist possesses the qualities of unconditional positive regard, empathic understanding, genuineness and congruence. ..

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Cognitive‐Behavioural Therapies Cognitive therapies focus on modifying the maladaptive cognitions that are believed to underlie emotional problems and self‐defeating behaviour. Ellis’s rational‐emotive therapy focuses on disputing the irrational beliefs that occasion emotional distress and substituting adaptive behaviour for maladaptive behaviour. Beck’s cognitive therapy focuses on helping clients identify, challenge, and replace distorted cognitions, such as tendencies to magnify negative events and minimize personal accomplishments. Meichenbaum’s cognitive‐behavioural therapy attempts to integrate behavioural principles and cognitive techniques in a way that reduces or eliminates problematic behaviours and changes dysfunctional thoughts and cognitions.

Eclectic Therapy Eclectic therapists make use of multiple models of psychotherapy. In technical eclecticism, therapists use techniques from different approaches without necessarily adopting the theoretical models on which they were based. In integrative eclecticism, therapists attempt to synthesize and integrate diverse theoretical models.

Group, Family, and Marital Therapy Group therapy has several advantages over individual treatment, such as reduced costs, opportunities for shared learning experiences and mutual support, and increased utilization of scarce therapist resources. The particular approach to group therapy depends on the orientation of the therapist.

Family therapists work with conflicted families to help them resolve their differences. Family therapists focus on clarifying family communications, resolving role conflicts, guarding against scapegoating individual members, and helping members develop greater autonomy. Marital therapists focus on helping couples improve their communications and resolve their differences.

Indigenous Healing Perspective Indigenous peoples view mental wellness as from a balance of physical, mental, emotional, and spiritual aspects and is on a continuum from minimal to optimal; all people are seen as interconnected, attaining optimal mental wellness requires the strengths of not only the individual but also the family and the community. In the Indigenous healing perspective healing and wellness promotion are multileveled, targeting the individual as well as the family and the community, while respecting both individual and group languages, customs, history, and environment.

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Computer‐Assisted Therapy Computer‐based interventions and therapy come in all forms, from online cognitive‐behavioural therapy with a live therapist using a video‐chat service to self‐guided behaviour therapy for children with anxiety. Computer‐based interventions for various disorders have the potential to dramatically expand and alter the landscape of treatment.

Does Psychotherapy Work?

Psychotherapy researchers have generated encouraging evidence of the effectiveness of psychotherapy. Although there are few well‐designed head‐to‐ head comparative treatment studies, the results of meta‐analyses of research studies that compare psychotherapy with control groups support the efficacy of various approaches to psychotherapy.

Abnormal Psychology and Society Psychiatric Commitment and Patients’ Rights The legal process by which people are placed in psychiatric institutions against their will is called psychiatric or civil commitment. Psychiatric commitment is intended to provide treatment to people who are deemed to suffer from mental disorders and to pose a threat to themselves or others. Legal or criminal commitment, by comparison, involves the placement of a person in a psychiatric institution for treatment who has been acquitted of a crime by reason of insanity. In voluntary hospitalization, people voluntarily seek treatment in a psychiatric facility, and can leave of their own accord, unless a court rules otherwise.

Although people must be judged dangerous to be placed involuntarily in a psychiatric facility, mental health professionals have not demonstrated any special ability to predict dangerousness Mental Illness and Criminal Responsibility Three court cases established legal precedents for the insanity defence. In 1834, a court in Ohio applied a principle of irresistible impulse as the basis of an insanity defense. The M’Naughten rule, based on a case in England in 1843, treated the failure to appreciate the wrongfulness of one’s action as the basis of legal insanity. People who are criminally committed may be hospitalized for an indefinite period of time, with their eventual release dependent on a determination of their mental status.

People who are accused of crimes but are incapable of understanding the charges against them or assisting in their own defence can be found incompetent to stand trial and remanded to a psychiatric facility.

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Chapter Outline: Assessment, Classification, and Treatment of Abnormal Behaviour 40 Methods of Assessment 42 The Clinical Interview 42 Psychological Tests of Intelligence and Personality 43 Neuropsychological Assessment 50 Behavioural Assessment 51 Cognitive Assessment 54 Physiological Measurement 55 Probing the Workings of the Brain 56 Sociocultural Factors in Psychological Assessment 56 REVIEW IT Methods of Assessment 58 Classification of Abnormal Behaviour 59 Systems of Classification 59 The Diagnostic and Statistical Manual of Mental Disorders (DSM) 59 DSM‐5 62 REVIEW IT Classification of Abnormal Behaviour 64 Methods of Treatment 64 Types of Mental Health Professionals in Canada 65 Biological Therapies 66 Psychodynamic Therapies 69 Behaviour Therapy 72 Humanistic‐Existential Therapies 74 Cognitive‐Behaviour Therapies 76 Eclectic Therapy 79 Group, Family, and Marital Therapy 79 Indigenous Healing Perspective 80 Computer‐Assisted Therapy 81 Does Psychotherapy Work? 81 REVIEW IT Methods of Treatment 84 Abnormal Psychology and Society 85 Psychiatric Commitment and Patients’ Rights 87 Mental Illness and Criminal Responsibility 91 REVIEW IT Mental Illness and Criminal Responsibility 93 CONCEPT MAP 96

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Students Should Be Able to: 1. Describe clinical interviews.

2. Describe psychological tests.

3. Identify the major types of psychological tests used by clinicians.

4. Describe neuropsychological assessment.

5. Discuss some of the methods used in behavioural assessment.

6. Describe cognitive assessment.

7. Describe how clinicians and researchers study physiological functioning.

8. Describe the features of the DSM system and evaluate its strengths and weaknesses.

9. Describe the major biological approaches to treating abnormal behaviour patterns.

10. Describe psychotherapy and psychodynamic therapy.

11. Describe behavior, and humanistic‐existential therapies.

12. Explain the three major approaches to cognitive‐behavioural therapy.

13. Identify the general aims of group therapy, family therapy, and marital therapy.

14. Summarize the effectiveness of psychotherapy.

15. Review multicultural issues involved in psychotherapy.

16. Identify and describe the legal bases of Canada’s insanity defense.

17. Describe what is meant by the legal concept of competency to stand trial.

Lecture and Discussion Suggestions: 1. Psychological assessment. Assessment is the process of collecting and processing information from a client, to determine the person’s problems leading to the goals and strategies to use in treatment. Using a variety of measures results in a balanced assessment of the individual. In actual practice, clinicians tend to be highly selective in their choice of methods that depend partly on the client and her or his problem. For instance, when a client expresses paranoid ideas, the clinician might include the MMPI‐2 to identify specific patterns of abnormality. In another instance, when a client is intensely fearful of mingling with others in public places, the clinician may want to do a functional or behavioural analysis of the phobic behaviour to identify the conditions in which the problem behaviour occurs. Finally, a psychological assessment should include the client’s overall strengths and weaknesses, not simply what’s wrong with the person.

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2. Clinical versus statistical prediction. Can machines do better at making accurate diagnoses?

In this research area clinical judgment is pitted against statistical formulas—the same set of psychological test scores about patients is given to clinicians to think about, and is also plugged into statistical prediction formulas. Since the early 1950s, studies have shown that the formulas do at least as well as the clinicians. In fact, in recent research statistical techniques have actually been found to predict how the clinicians reach their decisions. It is possible to read this research and reach three general conclusions: a. Clinicians rarely do better than statistical formulas. b. The formulas in many cases are more accurate than the clinicians. c. Clinicians should be replaced by the statistical formulas.

Needless to say, such conclusions do not sit well with clinicians. Clinicians have argued that there is more to understanding a client than just his or her test scores—formulas cannot make behaviour observations.

A more moderate conclusion is that while some clinical tasks can clearly be automated, it is probably best in most cases to combine clinical and statistical methods. Statistics are not a replacement for a clinician, but a tool the clinician can use.

Murphy, K. R., & Davidshofer, C. 0. (1994). Psychological Testing: Principles and Applications, 3rd Ed. Englewood Cliffs, N. J.: Prentice‐Hall.

3. The clinical interview. This continues to be the oldest and most widely‐used method of assessment for good reasons. First, a face‐to‐face setting allows clients to describe their symptoms in their own words. Second, the clinician may observe a variety of nonverbal behaviours, which also provide clues as to the client’s personality and problems. And third, the interviewer may orient the interview to the person rather than vice versa. At the same time, a major disadvantage of the interview is that the data may be distorted by the particular questions asked as well as the interviewer’s personal and cultural biases.

Furthermore, each clinician may interpret the same data in different ways. Therefore, it is often advisable to supplement the clinical interview with personal and family data, as well as other methods of assessment, such as standardized personality tests.

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4. Classifying abnormal behaviours. Have students discuss the pros and cons of classifying abnormal behaviours. You might point out the benefits of the shift away from psychodynamic assumptions of causality to a more descriptive and cause‐neutral approach.

Further, describe the significant changes in o the DSM‐ 5 over earlier approaches, especially the shift away from the five‐level multiaxial system. You might also discuss the fact that critics of classification systems believe any system of classification greatly restricts the amount of information included about the person, overlooks the individual’s uniqueness, and results in social stigmas. You might begin this discussion by simply asking “Why do we need a system for classifying abnormal behaviours?” and move the discussion from there to the various pros and cons of such a system.

5. Intelligence tests. Ask students for their opinions about intelligence tests, including their usefulness and limitations. Because of the controversy surrounding intelligence testing, clinicians now use these tests more selectively, preferably along with other measures.

Intelligence tests may be useful in a number of ways, including the high correlation between measures of intelligence and standardized achievement test scores. Yet, such tests also may be culturally biased and might be misinterpreted, especially in the case of individuals from culturally diverse or disadvantaged backgrounds.

6. Personality tests. Discuss the usefulness of personality tests from the client’s perspective.

Ask volunteers to share their experiences in getting results of a personality or career inventory. A common misunderstanding of career inventories such as the Strong‐Campbell Interest Inventory (SCII) is that this instrument tells us which careers we should choose. But in reality, the results indicate which clusters of careers tend to be most compatible with our interests, and thus those in which we are most likely to persist, but not the ones that we should choose.

7. On Being Sane in Insane Places. Rosenhan’s article, On Being Sane in Insane Places (Science, 1973, 179, pp. 250‐258) is engaging for students to read and can be counted onto provide material for classroom discussion. Replies to the article (Science, 1973, 180, pp. 1116‐1122) are also particularly valuable to assign, as they present a wide variety of viewpoints on the study. A few questions such as: Was Rosenhan setting up the psychiatrists? Is insanity in the eye of the beholder? What are the effects of the label “insane?” Can medicine detect liars?

There should be sufficient information to sustain discussion on that controversial piece of research.

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8. Personality tests and job screening. A somewhat disturbing trend that appears to be increasing in recent years is the tendency of companies to use personality tests, such as the MMPI in their applicant screening process for new hires. Ask students to discuss the pros and cons of using personality tests in this situation. In discussing the cons, you might point out that tests like the MMPI were not really designed to be administered on a massive scale to a “normal” population and might pose a significant problem of “false positives” when used this way. Also, there is the related issue of personnel departments not always having employees who are properly trained to interpret the subtleties that are often involved in understanding the meaning of the scores provided by many of these tests. Should these tests be used in these situations to begin with? What are the dangers in having tests like these administered and interpreted by employees with often minimal training in interpreting the scores?

9. Distinguish between a psychological disorder and an illness. A common misunderstanding of the DSM system of assessment stems from our greater familiarity with the medical model, in which symptoms are necessarily linked with causes in the course of diagnosing and treating an illness. However, in the DSM‐ 5, abnormal behaviours are viewed as signs of mental disorders, which are clinically significant clusters of features that may be identified and treated without necessarily knowing the underlying causes. In fact, for most mental disorders, the etiology is unknown. Thus, the DSM‐5 is theoretical with regard to etiology or causal factors, except in regard to those disorders for which this is well established, as in many of the cognitive disorders with organic origins. The major justification for this approach is that the inclusion of etiological theories would be an obstacle for the use of the manual by clinicians of varying theoretical orientations, including psychologists. Also, it would not be possible to present all the reasonable theoretical orientations.

10. Discuss the disadvantages of the DSM approach. One critic of the previous DSM system, George Valliant, found five problems with this DSM approach: a. The DSM ignores other cultures and is too anchored in American ideas. b. The DSM ignores the fact that most diagnoses reflect dimensions and not categories.

He states “pregnancy is a black‐and‐white diagnosis, schizophrenia is not.” c. DSM pays too much attention to surface phenomena and too little attention to the longitudinal course of problems. d. DSM does not pay enough attention to the underlying psychological causes of problems. e. DSM sacrifices validity for the sake of reliability. Valiant likens the DSM’s emphasis on being objective to drafting all seven footers for pro basketball—it is a very reliable method, but ignores the more crucial skill of ball handling.

In particular, you might discuss whether the new DSM‐5 addresses Valiant’s concerns.

Valliant, G. E. (1984). The Disadvantages of DSM‐III Outweigh its Advantages. Ainerkan Journal of Psychiatry, 141, 542‐545. ..

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11. The fundamental attribution error. Social scientists tend to regard human behaviour as resulting from the interaction between the individual’s dispositional tendencies (intentions, traits, etc.) and his or her situational influences or immediate environment. However, when it comes to explaining behaviour, social scientists are well aware of the biases in the way we interpret behaviour, depending mainly on whether it’s our own or someone else’s behaviour. According to the fundamental attribution error, we tend to overemphasize personal, or dispositional, causes in accounting for other people’s behaviour, but underemphasize these causes for our own behaviour. Expressed differently, we readily excuse our behaviour because of unfavorable circumstances, while jumping to unwarranted conclusions about other people’s motives in similar behaviours and circumstances. Thus, when speaking about ourselves, we use words that denote our actions and reactions to a situation, such as “I get angry when” and I become violent when.” But when talking about someone else, we generally use words that describe that person’s traits or personality, such as “He has such a bad temper” or “She is a violent person” (McGuire and McGuire, Journal of Personality and Social Psychology, 1986, 51, pp. 1135‐1143). The risk of the fundamental attribution error occurs when jury members must decide whether an act of violence such as an assault or shooting was malicious (due to dispositional factors) or in self‐defence (situational influences).

12. The impact of malpractice litigation. The exorbitant rise in insurance rates in the 1980s and 1990s and the increased frequency of malpractice cases brought against professionals have had a mixed impact on mental health care. On the one hand, these changes have alerted mental‐health professionals to become more conscientious about making risk assessments in their clients, to balance confidentiality with the need to warn, and to assure continuation of care. All these changes are in the best interest of the client as well as the professional.

On the other hand, malpractice litigation has also spurred various negative, defensive practices among professionals. For instance, some professionals tend to engage in excessive risk‐avoidance, such as refusing to treat clients who are viewed as potentially violent. Or they may avoid asking questions that could yield information about the likelihood of violent behaviours. While certain defensive practices may protect professionals against litigation, as well as further rises in insurance rates, they are not in the best interests of clients.

13. Mutual‐help groups. Today, more than 12 million people participate in an estimated 500,000 mutual‐help or self‐help groups—groups whose members share a common problem and meet regularly to share their concerns without the guidance of professionals.

Although these groups often have multiple functions, such as fostering self‐help and lobbying for reform, most have the same underlying purpose, namely, to provide practical help as well as social support in dealing with a problem common to all members. A major assumption is that no one understands you or may help you better than someone who has the same problems, such as alcoholism, obesity, or bereavement. In an atmosphere that is friendly and compassionate, new members soon realize that participation is voluntary with no strings attached. There is usually an unwritten code of confidentiality within the group.

Even when there is a specified path to recovery, as in the various “anonymous” groups, members can proceed at their own pace. Groups that deal with addictive behaviours or ..

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emotional disorders often use a “buddy” system so that new members can count on a familiar person for encouragement and support. In an atmosphere of acceptance and mutual support, members can communicate more openly, view their problems more objectively, and find more effective coping strategies.

14. Predicting violence. Discuss the problems of predicting violence. Because incidents of violence in the community by mentally ill persons tend to get a high degree of media coverage, there tends to be an impression that people who are mentally ill are much more violent than others. Students might be interested to know that people with abnormal behaviours without prior history of violent behaviour are no more likely than the general population to engage in violence. What pressures are therapists under and what factors do they have to consider when they attempt to make predictions about potential violent behaviour from a patient being considered for release into the community?

15. The insanity plea. Discuss the insanity plea. How do students feel about a person accused of a vicious crime being declared “not guilty by reason of insanity?” What are the pros and cons of the alternative “guilty but mentally ill” verdict? What would be the pros and cons of scrapping the insanity defence entirely?

Do students feel that most people accused of crimes get off on the insanity defence? They don’t! Only a small percentage of criminals use the defence, and only a small percentage of them use the defence successfully. Do students feel that people who are found not guilty by reason of insanity spend less time in confinement than those found guilty of the same crime? Again, they don’t! The average person found not guilty by reason of insanity spends more time in a mental hospital than the person found guilty of the same crime spends in prison (when parole, probation, and early release programs are taken into account).

In discussing this, you might consider that recently one U.S. state legislature passed a bill requiring that psychiatrists and psychologists giving testimony in court cases wear a tall conical hat and wave a “magic” wand during their testimony. Fortunately, the bill was vetoed by the governor. What do actions like this say about the public’s perception of the “expertise” of psychologists and psychiatrists giving “expert” testimony in court? How has the insanity plea contributed to these perceptions?

Student Activities: 1. Reflective listening. Instruct students to pair up in dyads. One person is to select a concern or problem he or she feels comfortable sharing. Then the person is to share this problem with his or her partner for about five minutes or so. The partner is to listen with empathy, giving only nonjudgmental feedback, without adding to or analyzing what is being expressed. Then have the partners switch roles. After the dyads have completed their role‐playing, ask the participants how it feels to be listened to. How does active or reflective listening differ from everyday conversation? It’s been said that social ..

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conversation is often a competitive exercise in which the first person to thaw a breath is declared the listener. But we might add‐‐‐a reluctant, frustrated listener, is one who doesn’t listen at all, but merely awaits his or her turn to speak.

2. Selecting a therapist. Ask students how they would go about selecting a therapist for themselves. You might have students share their suggestions orally or jot them down and then share them. In selecting a therapist, psychiatrist J. Ingram Walker (Everybody’s Guide to Emotional Well‐Being, Harbor Publishing, 1982) suggests that we consider two key questions: (1) Is the therapist professionally trained and certified or licensed? (2) Do I feel comfortable with this person? Ordinarily people must be qualified to list themselves as a psychologist, psychiatrist, or social worker in the telephone book. Also, professionals usually display their provincial licence or other certificates in a prominent place in their offices. But you also want to know whether you’ll feel comfortable talking to the therapist. Does this person really listen to you? Is he or she warm or empathic without being condescending?

Once you’ve selected a therapist, in the initial session it’s appropriate to discuss such matters as the person’s approach to therapy, the length of treatment, and the fees.

3. Locating therapists. Assign students to prepare a list of therapists in your area, with regard to degrees, areas of specialization, forms of treatment, and other factors. They might call some therapists for such information, consult a local mental health association, check the Internet, and consult phone book listings as ways of gathering this information. They can compare availability of the many types of treatment discussed in this chapter.

4. Design an outcome study. Break the class into groups and give them the task of designing a research study to evaluate a psychotherapy technique. They are to consider therapist and technique variables, control groups, measures of outcome, and follow‐ups. Let the group report their designs and use this to discuss some of the complexities of research described in the text.

5. Self‐help resources. Not everyone goes to a therapist for help. Millions of Americans turn to self‐help sections in their libraries and bookstores. Have students collect examples of various self‐help manuals, guides, and books. Ask them to critically evaluate these with regard to evidence presented for their effectiveness.

6. The MMPI‐2. Ask students to jot down their true or false responses to the following statements: “I never read comics,” “I am an important person,” “I usually get nervous before an important exam.” Then ask how many students answered “true” to the statement “I am an important person.” Originally, this item was designed as a measure of self‐ importance and grandiosity in the earlier versions of the MMPI, with fewer than 1 out of 10 respondents in a normal sample endorsing it over 50 years ago. However, the connotations of this statement have changed with the times, especially due to social changes and the human potential movement of the past two decades. Today, 5 out of 10 males and 7 out of 10 females endorse this statement. As a result, people’s responses to such test items were reexamined in the re‐standardization project that produced the revised MMPI or MMPI‐2. ..

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7. Projective techniques. Get students’ responses to a TAT card or some ambiguous scene in a magazine involving one or more people. Then display the picture and ask students to write a paragraph or so in response to the following questions: What are the people in this picture doing? What are they saying to each other? And how do you think this situation will turn out? Now ask volunteers to share their responses. You’ll usually find that responses vary considerably from one person to another, illustrating how each of us tends to project our own motives and feelings into the figures shown. You might point out that it is the common themes in a person’s responses to a series of pictures that provide important clues to his or her personality, not simply the responses to a given picture.

8. Designing an assessment program. Break students into groups. Then tell them that they have been chosen to design an assessment program for a community mental health centre.

Students can discuss the types of problems they are most likely to encounter in such a setting and discuss the sort of assessment instruments they might make available to their clinicians. They might also discuss how they would evaluate the reliability and validity of the diagnoses made by their clinicians. Finally, students can discuss which assessment techniques appear to be best suited to particular presenting problems, such as family issues, school and learning problems, substance abuse disorders, etc. When students have completed their plans, have each group present its assessment program, explaining and supporting their decisions.

9. Rorschach ink‐blot test demonstration. Most students are interested in seeing the Rorschach cards and trying their hand at answering and interpreting them. A demonstration might accompany a lecture on the influence of psychological perspectives on Rorschach interpretation. Show several cards to the class and ask students “What might this be?” and have them write down their associations. 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 look at the whole thing?).

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. When students have written their answers down, then you might have them share their answers (voluntarily) with the class and discuss with them some aspects of how the test is scored, as well as the way different psychological perspectives would view a given response to a Rorschach card.

10. Role play an interview. Find a student volunteer to be interviewed by you in front of the class. The interview does not need to inquire about pathology, but might include questions of interests, hobbies, career aspirations, and so on. Assign half of the class to record the subject’s nonverbal behaviours—eye contact, posture, tone of voice, gestures, smiles and frowns, etc. Have the other half of the class do the same thing for the interviewer. After about 10 minutes of interview, have the class present and discuss their observations. Look for evidence of reliable recordings across students. Compare and contrast nonverbal behaviours of the subject and the interviewer. ..

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11. Construct an anxiety test. This can be done either as an in‐class activity or as an extra assignment. Have the students play the role of a test‐developer for a new test of anxiety.

First, they must define what they want to measure, then select a format, and then generate test items. Have them field test the resultant anxiety test on each other. They can then discuss the problems with the test from both the test‐ developer and test‐taker point of view. You might have them do a reliability study by administering their test, waiting a couple of days, and administering it again. There are many discussion issues that will arise as students tackle this assignment.

12. Collect “pop‐psych” tests. It is interesting to have students search for self‐ tests in various magazines and other popular media. Have them collect examples of these tests, and then use the examples to discuss issues such as reliability and validity.

13. Interviews of homeless people. Since many homeless people suffer from mental illness and would have been institutionalized 30 years ago, they are a population suitable for discussion in this unit. Have several students go to a local shelter and interview some homeless people (with the shelter’s permission, of course). You might ask several volunteers to do this and to report their impressions to the class. Or you could invite someone who works with homeless people to speak to your class. Either way, one of the aims of this exercise is to help students gain a realistic understanding of the homeless and of homelessness. Hopefully, you may dispel some of the stereotypes about the homeless, such as they are all deadbeats who are too lazy to work. At the same time, it would be interesting to discover what proportion of your sample of homeless people are either former mental patients or might have been hospitalized involuntarily under the less stringent standards of earlier eras.

14. Patients’ rights. The purpose of this exercise is to determine how knowledgeable students are about mental patients’ rights. You might make up a true‐false quiz on patients’ rights.

Then ask for several volunteers to administer this quiz to a sample of students who are not taking abnormal psychology, and report their findings to the class. In order to guard against the “set” response, in which respondents might detect that all the items are true and thus “see through” the test, you might intersperse several “filler” items which are false. Some suggested filler items are: a. All patients have the right to at least one weekend home leave each month if they should desire it. b. Patients may not refuse to perform work which is done for the maintenance of the hospital facility if they are physically and mentally capable of performing the work. c. Patients have the absolute right to choose their own therapists.

15. Locating community resources. Have students look in the community for resources beyond the traditional mental health delivery system: paraprofessionals, support groups, rescue missions, outreach agencies, and so on. Their task is to identify some of the kinds of helpers discussed in this chapter. ..

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16. The role of the police. Encourage students to interview police officers, or have a police officer speak to your class about the police’ role in the mental health system and problems police officers encounter when dealing with individuals with mental disorders. The police are a key resource in the community in helping to identify people with mental disorders, and often in physically transporting them to the proper treatment facilities. How do police officers deal with psychotic behaviour, abusive situations, and so on? An officer speaking to the class about the police role in the mental health system, will be a value‐add.

17. Commitment laws. Have students investigate the procedures in your area for involuntary commitment. In many places the county attorney’s office can be a good place to begin.

How often are people involuntarily committed? Should a family wish to undertake this step for a member, exactly how would they go about it?

Online Discussion Questions: 1.

Controlling brain chemistry (neurotransmitter levels), is the best approach to treating mental disorders. Discuss.

2.

Cognitive‐behavioral treatment is the best approach in treating people suffering with mental disorders. Discuss.

3.

If a qualified mental health professional knows that treatment will make a person’s life better they should be able to force treatment regardless of the patient’s willingness to seek treatment. Discuss.

Online Resources: CPA Code of Ethics https://www.cpa.ca/docs/File/Ethics/cpa_code_2000_eng_jp_jan2014.pdf Visit this page to read the Canadian Psychological Association’s code of ethics for psychologists.

Mental Health Info Source: Canadian Mental Health Association https://cmha.ca/ This is a mental health education website.

Mental Help Net https://www.mentalhelp.net/ This site has articles and descriptions of psychological disorders. It also provides links to assessment tools and other mental health resources and services.

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Psychiatry Online www.priory.com/psych.htm This site provides an international forum for psychiatry and has links to the latest articles, papers, and journals.

The Section on Clinical Psychology of the Canadian Psychological Association https://www.cpa.ca/aboutcpa/cpasections/clinicalpsychology/ This Canadian Psychological Association site is home to the Section on Clinical Psychology. It is a central source for information about the clinical psychology profession in Canada.

Statistics Canada—Mental Health and the Criminal Justice system www.statcan.gc.ca/pub/85‐561‐m/2009016/section‐a‐eng.htm Information is provided here on mental health and the Canadian criminal justice system, including statistics.

Video Resources: Assessment and Diagnosis of Childhood Psychopathology, 26 min. colour (Penn State Univ.).

Provides an overview of standard psychiatric assessment.

DSM‐III‐R Training Guide, 60 min. colour (Brunner/Mazel). Although it does not reflect the changes from the DSM‐Ill‐R to the DSM‐IV, it still provides a useful practice for assessment.

Presents 5 vignettes for practice assessment.

The Assessment/Therapy Connection, 29 min. colour (Research Press). Arnold Lazarus makes a multi‐modal assessment of a 45‐year‐old depressed woman.

Behavioural Interviewing with Couples, 14 min. colour (Research Press). Demonstrates the six basic stages of an initial marriage counseling interview.

Dr. Jeffrey Nevid's DSM‐5 Updates Webinar in this video Dr. Nevid explains the DSM‐5 Updates.

Intelligence: A Complex Concept, 28 min. colour (MGHF). Examines a variety of intelligence tests and discusses the problems that confront the effort to provide measures of intelligence.

Personality, 30 min. colour (CRM/McGraw‐Hil1). A college student volunteers for a thorough assessment by a clinical psychologist. Includes self‐views, views of parents and others, and the use of intelligence and projective tests.

Simulated Psychiatric Patient Interview, 90 min. 6 cassettes, colour (UCLA School of Medicine).

Shows methods used in interviewing patients with schizophrenia, organic brain syndrome, and phobias. ..

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Unconscious Motives, 40 min. (IU). Shows how psychological tests and interview techniques are able to uncover a situation implanted in the “unconscious” of two subjects through hypnosis.

What Is Normal? 30 min. colour (Insight Media). Experts discuss classifying behaviour according to the DSM‐II‐R. Commitment Evaluation, 20 min. colour (IU). Shows a patient being evaluated for commitment to a psychiatric hospital, with a discussion of the issues involved.

Crime anti Insanity, 52 min. colour (Films, Inc.). Explores the issue of releasing patients from mental hospitals when they are deemed to be no longer dangerous.

Involuntary Hospitalization of the Psychiatric Patient: Should It Be Abolished? 29 min. black and white, made in 1969 (NMAC). Dr. Thomas Szasz debates this issue with Dr. Masserman.

Mental Retardation and the Law, 22 min. black and white (Michigan Media). Three films that present case vignettes raising pertinent issues in the areas of civil rights, psychological testing, and institutional commitment.

These People, 28 min. colour (Horizon House Institute). Depicts citizens’ reactions to the release of patients from a nearby state mental hospital.

Titticut Follies, 85 mm, colour (Grove Press). Describes patients’ reactions to their treatment at a prison for the criminally insane.

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Chapter 1 What Is Abnormal Psychology?

Chapter Overview: How Do We Define Abnormal Behaviour?

Criteria for Determining Abnormality Various criteria are used to define abnormal behaviour. Psychologists generally consider behaviour as being abnormal when it meets some combination of the following criteria: (1) unusual or infrequent; (2) socially unacceptable or in violation of social norms; (3) fraught with misperceptions or misinterpretations of reality; (4) associated with states of severe personal distress; (5) maladaptive or self‐defeating, or; (6) dangerous.

Cultural Bases of Abnormal Behaviour The determination of which behaviour patterns are deemed abnormal depends on cultural beliefs and expectations. Concepts of health and illness may also have different meanings in different cultures. Abnormal behaviour patterns may take different forms in different cultures, and societal views of abnormal behaviour vary across cultures.

The Continuum between Normal and Abnormal Behaviour Most behaviours can be placed on a continuum where individuals with no symptoms or those “struggling” do not meet criteria for abnormality, while individuals with mild, moderate, or severe display of symptoms meet criteria from abnormality. The present approach to diagnoses is categorical.

Historical Perspectives on Abnormal Behaviour The Demonological Model Ancient societies attributed abnormal behaviour to divine or supernatural forces, known as the demonological model. Stone Age skulls have shown that our prehistoric ancestors practice trephining – cutting a hole in a person’s skull – possibly as a means of releasing demons.

Origins of the Medical Model: An “Ill Humour” There were some authorities in ancient times, such as the Greek physicians Hippocrates and Galen, who believed that abnormal behaviour reflected natural causes. Hippocrates, for example, proposed that abnormal behaviour was due to an imbalance of humours, or vital fluids: phlegm, black bile, blood, and yellow bile. The importance of this theory was that it foreshadowed the development of the modern medical model of abnormal behaviour by which disorder and disease are seen as resulting from underlying biological processes. ..

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Medieval Times The Middle Ages saw a return to the doctrine of possession, revitalized by the Roman Catholic Church.

Witchcraft Exorcisms became a common practice to expel evil spirits or demons from affected individuals.

Later, beginning in the 15th century, people who displayed abnormal behaviours were considered witches.

Asylums in Europe and the New World Asylums, or “madhouses,” began to crop up throughout Europe in the late 15th and early 16th centuries, often on the site of former leprosariums. Conditions in these asylums were dreadful and in some, such as the Bethlehem Hospital in England, a circus atmosphere prevailed. With the rise of moral therapy in the 19th century, largely spearheaded by the Frenchmen Jean‐ Baptiste Pussin and Phillipe Pinel, conditions in mental hospitals improved.

The Reform Movement and Moral Therapy in Europe and North America Proponents of moral therapy believed that mental patients could be restored to functioning if they were treated with dignity and understanding. The decline of moral therapy in the latter part of the 19th century led to a period of apathy and to the belief that the “insane” could not be successfully treated. Conditions in mental hospitals deteriorated, and they offered little more than custodial care.

Drugs and Deinstitutionalization: The Exodus from Provincial Psychiatric Hospitals Not until the middle of the 20th century did public outrage and concern about the plight of mental patients mobilize legislative efforts toward the development of community mental health centres as alternatives to long‐term hospitalization. This movement toward deinstitutionalization was spurred by the introduction of psychoactive drugs called phenothiazines, which curbed the more flagrant features of schizophrenia.

Deinstitutionalization in Canada has resulted in many homeless individuals with mental health issues who got lost in the transition from psychiatric institutionalization to largely inadequate community mental health services. In 2007, the federal government announced funding for the Canadian Mental Health Commission in order to implement a national mental health‐care strategy.

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Pathways to the Present: From Demonology to Science The 19th century German physician Wilhelm Griesinger argued that abnormal behaviour was caused by diseases of the brain. He along with another German physician who followed him, Emil Kraepelin, were influential in the development of the modern medical model, which likens abnormal behaviour patterns to physical illnesses.

Current Perspectives on Abnormal Behaviour Abnormal behaviour may be viewed from various contemporary perspectives. The medical model conceptualizes abnormal behaviour patterns like physical diseases, in terms of clusters of symptoms, called syndromes, which have distinctive causes that are presumed to be biological in nature.

Biological Perspectives on Abnormal Behaviour Biological perspectives incorporate the medical model but refer more broadly to approaches that relate abnormal behaviour to biological processes and apply biologically based treatments.

Psychological Perspectives on Abnormal Behaviour Psychodynamic perspectives reflect the views of Freud and his followers, who believed that abnormal behaviour stemmed from psychological causes involving underlying psychic forces.

Freud developed psychoanalysis as a means of uncovering the unconscious conflicts dating back to childhood that he believed were at the root of mental disorders such as hysteria. Learning theorists posit that the principles of learning can be used to explain both abnormal and normal behaviour. Behaviour therapy is an outgrowth of the learning model. Humanistic‐ existential perspectives reject the determinism of psychodynamic theory and behaviourism. Humanistic and existential theorists believe that it is important to understand the obstacles that people encounter as they strive toward sell‐ actualization and authenticity. Cognitive theorists focus on the role of distorted and self‐defeating thinking in explaining abnormal behaviour.

Sociocultural Perspectives on Abnormal Behaviour Sociocultural theorists believe that abnormal behaviour is rooted in social ills, such as poverty, societal stress, and institutionalized prejudice and discrimination, not in the individual. They believe that to eliminate “abnormality,” one must first correct the societal problems that caused it. Some sociocultural theorists argue that mental illness is a myth created to stigmatize people who do not conform to prevailing social standards.

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Interactionist Perspectives Today, many theorists believe that multiple factors interacting in complex ways are involved in the development of abnormal behaviour patterns. The leading interactionist model, the diathesis‐stress model, posits that some people have predispositions (diathesis) for particular disorders, but whether these disorders actually develop depends upon the type and severity of the stressors they experience.

Chapter Outline: What Is Abnormal Psychology? 1 How Do We Define Abnormal Behaviour? 3 Criteria for Determining Abnormality 3 Cultural Basis of Abnormal Behaviour 5 The Continuum between Normal and Abnormal Behaviour 6 REVIEW IT How Do We Define Abnormal Behaviour? 8 Historical Perspectives on Abnormal Behaviour 8 The Demonological Model 8 Origins of the Medical Model: An “Ill Humour” 8 Medieval Times 9 Witchcraft 9 Asylums in Europe and the New World 10 The Reform Movement and Moral Therapy in Europe and North America 10 Drugs and Deinstitutionalization: The Exodus from Provincial Psychiatric Hospitals 11 Pathways to the Present: From Demonology to Science 14 REVIEW IT Historical Perspectives on Abnormal Behaviour 17 Current Perspectives on Abnormal Behaviour 18 Biological Perspectives on Abnormal Behaviour 18 REVIEW IT Biological Perspectives 22 Psychological Perspectives on Abnormal Behaviour 22 REVIEW IT Psychological Perspectives 34 Sociocultural Perspectives on Abnormal Behaviour 33 REVIEW IT Sociocultural Perspectives 34 Interactionist Perspectives 34 REVIEW IT Interactionist Perspectives 35 CONCEPT MAP 38

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Students Should Be Able to: 1. Discuss the criteria used by mental health professionals to define abnormal behaviour.

2. Explain what psychological disorders are.

3. Discuss the relationships between cultural beliefs and norms in classifying abnormal behaviour.

4. Discuss how views about abnormal behaviour have changed over time.

5. Discuss how the treatment of people with psychological disorders has changed over time.

6. Understand the roles of psychiatric hospitals and present‐day general hospital psychiatric units.

7. Understand the concept and success of deinstitutionalization.

8. Discuss the distinguishing features of the biological perspectives on abnormal behaviour.

9. Discuss the major psychological perspectives on abnormal behaviour.

10. Discuss the basic concepts underlying sociocultural perspectives.

11. Discuss the distinguishing feature of the interactionist perspectives.

Lecture and Discussion Suggestions: 1. New terms. A large number of new terms are introduced to students in this chapter. This may be a bit overwhelming to students so early in the class, yet many of the terms and concepts in this chapter form the backbone of the text. Providing students with a list of “key terms” and having students find their definitions from the text and then discussing their meaning in class can help clarify many of these new terms for students. In a subsequent session, you may want to give a short quiz on the terms discussed during this exercise.

2. Explain the criteria for abnormal behaviour. After stating that there is no clear and universally agreed upon definition of abnormal behaviour (or of normal behaviour, for that matter), explain and illustrate each of the six criteria of abnormal behaviour given in the text, including behaviour that is: (1) unusual, (2) socially unacceptable, (3) based on a misinterpretation or perception of reality, (4) personally distressful, (5) maladaptive or self‐ defeating, and (6) dangerous. Point out that clinicians use a combination of these criteria to identify abnormal behaviour in a particular person and situation. You might also point out that clinicians are often hesitant to label someone as “abnormal” based on the first two criteria alone. Many behaviours are statistically unusual but are not necessarily a sign of mental illness. Many behaviours may be socially unacceptable because they deviate from accepted social or cultural norms, not because the behaviour itself is inherently “sick” or a sign of illness. Many behaviours considered “normal” in our culture may be considered “abnormal” in other cultures, and vice‐versa.

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A good example of how one must be cautious in using the first two criteria is homosexuality. Homosexuality is statistically unusual in that only between 4% and 8% (maximum) of people are exclusively or primarily homosexual. It is also considered culturally and morally unacceptable to many people if not the majority of people in our culture. Yet psychologists and psychiatrists do not treat homosexuality, in and of itself as a mental illness.

3. Distinguish between a “mental or psychological disorder” and abnormal behaviour.

According to the DSM‐5, a mental disorder is a clinically significant behavioural or psychological pattern that occurs in a person and is associated with: (I) present distress, (2) disability in one or more areas of functioning, (3) significantly increased risk of suffering disability, pain, or death, and (4) an important loss of freedom or personal control. In addition, these features must not be merely an expectable response to a predictable event, such as grief over a loved one’s death. Thus, some behaviours, such as bathing nude at a public beach may be socially deviant without being classified as a mental disorder.

4. Ask students to define “normal.” While the concept of “normal” tends to be one of those concepts that people “know it when they see it,” in real‐life behaviour, it can be very difficult to define operationally. Asking students to define “normal” and to discuss how they arrived at their definitions as well as what problems they see in each other’s definitions can be a fruitful exercise that leads them to see why psychologists have adopted the specific criteria for abnormality discussed in the text.

5. Ask students how they personally determine when someone’s behaviour is abnormal. To what extent do they rely on the six criteria identified in the text? Since the designation of abnormality is partly a social judgment; discuss the importance of how such a judgment is made as well as its subjective and irrational aspects.

You might cite psychiatrist Thomas Szasz’s book The Myth of Mental Illness, including the point that psychological labels are often used as a convenient way of avoiding people who are different or threatening to us.

6. Discuss supernatural explanations of abnormality. Discuss how supernatural explanations of behaviour are still alive in the form of astrology, demonic possession, and satanic worship. You might point out that people resort to such explanations because of the difficulty understanding bizarre or evil behaviours in conventional medical and psychological terms. You might also point out that because of the power of selective perception, placebo effect, and the types of “Barnum statement” predictions made by these belief systems, they can be very difficult to debunk or refute.

7. Discuss the popularity of supernatural explanations. Many observers have noted that beliefs in the supernatural have increased in recent years. Given that, as a society, North Americans are better educated than ever before, one would think that belief in the supernatural would be declining rather than increasing. Do students believe this to be true?

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8. Describe Hippocrates’ “four‐fluids theory”. While technically inaccurate, you might point out that Hippocrates’ general idea of imbalances in bodily fluid causing mental illness may have been more accurate than he is generally given credit for. Point out the number of “mental” illnesses, such as some types of depression, that are clearly linked to imbalances in neurotransmitters in the brain, and other disorders such as PMS which are linked to hormone fluctuations and imbalances in the body. While phlegm, black bile, and yellow bile are clearly not hormones or neurotransmitters, they are similar in that both represent bodily fluids of a sort.

You might also point out that not all of Hippocrates’ ideas were as accurate as this one, even at a very general level. His claims that hysteria in females was caused by a “wandering uterus” and could only be cured by marriage are clearly unsupported.

9. Discuss some of the implications of holistic medicine for mental health. The emphasis on positive physical health rather than sickness has led to greater concern for prevention, nutrition, fitness, and stress management. But to what extent has the emphasis on positive health affected our attitudes and practices in the area of mental health?

10. Discuss whether or not neurotic discomfort is necessary to creativity and originality. Many well‐known historical and creative figures have displayed behaviours which were eccentric or deviant, but not maladaptive. At times such eccentricity and even some degree of neurosis has been seen as a necessary prerequisite for artistic genius to the point where some writers and artists have refused to seek therapeutic help for fear of eliminating the inner pain and turmoil which stoked their creative fires. Examples of such people are Renoir, Van Gogh, Edna St. Vincent Millay, and Edgar Allan Poe. These examples are all generally acknowledged to be highly creative but manifest some maladaptive behaviour.

11. Describe the movement toward deinstitutionalization of mental patients. Point out that a variety of factors led to this movement, including rising criticism of the inhumane treatment of mental patients as well as the discovery of powerful antipsychotic drugs, such as phenothiazines, that helped patients live outside the hospital.

You might discuss some of the pros and cons of deinstitutionalization, such as the establishment of community‐based services (a plus) as well as the increased number of ex‐ patients who have swelled the ranks of the homeless people in nearby cities (a minus). The aim here is to stimulate students’ thinking about the mixed impact of deinstitutionalization.

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12. Describe ft. L. Rosenhan’s famous study “On Being Sane in Insane Places” (Science, 1973, 179, pp. 250‐257). In this study, eight mentally healthy people, several of them psychologists and psychiatrists, complained of hearing voices and were admitted to mental hospitals. Once inside, they acted normally again. Their normal behaviours were often misinterpreted as “hostile,” “aggressive,” or “deviant” by unsuspecting staff members.

Ironically many of the hospitalized patients realized that the impostors were faking, but none of the staff did. All impostors were labeled schizophrenics and their stays ranged from 7 to 52 days with an average stay of 19 days.

This study is useful because it offers a striking glimpse at how powerfully labels, setting, and expectations can affect how we perceive and judge the behaviours of others.

13. Elaborate the role of neurotransmitters in abnormal behaviour. Although the exact causal relationships have not always been determined, there is mounting evidence that neurotransmitters play a significant role in various abnormal behaviours. For instance, deficiencies in dopamine are linked to Parkinson’s disease, whereas excesses in dopamine reactivity are found in schizophrenia. The powerful antipsychotic drugs are thought to alleviate the symptoms of schizophrenia by blocking the action of dopamine. Excesses and deficiencies of norepinephrine which act as a neurotransmitter and a hormone, are involved in mood disorders and eating disorders; and serotonin may be linked with anxiety, insomnia, and mood disorders.

14. Discuss the implications of unconscious motivation for everyday behaviour. You might ask, “Can you love and hate the same person?” Most students will say yes but have a difficulty in explaining why. In contrast, psychodynamic theorists tend to explain this phenomenon in terms of the fundamental polarity of unconscious drives and the importance of ambivalence in our behaviour, especially in close relationships.

15. Discuss the Psychoanalytic Theory and Sexism. One of the most controversial of Freud’s views involves his notions about the phallic stage of development. A particularly controversial topic within this stage is his concept of penis envy. Briefly, Freud believes that when a little girl notices how she differs from little boys, she feels cheated. She blames her mother for her lack of a penis, and rejects the mother trying to displace her in father’s eyes — in effect, to become “daddy’s darling.” The hale girl unconsciously hopes that her father will give her a penis. When he does not, she compensates with the wish for a child. There are a number of important consequences of this process, each with applications for abnormal psychology: a. b. c. d.

Women have weaker superegos than males.

Women feel inferior to men and contemptuous of other women.

Women become passive, vain, jealous, and masochistic.

Women should give up infantile gratification from the clitoris and prepare for adult gratification through intercourse.

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This view has been criticized for decades. Some believe it has helped instill a bias toward diagnosing more abnormal disorders among women. Others say that the concept has no validity. Still others believe that women are indeed envious— of the power and control males have traditionally enjoyed. This topic is likely to produce a lively debate among students.

Lips, H. M. (1993). Sex and Gender: An Introduction. Mountain View, CA: Mayfleld Co. Travis, C. & Wade, C. The Longest War: Sex Differences in Perspective, 2nd Ed. New York: Harcourt Brace Jovanovich.

16. Discuss defense mechanisms and psychopathology. An interesting way to apply the psychodynamic perspective to psychopathology is through the use of Valiant’s approach. In Empirical Studies of Ego Mechanisms of Defense (1986), Valiant relates ego‐defense mechanisms to different levels of maturity and their association with various types of abnormal behaviour as follows: Level I defenses, such as repression, denial, and delusional projection are found in the psychoses. Level II defenses, such as assimilative projection, frequently occur in passive‐aggressive behaviours. Level III defenses, such as displacement, isolation, intellectualism, and rationalization can be seen in various anxiety disorders. Level IV defenses, such as conscious suppression, impulse delay (inhibition), and sublimation are characteristic of normal, healthy human behaviours.

17. How do students explain the relative lack of self‐actualization in our lives? This should elicit a wide range of responses. Possible reasons include: the fear of becoming our best (fear of success), the fear of not being accepted socially, too many work, school, and child‐ rearing demands on one’s time, the inner core of growth is relatively weak and undeveloped in many people, a lack of supportive circumstances, and conflicts between the desire for security and avoidance of risk.

18. Discuss cognitive factors in abnormal behaviour. Point out the mediating role of the cognitive approach in relation to the psychodynamic perspective and the behavioural perspective. Psychodynamic therapies tend to probe for deep‐seated causes of behaviour, with the aim of bringing about change through increasing the client’s self‐understanding. At the opposite extreme, classical and operant behaviour therapies rely on a functional analysis of the various stimuli associated with a given behaviour, minimizing the role of cognitive factors. However, the cognitive perspective, now more commonly characterized as a cognitive‐ behavioural approach, occupies a more “middle‐of‐the‐road” position, and employs both cognitive and behavioural approaches to therapy.

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19. Discuss the issue of free will versus determinism as it applies to mental illness and therapeutic treatment approaches. The issue of free will and determinism is an underlying theme in any discussion of mental illness and its treatment, and students often bring strong opinions about this subject into the course. At this point in the course it may be useful to ask the following questions: a. What are the psychological implications of not believing in free will? Determinism implies a loss of control; belief in free will may be adaptive if it increases our self‐ efficacy. This issue can be related to the concept of internal vs. external locus of control. Is it healthier to believe in free will or to live as if we have free will, whether or not it exists? b. Is the scientific study of human behaviour compatible with a belief in free will? c. Is free will something that can be studied empirically? If so, how? d. What view of human behaviour does our society hold, as evidenced by various religious and legal beliefs? e. Can a psychopathologist who believes in free will logically support an exception for being not guilty by reason of insanity?

20. Discuss perspectives and abnormality. Students often enjoy and learn from applying the theoretical material in the course to actual cases. To facilitate this, you might divide the class into six groups, and have each group adopt one of the theoretical perspectives described in this chapter. Using a case from the text, or one from your own experience, have each group attempt to explain the “client’s” behaviour from the theoretical perspective they have adopted. After each group has presented its perspective, groups may then debate key questions and issues, each group trying to point out how its explanation is better supported than alternative explanations.

21. Discuss psychodynamic vs. learning approaches. Psychodynamic and learning advocates have long argued about the efficacy of each other’s therapeutic techniques. At issue is whether the behavioural “symptom” or the “underlying” cause should be treated. Consider the case of an autistic child with a pattern of repetitious, self‐injurious behaviour. One could treat the behavioural symptom with operant conditioning techniques but would that be sufficient to prevent a relapse of the behaviour pattern, or some similar one, in the future?

Or could it result in the substitution of a new, even more injurious behaviour pattern for the original behaviour that was eliminated? If there is an underlying cause and it is left untreated, might not a problem recur? If an underlying cause is identified and treated, how would this be done?

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22. Elaborate on personal perspectives. The theoretical perspective of behaviour that a student adopts has an impact not just on the student’s view of psychology, but also on the student’s view of him or herself. Do I want to think of my own behaviour as being caused by unconscious processes, by my biological make‐ up, by past learning experiences, or by the way I construe the world? How can I change myself if I can change myself at all? Can I learn new ways of behaving? Must I have my biological make‐up altered if I want to change? Will change only occur after many years of analysis, or do I really need some understanding and caring? While scientists and students are striving to be objective, personal values can influence the answers we seek and those we are willing to accept. At times, our values and perceptions may persuade us more than the objective data we find.

23. Women and Witchcraft. From the mid‐sixteenth through the mid‐ seventeenth centuries, a kind of hysteria swept Europe, and also parts of the American colonies. Suddenly, large numbers of people were accused, tried, and often convicted of consorting with the devil and becoming witches. Some witchcraft accusations have been made from the beginning of civilization, but never before in such large numbers.

Not all of these accused women were mentally ill, as Schoeneman (1983) has pointed out.

Many of these women were poor, without husbands, aged, and/or seen as troublemakers or having questionable knowledge. About a third of those accused were sentenced to death by burning. Some survived by confession and recanting. Others died while undergoing interrogations, such as the case in the “water‐float test.”

What caused this upsurge and why was it directed mostly against women? The sixteenth century was an age of both intense religious belief and great, misery‐ producing disruption; in that age, witches were easily accepted as troublemakers. What is perhaps most interesting is why the accusations were so skewed against certain sorts of women. Some historians say that these women were essentially targeted not directly as women, but rather because they were poor and disruptive in an age that feared disorder and saw the poor as dangerous. It was just their bad luck that women without families to protect them were by far the most likely to be poor, and to have to challenge society’s “haves.” Others, however, point out that the most basic assumptions of the age also made women likely victims. Women were commonly seen as “weaker vessels,” with weaker reason and great sexual vulnerability, and so open to the devil’s temptations. Also (especially within Protestant lands), women’s one “natural” sphere was within the home under male authority, and anyone who operated outside of that hierarchy was naturally seen as disorderly and dangerous.

Recommended readings for interested students can include William Monter, “Protestant Wives, Catholic Saints, and the Devil’s Handmaid: Women in the Age of Reformations” in Renate Bridenthal, et. al., Eds., Becoming Visible: Women in European History, 2nd Ed. (1987).

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24. Discuss insurance reimbursement and psychotherapy. There has been a push to conduct more psychotherapy outcome research for a very practical reason: insurance companies that reimburse certain mental health professionals for conducting psychotherapy want to know that they are getting something for their money. As potential consumers of psychotherapy services (or as nonconsumers concerned about the high cost of insurance), what do students think about the provision of third‐party payment for psychotherapy?

Should only therapies that have been demonstrated to be effective be paid for by insurance companies? Should reimbursement cover lengthy psychoanalysis, which may involve several appointments a week over a number of years? Should only certain mental health professionals be reimbursed? What is the empirical justification for such a policy? Putting this discussion in the context of licensing laws and reimbursement policies in your own state will make it more relevant.

Student Activities: 1. Irrational beliefs and problem behaviours. Select one or more items from Ellis’ list of irrational beliefs (Such as “To be a good person, I must be perfect in everything I do,” or “Once something has negatively affected me, it will always affect me,” or “To be a good person, everyone in my life should like me.”) Then illustrate how this belief affects our behaviour. For example, you might take “life must go the way you want it to go.” How would this belief affect your reaction to a situation in which things do not turn out the way you expect, as so often happens? Now, convert the same statement to a rational one, such as “when things don’t turn out the way I want, it’s not the end of the world—have other options.” Discuss the difference this might make in your behaviour.

2. Biological or environmental causes of abnormality. Have students draw a Likert‐type scale with “all biology” on one end of the scale and “all‐environment” on the other end of the scale. Then ask them to place the various theorists discussed in chapter two on the appropriate point on the scale. While some theorists like Freud or Skinner should be relatively easy to place, others will be more difficult and should lead to some discussion of the differences in how the theories approach this dimension of personality. You might then ask students to discuss how theories that are highly biological in theft perspective would necessarily differ in theft conceptualization of abnormality, and in the development of treatment, from those theories that are highly environmental in their orientation.

As an additional activity, you might ask students to draw another Likert scale with “all good” on one end of the scale and “all evil” on the other end of the scale and have students place the various theorists on the appropriate point on the scale for theft theoretical orientations.

Again, you might ask how those theorists who view people as “inherently good” might differ in their conceptualizations and treatments of abnormality from those who view people as “inherently evil.”

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3. Violating social norms. Ask students to think of something that is unusual, such as dressing in a nonconforming way either in class or at a social gathering or doing something that is socially unacceptable, such as reading comic books in class or eating in a library, then have them engage in the behaviour. Caution them to avoid doing anything that is illegal or contrary to others’ rights. Ask them to report on how difficult it was to carry out the behaviour, their feelings about it, and others’ reactions. This exercise usually helps students appreciate the importance of social norms.

4. Interview individuals exhibiting features of mental disorders. Ask for several volunteers, each of whom will identify with a given mental disorder, like obsessive‐compulsive disorder, schizophrenia, and bipolar disorder. Assist each volunteer to become familiar with some of the characteristic behaviours of his or her particular disorder, including verbal expressions and nonverbal behaviours. Then have members of the class as a whole interview each volunteer and try to guess that person’s mental disorder. This exercise may help students to appreciate the difficulties of assessing a person’s psychological problems.

5. Discovering your own problems through social interaction. Select various diagnostic labels from the text or the DSM‐5, and write them on an 8 x 11 sheet of paper. Place them face down on a table and have each student draw one and have the instructor pin it on his or her back so that the individual cannot see his or her diagnostic label but everyone else can. Then allow about 20 minutes for students to mingle socially with the other students, trying to guess their own mental disorder. Students may ask questions such as “What are some of my complaints?” “Do I need medication?” “Have I ever been to a mental hospital?” Although this exercise serves as a good social mixer, it also underlines the importance of feedback and social comparison for our personal identity.

6. Are we really scientific today? As Chapter 1 illustrates, much of history has been coloured by superstitious views of human behaviour. Have students collect modern examples of less‐ than‐scientific concepts about behaviour. Examples might be astrology, or headlines from the supermarket tabloids. A visit to a bookstore’s self‐help or occult sections might also yield examples of unusual, and less‐than‐scientific prescriptions for happiness, adjustment, and meaning in life.

It may also be interesting to have students track down research evidence that debunks certain beliefs. One example is the influence of the moon on abnormal behaviour (do the “crazies” really come out when the moon is full?). In 1978, D. K Campbell and J. L. Betts reviewed research in “Lunacy and the moon,” Psychological Bulletin, 85, 1123‐1129.

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7. A Historical Talk Show. An activity that can prove very interesting is to have students assigned to portray some of the historical figures discussed in Chapter 1. Each will have to do some research on the person’s views beyond what is in the text and will adopt that figure’s beliefs about the causes and cures of deviant behaviour. Select a mix of traditional and reform views—for example, Hippocrates might debate Skinner or some other figure from our time. Much like one of the daytime talk shows, the panel could be questioned by a moderator in the audience, who stops occasionally to solicit questions from the audience (class) members to the panel.

8. What myths do people have about abnormal psychology? Have students survey five of their friends about perceptions of abnormal behaviour. If time allows, you might solicit students’ input on the design of the questionnaire. Survey questions can include: Mental illness is due to emotional weakness. Yes No Bad parenting is a major cause of mental illness. Yes No Sinful behaviour is responsible for much mental illness. Yes No The mentally ill could recover if they really wanted to. Yes No The mentally ill are more violent than “normal” people. Yes No Mental illnesses are generally incurable. Yes No Mental illness has a biological cause. Yes No Most people who claim to be mentally ill are really just looking for attention or are faking to avoid responsibility for their behaviour. Yes No

Online Discussion Questions: 1.

With our current understanding, defining abnormal is relatively straightforward. Give some possible reasons of why this is a straightforward (or not) task.

2.

Abnormal behaviour results from a combination of biological (including genetic), behavioural, cognitive, and environmental factors.

3.

Labeling people is the most helpful way for us to understand those suffering with mental disorders. Support your answer with procedures commonly used by mental health professionals in diagnosing their clients.

4. The deinstitutionalization of mental patients is almost always the best approach to treating those suffering from mental disorders.

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Online Resources: Canadian Psychological Association (CPA) www.cpa.ca This is the homepage for Canada’s national psychological association. It is the central source for information about the profession of psychology in Canada.

Canadian Psychiatric Association (CPA) www.cpa‐apc.org This is the homepage for Canada’s national professional association for psychiatrists. It contains psychiatric e‐journals and information on a variety of professional matters.

Canadian Mental Health Association (CMHA) www.cmha.ca The CMHA is a voluntary organization that is dedicated to the promotion of mental health for all Canadians. Its website contains a diverse selection of mental health resources.

Mental Health Commission of Canada www.mentalhealthcommission.ca The MHCC promotes mental health in Canada, and works with stakeholders to change the attitudes of Canadians toward mental health problems and to improve services and support. It contains reports and videos.

Mental Health Page at Health Canada www.hc‐sc.gc.ca/hl‐vs/mental/index_e.html This website provides convenient access to a range of online materials related to the promotion of mental health, mental health programs and services in Canada, and the mental health issues, problems, and disorders encountered by Canadians.

Centre for Addiction and Mental Health (CAMH) www.camh.net CAMH is Canada’s largest teaching and research centre for mental health and addiction problems. The site contains resources on a wide range of mental health and addiction concerns.

Video Resources: Abnormal Behaviour, 26 mm. colour (CRM/McGraw‐Hill). Shows selected types of abnormal behaviour, including the anxiety disorders and psychoses such as schizophrenia.

Abnormal Behaviour: A Mental Hospital, 28 mm. colour (CRM/McGraw‐Hill). Portrays life in a modem psychiatric hospital, including views of schizophrenic patients as well as a scene of a patient receiving electroconvulsive therapy (ECT).

Abnormal Psychology, 29 min. colour (Coast Telecourses). Shows the difficulties in distinguishing between normal and abnormal behaviour in reference to the DSM system of classification ..

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Abnormal Psychology: The Psychoses, 22 min. colour (Harper & Row). Viewers see a tour of a ward of a mental hospital which includes interviews with patients and a discussion of their disorders and outlook for recovery.

Asylum, (Direct Cinema Limited). This documentary focuses on St. Elizabeth’s hospital in Washington, and traces the changes in treatment over time. There is a discussion of controversies such as deinstitutionalization, and the status of the homeless mentally ill.

B. F. Skinner and Behaviour Change, 45 min. colour (Research Press). Skinner and other renowned behaviour therapists discuss behavioural psychology and therapy.

Behaviour Therapy: An Introduction, 23 min. colour (Harper & Row). Demonstrates three basic behavioural procedures, including contingency management, counterconditioning, and role playing, as applied to three individuals.

Being Abraham Maslow, 30 min. colour (FLMLIB). Excerpts from an interview in which Maslow discusses factors that influenced his life and theory.

The Brain, Mind, and Behaviour, Spans, 60 min. each, colour (PBS Video). One part on the “Enlightened Machine” focuses on the mysteries of consciousness and the brain. Another part on Rhythms and Drives examines the effects of the brain and hormones on behaviour.

Brain waves, 60 min. (PBS Video). This is from a 5‐part series Madness by Jonathon Miller. Miller begins in the late 18th century and describes the rise of physical explanations for abnormal behaviour.

Carl Gustav Jung, 38 min. (Time‐Life Films). Includes a conversation with Jung about his work and his relationship with Freud. The total span of Jung’s life and work are covered.

Carl Rogers Conducts an Encounter Group, 70 min. colour (APGA). Rogers explains how groups should operate. The film shows the quality of Rogers personal interaction with people in the group.

Classical and Instrumental Conditioning, 20 min. colour (BAR). Defines, compares, and demonstrates these two learning principles.

Committed in Error: The Mental Health System Gone Mad, 52 min. (Films for the Humanities & Sciences). A man spends 55 years in mental institutions, although there was never anything wrong with him.

Dialogues: Dr. Carl Rogers, Parts l and II, 100 min. (UCEMC). Wide‐ranging interview with Carl Rogers covering client‐centered theory and some contemporary issues.

Discovering Psychology: The Responsive Brain, 30 min. colour (Annenberg/CPB Collection).

Looks at the interaction of the brain, behaviour, and the environment. Also shows how brain structure and function are changed by behavioural and environmental factors. ..

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Discovering Psychology: Understanding Research, 28 min. colour (Annenburg /CPB collection).

This film explores the research methods and procedures of psychologists.

Everybody Rides the Carousel, 73 min. colour (PFP). Real‐life episodes are used to illustrate Erikson’s eight stages of development.

Faith Healing and Witchcraft, 28 mm. colour (Films for the Humanities and Sciences).

Frankl and the Search for Meaning, 30 min. colour (Psychological Films). Victor Frankl discusses his approach to therapy.

Hurry Tomorrow, black & white (TFC). A documentary film in a Los Angeles psychiatric hospital depicting the attitudes of staff and patients and the treatment of patients.

Hypnosis: Can Your Mind Control Pain? 53 min. colour (BBC). Presents several case studies in which hypnosis is used as anesthesia.

Is Mental Illness a Myth? 29 mm. black and white (NMAC‐T 2031). Debates whether mental illness is a physical disease or a collection of socially learned actions. Panelists are Thomas Szasz, Nathan Kline, and F. C. Redlich.

King of Hearts, colour (United Artists). A classic film about an English soldier scouting a French village behind German lines in WWI which has been abandoned by all but residents of the local insane asylum, who have escaped and taken over the town.

Madness and Medicine, 49 min. (2 parts) colour (CRM/McGraw Hill). Part I covers life in a mental hospital; Part II explores the pros and cons of the various types of treatment, including insight therapy and ECT. Miracle Healers, 50 min. colour (ITVFP). Investigates alternative forms of healing such as psychic surgery, faith healing, and magnetism.

Mental Health: New Frontiers of Sanity, 22 min. colour (EMC). Documents the extent of mental health problems in North America, and traces the history of therapy.

Methodology: The Psychologist and the Experiment, 30 mm. colour (CRM/McGraw‐Hill). This film overviews research methodologies used by psychologists.

Mysteries of the Mind 58 mm. (Films for the Humanities and Sciences). Examines the neurochemical and genetic components in various disorders.

To Define True Madness, 60 mm. (PBS Video). This is from the 5‐part series Madness by Jonathon Miller. Miller examines views of mental illness throughout the history of Western society, and explores from various perspectives what it means to be a mentally ill patient.

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The Otto Series, 27‐29 min. each (5 parts) colour (lU). A series of films that begin with an open‐ ended dramatization of abnormality in a middle‐aged man, then offers four perspectives for understanding and treatment: behavioural, phenomenological, psychoanalytic, and social.

Pavlov: The Conditioned Reflex, 25 min. black and white (Films for the Humanities). Accurate biography of Pavlov’s life and work.

Psychodynamic Considerations and Defense Mechanisms, 29 min. colour. (Health Sciences Consortium). Shows how the unconscious is manifested verbally and behaviourally.

The Psychology of Jung: Passions of the Soul, 4 parts, 60 to 90 min. each, colour (Films for the Humanities). In‐depth exploration of Jung’s life and theory.

Psychotherapy, 26 min. colour (CRM/McGraw‐Hill). Demonstrates the process of therapy with three different clients and therapists.

Ratman, 53 min. colour. (Time‐Life Films/Videos). Dramatizes Freud’s treatment of an obsessive patient dubbed “Ratman” by Freud.

Sigmund Freud: His Office and Home, Vienna, 1938, 17 min. colour (Filmaker’s Library).

What Makes Us Tick? 24 mm. (Films for the Humanities and Sciences). The relationship between genes and environment in the formation of human personality.

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Chapter 3 Anxiety, Obsessive‐Compulsive, and Trauma‐and Stressor‐ Related Disorders Chapter Overview: Anxiety, a generalized sense of apprehension or fear, is normal and desirable under some conditions, but it can become abnormal when it is excessive or inappropriate. Anxiety may be experienced with a range of physical features, cognitions, and behaviours.

Anxiety Disorders Disorders involving anxiety were historically classified as neuroses, which were originally believed to be organic in nature. Psychodynamic theory posited that the origins of neurosis lay in psychological factors, that neuroses reflected the threat of the conscious emergence of repressed unacceptable impulses. Freud believed that the different kinds of neuroses reflected the different ways in which the ego defended itself from anxiety. This etiological hypothesis united current anxiety, dissociative, and somatoform disorders as neuroses.

Panic Disorder Panic disorder refers to recurrent unexpected panic attacks (Criterion A). A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four or more of a list of 13 physical and cognitive symptoms occur. … The worries about panic attacks or their consequences usually pertain to physical concerns, such as worry that panic attacks reflect the presence of life‐threatening illness…; social concerns, such as embarrassment or fear of being judged negatively by others because of visible panic symptoms; and concerns about mental functioning, such as “going crazy” or losing control (Criterion B). (APA, 2013) There are also two exclusion criteria for Panic Disorder – the disorder cannot be due to use of a substance (e.g., drug or medication) or medical condition and the disorder cannot be better explained by a comorbid disorder.

Panic disorder is often comorbid with another disorder namely, agoraphobia. About one third to one half of people with panic disorder also have agoraphobia, and the majority of people with agoraphobia have a history of panic attacks.

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Agoraphobia In the new DSM‐5 Agoraphobia is a distinct disorder involving a fear, concern, anticipatory anxiety, or excessive worry about being in open spaces, closed spaces, using public transportation, standing in line, being in crowds, and in general anyplace outside the home environment. Agoraphobia is diagnosed separately from panic disorder. If both exist, two diagnoses are given. (APA, 2013) Generalized Anxiety Disorder Generalized anxiety disorder (GAD) is characterized by persistent feelings of anxiety that are not triggered by any specific object, situation, or activity but rather seem to be what Freud labelled “free floating.” People with GAD are chronic worriers. Chronic worrying is accompanied by general feelings of dread, foreboding, and heightened states of sympathetic arousal.

Phobic Disorders Phobias are excessive irrational fears of specific objects or situations. Phobias involve a behavioural component, avoidance of the phobic stimulus, in addition to physical and cognitive features. Specific phobias are excessive fears of particular objects or situations, such as mice, spiders, tight places, or heights. Social Anxiety Disorder involves an intense fear of being judged negatively by others.

Obsessive‐Compulsive and Related Disorders Obsessive‐Compulsive Disorder (OCD) Obsessive‐compulsive disorder involves recurrent patterns of obsessions, compulsions, or a combination of the two. Obsessions are nagging, persistent thoughts that create anxiety and seem beyond the person’s ability to control. Compulsions are apparently irresistible repetitious urges to perform certain behaviours, such as repeated elaborate washing after using the bathroom.

Trauma‐and Stressor‐Related Disorders Adjustment Disorders Adjustment disorders are among the mildest of psychological disorders. An adjustment disorder is a maladaptive reaction to an identified stressor that develops within a few months of the onset of the stressor. The maladaptive reaction is characterized by significant impairment in social, occupational, or academic functioning or by states of emotional distress that exceed those normally induced by the stressor.

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Acute and Posttraumatic Stress Disorder In acute and posttraumatic stress disorder (PTSD), people develop stress reactions that follow exposure to traumatic events. Acute stress disorder occurs in the days and weeks following exposure to a traumatic event. Posttraumatic stress disorder persists for months or even years or decades after the traumatic experience and may not begin until months or years after the event.

Theoretical Perspectives Psychodynamic Perspectives Psychodynamic theorists view anxiety disorders as attempts by the ego to control the conscious emergence of threatening impulses. Feelings of anxiety are warning signals that threatening impulses are nearing awareness. The ego mobilizes defense mechanisms to divert the impulses, thus leading to different anxiety disorders. Phobic objects symbolize aspects of unconscious conflicts, for example.

Behavioural Perspectives Learning theorists explain anxiety disorders through conditioning and observational learning.

Mowrer’s two‐factor model incorporates classical and operant conditioning in the explanation of phobias. Phobias, however, appear to be moderated by cognitive factors, such as self‐efficacy expectancies. The principles of reinforcement may help to explain patterns of obsessive‐ compulsive behaviour. People may be genetically predisposed to acquire certain types of phobias that may have had survival value for our prehistoric ancestors. Cognitive factors may also play a role in the anxiety disorders, such as over‐predictions of fear, irrational beliefs, self‐ efficacy expectancies, self‐defeating thoughts, and attributions for panic attacks.

Cognitive Perspectives Cognitive Perspectives focus on how dysfunctional patterns of thinking may set the stage for anxiety disorders. Self‐defeating thoughts can heighten and perpetuate anxiety disorders.

Irrational beliefs may involve exaggerated needs to be approved of by everyone one meets and to avoid any situation in which negative appraisal from others might arise Biological Perspectives Biological perspectives have sought explanations of anxiety disorders on the basis of studies of genetic factors, neurotransmitters, and the induction of panic by biological means.

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Tying It Together Anxiety disorders can develop from the complex interactions of environmental, physiological, and psychological factors. The factors are: behavioural, social‐environmental, biological, and emotional and cognitive factors.

Treatment Psychodynamic Approaches Each theoretical perspective is connected with methods of treating anxiety disorders.

Traditional psychoanalysis helps people work through unconscious conflicts that are thought to underlie anxiety disorders. Modem psychodynamic approaches also focus on current disturbed relationships and encourage clients to assume more adaptive behaviour patterns.

Humanistic Approaches Humanistic theorists suggest that our anxieties result from the social repression of our true, inner selves.

Biological Approaches The biological perspectives have spawned the development of various drugs to treat anxiety.

Cognitive and Behaviour‐Based Approaches Learning‐based approaches encompass a broad range of behavioural and cognitive‐behavioural techniques to help people overcome anxiety‐related problems. Exposure methods help people with phobias overcome fears through gradual exposure to phobic stimuli. Cognitive restructuring helps clients pinpoint self‐defeating thoughts and substitute rational alternatives.

Obsessive‐ compulsive disorder is often treated with a combination of exposure and response prevention. Relaxation training is often used to help people with generalized anxiety learn skills of self‐relaxation. Behavioural treatment of PTSD incorporates progressive exposure to trauma‐ related cues and training in stress management skills, such as self‐relaxation.

Cognitive approaches, such as rational‐emotive therapy and cognitive therapy, help people identify and correct cognitive errors that give rise to or maintain anxiety disorders. Cognitive‐ behavioural approaches to the treatment of panic disorder help people with a proneness to panic disorder learn to cope more effectively with cardiovascular and other bodily sensations.

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Chapter Outline: Anxiety, Obsessive‐Compulsive, and Trauma‐and Stressor‐Related Disorders 100 Anxiety Disorders 103 Panic Disorder 104 Agoraphobia 106 Generalized Anxiety Disorder 108 Phobic Disorders 109 Obsessive‐Compulsive and Related Disorders 113 Obsessive‐Compulsive Disorder (OCD) 113 Trauma‐and Stressor‐Related Disorders 115 Adjustment Disorders 115 Acute and Posttraumatic Stress Disorders 116 REVIEW IT Anxiety, Obsessive‐Compulsive, and Trauma‐and Stressor‐Related Disorders 120 Theoretical Perspectives 120 Psychodynamic Perspectives 120 Behavioural Perspectives 121 Cognitive Perspectives 122 Biological Perspectives 125 Tying It Together 128 REVIEW IT Theoretical Perspectives 130 Treatment 130 Psychodynamic Approaches 130 Humanistic Approaches 130 Biological Approaches 131 Cognitive and Behaviour‐Based Approaches 131 REVIEW IT Treatment of Anxiety, Obsessive‐Compulsive, and Trauma‐ and Stressor‐Related Disorders 138 CONCEPT MAP 140

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Students Should Be Able to: 1.

2.

3.

4.

5.

6.

7.

8.

9.

Describe the major features of panic disorder.

Define and describe agoraphobia.

Define and describe generalized anxiety disorder.

Describe phobic disorders.

Define and describe obsessive‐compulsive disorder (OCD).

Describe and differentiate between acute and posttraumatic stress disorders.

Understand how anxiety disorders conceptualized within the psychodynamic perspective.

Describe how learning/behaviour theorists view anxiety disorders.

Explain how the biological perspective seeks to inform our understanding of anxiety disorders.

10. Explain how the treatment of anxiety, obsessive‐compulsive, and trauma‐ and stressor‐ related disorders is approached from the major contemporary theoretical perspectives.

Lecture and Discussion Suggestions: 1. Explain the difference between neurosis and anxiety disorders. Although the category of neuroses included all the disorders now grouped under the DSM‐ 5 category of anxiety disorders, they also included disorders now classified as somatoform disorders (conversion disorder and hypochondriasis) as well as some dissociative disorders like psychogenic fugue and amnesia. Point out that the anxiety disorders are now classified according to the similarities in their behaviour patterns and distinctive features rather than theoretical assumptions of causation, as in the concept of neurosis.

2. Describe the difference between phobias and normal fears. While growing up, most of us acquire a variety of fears, such as the fear of snakes and being in high, exposed places.

However, most of these fears are relatively mild and usually outgrown. By contrast, phobias evoke intense anxiety and avoidant behaviours that interfere greatly with everyday living and usually require professional treatment. The key differences are that normal fears are typically proportionate to the threat posed by the object of causing your fear, whereas the phobic reaction is irrational in that it goes so far beyond any realistic threat posed by the object of the phobia.

Various types of phobias tend to appear at different ages, reflecting cognitive developmental factors and the nature of life experiences. For instance, as children reach school age, and Piaget’s stage of concrete operational thought, animals are commonly found in children’s fantasies and phobias. By contrast, social anxiety disorder such as stage fright are more likely to appear at adolescence, when concern over peer acceptance and criticism plays a larger role. Finally, the kinds of experience that may be related to reluctance to leave the house (in agoraphobia) may accumulate over several years of adult ..

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life. Consequently, the initial onset of agoraphobia occurs, on the average, at about 28 years of age. Agoraphobia, which occurs more commonly among women than men, is also the phobia for which people are most likely to seek treatment.

3. Discuss the treatment of anxiety disorders. Describe the different methods used in treating anxiety disorders, including psychodynamic therapy, humanistic‐ existential approaches, cognitive, and behavioural methods. You might draw a line on the chalkboard to represent a continuum of methods for handling anxiety, depending primarily on the extent to which the aim of treatment is long‐term personality change or shorter‐term behaviour change or symptom reduction. Thus, you might place the psychoanalytic approaches aimed at personality change at the extreme left. And you could put the biological approaches, such as the use of tranquilizers, at the extreme right. In between those two extremes, you might locate the other methods commonly used to treat anxiety disorders, such as desensitization, gradual exposure, and cognitive‐behavioural methods. You might also discuss the widespread use of tranquilizers and their abuse versus the increasing use of cognitive‐ behavioural methods that minimize the use of medication.

4. Case studies from TV. At the risk of letting your students know that you occasionally do something as mundane as watching TV, you can help illustrate some of the disorders (as well as some of the “normal” behaviours) discussed in this and subsequent chapters by diagnosing various characters from TV or movies (particularly some of Woody Allen’s early movies). Daytime “soap operas” provide a virtual gold mine of neurotic and generally disturbed individuals.

5. Situational anxiety. Ask students to suggest typical situations that make them anxious. You might list these on the chalkboard. Do they believe their fears are justified or phobic? Then ask students to tell how they personally cope with these situations. What coping strategies do they find most effective?

6. Fears and aging. Discuss how people’s fears change with age. Many fears increase or decrease during certain stages of life, such as the young child’s fear of the dark and the adolescent’s fear of academic failure. What are some characteristic fears of college students? Often, young people assume that fears of death increase as people get older. This is only partially true, as researchers have found that fears of death tend to peak during middle age, not old age. Why do students think this happens?

7. Overcoming fears and phobias. Have students had any successful experiences in overcoming fears or phobias? How did they do it? You might ask students to describe such experiences in the form of a note, submitted anonymously, if they prefer not to identify themselves in class. Then relate the methods that students have used on their own to those described in the text. You might also discuss why many attempts at self‐treating phobias do not work and explore how those attempts could have been more successful.

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8. Posttraumatic stress disorder. The PTSD diagnosis has always been controversial. During World War I, the German army outlawed “shell shock,” as it was known at the time and ordered that all victims of it be shot. No cases were subsequently reported. Punitive measures were also taken by the British and French against shell‐shocked soldiers. By the time of World War II, attitudes had become more kind toward “battle fatigue.” For example, when U. S. Army general George Patton slapped a soldier suffering from battle fatigue in a field hospital in Italy, he was reprimanded and forced to publicly apologize for his act. By the time of Korea and Vietnam, “combat exhaustion” was treated using psychological methods.

Vietnam veterans suffered extremely high rates of PTSD (compared to WWII or Korean veterans). Why do students think this happened?

Have students suggest reasons for the change in attitude over the years toward PTSD, Do they feel that the diagnosis is controversial even today?

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

10. Worry. Worry is a part of generalized anxiety disorder, but it is also an activity we all engage in from time to time. Psychologist Tom Borkovec describes worry as an attempt to cope with the things we fear. Unfortunately, what begins as a well‐intentioned effort to solve a problem can sometimes turn into a chain of imagined horrors and catastrophes. Borkovec defines the chronic worrier as anyone who has spent eight hours a day worrying on many days. About 15% of us are chronic worriers. About 30% of us are nonworriers, who worry less than an hour and a half a day. The rest of us are somewhere in between these extremes.

What keeps worry going so long? Borkovec believes that worry is subject to a process of incubation. Research shows that fear subsides under two types of conditions: after repeated short exposures to a fear stimulus (10 minutes or less) or after a very long exposure of over 30 minutes. In between, though, thinking about a fearful situation only intensifies the fear.

This is incubation. Worriers often worry in chunks of about 15 minutes, shift attention back to real life, and then go back to worrying. These moderate exposures provide fertile ground for worries to breed and grow.

One suggestion Borkovec has for us is to establish a regular worry period. Try to make this about the same time every day. Do your worrying in only one place. Keep the worry workout short, no more than 30 minutes. To keep worrying under control in‐between worry periods, learn to replace oncoming worry with present‐ moment exercises, such as attending to things in the situation or concentrating on a task. Treatment based on this prescription has been effective with some worriers. ..

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Discuss with your students how they worry, and see if it matches Borkovec’s pattern.

Contrast the effects of everyday worrying with those felt by GAD patients.

Borkovec, T. D. (1985). “What’s the Use of Worrying”. Psychology Today, December, pp.59‐ 64.

11. Gender Differences. Your students will usually notice that most of the anxiety disorders are diagnosed in women, especially the phobias. Why the gender imbalance?

The stereotype of the easily‐frightened woman abounds in movies, television, and other media. Is this stereotype accurate? It is in that women score as more anxious than men on tests of anxiety, and they present themselves more often for treatment, as reflected in the preponderance of women phobics. Some authors have noted, though, that this follows the cultural expectation. A male, on the other hand, is supposed to be strong, tough, and brave.

It is difficult and threatening for many men to acknowledge fear. The result, says Carol Tavris, is that men become “white knucklers.” They tense up on the inside and often endure tremendous anxiety but persist in the brave front. Often, they try to drown their anxiety in alcohol. When anxiety does become a problem, men are likely to cite a physical factor as the cause rather than admit a fear.

The stereotypes about anxiety cost both sexes. The view of women casts them as easily frightened, anxious creatures. The view of men forces them to take their anxiety underground, often compounding it with drugs.

Tavris, C. (1986). “Coping with Anxiety”. Science Digest, February 12‐19.

12. Embarrassment. Social phobics fear embarrassment. Embarrassment, is a common, but painful, experience for most of us. It is also one that has been around off and on since childhood. About 20% of 3‐year‐olds and 50% of 5‐year‐olds show signs of embarrassment, according to parents (Buss, 1980), and several different things occur when embarrassment strikes.

First, there is the awareness that we are blushing. This is perhaps the most exasperating thing about embarrassment. We can often hide anxiety and other feelings, but no matter how much we disclaim feeling embarrassed, a red face is a dead giveaway. Why we blush is not known. Charles Darwin wrote what is still the most complete essay on blushing, and he concluded that only people do. Other species turn red in the face sometimes, but that is from rage, not embarrassment.

Second, the embarrassing feelings cause a temporary drop in self‐esteem. We feel clumsy, incompetent, and foolish. It is not surprising, then, that a third part of embarrassment is often an attempt to escape the situation. Perhaps most interesting, though are the behaviours of embarrassed people Zimbardo (1977) calls “lacework.” ..

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When embarrassed we do things to try to save face, and maintain our dignity. We might quickly change the subject, make excuses, show off other good qualities, or fish for reassurance. Also, we become an easier mark for requests for help when we are embarrassed.

Ask your students to discuss embarrassment, and use this to highlight how uncomfortable this fear is for the social phobic, who is preoccupied with fear of scrutiny by others.

Buss, A. R. (1980). Self‐Consciousness and Social Anxiety. San Francisco: Freeman.

Zimbardo, P. G. (1977). Shyness: What It Is, What to Do About It. Reading, Mass.: Addison‐ Wesley.

Student Activities: 1. Construct a hierarchy of anxiety‐provoking situations. Ask the class to list several situations that commonly arouse anxiety in college students. Then elicit their suggestions for constructing a hierarchy of these situations that could be used in systematic desensitization by pairing the items with relaxation. Write their suggestions on the chalkboard. Then prioritize them in an ordered sequence of no more than 12 to 15 items. Then discuss how such a prioritized list might be used in systematic desensitization to help someone overcome these fears.

2. Cognitive restructuring. Have class members think of a stress‐provoking situation that is commonly experienced by students. Then identify the characteristic self‐defeating thoughts that occur before, during, and after the stressful event. Then pair each self‐defeating thought with a more rational, coping alternative, as in the example below: Self‐defeating thoughts

Coping thoughts

I’m sick with worry.

I’m so confused.

What if I Fail?

I’ll never make it.

Worrying won’t help things.

What is it I have to do?

Concentrate on what I’m doing!

One step at a time.

Now do the same thing with self‐defeating and coping thoughts during the stressful situation and afterwards.

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3. Building social self‐confidence. People who are socially anxious usually try to avoid attracting any attention to themselves. To help them become more comfortable in dealing with people, Emmelkamp (1982) assigns a series of practice exercises. These are intended to build social self‐confidence gradually. Have your students try some of these and report back with their feelings and reactions. a. Go to a music shop and ask for a particular type of music. Pick a recording and ask to listen to part of it, but do not buy anything. b. Visit a store that sells alarm clocks. Set one of them off to see what it sounds like. Do not buy it. c. Go to a shoe store and try on several pairs of shoes. Do not buy any. d. Go to a travel agency and ask about trips to a place you choose. Ask about hotels and such things. e. Go to a store and change $25 for two 10’s and five 1’s. Do not buy anything. f. Go into a grocery store and buy one article. When in the checkout line, ask the person in front of you if you can go ahead of them. g. Stop a person in the street and ask for directions to a place in your area. h. Buy a piece of cheese in a deli and ask first if you can taste it.

Your students might find some of these exercises seem silly, because they are so easy.

Remind them that these are challenging for socially anxious people, who need such practice to build up their self‐confidence.

Emmelkamp, P. M. G. (1982). Phobic and Obsessive‐Compulsive Disorders: Theory, Research and Practice. New York: Plenum.

Online Discussion Questions: 1. Historically there have been many attempts to explain the development of Phobic Disorders.

Explain how either the Psychodynamic, Learning, Biological or Cognitive perspectives attempt to explain the psychopathology of these disorders in the most comprehensive way.

2. The causes and treatment of Generalized Anxiety Disorder can be fully explained using only the Learning perspective. Discuss.

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Online Resources: Anxiety Treatment and Research Centre www.stjoes.ca/anxiety Information on anxiety disorders, including Canadian treatment resources.

Anxiety Disorders Association of Canada www.anxietycanada.ca Information and links to provincial anxiety disorder associations.

Anxiety Disorders Association of America www.adaa.org The ADAA’s website contains information on the nature and treatment of anxiety disorders, as well as links to self‐help books and other resources.

International OCD Foundation https://iocdf.org/ This nonprofit organization provides information on obsessive‐compulsive disorder and its treatment.

National Center for PTSD http://www.ptsd.va.gov/ This organization’s site contains a good deal of useful information on posttraumatic stress reactions and their treatment.

Video Resources: Anxiety: Decision at the Synapse, 27 min. colour (Abbott Labs). Summarizes information on the etiology and physiology of anxiety. Made in 1975.

Anxiety: The Endless Crisis, 59 min. colour (IU). Presents a wide range of anxiety‐arousing situations, demonstrating both situational and trait anxiety.

The Compulsive Mind: Tourette’s Syndrome/OCD, 19 min. colour (Films for the Humanities and Sciences). Profiles a man with Tourette’s syndrome and explores possible chemical causes of OCD and the role of medication and behaviour therapy in its treatment.

Descriptions and Interventions, 17‐25 min. filmstrips (CM). The filmstrips deal with the origins of abnormal behaviour, anxiety disorders, personality disorders, and schizophrenia.

Fear itself 26 min. colour (Films for the Humanities and Sciences). Explores the organic causes of phobias as well as possible treatments, focusing on agoraphobia.

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The Fragile Mind, 53 min. colour (ABC‐TV). Joanne Woodward introduces several in‐depth cases involving disabling anxiety.

Getting Anxious, 30 min. colour (Insight Media). Shows phobics before and after treatment and shows how anxiety disorders are treated.

Image in a Mirror, 9 min. colour (NYU Film Library). Shows a student convinced she will fail despite having good grades. Viewers are asked to consider what the teacher can do help this student gain self‐confidence.

Neurotic Behaviour: A Pyschodynamic View, 19 min. colour (CRM/McGraw‐Hill). Examines the exaggerated anxieties involved in self‐defeating behaviours, along with the various defense maneuvers used to cope with such anxiety.

Obsessive‐Compulsive Disorder, 24 min. colour (Films for the Humanities and Sciences).

Examines the effects of drug treatment on uncontrollable urges and needs to act.

Obsessive‐Compulsive Disorder: The Boy Who Couldn’t Stop Washing, 28 min. colour (Films for the Humanities and Sciences). Adapted Phil Donahue segment that examines obsessive‐ compulsive behaviour.

Panic! 26 min. colour (Films for the Humanities and Sciences). Explains anxiety disorders and examines panic attacks, phobias, and agoraphobia.

Pathological Anxiety, 30 min. (PCR‐2 122). Case study of an office worker who experiences panic and terror that prevents him from leading a normal life. Made in 1961 so it is somewhat dated.

Post‐Traumatic Stress Disorder, 28 min. colour (Films for the Humanities and Sciences).

Examines various causes of PTSD through interviews with PTSD victims.

What Happens in Emotions, 30 min. black and white (IU). Discusses bodily functions that operate during emotional states, including charts and diagrams to explain the sympathetic and parasympathetic nervous systems.

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Chapter 4 Depressive Disorders, Bipolar and Related Disorders, and Suicide Chapter Overview: Depressive Disorders Mood disorders are disturbances in mood that are serious enough to impair daily functioning.

There are various kinds of mood disorders, including depressive (unipolar) disorders such as major depression and persistent depressive disorder, and disorders involving mood swings, such as bipolar disorder and cyclothymic disorder.

Major Depressive Disorder People with major depressive disorder (MDD) experience profound changes in mood that impair their ability to function. There are many associated features of major depression, including depressed mood, changes in appetite, difficulty sleeping, reduced sense of pleasure in formerly enjoyable activities, feelings of fatigue or loss of energy, sense of worthlessness, excessive or misplaced guilt, difficulties concentrating, thinking clearly or making decisions, repeated thoughts of death or suicide, attempts at suicide, or even psychotic behaviours (hallucinations and delusions).

About twice as many women as men seem to be affected by major depression, but the reasons for this gender difference remain unclear. Depression can begin or recur at any age, but the risk of initial onset of depression is age related. Major Depressive Disorder has been increasing worldwide.

Persistent Depressive Disorder Persistent depressive disorder is a form of chronic depression, dysthymia, that is milder than major depression but may nevertheless be associated with impaired functioning in social and occupational roles.

Bipolar Disorder and Related Disorders Bipolar I Disorder Bipolar I disorder is identified by the occurrence of one or more manic episodes, which generally but not necessarily occur in persons who have experienced major depressive episodes. Manic episodes are characterized by periods of unrealistically heightened euphoria, extreme restlessness, and excessive activity characterized by disorganized behaviour and impaired judgment.

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Bipolar II Disorder In bipolar II disorder, depressive episodes occur along with hypomanic episodes, but without the occurrence of full‐blown manic episodes. Hypomanic episodes are less severe than manic episodes and are not accompanied by the severe social or occupational problems associated with full‐blown manic episodes.

Cyclothymic Disorder Cyclothymic disorder is a type of bipolar disorder characterized by a chronic pattern of mild mood swings between depression and hypomania that are not of sufficient severity to be classified as bipolar disorder.

Theoretical Perspectives Stress Research indicates that there is a robust and causal association between stressful life events and major depressive episodes (Colman et al., 2014; Hammen, 2005); major depression is often preceded by stressful events, although not everyone who experiences such events will become depressed. Stressors such as the loss of a loved one, prolonged unemployment, physical illness, marital or relationship problems, economic hardship, pressure at work, racism, and discrimination may all contribute to the development and recurrence of mood disorders, especially major depression.

Psychodynamic Perspectives.

In classic psychodynamic theory, depression is viewed in terms of inward‐directed anger. People who hold strongly ambivalent feelings toward people they have lost, or whose loss is threatened, may direct unresolved anger toward the inward representations of these people they have incorporated or introjected within themselves, producing self‐loathing and depression. Bipolar disorder is understood within psychodynamic theory in terms of the shifting balances between the ego and superego. More recent psychodynamic models, such as the self‐ focusing model, incorporate both psychodynamic and cognitive aspects in explaining depression in terms of the continued pursuit of lost love objects or goals that would be more adaptive to surrender.

Learning Perspectives Learning (behavioural) perspectives focus on situational factors in explaining depression, such as changes in the level of reinforcement. When reinforcement is reduced, the person may feel unmotivated and depressed, which can lead to inactivity and further reduction in opportunities for reinforcement. Coyne’s interactional theory focuses on the negative family interactions that can lead family members of depressed people to become less reinforcing to them. ..

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Cognitive Perspectives Cognitive theorists relate the origin and maintenance of depression to the ways in which people see themselves and the world around them. Beck’s cognitive theory focuses on the role of negative or distorted thinking in depression. Depression‐prone people hold negative beliefs toward themselves, the environment and the future. This cognitive triad of depression leads to specific errors in thinking, or cognitive distortions, in response to negative events, that in turn lead to depression. Martin Seligman’s (1975) learned helplessness model is based on the belief that people may become depressed when they come to view themselves as helpless to control the reinforcements in the environment or to change their lives for the better. A reformulated version of the theory held that the ways in which people explain events—their attributions— determine their proneness toward depression in the face of negative events. The combination of internal, global, and stable attributions for negative events renders one most vulnerable to depression.

Biological Perspectives.

Genetics appears to play a role in mood disorders, especially in explaining major depressive disorder and bipolar disorder. Imbalances in the neurotransmitter activity in the brain appear to be involved in depression and mania.

Tying It Together The diathesis‐stress model is used as an explanatory framework to illustrate how biological or psychological diatheses may interact with stress in the development of depression.

Psychological and biological vulnerability lead to depression in the presence of potential stress factors such as unemployment, divorce, and pressing sociocultural factors. Potential protective factors such as coping resources and social support can protect from depression, while the lack of these protective factors can aggravate depression.

Treatment Psychodynamic Approaches Psychodynamic treatment of depression has traditionally focused on helping the depressed person uncover and work through ambivalent feelings toward the lost object, thereby lessening the anger directed inward. Modern psychodynamic approaches tend to be more direct and briefer and focus on developing more adaptive means of achieving self‐worth and resolving interpersonal conflicts.

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Behavioural Approaches Learning theory approaches have focused on helping people with depression increase the frequency of reinforcement in their lives through such means as increasing the rates of pleasant activities in which they participate and assisting them in developing more effective social skills to increase their ability to obtain social reinforcements from others.

Cognitive Approaches Cognitive therapists focus on helping depressed people identify and correct distorted or dysfunctional thoughts and learn more adaptive behaviours.

Biological Approaches Biological approaches have focused on the use of antidepressant drugs and other biological treatments, such as electroconvulsive therapy (ECT). Antidepressant drugs appear to increase the levels of neurotransmitters in the brain. Bipolar disorder is commonly treated with lithium.

Suicide Who Commits Suicide?

Mood disorders are often linked to suicide. Although women are more likely to attempt suicide, more men actually succeed, probably because they select more lethal means. The elderly, not the young, are more likely to commit suicide, and the rate of suicide among the elderly appears to be increasing.

Why Do People Commit Suicide?

People who attempt suicide are often depressed, but they are generally in touch with reality.

They may, however, lack effective problem‐solving skills and see no way to deal with their life stress other than suicide.

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Theoretical Perspectives on Suicide Freud (1920/1987) speculated that suicide may be motivated by the “death instinct,” a tendency to return to the tension‐free state that preceded birth. Existential and humanistic theorists relate suicide to the perception that life is meaningless and hopeless. Sociocultural theorists likewise believe that alienation in today’s society may play a role in suicide. Learning theorists point to the reinforcing effects of prior suicide threats and attempts and to the effects of stress, especially when combined with inability to solve personal problems. Social‐cognitive theorists suggest that suicide may be motivated by positive expectancies and by approving attitudes toward the legitimacy of suicide (Joiner, 2006). Biological factors that appear to be involved in suicide are serotonin deficits (linked to depression), genetics, and familial history of suicidal behaviour.

Predicting Suicide Evidence points to the role of hopelessness as an important predictor or perhaps contributor to suicidal thinking and behaviour (Brent & Mann, 2006; Joiner, 2006; Marco, Pérez, & Garcia‐ Alandete, 2016). Researchers have found that people who committed suicide dispose of their possessions, suddenly try to sort out their affairs, and may purchase guns despite lack of prior interest in firearms.

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Chapter Outline: Depressive Disorders, Bipolar and Related Disorders, and Suicide 142 Depressive Disorders 144 Major Depressive Disorder 144 Persistent Depressive Disorder 151 Bipolar and Related Disorders 152 Bipolar I Disorder 152 Bipolar II Disorder 154 Cyclothymic Disorder 154 REVIEW IT Depressive and Bipolar and Related Disorders 155 Theoretical Perspectives 155 Stress 155 Psychodynamic Perspectives 156 Learning Perspectives 157 Cognitive Perspectives 159 Biological Perspectives 164 Tying It Together 165 REVIEW IT Theoretical Perspectives on Depressive and Bipolar Disorders 166 Treatment 166 Psychodynamic Approaches 167 Behavioural Approaches 168 Cognitive Approaches 168 Biological Approaches 170 REVIEW IT Treatment of Depression 175 Suicide 175 Who Commits Suicide? 176 Why Do People Commit Suicide? 177 Theoretical Perspectives on Suicide 177 Predicting Suicide 180 REVIEW IT Suicide 182 CONCEPT MAP 184

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Students Should Be Able to: 1.

2.

3.

4.

5.

6.

7.

Explain the features associated with major depressive disorder Describe the features of persistent depressive disorder.

Explain and distinguish between Bipolar I and Bipolar II disorders.

Explain the characteristics of manic episodes.

Explain the characteristics of hypomanic episodes, and how they differ from manic episodes.

Describe the features of cyclothymic disorder.

Understand how depressive and bipolar disorders are conceptualized within the psychodynamic model.

8. Discuss how learning theorists and cognitive models view depression.

9. Discuss what the learned helplessness model is, and how it makes an individual vulnerable to depression.

10. Enumerate the contribution of biological factors in depressive and bipolar disorders.

11. Discuss the approaches taken by the major theoretical perspectives in treating depressive and bipolar disorders.

12. Discuss the significant factors linked to suicide.

13. Assess why one should never ignore a person’s threat to commit suicide.

Lecture and Discussion Suggestions: 1. Interpersonal aspects of depression. Our interactions with others may be an important factor in the onset and management of depression. Especially helpful here is James Coyne’s interactional theory, described in this chapter. According to this view, people who are depressed affect and are affected by their interactions with loved ones. Coyne holds that living with a depressed person can become so stressful that this person’s partner or family become progressively less reinforcing toward the depressed person.

Initially the depressed person may succeed in eliciting support from others. However, over time, the depressed person’s demands evoke feelings of annoyance, anger, and eventually aversive reactions. The depressed person may then react to rejection by becoming more demanding, which results in further rejection and withdrawal of positive reinforcement in vicious cycles. Consequently, the depressed person becomes more depressed and family members living with the person also experience higher stress and depression.

Coyne found that as many as 40 percent of family members of depressed people were sufficiently depressed as to need therapeutic intervention. This theory has important implications for managing depression, including modifying the depressed person’s demands for support and helping family members to sustain realistic but helpful levels of reinforcement. ..

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2. Beck’s cognitive theory of depression. Aaron Beck’s cognitive theory of depression holds that people who adopt a habitual style of negative thinking are more likely to become depressed. The cognitive triad of depression, described in this chapter, involves the adoption of negative thinking about oneself (“I’m no good”), the environment (“school is awful”), and the future (“nothing will ever turn out right for me”). Early learning experiences are believed to play a major role in shaping these negative attitudes. Once adopted, however, such habitual negative thinking is manifested in “automatic thoughts,” or cognitive distortions, such as all or nothing thinking, overgeneralization, and disqualifying the positive. These spontaneous cognitive distortions then sensitize people to interpret any disappointment or failure as a total defeat, which then leads to depression. Therapeutic intervention includes helping depressed persons to identify their particular pattern of cognitive distortions and modify them accordingly.

3. Exercise and depression. Many studies have shown a link between regular physical exercise and the alleviation of depression. People who exercise regularly are less depressed. But it works the other way too, so that people who are more depressed simply exercise less. In order to demonstrate a causal link between exercise and depression, Lisa McCann and David Holmes (“Influence of Aerobic Exercise on Depression,” Journal of Personality and Social Psychology, 1984, 46, pp. 1142‐1147) performed an experiment with college women at the University of Kansas. Students were randomly assigned, either to an exercise group, involving running and aerobic exercise, or to a control group, which involved no exercise.

The women were tested for depression at the outset, 5 weeks into the program, and again after 10 weeks of exercise. Results showed that only the students in the exercise group became markedly less depressed. But it is not clear how or why exercise alleviates depression. Some explanations focus on the changes in body and brain chemistry, such as the rising levels of endorphins in the blood during exercise. Other explanations emphasize the sense of mastery over one’s body gained through exercise, which may also contribute to a greater sense of personal control over other aspects of one’s life.

4. Suicide on TV. Many studies suggest that suicide rates increase following depiction of suicide in the media. These findings have raised public concern about imitation effects. We might hypothesize that youths would be particularly prone to such effect, and indeed, some research has demonstrated an increase in imitative youth suicides following both news stories of suicide and television movies about suicide. However, more recent evidence raises doubt about the suggested negative effects of depicting suicide on TV. Berman (American Journal of Psychiatry, 1988, 145, 982‐986) reviewed research on youth suicide following made‐for‐television movies depicting suicide, and conducted a study to improve methodological problems identified in previous research. The re‐analysis found a significant decrease in the number of suicides following the broadcast of three films depicting suicide in 1985 and 1986. The decrease was nonsignificant for those age 24 or younger. However, the findings suggested that films which depict a specific method of committing suicide may result in selection of that method over other methods in subsequent suicides.

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The authors conclude that a complex interplay of the person, the stimulus, and the environment affect the impact of media suicide, and further suggest that beneficial effects of the depiction of suicide cannot be ruled out.

5. Getting rid of “the blues.” Ask students what they do to get rid of “the blues.” Everyone has an occasional “down” day. Ask students to share their strategies for shaking off such moods.

How successful are these strategies? How many of the activities they describe are listed in the Pleasant Events Schedule in the text? How can they tell “the blues” from a more serious depression?

6. Depression and politics. Invite students to discuss their feelings about having a Presidential or Vice‐Presidential candidate who has been treated for depression. When there was a public disclosure that Senator Thomas Eagleton, a democratic candidate for Vice‐President in the 1972 election, had been given electroconvulsive treatment for depression, his name was reluctantly withdrawn due to the uproar that followed the disclosure. Was Eagleton treated fairly? Should we make treatment available and then effectively punish public figures who choose to get treated? Does suffering from a mood disorder or other mental illness once mean that one is never qualified for public office thereafter?

7. Postpartum depression. Postpartum mood changes following childbirth can reach the level of depression and even psychosis in some women. In these situations, the affected woman can present a danger to herself as well as her newborn child. Invite students to analyze postpartum depression according to the major perspectives presented in the text: psychodynamic, learning, cognitive, interactional, humanistic, existential, and biological.

For example: Is the new mother reexperiencing unresolved childhood conflicts? Has she learned that some reinforcers are contingent upon the role of depressed person? Are certain distorted cognitions playing a part in her disorder? Or, is it primarily a result of hormonal changes that occur after childbirth? How might postpartum depression be viewed from the interactional perspective?

8. Depression and children. The Journal of the American Academy of Child and Adolescent Psychiatry, 1992, 31) devotes several articles to various aspects of the occurrence of mood disorders in children and adolescents. Of special interest is an article by Weissman, Fendrich, Warner, and Wickramaratne titled “Incidence of Psychiatric Disorder in Offspring at High and Low Risk for Depression.”

Of the 174 children in the study, 121 were offspring of one or more depressed parents. In a 2‐year longitudinal study, first onsets of suicide attempts and psychiatric disorders in these children were determined. Of the children of depressed parents, 7.8 percent reported making at least one suicide attempt in their lives, while 1.4 percent of nondepressed parents’ children made an attempt. All of the cases of major depression (10) and anxiety ..

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disorder (8) occurred in children of depressed parents. Incidence of substance abuse did not differ for the 2 groups. Conduct disorder rates were higher among the children of depressed parents, but not significantly so. The cumulative probability by age 20 for the children of depressed parents that they will report having a major depression is over 50 percent. What implications can students draw from these results about the occurrence of mood disorders in children? Would periodic assessment of children at some risk for depression due to their parents’ depression be ethical? The federal law mandating early childhood intervention for children at risk, PL 99‐457, makes provision for family‐centered and family‐sensitive assessment for children at risk for many disorders. Do students feel that a case could be made for early intervention and assessment for something like depression? What could go wrong with an effort at massive intervention like this?

9. Gender and depression. There have been many different explanations for the higher incidents of depression in women versus men. Susan Nolen Hoeksema (1987) offers an excellent review of these theories, then offers her own. She believes that we all get depressed at times, but that the genders react to these depressions in different ways. Men try to distract themselves, such as by playing a sport, taking drugs, or doing physical work.

Women, on the other hand, are less active in their response. They ruminate more about the causes of their depression. Nolen‐Hoeksema believes it is this rumination that leads to helpless feelings, remembering of sad things, and self‐blame. This tendency to think and ruminate is possibly socialized early in life. This theory suggests that women might respond to depression by engaging in pleasant activities and other (non‐ drug taking) distractions as a way to fight the mild depressions we all experience.

Discuss this theory with your students and see if it fits their experience and reactions to the everyday down times.

Nolen‐Hoeksema, S. (1987) “Sex Differences in Unipolar Depression: Evidence and Theory.”

Psychological Bulletin, 101, 259‐282.

10. Is depression contagious? What is it like to be around depressed people? Many experts believe it exacts a toll on families of those seriously depressed. James Coyne’s interactional theory is concerned with this effect. In an early study, he had college student’s talk on the phone to a seriously depressed person who was under treatment for that problem. After only a few minutes the students experienced various negative feelings, including depression, anxiety, and hostility. In a later study, students spoke to a person who was only mildly depressed. Nevertheless, the conversation provoked the same negative feelings reported in the first study. Along with the lower mood, subjects in these studies also tended to devalue or reject the depressed people they talked to.

All of this suggests that depression and social rejection are a two‐way street. Sometimes being rejected is depressing; other times being depressed induces rejection by depressing others. As Coyne suggests, depression is not just a problem within the person who has it. It elicits social reaction, which in turn can aggravate the depression. ..

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Solicit your student’s reactions to Coyne’s idea. Does it fit with their experiences? Coyne, 3.

C., Kessler, R. C., Tal, M., Turnball, J. Wortman, C. B., & Greden, J.F. (1987). “Living With a Depressed Person”. Journal of Consulting and Clinical Psychology, 55, 347‐352.

11. Are anxiety and depression the same thing? Now that you have covered both anxiety and mood disorders, it is useful to remind the class how similar these are. For instance, tests of anxiety and depression typically correlate from moderately to strongly with each other. How are depression and anxiety alike or different? Leanna Clark and David Watson are among those who cite the broad personality dimensions of positive affectivity (PA) and negative affectivity (NA) as explanatory factors. PA is the tendency to experience positive moods, such as feeling cheerful or proud. NA is the tendency to experience anxiety, anger, and other negative moods. Each of us differs in the relative levels of these two tendencies, and PA and NA are uncorrelated across people. Clark and Watson believe that high NA characterizes both anxiety and depression. This no doubt accounts for the high intercorrelation of tests of those two constructs. The difference comes in that depression is related to low levels of PA, while anxiety is not. Anxiety is marked more by physiological arousal rather than low PA. This is seen in the clinical world, where many patients seem to have an equal mix of anxiety and depression, while others have a high degree of one and at least some of the other. So, anxiety and depression are alike, but they are also different.

Clark, L. A. & Watson, D. (1991). “Tripartite Model of Anxiety and Depression: Psychometric Evidence and Taxonomic Implications”. Journal of Abnormal Psychology, 100, 3 16‐336.

12. Warning signs of suicide. Discuss the warning signs of suicide. Ask the class if anyone has lost a friend or loved one through suicide. Did that person exhibit any of the warning signs of suicide? You might point out here that often, because we don’t normally go around intensively looking for these warning signs in our friends and loved ones, we don’t realize we are seeing the warning signs until after the suicide or suicide attempt. Survivor guilt is a common after‐effect of suicide and it means that in discussing this with students, one needs to be sensitive about how this material is presented. Some of the classic signs of suicide are expression of suicidal thoughts, prior suicide attempts, giving away prized possessions, intense depression over broken relationships, despair over a chronic illness or problem, change in eating or sleeping habits, marked personality change, abuse, or increased abuse, of alcohol or drugs, a sense of helplessness and hopelessness, veiled warnings or hints that the person might not see you again or may not be around much longer, and increased withdrawal and isolation.

In discussing this, you should also discuss with students what to do if they see the warning signs in a friend or loved one and suspect that the person is thinking about attempting suicide. The “Closer Look: Suicide Prevention” box in this chapter provides a good basic outline of the things to do when faced with such a situation.

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13. Suicide and its effects. The effects of suicide on those in a relationship with the person who dies are complex, involving both pain and anger. Brent and colleagues interviewed 58 adolescent friends and acquaintances of 10 adolescent suicide victims six months after their deaths. They compared the rate of psychiatric disorders in these 58 people with that of 58 matched control subjects. The study found that exposure to suicide was “clearly associated with significant psychiatric sequelae, namely major depression and symptoms of PTSD (p. 636).” The evidence showed no imitation of suicidal behaviour. In fact, suicides seemed to act to make the friends less inclined to try it. The most common effect was major depression, which was found to be correlated with severity of grief. The depression and grief were both correlated with closeness of relationship to the victim.

Discuss with the class any experiences that they feel comfortable talking about. Be sure not to ask questions that are intrusive; let people share whatever they wish to, and recognize that sometimes after discussing deeply held emotions like these (sometimes for the first time in public) students may feel embarrassed and reexperience some pain and grief Providing support for these students may be necessary if you use this exercise.

Brent, D. A., Perper, J., Moritz, G., Aliman, C., Friend, A., Schweers, J., Roth, C., Balach, L., & Harrington, K. (1992). “Psychiatric Effects of Exposure to Suicide Among the Friends and Acquaintances of Adolescent Suicide Victims.” Journal of the American Academy of Child and Adolescent Psychiatry, 31, 629‐640.

14. Clinical, ethical, and philosophical issues in handling suicide. The topic of suicide is likely to raise personal issues in any classroom; the odds are that at least one person in an average class has had a personal experience with a friend or relative attempting or committing suicide, or perhaps personally grappling with suicidal ideas. In regards to discussion topic #2 (above), you might point out that psychiatrist Thomas Szasz views suicide as a fundamental right, in a manner not too different philosophically from the position claimed recently by Dr. Jack Kervorkian. Szasz believes that responsibility for a decision to commit suicide rests squarely in the hands of the patient, not the therapist or caregiver. He opposes the use of coercive means in preventing suicide in adults. While Szasz has not gone so far as Dr. Kervorkian to the point of actually assisting in a patient’s suicide attempt, he stakes out philosophical ground that is only one step away from such action.

Ask students what they think of Szasz’s and Kervorkian’s ideas and actions. What are the pros and cons of our current laws and ethical rules regarding suicide? What are the pros and cons of Szasz’s approach or Kervorkian’s approach? Should Kervorkian have been convicted for his actions? What responsibilities do mental health professionals have in preventing suicide? Can they ethically support a “pro‐suicide” position?

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Student Activities: 1. The Pleasant Events Schedule. Have students do a personal experiment regarding the relationship between their moods and activities, by making up a “Pleasant Events Schedule.” Students are instructed to rate their daily moods by using a scale from I to 10, with 1 being “severely depressed” and 10 being “the best possible mood—feeling wonderful.” It’s suggested that they rate their moods for several weeks, at the same time each day before retiring for bed. Have students select several pleasurable events and engage in them sometime each week. Then they are to average their daily mood ratings for each week and see whether or not their average daily mood is related to the kinds of pleasant activities they engaged in that week.

Cognitive distortions. Ask students to select a half‐dozen negative thoughts they tend to engage in from time to time. If they find it difficult to recall any, have them choose some representative thoughts listed in table 4.5 in this chapter of the text. Once they have chosen some characteristic negative thoughts, have them identify the kind of cognitive distortion each thought represents along with a rational response as below.

Automatic Thought Cognitive Distortion Rational Response “I rarely succeed at anything” Overgeneralization “Sometimes I succeed, sometimes I don’t” You might have students write a brief one‐page reaction paper, telling what they have learned from doing this exercise.

2. How common is depression? Have the student’s survey friends and family about depression. How often do they have down periods? How long do they last? What kinds of things trigger them? How do they come out of those down times? Community studies show that virtually everyone has at least mild depressions from time to time. This activity can shed light on just how common this is, and help the students see how their own behaviour relates to the experience of others.

3. The “Are You Depressed?” Scale. Have students fill out the “Are you Depressed?” scale in the text. Since students with high scores may feel embarrassed about revealing their scores, you might have them write their scores anonymously on a slip of paper and collect the slips from them. Scan through the slips and see what the scores are. There may be no surprises here, but often the scores will average much higher than you, or the students, might expect.

This can lead to a discussion of what types of things are causing depression among students and what are the various ways they can cope or get help.

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Online Discussion Questions: 1.

Given the latest advancements in the biological treatment of mood disorders, anti‐ depressants are the best option for treatment. Discuss.

2.

Even with the most ground‐breaking research in biochemistry, cognitive‐behavioural therapy is the best approach for most suffering with depression. Discuss.

3.

Although certainly not all people who threaten suicide go on to commit the act, many do.

People who commit suicide almost always signal their intentions, by telling others about their suicidal thoughts, for example. Assess these statements.

Online Resources: Mood Disorders Society of Canada https://mdsc.ca/ The Mood Disorders Society of Canada is a national, not‐for‐profit organization that is committed to improving the quality of life for people affected by depression, bipolar disorder, and other related disorders. The site provides information and treatment resources for mood disorders, including major depression and bipolar disorder.

Internet Mental Health www.mentalhealth.com A good source of information and numerous links on major depression and bipolar disorder.

Video Resources: Beck’s Cognitive Therapy, Part of the “Three Approaches to Psychotherapy” series, 42 min. colour (Psychological Films, Inc.). Aaron Beck explains and demonstrates his cognitive therapy with a depressed client.

Biochemistry of Depression, 29 min, colour (CM). Presents a wide range of technical material relating to the biochemical underpinnings of depression.

Depression, 19 min. colour (Films for the Humanities and Sciences). Explains the difference between occasional and realistically motivated mood changes and depression.

Depression, 59 min. colour (Kent State Univ.). Follows the lives of people suffering from depression or bipolar disorder, and includes a discussion of the causes of depression and suicide risks.

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Depression: A Study in Abnormal Behaviour, 26 min. colour (CRM/McGraw‐Hill Films). Follows a young teacher and homemaker through her depression and includes various approaches to treatment, including hospitalization.

Depression: Biology of the Blues, 26 min. colour (Films for the Humanities and Sciences).

Focuses on the biological causes of depression.

Depression: Recognizing it and Treating It, 42 min. colour (Human Relations Media). An overview of the treatment of depression, including psychodynamic, cognitive, and biochemical approaches.

Depression: The Shadowed Valley, 57 min. colour (IU). An overview of the various forms of depression, including suicide as the extreme form, and various treatment approaches.

Depression and Suicide: You Can Turn Bad Feelings into Good Ones, 26 min, colour (PCR).

Explores some of the causes of depression in teenagers and ways to prevent feelings related to depression from becoming overwhelming.

Do I Really Want to Die? 31 min. colour (Polymorph Films). Shows a series of interviews with people who have attempted suicide.

Dying to be Heard: Is Anybody Listening? 25 min. colour (Films for the Humanities and Sciences).

Offers specific advice on how to recognize suicide warning signs in teens and how to intervene successfully.

Gifted Adolescents and Suicide, 26 min. colour (Films for the Humanities and Sciences). Specially adapted Phil Donahue program focusing on two couples who each lost a gifiedl7‐year‐old child to suicide.

Grief Therapy, 19 min. colour (Carousel Films). A therapeutic interview with a woman who lost her mother and daughter in a fire.

Mysteries of the Mind, 58 min. colour (Films for the Humanities and Sciences). Explores bipolar disorder, obsessive‐compulsive disorder, alcoholism, and related mood disorders.

On Death and Dying, 40 min. colour (Fl). Elizabeth Kubler‐Ross discusses the stages of death and dying and how the process can be made more humane.

One Man’s Madness, 31 min. colour (BBC). Documentary of a writer who developed bipolar disorder. Shows extreme symptoms and treatment in the hospital.

Psychopathology: Diagnostic Vignettes: No. 1, Persistent Depressive Disorder and Major Affective Disorder, 38 min. colour (IU). Shows a group of depressed patients with characteristic symptoms of these disorders. ..

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The Suicide Clinic, 28 min. black and white (IU). Somewhat dated (1969), shows work in a suicide clinic and discusses psychological characteristics of suicides.

Serious Depression, 28 min. colour (Films for the Humanities and Sciences). Explains that women are at higher risk for depression than men and interviews experts on the causes and treatment of depression.

Suicide Survivors, 26 min. colour (Films for the Humanities and Sciences). Explores the special needs of suicide survivors.

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Chapter 5 Dissociative and Somatic Symptom and Related Disorders Chapter Overview: The dissociative and somatic symptom and related disorders were historically linked with anxiety disorders as forms of neuroses. Anxiety is expressed directly in different forms in the anxiety disorders, but its role in the dissociative and somatic symptom and related disorders is inferred.

Dissociative Disorders Dissociative disorders involve changes or disturbances in identity, memory, or consciousness that affect the ability to maintain an integrated sense of self Dissociative disorders include dissociative identity disorder, dissociative amnesia with or without dissociative fugue, and depersonalization/derealization disorder.

Dissociative Identity Disorder In dissociative identity disorder sometimes referred to as split personality, two or more distinct personalities, each possessing well‐defined traits and memories, exist within the person and repeatedly take control of the person’s behaviour. Each of the personalities usually shows an integrated functioning on cognitive, emotional, and behavioural levels.

Dissociative Amnesia Dissociative amnesia involves loss of memory for personal information. The person experiences memory losses in the absence of any identifiable organic cause; general knowledge and skills are usually retained. There are five types of dissociative amnesia: localized, selective, generalized, continuous, and systematized. In dissociative fugue, the person travels suddenly away from home or place of work, shows a loss of memory for his other personal past, and experiences identity confusion or takes on a new identity.

Depersonalization/Derealization Disorder Depersonalization/derealization disorders involve persistent or recurrent episodes of depersonalization, derealization, or both, that are of sufficient severity to cause significant distress or impairment in functioning. Depersonalization involves feelings of unreality or detachment from one’s self or one’s body, as if one were a robot or functioning on automatic pilot or observing oneself from outside. In derealization there is a loss of the sense of reality of one’s surroundings, experienced in terms of strange changes in one’s environment (e.g., people or objects changing size or shape) or in the sense of the passage of time. ..

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Theoretical Perspectives Psychodynamic theorists view dissociative experiences as a form of psychological defense by which the ego defends itself against troubling memories and unacceptable impulses by blotting them out of consciousness. There is increasing documentation of a link between dissociative disorders and early childhood trauma, which lends support to the view that dissociation may serve to protect the self from troubling memories.

To learning and cognitive theorists, dissociative experiences involve ways of learning not to think about certain troubling behaviours or thoughts that might lead to feelings of guilt or shame. Relief from anxiety negatively reinforces this pattern of dissociation. Social‐ learning theorists and cognitive theorists suggest that multiple personality may represent a form of role‐playing behaviour. Some dissociative states, like dissociative amnesia and fugue, may be transient and terminate abruptly.

Treatment of Dissociative Disorders Psychodynamic approaches help the individual uncover and cope with dissociated painful experiences from childhood. Research suggests that cognitive‐behavioural therapy and some types of medication may be helpful in treating depersonalization disorder. Biological approaches focus on the use of drugs to treat the anxiety and depression often associated with the disorder, but drugs have not been able to bring about reintegration of the personality.

Somatic Symptom and Related Disorders In somatic symptom disorders, there are physical complaints that cannot be accounted for by organic causes. Thus, the symptoms are theorized to reflect psychological rather than organic factors.

Conversion Disorder (Functional Neurological Symptom Disorder) In conversion disorder (functional neurological symptom disorder), symptoms or deficits in voluntary motor or sensory functions occur which suggest an underlying physical disorder but no apparent medical basis for the condition can be found. The symptoms are not intentionally produced; the person is not malingering; physical symptoms usually come on suddenly in stressful situations.

Illness Anxiety Disorder Illness anxiety disorder is a preoccupation with the fear of having, or the belief that one has, serious medical illness, but no medical basis for the complaints can be found and fears of illness persist despite medical reassurances. One subtype, the care‐avoidant subtype, applies to people who postpone or avoid medical visits or lab tests because of high levels of anxiety about what might be discovered. The second subtype, called the care‐seeking ..

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subtype, describes people who go doctor shopping, in the hope of finding the one medical professional who might confirm their worst fears.

Somatic Symptom Disorder People with somatic symptom disorder have troubling physical symptoms, and they are excessively concerned about their symptoms to the extent that it affects their thoughts, feelings, and behaviours in daily life. The symptoms may include such complaints as gastric (stomach) distress and various aches and pains. Somatic symptom disorder usually begins in adolescence or young adulthood and appears to be a lifelong disorder involving major disability Factitious Disorder Factitious disorder is a type of psychological disorder characterized by the intentional fabrication of psychological or physical symptoms for no apparent gain. The two major subtypes of factitious disorder are (1) factitious disorder on self (characterized by faking or inducing symptoms in oneself) and (2) factitious disorder imposed on another (characterized by inducing symptoms in others).

Theoretical Perspectives The psychodynamic view holds that conversion disorders represent the conversion into physical symptoms of the leftover emotion or energy that is cut off from unacceptable or threatening impulses that the ego has prevented from reaching awareness. The symptom is functional, allowing the person to achieve both primary and secondary gains.

Learning theorists focus on the reinforcements that are associated with conversion disorders, such as the reinforcing effects of adopting a “sick role.’ A learning theory view likens illness anxiety disorder to obsessive‐compulsive behaviour. Cognitive factors in illness anxiety disorder include self‐handicapping strategies and cognitive distortions.

Treatment of Somatic Symptom and Related Disorders Psychoanalysis seeks to uncover and bring to the level of awareness the unconscious conflicts, originating in childhood, that are believed to be at the root of the problem. Once the conflict is uncovered and worked through, the hysterical symptom should disappear because it is no longer needed as a partial solution to the underlying conflict. Behavioural approaches focus on removing sources of reinforcement that may be maintaining the abnormal behaviour pattern. Behaviour therapists may also work more directly to help people with somatic symptom and related disorders learn to handle stressful or anxiety‐ arousing situations more effectively.

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Chapter Outline: Dissociative and Somatic Symptom and Related Disorders186 Dissociative Disorders 188 Dissociative Identity Disorder 188 Dissociative Amnesia 193 Depersonalization /Derealization Disorder 194 Theoretical Perspectives 196 Treatment of Dissociative Disorders 198 REVIEW IT Dissociative Disorders 200 Somatic Symptom and Related Disorders 201 Conversion Disorder (Functional Neurological Symptom Disorder) 201 Illness Anxiety Disorder 202 Somatic Symptom Disorder 203 Factitious Disorder 204 Theoretical Perspectives 205 Treatment of Somatic Symptom and Related Disorders 207 REVIEW IT Somatic Symptom and Related Disorders 209 CONCEPT MAP 211

Students Should Be Able to: 1. Describe dissociative disorders.

2. Describe the major features of the dissociative identity disorder, and the clinical symptoms associated with dissociative amnesia and depersonalization/derealization disorder.

3. Discuss how psychodynamic theorists, learning theorists, and cognitive theorists explain dissociative disorders.

4. Describe various methods for treating dissociative identity disorder.

5. Understand the characteristics of somatic symptom and related disorders.

6. Describe the features of conversion disorder, illness anxiety disorder, somatic symptom disorder, and factitious disorder.

7. Discuss various theoretical perspectives on somatic symptom and related disorders.

8. Discuss the treatment of conversion disorder as approached by the various theoretical perspectives.

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Lecture and Discussion Suggestions: 1. Differentiating dissociative identity disorder and schizophrenia. People easily confuse these two disorders, yet they are very different disorders. The term schizophrenia comes from two Greek words meaning “to split” “the mind.” However, Bleuler, who proposed the term schizophrenia was not referring to a splitting of the person into different personalities, as occurs in dissociative identity disorder. Instead, the split in schizophrenia occurs at the core of the person, loosening the connections between the various psychic functions. Thus, in the mind of the person with schizophrenia, ideas, perceptions, emotions, and behaviour don’t operate as an integral whole; rather he or she may think and act inappropriately in a given situation.

Consequently, schizophrenia is a psychotic disorder that usually requires periods of hospitalization and medication as well as a prolonged time for recovery. People who have recovered from an acute episode of schizophrenia often remain loners or underemployed in the workplace. In contrast, many people with dissociative identity disorder may go unrecognized or be alternatively diagnosed for years after the initial evaluation. Some of them lead accomplished lives. Well‐functioning people with multiple personalities may elude diagnosis because clinicians are not likely to probe for evidence among those who function so well. Also, such people may have developed elaborate strategies for concealing their alternate personalities, aided by the stabilizing influences of their careers.

An analogy instructors use in their classes to help students visualize the differences between the two disorders is that dissociative identity disorder is somewhat like taking a large mirror and neatly cutting it into several small mirrors. They are smaller but they are still clearly mirrors. Schizophrenia, however, is like taking that same large minor and shattering it with repeated hammer blows. What you have left is a collection of glass fragments, none of them comprising a recognizable mirror. While this analogy is not perfect, students typically find it helpful.

2. Child sexual abuse and the Dissociative and Somatic Symptom and Related Disorders. Freud first identified childhood experiences of sexual abuse as a significant factor in the psychoneuroses, though he eventually dismissed them as fantasies.

Today, however, there is increasing documentation of childhood sexual abuse in the lives of those who develop dissociative identity and somatic symptom disorder. For instance, it has been estimated that as many as 1 out of 4 or 5 girls and I out of 9 or 10 boys are sexually abused before they reach 18. Certainly, only a few of these children who suffer such childhood traumas develop multiple personalities. Yet, recent recognition that this disorder is not as rare as once thought suggests that we not overlook the link between child sexual abuse and dissociative identity disorder.

Similarly, one study of women with somatic symptom disorder, compared to those who suffered from a mood disorder, showed significant differences. Although women in both groups reported similar childhood sexual experiences, such as masturbating and kissing games, women with somatic symptom disorder were more likely to report experiences of childhood sexual abuse. More than 1 out of 2 women with somatic ..

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symptom disorder had been sexually abused, compared to only 1 out of 6 of those with a mood disorder (Morrison, American Journal of Psychiatry, 1989, 146, pp. 239‐ 241).

3. Illness Anxiety Disorder. Estimates of anywhere from 1/4 to 3/4 of the patients who consult physicians resemble those with illness anxiety Disorder or some other somatic symptom disorder. A disproportionate number of these people are from the lower socioeconomic groups, who complain more about physical symptoms than psychological discomforts. Also, people coping with bereavement over the loss of loved ones are especially prone to symptoms that mimic signs of physical illnesses.

Even though older people are susceptible to genuine age‐related changes in their health, their complaints often reflect the changing health status of older people.

Because people with illness anxiety disorder are often offended at the suggestion that their beliefs or fears may be unwarranted, they frequently become “doctor shoppers” and complain that they are not getting proper care, thereby alienating themselves from doctors. Furthermore, they frequently refuse referral for psychotherapy, and are not often seen in mental health facilities. In some instances, past experience with a true organic disease, either in one’s self or family member, predisposes one to this illness. At the same time, because many complaints may be manifestations of early stages of neurological or endocrine disorders, the most important differential diagnosis is the lack of a true organic disease. However, according to the DSM‐5, even the presence of a genuine physical illness doesn’t preclude the coexistence of illness anxiety disorder.

4. Differential development of dissociative disorders. Ask students why some people who are sexually abused as children develop dissociative identity disorder while most don’t. Individuals who develop dissociative disorders are much more susceptible to self‐hypnosis and hypnotic suggestion than the average person. But why is this disorder more common among females than males?

5. Multiple personalities. Pose the question “Don’t all of us have multiple personalities to some extent?” Some people question whether multiple personality disorders represent more than an extreme form of the multiple selves found in all of us. That is, our self‐concept includes hundreds of self‐perceptions of varying degrees of clarity and intensity, which represents various self‐images, needs, interests, and social roles integrated within our personality in varying degrees. Expression of these various selves may account for much of the inconsistency in our behaviour on occasions.

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6. Malingering. Ask students how they can tell when someone is faking a dissociative disorder or an illness. According to the DSM‐5, the essential feature of malingering (pretending) is intentional production of false or grossly exaggerated physical or psychological symptoms, motivated largely by external incentives such as avoidance of work or military duty, or obtaining financial compensation or drugs. Also, the presenting symptoms are less likely to be symbolically related to underlying emotional conflicts, as they are in dissociative and somatic symptom and related disorders, nor relieved by hypnosis or suggestion.

7. Out of Body Experiences. Two of the most well publicized types of dissociation are the so‐called “out of body” experiences and “near death experiences.” You might ask students to relate any knowledge they have of these experiences and then explore how various theoretical viewpoints might scientifically explain them. You might also point out that while most scientists remain skeptical about people actually leaving their bodies, many readily admit that the people claiming to have had the experiences appear to be truthful in their belief that the experience was real. What scientific evidence is there to support or refute claims that one’s soul has left one’s body? What alternative explanations are there and what scientific evidence is there to support them? This topic makes for an interesting discussion as it is an area that many students are keenly curious about.

8. Depersonalization / derealization experiences. The text describes some of the forms depersonalization/ derealization can take. Some of these forms occur from time to time in otherwise normal individuals. Because your students might read this section and wonder “Do I have depersonalization/ derealization disorder?” it is useful to point out how common such episodes are. Ross, Joshi, and Currie (1990) found that these were especially reported by people age 25‐44. For instance, 28% of those 25‐34 and about 27% of those 35‐44 indicated they had experienced depersonalization, derealization, or both. Rates were from 8‐10% for most other age groups. It is also important to remind students that DSM‐5 considers depersonalization/ derealization disorder only when it is persistent and results in significant impairment of functioning.

Ross, C. A., Joshi, S., & Currie, R. (1990). Dissociative Experiences in the General Population. American Journal of Psychiatry, 147, 1547‐1552.

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9. Repressed memories? The topics of dissociative identity disorder and amnesia discussed in this chapter lead well into one of the major controversies of the day— repressed memory therapy. The roots of this issue go back at least to Sigmund Freud, who originally felt that many of the problems reported to him by female patients were due to childhood experiences of incest. These women were telling Freud, often while under hypnosis, that they had begun to remember these acts. Freud believed this for a while, but gradually became convinced most of these incestual experiences were fantasized. This was a widely held opinion until about 1980, when it became clear that incestuous child abuse was much more common than thought. Then, as writer Martin Gardner tells it, “in the latter 1980’s a bizarre therapeutic fad began to emerge in the United States. Hundreds of poorly trained therapists, calling themselves “traumatists” began to practice the very techniques Freud discarded.”

What began was a wave of incidents in which patients, generally women 25‐45 years old, began to recall childhood sexual traumas that had allegedly lain buried in the unconscious, often for decades. In 1990 the first conviction based on repressed memories was banded down to a man for murdering a young girl in 1969. Observers of the trial felt that the conviction was obtained almost entirely on the basis of his daughter’s memories that had lain buried until a sudden awakening of them. Gardner summarizes the thoughts of psychologists and others who are quite concerned about what they feel is false memory syndrome. These critics allege that well‐meaning and sincere therapists begin treating patients with the assumption that a sexual or other trauma had occurred early in the patients’ early life, and then these therapists use leading questions to slowly implant memories of events that never really happened.

There are, of course, therapists who argue that such repressed memories are real.

Many psychologists, however, doubt that the kind of repression that is claimed in these cases is possible. This is an interesting topic to discuss with students. Ask students to collect examples and also to search for empirical evidence to support repressed memories.

Gardner, M. (1993). The False Memory Syndrome. Skeptical inquirer, Summer.

10. Women and Somatic Symptom Disorders. Women in general use health services more than men, even after use related to pregnancy and childbirth is accounted for. Most somatic symptom disordered patients are women. Discuss with the class what they think explains these facts. It may be that traditional sex roles have made it more acceptable for women to admit problems and seek treatment, while for men, being sick violates the strong, sometimes “macho” image assigned to their gender. If so, why are there at least as many males as females with illness anxiety disorder? This topic can provoke a lively class discussion.

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11. Reporting bodily symptoms. Ask students whether they feel that they tend to over‐ report bodily aches and pains as symptoms of illness, often seeking out medical assistance, or tend to underreport them, shrugging them off and going about business as usual. Then have them relate their tendencies to the following finding. According to Paul Costal and Robert McGraw (American Psychologist, 40, 1985, 19‐28), each of us differs in the tendency to label our bodily aches and pains as a symptom of illness.

People who habitually complain of unfounded ailments exhibit a cluster of personality traits labeled neuroticism. Those high in neuroticism tend to be anxious, overly self‐ conscious, hostile, depressed, impulsive, and usually have low self‐esteem. In contrast, people who underreport their bodily aches and pains exhibit another cluster of traits labeled extroversion and tend to be warm and outgoing and sufficiently involved in life that they don’t have time to complain of their ailments.

After you have presented these descriptions, ask students which tendency is dominant in their particular personality and the degree to which it is manifested in underreporting or overreporting bodily aches and pains.

12. Alien Abductions? Shows such as The X‐Files and best‐selling books such as Whitley Strieber’s Communion have popularized the alien abduction phenomenon to the point where it would be difficult today to get an “uncontaminated” sample of subjects to experimentally study the phenomenon. Do students know of anyone who has claimed to have experienced this? What do they think is causing these experiences and why the recent upsurge in reported cases? Real aliens? Placebo effect? Mass hysteria?

Sleep‐induced hallucinations? Or perhaps some type of stress‐induced dissociative experience? This should make for an interesting discussion.

Student Activities: 1.

Hypnosis. Have someone skilled in hypnosis conduct a class demonstration to determine how susceptible to hypnosis your students are. You might point out that individuals with multiple personality disorder are quite susceptible to self‐ hypnosis and are especially likely to dissociate in coping with a trauma. However, hypnotic suggestibility has many constructive uses, such as enhancing relaxation, creativity, weight loss programs, and smoking cessation.

2.

Right‐left hemisphere differences. Researchers have found that conversion symptoms are more likely to occur on the left side of the body than the right (leading to the hypothesis that they relate to the functioning of the right hemisphere and emotional arousal), may be used in a discussion of right and left hemisphere differences. A simple demonstration of the differential functioning of the hemispheres can be done by having students briefly interview one or two people outside of class. The question asked should be a problem which most college students could accomplish with concentration. For instance: “How many letters are there in the word Washington?” or “Multiply 12 by 13.” The interviewer’s task is to record the direction of the subject’s ..

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eye movements when he or she pauses to think about the question. It has been reported that when people concentrate on a reasoning problem, their eyes tend to shift up and to the right.

3.

Multiple personality in film. Two of the most famous film examples of multiple personality (now called dissociative identity disorder in the DSM‐5 are Three Faces of Eve and Sybil. These are generally too long to show in class, but it is possible to have students rent the videos of these films and have a get‐ together where they can view one or the other. They can report to class on the behaviour of Eve and Sybil, and how it corresponds to the text discussion.

Online Discussion Questions: 1. Dissociative identity disorder is a genuine mental disorder and not “role playing” as some suggest. Discuss.

2. Dissociative identity disorder is simply “role playing” and not a genuine mental disorder, as some suggest. Discuss.

3. The historical changes in the classification of dissociative and somatic symptom and related disorders are an indication that these disorders are determined mostly by the culture in which they occur.

Online Resources: Sidran Institute www.sidran.org The Sidran Institute’s website contains information on dissociative disorders, including links to books and educational materials.

Recovered Memories http://psych.athabascau.ca/html/aupr/psyclaw.shtml#Recovered_Memories Contains useful links on recovered memories.

False Memory Syndrome Foundation www.fmsfonline.org Further useful information on repressed and recovered memories and dissociative disorders.

Psychology Works for Intense Illness Concern (Illness Anxiety Disorder) www.cpa.ca/cpasite/userfiles/Documents/factsheets/hypo.pdf Fact sheet and links on Illness Anxiety Disorder from the Canadian Psychological Association. ..

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Video Resources: Case Study of a Multiple Personality, 30 min. (Penn State). Cleckley’s “classic” case study of the three personalities of “Eve,” including an interview with the patient herself.

Child Abuse, 19 min. colour (Films for the Humanities and Sciences). Describes the common characteristics of offenders and the effects of abuse on children.

Childhood Sexual Abuse, 26 min. colour (Films for the Humanities and Sciences). Shows how adult women learn to work out the problems caused by sexually abusive fathers.

Experts explain how the pattern of abuse spreads and is kept secret.

Illness Anxiety Disorder and Health Care: A Tug of War, 38 min. colour (Workshop Films).

Lecture and simulated interviews with people with Illness Anxiety Disorder and ways of dealing with it.

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Chapter 6 Personality Disorders Chapter Overview: Types of Personality Disorders Maladaptive or rigid behaviour patterns or personality traits that are associated with states of personal distress or impair the person’s ability to function in social or occupational roles are called personality disorders. People with personality disorders do not generally recognize a need to change themselves. Personality disorders may be organized into three clusters, as follows: Personality Disorders Characterized by Odd or Eccentric Behaviour People with paranoid personality disorder are unduly suspicious and mistrustful of others, to the point that their relationships suffer. But they do not hold the more flagrant delusions typical of schizophrenia. Schizoid personality disorder describes people who have little if any interest in social relationships, show a restricted range of emotional expression, and appear distant and aloof. Schizotypal personalities appear odd or eccentric in their thoughts, mannerisms, and behaviour, but not to the degree found in schizophrenia.

Personality Disorders Characterized by Dramatic, Emotional, or Erratic Behaviour Antisocial personality disorder (APD) describes people who persistently engage in behaviour that violates social norms and the rights of others and who tend to show no remorse for their misdeeds. Borderline personality disorder (BPD) is defined in terms of instability in self‐image, relationships, and mood. People with borderline personality disorder often engage in impulsive acts that are frequently self‐ destructive. People with histrionic personality disorder tend to be highly dramatic and emotional in their behaviour, whereas people with narcissistic personality disorder have inflated or grandiose senses of themselves and like those with histrionic personalities, demand to be the center of attention.

Personality Disorders Characterized by Anxious or Fearful Behaviour Avoidant personality disorder describes people who are so terrified of rejection and criticism that they are generally unwilling to enter relationships without unusually strong reassurances of acceptance. People with dependent personality disorder are overly dependent on others and have extreme difficulty acting independently or making even the smallest decisions on their own. People with obsessive‐compulsive personality disorder have various traits such as orderliness, perfectionism, rigidity, and excessive attention to detail, but are without the true obsessions and compulsions associated with obsessive‐compulsive (anxiety) disorder. ..

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Problems with the Classification of Personality Disorders Various controversies and problems attend the classification of personality disorders, including lack of demonstrated reliability and validity, too much overlap among the categories, difficulty in distinguishing between variations in normal behaviour and abnormal behaviour, underlying sexist biases in certain categories, and confusion of labels with explanations.

To address the problem of overlap of diagnoses, the DSM‐5 proposed a research model for personality disorder diagnosis and conceptualization. This model emphasizes functional impairments in personality and traits with underlying pathology. Six personality disorders are derived from the model and include: antisocial, avoidant, borderline, narcissistic, obsessive‐ compulsive, and schizotypal personality disorders (APA, 2013). Since the model includes both traits and disorders, it would allow a clinician to take into account the antisocial traits of a person without diagnosing APD. Theoretical Perspectives Psychodynamic Perspectives Traditional Freudian theory focused on unresolved oedipal conflicts in explaining normal and abnormal personality development. More recent psychodynamic theorists have focused on the pre‐Oedipal period in explaining the development of such personality disorders as narcissistic and borderline personality.

Learning Perspectives Learning theorists view personality disorders in terms of maladaptive patterns of behaviour, rather than personality traits. Learning theorists seek to identify the early learning experiences and present reinforcers that may explain the development and maintenance of personality disorders.

Family Perspectives Many theorists have argued that disturbed family relationships play roles in the development of many personality disorders. Antisocial personality disorder is connected with parental rejection or neglect, and parental modeling of antisocial behaviour.

Cognitive‐Behavioural Perspectives Albert Bandura, a social‐cognitive theorist, has focused on the role of observational learning in aggressive behaviour, which is one of the common components of antisocial behaviour, and that children acquire skills, including aggressive skills, by observing the behaviour of others. Cognitive‐ behaviour–oriented psychologists have shown that the ways in which people with personality disorders interpret their social experiences influence their behaviour. . ..

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Biological Perspectives Research on biological perspectives has shown familial links in various personality disorders that are consistent with, but do not prove, genetic means of transmission. Some research evidence shows that people with antisocial personalities not only lack emotional responsiveness to physically threatening stimuli, but also have reduced levels of autonomic reactivity. People with antisocial personalities may also require higher levels of stimulation to maintain optimal levels of arousal.

Sociocultural Views Sociocultural theorists focus on adverse social conditions that may contribute to the development of personality disorders, especially antisocial personality. The effects of poverty, urban blight, and drug abuse can lead to family disorganization and disintegration, making it less likely that children will receive the nurturance and support to help them develop more socially adaptive behaviour patterns.

Treatment Psychodynamic Approaches Promising results have been reported using structured forms of psychodynamically oriented therapies in treating personality disorders (e.g., Gunderson, 2011; Leichsenring & Leibing, 2003; Vermote et al., 2015). These therapies raise clients’ awareness of how their behaviours cause problems in their close relationships.

Cognitive‐Behavioural Approaches Behaviour therapists see their task as changing clients’ behaviour rather than their personality structures. They focus on attempting to replace maladaptive behaviour with adaptive behaviour through techniques such as extinction, modelling, and reinforcement.

Biological Approaches Drugs do not alter the long‐standing patterns of maladaptive behaviour that may give rise to distress. However, antidepressants of the selective serotonin‐reuptake inhibitor class (e.g., Prozac) can reduce aggressive behaviour and irritability in impulsive and aggressive individuals with personality disorders (Gunderson, 2011; Rivas‐Vazquez & Blais, 2002).

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Canadian Treatment Services Because of the diversity of problems associated with personality disorders, no single therapy modality works with all patients. Added to this are the cost‐containment constraints on mental health services across Canada and the need for service‐delivery mechanisms that must be comprehensive and flexible yet efficient and effective.

Chapter Outline: Personality Disorders 213 Types of Personality Disorders 214 Personality Disorders Characterized by Odd or Eccentric Behaviour 215 Personality Disorders Characterized by Dramatic, Emotional, or Erratic Behaviour 217 Personality Disorders Characterized by Anxious or Fearful Behaviour 226 Problems with the Classification of Personality Disorders 229 REVIEW IT Types of Personality Disorders 232 Theoretical Perspectives 232 Psychodynamic Perspectives 232 Learning Perspectives 234 Family Perspectives 236 Cognitive‐Behavioural Perspectives 236 Biological Perspectives 237 Sociocultural Views 239 REVIEW IT Theoretical Perspectives 240 Treatment 240 Psychodynamic Approaches 241 Behavioural Approaches 241 Biological Approaches 242 Canadian Treatment Services 242 REVIEW IT Treatment of Personality Disorders 244 CONCEPT MAP 246

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Students Should Be Able to: 1. Define personality disorders.

2. Describe the classes of personality disorders within the DSM system.

3. Describe the features associated with personality disorders characterized by odd or eccentric behaviour.

4. Identify the features associated with personality disorders characterized by dramatic, emotional, or erratic behaviour.

5. Explain the features associated with personality disorders characterized by anxious or fearful behaviour.

6. Discuss problems in the classification of personality disorders, including their reliability, validity, and sexist biases.

7. Evaluate how traditional Freudian concepts of disturbed personality development compare with more recent psychodynamic approaches.

8. Discuss the view adopted by learning theorists towards personality disorders.

9. Explain the role of family relationships in personality disorders.

10. Differentiate how cognitive encoding strategies of antisocial adolescents differ from those of their peers.

11. Identify the possible role that biological factors play in personality disorders.

12. Explain the role played by sociocultural factors in the development of personality disorders.

13. Describe different approaches adopted by therapists in the treatment of personality disorders.

Lecture and Discussion Suggestions: 1. Antisocial personality and criminality. There is a strong relationship between antisocial personality traits and criminality, but they are not synonymous. This is why the DSM includes two categories of antisocial behaviour. One is antisocial personality disorder, in which antisocial behaviour is presumed to be a function of psychological disturbance. The other category is adult antisocial behaviour, in which the deviant behaviour is not due to emotional disturbance. A large proportion of criminals fall into this latter category, committing crimes for such simple reasons as to get money, drugs, or revenge. Conversely, many people with antisocial personalities do not commit crimes. Indeed, such people may be found among the most respected people in the community, including doctors, lawyers, politicians, and business executives. Many of these individuals may possess the characteristic traits of antisocial personalities, such as superficial charm, insincerity, and lack of remorse for injurious behaviour without getting into trouble with the law.

Accordingly, the emphasis in the DSM is on specifically undesirable behaviours, such as lying, cheating, or criminal behaviour. And the single best predictor of criminal behaviour is past criminal behaviour, rather than the diagnosis of antisocial personality disorder. ..

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2. Antisocial personalities and success. Ask students how they can account for the apparent success enjoyed by some people with antisocial personality in our society. Ferdinand Demara won the title “the great impostor” by spending his life posing variously as a Trappist monk, Baptist minister, dean of philosophy, teacher, deputy warden, cancer researcher, doctor of philosophy, zoologist, and surgeon in the Royal Canadian Navy, all without the requisite credentials.

3. Psychopaths and society. Given that people with psychopathy are by definition people who repeatedly engage in antisocial behaviour, and given also that they do not seem to learn from experience or respond to therapy, how should society treat them? Should they be punished the same as other lawbreakers? Would students consider the death penalty for violent psychopaths more appropriate (given that rehabilitation is less likely and as long as they are alive they are a threat to escape and continue their murderous behaviours, as happened with Ted Bundy before he was caught again and executed) or less appropriate (given that they have a mental disorder) than for other criminals. Should they be considered insane and committed to treatment as an alternative to going to jail (even considering their high rate of failure to respond successfully to treatment and the fact that many psychopaths are pathological liars who become expert at convincingly telling the therapist what he or she “wants to hear”)? Or is there a larger responsibility to keep them incarcerated, especially the violent ones, to protect society from their depredations, especially given the low success rates in “curing” them?

4. Adopt a psychopath? Should adoptive parents be told if the child they are about to adopt is the offspring of a psychopath? As an adoptive parent, would you want to know this information? If you were told, what steps would you take to maximize the likelihood of the child growing up to be a normal adult? Would you still adopt the child? Would revealing this information to prospective parents be fair to the child? Is not revealing it fair to the prospective parents? Ask students to propose ways to prevent psychopathy by intervening in childhood.

5. Antisocial personality versus psychopathy. There was some controversy when DSM‐III changed the way antisocial personality was defined. That change, which is very similar to the present DSM‐5, moved away from the view of psychopathy articulated by Hervey Cleckley. That view, which was the basis of DSM‐II, focused less on illegal behaviours and more on personality. Cleckley saw people with psychopathic personalities as lacking in the normal range of emotion; they seldom became anxious, for example. These people had no sense of shame. Often suave and charming, they go through life conning and manipulating.

The person with psychopathic personality, said Cleckley, seldom learns from being punished, and often does things for the pure thrill of it, even when the risk of capture is high.

Research has shown that 75 to 80 percent of convicted felons will meet the criterion for antisocial personality disorder, but only 15‐25 percent of these will be the glib, unemotional, manipulator who has a psychopathic personality. Many feel that most people ..

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with psychopathic personality never get captured, at least for long, and that some of them are actually very “successful” in various walks of life. It is important to discuss with the class that not all criminals have antisocial personalities, and not all people with DSM‐5 antisocial personality disorder have a psychopathic personality.

Hare, S. D., & Hare, R. D. (1989). “Discriminant Validity of the Psychopathy Checklist in a Forensic Psychiatric Population”. Psychological Assessment, 1, 211‐ 218.

6. The family backgrounds of people with antisocial personality. One of the landmark studies of antisocial behaviour was a 30‐year follow‐up of juvenile delinquents by Lee Robbins (1966). These subjects had originally been referred to a child guidance clinic, where information was obtained about their home life and other factors. Robbins studied the association between these factors and adult antisocial behaviour.

One predictive factor for later adult antisocial personality was an early start on such behaviours. The future antisocial boys had histories as children and young adolescents of theft, aggression, assaults, truancy, telling lies, and irresponsibility with money. Another factor Robbins found was an antisocial or alcoholic father; the importance of role models has been stressed by many writers and is evident here. Finally, a significant factor was the type of discipline in the home. Predictive of adult antisocial behaviour was either no discipline, or inconsistent discipline. The lack of any discipline of course gives the child no sense of rules or obligations. Inconsistent discipline tells the child rules are made to be broken.

Discuss with the class how these factors might operate to “produce” an antisocial adult.

Point out also that Robbins’ study was very influential in the DSM’s inclusion of early antisocial acts (before age 15) as one criterion for antisocial personality disorder.

Robbins, L. N. (1966). Deviant Children Grown Up. Baltimore: Williams and Wilkins.

7. The narcissistic personality. This is thought by many to be the characteristic disorder of our time, with many otherwise normal individuals in our society exhibiting undue self‐interest and grandiose views of themselves. Actually, a certain degree of narcissism may enhance personal and social adjustment. Self‐ centered individuals may focus on their careers, ensuring a quick rise to fame and wealth. Self‐absorption may also provide a shield from disappointment and criticism. And superficial relationships may provide reassurance with reduced risk of being hurt by others.

Heinz Kohut, a psychodynamic theorist who has focused much of his attention on this disorder, explains that people with narcissistic personalities are compensating for inadequate affection and approval in childhood. Such individuals have never outgrown the normal “healthful narcissism” of early childhood. Lacking parental empathy and support, these children fail to develop a sturdy sense of self‐esteem. Instead, they construct grandiose self‐images as a way of avoiding their perceived inadequacies and need constant ..

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reassurance to maintain their inflated self‐esteem. In contrast, cognitive and social learning theorists view narcissistic personalities as the products of exaggerated expectations of what children will achieve in adulthood, based on inflated views of their talents. Whatever the primary causes, narcissism may be fostered by many forces in today’s society, including the “overvaluing” of children, rushing children into adulthood, heightened expectations among youth, prominence of television, and the pervasive consumer orientation in today’s society.

8. Narcissistic personality. As a follow‐up to lecture suggestion #7 (above), discuss the notion that narcissistic personality has become the characteristic disorder of our time. Do students agree with this idea? Why or why not? What influences have fostered this belief? At what point does self‐interest become narcissistic and self‐defeating? How does media hyping of celebrities, athletes, and even criminals contribute to this?

9. Borderline personality. The current debate over the classification of borderline personality disorder concerns its relationship to mood disorders. In a paper presented at the 1992 APA convention (Rogers, Widiger, and Krupp, Aspects of Depression Associated with Borderline Personality Disorder), the authors reported findings that suggest that the depression accompanying borderline personality disorder (BPD) is in some respects unique and distinct from that of persons with mood disorder. They report a “significant relationship between BPD and self‐ condemnation, loneliness/abandonment, relationship with somatic complaints, guilt, and cognitive dysfunction.”

10. The passive‐aggressive personality. DSM‐IIIR included the passive‐ aggressive personality among the personality disorders. In DSM‐5 it is removed, or at least relegated to an appendix needing further study. The DSM‐5 subtitles this the negativistic personality.

Research criteria revolve around a pervasive pattern of “negativistic attitudes and passive resistance to demands for adequate performance.”

These people are thought to resist completing tasks via passive resistance—they dawdle, forget, delay, and stall rather than make any direct objection or refusal. The negativistic person is a complainer who feels misunderstood. He or she is critical of authority, and envious of others who seem to be more successful. There is a conflict in these people between whether to be dependent or assertive.

Some argue that this should be again in the personality disorder list. Others believe it is more a style that cuts across disorders, rather than being a discrete category. Even the DSM‐5 notes that passive‐aggressive behaviours can occur in borderline, histrionic, paranoid, dependent, antisocial, and avoidant personality disorders. Discuss with the class their experience with people with passive‐ aggressive/negativistic personalities. How do such people alienate others?

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11. The self‐defeating personality. Some personality disorders have aroused great controversy; controversy that is political as well as theoretical. One such storm has surrounded the self‐ defeating personality since it was suggested for inclusion in the DSM‐IIIR. This personality was thought to involve excessive self‐ sacrifice. These people get themselves into situations where they are taken advantage of, and often reject offers to help them get out of these situations. In general, they make life choices that often result in disappointment, abuse, and failure.

The controversy arose mainly from women’s groups within the mental health professional community, who felt this disorder had extreme sexual overtones. To them, the self‐ defeating personality sounded like a label applicable mainly to women, in whom our culture has fostered such self‐sacrificing behaviour. In particular, there was concern that the disorder would be applied to victims of domestic violence, most of whom are women. What could be the consequences of this? Critics felt that the victim of violence could be painted as the disturbed person, rather than the perpetrator.

The authors of DSM‐III‐R decided to place self‐defeating personality disorder in the appendix as needing further study. The category has disappeared entirely from DSM‐5.

Discuss with the class the implications that come when we label some behaviours as abnormal and fail to label others because of the concerns of specific subgroups (in this case women’s groups). If we should not have a label for self‐defeating personality disorder because it might apply mainly to women, should we have a label for antisocial personality disorder, which has been proven to apply overwhelmingly to men? If one is sexist is the other not sexist too? Those who support the inclusion argue that, sad as it may be, there are people who behave in these ways, and that it does a disservice to ignore their need for psychological help.

12. Therapy with personality disorders. Therapeutic efforts with personality disorders have not been very successful; that is, personality disorders are resistant to treatment efforts. In addition, persons with personality disorders rarely come in for treatment of their own volition. Often, they end up in therapy because of external pressure, such as a court order or a demand by a spouse who threatens to leave them. Can one ethically justify an intensive and expensive effort to alter someone’s style of life? Especially when that person doesn’t want to be there and the chances of success are often minimal? What conditions make this therapeutic effort more justifiable?

13. Personality disorders: mental disorders? If personality disorders are maladaptive personality traits that interfere with functioning, should they be considered to be “mental disorders?” Are they disorders in the same sense as agoraphobia or bipolar disorder? Or are they instead just a reflection of the individual’s personality? Does calling such behaviour a disorder excuse it and allow the individual not to take responsibility for his or her behaviour (as some have asserted regarding the controversial proposed diagnosis, sadistic personality disorder)? What trait, if it was maladaptive and interfered with functioning, wouldn’t quality as a personality disorder? ..

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14. Paranoid personalities? Recent press reports of “right‐wing” extremists often linked to “militia” and other para‐military groups, and incidents like the Oklahoma City bombing, describe members and leaders of these groups, and perpetrators of these acts, as paranoid.

Much of their literature provides evidence that one could easily use to build a substantial case for paranoid and even delusional thinking. Discuss with the class whether or not these people are exhibiting paranoid behaviour. Would they qualify under the DSM‐5 for having paranoid personality disorder? Or, given the government’s alleged mishandling of the Branch Davidians in Waco, Texas, and the “Ruby Ridge” incident, is some of their so‐called “paranoia” justified? This discussion should bring out one of the many problems with personality disorders: how abnormal some of the behaviours are may be in the eye of the beholder based on perceived justification. Either way, it should provide a lively, if not heated class discussion, particularly if some class members are fairly conservative in their political beliefs.

15. “Explosive” personalities? This might be a good chapter in which to discuss the recent tragedies in the nation’s schools where students have gone on explosive rampages and killed or wounded dozens of fellow students, faculty, and staff. Were these students suffering from some type of mental disorder? Their behaviour in many ways resembles what used to be called “explosive personality.” Clearly these students were seriously disturbed, but does that excuse them from their actions? Do students feel that violent video games and movies caused or contributed to these rampages? What other factors might contribute to these tragic outbursts?

Student Activities: 1. Healthy Narcissism and Destructive Narcissism. Instruct students to select two experiences in their lives that may illustrate the effects of normal and narcissistic self‐ interest. One experience should be a situation in which they acted out of normal self‐ interest and the effects this had upon themselves and others. The other experience should be a situation in which they overreacted to some event or experience in an extreme, perhaps narcissistic way, and the (destructive) effects of such behaviour.

Students may find Table 6.2, “Healthy Narcissism and Destructive Narcissism,” helpful in distinguishing between these two types of experiences. Have students reflect on the extent to which self‐ interest may enhance our personal and social adjustment, up to a point at least, and how inflated views of ourselves and our expectations tend to be self‐ defeating, causing problems in our relationships and our careers. You could do this exercise in a discussion format in class, in small groups, or in a written assignment.

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2. Sensation‐seeking. Have students check their responses to the items in the abbreviated sensation‐seeking scale presented in this chapter, and then score their responses with the answers given at the end of this chapter. Since this scale measures sensation‐seeking, the greater the proportion of correct responses the greater the tendency toward sensation‐ seeking behaviour. Then have students reflect on their scores and the extent to which they engage in any of the related behaviours indicated in the text. The four factors related to sensation‐seeking are: (1) pursuit of thrill and adventure, (2) disinhibition, or inclination to express one’s impulses, (3) pursuit of novel experience, and (4) susceptibility to boredom.

People high in sensation‐seeking tend to engage in risky sports, or in a variety of sexual and drug experiences, behave fearlessly in commonly feared situations, drive fast, prefer exotic foods, and gamble.

3. Antisocial acts around us. Ask students to consider ways in which otherwise normal people do potentially antisocial things. A good example is academic dishonesty—cheating. Have your students put on index cards their personal or observed examples of cheating, such as copying answers on a test, or plagiarizing a term paper. Collect and shuffle the cards, and have the frequency of cheating tabulated.

This can be an interesting vehicle for discussing the range of behaviours that have antisocial elements. Students can also be encouraged to seek some of the research literature on academic dishonesty, and report back on what the research has uncovered about cheaters and their behaviour.

Online Discussion questions: 1.

Personality disorders are relatively easy to diagnose. Discuss.

2.

Problems in the classification of personality disorders, including their reliability and validity, and sexist biases, prevent the accurate diagnosis of the disorder. Discuss.

3.

Since employees with severe personality disorders rarely seek treatment, it should be mandated by their employers.

Online Resources: Personality Disorders www.phac‐aspc.gc.ca/publicat/miic‐mmac/pdf/chap_5_e.pdf A chapter on personality disorders from Health Canada’s A Report on Mental Illness in Canada (2002b).

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Internet Mental Health http://mentalhealth.com/p20‐grp.html This site includes a list of personality disorders linked to relevant information about description, diagnosis, treatment, and research.

MentalHelp.Net https://www.mentalhelp.net/articles/personality‐disorders/ This site includes a list of personality disorders linked to information about symptoms and treatment.

Video Resources: Descriptions and Interventions, 17‐25 min. colour, filmstrip (CM). One film in this series covers personality disorders. Others cover anxiety disorders, schizophrenia, and origins of abnormal behaviour.

In Cold Blood, Black and White (Swank). Truman Capote’s chilling account of the murder of a family by two psychopaths.

The Mind of a Serial Killer, 60 min. colour (Films for the Humanities and Sciences). NOVA program that examines the real FBI unit that inspired Silence of the Lambs.

Obsessive‐Compulsive Disorder, 24 min. colour (Films for the Humanities and Sciences).

Examines biological causes to OCD and looks at new drug treatments for the disorder.

Obsessive‐Compulsive Disorder: The Boy Who Couldn’t Stop Washing, 28 min. colour (Films for the Humanities and Sciences). Specially adapted Phil Donahue program.

Psychopath, 30 min. (Penn State Univ.). Case history of a patient with antisocial personality.

Shotgun Joe, 25 min. colour (U. of Cal. Extension Media Center). Shows contradiction between outwardly charming behaviour and lack of conscience and concern for others in a teenager in custody.

The Violent Mind, 90 min. (PBS Video). Explores how changes in anatomy and chemistry of the brain can cause violent behaviour and other antisocial acts.

Violent Youth: The Unmet Challenge, 23 min. colour (HR). Features a discussion with three jailed juveniles about themselves, their crimes, and society.

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Chapter 7 Substance‐Related and Addictive Disorders Chapter Overview: Classification of Substance‐Related and Addictive Disorders The DSM‐5 classifies substance‐related disorders into two major groups: substance use disorders and substance‐induced disorders. Substance‐use disorders involve maladaptive use of psychoactive substances. These types of disorders include substance abuse and substance dependence.

Substance‐Induced Disorders Substance‐induced disorders are disorders induced by the use of psychoactive substances, including intoxication, withdrawal syndromes, mood disorders, delirium, and amnesia.

Substance Use Disorders According to the DSM, substance use disorders involve a pattern of recurrent use of a substance that repeatedly leads to damaging consequences. Substance use disorder, which often includes features of physiological dependence, involves impaired control over use of a substance.

Addiction, Physiological Dependence, and Psychological Dependence People define addiction in different ways. For our purposes, we define it as the habitual or compulsive use of a drug accompanied by evidence of physiological dependence. The major signs of physiological dependence involve the development of tolerance and/or an abstinence syndrome. A psychological dependence involves a pattern of compulsive use associated with impaired control over the use of a drug.

Pathways to Substance Use Disorder Although the progression to substance use disorder varies from person to person, some common pathways can be described according to the following stages: experimentation, routine use, addiction or dependence.

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Drugs of Abuse Depressants Depressants are drugs that lower the level of activity of the central nervous system by reducing feelings of tension and anxiety, causes movements to become sluggish, and impairs cognitive processes. In high doses, depressants can arrest vital functions and cause death. Depressants include alcohol, barbiturates, sedatives and minor tranquilizers, and opioids. Effects of alcohol include intoxication, impaired coordination, slurred speech, and impaired intellectual functioning. Chronic disordered alcohol use has been connected with disorders such as alcohol‐ induced persisting amnestic disorder (Korsakoffs syndrome), cirrhosis of the liver and other physical disorders, and with fetal alcohol syndrome. Barbiturates are depressants or sedatives that have been used medically for relief of anxiety and short‐term insomnia, among other uses.

Opioids such as morphine and heroin are derived from the opium poppy. Others are synthesized. Used medically for relief of pain, they are strongly addictive. The disease model treats problems of substance abuse and dependence as disease processes.

Stimulants Stimulants increase the activity of the nervous system. Amphetamines and cocaine increase the availability of neurotransmitters in the brain, heightening states of arousal. High doses can produce an amphetamine psychosis, which mimics features of paranoid schizophrenia.

Repeated use of nicotine, usually in the form of cigarette smoking, can lead to physiological dependence.

Hallucinogens Hallucinogens, also known as psychedelics, are a class of drugs that produce sensory distortions or hallucinations. Hallucinations involve major alterations in colour perception and hearing. Hallucinogens may also have additional effects, such as relaxation and euphoria or, in some cases, panic. Hallucinogens include LSD, psilocybin, and mescaline. Other drugs with similar effects are cannabis (marijuana) and phencyclidine (PCP). There is little evidence that these drugs induce physiological dependence, although psychological dependence may occur.

Inhalants Inhalants are substances that produce chemical vapours that are inhaled for its psychoactive effect. Many substances can produce fumes, which, when inhaled, can induce feelings of intoxication and euphoria by their action on GABA and dopamine systems. The psychological and physical effects of inhalants can be very serious and even one use can be fatal.

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Theoretical Perspectives Biological Perspectives Biological perspectives focus on uncovering the biological pathways that may explain mechanisms of physiological dependence. These perspectives focus on the role of neurotransmitters and genetic factors in vulnerability to dependence.

Learning Perspectives Learning theorists view substance abuse disorders as learned patterns of behaviour and can, in principle, be unlearned. They focus on the roles of operant and classical conditioning and observational learning. Substance use problems are regarded not as symptoms of diseases but rather as problem habits.

Cognitive Perspectives Cognitive perspectives emphasize the roles of attitudes, beliefs and expectancies in accounting for substance use and abuse. Research suggests that the one‐drink effect may be a self‐fulfilling prophecy.

Psychodynamic Perspectives Psychodynamic theorists view problems of substance abuse, such as excessive drinking and habitual smoking, as signs of oral fixation. With a mixed research support, an empirical connection between dependence and alcoholism does not establish that alcoholism represents an oral fixation that can be traced to early development.

Sociocultural Perspectives Sociocultural perspectives lay importance on the adoption of culturally sanctioned prohibitions against excessive drinking in explaining differences among various ethnic and religious groups in rates of alcoholism. Social factors, such as peer pressure also influence the development of substance abuse.

Tying It Together Substance use disorders are complex patterns of behaviour that involve an interplay of biological, psychological, and environmental factors. Genetic predispositions may interact with environmental factors that increase the potential for drug abuse and dependence. Cognitive factors, especially positive drug expectancies may also raise the potential for alcohol or drug problems. Sociocultural factors include factors such as the availability of alcohol and other drugs, and the presence or absence of cultural constraints. Learning theorists attribute addiction to the positive and negative reinforcements arising from the effects of drugs.

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Substance use disorders should be approached considering the complex interplay of all these factors.

Treatment Biological Approaches Biological approaches to substance use disorders include detoxification; the use of disulfiram, methadone, naloxone, and antidepressants, and nicotine replacement therapy.

Nonprofessional Support Groups Nonprofessional support groups, like Alcoholics Anonymous (AA), Narcotics Anonymous, and Cocaine Anonymous promote abstinence within a supportive group setting. The most widely used nonprofessional program, Alcoholics Anonymous, is based on the belief that alcoholism is a disease, not a sin. There are more than 65 000 chapters of AA in North America (Alcoholics Anonymous, 2016).

Residential Approaches Residential treatment approaches include hospitals and therapeutic communities. Outpatient treatment is less costly and often indicated when withdrawal symptoms are less severe, clients are committed to changing their behaviour, and environmental support systems, such as families, strive to help clients make the transition to a drug‐free lifestyle.

Psychodynamic Approaches Psychodynamic therapists focus on uncovering the inner conflicts, originating in childhood that are believed to be at the root of substance use disorders.

Cognitive‐Behavioural Approaches Behaviour therapists focus on helping people with substance‐use related disorders change problem behaviours through such techniques as self‐control training, social‐skills training, cue‐ exposure training, and motivational enhancement therapy (MET) approaches.

Relapse‐Prevention Training Regardless of the initial success of a treatment technique, relapse remains a pressing problem in treating people with substance use disorders. Relapse‐prevention training employs cognitive‐ behavioural techniques to help those in recovery cope with high‐risk situations and to prevent lapses from becoming relapses by helping participants to interpret lapses in less damaging ways.

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Chapter Outline: Substance Related and Addictive Disorders 248 Classification of Substance‐Related and Addictive Disorders 251 Substance‐Induced Disorders 251 Substance Use Disorders 252 Addiction, Physiological Dependence, and Psychological Dependence 254 Pathways to Substance Use Disorders 254 REVIEW IT Classification of Substance‐Related Disorders 255 Drugs of Abuse 255 Depressants 256 Stimulants 264 Hallucinogens 268 Inhalants 270 REVIEW IT Drugs of Abuse 271 Theoretical Perspectives 271 Biological Perspectives 271 Learning Perspectives 273 Cognitive Perspectives 275 Psychodynamic Perspectives 277 Sociocultural Perspectives 277 Tying It Together 278 REVIEW IT Theoretical Perspectives 278 Treatment 279 Biological Approaches 279 Nonprofessional Support Groups 281 Residential Approaches 282 Psychodynamic Approaches 283 Cognitive‐Behavioural Approaches 283 Relapse‐Prevention Training 285 REVIEW IT Treatment 287 CONCEPT MAP 290

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Students Should Be Able to: 1.

2.

3.

4.

5.

6.

Understand how the DSM describes substance use disorders.

Understand how the DSM describes substance‐induced disorders.

Describe depressants.

Describe stimulants.

Understand what hallucinogens are.

Discuss how problems of substance use disorders conceptualized within the major theoretical perspectives.

7. Describe various treatment approaches that are used to help people overcome substance use disorders.

Lecture and Discussion Suggestions: 1. Drug effects—psychological considerations. The general effect of most drugs is greatly influenced by a variety of psychological and environmental factors. Accordingly, in determining the effect of a given drug, it may be helpful to consider three types of influences as follows: (1) Pharmacological effects. The physiological effect of a given drug is a crucial factor, with the entire field of pharmacology devoted to discovering the makeup and effects of drugs. Greater knowledge of drugs has led to specifying drug dependence by specific type, such as drug dependence of the cocaine type. (2) Mental set. This is a collective term for a variety of psychological factors that may contribute to the effects of a drug, including the individual’s personality, his or her past history of drug experience, attitudes toward the drug, motivation for taking the drug, and expectations of its effects.

For instance, experiments have shown that when people believe they have drunk alcohol (when they have actually consumed only tonic water) they show increases in sexual arousal, whereas those who have actually imbibed alcohol but believe they have drunk only tonic water show decreased sexual response.

(3) Setting. This refers to environmental factors, including the social influence of people.

Thus, a few drinks of an alcoholic beverage may make a person feel drowsy and fatigued in some situations, whereas under different circumstances, the same amount of alcohol may psychologically stimulate and arouse that person. Set and setting are believed to be of greater significance with respect to psychoactive drugs, especially psychedelic and hallucinogenic substances.

2. Is alcoholism a disease? Elvin Morton "Bunky" Jellinek is probably most responsible for initiating a disease view of alcoholism. Such a view is a cornerstone of Alcoholics Anonymous. Polls consistently show that the public also views alcoholism as a disease.

Indeed, some believe that the vigor of disease proponents has weakened support for Copyright © 2019 Pearson Canada Inc. 7-6

research on controlled drinking strategies. Not everyone agrees with the disease view of alcoholism, though. In his controversial book, The Diseasing of America, Stanton Peele argues against a disease interpretation of alcoholism. Some of his arguments include the following: a. Drinking is not uncontrollable, as the disease view argues. Drinkers drink to achieve a desired effect. They are not out of control. b. The evidence for genetics is not particularly strong. c. Alcoholism is not the primary disease; these people often recover when other life problems and stresses are solved. d. Not everyone is equally susceptible, as disease‐model advertising has suggested.

Demographic predictors are accurate; alcoholism does not strike just everyone. e. AA and other disease‐model treatments have had little effect.

Ask students to discuss these arguments in regards to evidence supporting the disease model of alcoholism. What are the social and legal ramifications of calling alcoholism a disease? Peele S. (1989). The Diseasing of America: Addiction Treatment Out of Control.

New York: Lexington Books.

3. Alcohol use and disordered use. Ask students where they draw the line between the use and disordered use of alcohol. Do their responses focus more on the amount or type of alcohol used? Or are they aware of the psychological and behavioural considerations used in the DSM‐5, such as continued use despite knowledge of the problems caused by alcohol or recurrent use in situations where use is dangerous?

4. Controlled Drinking. A controversial issue in regard to treating problem drinkers is whether such persons must practice abstinence or may engage in controlled drinking. According to the disease model (discussed above), once you’re an alcoholic, you’re always an alcoholic.

Thus, organizations like Alcoholics Anonymous assert that abstinence is the only way to insure a successful recovery from alcoholism. However, critics of the disease model argue that some problem drinkers may recover with controlled drinking. Much of the evidence is drawn from a study in which over 900 people with alcoholism were studied after they had been admitted to a federal alcoholism treatment center. (Polich and Amor, The Course of Alcoholism, 1980, Rand). After four years, about half the subjects were either abstaining from alcohol or drinking in a controlled manner. Especially interesting is the finding that alcoholics over age 40 who were strongly alcohol dependent had lower relapse rates when they abstained completely, whereas those under 40 who exhibited lower levels of dependence were less likely to relapse if they practiced controlled drinking rather than abstinence. Similar studies with mixed results are described in this chapter. Such findings suggest that controlled social drinking may be effective with younger problem drinkers who exhibit relatively low levels of alcohol dependence. But abstinence remains the most dependable course of treatment for chronic alcoholics.

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5. Relationships with drugs. In their book, Chocolate to Morphine, Andrew Well M. D. and Winifred Rosen (Boston: Houghton‐Mifflin, 1983) provide some guidelines for distinguishing between good and bad relationships with drugs as follows: (1) Recognition that the substance you are using is a drug and being aware of what it does to your body. People who develop the worst relationships with drugs have little understanding of the drug they are using. So a necessary first step is to understand the nature and effects of the substances being used, including caffeine and nicotine. (2) Experience of a useful effect of the drug over time. Since the effects of a drug diminish with use, people in bad relationships with drugs tend to use them heavily but get the least out of them. In contrast, when the experience people like from a drug begins to fade, that is a sign they are using too much. (3) Ease of separation from using the drug. One of the striking features of drug abuse is dependence on a drug—psychological or physiological. People with a good relationship with a drug can take it or leave it. Unfortunately, many drug disordered users believe they can take it or leave it when it is abundantly clear to those around them that they are cannot. (4) Freedom from adverse effects on health and behaviour. Some people can take a drink before dinner without it disrupting their family lives or work, while other people’s drinking contributes directly to their troubles at home or work. Adverse effects on one’s health and behaviour is another characteristic of disordered drug use.

6. AIDS and intravenous drug use. Acquired immunodeficiency syndrome (AIDS) has greatly increased the urgency of modifying behaviours associated with drug addiction; sharing needles for intravenous drug use results in an exchange of contaminated blood and is a leading mode of transmission of HIV. In addition, IV drug users infected with HIV can transmit the disease to non‐drug users through sexual contact, and infected pregnant women can pass the disease to their children.

Researchers have derived three principles for AIDS risk reduction among IV drug users: (I) IV drug users need basic information about HIV transmission before they change their needle‐ sharing behaviour; (2) information is not sufficient; means for behaviour change (such as sterilized needles or bleach for sterilizing) must be readily available for change to occur; and (3) sustained reinforcement for risk reduction behaviours, especially new peer norms favoring safer behaviour, may be necessary for change to occur.

7. Legalizing illegal drugs. Ask students if they think illegal drugs should be legalized. You might have them list the pros and cons of legalization versus keeping drugs illegal. How do students feel about this today, compared with students of the 1970s? Do they favor legalizing marijuana more than drugs like cocaine? What are the parallels and differences in legalizing drugs today compared to legalizing alcohol earlier in this century? What are the parallels and differences in keeping drugs illegal today compared to the prohibition of alcohol in the 1920s?

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8. Drug education. Discuss the effectiveness of drug education today. How early in school should such a program begin? What are the most effective strategies? Are scare tactics overrated? How effective have current efforts, like D.A.R.E., been in preventing children from going on to be drug abusers? Since many programs like D.A.R.E. are aimed at grade schoolers and do not continue into middle school, which is when many preteens and adolescents begin drug use, should these programs be extended into the middle‐school years? Or wouldn’t it matter?

9. Smoking. Surveys indicate that cigarette smoking among young people has increased significantly in recent years, after years of steady declines. Given the enormous amounts of information available about the dangers of smoking, why do students believe these increases are occurring? Is it mass marketing of cigarettes through ads aimed at teenagers (as the government claims) or are their other factors involved? If so what are they? If smoking is so dangerous, why doesn’t the government just ban cigarettes completely? Or would we see a repeat of 1920s prohibition in which alcohol sales and production were banned?

Student Activities: 1. The most commonly used drugs. Instruct students to list the three most commonly used drugs among people ages 15‐30. Have them rank order their responses, putting the most frequently used drug first, and so forth. Then have someone pick up the lists and summarize the results on the chalkboard or an overhead projector. In discussing the results, remind students that caffeine, nicotine, and alcohol are defined as drugs with addictive potential.

Are students aware that caffeine is found in such diverse products as coffee, tea, hot cocoa, soft drinks, milk chocolate candy, baking chocolate, pain relievers, alertness tablets, and cold/allergy relief remedies?

2. Risk factors for disordered alcohol use. Have students complete the inventory adapted from the National Council on Alcoholism and Drug Dependence’s self‐test found on their website (https://www.ncadd.org/get‐help/take‐the‐test). Then have them discuss their responses. Do most students feel they have their drinking habits well under control? How much awareness do they show of the various risk factors for alcoholism discussed in the text? Are they aware that the best predictor for problem drinking in adulthood appears to be family history of alcoholism?

3. Alternatives to drugs. Ask students to list various reasons students use drugs in regards to the needs and motives being met. Then have them suggest alternative ways to meet these same needs. For example, if people drink alcohol to relax or feel good, have students list alternative ways to accomplish this, including relaxation, food, constructive exercise, swimming, and yoga. Similarly, if people smoke or drink to fit into the crowd, have them list alternative ways to meet this need, such as participation in clubs, sports, hobbies, growth groups, or social skills training. Also, those who use drugs to magnify sensory experience Copyright © 2019 Pearson Canada Inc. 7-9

might try sauna, massage, art training, meditation, outdoor activities such as hiking, canoeing, or bicycling, or more risky and adventurous activities like hang gliding, skydiving, or white‐water rafting. Although most of the alternatives to drugs require an initial investment of time, effort, and the acquisition of skills, they remind us that we have the capacities within ourselves to feel good and can do so without huge expenditures of time or money, much less the detrimental effects of drugs.

4. Pre‐test on alcohol expectations. Before 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 questions on a questionnaire and compile the results. After reading the chapter, these impressions can be discussed in terms of the impact that expectations about drug effects have on the behaviour of those under the influence of a drug. How might expectancies influence other responses to alcohol or to other drugs? What are the expectancies about the effects of cigarette smoking, marijuana use, or psychedelics?

5. 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? (4) How could the mass media be used to help in the prevention program? (5) How would you measure the effectiveness of your program?

6. Personal experiences with alcohol. Conduct the same exercise as number 5 (above), only this time have students discuss their alcohol‐related experiences.

7. Local resources. What local resources exist for the diagnosis and treatment of substance disorders? Students can assemble a list and description of these resources, as well as resources that exist for family members of substance abusers. Perhaps a representative from a detoxification center or treatment program can speak to the class about what goes on in their work.

Online Discussion questions: 1. Personality disorders are relatively easy to diagnose. Discuss.

2. Problems in the classification of personality disorders, including their reliability and validity, and sexist biases, prevent the accurate diagnosis of the disorder. Discuss.

3. Since employees with severe personality disorders rarely seek treatment, it should be mandated by their employers.

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Online Resources: Centre for Addiction and Mental Health (CAMH) www.camh.ca This is a public hospital providing direct patient care for people with mental health and addiction problems. CAMH is also a research facility, an education and training institute, and a community‐based organization providing health promotion and prevention services across Ontario.

Canadian Centre on Substance Use and Addiction www.ccsa.ca This website provides statistics and other information on substance use disorders.

Alcoholics Anonymous www.aa.org AA’s website provides information on the nature and treatment of alcohol problems.

Mothers Against Drunk Driving (MADD) www.madd.ca MADD’s Canadian site provides information on the prevalence and cost of alcohol abuse.

National Council on Alcoholism and Drug Dependence www.ncadd.org This site contains numerous links providing information on the nature and treatment of substance use disorders.

FASworld www.fasworld.com FASworld is a Canadian‐based organization providing information about fetal alcohol spectrum (FAS) disorders.

Video Resources: Acid, 26 min. colour (UCEMC). Reviews the history of LSD and its use in research involving humans and animals.

Addiction and the Family, 19 min. colour (Films for the Humanities and Sciences). Demonstrates how alcohol affects everyone in the family and the effectiveness of family counselling.

Adult Children of Alcoholics: A Family Secret, 52 min. colour (Films for the Humanities and Sciences). Celebrities speak out about their own childhood experiences with alcoholic parents.

Explores the difficulty of coping with the damage inflicted by an alcohol‐centered childhood.

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Alcohol Addiction, 28 min. colour (Films for the Humanities and Sciences). Explores the nature of alcohol addiction and concludes that it is a biochemical disorder best treated by behavioural interventions.

Alcohol and the Family: Breaking the Chain, 25 min. colour (Films for the Humanities and Sciences). Analyzes the signs of alcoholism and shows how someone can help break the chain of alcoholism within a family.

Alcoholism: A Model of Drug Dependency, 20 min. colour (CRM/McGraw‐Hill). This film explores the problems of alcoholism in our society.

Alcoholism: Out of the Shadows, 30 min. colour (ABC‐TV). Well‐done documentary of alcoholics telling their stories in order to help others.

A Man with a Problem, 17 min. (PCR‐2 160). Demonstrates the treatment of alcoholism by aversion and relaxation techniques and the development of more adaptive behaviours using operant conditioning principles.

An Ounce of Prevention, 20 min. colour (HR). Examines the causes of alcoholism, the damage to individuals and families, and describes treatment and prevention programs.

Calling the Shots, 30 min. colour (Cambridge Documentary Films). Shows the way alcohol is advertised and how we are encouraged to drink.

Cigarettes: Who Profits, Who Dies? 49 min. colour (Films for the Humanities and Sciences).

Explores tactics used by tobacco companies to sell cigarettes. Also shows former cigarette advertising models who are now dying of cigarette‐related cancer.

Compulsive Shopping, 30 min. colour (Films for the Humanities and Sciences). Overviews the problem of impulsive, binge shopping and its impact on the compulsive shopper and his or her family.

Cracking a Craving, 26 min. colour (Films for the Humanities and Sciences). Explains the 1980s surge in cocaine use and the physiological effects of cocaine on the brain.

Dealing with Drugs, 6 parts, 15 min. each, colour (Films for the Humanities and Sciences).

Explores who takes drugs and why; the effects of alcohol, caffeine, and nicotine; the effects of illegal drugs; and coping with peer pressure to take drugs.

The Distant Drummer: Flowers of Darkness, 22 min. colour (PCR‐2 1280). Traces the history of opium to the present day use of heroin.

Kick the Habit, 19 min. colour (Films for the Humanities and Sciences). Focuses on the effects of cigarette smoking on the body and on the battle against smoking.

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Kids Under the Influence, 58 min. colour (Films for the Humanities and Sciences). Explains why alcohol is so easily abused by children, the effects of such abuse, and what can be done to deal with it.

LSD: Insight or Insanity, 18 min. colour (Phoenix/BFA Films and Video, Inc.). Shows the physical and psychological effects of LSD, with an emphasis on the adverse effects.

Medical Aspects of Alcohol, 2 parts, 60 min. colour (FMS Productions). Examines alcohol’s effects on the brain and other organs.

Methadone: Escape from Heroin, 28 min. colour (UCEMC). Examines the strengths and weaknesses of a New York City methadone treatment program for heroin addicts.

Nine to Five High, 28 min. colour (Films for the Humanities and Sciences). Explores substance abuse in the workplace and the dangers it poses.

The Perfect Drug Film, 31 min. colour (IU). Shows the effects of a fictional perfect drug in our society, including a history of drug use from ancient to modem times.

The Power of Addiction, 19 min. colour (Films for the Humanities and Sciences). Examines causes and effects of both chemical and behavioural addictions and describes the signs of compulsive behaviour.

Pregnancy and Substance Abuse, 28 min. colour (Films for the Humanities and Sciences).

Follows several couples through pregnancy and prenatal care. Examines risks of smoking and drinking during pregnancy.

Smokers Are Hazardous, 50 min. colour (Films for the Humanities and Sciences). Explores the hazards posed by secondary smoke.

Walking Through Fear: Women and Substance Abuse, 28 min. colour (Films for the Humanities and Sciences). Explores why women do not seek help for substance abuse addictions and the problems they face when they seek such help.

Copyright © 2019 Pearson Canada Inc. 7-13

Chapter 8 Feeding and Eating Disorders and Sleep‐Wake Disorders Chapter Overview: Feeding and Eating Disorders Feeding and eating disorders are psychological disorders involving disturbed eating patterns and maladaptive ways of controlling body weight.

Anorexia Nervosa Anorexia nervosa is an eating disorder, primarily affecting young women; it is characterized by maintenance of an abnormally low body weight, distortions of body image, and intense fears of gaining weight.

Bulimia Nervosa Bulimia nervosa is an eating disorder characterized by a recurrent pattern of binge eating followed by inappropriate compensatory behaviours, such as purging eaten food, to prevent weight gain; it is accompanied by persistent overconcern with body weight and shape.

Causes of Anorexia and Bulimia Anorexia and bulimia involve a complex interplay of a host of biopsychosocial factors.

Increasingly, researchers are finding that eating disorders arise when underlying genetic and neurobiological vulnerabilities interact with the social pressures felt by young people that lead them to put a high value on their physical appearance, especially their weight (Steiger, 2007).

Treatment of Anorexia Nervosa and Bulimia Nervosa People with anorexia may be hospitalized, especially when weight loss is severe or body weight is falling rapidly. The best outcomes result from treatment that involves psychotherapy combined with nutritional management and family interventions (Kaplan, 2002). Other therapies that benefit patients with eating disorders are: cognitive analytic therapy, behaviour therapy, and cognitive‐behavioural therapy (CBT).

Binge‐Eating Disorder Binge‐eating disorder (BED) is an eating disorder characterized by repeated episodes in which binge eating occurs but is not followed by purging.

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Sleep‐Wake Disorders Sleep disorders form a diagnostic category representing persistent or recurrent sleep‐related problems that cause significant personal distress or impaired functioning. Polysomnographic (PSG) recording, the simultaneous measurement of multiple physiological responses during sleep or attempted sleep, is used to assess sleep disorders.

Insomnia Disorder People suffering from insomnia disorder difficulties falling asleep, remaining asleep, or achieving restorative sleep. University of Ottawa psychologists found that high levels of anxiety were associated with moderate to severe sleep‐onset chronic insomnia (Viens, De Koninck, Mercier, St‐Onge, & Lorrain, 2003).

Hypersomnolence Disorder In people suffering from hypersomnolence disorder, a persistent pattern of excessive sleepiness during the day is observed; these persons do not feel refreshed after daytime naps.

Narcolepsy Narcolepsy is a sleep–wake disorder characterized by sudden, irresistible episodes of sleep (sleep attacks). It is accompanied by cataplexy, a brief, sudden loss of muscular control, typically lasting from a few seconds to as long as two minutes.

Breathing‐Related Sleep Disorders People with breathing‐related sleep disorders experience repeated disruptions of sleep due to respiratory problems (APA, 2013). These frequent disruptions of sleep result in insomnia or excessive daytime sleepiness. Apnea Temporary cessation of breathing. Obstructive sleep apnea hypopnea is a type of breathing‐related disorder involving repeated episodes of either complete or partial obstruction of breathing during sleep.

Circadian Rhythm Sleep–Wake Disorders Circadian rhythm sleep–wake disorders are sleep disorders characterized by disruption of sleep caused by a mismatch in sleep schedules between the body’s internal sleep–wake cycle and the demands of the environment. The disruption in normal sleep patterns can lead to insomnia or hypersomnia.

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Parasomnias Parasomnias, a category of sleep–wake disorders, involves the occurrence of abnormal behaviours or physiological events during sleep or at the transition between wakefulness and sleep; it is further divided into disorders associated with REM sleep and those associated with non REM sleep.

Treatment of Sleep–Wake Disorders The most common pharmacologic method for treating sleep–wake disorders in Canada is the use of sleep medications called anxiolytics. However, because of problems associated with these drugs, nonpharmacological treatment approaches, principally cognitive‐behavioural therapy, have come to the fore.

Chapter Outline: Feeding and Eating and Sleep‐Awake Disorders 292 Feeding and Eating Disorders 293 Anorexia Nervosa 294 Bulimia Nervosa 297 Causes of Anorexia and Bulimia 299 Treatment of Anorexia Nervosa and Bulimia Nervosa 304 Binge‐Eating Disorder 307 REVIEW IT Eating Disorders 307 Sleep‐Wake Disorders 307 Insomnia Disorder 308 Hypersomnolence Disorder 309 Narcolepsy 309 Breathing‐Related Sleep Disorders 310 Circadian Rhythm Sleep–Wake Disorders 311 Parasomnias 312 Treatment of Sleep‐Wake Disorders 314 REVIEW IT Sleep‐Wake Disorders 317 CONCEPT MAP 319

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Students Should Be Able to: 1.

2.

3.

4.

Describe the major types of eating disorders.

Discuss some of the factors involved in major types of eating disorders.

Describe the major types of sleep–wake disorders.

Discuss the major forms of treatment for sleep–wake disorders.

Lecture and Discussion Suggestions: 1. Losing weight. Have students share their ideas regarding the best way to lose weight.

People generally talk about dieting and diet‐oriented foods. Yet the most effective ways to lose weight inevitably involve eating less, especially less fat, and exercising more. Also, the most effective weight‐loss programs generally include behavioural training to provide greater awareness and control of one’s eating and exercise habits.

2.

Anorexia nervosa and bulimia nervosa. Although anorexia nervosa and bulimia nervosa occur relatively rarely in their full‐blown clinical form, many students report having known or currently knowing someone who shows some of the behaviours associated with these disorders. Ask students to describe the situation they encountered. What sort of personality and family dynamics would they associate with the disorders from their observations?

Anorexia and bulimia are also being seen more commonly among younger and younger women. Where once they were only found in college, it is now not that uncommon to see high schoolers and even middle schoolers showing behaviours associated with these disorders. Since our culture’s ultra‐thin standards for attractiveness go back to the “Twiggy” era of the 1960s, why are we seeing these increases among younger women now?

3. Binge‐Eating Disorder. Have students discuss their own binge‐eating and whether or not it is a concern. Alternately have them discuss the binge‐eating of someone with this disorder.

It is important to understand the difference between anorexia nervosa, bulimia nervosa, and binge‐eating disorder.

4. Obesity Discrimination. While obesity is a major health problem in our country, many overweight and obese people complain that they are unfairly discriminated against because of their weight. Have students encountered any examples of this? Do they see this as a problem? Cases of alleged discrimination against obese people have led to the formation of clubs, support groups and other activist groups aimed at combating such discrimination or building the self‐ esteem of overweight people, through “big is beautiful” or other similar campaigns. Do students feel these campaigns help obese people fight legitimate discrimination or do they promote denial among obese people of a serious health problem?

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5. Hidden Calories in Food. The “hidden” calorie content of many foods surprises even experienced dieters and often frustrates their efforts to lose weight. For example, ask your students this question: “Which of these drinks contains the most calories and which the fewest calories per fluid ounce: Coca Cola, orange juice, or tomato juice?” It might surprise them to learn that orange juice actually contains the most calories, Coca Cola the second most, and tomato juice the fewest. Many dieters avoid sugared soft drinks such as Coke or Pepsi like the proverbial plague, but unknowingly consume even more calories by drinking concentrated fruit juices like orange juice or grapefruit juice (yes, grapefruit juice is also loaded with calories). This is not to suggest that highly sugared soft drinks are preferable to juices, because juices have other nutritional values lacking in the soft drinks. However, the point is that dieters should be aware that some juices, like tomato juice, offer nutritional value, taste, and are low in calories. Others, like orange juice, offer nutritional value and taste, but are not low in calories. This is but one illustration of hidden calories. Most supermarkets carry the small pocket books listing calories and nutritional contents of common foods. It might be informative for your calorie‐conscious students to review some of this information in class.

6. Common Sense and Weight Control. When dealing with weight control, always urge common sense. While frustration with one’s weight and with efforts to lose weight is often understandable, warn that the desire for a “quick fix” regarding weight loss almost always leads to discouragement and greater frustration in the long run. Have students list weight control strategies geared toward long‐term change.

7. Regular Exercise. Ask students what types of exercise they engage in and how often.

Discuss the material in the text about the long‐term benefits of exercise. You might point out that while exercise has benefits at any age, the benefits appear to be maximized if a regular exercise program is begun while the person is still young and healthy. Research findings indicate that it slows down or even reverse the muscle loss and stiffening associated with aging. It also seems to counteract anxiety and depression and helps people effectively cope with stress.

8. Nightmares and “falling” dreams. In discussing nightmares, ask how many class members have had dreams of falling into a “bottomless” pit or void. Or just falling off a building or cliff? Many have probably heard the old adage that if you “hit bottom, you will die.” You might point out to students that there is no evidence that this is true and that some people have reported hitting bottom, and although frightening, it was obviously not fatal, since they lived to tell about it. For most people the very fear of such a dream will usually wake them up before they hit bottom. How many class members have had dreams about flying or floating? This is another common dream experience that may have led to many people reporting that their “soul” or “astral body” has left their physical body during these periods.

Again, you might point out that there is no replicated empirical evidence to date to support the “astral projection” claims, but that dreams of flying and falling are quite common.

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How many class members have had nightmares in which they were trying to run away from something but they could not get their feet and legs to move? This is another common experience that may be related to the fact that during REM sleep, most of the voluntary muscles below the head are effectively limp, or paralyzed, and are incapable of movement.

It may be that during these nightmares, the brain becomes aware that the legs aren’t moving and incorporates that fact into the dream itself 9. Sleep and Depression. Discuss the connection between steep and stress or sleep and depression. You might point out that when people are mildly depressed or stressed out they often require more sleep. Some students who “burn the candle at both ends” sleep constantly but are still consistently exhausted. Instructors hear a problem called “student sleep syndrome” by many college counseling centre staff, as the condition tends to be associated with the stress of trying to juggle classes, a social life, and/or family life, as well as part‐time or full‐time work. This condition is not unique to a few students only, but reflects their situation and will usually disappear when their stress levels are reduced.

Students should be cautioned, however, that any physical condition that is not normal for them should be checked out by their physician, just to be sure.

10. Home Remedies for Insomnia. Ask students to list some common home remedies for battling insomnia. Among the methods commonly mentioned are counting sheep, making one’s mind go blank by thinking of nothing, focusing on slow, deep, relaxed breathing, drinking a glass of warm milk, and so forth. Point out that most of these methods, except the milk drinking, involves the meditative practice of inducing relaxation through a process of narrowing attention. Discuss how other techniques, such as progressive relaxation and the use of fantasy, can also be used to create a relaxed state compatible with sleep induction. Point out, too, that one of the other problems with using sleeping pills, not mentioned in the text, is that sleeping pills may alter the amount of time that a person spends in the various stages of sleep. So, a person might get a full night’s sleep by using sleeping pills but may not get the optimally restful and healthy quality sleep he or she really needs.

You might point out that drinking milk before bedtime to induce sleep actually has some scientific support. Milk, as does turkey, contains the chemical precursor L‐ tryptophan, which, when digested, causes the brain to increase production of neurotransmitters associated with relaxation and sleep. In addition, it has been noted for centuries that people typically feel drowsy after eating. For example, the Mexican “siesta,” or after‐lunch rest, is probably no accident. This drowsiness effect of eating and digesting food may help people who eat a small snack before bedtime actually get to sleep faster, although it will probably work better if the snack does not contain a lot of caffeine or simple sugars (such as coffee with a slice of cake or a sugar doughnut).

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11. Personal Accounts of Sleep Disorders. It is found that when sleep disorders are discussed with students, usually several students either have suffered from sleep disorders themselves or know someone firsthand who has suffered from them. Ask students about this, in terms of how it affected their lives and their jobs or careers. Were they misdiagnosed at first (which is not uncommon), and what effects did they suffer from this?

What was done to help them cope with or correct the problems they experienced?

Related to this, if you are fortunate enough to have a sleep disorder clinic in your area, see if you can have someone from the clinic talk to your class about their experiences.

Student Activities: 1. Fear of Fat. You might discuss with your students, various research articles indicating that beginning in early adolescence, women tend to have more negative self‐body‐images than do men. In particular, they are more likely to think they are too fat (men with negative body images are more likely to think they are too thin). You can use this discussion as a tool for exploring how distorted self‐images can lead to eating disorders.

2. The Body Shape Questionnaire. As an extension to suggestion 1 (above), you might have students take the “The Body Shape Questionnaire” on page 304 in the text. Discuss their results in terms of how they compare to research studies on women’s and men’s body images and body shapes.

3. Eating Binges. Many college women have eating binges, although very few involve purging.

Students might anonymously contribute personal examples, or could survey friends about the frequency of eating binges. It would also be of interest to collect the thoughts of women about the so‐called passion for thinness in this country. How strongly and in what ways do they feel these pressures?

4. How Long to Fall Asleep? Ask students to describe what they do to fall asleep and how long it usually takes them. As a class exercise, it could be interesting to examine these records to see if sleep styles correlate with sleep latencies. Expect those students who engage in more structured rituals have longer sleep latencies and perhaps more healthy sleep patterns. Of course, this doesn’t establish causal patterns ‐ sleep rituals may be a response to underlying sleep disturbances rather than vice versa.

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Online Discussion questions: 1.

Eating disorders are caused by unhealthy and unrealistic images in the media. Discuss.

2.

Eating disorders are primarily a North American phenomenon. Discuss.

3.

You can make up for lost sleep during the week by sleeping in on weekends. Discuss.

Online Resources: Eating Disorders www.phac‐aspc.gc.ca/publicat/miic‐mmac/pdf/chap_6_e.pdf This site links to a chapter on eating disorders from Health Canada’s A Report on Mental Illness in Canada.

Internet Mental Health http://mentalhealth.com/dis/p20‐et01.html The Internet Mental Health site has links to information about anorexia nervosa and bulimia.

Bulimia Anorexia Nervosa Association http://www.bana.ca This site offers Canadian‐focused information and support for eating disorders.

National Eating Disorder Information Centre (NEDIC) www.nedic.ca This site provides Canadian information and resources on eating disorders and weight preoccupation.

Canadian Sleep Society (CSS) www.css.to The CSS’s website has information on research on sleep, and links to treatment centers.

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Video Resources: Anorexia, 28 min. colour (Films for the Humanities and Sciences). Special Phil Donahue show with anorexics and a physician specializing in the treatment of anorexia.

Anorexia and Bulimia, 19 min. colour (Films for the Humanities and Sciences). Explains the addictive nature of these disorders and describes their effects on the cardiovascular and central nervous systems.

Bulimia, 20 min. colour (Research Press). The causes and effects of bulimia are discussed.

Diet Unto Death: Anorexia Nervosa, 17 min. colour (MIT Teleprograms). Shows anorexic patients in a hospital setting.

Dream Voyage, 26 min. colour (Films for the Humanities and Sciences). Explores the functions and stages of sleep, focusing particularly on REM sleep.

Dreams: Theatre of the Night, 28 min. colour (Films for the Humanities and Sciences). Explores the various theories and facts regarding the causes of dreaming and the meaning of dreams.

Eating Disorders, 26 min. colour (Films for the Humanities and Sciences). Explores the personality profiles of the people most likely to develop eating disorders.

Sleeping and Dreaming, 30 min. colour (Insight Media). Leading sleep researchers discuss the mechanics of sleep and possible purposes for sleeping and dreaming. Also explored are various types of sleep disorders.

The Fat Fighters, 21 min. colour (Brigham Young University). Follows eight overweight women in a weight reduction program. Demonstrates the role of social variables such as social attitudes, will power, hunger, and so on.

The Psychology of Eating, 27 min. colour (Harcourt Brace). Explores the various biological and psychological factors that affect eating.

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Chapter 9 Gender Dysphoria, Paraphilic Disorders and Sexual Dysfunctions Chapter Overview: Gender Dysphoria In gender dysphoria an individual experiences significant personal distress or impaired functioning as a result of a discrepancy between his or her anatomic sex and gender identity.

Theoretical Perspectives Psychodynamic theorists point to extremely close mother–son relationships, parents with empty relationships, and fathers who were absent or detached (Stoller, 1969). Learning theorists similarly point to father absence in the case of boys—to the unavailability of a strong male role model. Prenatal hormonal imbalances may also be involved. Perhaps the brain is “masculinized” or “feminized” by sex hormones during certain stages of prenatal development.

Treatment of Gender Dysphoria Recommended treatments of gender dysphoria include hormone therapy, real‐life experience (living as the identified gender), sex reassignment surgery, and psychotherapy (Coleman et al., 2012).

Paraphilic Disorders Types of Paraphilic Disorders Paraphilic disorders are types of sexual disorders in which a person experiences recurrent sexual urges and sexually arousing fantasies involving nonhuman objects (such as articles of clothing), inappropriate or nonconsenting partners (e.g., children), or situations producing humiliation or pain to oneself or one’s partner. The person has either acted on such urges or is strongly distressed by them. Types of paraphilic disorders discussed in the text include exhibitionistic disorder, fetishistic disorder, transvestic disorder, voyeuristic disorder, frotteuristic disorder, pedophilic disorder, sexual masochism disorder, hypoxyphilia, sexual sadism disorder, and sadomasochism.

Theoretical Perspectives Psychodynamic theorists see many paraphilic disorders as defences against leftover castration anxiety from the Oedipal period. Learning theorists explain paraphilic disorders in terms of conditioning and observational learning (Pfaus, Kippin, & Centeno, 2001; Seto, 2004); some object or activity becomes inadvertently associated with sexual arousal. paraphilic disorders may involve multiple biological, psychological, and sociocultural factors. ..

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Treatment of Paraphilic Disorders Therapists of various theoretical persuasions have attempted to treat clients with paraphilic disorders. Psychoanalysts, for example, attempt to bring childhood sexual conflicts (typically of an Oedipal nature) into awareness so they can be resolved in the light of the individual’s adult personality. Behaviour therapists have used aversive conditioning to induce a negative emotional reaction to paraphilic stimuli or fantasies. Selective serotonin‐reuptake inhibitors (SSRIs) are used in treating exhibitionism, voyeurism, and fetishism (Thibaut, 2011, 2016) Efforts to treat paraphilias are compromised by the fact that most people with these disorders do not wish to change.

Sexual Assault Sexual Assault is a violent crime, not a sexual disorder. The desires to dominate women or express hatred toward them may be more prominent motives for rape than sexual desire. A sociocultural perspective suggests that cultural attitudes, such as stereotype of male aggressiveness and social dominance, underlie propensities to rape. Rape survivors often suffer a range of immediate and long‐ term effects.

Sexual Dysfunctions Types of Sexual Dysfunctions Sexual dysfunctions involve problems with sexual interest, arousal, or response, and can be grouped into the following categories: (1) disorders involving problems with sexual interest or arousal; (2) disorders involving problems with orgasmic response; and (3) problems involving pain during sexual intercourse or penetration (in women).

Theoretical Perspectives Sexual dysfunctions, like most psychological disorders, reflect a complex interplay of biological, psychological, and other factors. Sexual dysfunctions can stem from biological factors (such as disease or the effects of alcohol and other drugs), psychological factors (such as performance anxiety, unresolved conflicts, or lack of sexual competencies), and sociocultural factors (such as sexually restrictive cultural learning).

Treatment of Sexual Dysfunctions Sex therapy focuses on directly modifying problematic sexual behaviour by enhancing self‐ efficacy expectancies, teaching sexual competencies, improving sexual communication, and reducing performance anxiety.

..

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Chapter Outline: Gender Dysphoria, Paraphilic Disorders, and Sexual Dysfunctions 321 Gender Dysphoria 323 Theoretical Perspectives 326 Treatment of Gender Dysphoria 327 REVIEW IT Gender Dysphoria 328 Paraphilic Disorders 328 Types of Paraphilic Disorders 328 Theoretical Perspectives 335 Treatment of Paraphilic Disorders 336 Sexual Assault 337 REVIEW IT Paraphilic Disorders 341 Sexual Dysfunctions 342 Types of Sexual Dysfunctions 342 Theoretical Perspectives 345 Treatment of Sexual Dysfunctions 349 REVIEW IT Sexual Dysfunctions 353 CONCEPT MAP 355 Students Should Be Able to: 1.

2.

3.

4.

5.

6.

7.

8.

9.

Describe gender dysphoria.

Explain how gender dysphoria is different from sexual orientation.

Define and describe the features of paraphilic disorders.

Describe the major types of paraphilic disorders.

Explain the causes of paraphilic disorders, and what makes them so difficult to treat.

Discuss the factors underlying tendencies to sexually assault Discuss the major types of sexual dysfunctions.

Identify the causes of sexual dysfunctions.

Review the major goals of sex therapy.

..

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Lecture and Discussion Suggestions: 1. Survey methods used to study sexual behaviour. Students are likely to have read surveys of sexual attitudes in various magazines or books. Many of these surveys imply that their findings are representative of most Americans. Rarely, though, it is possible to make this claim with any confidence. Most of the surveys by magazines are based on the responses of their readers. Thus, answers only come from those readers of their magazine who were interested in answering the survey and motivated to mail it back to the magazine.

Telephone surveys can suffer from the same problem. Some well‐known books have been written based on a response rate of one person in five. Most people hang up or refuse to talk. Without a carefully drawn sample, telephone surveys are not representative.

Many studies of sexual beliefs and attitudes have been done in academic settings, with students as subjects. Some researchers call this convenience sampling, since students are readily available in large numbers. This group tends to be white, middle class, and, of course, well‐educated. Their sexual behaviour may not be representative of sexual behaviour in other segments of society.

No study can perfectly represent the general population. The consumer of this type of research should carefully examine the sampling procedure used in any survey.

2. Transvestites and homosexuality. When a popular columnist wrote that all transvestites are either homosexual or bisexual, she received a flood of angry responses from hundreds of transvestites, their wives, and girlfriends. Most letters asserted that cross‐dressing occurs mostly among married men with a heterosexual orientation. After checking with several distinguished psychiatrists, the columnist printed a retraction stating that some transvestites may be either homosexual or bisexual, but the majority are heterosexual. They simply derive pleasure out of dressing up in women’s clothes on occasion, but that is as far as they go.

3. Androgens and female sex drive. Androgens (masculinizing sex hormones) may have an even stronger effect on female sexual desire than on male sexual desire. Experimental and clinical evidence suggests that increasing androgen levels will increase female sex drive and that reducing androgen levels will reduce sex drive. Androgen therapy is not recommended in most cases of low female sex drive because of its marked masculinizing side‐effects, including clitoral enlargement, body and facial hair growth, and voice changes. Variations in estrogen levels do not seem to affect sexual desire in females.

..

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4. The “PLISSIT” model of sex therapy. Describing the techniques of therapy for sexual dysfunction may be enhanced by presentation of the “PLISSIT” model, which contains the following elements: Permission Limited Information Specific Suggestions Intensive Therapy The model suggests that sex therapy proceeds from one level to the next depending on the couple’s (or individual’s) needs and the likely etiology of the presenting problem. For some people, permission and limited information may be enough to overcome their sexual dysfunction; lengthier or “in‐depth” therapy is often unnecessary.

Permission involves giving the individual explicit permission to be sexual, without making judgments. This may be an important step for someone whose sexual dysfunction is rooted in religious or parental prohibitions, which have prevented them from finding sex enjoyable or relaxing.

Limited information refers to giving the person basic facts about human sexuality, which they may never have learned, such as the importance of clitoral stimulation for women to reach orgasm. This is the level of “therapy” that Dr. Ruth employs, which is quite helpful for many people.

Specific suggestions are the meat of behavioural sex therapy, involving teaching techniques known to help alleviate particular sexual dysfunctions. The suggestions are tailored for the individual presenting problem.

While the vast majority of sex therapy cases involve only the first three levels, intensive therapy may be necessary in some cases. For example, some couples find themselves unable to follow the specific suggestions (homework assignments), and the therapist needs to find out why. A person with deep ambivalence about sexual pleasure, for example, may be unable to enjoy sensate focus exercises. A person who was sexually molested as a child may find intercourse frightening and threatening, and be unable to complete homework assignments with his or her spouse.

5. Sexual fantasies. Discuss the use of sexual fantasies. Ask students whether people who rely on such fantasies are normal or disturbed. Actually, sexual fantasies serve a variety of purposes, ranging from the reduction of anxiety to focusing one’s thoughts and feelings, thereby avoiding distraction. Sexual fantasies are especially helpful in counteracting boredom, a major obstacle in long‐term relationships.

6. Exhibitionism. Ask students how they would react if confronted by an exhibitionist. Point out that exhibitionists count on evoking shock and embarrassment in their victims. In contrast, simply viewing the exhibitionist with indifference and continuing on one’s way and then notifying the authorities may discourage future acts.

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7. Paraphilias. Discuss the fact that most people exhibiting the paraphilias are men. Some authorities point out that the prevalence of these disorders among men is partly attributable to the fact that the data comes from arrest records and men are more likely than women to be arrested. Another view is that female sexuality, especially in the past, has been repressed in the process of socialization. A third view is that males have less latitude in regard to sexual behaviour than females do. Thus, women may wear either skins or pants, but men who don skirts are regarded by our culture as abnormal.

8. Attitudes toward homosexuality. Men and women hold different attitudes toward homosexuality. Women are more lenient and accepting of homosexual behaviour among men. What might account for difference in attitudes about homosexual behaviour among males?

9. Tomboys and sissies. The terms “tomboy” and “sissy” denote similar concepts: children of one gender who engage in behaviours that are stereotyped as being appropriate for the opposite gender. 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 gender roles? We often think of females as having the more narrowly defined cultural gender role, but is that really the case?

10. Gay bashing. Recent cases in which gay males have been brutally tortured and killed because they were gay have pointedly reminded us that homophobia and hatred of gay males and lesbians are still very prevalent in some segments of North American society.

How do students feel about this issue? Is gay bashing any different than other forms of prejudice? Is it ever justified? What can be done, if anything, to help alleviate this problem?

11. Date rape. It is widely believed that the majority of rapes still go unreported, particularly date rapes. It may be worthwhile to ask students what they believe constitutes date “rape” as opposed to just having sex on a date. Many students, particularly male students, have misconceptions on what constitutes “rape” on a date. Many males are still convinced that if they pay for dinner, etc. on a date, or if a female invites them into her room, etc., that they have somehow earned the “right,” or she has given them “permission” to have sex with her.

Many are not sure how to read the mixed signals that some females send regarding sexual activity, often seeing what they want to see instead of attending to the entire message.

Some still believe that when a woman says “No!” she is just playing “hard to get” or is trying to preserve her “reputation” by not seeming too “easy,” but she really means yes.

It is important to instill in students mind that no matter how mixed the signals may be, that when someone says “No!” or “Stop,” or physically resists even if nothing definitive is said, failure to stop is legally considered to be rape and could result in charges being filed.

Presenting a few verbal accounts from date rape survivors of the effects the rape had on them can provide a very sobering and eye‐opening experience for students.

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12. Performance anxiety. Studies by Barlow (1986) seem to provide some insight into the role of performance anxiety in disorders of sexual function for men. “Normal” subjects and subjects who had reported difficulty achieving erection were asked to watch sexually arousing films. In one condition, subjects were instructed to “achieve their best erections.”

In the other condition, subjects were not pressured to perform (in terms of achieving an erection). Those subjects who experienced sexual dysfunction difficulties prior to the experiment produced their best erections when there was no performance demand, and had difficulty achieving erection in the “performance” condition. This study offers clear evidence that performance anxiety can play an important role in male erectile failure.

Barlow, D. H. (1986). “Causes of Sexual Dysfunction: The Role of Anxiety and Cognitive Interference”, Journal of Consulting and Clinical Psychology, 54, 140‐ 148.

Student Activities: 1. Gender differences in personal space. Have all the males in the class stand in two equal lines facing each other from across the room. Instruct them to slowly walk toward the person opposite them, stopping at a place where they feel comfortable with the distance between themselves and their “partners.” After noting the distance, ask the partners to approach each other as closely as they feel comfortable. Then have them sit down. Now repeat the procedures with the female students. If you have time, you might repeat the procedure again with mixed‐gender couples. After you have completed the exercise, ask students to share their feelings and observations. Do you find that the males are more hesitant to get close to other males? Point out that in our society females tend to be more comfortable at closer distances with males and with females than males do.

2. What is normal? Construct a list of sexually related behaviours and have students rate how normal each is. A good example is found in Kite (1990). Students first complete the survey, then break into groups. The task of each group is to build a definition of what is normal sexual behaviour, and what is not. Let the groups present their definitions for class discussion. Kite reports that students have difficulty separating normal from abnormal.

Remind students that for most paraphilias, the DSM states that the diagnosis requires either impairment in behaviour or personal distress—without these, a fetish or cross‐dressing would not be considered abnormal by the DSM. 3. Sexual concerns and questions. Ask students to jot down on a 3 x 5 card any concerns or questions they might have about sexuality, including the variations in sexual behaviour.

Then pick up the cards. It’s often helpful to have the cards completed at least one class period before the one in which you plan to respond to the questions, giving yourself time to look over the questions, do any necessary research, and make any desired notes. During class, read a card, comment on it, and then invite comments and discussion from the class.

In some cases, it may be more interesting to invite comments from the class before you make your comments. This exercise usually elicits questions students may be reluctant to ask directly in class. ..

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4. Sexuality laws. Many paraphilias are illegal in addition to being disorders. Have students collect information on the laws in your area. What sexual behaviours are illegal? What are the penalties? Students could also collect information, perhaps from police, about how many people are arrested and charged with these offenses. This information can be used to generate discussion or societal views of sexual behaviour in general, and the paraphilias in particular.

5. Community resources. Most areas have many different resources available for helping survivors of rape and abuse, as well as for helping abusers. Have students compile a list of various crisis intervention centers, rape victim treatment centers, organizations that provide “safe houses” and counseling for rape and abuse victims, and family crisis and counseling centers in your area.

6. Sexual harassment. Have students generate a list of some hypothetical workplace or school situations ranging from what could be considered “borderline” harassment situations (someone telling an “off‐colour” joke in the office/faculty lounge) to blatant harassment situations (someone demanding sex for a grade or a promotion) and have students discuss whether they believe each situation is harassment or not. Be prepared to add several “borderline” situations of your own. Focusing on several “borderline” situations and discussing why even borderline cases are harassment if someone is threatened or uncomfortable by the situation, can be useful for students, who often think of harassment only in terms of the blatant situations. Many do not understand the liability a company faces for failing to deal with harassment complaints, which is why most companies take harassment very seriously. You might emphasize that just allowing a “hostile atmosphere” to exist where harassment can take place leaves a company liable for a lawsuit.

You also might ask students (sensitively) if they know of anyone who has been harassed, how they dealt with it and what impact it had on them. Some students may volunteer first‐ hand accounts, which must be handled respectfully and carefully.

Online Discussion questions: 1. Most people who were sexually abused in childhood develop sexual paraphilias, sexual dysfunctions and/or severe personality disturbances in adulthood. Discuss.

2. Gender is a social construction, not a biological imperative. Discuss.

3. Sexual paraphilias are not real psychological disorders. Discuss.

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Online Resources: SexualityandU.ca http://www.sexualityandu.ca/ One of the best sources of sexuality information for young adults in Canada. Includes information for young people, parents, and physicians backed by current research.

Board of Examiners in Sex Therapy & Counselling in Ontario http://www.bestco.info/ The BESTCO organization set standards for the granting of registered status in sex therapy. It also identifies clinicians who have expertise in sex therapy.

Notes on Gender Role Transition www.avitale.com This website contains information on gender identity disorder and some paraphilias.

The Lesbian, Gay, Bisexual, and Transgender Community Center www.gaycenter.org This site provides information on gender identity disorder.

Gender Identity Clinic http://www.camh.ca/en/hospital/care_program_and_services/A‐ Z_Directory_of_Programs_and_services/Pages/A‐Z‐Directory‐of‐Programs‐ Services1.aspx?select=G This site describes programs and services available from Toronto’s Centre for Addiction and Mental Health: select “G” to access “Gender identity Clinic”.

Video Resources: The Boys in the Band, Black and White (Swank). Based on the Broadway play. Depicts the conflicts and various roles experienced by gay men in the 1960s.

Childhood Sexual Abuse, 26 min. colour (Films for the Humanities and Sciences). Explains how adult women cope with the problems caused by abuse. Also explores how abuse spreads throughout a family and why children keep quiet about it.

Dating Rites: Gang Rape on Campus, 30 min. colour (Filmmaker’s Library). Four Men Speak Out on Surviving Childhood Sexual Abuse, 28 min. colour (Varied Directions International).

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Homosexuality, 26 min. colour (Films for the Humanities and Sciences). Explores the origins of human sexuality and the basis of sexual orientation.

Homosexuality: What About McBride? 10 min. colour (CRM). Friends on a raft trip argue over their questions and anxieties about homosexuality.

Killing Us Softly, 30 min. colour (Cambridge Documentary Films). Shows how women are portrayed in advertising.

The Lust Taboo: Incest, 28 min. colour (Motorola Teleprograms). Portrays six victims of childhood sexual abuse, including the long‐term damage from such experience and subsequent recovery.

Michael: A Gay Son, 27 min. colour (Filmmaker’s Library). Explores the difficulties in disclosing a gay male sexual orientation to one’s family.

No More Secrets, 24 min. colour (Films for the Humanities and Sciences). Discusses the long‐ term damage that can result from childhood sexual abuse.

Normalcy— What Is It? 29 min. 2” colour videotape (PUBTEL). Illustrates a variety of definitions of normalcy and explores the idea of normalcy in sexual behaviour.

Pink Triangles, 35 min. colour (Cambridge Documentary Films). Describes attitudes toward lesbians and gay men, with an emphasis on homophobia. Rape: An Act of Hate, 30 min. colour (Films for the Humanities and Sciences). Explores myths of rape, why people rape, and how people can protect themselves from rape.

Rape and DNA Testing, 28 min. colour (Films for the Humanities and Sciences). Specially adapted Phil Donahue program examines the pros and cons of using DNA testing in rape cases.

Rape Culture, 35 min. colour (Cambridge Documentary Films). Discusses the link between social attitudes and rape, questioning the views toward rape in our society.

Rape: It Can Happen to You, 17 min. colour (AIMS Media). Five women rape survivors discuss their rapes and the value of self‐protection and common sense.

Sex Differences in Children’s Play, 16mm colour (PCR). Demonstrates sex differences in the play of young children.

Sex Hormones and Sexual Destiny, 26 min. colour (Films for the Humanities and Sciences).

Explores biological and environmental factors that influence masculine and feminine behaviour, as well as left‐brain/right‐brain effects on behaviour.

Sexes: Breaking the Barriers, 22 min. colour (UCEMC). Includes a discussion with Masters and Johnson, a nude encounter and therapy group, scenes of a homosexual wedding between two men, and a brief description of gay liberation movement activities.

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Sexual Dysfunction, (19 min. (Films for the Humanities and Sciences). The psychological causes of sexual dysfunction are explored.

Sexuality: The Human Heritage, 59 min. colour (AVC). Points out the various factors influencing the development of sexual identity.

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Chapter 10 Schizophrenia Spectrum and Other Psychotic Disorders Chapter Overview: Clinical Features of Schizophrenia Historical Contributions to Concepts of Schizophrenia Emil Kraepelin was the first to describe the syndrome we identify as schizophrenia. He labeled the disorder dementia praecox and believed that it was a disease that develops early in life and follows a progressively deteriorating course. Eugen Bleuler renamed the disorder schizophrenia and believed that its course is more variable. He also distinguished between primary symptoms (the four A’s, namely, associations (disturbed), affect (inappropriate), ambivalence (of feelings), and autism (withdrawal into a private fantasy world)), and secondary symptoms of hallucinations and delusions. Kurt Schneider distinguished between first‐ rank symptoms that define the disorder and second‐rank symptoms that occur in schizophrenia and other disorders.

Prevalence and Costs of Schizophrenia According to the best estimates, about 1% of the adult Canadian population suffers from schizophrenia at some point in their lives (Statistics Canada, 2012a).

Phases of Schizophrenia Schizophrenia usually develops in late adolescence or early adulthood. Its onset may be abrupt or gradual. The period of deterioration preceding the onset of acute symptoms is called the prodromal phase. An acute episode involves the emergence of clear psychotic features. The residual phase is characterized by a level of functioning that was typical of the prodromal phase.

Major Features of Schizophrenia Among the more prominent features of schizophrenia are disorders in the content of thought (delusions) and form of thought (thought disorder), disorganized speech, as well as the presence of perceptual distortions (hallucinations), emotional disturbances (flattened or inappropriate affect), and grossly disorganized or catatonic behaviour. There are also dysfunctions in the brain processes that regulate attention to the external world.

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Theoretical Perspectives Psychodynamic Perspectives In the traditional psychodynamic model, schizophrenia represents a regression to a psychological state corresponding to early infancy in which the proddings of the id produce bizarre, socially deviant behaviour and give rise to hallucinations and delusions.

Learning Perspectives Learning theorists propose that some form of schizophrenic behaviour may result from lack of social reinforcement, which leads to gradual detachment from the social environment and increased attention to an inner world of fantasy. Modeling and selective reinforcement of bizarre behaviour may explain some schizophrenic behaviours in the hospital setting.

Biological Perspectives Research has demonstrated strong linkages between biological factors and schizophrenia.

Evidence for genetic factors comes from studies of family patterns of schizophrenia, twin studies, and adoption studies. The mode of genetic transmission remains unknown. Most researchers believe the neurotransmitter dopamine plays a role in schizophrenia, especially in the more flagrant features of the disorder. Viral factors may also be involved, but definite proof of viral involvement is lacking. Evidence of brain dysfunctions and structural damage in schizophrenia is accumulating, but researchers are uncertain about causal pathways.

The Diathesis‐Stress Model The diathesis‐stress model posits that schizophrenia results from an interaction of a genetic predisposition (the diathesis) and environmental stressors (e.g., family conflict, child abuse, emotional deprivation, loss of supportive figures, and early brain trauma).

Family Theories Family factors such as communication deviance and expressed emotion (EE) may act as sources of stress that increase the risk of development or recurrence of schizophrenia among people with a genetic predisposition.

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Treatment Biological Approaches Treatment of schizophrenia tends to be multifaceted, incorporating pharmacological and psychosocial approaches. Antipsychotic medication is not a cure but tends to stem the more flagrant aspects of the disorder and to reduce the need for hospitalization and the risk of recurrent episodes.

Psychoanalytic Approaches Psychoanalytic approaches have not been shown to be effective in treating schizophrenia.

Learning‐Based Approaches Learning‐based approaches, such as token‐economy systems, and cognitive‐behavioural interventions with social‐skills training, have achieved some successes in increasing adaptive behaviour among people with schizophrenia.

Psychosocial Rehabilitation Psychosocial‐rehabilitation approaches help people with schizophrenia adapt more successfully to occupational and social roles in the community.

Family‐Intervention Programs Family intervention programs help families cope with the burden of care, communicate more clearly, and learn more helpful ways of relating to the patient.

Early‐Intervention Programs There are two main forms of early intervention. The first is to initiate treatment as early as possible once the person has developed schizophrenia, and the second is to intervene before the onset of schizophrenia (i.e., prevention programs).

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Chapter Outline: Schizophrenia Spectrum and Other Psychotic Disorders 357 Clinical Features of Schizophrenia 359 Historical Contributions to Concepts of Schizophrenia 359 Prevalence and Costs of Schizophrenia 360 Phases of Schizophrenia 362 Major Features of Schizophrenia 362 REVIEW IT Clinical Features of Schizophrenia 369 Theoretical Perspectives 369 Psychodynamic Perspectives 369 Learning Perspectives 370 Biological Perspectives 370 The Diathesis‐Stress Model 375 Family Theories 378 REVIEW IT Theoretical Perspectives 381 Treatment 381 Biological Approaches 382 Psychoanalytic Approaches 383 Learning‐Based Approaches 383 Psychosocial Rehabilitation 385 Family‐Intervention Programs 385 Early‐Intervention Programs 386 REVIEW IT Treatment Approaches 387 CONCEPT MAP 389

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Students Should Be Able to: 1. Discuss what schizophrenia is, and its prevalence.

2. Identify the key historical figures in psychiatry who influenced our conceptions of schizophrenia 3. Explain the major phases of schizophrenia.

4. Discuss the most prominent features of schizophrenia.

5. Evaluate how schizophrenia is conceptualized in traditional psychodynamic theory and learning perspectives.

6. Discuss what is known about the biological bases of schizophrenia.

7. Explain how schizophrenia is conceptualized in the diathesis‐stress model.\ 8. Discuss how family factors are related to the development and course of schizophrenia.

9. Explain how the treatment of schizophrenia involves a multifaceted approach.

10. Describe the types of psychosocial interventions have shown promising results in the treatment of schizophrenia.

Lecture and Discussion Suggestions: 1. Famous Schizophrenics. Students, like the general public, often think schizophrenia is synonymous with chronic impairment. Yet, some people who have suffered from schizophrenia also have achieved fame. Psychiatrist J. Ingram Walker, in his book Everybody’s Guide to Emotional Well‐Being (San Francisco: Harbor Publishing, 1982), tells of several such people.

Virginia Woolf, the novelist, had intermittent psychotic episodes throughout her life. She believed that the leaves of trees were controlling her thoughts and feelings. When not floridly psychotic she was reclusive and depressed. Some authorities think she had manic‐ depressive (bipolar affective) disorder, while others believe it was schizophrenia.

Vasla Nijinsky, a famous Russian ballet dancer, was a patient of Eugen Bleuler, the psychiatrist who coined the term “schizophrenia.” Nijinsky wrote in his diary: “I am God ...I love God, and therefore I smile upon myself” Zelda Fitzgerald, the wife of writer F. Scott Fitzgerald, was ill most of her adult life despite receiving the best psychiatric care available. She died in a 1948 Highland Hospital fire.

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2. The diathesis‐stress model. This model, which views schizophrenia in terms of the interaction of genetic vulnerability and environmental stressors, can be especially helpful in dealing with a complex disorder like schizophrenia. We can use this model to integrate the vast amount of research findings into meaningful patterns to identity the combination of factors that may increase or decrease one’s vulnerability to schizophrenia. Selected factors pertaining to the dispositional vulnerability (diathesis) would include: a family history of this disorder, degree of kinship with the schizophrenic individual, and the severity of the schizophrenic relative’s disorder. In turn, these factors would be considered along with environmental factors such as the presence of a secondary caregiver and a supportive and nurturing environment for childrearing. For instance, an individual born to a single‐parent mother who experienced severe schizophrenia, who has been in and out of hospitals, and who expresses little acceptance or warmth toward her child would be at relatively high risk of schizophrenia. In contrast, someone born to a mother who had experienced a brief, mild schizophrenic episode, made a good recovery, and demonstrated good nurturance toward her child would have a much lower risk of schizophrenia. In both instances, it is the combined effects or interaction of one’s dispositional vulnerability with environmental stressors/supports that result in the individual’s actual risk of schizophrenia.

3. Outlook for recovery. Numerous studies have indicated a group of factors associated with a more favorable course of schizophrenia as follows: Premorbid adjustment. The more adequately a person functions prior to the active phase of the disorder, the better the outcome. a. Precipitating event. When the onset of schizophrenic features occurs after a precipitating event, such as the death of a parent, the possibility of a more complete recovery is favorable. b. Sudden onset. The more acute the onset, the better the prognosis. c. Age of onset. The later in life the initial schizophrenic episode occurs, the better. Men are more at risk before the age of 25; women are more at risk after 25. d. Affective behaviour. Presence of anxiety and other emotions, including depression, is a favorable sign. A state of hopelessness not accompanied by depression is a poor sign. e. Supportive family. When families are taught to understand and support family members who have schizophrenia, the latter have a better chance of achieving more positive outcomes. f. Response to treatment. The better schizophrenic individuals respond to antipsychotic medication, staff personnel, and psychotherapy the better their chances for improved functioning. The more resigned they are to being sick, the poorer the outlook.

4. Kraepelin and the diagnosis of schizophrenia: then and now. A demonstration of just how far the North American concept of schizophrenia has swung back toward Kraepelin’s original definition of the disorder can be found in a 1981 study by James and May in the American Journal of Psychiatry (138, pp. 501‐504). The authors re‐diagnosed the patients in 32 case histories that were presented in Kraepelin’s textbooks. Material relevant to Kraepelin’s original diagnoses was stricken from the case histories so that the modem‐day raters were blind to his diagnoses. DSM‐II1 diagnostic criteria were then used to make new, ..

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independent diagnoses. In addition, independent diagnoses were made according to Spitzer’s Research Diagnostic Criteria. The results? Of 15 cases diagnosed as dementia praecox by Kraepelin, 14 were diagnosed as schizophrenia according to modem criteria. Of 13 cases diagnosed as manic, depressed, or manic‐depression by Kraepelin, 11 were similarly diagnosed according to the DSM‐III. Two cases of paranoia were identically diagnosed by Kraepelin and the DSM‐III as was one case of somatization disorder (hysteria in Kraepelin’s terms). Finally, one case that Kraepelin diagnosed as senile dementia was classified as atypical psychosis according to the DSM‐III. Overall, the reliability of diagnosis was 91% between rates making judgments 75 years apart. Kraepelin would apparently be quite comfortable making diagnoses according to modem criteria.

5. Violence and schizophrenia. Discuss the idea that whenever a highly publicized act of violence is perpetrated by an ex‐mental patient, people automatically think the person has schizophrenia. But how violence‐prone are most people with schizophrenia? Is the “violent schizophrenic” more a myth than a reality? Clearly, the media creates the impression that “mentally disturbed” people are more prone to violence. Is this, however, really the case?

Frankly, it is a difficult question and the answer you get depends upon who you ask. Scott Lilienfeld has assembled two opposing works on the subject, and he describes the complexities of drawing clear conclusions.

John Monahan notes that most reviews of the subject find a statistical association between mental illness and violence, particularly when that violence is related to delusions and hallucinations — the hallmarks of schizophrenia. Linda Teplin, however, takes issue with these findings. She argues that the data are usually based on arrest records, which can be deceptive. Not all arrests lead to convictions, sometimes police are prone to arrest prior offenders more often than others, and arrests don’t always minor the actual crime committed. She reports a study that shows virtually no relationships between mental illness and crime. Monahan, however, argues that although many of the studies indeed have flaws, there is sound research supporting the association. For example, across many studies a median of 15% of future psychiatric patients commit a violent act prior to hospitalization; from 25‐30% of released male patients with a past history of violence commit another such act within a year of release.

Who is right? Lilienfeld provides an excellent synthesis of this issue. Monahan offers some useful conclusions also. First, he reminds us that even with the relationship he believes to exist, the vast majority of severely disturbed people are never violent. He also makes points that will be excellent discussion topics with your students. Public education has typically stressed that the mental illness‐violence relationship is a myth. If it is not, how should public education change? What are the implications as the number of disturbed people outside of institutions has increased? How should society respond— with more treatment and community care, or with easier rules for involuntary commitment?

Lilienfeld, S. (1995). Seeing Both Sides: Classic Controversies in Abnormal Psychology. Pacific Grove, CA: Brooks/Cole. ..

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Monahan, J. (1992). Mental Disorder and Violent Behaviour: Perceptions and Evidence.

American Psychologist, 47, 511‐521.

Teplin, L. A. (1985). The Criminality of the Mentally Ill: A Dangerous Misconception.

American Journal of Psychiatry, 142, 593‐599.

6. “Once a schizophrenic, always a schizophrenic?” Discuss the idea that once a person is hospitalized for schizophrenia that person will always suffer from schizophrenia, even if they have achieved a good adjustment. What are some of the negative consequences of labeling people schizophrenic? Why does the DSM‐5 refer to the signs, features, and behaviours associated with schizophrenia?

7. Is schizophrenia a myth? Discuss Thomas Szasz’s idea that mental illness, including schizophrenia, is a myth. That is, schizophrenia is properly regarded as problems of living in a society that mistreats individuals who are different. Is there some truth to this notion?

What evidence is there that schizophrenia is a viable mental disorder?

8. Genetic counseling. What sort of genetic counseling would members of the class offer to an apparently healthy 25‐year‐old who wanted to have children but had a parent who had schizophrenia? Along the same lines, what sort of intervention programs, or childrearing experiences, would class members want to provide to children at risk for developing schizophrenia? Encourage students to try and apply research findings, not just speculate.

9. Mental hospitals. Have any class members ever been in or worked in a mental hospital?

What were their experiences like? What was the physical layout of the ward and how did this affect patient behaviour? Was there much contact between the patients and the professional staff? What would it be like to be a patient there?

10. Nervous breakdown. The term “nervous breakdown” is sometimes used to describe an individual who has experienced a psychotic episode. Invite students to share their ideas of what a nervous breakdown is or of what a psychotic state consists. Does the consensus of ideas include schizophrenic symptoms? Is a nervous breakdown only applied to schizophrenia and other psychotic disorders, or can it be used with anxiety disorders and affective disorders as well?

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Student Activities: 1. Worst‐case/best‐case scenarios for high—risk individuals. This exercise may help students to summarize the various research findings associated with an increased or decreased risk of schizophrenia. State that you are dealing with people already at high risk of schizophrenia because of a family history of the disorder, including a mother or father who has had this disorder in the past. Then ask students to identify those factors, both dispositional and environmental, that would make for a worst‐case scenario. Then have students do the same exercise for a best‐case scenario. More specifically, what combination of factors is associated with a favorable outlook for a high‐risk individual?

2. Delusional beliefs held by groups. Ask students to identify some groups or organizations endorsing beliefs that may be difficult to distinguish from delusions. Possible examples would be various cults, some religious groups, and groups claiming some type of gender, ethnic, or racial superiority. You might discuss the difference between someone who has a delusional disorder and otherwise normal people who belong to groups that espouse similar delusional beliefs. According to the DSM, when experiences or beliefs are shared and accepted by members of a cultural group, they are not considered to be evidence of a delusional disorder. What are some of the implications of this view?

3. Biographies of individuals with a mental illness. It may be useful to assign a biography for the class to read in order to have them get a closer feel for the phenomenology 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” portrayed in such popular literature are really misdiagnoses and that this leads to undue optimism about the possibility of recovery from schizophrenia.

4. Simulating a thought disorder. Osberg (1992) describes a way of demonstrating some of the thought and communication problems associated with schizophrenia, such as loose associations and odd use of language. You might ask a student (perhaps one who is more theatrically inclined) to learn this speech and act it out before the class. Osberg suggests trying it yourself, committing to memory and coming into class talking this way. This is not a demonstration many of us would feel comfortable performing, but a student volunteer can perhaps be an effective role player. Certainly, letting students hear and discuss a “live” example of schizophrenic‐type speech can be useful.

Osberg, T. M. (1992). The Disordered Monologue: A Classroom Demonstration of the Symptoms of Schizophrenia. Teaching of Psychology, 19, 47‐48.

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5. The Three Christs of Ypsilanti. There are many literary and professional works that provide in‐depth histories of schizophrenic behaviour. Few are as fascinating as Milton Rokeach’s famous Three Christs in which he describes an experiment of sorts. He found three men in the Michigan mental health system who each had the delusion that he was Christ. Rokeach wondered how firm these beliefs were; would they stand up to close scrutiny and challenge.

He saw to it that the three men were housed together for a time, and his book concerns their interactions. Should your class involve book reports or group presentations, this work should interest them. Just giving a synopsis of the book in class should be interesting to students.

Rokeach, M. (1964). The Three Christs of Ypsilanti: A Narrative Study of Three Lost Men. New York: Alfred A. Knopf.

Online Discussion Questions: 1.

Most professionals understand schizophrenia to be a genetically inherited disorder. Discuss.

2.

The relative benefits of antipsychotic drugs far outweigh the relative risks for the individual.

Discuss.

Online Resources: Schizophrenia Society of Canada www.schizophrenia.ca This site offers information in English and French about the causes and treatments of schizophrenia. It contains a number of useful links.

Schizophrenia – NIMH http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml The National Institute of Mental Health’s schizophrenia page provides useful information on the disorder.

Schizophrenia.com www.schizophrenia.com Another informationally rich website, containing many links and discussion forums concerning schizophrenia.

Early Psychosis Intervention https://cmha.ca/?s=diagnosis+of+psychosis Information from the CAMH on early diagnosis of psychosis.

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Video Resources: A True Madness, 35 min. black and white (Time‐Life Films). 1971. Researchers discuss possible causes of schizophrenia. Film includes conversations with schizophrenics.

Abnormal Behaviour: A Mental Hospital, 28 min. colour (CRM/McGraw‐Hill). Portrays life in a mental hospital, including interviews with people who have schizophrenia, their treatment, and an example of electroconvulsive treatment.

Escape from Madness, 52 min. colour (Films Inc.). Describes the use of drugs in eliminating bizarre behaviour and pragmatic strategies used to help people with schizophrenia cope with everyday life.

Interview with a schizophrenic, 50 min. colour (Media Guild). Features an interview focusing on the phenomenology of schizophrenia.

Madness, 60 min. colour, part of the PBS series “the Brain” (PBS Video). An excellent overview of the research and treatment of schizophrenia.

Psychopathology (no. 3: Schizophrenic Disorders), 35 min. colour (IU). Portrays the various features of classic schizophrenia.

R. D. Laing: A Dialog on Mental Illness and Its Treatment, 22 min. colour (Harper & Row). The famous psychiatrist discusses schizophrenia, therapy, and his criticisms of psychiatry.

Schizophrenia, 28 min. colour (Films for the Humanities and Sciences). Specially adapted Phil Donahue program offers basic information about schizophrenia.

Schizophrenia: Out of Mind, 52 min. colour (Films for the Humanities and Sciences). “48 Hours” program shows patients, families, and health‐care professionals dealing with schizophrenia.

Schizophrenia: The Shattered Mirror, 60 min. black and white (UCEMC). Dated (1966). Discusses possible causes of schizophrenia and various somatic and psychological treatments. Excellent views of actual schizophrenic patients.

Schizophrenia: The Voices Within, the Community Without, 19 min. colour (Films for the Humanities and Sciences). Explores the nature, symptoms and treatment of schizophrenia focusing on deinstitutionalization and the problems associated with it.

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Victorian Flower Paintings: Pictorial Record of a Schizophrenic Episode, 7 min. 1968 (UCEMC).

Shows a series of paintings by done between 1863 and 1868 by someone who was undergoing a schizophrenic episode. Paintings reflect the various levels of disintegration and recovery of the patient/artist. Graphic visual image of the effects of schizophrenia on coherent, integrative functioning (with regard to painting).

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Chapter 11 Abnormal Behaviour Across the Lifespan Chapter Overview: Neurodevelopmental Disorders Autism Spectrum Disorder Autism spectrum disorder (ASD) is one of the most severe childhood disorders, autism spectrum disorder is characterized by pervasive deficits in the ability to relate to and communicate with others, and by a restricted range of activities and interests. Children with autism spectrum disorder lack the ability to relate to others and seem to live in their own private worlds.

Intellectual Disability (Intellectual Developmental Disorder) Intellectual disability, also called intellectual developmental disorder, involves a broad delay in the development of cognitive and social functioning. In many cases, intellectual disability can be traced to biological causes, including chromosomal and genetic disorders, infectious diseases, and brain damage. The most common chromosomal abnormality resulting in intellectual disability is Down syndrome. Other genetic abnormalities include fragile X syndrome, phenylketonuria (PKU), and Tay‐Sachs disease. Other than chromosomal abnormalities, intellectual disabilities may be caused by prenatal factors such as maternal diseases and alcohol (and other drug) use; and cultural/familial factors associated with intellectually impoverished home environments.

Specific Learning Disorder Specific learning disorder is a deficiency in a specific learning ability noteworthy because of the individual’s general intelligence and exposure to learning opportunities. DSM‐5 classifies specific learning disorder as a single disorder with three subtypes: impairment in mathematics, impairment in written expression, and impairment in reading.

Attention‐Deficit/Hyperactivity Disorder Attention‐deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by excessive motor activity, impulsivity, and/or an inability to focus one’s attention. Stimulant medication is generally effective in reducing hyperactivity, but does not lead to general academic gains. Cognitive‐behavioural treatments help children with ADHD adapt better to school.

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Disruptive, Impulse‐Control, and Conduct Disorders Conduct Disorder Children with conduct disorder (CD) purposefully engage in patterns of antisocial behaviour that violate social norms and the rights of others. The DSM‐5 lists two types of conduct disorder: childhood‐onset type (symptoms appear before age 10) and adolescent‐onset type.

Oppositional Defiant Disorder Oppositional defiant disorder (ODD) is a disorder occurring in childhood or adolescence and is characterized by excessive oppositionality or tendencies to refuse requests from parents and others. Many children with conduct disorders, especially boys, display aggressive behaviour and have problems controlling their anger. Behaviour therapy and other psychosocial interventions may be helpful in modifying behaviours of children with conduct disorder or oppositional defiant disorder.

Anxiety and Depression in Childhood and Adolescence Separation Anxiety Disorder Separation anxiety disorder is a childhood disorder characterized by extreme fears of separation from parents or others on whom the child is dependent. The development of separation anxiety disorder frequently follows a stressful life event, such as illness, the death of a relative or pet, or a change of schools or homes.

Perspectives on Anxiety Disorders in Childhood Psychoanalytic theorists argue that childhood anxieties and fears, like their adult counterparts, symbolize unconscious conflicts. Cognitive theorists focus on the role of cognitive biases underlying anxiety reactions. Learning theorists suggest that the occurrence of generalized anxiety may touch on broad themes, such as fears of rejection or failure that carry across situations.

Depression in Childhood and Adolescence Depressed children and adolescents typically show a greater sense of hopelessness, display more cognitive errors and negative attributions (e.g., blaming themselves for negative events), have lower perceived competence or self‐efficacy, and have lower self‐esteem than do their nondepressed peers (Maughan, Collishaw, & Stringaris, 2013). They often report episodes of sadness, crying, and apathy as well as insomnia, fatigue, and poor appetite. They may refuse to attend school, express fears of their parents’ dying, and cling to their parents or retreat to their rooms. They may have suicidal thoughts or attempt suicide. Depression may also be masked by other problems, such as conduct/school‐related problems, physical complaints, and overactivity. ..

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Suicide among Children and Adolescents The rates of suicide climb with age, rising from 1.9 in 100 000 between the ages of 10 and 14 years to 7.7 in 100 000 between the ages of 15 and 19 (Statistics Canada, 2017a). Among youth aged 15 years and over, the rates are greater for males than females; the rates are five to seven times greater for First Nations youth.

Neurocognitive Disorders Neurocognitive disorders are caused by physical or medical diseases, or drug use or withdrawal that affects the brain’s functioning. These disorders arise when the brain is either damaged or impaired in its ability to function because of injury, illness, exposure to toxins, or use or abuse of psychoactive drugs.

Delirium Delirium is a state of extreme mental confusion in which people have difficulty focusing their attention, speaking clearly and coherently, and orienting themselves to the environment. The prevalence of delirium is estimated at about 1–2% in the general community, but rises to 14% among people over the age of 85 (Inouye, 2006). Treatment typically involves medication, environment changes, and family support (APA, 2013).

Major Neurocognitive Disorder (Dementia) Major neurocognitive disorder (commonly called dementia) represents a profound decline or deterioration in mental functioning characterized by significant impairment of memory, thinking processes, attention, and judgment and by specific cognitive deficits. The most frequent cause is the disabling and degenerative brain disease called Alzheimer’s disease (AD), characterized by memory loss and deterioration of other cognitive functions, including judgment and ability to reason. Scientists are exploring the underlying processes involved in AD, focusing on the loss of synapses in the brain, in addition to the formation of amyloid plaques and neurofibrillary tangles that are seen in the brains of those with AD.

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Chapter Outline: Abnormal Behaviour Across the Lifespan 391 Neurodevelopmental Disorders 393 Autism Spectrum Disorder 393 REVIEW IT Autism Spectrum Disorder 398 Intellectual Disability (Intellectual Developmental Disorder) 398 REVIEW IT Intellectual Disability 405 Specific Learning Disorder 405 REVIEW IT Specific Learning Disorder 408 Attention‐Deficit/Hyperactivity Disorder 408 REVIEW IT Attention‐Deficit/Hyperactivity Disorder 412 Disruptive, Impulse‐Control, and Conduct Disorders 412 Conduct Disorder 412 Oppositional Defiant Disorder 413 REVIEW IT Disruptive, Impulse‐Control, and Conduct Disorders 416 Anxiety and Depression in Childhood and Adolescence 416 Separation Anxiety Disorder 416 Perspectives on Anxiety Disorders in Childhood 418 Depression in Childhood and Adolescence 418 Suicide among Children and Adolescents 419 REVIEW IT Anxiety, Depression, and Suicide 421 Neurocognitive Disorders 422 Delirium 422 REVIEW IT Delirium 424 Major Neurocognitive Disorder (Dementia) 425 REVIEW IT Dementia 428 CONCEPT MAP 431

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Students Should Be Able to: 1. Describe autism spectrum disorder.

2. Explain the clinical features of autism spectrum disorder.

3. Discuss intellectual disability, and its assessment.

4. Identify the causes of intellectual disability.

5. Explain specific learning disorder.

6. Discuss the causes of specific learning disorder and approaches adopted to treat it.

7. Explain attention‐deficit/hyperactivity disorder.

8. Discuss the various methods employed in treating attention‐deficit/hyperactivity disorder.

9. Describe disruptive, impulse‐control, and conduct disorders.

10. Discuss the treatment methods of disruptive, impulse‐control, and conduct disorders.

11. Describe the types of anxiety disorders that affect children.

12. Identify the distinguishing features of depression in childhood and adolescence.

13. Describe delirium.

14. Discuss whether memory impairment is the only indication that a person is developing dementia.

Lecture and Discussions Suggestions: 1. Overcontrolled/Under‐controlled Children. A helpful way of viewing childhood problems is the distinction between overcontrolled and under‐controlled behaviours. Using a factor analysis of reported behaviour problems in children, T.M. Achenbach and C. S. Edelbock (Psychological Bulletin, 1987, 85) classify childrens’ psychological problems into two main categories: overcontrolled and under‐controlled. Problems in the under‐controlled category tend to be manifested externally, and include aggressive, acting‐out behaviours. Examples would be attention‐deficit disorders, such as hyperactivity, and the various conduct disorders. Problems in the overcontrolled category tend to be manifested in intrapsychic conflicts, and include shyness and withdrawal behaviour. Included here would also be the anxiety disorders, phobias, eating disorders, and affective disorders. The fact that a greater proportion of boys exhibit under‐controlled behaviours and are more likely to express their difficulties in outward behaviour may help to explain why more boys than girls are referred for psychological help during adolescence. The same distinction may also help to explain the preponderance of disadvantaged youth referred for help, with many of their problems involving under‐controlled, externalized behaviour.

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2. Difficulty distinguishing abnormality in childhood and adolescence. Experienced clinicians have long realized that it is more difficult to distinguish between normal and abnormal behaviour during childhood and adolescence than at any other stage of life. Because of the intense period of rapid physical, cognitive, and emotional growth, symptoms that might suggest disturbance in adults often turn out to be considerably less serious in adolescents.

The close link between development and disturbance presents two opposing dangers to adults and clinicians. One danger is to overinterpret the signs of disturbance, thereby undermining the youth’s self‐confidence and creating self‐fulfilling expectations among youths and adults alike. The opposite danger is to dismiss serious problems, thereby avoiding needed treatment and allowing problems to get out of hand. As a way of minimizing these dangers, concerned adults might assess the child’s or adolescent’s troubled behaviour in terms of the following questions: a. b. c. d. e.

Has the problem lasted beyond the expected age?

Does such behaviour resist ordinary efforts to change it?

How frequently is it displayed?

Does the behaviour interfere with school?

How seriously does it interfere with the adolescent’s relationships with peers and adults? f. If such behaviour continues, will it interfere with adult adjustment?

3. Parenting for competence. What can parents do to help avoid problems in their children?

Baumrind has identified two dimensions of parenting behaviour: control or demandingness, and responsiveness or warmth. Each dimension has two extremes: high and low. The parent who is high in control sets high standards for maturity and responsibility and expects the child to live up to them. In contrast, the parent who is low in control does not establish such standards. The parent who is high in warmth is interested in and sensitive to the child’s needs and responds readily and positively to the child. In contrast, the parent who is low in warmth is not interested in the child’s needs and may be aloof or actively rejecting.

Baumrind refers to parents who are high on both warmth and control as authoritative parents. Parents low on warmth but high on control are authoritarian; parents high on warmth but low on control are permissive. Those low in both factors have sometimes been called uninvolved parents. In her early work, Baumrind found that children of authoritative parents were rated as self‐ controlled, enthusiastic, and self‐reliant in mastering new tasks.

In contrast, preschool children of authoritarian parents were withdrawn, anxious, and tended to react to frustration with hostility. Preschoolers of permissive parents were extremely immature, being both dependent on and demanding of adults, and extremely negative and disobedient when requested or told to do something that they did not wish to do. Later researchers have generally confirmed these observations.

Baumrind, D. (1983). Rejoinder to Lewis’s Reinterpretation of Parental Firm Control Effects: Are Authoritative Families Really Harmonious? Psychological Bulletin, 94, 132‐142. ..

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4. Is there something wrong with society? One way of interpreting the statistics showing high rates of childhood disorders is to argue that broad social factors are at work. Is that so? If so, what are those factors? Perhaps poor parenting, such as noted above, may be the problem. Some believe we do not spend enough money researching child and adolescent disorders. What kinds of solutions might be tried? Perhaps parents should be required to take training or pass some kind of a course? Maybe the government and schools should monitor children more closely, such as through mandatory psychological testing? These questions can lead to some interesting class discussion.

5.

Adolescent suicide. Although relatively uncommon in children under the age of 10, for youth aged 10 to 19 years, suicide is the second leading cause of death. The risk of suicide increases with age, with late adolescents and young adults at greater risk than younger adolescents. The increased suicide rate probably is due to a combination of factors, including the following: a. Youth experience greater stress growing up. Children and adolescents reared with the “hurried child syndrome” feel greater pressure, heightened expectations, and more competitiveness than youth did in the past. b. Disruptive family relationships have increased. Included here are the increased number of family conflicts, latchkey children, parental divorces, and blended families, with family problems present in about three‐fourths of all suicide attempters. c. Incidence of depression is rising among youth. Young people born since 1960 are several times more likely to report being depressed than those born 50 years earlier, with at least half of those who commit suicide suffering from depression. d. Social contagion is often a factor in suicides. Suicides sometimes occur in clusters, with a prior suicide or suicide attempt among siblings, friends, or relatives of the suicide victim.

Adolescent suicides also occur in bunches in a particular community, especially when a publicized suicide suggests a way for finally resolving one’s own problems. Yet, suicide in adolescence is especially tragic in that suicide is a permanent solution for temporary problems, which in fact lend themselves to less drastic, more viable solutions.

6. The scope of PL 94‐142. The most significant and influential legislative enactment in the United States was the Education for All Handicapped Children Act, Public Law 94‐142. PL 94‐ 142 mandated that children with special needs must be educated in the least restrictive environment, with an Individual Education Plan (IEP) developed, maintained, and evaluated for every child. It is worth informing students of the broad scope of PL 94‐142 and its influence on education since its implementation in 1975. Since the passage of PL 94‐ 142, public schools are required to provide (or pay for a private school to provide) adequate education for all children with handicapping conditions, including those with severe emotional disturbance and specific learning disabilities, as well as those with severe developmental disabilities such as intellectual disability and autism spectrum disorder. The law greatly increased the responsibility of the public‐school system for educating all children, and has required school districts to require programs for both assessing the needs of special‐needs children and for providing specialized education when indicated, either ..

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within a normal classroom, through a separate classroom within the public school, or through providing funds for a specialized private classroom.

7. Mainstreaming. Discuss the topic of mainstreaming students with intellectual disability.

What are the pros and cons of this issue? Does mainstreaming risk setting up the child with intellectual disability for social rejection?

8. Learning disabilities as psychological disorders. Ask students how they feel about labeling learning disabilities as psychological disorders. Since many learning‐disabled students show few, if any, signs of emotional disturbance, some authorities question classifying learning disabilities as psychological disorders.

9. Depression in children and adolescents. Ask students to identify different ways in which depression may be masked in children and adolescents. Some common signs of masked depression are: boredom, fatigue, excessive complaining, preoccupation with bodily complaints, lack of interest in school, and dropping out of school. The masking of depression also consists of efforts to ward off depression, such as restlessness, the search for stimulating activities, and need for constant companionship.

10. Use of stimulants with children. The use of stimulant medications, such as Ritalin, has developed as one of the more effective treatments for attention‐ deficit/hyperactivity disorder. The drugs reduce the activity‐level problems, thereby making the child more manageable at home and in the classroom. These drugs appear to work in about 65% of children with overactive behaviour symptoms. As indicated in the text, however, long‐lasting effects such as academic improvement and social skills are not directly acquired via the use of medication.

Ask students to put themselves in the roles of parents, teachers, and children to discuss the implications, both positive and negative, of using stimulant medications to control children’s behaviour. The overuse of stimulant drugs that occurred in the 1970s points out the potential to misuse these drugs with children. How would physicians develop a procedure to ensure that only children with critical levels of behaviour impairment received the medication?

11. Teenage Violence. This chapter provides another opportunity to discuss the issues surrounding teenage violence, which has gotten so much coverage because of the recent shootings at schools like the incident in Columbine, Colorado. Why do students feel these shootings are occurring? Are incidents like this really happening more often now or are they just receiving more press coverage? What do students suggest be done to prevent these tragedies from occurring, if they can be prevented at all?

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Student Activities: 1. Working with children with intellectual disability. Invite someone who works with children with intellectual disability to speak to your class. Now that these children have been deinstitutionalized in most provinces, many of them live in group homes and participate in supervised activities in the community. Students in human services and social work often have experience with this population. Having someone who is working in this area and speaks from first‐hand experience, often gives students a more concrete, tangible account of the possibilities and problems for this segment of the population.

2. Child observation. You could make this a written assignment or use it as a small group exercise in class. Ask students to observe a child or adolescent, preferably an individual who exhibits one of the types of problems discussed in this chapter. Depending on the age of the child and the type of problems involved, they might interview the child and his or her parents, and write a one‐ or two‐page report of their observations. Emphasize that the aim is to learn from observing the child, not to analyze or diagnose, which students are not qualified to do. Such observations usually bring home to students that each child or adolescent, even with the same type of psychological problems or disorders as other children or adolescents, is special and unique, and needs to be understood as such.

3. Resources for children. In many places it is easier to find treatment resources for adults than for children. Ask the students to survey their area regarding available services for children with psychological disorders. Are there particular problems these services address?

What about cost factors?

Online Discussion questions: 1. Children with ADHD are over‐medicated. Discuss.

2. Early intervention programs for children with developmental disorders can significantly improve their prognosis. Discuss.

3. There are specific steps one can take to prevent dementia. Discuss.

Online Resources: Autism Society Canada https://autismcanada.org/ This website is a primary source for Canadian information about autism spectrum disorder, services, and resources.

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Canadian Association for Community Living www.cacl.ca This site provides information about Canadian community supports and services for persons of all ages who have intellectual disabilities.

Special Olympics Canada www.specialolympics.ca Homepage for Special Olympics Canada, a nonprofit organization dedicated to enriching the lives of Canadians with intellectual disabilities.

Learning Disabilities Association of Canada (LDAC) http://www.ldac‐acta.ca/ This site is Canada’s central repository for information about learning disabilities, resources, and supports.

Children and Adults with Attention Deficit Disorders http://www.chadd.org/ This Canadian site is dedicated to the support, education, and betterment of the lives of children and adults with attention deficit disorders.

Children and Youth ‐ CMHA http://ontario.cmha.ca/mental‐health/ This page from the Canadian Mental Health Association provides information about a wide range of mental and emotional problems of children and youth.

Alzheimer Society http://www.alzheimer.ca The Alzheimer Society is a leading national not‐for‐profit health organization. Its aim is to improve the quality of life for Canadians affected by Alzheimer’s disease and related dementias and advance the search for the cause and cure.

Canadian Dementia Action Network http://www.cdan.ca/aboutus.html CDAN brings together Canada’s world‐class biomedical researchers and clinicians for the purpose of quickly identifying promising treatments for Alzheimer’s disease and related dementias (ADRD).

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Video Resources: A Boy Named Terry, 58 min. colour (JU). Examines the treatment of a boy with autism spectrum disorder.

Adolescent Suicide, 39 min. colour (American Association for Counseling and Development).

Covers the reasons for adolescent suicide and the types of stress that contribute to suicide.

Afraid of School, 31 min. black and white, made in 1965 (IU). Case study of school phobia.

Aphasia in Childhood, 30 min. black and white (USC). Examines the case of a 12‐year‐old girl with aphasia, which developed from a head injury suffered at age 10.

The Autistic Child, 26 min. colour (Media Guild). Shows the case of a child with autism spectrum disorder and includes views of the parents, special educators, and a psychiatrist.

Autism’s Lonely Children, 20 min. black and white, made in 1967 (PCR). An excellent, if somewhat dated film that portrays many childhood psychological disorders.

Education for All Children, 28 min. colour (Research Press). Explores attitudes toward handicapped children and their right to an appropriate education.

The Hyperactive Child, 34 min. colour, made in 1969 (Penn. State Univ.). Portrays a hyperactive child at home and at school. Some causes of and treatments for hyperactivity are discussed.

Intelligence, 30 min. colour (Insight Media). Examines the differences between retardation and the gifted and explores the use of I. Q. tests and problems in defining intelligence.

Interview with a Mother and a Teacher of a Hyperactive Child, 50 min. colour (Media Guild).

Includes different views on the hyperactive child, from the perspective of the educator and parents of hyperactive children.

One Child in a Hundred, 20mm colour (Time‐Life Films/Video). Shows the techniques of developing the capabilities of children with intellectual disability, and the problems of living with a child with his condition.

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