Abnormal Psychology in a Changing World, 9E Jeffrey S Nevid Spence A Rathus Beverly S Greene Solutio

Type:

Solution Manual

Resource:

Abnormal Psychology in a Changing World

Edition:

9th Edition

Author(s):

Jeffrey S. Nevid Spencer A. Rathus Beverly S. Greene

CHAPTER ONE INTRODUCTION AND METHODS OF RESEARCH Learning Objectives 1.1 Define the term psychological disorder.

1.2 Identify criteria professionals use to determine whether behavior is abnormal.

1.3. Apply these criteria to case examples discussed in the text.

1.4 Describe the cultural bases of abnormal behavior.

1.5 Describe the historical changes that have occurred in conceptualizations and treatment of abnormal behavior through the course of Western culture.

1.6 Describe the major contemporary perspectives on abnormal behavior.

1.7 Identify the objectives of science and the steps in the scientific method.

1.8 Identify the ethical principles that guide research in psychology.

1.9 Describe the major types of research methods scientists use to study abnormal behavior and evaluate the strengths and weaknesses of these methods.

1.10 Apply key features of critical thinking to the study of abnormal behavior.

Chapter Outline I. How Do We Define Abnormal Behavior?

A. Criteria for Determining Abnormality B. Cultural Biases of Abnormal Behavior II. Historical Perspectives on Abnormal Behavior A. The Demonological Model B. Origins of the Medical Model: In "Ill Humor" C. Medieval Times D. Witchcraft E. Asylums F. The Reform Movement and Moral Therapy G. A Step Backward H. The Role of the Mental Hospital Today I. The Community Mental Health Movement J. Deinstitutionalization and the Psychiatric Homeless Population K. Deinstitutionalization: A Promise as Yet Unfulfilled III. Contemporary Perspectives on Abnormal Behavior A. The Biological Perspective B. The Psychological Perspective C. The Sociocultural Perspective D. The Biopsychosocial Perspective IV. Research Methods in Abnormal Psychology A. Description, Explanation, Prediction, and Control: The Objectives of Science B. The Scientific Method C. Ethics in Research D. Naturalistic Observation E. The Correlational Method .

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F. The Experimental Method G. Epidemiological Studies H. Kinship Studies I. Case Studies V. Summing Up Chapter Overview How Do We Define Abnormal Behavior?

Various criteria are used to define abnormal behavior. Psychologists generally consider behavior 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; and (6) dangerous.

The determination of which behavior patterns are deemed abnormal depends on cultural beliefs and expectations. Concepts of health and illness may also have different meanings in different cultures.

Abnormal behavior patterns may take different forms in different cultures, and societal views of abnormal behavior vary across cultures.

Historical Perspectives on Abnormal Behavior Ancient societies attributed abnormal behavior to divine or supernatural forces. In medieval times, exorcists were used to rid people who behaved abnormally of the evil spirits that were believed to possess them. There were some authorities in ancient times, such as the Greek physicians Hippocrates and Galen, who believed that abnormal behavior reflected natural causes. The nineteenth century German physician Wilhelm Griesinger argued that abnormal behavior was caused by diseases of the brain. Along with Emil Kraeplin, another German physician who followed him, Griesinger was influential in the development of the modern medical model, which likens abnormal behavior patterns to physical illnesses.

Asylums, or "madhouses," began to crop up throughout Europe in the late fifteenth and early sixteenth 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 nineteenth century, largely spearheaded by the Frenchmen Jean-Baptiste Pussin and Phillipe Pinel, conditions in mental hospitals improved.

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 nineteenth 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 the hospitals offered little more than custodial care.

In the middle of the twentieth century, public outrage and concern about the plight of mental patients mobilized legislative efforts toward the development of community mental health centers 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.

Research Methods in Abnormal Psychology The scientific approach focuses on four general objectives: description, explanation, prediction, and control. There are four steps to the scientific method: formulating a research question, framing the .

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research question in the form of a hypothesis, testing the hypothesis, and drawing conclusions about the correctness of the hypothesis. Psychologists follow the ethical principles that govern research with human and nonhuman subjects. Two of the key ethical provisions guiding research with human participants are informed consent and confidentiality.

Research samples need to be representative of the target population. The naturalistic observation method allows scientists to measure behavior under naturally occurring conditions. Correlational research explores the relationship between variables, which may help predict future behavior and suggest possible underlying causes of behavior. But correlational research does not directly test cause-and-effect relationships. Longitudinal research is a type of correlational design that involves the study of selected subjects at periodic intervals over long periods, sometimes spanning decades.

In the experimental method, the investigator directly controls or manipulates the independent variable under controlled conditions in order to demonstrate cause-and-effect relationships. Experiments use random assignment as the basis for determining which subjects (called experimental subjects) receive an experimental treatment and which others (called control subjects) do not. Researchers use various methods, including single-blind placebo-control studies, double-blind placebo-control studies, and attention-placebo control studies to attempt to control for subjects' and researchers' expectations.

Experiments are evaluated in terms of their experimental validity. Internal validity refers to the ability of an experimental study to justify a cause-and-effect relationship between the independent and dependent variables. Internally valid studies control for possible confounds, or rival hypotheses. External validity refers to the degree to which experimental results can be generalized to other subjects, settings, and times.

Construct validity refers to the degree to which treatment effects can be accounted for by the theoretical mechanisms, or constructs, that are represented by the independent variables.

The epidemiological method examines the rates of occurrence of abnormal behavior in various population groups or settings. Evidence of how disorders cluster in certain groups or geographic areas may reveal underlying causes. Kinship studies attempt to disentangle the contributions of environment and heredity.

Case-study methods can provide a richness of clinical material, but they are limited by difficulties of obtaining accurate and unbiased client histories, by possible therapist biases, and by the lack of control groups. Single-case experimental designs are intended to help researchers overcome some of the limitations of the case-study method.

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," having students find their definitions from the text, and then discussing the meanings of the definitions 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. The student study guide has several quizzes and exercises that students may use to facilitate learning these terms.

2. Discuss the ways in which the field of psychology and definitions of what is normal and abnormal reflect the political, social, and moral issues of the time. Over the last 200 years, the field of psychology has changed dramatically. Ideas of abnormality, definitions of mental illness, and which conditions are diagnosed have gone through considerable changes and will continue to do so in the future.

For example, in the early 1800s, Dr. Samuel Cartwright defined two mental disorders that were unique to .

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slaves. “Drapetomania,” meaning “flight-from-home mania,” was characterized by the presumably irrational urge to run away from slavery in the pursuit of freedom. The second disorder was named “Dysathesia Aethiopia,” and was diagnosed when a slave engaged in the following behaviors: destroying his or her owner’s property, being disobedient, fighting with one’s master, or refusing to comply with work demands. In the more recent past, “Homosexuality” was listed as a formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM), but in 1973, this diagnosis was dropped and is no longer officially defined as a form of mental illness. Controversy continues in the most recent versions of the DSM. Currently, the DSM has been criticized for its inclusion of disorders that characterize victims of abuse, such as Posttraumatic Stress Disorder (PTSD), while offering few diagnoses for the perpetrators of many common forms of abuse and prejudice (e.g., racism, sexism, and homophobia). Ask students to reflect on the meaning of such changes and how political, social, and moral issues may both impact and be impacted by the field of psychology.

3. Explain the criteria for abnormal behavior. After stating that there is no clear and universally agreed-upon definition of normal or abnormal behavior, explain and illustrate each of the six criteria of abnormal behavior, which state that abnormal behavior is: (1) unusual, (2) socially unacceptable, (3) based on a misinterpretation or misperception of reality, (4) personally distressful, (5) maladaptive or selfdefeating, and (6) dangerous. Clinicians use a combination of these criteria to identify abnormal behavior, but are often hesitant to label someone as "abnormal" on the basis of first two criteria alone. For example, many behaviors are statistically unusual, but are not necessarily a sign of mental illness. Other behaviors may be socially unacceptable because they deviate from accepted social or cultural norms, not because the behavior itself is inherently "sick" or a sign of illness. Many behaviors considered "normal" in our culture are considered "abnormal" in other cultures, and vice versa. For example, have your students pick their own behaviors (e.g., flirting, praying, drinking alcohol, etc.), then have your students (maybe in groups of three) define these behaviors as being abnormal or normal based upon the six criteria of abnormal behavior. This is an excellent exercise to demonstrate how definitions of normal and abnormal are often untidy and inconsistent.

4. Distinguish between a "mental or psychological disorder" and abnormal behavior. According to the DSM-V, a mental disorder is a clinically significant behavioral or psychological pattern that occurs in a person and is associated with (1) 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 behaviors, such as bathing nude at a public beach, may be socially deviant without being classified as a mental disorder.

5. Ask students to define "normal." While the concept of "normal" tends to be one of those concepts that people "know when they see it," in real-life behavior, 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 others' definitions, can be a fruitful exercise that leads them to see why psychologists have adopted the specific criteria for abnormality discussed in the text.

6. Ask students how they personally determine when someone's behavior 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.

7. Discuss supernatural explanations of abnormality. Discuss how supernatural explanations of behavior are still alive in the form of astrology, demonic possession, and satanic worship. You might .

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point out that people resort to such explanations because of the difficulty in understanding bizarre or evil behaviors in conventional medical and psychological terms. You might also point out that because of the power of selective perception, the placebo effect, and the types of "Barnum statement" predictions made by these belief systems, they can be very difficult to debunk or refute.

8. Discuss the reasons why certain populations, such as lesbians, gay men, and people of color, appear to be at greater risk for being diagnosed with psychological problems. Although these populations appear to be diagnosed with psychological disorders at a higher rate than others, appropriate explanations for this phenomenon require that the field look beyond the individual as the source for pathology. These populations experience higher levels of social stress and stigma, and they are disproportionately targeted for prejudice and discrimination. Continuous stress has been linked to higher incidences of mental illness and may offer a better explanation of higher incidence rates among these populations than a theory proposing that these groups are inherently vulnerable or deficient. In addition, discussions should address bias in diagnosis and assumptions of pathology among stigmatized populations. Finally, encourage students to consider the strengths and resilience among such groups which results in a relatively low proportion of people with clinically significant levels of pathology given the extent of their social stress.

9. Describe Hippocrates's four-fluids theory. While technically inaccurate, you might point out that Hippocrates’s 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, that 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 types of entity represent bodily fluids of a sort. You might also point out that not all of Hippocrates's ideas were as accurate as this one, even at a very general level. For example, his claims that hysteria in females was caused by a "wandering uterus" and could only be cured by marriage are clearly unsupported.

10. Women and witchcraft. From the mid-sixteenth through the mid-seventeenth centuries, a kind of hysteria swept Europe and parts of the American colonies. Suddenly, large numbers of people were accused, tried, and often convicted of consorting with the devil and becoming witches. These accusations were new in two ways: (1) Although some witchcraft accusations have been made from the beginning of civilization, they never before occurred in such large numbers. (2) Also, perhaps as many as 80 percent of those accused were women, whereas in the past, accusations had been made about equally against men and women. Not all of these accused women were mentally ill, as Schoeneman (1983) has pointed out.

Many of the women were poor, without husbands, aged, or seen as troublemakers or having questionable knowledge. About a third of those accused were sentenced to death by burning. Some survived by confessing and recanting. Others died while undergoing interrogations, such as the questions 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), a woman’s one “natural” sphere was within the .

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home under male authority, and anyone who operated outside of that hierarchy was 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, 2d ed. (1987). Also, Thomas Schoeneman offers perspectives on the witch and her place in the history of abnormal behavior in “The mentally ill witch in textbooks of abnormal psychology: Current status and implications of a fallacy,” Professional Psychology, 1983, 14, 22–40.

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. Then, describe the dramatic reduction in the census of state mental hospitals in the United States from about 560,000 in 1955 to about 125,000 in 1981. 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.

12. Describe D. L. Rosenhan's famous 1973 study "On Being Sane in Insane Places" (Science, 179, 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 behaviors 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 of the impostors were labeled schizophrenics, and their stays ranged from seven to fifty-two days with an average stay of nineteen 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 behaviors of others.

13. Discuss the ethical dilemmas involved in the use of control groups in research. Often, researchers know prior to or early into a research study that treatment subjects are getting a significantly beneficial treatment and that control subjects can never catch up and may suffer significant health risks or even death by getting a placebo rather than the experimental treatment. What ethical questions are raised by these situations? Similarly, is it ethical to try new drugs or experimental procedures on terminally ill patients? What ethical issues are raised by research conducted with terminally ill patients in this regard?

14. What’s the opposite of abnormal? You are about to spend a whole semester studying abnormal behaviors, affects, perceptions, and cognitions—but what is normal? Ask your students what they think the opposite of abnormal is in the context of behaviors, affects, perceptions, and cognitions…? Might the opposite of abnormal in this context be a human’s strengths and virtues? Introduce the concept of positive psychology to your students—the branch of psychology that, in a way, is opposite that of abnormal psychology. Positive psychology focuses on human strengths and virtues. Should your class involve book reports or group presentations, you may want them to read a recently published, highly interactive book on positive psychology by Don Lucas (Being: Your Happiness, Pleasure, and Contentment). This book introduces readers to positive psychology and then takes its readers on a journey to investigate their own strengths and virtues. Just giving a synopsis of the book in class should be interesting to students.

Lucas, D. (2010). Being: Your Happiness, Pleasure, and Contentment. .

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Plymouth: Hayden-McNeil.

Think About It How would you recognize abnormal behavior? What criteria would you use to distinguish abnormal behavior from normal behavior? Two ways to recognize abnormal behavior are to determine whether it is appropriate to the situation and to assess the magnitude of the problem.

Mental health professionals apply various criteria for determining abnormality, including the following: 1) the behavior is unusual, 2) the behavior is socially unacceptable or violates social norms, 3) the perception or interpretation of reality is faulty, 4) the person is in significant personal distress, 5) the behavior is maladaptive or self-defeating, 6) the behavior is dangerous.

How do judgments about abnormal behavior reflect the cultural context in which they are made?

Give at least one specific example. Judgments about abnormal as well as normal behavior are a function of the cultural context. The book goes into some detail about Native American culture, contrasted with Western society. For example, hearing voices in Western society is taken as a sign of mental illness, whereas the same event in a Native American context would be viewed as a celebration of communion with the spirit world.

What behaviors have you observed in members of other cultural groups that might be considered abnormal in your own? What behaviors in your own cultural group might members of other groups consider abnormal? Cultural differences in views of abnormality are common. For example, in West Africa, it would be viewed as highly abnormal to reach for anything with the left hand at the dinner table. The left hand is used for toileting and personal hygiene, so it would be quite a faux pas to use the left hand when eating. The American habit of smiling and greeting strangers on the street may seem abnormal to those in other cultures. In most societies, strangers are kept at a distance and treated with skepticism.

How have beliefs about abnormal behavior changed over time? What changes have occurred in how society treats people considered mentally disturbed? Over time, treatment of those considered abnormal tends to cycle from demonological views to more biologically centered views. Belief in witchcraft, demonology, and evil spirits as the cause of abnormal behavior has given way to a more biologically based approach to mental illness analogous to physical illness. As a result, today we rely strongly on the medical model of mental illness and tend to look for a disease process to explain problems in living.

What role did hypnosis play in the development of a psychological model of abnormal behavior?

Charcot was a highly respected neurologist who experimented with hypnosis in the treatment of hysteria.

In the late nineteenth century, Freud studied with Charcot. Freud reasoned that if hysterical symptoms could be made to disappear or reappear through hypnosis, then they must be psychological in nature. He concluded that whatever psychological forces gave rise to hysteria must lie outside of the range of conscious awareness. This is the cornerstone of the psychodynamic model.

Why should we not assume that because two variables are correlated they are causally linked?

Correlation does not prove causation. Sometimes there is no causal connection between two variables.

Sometimes a connection may be due to a third, unknown factor. For example, say there was a correlation between the number of churches in a community and the crime rate; as the number of churches in the community increases, the crime rate increases. This does not necessarily mean that the increase in

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churches caused an increase in crime. It could be a coincidence, or it could be that the town is simply growing in sheer numbers of people.

Why is a double-blind experimental design preferable to a single-blind design? How can a therapist’s knowledge or expectations affect the results of an attention-placebo study? How are these two problems related? In a double-blind experiment, neither the experimenter nor the subject knows who’s getting which treatment. For obvious reasons this is ideal. Researchers want to minimize possible experimenter bias. This is one of the strongest and most popular designs, especially in drug research. The attention-placebo study is meant to separate the effects of a particular treatment from placebo effects. The subject does not know that he or she is not receiving any treatment because the subject is exposed to credible, yet nonspecific, therapies. Since the therapist does know which treatment is being administered, it is not a double-blind study. Problems with experimenter bias may creep in.

How do investigators attempt to separate out the effects of heredity and environment? The effects of heredity and environment can be disentangled through kinship studies such as twin studies and adoption studies. The more closely people are related, the more genes they have in common. To determine whether abnormal behavior runs in a family, the researcher would locate a person with a disorder and then study how the disorder is distributed among the person’s relatives. But, environmental factors must also be controlled; the closer the degree of kinship, the more similar the environment. For this reason, researchers use twin and adoption studies to separate issues relating to heredity and the environment.

What are the major methods of research used to study abnormal behavior? What are their strengths and weaknesses? The major research methods include (1) naturalistic observation, 2) the correlational method, (3) the experimental method, (4) the epidemiological method, and (5) the case-study method. Each has advantages and disadvantages. Naturalistic observation allows scientists to measure behavior under naturally occurring conditions, but the researcher’s mere presence may skew the results.

The correlational method allows for prediction but cannot directly test cause-and-effect relationships. In the experiment, the researcher directly controls or manipulates variables to demonstrate cause-and-effect relationships. This is the method of choice for researchers, but it cannot always be performed due to ethical or cost issues. The epidemiological method examines the rates of occurrence of abnormal behavior in a given population, but this presupposes a large enough population. Case-study methods can provide a richness of clinical material, but they are limited by difficulties in getting unbiased, accurate data and by the lack of control groups.

Activities/Demonstrations 1. Examining images of abnormal behavior and mental illness in popular culture. We are continually exposed to images of abnormal behavior through the media. These images have a powerful impact on our beliefs regarding mental illness and how we define what is normal and what is abnormal.

Throughout the semester, ask students to study the ways abnormal behavior and mental illness are presented on television. Ask students to record a 3- to 5-minute segment from the news, TV dramas, sitcoms, or “Reality TV” to share with the class. Discuss the accuracy of the image presented, how it influences perceptions of mental illness, and the message conveyed about normality and abnormality.

2. Violating social norms. Ask students to think of some behavior 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 behavior. 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 behavior, their feelings about it, and others’ reactions. .

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Students may choose to do this in pairs, where one acts out the unusual behavior and another acts as a naturalistic observer assessing the reactions of others. This exercise usually helps students appreciate the importance of social norms and can connect students to the research segments of the chapter.

3. Discovering your own problems through social interaction. Select various diagnostic labels from the text or the DSM-V and write them on an 8 x 11 sheet of paper. Place them face down on a table, have each student draw one, and have the instructor pin it on the student’s 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?” and "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.

4. Are we really scientific today? As Chapter 1 illustrates, much of history has been colored by superstitious views of human behavior. Have students collect modern examples of less-than-scientific concepts about behavior. 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 behavior. (Do the “crazies” really come out when the moon is full?). In 1978, D. E. Campbell and J. L. Betts reviewed research in “Lunacy and the moon,” Psychological Bulletin, 85, 1123–1129.

5. Determining if behavior is normal or abnormal. Provide students with the following example: “Cameron was discovered defecating in his bedroom closet. Is his behavior normal or abnormal?” Ask students to decide what information is needed to determine whether or not this behavior is normal. How do the answers to relevant questions change their interpretation of Cameron’s behavior? Relevant information may include: Cameron’s age, mental development, physical development, possible physical ailments, frequency of the behavior, his explanation for the behavior, and recent trauma.

6. What myths do people have about abnormal psychology? Have students survey five of their friends about perceptions of abnormal behavior. 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 behavior 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 curable.

Yes

No

Mental illness has a biological cause.

Yes

No

7. What is abnormal? Ask students to imagine a situation where they have encountered abnormal behavior. They should be able to think of a time when they said to themselves, “That person is abnormal.” Have the students consider how their degree of comfort, the predictability of the behavior, how safe they felt, and the attributions they made for the behavior affected their perception of the .

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behavior. Did the person’s abnormal behavior make him or her feel comfortable or uncomfortable, was the behavior predictable or unpredictable, did it make the person feel safe or unsafe, and did he or she attribute the behavior to internal or external causes?

Break into discussion groups of four to five so that students can freely share their stories. The majority of students report that they label behavior as abnormal when it makes them feel uncomfortable, is unpredictable and unsafe, and when they believe the behavior is caused by internal factors. This is a good starting point to dispel stereotypes of abnormal behavior.

Media Resources Video–Recent Trends in Treatment (2:14) An interview with psychologist Sue Mineka about the interaction between biological and psychological treatments for mental illnesses.

Video available on MyPsychLab.com Video–Asylum: A History of the Mental Institution in America (3:30) This brief video clip discusses the old asylums and includes video footage from the 1930s, 1940s, and 1950s of various experimental treatments.

Video available on MyPsychLab.com

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CHAPTER TWO CONTEMPORARY PERSPECTIVES ON ABNORMAL BEHAVIOR AND METHODS OF TREATMENT Learning Objectives 2.1 Identify the parts of the neuron and describe their functions.

2.2 Identify the major parts of the nervous system and the cerebral cortex, and describe their functions.

2.3 Evaluate biological perspectives on abnormal behavior.

2.4 Describe the major psychological models of abnormal behavior, identify the major theorists, and evaluate these models.

2.5 Describe the sociocultural perspective and evaluate its importance in understanding abnormal behavior.

2.6 Describe and evaluate the biopsychosocial perspective on abnormal behavior, and identify a major biopsychosocial model.

2.7 Identify the major types of helping professionals, and describe their training backgrounds and professional roles.

2.8 Describe the goals and techniques of various forms of psychotherapy: psychodynamic therapy, behavior therapy, person-centered therapy, cognitive therapy, cognitive behavior therapy, eclectic therapy, group therapy, family therapy, and couple therapy.

2.9 Evaluate the effectiveness of psychotherapy and the role of nonspecific factors in therapy.

2.10 Describe the importance of multicultural factors in psychotherapy, and barriers to use of mental health services by ethnic minorities.

2.11 Identify the major categories of psychotropic or psychiatric drugs and examples of drugs in each type, and evaluate their strengths and weaknesses.

2.12 Describe the use of electroconvulsive therapy and psychosurgery, and evaluate their effectiveness.

2.13 Evaluate biomedical treatment approaches.

Chapter Outline I. The Biological Perspective A. The Nervous System B. Evaluating Biological Perspectives on Abnormal Behavior II. The Psychological Perspective A. Psychodynamic Models B. Evaluating Psychodynamic Models C. Learning-Based Models D. Evaluating Learning Models E. Humanistic Models F. Evaluating Humanistic Models G. Cognitive Models H. Evaluating Cognitive Models III. The Sociocultural Perspective A. Ethnicity and Mental Health B. Evaluating the Sociocultural Perspective

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IV. The Biopsychosocial Perspective A. The Diathesis-Stress Model B. Evaluating the Biopsychosocial Perspective C. The Case of Jessica—A Final Word V. Methods of Treatment VI. Types of Helping Professionals VII. Psychotherapy A. Psychodynamic Therapy B. Behavior Therapy C. Humanistic Therapy D. Cognitive Therapy E. Cognitive-Behavioral Therapy F. Eclectic Therapy G. Group, Family, and Couple Therapy H. Evaluating the Methods of Psychotherapy I. Multicultural Issues in Psychotherapy J. Barriers to Use of Mental Health Services by Ethnic Minorities VII. Biomedical Therapies A. Drug Therapy B. Electroconvulsive Therapy C. Psychosurgery D. Evaluation of Biomedical Approaches Summing Up

Chapter Overview The Biological Perspective Abnormal behavior may be viewed from various contemporary perspectives. The medical model conceptualizes abnormal behavior 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 incorporate the medical model but refer more broadly to approaches that relate abnormal behavior to biological processes and apply biologically-based treatments.

The Psychological Perspective Psychodynamic models reflect the views of Freud and his followers, who believed that abnormal behavior 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 behavior. Behavior therapy is an outgrowth of the learning model. .

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Humanists reject the determinism of psychodynamic theory and behaviorism. Humanistic theorists believe that it is important to understand the obstacles that people encounter as they strive toward selfactualization and authenticity.

Cognitive theorists focus on the role of distorted and self-defeating thinking in explaining abnormal behavior. They apply some of the behavioral techniques to cognitive therapies.

The Sociocultural Perspective Sociocultural theorists believe that abnormal behavior is rooted in social ills, such as poverty, discrimination, and social stressors, not in the individual. Today, many theorists believe that multiple factors interacting in complex ways are involved in the development of abnormal behavior patterns.

The Biopsychosocial Perspective 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.

Methods of Treatment The treatment someone with a psychological disorder receives is likely to vary not only with the type of disorder involved but also with the therapeutic orientation and professional background of the helping professional. A psychiatrist might recommend medication, perhaps in combination with psychotherapy. A cognitively oriented psychologist might suggest a program of cognitive therapy.

Types of Helping Professionals Many people are confused about the different types of mental health professionals. The major professional groupings of mental health professionals include psychologists, psychiatrists, social workers, nurses, and counselors.

Psychotherapy Psychotherapy involves a systematic interaction between therapists and clients that incorporate psychological principles to help clients overcome abnormal behavior, solve problems in living, or develop as individuals. The various approaches to psychotherapy employ theory-based specific treatment factors and nonspecific factors, such as the quality of the therapeutic relationship and the installation of hope.

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 through them in the light of their adult personalities. More recent psychoanalytic therapies are generally briefer and less intensive.

Behavior therapy applies principles of learning to help people make adaptive behavioral changes.

Behavior therapy techniques include systematic desensitization, gradual exposure, modeling, aversive conditioning, operant conditioning approaches, social skills training, self-control techniques, and relaxation techniques.

Humanistic approaches focus on the client's subjective, conscious experience in the here and now. Rogers' .

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person-centered therapy helps people increase their 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.

Cognitive therapies focus on modifying the maladaptive cognitions that are believed to underlie emotional problems and self-defeating behavior. Ellis' rational-emotive therapy focuses on disputing the irrational beliefs that cause emotional distress and substituting adaptive behavior for maladaptive behavior. 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.

Cognitive-behavior therapy integrates the behavioral and cognitive approaches.

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 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.

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 metaanalyses of research studies that compare psychotherapy with control groups support the efficacy of various approaches to psychotherapy.

Therapists need to take cultural factors into account in determining the appropriateness of Western forms of psychotherapy for different cultural groups. Some groups, for example, may have different views of the importance of the autonomy of the individual, or may place more value on spiritual than psychotherapeutic interventions.

Biomedical Therapies Biological approaches include drug therapy, deep brain stimulation, electroconvulsive shock therapy (ECT), 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 known to be effective in treating depressive disorders, and lithium has been known to be effective in treating bipolar disorder. ECT and deep brain stimulation are often associated with dramatic relief from severe depression, but questions remain about side effects. Psychosurgery is conducted only rarely because of adverse consequences.

Lecture and Discussion Suggestions 1. Neurotransmitters in abnormal behavior. There is mounting evidence that neurotransmitters play a significant role in various abnormal behaviors; however, the exact causal mechanisms have not been determined. For instance, deficiencies in dopamine are linked to Parkinson's disease, excesses in .

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dopamine reactivity are found in schizophrenia, and antipsychotic drugs are thought to alleviate psychotic symptoms by blocking the action of dopamine. Excesses and deficiencies of norepinephrine (both a neurotransmitter and a hormone) are involved in mood disorders and eating disorders. Also, serotonin may be linked with anxiety, insomnia, and mood disorders.

2. 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 mother and tries to displace her in father’s eyes—in effect, to become “daddy’s darling.” The little 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.

This view has been criticized for decades. Some believe it has helped instill a bias toward diagnosing more abnormal disorders among women. Others say 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: Mayfield Co. Travis, C. & Wade, C. The Longest War: Sex Differences in Perspective, 2nd Ed. New York: Harcourt Brace Jovanovich.

3. Consider the implications of the Human Genome Project. The mapping of the human genome was a controversial project involving scientists across the world. Many feared that once the project was complete, the eugenics movement would flourish and society would use prenatal DNA testing to select for and/or manipulate genes to create a society of “perfect” people. Have students discuss these fears and future possibilities resulting from these scientific advances. Should limitations be placed on the use of these technologies? Equally important, given that most conditions are polygenetic (they require the unique combination of many genes rather than a single gene), have students consider the reasonableness of such fears.

4. The family systems perspective. Students may be interested in contrasting the view of abnormal behavior, which family systems theorists take, with the other perspectives presented in the chapter. Of particular interest is the idea that a person's behavior and emotions need to be examined within their social context, rather than as isolated phenomena. Family systems theorists view abnormal (and normal) behavior as an interaction between two people, not as a unilateral action by one person. They argue that many behaviors that initially appear to be abnormal turn out to be highly adaptive given the unique and often “abnormal” environment in which the person is operating.

5. 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 at may be useful to ask the following questions: .

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1. 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?

2. Is the scientific study of human behavior compatible with a belief in free will?

3. Is free will something that can be studied empirically? If so, how?

4. What view of human behavior does our society hold, as evidenced by various religious and legal beliefs?

5. Can a psychopathologist who believes in free will logically support an exception for being not guilty by reason of insanity?

6. Perspectives and abnormality. Students often enjoy and learn from applying the theoretical material in the course to actual cases. Divide the class into six groups, and have each group adopt one of the theoretical perspectives described in this chapter (biological, psychodynamic, behavioral, learning, humanistic, and cognitive). Using a case from the text (e.g., “Jessica’s ‘Little Secret’”), or one from your own experience, have each group attempt to explain the “client's” behavior from the theoretical perspective they have adopted. After each group has presented its perspective, have group members debate key questions and issues in an attempt to demonstrate the merit of their theoretical perspective.

Students should consider concerns with each perspective, such as theories of etiology, treatment implications, ability to test hypotheses suggested by each perspective, and so on. After the debate, challenge students to consider whether there are factors in the case that, if changed, might convince students that a different perspective would be more accurate. For example, would students be more likely to consider a biological perspective if they discover many family members, even those adopted into other families at birth, shared the condition? Similarly, would they consider a diathesis-stress model if the condition only developed after a stressful or traumatic event?

7. Psychodynamic vs. learning approaches. Psychodynamic and learning advocates have long argued about the efficacy of each other's therapeutic techniques. An issue is whether the behavioral “symptom” or the “underlying” cause should be treated. Consider the case of an autistic child with a pattern of repetitious, self-injurious behavior. One could treat the behavioral symptom with operant conditioning techniques, but would that be sufficient to prevent a relapse of the behavior pattern, or some similar one, in the future? Or could it result in the substitution of a new, even more injurious behavior pattern for the original behavior 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?

8. Length of treatment and client improvement. Much of the current research in this area is focused on specific, measurable factors that make therapy effective, using meta-analysis. Meta-analysis is a statistical technique that provides a more robust and comprehensive understanding of a phenomenon by averaging the results of a large number of studies. In one study, Kenneth Howard and his colleagues (“The Dose-Effect Relationship in Psychotherapy,” American Psychologist, 1986, 41, 159–164) reviewed 15 studies with 2,431 clients and found a positive relationship between the length of treatment and client improvement. About one-third of the clients improved within the first three sessions, regardless of the eventual length of the treatment, and half improved by eight sessions. About three-fourths of the clients had improved by twenty-six sessions. However, the rate of improvement varied among the different types of clients. Depressed clients usually improved the most after the first few sessions. But, clients with anxiety disorders generally took a somewhat higher number of sessions before improving, and the more severely disturbed psychotic clients required the highest number of sessions of all. Although such findings do not prove that time-limited therapy is as effective as time-unlimited therapy, twenty-six sessions could be used as a point in the treatment process at which cases that have not shown any measurable improvement would be subjected to a clinical review. .

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9. When to terminate therapy. Clients and therapists sometimes find it difficult to determine when a client should terminate therapy. One reason is the gap between subjective (client) ratings and objective (therapist) ratings of improvement. One study by Kenneth Howard and his colleagues (American Psychologist, 1986, 41, 159–164) examined this phenomenon and found significant differences between the two. More specifically, clients begin to feel better long before their therapists see behavioral signs of improvement. Usually, it isn't until after about six months of therapy that clients' and therapists' ratings begin to merge. Even then, in making the decision to terminate therapy, Lester Luborsky (Archives of General Psychiatry, 1985, 42, 602–611) suggests using two criteria. First, does the client feel that the problems that brought him or her to therapy are under control? Second, does the client believe that the gains achieved in therapy can be maintained without the therapist? Generally, it is suggested that the client and therapist review the progress made in therapy in light of the client's original goals, with the client eventually having more say in whether these goals have been met. In addition, using psychological assessment tools to systematically assess the frequency and severity of symptoms at regular intervals throughout the course of therapy may also improve client-therapist congruence.

10. The therapeutic relationship. Ask students how a therapeutic relationship differs from a friendship.

What are the advantages of getting help from a therapist rather than a friend? Such advantages include expert opinion, confidentiality, objectivity, and separation from one's social relationships.

11. Drug treatment. Discuss the pros and cons of drug treatment (psychopharmacology) and the types of clients and problems where drugs may be a cost-efficient approach. Research indicates that even chronic conditions requiring life-long drug treatment are more effective when used in conjunction with psychotherapy. Discuss why this is the case (e.g., in many instances clients also need to develop better coping strategies for dealing with chronic mental illness and future problems the condition may create). It may also be useful to challenge resistance to drug treatment for psychological illness by comparing standards of care for other biologically based chronic illnesses such as diabetes. As evidence grows indicating that many psychological disorders are also based in biological systems, resistance to psychopharmacology may dissipate.

12. Ethics. Not all those offering psychotherapy services are ethical. Students can be reminded of some of the ethics of psychologists who offer their services to the public. For example, therapists should not practice outside their expertise. Psychologists do not treat those close to them, such as friends, relatives, or employees. They do not treat patients of another professional unless a clear referral has been made.

They avoid dual relationships (e.g., therapist and business consultant or friend) with clients. Ethical practices include safeguarding confidential records. Psychologists discuss your records with others only with your consent, except in certain unusual circumstances. Psychologists are responsible for the work performed by their assistants.

13. Nonspecific factors. Scott Lilienfield presents an interesting comparison between those who say psychotherapy works and those who are not yet so sure. In the process he reviews a classic work by Jerome Frank, where Frank argues that at least four nonspecific factors are responsible for almost any improvement that is seen. Discuss Frank's assertions, which are generally supported by some of the outcome literature: a. The therapist is the expert. Any of us might become more hopeful in the hands of this expert. b. Psychotherapy takes place in settings associated with helping. Typical trappings include degrees and licenses on the wall, receptionists to usher clients in, and so on. c. Most therapies proceed from a coherent theory or rationale. When explained to the patient, it also provides clear hope that his/her problem can be understood. .

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d. Therapy has techniques—rituals, according to Frank. Whether it is free association, exposure therapy, or relaxation, these create the impression that something is happening. Just exactly what is happening can be a bit mysterious to the client, which actually heightens the effect.

Therapists are not unlike faith healers, according to Frank.

14. Psychotherapy: Alternative views. It can be provocative to discuss some of the writers who have taken shots at psychotherapy. You might ask students to find and report on some of these. Here are two that are interesting. Psychoanalyst James Hillman argues that therapy causes people to look inward, thus ignoring worsening social and political conditions around them. Growth, a popular theme in many schools of therapy, is a fantasy that ignores the fact that the personality is relatively immune to change.

R. D. Rosen popularized the term “psychobabble” to denote the vague language, catchy terms, and cute phrases that are sometimes found in therapy jargon. Psychobabble implies, says Rosen that we can reach well-being immediately, just by asserting that we are no longer “uptight” or “hung up.”

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

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

15. Is aversive therapy ethical? In aversion therapy, a noxious stimulus is applied when unwanted behavior occurs. For example, an alcoholic might receive an electric shock when he picks up a drink, or a person with a sexual fetish for boots, likewise, receives an electric shock while viewing or handling boots.

Such aversive methods have been used with these disorders, as well as with people with mental retardation. Aversive methods have included electric shock, nausea-inducing drugs, and squirts in the mouth with lemon juice.

Discuss with the class the ethics of inflicting pain and discomfort as a treatment method. Is this ethical to use on a child with mental retardation, who is banging his or her head against the wall and in danger of hurting himself/herself? What about for a person with alcoholism, who has done so much damage to himself/herself that further drinking will likely kill him/her? How about with an exhibitionist, who keeps getting arrested and has failed to respond to other therapy?

A particularly difficult question involves using such aversive procedures on people who are too young or otherwise unable to give their informed consent to the procedure. If it is unethical to inflict pain via shock or drugs, is it likewise unethical for a therapist to rouse painful memories that a client in more traditional therapy might have?

It is important to point out to the class that aversive procedures are seldom used alone, and they are seldom the first choice by therapists. Such procedures are regulated, especially when they involve those unable to consent.

Think About It Do you believe that abnormal behavior is more a function of nature (biology) or nurture (environment)? Explain. This is a personal opinion question. Students should be able to give specifics about the nature/nurture controversy.

Encourage them to 1) maintain a skeptical attitude, 2) consider the definitions of the terms, 3) weigh the assumptions or promises on which arguments are based, 4) bear in mind that correlation is not causation, .

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5) consider the kinds of evidence on which conclusions are based, 6) do not oversimplify, 7) do not overgeneralize.

Can you think of examples of behaviors in others (or yourself) in which defense mechanisms may have played a role? A classic example of defense mechanisms is the use of denial. What student has not used a bit of denial in their school careers when it comes to a bad grade? Denial would be the minimizing, “forgetting” or ignoring of a poor test grade. That denial may turn into rationalization. Say a student failed his or her psychology exam. He or she may rationalize by saying, “Well, I had no time to study; I was out partying last night.” Or, “It’s my instructor’s fault; she never lectures on the book.”

Underlying the psychodynamic approach is the belief that we are not usually aware of the deeper motives and impulses that drive our behavior. Do you agree? Why or why not? This is a personal opinion question. Students should be aware of the role the unconscious plays in behavior.

How might a complex belief, such as belief in free will or majority rule, be shaped by the environment? Behaviorists Watson and Skinner believed that the environment shapes even complex beliefs. As a researcher in classical conditioning, Watson was interested in the induction of fears and phobias through classical conditioning. He is credited with saying: “Give me a dozen healthy infants, well-formed, and my own specified world to bring them up in and I'll guarantee to take any one at random and train him to become any type of specialist I might select—doctor, lawyer, artist, merchant-chief and, yes, even beggar-man and thief, regardless of his talents, penchants, tendencies, abilities, vocations, and race of his ancestors. I am going beyond my facts and I admit it, but so have the advocates of the contrary and they have been doing it for many thousands of years. [Behaviorism (1930), p. 82]” The idea was that free will could be induced through associations, classically. Skinner discarded beliefs of personal freedom and choice, and saw complex ideas such as these as solely the result of operant conditioning. He believed the role of reinforcement was all-important in establishing human behavior.

How has your present behavior been influenced by your learning history? What learning principles (classical conditioning, operant conditioning, and observational learning) can you use to account for your behavior, both normal and abnormal? This is a personal experience question. Students need to be very familiar with the differences among classical conditioning, operant conditioning, and observational learning.

Whom would you consider to be a self-actualizer? Why or why not? This is a personal opinion question. Students should know the principle of self-actualization.

Can you think of examples from your personal life in which your thinking style reflected one or more of the cognitive distortions identified by Beck—selective abstraction, over-generalization, magnification, or absolutist thinking? What effects did these thought patterns have on your moods?

On your level of motivation? Do you think you can change how you think about your experiences?

Why or why not? This is a personal experience question. Students should know Beck’s cognitivebehavioral principles and apply them to their life.

How can researchers distinguish the effects of socioeconomic status from that of ethnicity?

Researchers recognize that income or socioeconomic status needs to be considered when comparing rates of a given diagnosis across ethnic groups. They must be cautious and think critically when interpreting ethnic group differences in rates of diagnosis. The differences might reflect other issues in socioeconomic level, living conditions, and cultural backgrounds. When findings are controlled for socioeconomic levels, supposed differences often disappear. For example, higher rates of mental illness found in African American populations disappear when compared by socioeconomic status. .

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Do you believe the root causes of abnormal behavior lie in the environment? In the person? In a combination of the two? Why? This is a personal opinion question. Students should be familiar with the sociocultural and learning perspectives in explaining abnormal behavior.

Why is it necessary to understand and consider multiple perspectives in explaining abnormal behavior? There are several models for understanding and explaining abnormal behavior. The fact that there are different ways of looking at the same phenomenon doesn’t mean that one model must be right and the others wrong. Many theorists today propose an interactional approach to the explanation of complex behavior. The biopsychosocial perspective considers how biological, psychological, and social factors are linked in the development of abnormal behavior patterns. Behavior is indeed complex. Perhaps no singular model can best explain it.

What are the major types of mental health professionals? How do they differ in their training and the types of roles they perform? The major mental health professions include psychologists, psychiatrists, social workers, nurses, and counselors. Psychologists are trained in graduate schools of psychology and typically earn an academic doctoral degree. Their expertise is in research, teaching, assessment, and clinical practice. Psychiatrists are trained in medical schools as physicians, and then specialize in psychiatry. They can prescribe medication and typically hold a biological view of mental illness. Social workers usually obtain a master’s degree in social work. They specialize in sociocultural aspects of mental illness including group and family interventions. Nurses are trained medically, and then specialize in psychiatric nursing. They are typically found in hospitals and clinics. The background and training of counselors vary in different states. A counselor usually has an advanced degree in some discipline but may not. Some states license counselors, requiring substantial credentials.

What are the basic features of psychotherapy? There are four basic features of psychotherapy: 1) Systematic interaction; therapists and clients must interact in a structure with plans and purposes that reflect the therapist’s theoretical point of view. 2) Psychological principles; psychotherapists draw on psychological principles, theory, and research in their practices. 3) Behavior, thoughts, and feelings; psychotherapy may be directed at behavioral, cognitive, and emotional domains to help clients better their lives. 4) Abnormal behavior, problem solving, and personal growth; many people benefit from psychotherapy, such as people with abnormal behavior problems, people who seek help for problems that are not regarded as abnormal, and people who seek personal growth.

What type of therapy would you prefer if you were seeking treatment for a psychological disorder?

Why? This is a personal opinion question. Students should be familiar with the wide variety of therapies and theoretical perspectives.

Encourage them to 1) maintain a skeptical attitude, 2) consider the definitions of the terms, 3) weigh the assumptions or promises on which arguments are based, 4) bear in mind that correlation is not causation, 5) consider the kinds of evidence on which conclusions are based, 6) do not oversimplify, 7) do not overgeneralize.

Is psychotherapy effective? What evidence exists to support the efficacy of psychotherapy? The effectiveness of psychotherapy receives strong support from research literature. Meta-analysis is a statistical technique that compares a large number of studies. A well-known 1977 study using metaanalysis found positive outcomes in the effectiveness of psychotherapy. (Clients in therapy were better off than 75 percent of those untreated.) Since then, we have more studies supporting the effectiveness of psychotherapy. Positive outcome is now so well established that the American Psychological Association has composed a list of empirically supported treatments. .

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What cultural issues do therapists need to consider when working with members of diverse cultural and racial groups? It is essential that culture, race, and ethnicity be taken into account when working with a diverse group. Therapists need to be sensitive to cultural differences and how they may affect the therapeutic process. They also need to avoid ethnic stereotyping and to demonstrate sensitivity to the values, languages, and cultural beliefs of members of racial or ethnic groups that are different than their own. Therapists need to know the cultural history and context of the groups they are working with. For example, therapists should not confuse the suspiciousness of an African-American client with paranoia given the cultural context of minimal self-disclosure. Differences in values need to be appreciated.

What problems do you see in taking pills to cope with anxiety or depression that may stem from academic or social difficulties? This is a personal opinion question. Students need to know the variety of drug classifications used in the treatment of anxiety and depression.

Activities/Demonstrations 1. Discuss some of the implications of wholistic 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?

2. Discuss the multiple social, cultural, and biological factors that contribute to ethnic differences in the rates of mental illness. The book describes several differences among ethnic groups in rates of general and specific forms of mental illness, abnormal behavior, and health. For example, adolescent and young adult Native American males have the highest suicide rates in the nation; Asian Americans in the U.S. have the lowest rates of psychological disorders, while rates among Native Hawaiians are significantly higher. However, rates of mental illness are no higher for African Americans than they are for Caucasians when socioeconomic status is taken into account. What are some of the factors that account for these differences? Encourage students to consider factors such as cultural norms concerning the expression of physical versus psychological symptoms, economic stress, acculturative stress, voluntary versus involuntary immigration, and the influence of racism and discrimination on mental health.

3. Irrational beliefs and problem behaviors. Select one or more items from Ellis's 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 behavior. 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—I have other options."

Discuss the difference this might make in your behavior.

4. 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 theories or relevant theorists discussed in Chapter 2 on the appropriate point on the scale. While some theorists like Freud or Skinner and biological perspectives 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 their perspective would necessarily differ in their conceptualization of abnormality, and in the development of treatment, from those theories that are highly environmental in .

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their orientation.

5. Which psychological perspective? Students can often solidify their understanding of the different perspectives when they compare and contrast them for a single example. Choose an event to which students can relate. Examples might include an honors student cheating on a test s/he was too tired to study for or an Olympic athlete taking performance-enhancing drugs despite the possibility that s/he will be subjected to random testing. Discuss the motivations of those involved. Why did they do it? Why would they risk getting caught? Apply each of the psychological perspectives to the events and describe how each perspective (biological, psychodynamic, behavioral, learning, humanistic, and cognitive) would explain the event.

6. 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 empathetically; 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 has been said that social conversation is often a competitive exercise in which the first person to draw a breath is declared the listener; however, this “listener” is often a reluctant, frustrated listener, who doesn't listen at all, but merely awaits his or her turn to speak.

7. Considering the role of culture in therapy and mental health. There are dozens of ways in which the manifestation of mental illness and the therapeutic process are influenced by culture and ethnicity.

Students should be able to conceptualize many different ways in which this occurs. A small number of ways in which culture and ethnicity influence these factors include—how symptoms of distress manifest (e.g., physical symptoms versus psychological), who can be a “helping professional” (e.g., folk-healer or community elder versus psychologist), treatment approaches that are most helpful (community or churchbased intervention versus one-on-one talk therapy), cross-cultural “tracking errors” between the therapist and client, social norms regarding acceptable behaviors with authority figures (e.g., if it is permissible for a client to make eye contact with a professional), and ways in which clients will accept influence from a therapist (e.g., confrontation, advice-giving, or communicating through themes within stories).

8. 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. Have groups report their designs, and use this to discuss some of the complexities of research the text authors describe.

9. Self-help resources. Not everyone goes to a therapist for help. Millions of Americans turn to selfhelp 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.

10. Which treatment? Write several short case-studies and present them to the class. Then ask students to pick from the various perspectives which treatment they would try first. You may want to make this a group activity—break into groups of four to six and assign each group a case for class presentation.

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Media Resources Video–Differences Between Collectivistic and Individualistic Cultures (3:28) This video compares individualistic cultures, such as the United States, that emphasize the role of the individual with collectivistic cultures, such as Taiwan, that place the needs of family and community above the needs of the individual.

Video available on MyPsychLab.com Video–The Basics: How the Brain Works Part 1 (5:04) Viewers learn about the different parts of neurons, how they communicate with each other, and how they function in the brain.

Video available on MyPsychLab.com

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CHAPTER THREE CLASSIFICATION AND ASSESSMENT OF ABNORMAL BEHAVIOR Learning Objectives 2.1 Describe the key features of the DSM system of diagnostic classification.

2.2 Describe the concept of culture-bound syndromes and identify some examples.

2.3 Explain why the new edition of the DSM, the DSM-5, is controversial.

2.4 Evaluate the DSM system, listing its strengths and weaknesses.

2.5 Describe the standards of clinical assessment.

2.6 Describe the major methods used in clinical assessment: the clinical interview, psychological tests, neuropsychological assessment, behavioral assessment, cognitive assessment, and physiological measurement.

2.7 Describe objective and projective personality tests and evaluate their usefulness.

2.8 Describe the role of sociocultural aspects of psychological assessment.

Chapter Outline I. How Are Abnormal Behavior Patterns Classified?

A. The DSM and Models of Abnormal Behavior II. Standards of Assessment A. Reliability B. Validity III. Methods of Assessment A. The Clinical Interview B. Computerized Interviews C. Psychological Tests D. Neuropsychological Assessment E. Behavioral Assessment F. Cognitive Assessment G. Physiological Measurement IV. Sociocultural Factors in Psychological Assessment V. Summing Up Chapter Overview Classification of Abnormal Behavior The first edition of the DSM was published in 1952. The latest version, the DSM-5, was published in 2013. Although widely accepted by most practitioners, the DSM has been criticized for relying too much on a medical model of diagnosis. In the DSM, abnormal behavior patterns are classified as mental disorders.

Although the DSM system, like the medical model, treats abnormal behaviors as signs or symptoms of underlying disorders or pathologies, it does not assume that abnormal behaviors necessarily stem from biological causes or defects. The DSM is descriptive, not explanatory. It describes the diagnostic .

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features—or, in medical terms, symptoms—of abnormal behaviors; it does not attempt to explain their origins or adopt any particular theoretical framework.

Unlike its predecessors, the DSM-III and DSM-IV, the DSM-5 dispenses with the multiaxial system used in these earlier versions. It attempts to include a dimensional aspect to its categorical structure. The new DSM has been criticized about the changes in diagnoses and structure. Primary issues of concern include the inclusion of many new diagnostic categories, changes in classification of mental disorders and changes in diagnostic criteria for particular disorders.

Methods of assessment must be reliable and valid. Reliability of assessment techniques is shown in various ways, including internal consistency, temporal stability, and interrater reliability. Validity is measured by means of content validity, criterion validity, and construct validity.

Methods of Assessment The clinical interview is the most widely used method of assessment. It 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 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 and MCMI, use structured items to measure various personality traits, such as anxiety, depression, and masculinityfemininity. 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.

Methods of neuropsychological assessment help determine organic bases for impaired behavior and psychological functioning. The Bender Visual Motor Gestalt Test requires subjects to reproduce nine geometric designs on a piece of paper. The Halstead-Reitan Neuropsychological Battery and Luria Nebraska Test Battery are more sophisticated batteries of tests measuring various perceptual, intellectual, and motor skills and performance.

In behavioral assessment, test responses are taken as samples of behavior rather than as signs of underlying traits or dispositions. The behavioral examiner may conduct a functional assessment, which relates the problem behavior to its antecedents and consequences. Methods of behavioral assessment include behavioral interviewing, self-monitoring, use of analogue or contrived measures, direct observation, and behavioral rating scales.

Cognitive assessment focuses on the measurement of thoughts, beliefs, and attitudes in order to help identify 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), the Cognitive Checklist (CCL), and the Dysfunctional Attitudes Scales (DAS).

Measures of physiological function include heart rate, blood pressure, galvanic skin response (GSR), muscle tension, and brain wave activity. Brain-imaging techniques such as EEG, CAT scans, PET scans, .

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MRI, and BEAM probe the inner workings and structures of the brain.

Sociocultural Factors in Psychological Assessment 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. Researchers need to disentangle psychopathology from sociocultural factors so as not to introduce cultural biases in assessment. Meanings can be lost or distorted in translation. For example, Spanish speakers are often judged to be more disturbed when interviewed in English than in Spanish (Fabrega, 1990).

Lecture and Discussion Suggestions 1. 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 linked with causes in the course of diagnosing and treating an illness. The DSM acknowledges that underlying causes of psychological disorders are often unclear and that there is no single theoretical perspective that may adequately explain symptomatology.

2. Psychological assessment. Essentially, assessment is the process of collecting and processing information from a client as a basis for determining the person's problems as well as the goals and strategies used in treatment. Ideally, this involves a variety of measures that will lead to a balanced assessment of the individual. In actual practice, however, clinicians tend to be highly selective in their choice of methods, depending partly on the particular client and his or her problem. For instance, when a client expresses paranoid ideas, the clinician might include the MMPI-2 to identify specific patterns of abnormality. If a client is intensely fearful of mingling with others in public places, the clinician may want to do a functional or behavioral analysis of the phobic behavior, identifying the conditions in which this behavior occurs. Finally, a psychological assessment should include the client's overall strengths and weaknesses, not simply what's wrong with the person.

3. 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 more 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: 1. Clinicians rarely do better than statistical formulas.

2. The formulas in many cases are more accurate than the clinicians.

3. Clinicians should be replaced by the statistical formulas.

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

A more moderate conclusion is that while some clinical tasks can clearly by 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. O. (1994). Psychological Testing: Principles and Applications, 3rd .

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Ed. Englewood Cliffs, N. J.: Prentice-Hall.

4. The advantages and disadvantages of the DSM approach. An advantage to the DSM is that it permits the clinician to readily match a client’s complaints and associated features with specific standards to see which diagnosis best fits the symptoms. Criticisms include the following concerns: 1. Is it useful to have particular symptoms or features associated with a particular syndrome or of specified diagnostic criteria?

2. The DSM is a medical model system designed for the primary purpose of determining a diagnosis for a client. This is based on a deficit, rather than a strength or a perspective, which presumes someone is demonstrating psychopathology. Some believe the process of labeling someone with a mental illness is inherently problematic and harmful. Such labels may also cause the individual and those around him/her to behave as if it is true and act accordingly.

3. The DSM is based on the premise that diagnoses are categorical, however, most diagnoses are dimensional. Although some diagnoses, such as pregnancy, fall neatly into a categorical distinction of present/not present, most (e.g., depression, anxiety) occur in degrees, with people having more or less of the factor at any given time.

4. Behavioral psychologists feel abnormal behavior is best approached by examining the interaction between the person and the environment. Conversely, the DSM aims to determine what “disorders” people “have”—not how well they can function in particular situations. The behavioral model, focuses more on what people do than on what they “are” or “have” and thus evaluate individuals from a broader perspective.

5. The DSM system might stigmatize people by labeling them with psychiatric diagnoses. Our society is strongly biased against people who are labeled as mentally ill. They are often shunned by others, even family members, and subjected to discrimination.

Ask students to discuss these criticisms. In particular, ask the class how they would design the next version of the DSM. .

5. 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 presenting complaints in their own words. Second, the clinician may observe a variety of nonverbal behaviors, 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.

6. Classifying abnormal behaviors. Have students discuss the pros and cons of classifying abnormal behaviors. You might point out the advantages of the DSM-5 over earlier approaches, especially the shift away from the psychodynamic assumptions of causality to a more descriptive and cause-neutral approach.

Yet, critics point out that 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 behaviors?" and move the discussion from there to the various pros and cons of such a system. .

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7. 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.

8. 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.

9. On Being Sane in Insane Places. Rosenhan's article, On Being Sane in Insane Places (Science, 1973, 179, 250–258) is engaging for students to read and can be counted on to provide material for classroom discussion. Replies to the article (Science, 1973, 180, 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"?, and Can medicine detect liars? should be sufficient to sustain discussion on that controversial piece of research.

10. 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 the meaning of the scores?

11. Reliability and chance agreement. The concept of accounting for chance agreement when evaluating reliability is an important idea to get across to students. Ask them this: Two psychiatrists are engaged in a study of the reliability of the diagnosis of schizophrenia. They are only making the diagnosis of schizophrenia or not schizophrenia, and each psychiatrist assigns the diagnosis of schizophrenic to 10 percent of the cases she sees. After seeing 1,000 cases the psychiatrists discover that they agreed upon the diagnosis in 82 percent of the cases. Is this reasonable reliability? On the surface it sounds fairly good, however, in reality, the two psychiatrists would be agreeing at exactly a chance level. Cases like this show how important it is for students to have a basic working knowledge of probability statistics when evaluating reliability. This provides a good example why "people persons" such as psychology majors need to take statistics classes and have a general idea of how numbers work in applied settings.

Think About It What are the advantages and disadvantages of using the DSM system to classify abnormal behavior patterns? Can you think of other ways we might classify abnormal behavior patterns? The DSM system’s major advantage is the designation of specific diagnostic criteria. Mental health professionals can match a patient’s specific complaints to an associated diagnosis. It has been criticized on the basis of questionable reliability and validity. Many challenge the reliance on the medical model. The DSM may .

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contribute to the stigmatization of people labeled with psychiatric diagnoses. An alternative way to classify abnormal behavior would be to focus on understanding behavior by examining the interaction of the person and the environment. Through behavior analysis, a great deal of information could be gathered about the patient’s strengths and weaknesses. This approach would avoid labels that stigmatize.

Suppose you wanted to develop a new psychological test or measure. How would you go about demonstrating that it was reliable and valid? To establish reliability, one must demonstrate that the psychological test or measure is consistent. The three main types of reliability include internal consistency, temporal stability, and interrater reliability. Internal consistency could be obtained by computing the intercorrelations of all test items. Temporal stability could be demonstrated by giving at least two administrations of the test over time (test–retest reliability). Interrater reliability could be established by having two different people administer the test. Validity includes content validity, criterion validity, and construct validity. The test would demonstrate content validity if the test shows an apparent relationship to the constructs it purports to measure. Criterion validity would mean a test of intelligence, for example, would have to relate to some external source such as school grades. In construct validity, if a test were supposed to measure the trait of anxiety, we’d expect the test to predict other behaviors that are related to anxiety.

Why is it important for clinicians to take cultural factors into account when diagnosing psychological or mental disorders? Clinicians must take cultural factors into account because an assessment technique might not be reliable or valid when used in a different cultural context. For example, couldn’t language or sociocultural factors account for differences in prevalence of depression found between Mexican Americans and Non-Hispanics in Los Angeles? Very often, adequate norms are not provided for different cultural and ethnic groups on psychological measures. Translations of psychological measures should not only translate words, but also include instructions on attitudes, values, and cultural beliefs.

What are the differences between projective and objective personality tests? Projective personality tests offer no clear, specified answers. A person must respond to ambiguous stimuli. They are based on the psychodynamic “projective hypothesis” which is the belief that people project their hidden psychological needs, drives, and motives onto unstructured, ambiguous stimuli. It is believed that much of these motivations and drives are unconscious. An objective test, on the other hand, is a forced choice test. Like the projective test, there are no right or wrong answers, but there is a limited range of possible responses. Objective tests often include checklists and self-report inventories. The MMPI-2 is an example of an objective test while the Rorschach Inkblot Test is an example of a projective test.

Consider the debate over the use of projective tests. Do you believe that a person’s response to inkblots or other unstructured stimuli might reveal aspects of his or her underlying personality?

Why or why not? This is a personal opinion question. Students should present evidence, either pro or con, on the reliability and validity of projective techniques. Encourage them to 1) maintain a skeptical attitude, 2) consider the definitions of the terms, 3) weigh the assumptions or promises on which arguments are based, 4) bear in mind that correlation is not causation, 5) consider the kinds of evidence on which conclusions are based, 6) do not oversimplify, 7) do not overgeneralize.

Have you ever taken a psychological test, such as an intelligence test or personality test? What was the experience like for you? What did you learn about yourself from the experience? This is a personal experience question. Students need to have experience with either an intelligence or personality test.

Jamie complains of feeling depressed since the death of her brother in a car accident last year.

What methods of assessment might a psychologist use to evaluate her mental condition? Students .

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should be familiar with all of the many assessment tools of psychologists. They could list and expand on the major categories of assessment including 1) the clinical interview, 2) psychological tests, 3) neuropsychological assessment, 4) behavioral assessment, 5) cognitive assessment, 6) physiological measurement. When discussing specific tests, students should be able to elaborate on the test they pick and why.

Activities/Demonstrations 1. The MMPI-2. Ask students to jot down their true or false responses to the following statements: "I never read the 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 restandardization project that produced the revised MMPI or MMPI-2.

2. Projective techniques. Get students' responses to a TAT card or some ambiguous scene in a magazine involving one or more persons. 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. NOTE: If you are concerned with students accidentally disclosing personal responses that may be embarrassing later, collect their responses and either redistribute them to the class so students are not reading their own answers, or collect them and read some out loud to discuss as a class.

3. 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 center. Students can discuss the types of problems they are most likely to encounter in this 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 why they made the decisions they made.

4. Rorschach demonstration. Option 1: 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 .

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aspects of how the test is scored, as well as the way different psychological perspectives would view a given response to a Rorschach card.

Option 2: Show a Rorschach card (on an overhead or projector) and discuss factors one might examine in an interview. Discuss the implications of clients using white space versus shading, naming popular images or uncommon images, seeing color on black and white cards, focusing on details or the whole card, etc.

5. Role-play an interview. Option 1: 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 behaviors—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 behaviors of the subject and the interviewer.

Option 2: Have students get into groups of three. One person should be the observer to take notes on nonverbal behaviors, additional information that would be helpful to assess, etc. Another should be the clinician and the third should be the interviewee. Have students role-play a clinical interview incorporating the five topics covered in most clinical interviews: identifying data, description of the presenting problem(s), psychosocial history, medical/psychiatric history, and medical problems/medication.

6. Construct an anxiety test. This can be done either as an in-class activity or as an extra assignment.

Have the students play test-developer for a new test of anxiety. They first 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.

7. 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.

8. Describe this person. Tell the class they are going to evaluate a mystery person on the basis of five adjectives. Create a handout for half the class with the following adjectives: industrious, competent, loyal, warm, intelligent. The other half of the class will receive a handout with the following adjectives: industrious, competent, loyal, cold, intelligent. The directions on the handout should read: Describe this person. You are a clinical psychologist doing personality assessment. Write a paragraph about this person.

What might he/she be thinking and feeling? How is he/she performing at work? What are his/her relationships like? Ask the class if they would like to get to know this person? Lively discussion follows the realization that the target traits varied only on the warm/cold dimension.

9. Cultural bias in IQ testing. Option 1: Show sample items of IQ tests and discuss possible cultural biases and whether some people (e.g., those whose parents are English professors or science teachers) would do better than others by simple exposure to the content. Get students to debate whether or not the items address IQ. Option 2: Get samples of outdated IQ test items and discuss the ways in which they are biased. Then, introduce items from current tests and discuss how items have improved and what changes are still .

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needed.

Option 3: Create a list of items that would only be known by a select population (e.g., the Amish community) and tell students it represents IQ. Have students take the test; presumably they will be upset because most will not do well. Let students actively argue how the test is biased before saying that it taps key factors within the selected community. Draw the analogy between their reactions and the assertions that traditional IQ tests are similarly biased.

Media Resources Video–Special Topics: Diagnosing Mental Disorders (7:01) A history of the development and refinement of The Diagnostic and Statistical Manual of Mental Disorders (DSM) and how it is used in diagnosing and treating mental disorders.

Video available on MyPsychLab.com Video–Thinking Like a Psychologist: Measuring Personality (6:30)

A description of various personality tests, including the MMPI-2, the TAT, and the Rorschach, and what makes a personality test valid.

Video available on MyPsychLab.com

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CHAPTER FOUR STRESS-RELATED DISORDERS Learning Objectives 4.1 Evaluate the effects of stress on health.

4.2 Identify and describe the stages of the general adaptation syndrome.

4.3 Evaluate evidence on the relationship between life changes and psychological and physical health.

4.4 Evaluate the role of acculturative stress in psychological adjustment.

4.5 Identify psychological factors that moderate the effects of stress.

4.6 Define the concept of an adjustment disorder and describe the key features of this disorder.

4.7 Describe the key features of acute stress disorder and posttraumatic stress disorder.

4.8 Describe ways of understanding and treating PTSD. Chapter Outline I. Stress and Health A. Stress and the Endocrine System B. Stress and the Immune System C. Writing About Stress and Trauma as a Coping Response D. Terrorism-Related Trauma E. The General Adaptation Syndrome F. Stress and Life Changes G. Acculturative Stress: Making It in America H. Psychological Factors That Moderate Stress II. Adjustment Disorders III. Traumatic Stress Disorders A. Acute Stress Disorder B. Posttraumatic Stress Disorder C. Theoretical Perspectives D. Treatment Approaches IV. Summing Up Chapter Overview Stress and Health Sources of stress can have profound effects on our physical and emotional health. Psychologists who study interrelationships between psychological factors, including stress, and physical health are called health psychologists.

Stress is implicated in a wide range of physical and psychological problems. Psychoneuroimmunology studies relationships between psychological factors, especially stress, and the workings of the immune system.

Stress and the Endocrine System .

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The endocrine system is the body’s system of glands that releases secretions called hormones directly into the bloodstream. Several endocrine glands are involved in the body’s response to stress. The hypothalamus releases a hormone that stimulates the nearby pituitary gland to secrete the adrenocorticotrophic hormone (ACTH). ACTH, in turn, stimulates the adrenal glands, which are located above the kidneys. Under the influence of ACTH, the adrenal cortex, releases hormones called cortical steroids. When stress persists, the body regularly pumps out stress hormones and mobilizes other systems, which over time can tax the body’s resources and impair health.

Stress and the Immune System The immune system is the body’s system of defense against disease and regulates the body’s inflammatory response to infection or injury. Under stress, the immune system becomes less capable of toning down its inflammatory response, leading to persistent inflammation that may contribute to the development of many physical disorders, including cardiovascular disease, asthma, and arthritis. Having a strong social support may help moderate or buffer the harmful effects of stress on the immune system.

Writing About Stress and Trauma as a Coping Response Many research studies show that expressive writing can reduce psychological and physical symptoms.

Writing about stressful situations may reduce the burden on the autonomic nervous system, which, if left in a state of tension, can weaken the effectiveness of the immune system.

Terrorism-Related Trauma Although most people exposed to traumatic events such as 9/11 do not develop PTSD, many do experience symptoms associated with the disorder, such as difficulties concentrating and high levels of arousal. Evidence gathered since 9/11 shows that experiencing positive emotions, such as feelings of gratitude and love, appear to have helped buffer the effects of stress.

The General Adaptation Syndrome Hans Selye (1976) coined the term general adaptation syndrome (GAS) to describe a common biological response pattern to prolonged or excessive stress. The GAS consists of three stages: the alarm reaction, the resistance stage, and the exhaustion stage. The alarm reaction mobilizes the body to prepare for challenge or stress. Earlier, in 1929, Walter Cannon termed this response pattern the fight-or-flight reaction. The fight-or-flight reaction most probably helped our early ancestors cope with the many perils they faced.

Cortical steroids are perhaps one reason that persistent stress may eventually lead to health problems.

Although cortical steroids help the body cope with stress, they also suppress the activity of the immune system.

Stress and Life Changes Life changes are sources of stress because they impose adjustment. These changes include both positive events and negative events. People who experience a greater number of life changes are more likely to suffer from psychological and physical health problems than those with fewer life events.

Acculturative Stress: Making It in America .

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Acculturative stress results from the demands placed on immigrant, native and ethnic minority groups to adjust to life in the mainstream culture. Two competing theories, the “Melting Pot” theory and the “Bicultural” theory attempt to understand the adjustment of immigrants to their host culture.

Psychological Factors That Moderate Stress Emotion-focused and problem-focused coping are two ways in which people react to stressful events.

Self-efficacy expectancies refer to our expectations regarding our abilities to cope with the challenges we face, to be able to perform certain behaviors skillfully, and to produce positive changes in our lives.

Another factor, postulated by psychologist Suzanne Kobasa, is the term “Psychological hardiness”. This term describes a cluster of traits that may help people manage stress.

Adjustment Disorders Adjustment disorders are maladaptive reactions to identified stressors. Impairment usually takes the form of problems at work or in social relationships or activities, or by signs of personal distress that are greater than expected given the circumstances.

Traumatic Stress Disorders Traumatic stress disorders are characterized by maladaptive patterns of behavior in response to trauma that involve marked personal distress or significant impairment of functioning. Two major types of traumatic stress disorders include acute stress disorder and posttraumatic stress disorder.

Acute Stress Disorder The symptoms or features of acute stress disorder vary and may include disturbing, intrusive memories or dreams about the trauma; re-experiencing the trauma in the form of flashbacks; feelings of unreality or detachment (“dissociation”) from one’s surroundings or from oneself; problems sleeping; and an exaggerated startle response to sudden noises. Persistent dissociation has been associated with the later development of PTSD for some individuals.

Posttraumatic Stress Disorder (PTSD) PTSD presents with a similar symptom profile as acute stress disorder, but may persist for months, years, or even decades. Genetic factors involved in regulating the body’s response to stress appear to play a part in determining a person’s susceptibility to PTSD in the wake of trauma.

Theoretical Perspectives The major conceptual understanding of PTSD derives from the behavioral or learning perspective.

Treatment Approaches Cognitive-behavioral therapy has produced impressive results in the treatment of PTSD. Exposure therapy has been effective in treating both acute stress disorder and PTSD. Training in stress management skills, such as self-relaxation, can also improve the client’s ability to cope with troubling symptoms of PTSD. EMDR is a controversial form of treatment for PTSD. Many question if the treatment works and, if it does work, why does it work?

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Lecture and Discussion Suggestions 1. Psychological hardiness and health. The complex relationship between stress and health has led to the investigation of the variables that moderate the effects of stress (e.g., social support, optimism, diet).

Suzanne Kobasa and her colleagues, described in the text (p. 143), have focused on the concept of psychological hardiness, which is based on three key personality traits: commitment, control, and challenge. Commitment refers to the tendency to invest ourselves in what we are doing, rather than feel alienated from our activities. Control involves the belief that we exercise a sense of personal control over events rather than being a helpless victim. Challenge refers to an attitude of acceptance, viewing change and unexpected events as challenges rather than threats. Kobasa's studies of top executives in the Fortune 500 companies have shown that those who exhibit high levels of psychological hardiness cope with stress most successfully and experience fewer stress-related illnesses.

2. Measuring stress. Despite its usefulness, the familiar life-events approach to measuring stress has several limitations. First, the particular events included may not be equally relevant for all groups of people. As a result, there are now many variations of Holmes and Rahe's original scale aimed at specific segments of the population, such as the student stress scale. Some stress scales now include not only a given event, but how frequently it has occurred. Others fail to include the positive, stress-fighting effects of regular exercise, having a strong support system, and other coping mechanisms. Another problem is that stress scales do not take into account how individuals perceive and adapt to a given change; e.g., the impact of one's expectations and personality differences. Still another difficulty is that the life events approach is built around social change and fails to include chronic stress, such as stress from a boring job or unhappy marriage. Finally, there is the issue of everyday hassles versus major life events. In sum, stress is difficult to measure, largely because the experience of stress varies greatly among different individuals.

3. Personal control. Personal control, in the sense of perceived control, is a key factor in the experience of stress. Considerable research has shown that people high in perceived control manage stress more effectively with fewer stress-related illnesses than others. In contrast, people who attribute too little or too much control to themselves have difficulty managing stress. On the one hand, people who experience a combination of uncontrollable events outside their control, such as losing their jobs because of a company layoff and losing a spouse through death, often exhibit learned helplessness—a maladaptive passivity to events. Martin Seligman, who has investigated this phenomenon, contends that learned helplessness is brought about less by the events themselves than how people perceive and interpret them. At the other extreme are people who put themselves under needless stress because they believe they exercise greater control over their lives than they actually do. Type A individuals, in particular, are prone to the illusion of control, believing they exert control over events when they don't. Such individuals set themselves up for disappointment, needless frustration, and pessimism—all because of their undue need to control events.

An excellent overview of research on perceived control can be found in E. Jerry Phare's chapter on "Perceived Control" in his Introduction to Personality (Scott, Foresman, and Company, 1988).

4. Diathesis-stress model. Because clear-cut cases of direct genetic causation of illness and abnormal behavior are rare, most illnesses are now understood in terms of the interaction of hereditary and environmental factors. According to this theory, certain genes or hereditary vulnerability give rise to a diathesis (a biological and/or genetic predisposition). When an individual's predisposition is then combined with certain kinds of environmental stress, illness may result. Considerable research has shown that certain illnesses, such as heart disease, high blood pressure, and cancer, are especially likely to run in families. In most cases, both hereditary and environmental factors play a role. The challenge in research and clinical practice is to identify specific risk factors in a given individual, including both family history and personal lifestyle. For instance, a man whose father died of lung cancer, who smokes two packs of cigarettes a day, and who lives in an urban, smog-polluted environment runs a high risk of eventually .

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contracting lung cancer. If he were to quit smoking and move to a place with less air pollution, his risk of getting lung cancer would likely decrease dramatically.

However, because of the possible biological/genetic predisposition (e.g., father having had lung cancer, lung damage from being exposed to second-hand smoke from his father as a child), his risk may still be elevated.

5. Lifestyle alteration. Ask students to name the single most important thing each of them could do to alleviate stress by altering their lifestyles. This generally evokes a wide variety of suggestions, illustrating how the experience of stress is often personal and multifaceted. Equally important, what is a significant stressor for one person may not be problematic for another, but may be devastating for a third person.

Include in this discussion how an expressive writing program might alleviate the psychological and physical ramifications of stress.

6. Hassles. Many studies have recognized that stress and stress-related illnesses are often the result of subtle but chronic "hassles" (daily stressors such as bills, roommate problems, family problems, traffic, etc.). Have students discuss the idea that it's the "little things" that get us down. How important are everyday hassles compared to larger life events? Some researchers believe that hassles act as a "grindstone," slowly wearing us down. By the time a major life event occurs, these chronic hassles have whittled away at our resistance, making it much more likely to make us "stressed-out" or ill. Perhaps it is the combination of hassles and major life events that causes many of the stress-related illnesses we see in society today.

7. Microaggressions and marginalized people. In addition to general chronic hassles, there is considerable evidence that marginalized people (e.g., the poor, women, people of color) also face repetitive stressful events due to oppression. For example, even without blatant acts of racial harassment, people of color face regular covert acts of subtle discrimination and differences in treatment that are stressful. Nancy Boyd-Franklin refers to these acts as microaggressions. She describes the impact of such events as constant nicks from arrows that scratch the surface of one’s skin, any one causing only a small amount of pain, but at the end of the day the constant barrage still leaves the target bloody. Encourage students to put these microaggressions into the context of daily hassles and stressors. How might these events contribute to the disparities in the excess death rate and stress-related illnesses found between people of color and Caucasian Americans?

8. Personal control. Discuss the importance of personal control in managing stress. You might mention that workers in lower level jobs tend to experience greater stress than those in executive positions. This is thought to be the result of workers in lower-level jobs having less personal control over their daily work life. For example, some lower-level jobs, such as cashier and waiter, are especially stressful because they involve high psychological demand with low decision control.

9. Family history. Ask students about any patterns of stress-related illnesses in their families. What sorts of illnesses, if any, tend to run in families? How much of this can be explained by personal lifestyles modeled and passed on from one generation to the next as opposed to heredity?

10. Optimism and cancer. How does optimism or fatalism impact one’s chances of eventually getting cancer? Optimists believe they can avoid cancer altogether by practicing good nutrition and fitness.

Fatalists think there's nothing you can do if cancer is in the genes. The truth usually lies somewhere inbetween, such that most people can reduce their chances of getting cancer by modifying the relevant risk factors in their lives. Ask students to raise their hands if they have optimistic or fatalistic beliefs regarding cancer, and afterwards discuss the ability to modify risk through lifestyle changes such as diet, exercise, and not smoking. .

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11. Terrorism-related stress: What is a normal reaction? After a large-scale act of terrorism, such as the September 11, 2001, attacks on the World Trade Center in New York, or the subsequent subway train bombings in Madrid, Spain, symptoms of shock, dissociation, and fear may continue for days and weeks for many people who are directly and/or indirectly exposed to the event. For some, additional ongoing stressors related to the event cause the trauma and the traumatic response to continue. For example, acts of bioterrorism and random attacks and threats against Muslim, Arab, and Middle-Eastern immigrants and citizens can prolong and exacerbate the trauma response. However, for most people the active symptoms of trauma related to these events have abated. Nevertheless, there remains a growing population of those suffering from chronic and severe terrorism-related stress as well as a large segment of the population whose feelings of safety and belief in a just world have been forever changed. Ask students to consider their own reactions to these events. What made the stressor more or less severe (e.g., number of times they watched video coverage of the planes crashing into the World Trade Center towers; whether or not they knew people who died in the towers; or their proximity to the towers during the attack)? What did they do to cope with their concerns? Did they know children who were fearful after the attacks? What lingering fears do they still have? In what ways have these events continued to influence their lives?

12. Developing good coping skills. When discussing stress management, students often want to know what they can do to help manage stress in their own lives. It is important to emphasize that long-term stress management involves more than a “quick fix,” such as popping a pill. It involves developing a stress-resistant lifestyle. While experts disagree about many of the specifics involved in this lifestyle, most agree on some general principles which can be helpful. These are as follows: 1. Self-Awareness. Learning about your stressors and how the things you do affect your stress levels. Learning what your strengths and weaknesses are and how to cope with or improve upon those weaknesses.

2. Time Management. Learning to schedule your time efficiently and build relaxation/personal time into your schedule. Much of the stress experienced by Americans today is directly related to trying to constantly cram 26 hours of work into a 24-hour day. Good time management can free up time so that you do not feel the need to constantly watch the clock.

3. A Support System. Having a network of close friends with whom you can be open and honest, and on whom you can lean when you are having problems is a crucial part of managing stress. This is particularly important for males as researchers have found that men tend to not maintain previous friendships as they get older. In addition, they do not build new friendships.

Hence, a major complaint among middle-aged and older men is loneliness.

4. Regular Exercise. Regular, noncompetitive, aerobic exercise is good for overall fitness because it burns off much of the physical tension that accompanies stress and helps in stress management. Feeling more relaxed physically may also help you feel more relaxed mentally.

5. Diet. While experts disagree on the exact role of diet and stress, eating a well-balanced diet, as with exercise, is not only good for your overall health, but may help you manage stress as well. In particular, avoiding excess caffeine and simple sugars is important because they can make .

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stressed people feel more “jittery” and anxious.

6. Relaxation Activities. Developing hobbies or personal activities that you enjoy and are relaxing can provide a sense of well-being that is useful in combating stress. What the activities are doesn’t matter as long as you enjoy them. Such activities can be important stress-fighting tools if you make regular time in your schedule for them so you can pursue them without feeling guilty.

7. Sleep. Most people in America today do not get enough sleep. NOT getting enough sleep is associated with physical sickness, poor memory, short attention spans, boredom, and distress. Sleep is an instinct—that is BOTH to go to sleep and to wake up. Tell students to throw away their alarm clocks for one week—and then ask them to report on their psychological and physical health after that week is through.

8. Attitude. This may be the most important of all. None of the above techniques will be very effective if you fill your head with negative, irrational thoughts and regularly view the world with a pessimistic, fatalistic attitude. Focusing on what you can do and on what you can control, and trying to find the best in each situation, will make each of the above techniques work much more effectively.

Think About It How does the body’s immune system help protect us from disease? What are the relationships between psychological factors, especially stress, and the functioning of the immune system? The immune system is the body’s system of defense against disease. The immune system contains millions of leukocytes, white blood cells that systematically search out and destroy pathogens. The leukocytes produce antibodies, specialized proteins, which attach to the foreign bodies and destroy them. There is evidence that stress can make us more vulnerable to disease by weakening the immune system. A weakened immune system makes us more susceptible to common illnesses, like colds and flu, and may increase our chances of developing chronic diseases, including cancer. The field of psychoneuroimmunology is devoted to research involving the effect of stress on our immune system.

What are the major changes in the body that occur during each of the phases of the general adaptation syndrome? The general adaptation syndrome is the term used to describe the common biological response pattern to prolonged or excessive stress. The GAS consists of three stages: the alarm reaction, the resistance stage, and the exhaustion stage. The alarm reaction has been termed the fight-orflight reaction. During this stage the brain’s pituitary gland stimulates the adrenal gland to pump out steroids that mobilize the body’s defenses. This fight-or-flight reaction was probably helpful in prehistoric times to enable us to flee predators. When a stressor persists, we progress to the resistance phase. Stress hormones remain at a high level as our body tries to renew energy and repair damage. The final stage is the exhaustion phase, which occurs as the stressors continue. This can lead to diseases of adaptation including allergic reactions, heart disease, and even death.

Does the evidence presented in the text seem to argue for or against a melting-pot model of American culture? What evidence presented suggests that maintaining a strong ethnic identity (such as what is presented with bicultural theory) may be beneficial? Acculturation refers to the process of adaptation in which immigrants and native groups identify with the new culture through making behavioral and attitudinal change. The melting pot theory argues that acculturation helps immigrants adjust to their host country. The bicultural theory holds that psychosocial adjustment is fostered by identification with both traditional and host cultures. The evidence presented in the book is .

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mixed. It suggests a more complex relationship may be involved in acculturation. Lower acculturation may in fact represent lower socio-economic status, for example.

Examine your own personality and behavior patterns. How might they be helping to promote your health? In what ways might these patterns damage your health or increase your risk of developing health-related problems? What changes can you make in your lifestyle to adopt healthier behaviors? This is a personal experience question. Students need to be aware of personality theories and health issues. Encourage them to 1) maintain a skeptical attitude, 2) consider the definitions of the terms, 3) weigh the assumptions or promises on which arguments are based, 4) bear in mind that correlation is not causation, 5) consider the kinds of evidence on which conclusions are based, 6) do not oversimplify, 7) do not overgeneralize.

Consider the level of stress in your own life. Might the stress you are encountering be affecting your psychological or physical health? In what ways? How might you reduce the level of stress in your life? How might you learn ways of coping more effectively with the stress you do encounter? This is a personal experience question. Students should examine the various theories of the effects of stress on behavior.

Activities/Demonstrations 1. The stress scale. Have students complete the Holmes and Rahe stress scale or one of the many variations of this stress scale either in class or at home (see Going Through Changes on p.138 for a short, easily administered and scored self-assessment). Instruct students to interpret their scores according to the information presented in the text. Then, have students discuss their reactions to their scores. Have those with higher stress scores also experienced a greater than average number of stress-related illnesses in the last year? Why do you suppose that some of them have while others have not?

2. The lifestyle awareness triangle. A simple way to help students visualize the stress in their lives is to have them draw a "lifestyle triangle." The first side of the triangle represents school and/or work, the second side represents leisure/relaxation activities, and the third side represents relationships. The length of each side represents the amount of time and emotional energy spent on this aspect of one's life, so the longer the side, the more time and energy involved. Many stress counselors claim that ideally, the lifestyle triangle should be an equilateral triangle. However, this may vary from student to student. I have found it more helpful to have students draw two triangles. First, have them draw the lifestyle triangle the way they wish it looked (how much time and energy they wish they were putting into each of the three sides). Instruct students to draw the triangle the way it really looks. In general, the bigger the difference between the two triangles, the more perceived stress the student will feel. You may find some students will draw triangles with a "work/school" side that is so long, the other two sides cannot connect with each other! After drawing the triangles, have students discuss the implications of what they have drawn and perhaps brainstorm some possible ways to change their triangle so that the "real" one is less stressful in the future.

3. Acculturative stress. Ask students to imagine moving to another community that is vastly different from their own. Few people know their language and the language spoken there is unintelligible to them.

Their typical ways of interacting with people (e.g., shaking hands when meeting someone new) are met with looks of suspicion, sometimes contempt or ridiculing laughs. Over several years, they learn enough of the new language to manage, but always feel out of place and somewhat unwelcome. Moreover, in their attempts to adjust to the new culture, they have had to give up many of their traditions and habits from home. Now when they visit home, they no longer feel as if they fully fit in their either. As they watch their children grow up, they realize the next generation is even less connected to their homeland.

Their children’s ability to blend in with the dominant culture helps the children be successful in the new .

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country, but also less connected to the traditions and expectations of their family and homeland. Let students write a few sentences on their reactions to this exercise and how they think they would adjust.

Ask them to also consider the possible psychological implications of trying to make such a transition and dealing with the multiple levels of loss. These reactions are analogous to the experiences of recent immigrants.

4. The Life Orientation Test. This measures the degree to which we possess an optimistic or pessimistic outlook on life, which in turn has a significant impact on our health. Have students complete the questionnaire presented in the chapter (p. 154). Then, tell them to use the scoring key at the end of the chapter to obtain their scores, paying special attention as to whether their scores represent a relatively optimistic or pessimistic outlook as indicated in the commentary accompanying the scoring key. Ask students to comment on the possible connection between their scores and their health history, including their responses to medical treatment and recovery from various illnesses. Which types of health problems are especially likely to be affected by an optimistic or pessimistic outlook?

5. Decreased immune function. Students often have depressed immune system functioning during stressful times, such as final exams. Have the students collect their own data on this point. They can survey fellow students to see if they have more colds, flu, and other such problems around the time of mid-term and final exams. Students can then present the results of their findings in class.

6. Locus of Control. Have your students search the Internet for the term “Locus of Control.” There are many Locus of Control tests that can be taken for free on the Internet. Reliability and validity may be questionable but it will give your students a feel for the concept. Have them take the test and relate it to their psychophyisiological health. Theoretically, internals (as contrasted with externals) should be more psychologically hardy.

Media Resources 1 – Julia: HIV Positive and Adjustment Disorder (2:26) Video available on MyPsychLab.com VIDEO BACKGROUND: In this interview, Julia discusses her life before and after contracting HIV and her resulting problems with adjustment. As a serious drug user living on the street and having promiscuous sex, she had little value for her life. Now that she has overcome her addiction and come to terms with her HIV diagnosis, she faces new obstacles and challenges on a daily basis including the disease’s physical effects, her medication’s side effects, and cognitive problems. She notes she has skin problems (dryness, rashes, scarring), constipation, headaches, and other somatic issues. An interesting segment involves Julia’s discussion of the compensatory strategies she uses to make her life easier (e.g., eating fiber, having a well-organized medication schedule). HIV has also had an impact on her relationships and she has difficulty determining when to discuss her HIV status with people.

DISCUSSION QUESTIONS: 1. What are some of the symptoms Julia faced from her HIV and her medication that led to her having difficulty adjusting? a) Cognitive deficits b) Physical problems c) Social issues d) all of the above .

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Answer: d.

Julia’s HIV status has caused her problems in numerous areas, including physically, cognitively, and socially.

2. What would be the best example of Adjustment Disorder? a) Feeling violated after a robbery b) Feeling angry after a divorce c) Feeling very depressed months after not getting a particular job d) Feeling very depressed after the death of a friend Answer: c.

Although the other choices involve a response to a stressor, a diagnosis of Adjustment Disorder focuses on a clinically significant reaction in excess of what would be expected given the nature of the stressor.

Choice C is the best answer because it is uncommon to experience severe depression months after failing to get a certain job.

3. Although Julia seems to have come to terms with her illness, many people who develop Adjustment Disorder have severe symptoms. What are examples of these symptoms?

Suggested answers: emotional or behavioral symptoms including excessive distress or significant social or occupational impairment.

4. Adjustment Disorders are caused by what is known as a stressor. What is the time frame for the development and disappearance of Adjustment Disorder in terms of the stressor?

Suggested answer: Adjustment Disorder must always develop after the stressor and must subside within 6 months of the removal of the stressor.

5. How does the stressor necessary for Adjustment Disorder differ from that required for PTSD? Suggested answer: PTSD requires a severe stressor/trauma, while Adjustment Disorder can be triggered by a stressor of any severity.

CLASS ACTIVITY: 1. It seems Julia has been successful in adjusting to her illness. Discuss some strategies people might use to adjust to stressors.

Suggested answers: psychotherapy, psychopharmacology, self-help, increased organization, increased social support, educating themselves, etc.

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2–Learned Optimism (1:56) In this video, psychologist Martin Seligman discusses how learned helplessness is related to optimism.

Video available on MyPsychLab.com

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CHAPTER FIVE ANXIETY DISORDERS AND OBSESSIVE–COMPULSIVE AND RELATED DISORDERS Learning Objectives 5.1 Describe the physical, behavioral, and cognitive features of anxiety disorders.

5.2. Describe the key features of panic disorder.

5.3. Describe the leading conceptual model of panic disorder.

5.4. Evaluate methods used to treat panic disorder.

5.5. Describe the key features and specific types of phobic disorders and explain how phobias develop.

5.6. Evaluate methods used to treat phobic disorders.

5.7. Describe the key features of generalized anxiety disorder and ways of understanding and treating it.

5.8. Evaluate ethnic differences in rates of anxiety disorders.

5.9. Describe the key features of obsessive–compulsive disorder and ways of understanding and treating it.

5.10. Describe the key features of body dysmorphic disorder and hoarding disorder and explain why these disorders are classified within the obsessive–compulsive spectrum.

Chapter Outline I. Overview of Anxiety Disorders II. Panic Disorder A. Theoretical Perspectives B. Treatment Approaches III. Phobic Disorders A. Types of Phobic Disorders B. Theoretical Perspectives C. Treatment Approaches IV. Generalized Anxiety Disorder A. Theoretical Perspectives B. Treatment Approaches V. Ethnic Differences in Anxiety Disorders VI. Obsessive–Compulsive and Related Disorders A. Obsessive–Compulsive Disorder B. Body Dysmorphic Disorder C. Hoarding Disorder Summing Up Chapter Overview Types of Anxiety Disorders Panic disorder is characterized by repeated panic attacks, which involve intense physical features, notably .

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cardiovascular symptoms that may be accompanied by sheer terror and fears of losing control, losing one's mind, or dying. Etiological speculation focuses on biological causes or interaction between biological and cognitive factors. Panic attack sufferers often limit their outside activity in fear of recurrent attacks. This can lead to agoraphobia, the fear of venturing into public places.

Generalized anxiety disorder involves persistent anxiety that seems to be “free floating.” The central feature of generalized anxiety disorder is worry. Although specific manifestations of anxiety vary from individual to individual, generally there are signs of motor tension, autonomic hyperactivity, apprehensive expectation, and vigilance.

Phobias are excessive irrational fears of specific objects or situations. Phobias involve a behavioral 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 phobia involves an intense fear of being judged negatively by others. Agoraphobia involves fears of venturing into public places. Agoraphobia can occur with or in the absence of panic disorder.

Theoretical 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.

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 behavior. 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 overpredictions of fear, irrational beliefs, self-efficacy expectancies, self-defeating thoughts, and attributions for panic attacks.

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.

Treatment of Anxiety Disorders 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. Modern psychodynamic approaches also focus on current disturbed relationships and encourage clients to assume more adaptive behavior patterns. The biological perspectives have spawned the development of various drugs to treat anxiety.

Humanistic theorists believe many of our anxieties stem from social repression of our genuine selves.

Anxiety occurs when the incongruity between one’s true inner self and one’s social façade draws closer to the level of awareness.

A variety of drugs are used to treat anxiety disorders. Medications such as the mild tranquilizers (benzodiazapines) and the antidepressants are quite effective. A potential problem with drug therapy is .

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that patients may attribute clinical improvement to the drugs and not their own resources.

Learning perspectives encompass a broad range of behavioral and cognitive-behavioral 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. Relaxation training is often used to help people with generalized anxiety learn skills of 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-behavioral 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.

Obsessive–Compulsive and Related Disorders Three major disorders in this category are covered: obsessive–compulsive disorder, body dysmorphic disorder, and hoarding disorder. Two other related disorders, trichotillomania (hair pulling disorder) and excoriation (skin picking) disorders, also fall under this category.

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 behaviors, such as repeated elaborate washing after using the bathroom.

Treatment Approaches Behavior therapists have achieved impressive results in treating obsessive–compulsive disorder with the technique of exposure with response prevention. SSRI antidepressants (selective serotonin reuptake inhibitors) also have therapeutic benefits in treating OCD. Body Dysmorphic Disorder People with this disorder are preoccupied with an imagined or exaggerated physical defect in their appearance, such as skin blemishes, wrinkling or swelling of the face, body moles or spots, or facial swelling. These preoccupations cause the individual to feel ugly or even disfigured. Body Dysmorphic Disorder is classified within the obsessive–compulsive spectrum because people with this disorder often become obsessed with their perceived defect and often feel compelled to check themselves in the mirror or engage in compulsive behaviors. Exposure therapy with response prevention is often used in treating body dysmorphic disorder.

Hoarding Disorder Hoarding Disorder is a new disorder classified by DSM-5, which is characterized by the accumulation of and need to retain stacks of unnecessary and seemingly useless possessions. Hoarding disorder has an important emotional component characterized by the need to accumulate and retain possessions in order to feel a sense of security. Hoarding disorder is different from obsessive–compulsive disorder (OCD) in that the obsessional thinking in hoarding disorder does not have the intrusive, unwanted thoughts found in OCD. Recent research suggests that people who hoard show abnormal patterns of activation in parts of the brain involved in such processes as decision making and self-regulation.

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Lecture and Discussion Suggestions 1. Explain the difference between neurosis and anxiety disorders. Earlier versions of the DSM used the term neurosis when describing disorders involving anxiety, as well as the dissociative and somatic symptom disorders discussed in Chapter 6. According to Freud, anxiety represents ways in which the ego attempts to defend itself against anxiety. Freud’s views on the origins of these problems united them under the general category of neuroses. Point out that the anxiety disorders are now classified according to the similarities in their behavior patterns and distinctive features rather than theoretical assumptions of causation, as in the concept of neurosis. As a result, the new grouping system has a more narrowly defined set of behaviors that outlines what may be an anxiety disorder.

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 behaviors 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 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. The 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 phobias 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 experiences that may cause one to be reluctant to leave the house (as in agoraphobia) may accumulate over several years of adult 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 behavioral 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 behavior 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-behavioral methods. You might also discuss the widespread use of tranquilizers and their abuse versus the increasing use of cognitive-behavioral methods that minimize the use of medication.

4. Case studies from TV. You can help illustrate some of the disorders (as well as some of the “normal” behaviors) discussed in this and subsequent chapters by diagnosing various characters from TV or movies. Daytime soap operas, reality TV shows, and primetime sit-coms provide a gold mine of neurotic and generally disturbed individuals. Reality shows such as Hoarders present case examples that students usually find surprising in terms of the severity of the hoarding.

5. Situational anxiety. Ask students to suggest typical situations that make them anxious. You might list these on the chalkboard. You can also have a list of common anxiety-arousing situations and have students raise their hands as you call out examples. Ask students to determine if such fears are justified or phobic. Then, ask students to tell how they personally cope with these situations and which strategies they find most effective.

6. Fears and aging. Discuss how people's fears change with age. Many fears increase or decrease .

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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.

8. Gender and agoraphobia. Estimates for agoraphobia demonstrate that women are disproportionately afflicted with this disorder (anywhere from 75–95 percent of those with agoraphobia are women).

Maureen C. McHugh has asserted that a feminist perspective that incorporates an analysis of the many sociocultural factors in American society that contribute to these gender discrepancies is essential. In particular, cultural gender roles that dictate that women’s domain is in the home, sexual inequalities that render public environments, especially at night, as potentially unsafe for women, and incidences of violence directed toward women that contribute to a generalized fear among women are all factors that must be considered. This discussion can be followed by showing segments of the movie Copycat and conceptualizing the development of agoraphobia in the main character as a result of violence.

9. Superstitious behavior and compulsions. Skinner drew an analogy between what he described as “superstitious behavior” resulting from chance reinforcement and compulsions. We all engage in a certain amount of superstitious behavior; students might be encouraged to consider ritualistic superstitions they may hold—professional athletes are prime examples of this. What similarities or differences are there between these behaviors 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 percent of us are chronic worriers. About 30 percent of us are non-worriers, 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 intensified 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.

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. .

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Borkovec, T. D. (1985). “What's the use of worrying?” Psychology Today, 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 stereotypes of the easily frightened woman abound 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 physical factors 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, 12–19.

12. Embarrassment. Social phobics fear embarrassment. Embarrassment, though, 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 percent of three-year-olds and 50 percent of five-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 behaviors of embarrassed people, what Zimbardo (1977) calls “facework.”

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.

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Think About It Anxiety may be a normal emotional reaction in some situations but not in others. Think of a situation in which anxiety would be a normal reaction and one in which it would be a maladaptive reaction. What are the differences? What criteria would you use to distinguish between the normal and abnormal? Anxiety is a generalized state of apprehension or foreboding. It is normal, even adaptive, to be somewhat anxious about certain aspects of life. For example, one could expect a certain amount of anxiety if you found a breast lump. This would motivate you to see a doctor. That same level of anxiety, however, would be inappropriate if felt every time the first signs of a cold became apparent. Anxiety is an appropriate response to threats, but anxiety can be abnormal when its level is out of proportion to the threat, or when it seems to come out of the blue.

Do you have any specific phobias, such as fears of small animals, insects, heights, or enclosed spaces? What do you think contributed to the development of the phobia (or phobias)? How has the phobia impacted on your life? How have you coped with it? This is a personal experience question.

Students need to know the various types of phobias and be comfortable sharing experiences. Encourage them to 1) maintain a skeptical attitude, 2) consider the definitions of the terms, 3) weigh the assumptions or promises on which arguments are based, 4) bear in mind that correlation is not causation, 5) consider the kinds of evidence on which conclusions are based, 6) do not oversimplify, 7) do not overgeneralize.

What are the distinguishing features of each of the anxiety disorders discussed in the text? The anxiety disorders include: Panic disorder: the occurrence of recurrent, unexpected panic attacks where there is a persistent concern about them. This can occur with or without agoraphobia. Generalized anxiety disorder: persistent and excessive levels of anxiety and worry that is not tied to any particular object, situation, or activity. Agoraphobia: fear and avoidance of places or situations in which it would be difficult or embarrassing to escape, or in which help might be unavailable in the event of a panic attack or panic-type symptoms. Specific phobia: clinically significant anxiety relating to exposure to specific objects or situations, often accompanied by avoidance of these stimuli. Social phobia: clinically significant anxiety relating to exposure to social situations or performance situations, often accompanied by avoidance of these situations.

How are anxiety disorders conceptualized within the psychodynamic, humanistic, biological, and learning-based perspectives? Psychodynamic theorists believe that anxiety is a danger signal that threatening impulses of a sexual or aggressive nature are nearing the level of awareness. To fend off these impulses, the ego tries to divert them by mobilizing its defense mechanisms. Humanistic theorists feel that many of our anxieties stem from social repression of our genuine selves. Anxiety occurs when the incongruity between one’s true inner self and one’s social façade draws closer to the level of awareness.

The biological approach explains anxiety in medical terms. In essence the disorder is explained as a chemical imbalance, therefore, a variety of drugs are used to treat anxiety disorders. From a learning perspective, anxiety disorders are acquired through the process of classical and operant conditioning and observational learning. In the classic two-factor theory of anxiety, fears are classically conditioned and operantly maintained.

What are the advantages and disadvantages of using antianxiety drugs? Some drugs are particularly effective with certain anxiety disorders. Obsessive–compulsive disorder appears to be especially responsive to the SSRI type antidepressants. The antianxiety drugs like Valium and Xanax, however, have major side effects. Though these benzodiazepines have calming effects, they can lead to physical dependence and addiction. A potential problem with any drug therapy is that patients may attribute clinical improvement to the drugs and not their own resources.

Select a particular anxiety disorder, obsessive-compulsive or related disorder and, using specifics, .

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describe how it would be treated using each of the major treatment approaches discussed in the text. Students have a variety of options to complete this question. They should be familiar with all of the disorders from which to choose. They need to know the specifics of the theoretical models: psychodynamic, humanistic, biological, and learning based theories, and be able to pick one.

John has been experiencing sudden panic attacks on and off for the past few months. During the attacks, he has difficulty breathing and fears that his heart is racing out of control. His personal physician checked him out and told him the problem is with his nerves, not his heart. What treatment alternatives are available to John that might help him deal with this problem? Some of the cognitive-behavioral treatments are most effective in dealing with panic attacks. These techniques include coping skills training, breathing retraining, relaxation training, and exposure therapy. The therapist may assist John to think differently about his bodily cues, such as sensations of dizziness or heart palpitations. Breathing retraining could then be used, which is a technique that aims at restoring a normal level of carbon dioxide in the blood by having clients breathe slowly and deeply from the abdomen to avoid hyperventilation. Through first-hand experience, John could learn to calm himself down and cope with his sensations rather than overreacting.

Do you know anyone who has received treatment for an anxiety disorder? What was the outcome?

What other treatment alternatives might be available? Which approach to treatment would you seek if you suffered from the same disorder? This is a personal experience question. Students should be very familiar with the variety of treatment options available for anxiety disorder.

Activities/Demonstrations 1. Examining images of anxiety disorders in popular culture. Movies often show portrayals of anxiety disorders that range from terrifying to comical. Show segments of movie portrayals of anxiety disorders and help students critically examine them for the accuracy of the portrayal. Also, encourage students to explore the contextual factors that contribute to the onset or perpetuation of the disorder. For example, the movie Copycat (produced by Warner Brothers) provides excellent portrayals of both agoraphobia and panic attacks. It also provides an opportunity to talk about the role of violence and abuse in the development of anxiety symptoms, particularly among women. Other movies to consider are Born on the Fourth of July, As Good as it Gets, and What About Bob? 2. Construct a hierarchy of anxiety-provoking situations. Ask students to list several situations that commonly arouse anxiety for students. Then, elicit 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.

3. 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?

Worrying won't help.

What is it I have to do?

Concentrate on what I'm doing! .

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I'll never make it.

I can do anything if I take it one step at a time.

Now do the same thing with self-defeating and coping thoughts during the stressful situation and afterwards. Encourage students to keep this list handy and practice them when they have any selfdefeating thoughts. If possible, re-visit their progress a week or so later, or have students keep a record of self-defeating thoughts and coping thoughts with a 1–10 rating of distress over the week. Ask them to compare their ratings of distress over the week, and see which coping thoughts were most effective.

4. 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.

1. 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.

2. Visit a store that sells alarm clocks. Set one of them off to see what it sounds like.

Do not buy it.

3. Go to a shoe store and try on several pairs of shoes. Do not buy any.

4. Go to a travel agency and ask about details of trips to a place you choose.

5. Go to a store and change $25 for two 10s and five 1s. Do not buy anything.

6. 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.

7. Stop a person in the street and ask for directions to a place in your area.

8. 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 selfconfidence.

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

5. Are you phobic? Students often wonder if they themselves have an anxiety disorder. The DSM-5 requires that a disorder must cause clinically significant levels of distress in any number of domains (work, social life, and relationships, etc.) before something is diagnosable. Ask the class if they have any fears. Spiders, snakes, roaches, heights, fear of flying, all make good possibilities. You may want them to pair off in dyads to discuss their specific situations. Ask them how they developed the specific fear. What age? What circumstances lead to the fear developing? Do they avoid the feared object? And finally to what extent does it interfere with their life? Most students are relieved to know their fears do not meet the diagnostic criteria for specific phobia.

6. Is Body Dysmorphic Disorder on the rise? Have students cite media themes around sex appeal and the achievement of the “perfect” body. Is there a relationship between these images and individual appearance satisfaction? Discuss media personalities (such as the late Michael Jackson) who have repeatedly undergone surgical alterations. How much is too much? What responsibility does a physician have with a client who repeatedly asks for surgeries?

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Media Resources Speaking Out Videos in Abnormal Psychology Steve: Social Phobia (Social Anxiety Disorder) (3:00) Video available on MyPsychLab.com VIDEO BACKGROUND: In this interview, Steve discusses his social phobia and how it has affected his life. Beginning in high school, Steve felt socially awkward and alienated, which led him to experiment with being a class clown or attempting to isolate himself completely. His occupational goal was to be an academic, but he felt constantly inept when teaching. When he goes out with his wife to a restaurant, he finds it difficult to converse because of the proximity of other diners; when he goes to even the simplest social gathering, he feels debilitated and unable to carry on a conversation for more than a few minutes. Steve notes his disorder is largely concerned with fears that others are listening to him “stumble” as he attempts to converse and that he will appear ignorant or stupid. A particularly interesting segment involves Steve’s discussion of how he feels physically when he experiences social phobia.

DISCUSSION QUESTIONS: 1. What is a common fear of people with social phobia? a) Being embarrassed in front of other people b) Looking foolish in front of others c) Not knowing what to say in social settings d) All of the above Answer: d.

Social phobia involves numerous fears involving social situations. However, these fears usually revolve around one’s appearance in social settings.

2. Social phobia is most associated with: a) panic attacks. b) anger outbursts. c) high levels of narcissism. d) suicidal ideation.

Answer: a.

Although it is possible that a person with social phobia might have an anger outburst, narcissistic traits, or suicidal thoughts, panic attacks are most closely related with social phobia.

3. What are some physical symptoms associated with social phobia?

Suggested answers: increased heart rate, sweating, fear, shortness of breath, stammering, etc.

4. Why is Steve comfortable talking during this interview?

Suggested answer: He is discussing the social phobia itself and thus he does not have to hide it and knows what to say. .

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5. Social phobia is often associated with having panic attacks. What is a panic attack?

Suggested answer: a period of fear or discomfort that includes symptoms such as increasing heart rate, sweating, shaking, shortness of breath, chest pain, nausea, dizziness, detachment, fear of losing control, etc.

CLASS ACTIVITIES: 1. Discuss the different areas of life in which people with social phobia may have difficulties, as well as what problems they might have.

Suggested answers: difficulty getting and maintaining employment in a setting involving other people, difficulty with relationships, difficulty appearing at public functions, etc.

2. Steve discussed his strategy of leaving a particular conversation when he felt he had nothing left to say, waiting until he had rebuilt his confidence, and then approaching another person to converse. What do you think of this approach and why would it work/not work?

Suggested answers: This approach is probably a bad one, as it has not worked for him in the past. Since his difficulty is not with a particular person but with people in general, beginning a conversation with a new person without changing his thoughts and behaviors would likely have little beneficial effect.

Dave: Obsessive–Compulsive Disorder (3:28) Video available on MyPsychLab.com VIDEO BACKGROUND: In this interview, Dave talks about how his obsessive–compulsive disorder has affected his life both positively and negatively. Dave’s disorder manifests itself in multiple ways—he has obsessions involving cleanliness, compulsions to clean and check locked doors, and disturbing intrusive thoughts. He notes that these symptoms, while negative at times, have also been of some benefit to him. For example, his attention to detail and level of cleanliness have led him to start successful car detailing and house cleaning businesses. However, when he leaves a home he has cleaned, he often has to check the door twenty times to make sure it has locked. Interesting segments of this video include Dave’s discussion of his intrusive thoughts (e.g., thinking about cutting up his sister and putting her in the oven) and how he obsesses about things (e.g., spending two weeks thinking about a conflict that other people would quickly move beyond).

DISCUSSION QUESTIONS: 1. What is an example of an obsession? a) Checking doors multiple times b) Washing hands repeatedly c) Fearing contamination from touching a door handle d) Avoiding cracks in the sidewalk Answer: c.

Fear of contamination is a persistent thought and thus an obsession. Note that the other behaviors are compulsions.

2. What is an example of a compulsion? .

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a) Checking doors multiple times b) Washing hands repeatedly c) Avoiding cracks in the sidewalk d) All of the above Answer: d.

All of the above are examples of compulsions—behaviors in which one regularly engages to overcome obsessive fears.

3. Dave discusses that he sometimes imagines cutting up his sister. This is a symptom of obsessive– compulsive disorder called what? a) Antisocial cognitions b) Intrusive thoughts c) Psychotic ideation d) Compulsions Answer: b.

People with OCD often have intrusive thoughts that they try to ignore, such as Dave’s thoughts of hurting his sister. Note that Dave feels guilty about these thoughts, does not believe they are reality, and he does not act on them, thus effectively ruling out other possibilities.

4. How do obsessions and compulsions relate to each other?

Suggested answer: Compulsions are often done to relieve the anxiety or distress caused by obsessions.

5. Define obsessions and compulsions.

Suggested answer: Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress. Compulsions are repetitive behaviors or mental acts, the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification.

Virtual Case Study simulations available on MyPsychLab.com SIMULATION BACKGROUND: Virtual Case Studies, found in Pearson’s MyPsychLab, is a new, science-based, interactive simulation where students can explore how a number of risk factors and protective factors may impact the development of a psychological disorder. Virtual Case Studies engages students through captivating narratives that they advance, allowing students to explore and critically think about the influence of biological, psychological, social and cultural factors in the development or regression of a disorder.

Virtual Case Study: Anxiety Disorders http://staging.allthingsmedia.com/pearson/virtual_case/src/vc_01.html

CLASS ACTIVITY: 1. Make a list of common obsessions and the compulsions people use to deal with them.

Suggested answers: fear of contamination/disease (washing, cleaning); fear of being burgled (checking doors); fear of accidents (checking stove); etc. .

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Sara: Posttraumatic Stress Disorder Video available on MyPsychLab.com VIDEO BACKGROUND: In this interview, Sara discusses the posttraumatic stress disorder that developed from a nine-year abusive relationship. During the course of that relationship, her boyfriend—who was an alcohol and cocaine abuser—began to collect and threaten her with numerous guns. This abuse led her to develop fear and paranoia, which eventually became so strong that she abandoned the relationship and went into hiding.

Now, Sara has begun to put her life back in order but still experiences flashbacks and nightmares relating to her time in the relationship. She avoids places she used to go to and feels physiological effects at the time of night when her boyfriend used to arrive even though now she realizes her fears are illogical. Of particular interest in this interview is Sara’s discussion of the symptoms of PTSD, both psychological and physical.

DISCUSSION QUESTIONS: 1. Which of the following would be adequate for a diagnosis of PTSD? a) Becoming very upset after moving to a new city b) Becoming very frightened after a horror movie c) Staying calm and collected during and after a severe earthquake d) Becoming very upset after being robbed at gunpoint Answer: d.

A diagnosis of PTSD requires that the person was exposed to a situation involving actual or threatened injury or death and had a strong emotional response to it involving fear, helplessness, or horror.

2. What other disorder relates to PTSD in terms of requiring a stressor? a) Schizophrenia b) Adjustment Disorder c) Borderline Personality Disorder d) Schizoid Personality Disorder Answer: b.

Although stressors may be involved in the other choices, only adjustment disorder requires a stressor.

3. What are the important features of PTSD? Suggested answer: a trauma occurs; psychological re-experiencing of the trauma, avoidance of stimuli associated with the trauma, and increased arousal.

4. What are some physiological symptoms of PTSD mentioned by Sara?

Suggested answers: increased heart rate, clammy hands, stiffness, tension, perceived paralysis, nausea, nightmares, flashbacks, rapid weight loss, sleep disorders, panic, fear, anger, avoidance, etc. .

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5. What characteristics must an event have to lead to a diagnosis of PTSD? Suggested answer: It must concern a situation involving actual or threatened injury or death, which evokes a strong emotional response involving fear, helplessness, or horror.

CLASS ACTIVITIES: 1. Certain groups of people are more likely to experience traumatic events that lead to PTSD. What are some groups of people who commonly suffer from PTSD? Suggested answers: survivors of war, captivity, rape, genocide, disasters, etc.

2. Discuss events that might have been the cause of PTSD. Suggested answers: September 11, Iraq War, Afghanistan War, Hurricane Katrina, etc.

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CHAPTER SIX DISSOCIATIVE DISORDERS, SOMATIC SYMPTOM AND RELATED DISORDERS, AND PSYCHOLOGICAL FACTORS AFFECTING PHYSICAL HEALTH Learning Objectives 6.1 Describe the key features of these major types of dissociative disorders: dissociative identity disorder, dissociative amnesia, and depersonalization/derealization disorder.

6.2 Explain why the concept of dissociative identity disorder is controversial.

6.3 Describe different theoretical perspectives on dissociative disorders.

6.4 Describe the treatment of dissociative identity disorder.

6.5 Describe the key features of these types of somatic symptom and related disorders: somatic symptom disorder, illness anxiety disorder, conversion disorder, and factitious disorder.

6.6 Explain the difference between malingering and factitious disorder.

6.7 Describe the key features of koro and dhat syndromes.

6.8 Describe the theoretical understandings of somatic symptom and related disorders.

6.9 Describe methods used to treat somatic symptom and related disorders.

6.10 Describe the role of psychological factors in physical health problems such as headaches, cardiovascular disease, asthma, cancer, and AIDS. Chapter Outline I. Dissociative Disorders A. Dissociative Identity Disorder B. Dissociative Amnesia C. Depersonalization/Derealization Disorder D. Culture-Bound Dissociative Syndromes E. Theoretical Perspectives F. Treatment of Dissociative Disorders II. Somatic Symptom and Related Disorders A. Somatic Symptom Disorder B. Illness Anxiety Disorder C. Conversion Disorder D. Factitious Disorder E. Koro and Dhat Syndromes: Far Eastern Somatic Symptom Disorders?

F. Theoretical Perspectives G. Treatment of Somatic Symptom and Related Disorders III. Psychological Factors Affecting Physical Health A. Headaches B. Cardiovascular Disease C. Asthma D. Cancer E. Acquired Immunodeficiency Syndrome IV. Summing Up

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Chapter Overview 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, dissociative fugue, and depersonalization disorder.

In dissociative identity disorder, two or more distinct personalities, each possessing well-defined traits and memories, exist within the person and repeatedly take control of the person's behavior. Dissociative amnesia involves loss of memory for personal information. 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 disorders involve persistent or recurrent episodes of depersonalization that are of sufficient severity to cause significant distress or impairment in functioning.

Dissociative amnesia is considered to be the most common form of a dissociative disorder. Persons with this disorder are unable to recall important personal information, usually involving traumatic or stressful experiences, in a way that cannot be accounted for by simple forgetfulness. Dissociative amnesias include: localized amnesia, selective amnesia, generalized amnesia, continuous amnesia and systematized amnesia. A rare subtype of dissociative amnesia is characterized by fugue, or “amnesia on the run.” In dissociative fugue, the person may travel suddenly and unexpectedly from his or her home or place of work.

Depersonalization is a temporary loss or change in the usual sense of our own reality. Derealization is a sense of unreality about the external world involving odd changes in the perception of one’s surroundings and may also be present. In order to be diagnosed with depersonalization/derealization disorder, these experiences must become persistent or recurrent and cause significant distress or impairment in daily functioning.

Culture-bound syndromes are similar to dissociative disorders. Amok, koro and zar are examples of culture-bound syndromes.

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 behaviors or thoughts that might lead to feelings of guilt or shame. Relief from anxiety negatively reinforces this pattern of dissociation.

Within the diathesis-stress model, dissociative identity disorder may be explained in terms of a diathesis consisting of psychological traits, such as a rich inner fantasy life and high levels of hypnotizability, interacting with traumatic stress in the form of severe childhood abuse.

Treatment of dissociative disorders from the biological approach focuses 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. Learning perspectives focus on the use of behavioral methods of reinforcement of the well-adjusted personality. .

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Somatic Symptom and Related Disorders An individual with a somatic symptom disorder presents with physical complaints that cannot be accounted for by organic causes. Thus, the symptoms are theorized to reflect psychological rather than organic factors. The major categories of somatic symptom disorders identified in the DSM-5 include: somatic symptom disorder, illness anxiety disorder, conversion disorder and factitious disorder. The term hypochondriasis is still in widespread use, but is no longer a distinct diagnosis in DSM-5. The majority of cases that were labeled as hypochondriasis in the past are now classified as somatic symptom disorders.

The DSM-5 has introduced a new diagnostic category of illness anxiety disorder (IAD) in order to identify a subgroup of people with hypochondriasis who complain of relatively minor or mild symptoms they take to be signs of a serious undiagnosed illness. The emphasis with individuals with this disorder is on the anxiety associated with illness rather than the distress the symptoms cause. In conversion 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. Hypochondriasis 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. People with factitious disorder fake or manufacture physical or psychological symptoms, but without any apparent motive. Münchausen syndrome is the more popularly known form of this disorder.

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 hypochondriasis to obsessivecompulsive behavior. Cognitive factors in hypochondriasis include self-handicapping strategies and cognitive distortions.

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. Behavioral approaches focus on removing sources of reinforcement that may be maintaining the abnormal behavior pattern. Behavior therapists may also work more directly to help people with somatoform disorders learn to handle stressful or anxiety-arousing situations more effectively. Cognitive techniques such as cognitive restructuring have been very helpful in treating hypochondriasis.

Psychological Factors Affecting Physical Health Psychological factors are involved in the origins, course, and treatment of many physical health problems.

The principle of individual response specificity holds that people respond to stress in idiosyncratic ways, giving rise to particular health problems.

Headaches are symptomatic of many medical disorders. The most common headache is the muscletension headache, which is often stress-related. Behavioral methods of relaxation training and biofeedback can be helpful in treating headaches.

Risk factors in cardiovascular disorders include age, gender, family history, socioeconomic status, obesity, hypertension, blood cholesterol, eating and drinking patterns, Type A behavior, anger, phobic .

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anxiety, stress, and a sedentary lifestyle.

Asthma attacks can be triggered by allergic reactions; cold, dry air; or emotional responses such as anger and stress. Treatment for asthma often consists of medications, including bronchodilators, but asthma sufferers can improve their breathing by muscle relaxation training and family therapy that reduces stresses on asthmatic children.

Risk factors for cancer include family history, dietary practices (especially high fat intake), heavy alcohol use, smoking, and sunbathing. Research shows that a fighting spirit and an optimistic outlook on treatment may help people recover from cancer. Psychological interventions help cancer patients cope better with the symptoms of the disease and its treatment.

Our behavior patterns influence our risk for contracting AIDS. Psychologists have become involved in the prevention and treatment of AIDS because AIDS, like cancer, has devastating psychological effects on victims, their families and friends, and society at large, and because HIV infection can be prevented through reducing risky behavior.

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 behavior 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 I have used in my 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 mirror 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 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 somatization disorder. For instance, it has been estimated that as many as one out of four or five girls and one out of nine or ten 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 .

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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 one out of two women with somatic symptom disorders disorder had been sexually abused, compared to only one out of six of those with a mood disorder (Morrison, American Journal of Psychiatry, 1989, 146, 239– 241).

3. Hypochondriasis. Estimates of anywhere from one-fourth to three-fourths of the patients who consult physicians resemble those with hypochondriasis 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 hypochondriasis 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 hypochondriasis.

4. Differential development of dissociative disorders. Ask students why some people who are sexually abused as children develop dissociative identity disorder while most do not. Certain personality traits have been associated with the development of dissociative identity disorder, such as proneness to fantasize, increased susceptibility to hypnotic suggestion, and openness to altered states of consciousness.

These factors may predispose them to dissociative responses to extreme stress. Although these factors explain why some develop dissociative identity disorder, it does not explain why females are more likely to develop it 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 selfperceptions 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 behavior on occasions.

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 experiences. The text describes some of the forms depersonalization 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 disorder," it is useful to point out how .

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common such episodes are. Ross, Joshi, and Currie (1990) found that these were especially reported by people age 25–44. For instance, 28 percent of those 25–34 and about 27 percent of those 35–44 indicated they had experienced depersonalization. Rates were from 8–10 percent for most other age groups. It is also important to remind students that DSM-5 considers depersonalization 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.

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 awhile, 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 1980s 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 handed 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. 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. Many psychologists doubt that such repression as takes place in these cases is possible.

Gardner, M. (1993). “The false memory syndrome.” Skeptical Inquirer, Summer.

10. Women and somatization. Women, in general, use health services more than men, even after use related to pregnancy and childbirth is accounted for. Most somatization disorder 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, though, why are there at least as many males as females with hypochondriasis? This topic can provoke a lively class discussion.

11. Reporting bodily symptoms. Ask students whether they feel that they tend to overreport 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 .

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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 under- or overreporting bodily aches and pains.

12. Personality and illness. Theories asserting that certain personality types can be risk factors for the development of disease are often controversial in both the medical and psychological communities.

However, the idea that certain personalities are more likely to develop heart disease has been around for 2,000 years, since the time of Hippocrates. This debate was rekindled by Ronald Grossarth-Meticek, a Yugoslavian psychologist who has conducted extensive experiments on this subject for over twenty years.

His work was summarized by Hans Eysenck in his article "Health's Character," in Psychology Today, 1988, 28–35. Grossarth-Meticek claims he has devised tests that can identify cancer-prone and heartdisease prone personalities. Cancer-prone personalities are characterized by an inability to express emotions such as anger, fear, and anxiety. Also, their inability to cope with stress results in high levels of hopelessness, helplessness, and depression. Although not all the components of the Type A personality predict heart disease, the ones that stand up best are the tendencies toward anger, hostility, and aggression. Extensive longitudinal studies by Grossarth-Meticek and his colleagues have shown that among type 1 (cancer-prone) personalities, 1/2 died from cancer, whereas fewer than 1/10 died of heart disease. Among type 2 (heart disease) personalities, 1/3 died of heart disease, but only 1/5 from cancer.

Types 3 and 4 personalities who can handle stress better have much lower rates of death. Luckily, there is hope. Death rates among people with cancer-prone and heart disease-prone personalities decrease after therapeutic intervention targeting those personality patterns related to cancer and heart disease.

13. Psychological factors in healing. Norman Cousins's experience of self-induced recovery from a lifethreatening illness aroused an obsession to better understand the role of the mind in healing.

Consequently, he spent the next 10 years on the faculty of the UCLA medical school gathering evidence on the importance of psychological factors in healing. He had access to the pioneers in the field of psychoneuroimmunology as well as clinicians on the forefront of cancer therapies. He presented his findings and case illustrations in the book Head First: The Biology of Hope (Dutton, 1989). Cousins tells his patients, "Don't deny the diagnosis, try to defy the verdict." That is, even when a life-threatening illness strikes, you can affect the outcome by bolstering the immune system with both psychological measures and conventional medicine. In one experiment, Cousins gathered patients with melanoma, an often fatal type of skin cancer, into a group dubbed "The Society of Challengers" for the purposes of sharing their experiences and learning new coping strategies. Blood samples drawn throughout the sixmonth study showed significant drops in depression and a greater rise in certain immune cells, compared to a control group. Cousins believes if you can reduce the depression that inevitably affects cancer patients, you can increase the body's own capacity for combating malignancies.

14. Psychological factors in delaying the disease progression of HIV/AIDS. Similar to Cousins’s findings (above) with skin cancer, recent research demonstrates that psychological factors, such as optimism and depression, can have a dramatic impact on the progression of HIV/AIDS-related illness. As a result of the stigma and general stress of living with HIV, rates of depression among HIV-positive populations are quite high. The disease progression and health outcomes related to HIV/AIDS are severely affected by depression. For example, Ickovics, Thayaparan, and Ethier (2000) found that HIVinfected women with depression were more likely to die from HIV/AIDS-related illnesses than HIVpositive women without depression. Furthermore, although medical advances have made it possible for HIV-positive people to live much healthier and longer lives than was the case 20 years ago, HIV-positive women with depression died much earlier than HIV-positive women without depression. .

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Think About It What is the hypothesized role of anxiety in the dissociative and somatic symptom disorders ? In the early versions of the DSM, the dissociative and somatic symptom disorders were grouped with the anxiety disorders under the general category of neurosis. The common grouping was based on the psychodynamic model, which holds that various disorders involve maladaptive ways of managing anxiety. In anxiety disorders, the appearance of disturbing levels of anxiety was expressed directly, but the role of anxiety in dissociative and somatoform disorders was inferred rather than expressed in behavior. It was theorized that symptoms mask unconscious sources of anxiety. The DSM now separates the anxiety disorders from the other categories of neurosis—the dissociative and somatic symptom disorders—with which they were historically linked.

Why is the diagnosis of dissociative identity disorder controversial? Do you believe that people with dissociative identity disorder are merely playing a role they have learned? Why or why not? This is an opinion question. Students should be familiar with the symptoms and features of dissociative identity disorder. Encourage them to 1) maintain a skeptical attitude, 2) consider the definitions of the terms, 3) weigh the assumptions or promises on which arguments are based, 4) bear in mind that correlation is not causation, 5) consider the kinds of evidence on which conclusions are based, 6) do not oversimplify, 7) do not overgeneralize.

What is the difference between dissociative amnesia and ordinary forgetfulness? The definition of dissociative amnesia excludes ordinary forgetfulness. Dissociative amnesia is when a person becomes unable to recall important personal information, usually involving traumatic or stressful experiences, in a way that cannot be accounted for by simple forgetfulness. Amnesia is not ordinary forgetfulness, such as forgetting someone’s name or where you left the car keys. Memory loss in amnesia is more profound or wide-ranging. Most cases of dissociative amnesia take the form of localized amnesia in which events occurring during a specific period of time are lost to memory.

What role does childhood physical and sexual abuse play in dissociative disorders? The most widely held view of dissociative identity disorders is that it represents a means of coping with and surviving severe, repetitive childhood abuse, generally beginning before the age of five. The great majority of people with dissociative identity disorder report being physically or sexually abused as children. The severely abused child may retreat into alter personalities as a psychological defense against unbearable abuse. In the face of continued abuse, these alter personalities may become stabilized, making it difficult for the person to maintain a unified personality.

What psychological formulations have been proposed to explain the development of dissociative disorders? What do they have in common? To psychodynamic theorists, dissociative disorders involve the massive use of repression, resulting in the “splitting off” from consciousness of unacceptable impulses and painful memories. Learning and cognitive theorists view dissociation as a learned response that involves not thinking about disturbing acts or thoughts in order to avoid feelings of guilt and shame evoked by such experiences. Biological theorists have found evidence that shows differences in brain metabolic activity between people with depersonalization disorder and healthy subjects. The commonality appears to be the recognition that a history of childhood abuse plays a pivotal role.

Why is it so difficult to distinguish psychological pain from medical pain? What criteria would you use to determine whether someone has psychological pain associated with pain disorder or medical pain associated with a physical/biological condition? Often, the underlying cause of medical pain is difficult to determine, but this does not mean the pain is purely psychological. The pain one feels, even if physical, can be heightened or lessened by psychological factors, such as one’s style of coping, making the experience of medical pain a psychological phenomenon as well as a physical one. As a result of this .

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diagnostic quandary, many debate whether somatoform pain disorder should be a separate diagnosable psychological condition.

Why is conversion disorder (now known as functional neurological symptom disorder in the DSM5) considered a treasure trove in the annals of abnormal psychology? What role did the disorder play in the development of psychological models of abnormal behavior? Conversion disorder used to be called hysterical neurosis and, as such, is considered classic in the history of abnormal psychology. It played an important role in the development of Freud’s psychoanalysis. Freud presented several classic cases of conversion disorder including the famous “Anna O.” Hysterical or conversion disorders seem to have been much more common in Freud’s day than they are today, when they are relatively rare.

Do you know anyone you would consider to be a “hypochondriac”? What is the basis of your opinion? Did reading the text change your view? This is a personal experience question. Students need to know the symptoms of hypochondriasis and that the main issue in hypochondrias is fear of illness.

Does koro or dhat syndrome seem strange to you? How might your feelings depend on the culture in which you were raised? How might behaviors found in your culture be viewed as strange by members of other cultures? This is a personal opinion question. Students should know the symptoms of both koro and dhat as well as the cultural factors that contribute to the manifestation of these disorders, such as the cultural belief in the life-preserving nature of semen contributing to dhat. Similarly, students should know which individual factors make it more or less likely that one will develop either disorder.

For example, Guangdong residents who are less superstitious and more highly educated are significantly less likely to develop koro.

Why is it so difficult to distinguish malingering from somatic symptom disorders and dissociative disorders? How might secondary gain contribute to the development or maintenance of these conditions? Those with somatic symptom and dissociative disorders are often accused of malingering, or faking illness. To date, few methods exist to distinguish the two. Moreover, there may be unseen benefits, or secondary gains, to having such a condition. Imagine the man with pain disorder who does not have to do any housework or heavy lifting as a result—so a real experience of pain is reinforced because the person experiences some benefit from its presence. There are also numerous accounts of World War II soldiers developing “night blindness” that prevented them from going on dangerous nighttime missions.

In these cases, how might you go about distinguishing these conditions?

Examine your own personality and behavior patterns. How might they be helping to promote your health? In what ways might these patterns damage your health or increase your risk of developing health-related problems? What changes can you make in your lifestyle to adopt healthier behaviors?

This is a personal experience question. Students need to be aware of personality theories and health issues. Encourage them to 1) maintain a skeptical attitude, 2) consider the definitions of the terms, 3) weigh the assumptions or promises on which arguments are based, 4) bear in mind that correlation is not causation, 5) consider the kinds of evidence on which conclusions are based, 6) do not oversimplify, 7) do not overgeneralize.

Consider the level of stress in your own life. Might the stress you are encountering be affecting your psychological or physical health? In what ways? How might you reduce the level of stress in your life? How might you learn ways of coping more effectively with the stress you do encounter? This is a personal experience question. Students should examine the various theories of the effects of stress on behavior.

What are the psychological factors implicated in physical disorders and diseases such as headaches, cardiovascular disorders, asthma, cancer, and AIDS? What role do psychological techniques play .

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in the treatment of physical health disorders and conditions? Physical disorders in which psychological factors play a role have traditionally been called psychosomatic. Many of the psychological factors implicated in physical disorders are stress related. One theory, individual response specificity, holds that people may respond to stress in idiosyncratic ways. Perhaps the form an illness takes depends on where you feel your stress. Psychological treatment techniques play a large role in the treatment of physical health disorders. Treatments such as biofeedback, relaxation, coping skills, and some types of cognitive therapy have been particularly helpful.

Activities/Demonstrations 1. An Inventory of Dissociative Experiences. Ask students to look over the Inventory of Dissociative Experiences presented in this chapter (p. 213) and to share their responses. One way to use the inventory is to have students go down the list, marking the frequency with which each item occurs, such as "often," "occasionally," or "rarely." Then, determine which types of dissociative experiences occur most often or most rarely. Or you might simply go down the list getting a show of hands for each item. Either way, ask students how they feel when they become aware of such discrepancies in their experience. Do most of them accept such occasional lapses in consciousness as normal?

2. 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 trauma. However, hypnotic suggestibility has many constructive uses, such as enhancing relaxation and creativity.

3. 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). 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 solve 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 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.

4. Multiple personality in film. Two of the most famous film examples of dissociative identity disorder 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 DVDs of these films and have a get-together where they can view one or the other. They can report to class on the behavior of Eve and Sybil, and how it corresponds to the text discussion.

5. Is multiple personality real? Organize a class debate. Divide the class into pro and con positions.

Have your students do a bit of research before the next class. Assign students to read The Case of Billy Milligan or recall an old talk show where “multiples” appeared. Using their “evidence,” allow a 20minute mock debate, presenting and refuting findings.

6. Münchausen syndrome by proxy (which the DSM-V now calls factitious disorder imposed on another). M. Night Shyamalan’s 1999 film The Sixth Sense tells the story of a boy who communicates with spirits that either do not know they are dead, or have a message to pass to the living. One of the spirits is a victim of Münchausen syndrome by proxy who wants to expose her mother’s abuse in order to save her younger sister. Show the segment of the movie after the child’s funeral and the showing of a secret video that shows the mother poisoning her daughter. Ask students to note the mother’s behaviors (such as the red dress she wore at the funeral) that may appear to be odd and/or attention-seeking. This .

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movie also provides an opportunity to discuss important facts associated with this disorder, such as the 6 percent mortality rate for victims.

7. Progressive relaxation. If you feel confident and have the time, darken the room and have students sit back and get as comfortable as possible. Then, go through the progressive relaxation procedure described in the text. Take your time and keep students focused on their deep breathing as well as the tensing and relaxation of the various muscle groups. Even in often uncomfortable classroom chairs, students usually find this exercise really relaxes them, and occasionally some students will fall asleep. (So, perhaps this exercise should be conducted at the end of class rather than at the beginning!)

8. Biofeedback. Students usually enjoy trying out this technique on themselves, measuring galvanic skin responses, heart rate feedback, and skin temperatures. Perhaps you can arrange to borrow biofeedback equipment from a psychologist who uses it in his or her clinical practice, or from colleagues in the physical education department who use it in their course on health and fitness. Have volunteers take a reading while engaged in normal activity. Then, have the volunteers practice increasing and decreasing some measurement, such as muscle tension in the forehead. The idea is that when people are given immediate feedback on their bodily functions, they may gain greater control over this functioning— through a process we don't yet fully understand. Biofeedback training has been used effectively with tension and migraine headaches, as well as muscle retraining following strokes and spinal cord injuries, though somewhat less effectively with hypertension.

9. The hand-warming technique. Norman Cousins uses this simple technique to demonstrate that each of us has greater power of the mind over the body than we realize. It is described in detail in his book Head First. The technique was developed by Dr. Elmer Green at the Menninger Clinic in Kansas for helping migraine sufferers. Students can do this exercise at home and report their results in class, or you can conduct the demonstration in class if each student has access to a fever thermometer. Have students grasp the bulb of the thermometer in one hand while you conduct the exercise. You can begin by asking students to do deep breathing exercises accompanied by mental imagery of some pleasant experiences in their lives. After several minutes of relaxation, move to the heart of the procedure. Instruct students to concentrate on a specific place in the body, just behind the eyes or in the center of the scalp. Ask if students experience a slight warm or tingling sensation in these places. Now have students visualize their heart pumping blood to the shoulders, now across the shoulders, now down the arm, past the wrist and into their hands. Now have them open their eyes and look at the thermometer. Average skin temperature runs from about 76 to 82 degrees. Many individuals can increase temperature to their hands by 10 degrees or more. Demonstrating that we have the ability to move our blood around suggests we have greater control over our bodies than we realize.

Speaking Out Videos in Abnormal Psychology 1. - Henry: Hypochondriasis (Somatic Symptom Disorder) (3:39) Video available on MyPsychLab.com VIDEO BACKGROUND: In this interview, Henry talks about his health problems, both real and psychologically imagined. He notes that he is hyperaware of his physical health and has possibly seen over 70 doctors since his 20s to help him relieve the worries he has about getting sick and losing physical functionality. Henry discusses how his perceived diseases cause him anxiety and although he studies medical issues, contradictory information makes him confused and distressed about how to be healthy. His strongest concerns are that he is “afraid of being sick” and that his disorder prevents him from enjoying life or being able to talk about other people’s problems without internalizing them. Of particular interest in this interview are the .

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disorders that Henry perceives he has experienced and/or worries about including: asthma, high cholesterol, respiratory problems, colon and lung cancer, heart disease, a heart attack, bloody urine/stool, and malaria.

DISCUSSION QUESTIONS: 1. People with a somatic symptom disorder: a) are preoccupied with fears of having serious diseases. b) often refuse to accept a clean bill of health from a doctor. c) often seek excessive reassurance from physicians. d) all of the above Answer: d.

Choice A is a partial definition of a somatic symptom disorder and choices B and C are common behaviors of people with Hypochondriasis.

2. The most important factor of somatic symptom disorder that results in a fear of diseases is: a) being told that someone you know is ill. b) learning about diseases from medical books. c) misinterpreting bodily symptoms. d) doing research about a particular disease that is popular in the media.

Answer: c.

Although the other choices may influence somatic symptom disorder, a person with somatic symptom disorder misinterprets bodily symptoms and feelings, which leads her to believe she is sick.

3. Why do people with somatic symptom disorder go to doctors frequently? Does this help them?

Suggested answers: They go to doctors to relieve the fear they feel about their perceived sickness.

Hypochondriasis, however, requires that their preoccupation with the disease continue despite medical evaluations and reassurance.

4. In addition to physical symptoms, what other factors do you think contribute to Hypochondriasis?

Suggested answers: the media, knowledge of medicine, friends or family being diagnosed with disorders, etc.

5. How are somatic symptom disorder beliefs different from psychotic delusions?

Suggested answer: People with hypochondriasis are able to acknowledge that they may be exaggerating the extent of the feared disease or that there may be no disease at all.

CLASS ACTIVITY: People with somatic symptom disorder experience numerous problems because of their fears of disease.

In addition to anxiety arising from this particular worry, what other problems might people with somatic symptom disorder experience?

Suggested answers: rejection or belittling by doctors, ridicule by associates, difficulty with work or relationships, etc. .

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2– Dissociative Identity Disorder: Dr. Holliday Milby (7:16) A brief video case study featuring psychologist Holliday Milby, who describes the signs and symptoms of dissociative identity disorder. She dispels the misconceptions between the diagnosis of schizophrenia and multiple personality disorder.

Video available on MyPsychLab.com

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CHAPTER SEVEN MOOD DISORDERS AND SUICIDE Learning Objectives 7.1 Define the term mood disorder and describe the key features of major depressive disorder.

7.2 Evaluate factors that may account for the increased rates of depression among women.

7.3 Describe the key features of persistent depressive disorder and premenstrual dysphoric disorder.

7.4 Describe the key features of bipolar disorder and cyclothymic disorder.

7.5 Evaluate the role of stress in depression.

7.6 Describe the major psychological models of depression.

7.7 Describe biological factors in depression.

7.8 Describe causal factors in bipolar disorders.

7.9 Identify and describe methods used to treat mood disorders.

7.10 Identify risk factors in suicide.

7.11 Identify the major theoretical perspectives on suicide.

7.12 Apply your knowledge of factors in suicide to steps you can take if someone you knew was experiencing suicidal thoughts.

Chapter Outline I. Types of Mood Disorders A. Major Depressive Disorder B. Persistent Depressive Disorder (Dysthymia) C. Premenstrual Dysphoric Disorder D. Bipolar Disorder E. Cyclothymic Disorder II. Causal Factors in Depressive Disorders A. Stress and Depression B. Psychodynamic Theories C. Humanistic Theories D. Learning Theories E. Cognitive Theories F. Learned Helplessness (Attributional) Theory G. Biological Factors III. Causal Factors in Bipolar Disorders IV. Treatment of Mood Disorders A. Treating Depression B. Biomedical Treatments C. Treating Bipolar Disorder V. Suicide A. Who Commits Suicide?

B. Why Do People Commit Suicide?

C. Theoretical Perspectives on Suicide D. Predicting Suicide .

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VI. Summing Up

Chapter Overview Types of Mood Disorders Mood disorders are disturbances in mood that are serious enough to impair daily functioning. The DSM-5 does not include a general category of mood disorders. Rather, mood disorders are now classified in separate categories called “Depressive Disorders” and “Bipolar and Related Disorders.” The depressive disorders include major depressive disorder, persistent depressive disorder, postpartum depression, premenstrual dysphoric disorder (PMDD), and seasonal affective mood disorder. The two major types of bipolar disorders are bipolar disorder and cyclothymic disorder (also called cyclothymia).

People with major depressive disorder 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 behaviors (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 depression has been increasing worldwide.

Seasonal affective (mood) disorder (SAD) occurs in individuals with the changing of the seasons from summer to fall and winter. The causes of this disorder are uncertain; it is speculated that seasonal changes in light may alter the body’s underlying biological rhythms that regulate processes such as body temperature and sleep–wake cycles. Women with postpartum depression experience a major depressive episode within four weeks of delivery. Women with a prior history of depression are more at risk for developing postpartum depression.

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

Premenstrual dysphoric disorder (PMDD) is a new addition to the DSM and is a more severe form of premenstrual syndrome (PMS). The diagnosis of PMDD is intended to apply to women who experience a range of significant psychological symptoms in the week before menses. The diagnosis of PMDD remains controversial. Critics fear it will pathologize the woman’s natural menstrual cycle and may stigmatize women who have serious premenstrual complaints by labeling them with a psychiatric diagnosis.

There are two general types of bipolar disorders: bipolar I disorder and bipolar II 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. In bipolar II disorder, depressive episodes occur along with hypomanic episodes, but without the occurrence of full-blown manic episodes. Manic episodes are characterized by sudden elevation or expansion of mood and sense of self-importance, feelings of almost boundless energy, hyperactivity, and extreme sociability, which often takes a demanding and overbearing form. People in manic episodes tend to exhibit pressured or rapid speech, rapid "flight of ideas," and decreased need for sleep.

Cyclothymic disorder is a type of bipolar disorder characterized by a chronic pattern of mild mood swings .

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and sometimes progresses to bipolar disorder.

Theoretical 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.

In the humanistic framework, feelings of depression reflect the lack of meaning and authenticity in the person's life.

Learning 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.

Beck's cognitive theory focuses on the role of negative or distorted thinking in depression. Depressionprone 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. The 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.

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. 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.

Treatment of Mood Disorders 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.

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

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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. Transcranial magnetic stimulation (TMS) shows promise as a new form of treatment for moderate depression.

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. 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.

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 (p. 262). According to this view, people who are depressed affect and are affected by their interactions with loved ones. Basically, Coyne holds that living with a depressed person can become so stressful that this person's partner or family becomes less supportive over time 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; however, there may be other contributing factors such as genetic and environmental overlap as well as selection-bias in choosing friends and mates. 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.

2. Beck's cognitive approach to 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. Drs. Aaron and Judith Beck have several training videos on using cognitive behavioral therapy to treat depression. Discuss Dr. Beck’s theory while interspersing video segments that demonstrate key aspects of the treatment protocol, how it links to Dr. Beck’s theory, and why it is effective in treating symptoms of depression.

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 .

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between exercise and depression, Lisa McCann and David Holmes ("Influence of aerobic exercise on depression," Journal of Personality and Social Psychology, 1984, 46, p. 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. 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 stress 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. In a recent exploration of the link between depression and exercise, Drs. Ruth L. Hall and Carole A. Oglesby find support for the benefit of integrating exercise, sports, and therapy in treating women with depression in their book, Exercise and Sport in Feminist Therapy: Constructing Modalities and Assessing Outcomes (2003; The Haworth Press, Inc. and a monograph published simultaneously as Women & Therapy, Vol. 25, No. 2.)

4. 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?

5. Postpartum depression. Postpartum mood changes attendant upon childbirth can reach the level of depression and even psychosis in some women. In these situations the 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 re-experiencing 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?

6. 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 1 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 non-depressed parents' children made an attempt. All of the cases of major depression (10) and anxiety disorder (8) occurred in children of depressed parents. Incidence of substance abuse did not differ for the two 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 .

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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 99457, 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?

7. 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 and 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.

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

Psychological Bulletin, 101, 259–282.

8. 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 not significant for those that were 24 years of age 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. 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.

Show the PBS film, The Silent Epidemic: Teen Suicide, and discuss factors unique to teens and suicide.

Given the proximity in age between high school and many college students, ask them to comment on the fear of imitation effects and copycat suicides.

9. 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 students 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 is a two-way street. Sometimes being rejected is .

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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.

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

Coyne, J. 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.

10. 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 have a moderate to strong correlation. 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 correlation 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, 316–336.

11. Warning signs of suicide. Discuss the warning signs of suicide. 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 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 "A Closer Look: Suicide Prevention" box in this chapter provides a good basic outline of the things to do when faced with such a situation.

12. 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. 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 behavior. In fact, suicides seemed to make the friends less inclined to it. The most common sequela 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.

Brent, D. A., Perper, J., Moritz, G., Allman, 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. .

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13. 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. 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 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? Talk about Kervorkian’s conviction and recent release from prison for his actions. What responsibilities do mental health professionals have in preventing suicide? Can they ethically support a "pro-suicide" position?

Think About It How do clinicians distinguish between normal variations in mood and mood disorders? Feeling down or depressed is not abnormal in the context of depressing events or circumstances. But people with mood disorders experience disturbances in mood that are unusually severe or prolonged and impair their ability to function in meeting their normal responsibilities. Some people become severely depressed even when things seem to be going well. Still others experience extreme mood swings from incredible highs to abysmal lows. For most of us, mood changes pass quickly or are not severe enough to interfere with our lifestyle or ability to function. People with mood disorders have mood changes that are more severe or prolonged and affect daily functioning.

“Women are just naturally more inclined to depression than men.” Do you agree or disagree?

Explain your answer. Students should be familiar with gender differences in the incidence and prevalence rates of depression. Encourage them to 1) maintain a skeptical attitude, 2) consider the definitions of the terms, 3) weigh the assumptions or promises on which arguments are based, 4) bear in mind that correlation is not causation, 5) consider the kinds of evidence on which conclusions are based, 6) do not oversimplify, 7) do not over generalize.

Why is it difficult to distinguish between cyclothymic and bipolar disorder? Cyclothymia and bipolar disorders are similar in that both involve abnormal mood swings. The boundaries between bipolar and cyclothymic disorder are not clearly established. Some forms of cyclothymic disorder may represent a mild, early type of bipolar disorder. Approximately 33 percent of people with cyclothymic disorder eventually develop bipolar disorder. We presently lack the ability to distinguish between people with cyclothymia who are likely to eventually develop bipolar disorder.

Which of the cognitive distortions, if any, that are listed in the text characterize your way of thinking about disappointing experiences in your life? What were the effects of these thought patterns on your mood? How did they affect your feelings about yourself? How might you change these ways of thinking in the future? This is a personal experience question. Students need to be familiar with the different cognitive distortions as outlined in the text.

What evidence supports a genetic contribution to mood disorders? Is genetics solely responsible?

Why or why not? Evidence has accumulated pointing to the important role of biological factors, especially genetics and neurotransmitter functioning, in the development of mood disorders. We know .

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mood disorders, especially bipolar disorders, tend to run in families. Twin studies and adoptive studies contribute evidence to the idea of genetic contribution with high concordance rates. However, genetics isn’t the only determinant. Moreover, genetics may not be the most important determinant.

Environmental factors, such as exposure to stressful life events, appear to play at least as great a role—if not a greater role—than genetics.

Jonathan becomes clinically depressed after losing his job and his girlfriend. Based on your review of the different theoretical perspectives on depression, explain how these losses may have figured in Jonathan’s depression. Depression and other mood disorders involve the interplay of multiple factors.

Consistent with the diathesis-stress model, depression may reflect an interaction of biological factors, psychological factors, and social/environmental stressors. In Jonathan’s case, certainly environmental and social factors come into play with the loss of both his girlfriend and job. He may be biologically at risk for depression from his family background. Certainly genetics and brain chemistry can be a factor.

Finally, Jonathan may be psychologically at risk. If he engages in cognitive distortions or has a sense of learned helplessness, depression can occur.

If you were to become clinically depressed, which course of treatment would you prefer—medication, psychotherapy, or a combination? This is a personal opinion question. Students need to know the different treatments available and the pros and cons of each. End with an emphasis on the effectiveness of combining both medication and psychotherapy for stable long-term improvement.

What factors are related to suicide and suicide prevention? Did your reading of the text change your ideas about how you might deal with a suicidal threat by a friend or loved one? If so, how?

This is a personal experience question. Students should know the facts relating to suicide and suicide prevention.

Activities/Demonstrations 1. Cognitive distortions. Ask students to select approximately six negative thoughts they engage in from time to time. If they find it difficult to recall any, have them choose some representative thoughts listed in table 8.5 in 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 (see 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 and how they can utilize these strategies in the future.

2. The “Are You Depressed?” Scale. Have students fill out the “Are you Depressed?” scale in the text (p. 252). 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. Often, the scores will average much higher than 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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Media Resources Speaking Out Videos in Abnormal Psychology Everette: Major Depression (2:03) Video available on MyPsychLab.com VIDEO BACKGROUND: In this interview, Everette talks about the major depression he has experienced since childhood.

Beginning at the age of two, Everette explains how his depression has affected many important areas of his life: he had difficulties with relationships, low self-esteem, poor occupational functioning, etc. To deal with his illness, Everette began self-medicating with prescription drugs as well as alcohol and eventually tried to commit suicide. He was reluctant to be hospitalized fearing stigma, but eventually spent more than six months in a hospital. Now he feels he has turned his life around and is working to “tear down the walls” he built in his relationships during the first 48 years of his life. A particularly interesting segment is his discussion of how one feels during a Depressive Episode.

DISCUSSION QUESTIONS: 1. Major Depression can begin: a) during childhood. b) during adolescence. c) during adulthood. d) all of the above Answer: d.

Although major depression is often thought of as an “adult’s disease,” it can begin at any age. As Everett notes, when he was younger, childhood depression may have been an uncommon diagnosis. Now childhood depression is more regularly recognized and diagnosed.

2. Which of the following would rule out a diagnosis of major depression? a) Psychotic features (i.e., hallucinations, delusions) b) Catatonia c) Mania d) Insomnia Answer: c.

Psychotic features and catatonia are both included in the subtypes of major depression. Insomnia can be a symptom of the required major depression episode. The presence of a non-drug induced manic episode, however, prevents a diagnosis of major depression.

3. Which of the following is NOT a diagnostic symptom of major depression? a) Diminished interest in activities b) Weight loss c) Weight gain .

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d) Irritability Answer: d.

Although one might associate irritability with depressed people, it is not a diagnostic feature of a major depressive episode. Note that both weight loss and gain are diagnostic features.

4. Everett discusses some of the cognitions associated with depression in this video. What kind of thoughts do people with depression commonly have?

Suggested answers: suicide, death, worthlessness, guilt, etc. In addition, their thoughts tend to be negative and pessimistic in regards to the self, the world, and the future.

5. Everett discussed the ways his depression affected his life. List some of the affected areas and the way in which they were affected.

Suggested answers: occupationally, feeling he was the “world’s worst teacher” and “world’s worst principal”; relationships, feeling like a bad father/spouse; self-esteem, feelings of worthlessness, etc.

CLASS ACTIVITY: 1. Although depression itself can be very difficult to overcome, often people continue to have problems after their depression is in remission. Discuss depression-related problems people might have after they feel they have overcome their depression. Suggested answers: difficulty mending relationships, difficulty finding a job, problems reorganizing life, etc.

Ann: Bipolar Disorder (3:50) Video available on MyPsychLab.com VIDEO BACKGROUND: In this interview, Ann discusses how her bipolar mood disorder has affected her life in multiple ways.

Although she has had only one major depressive episode, Ann’s Manic Episodes have led to significant difficulties including the loss of her marriage, job, friends, and custody of her daughter. She also experienced delusions throughout the course of her disorder, including beliefs that she was in line for the presidency of Harvard or MIT, that her mother was disguised as Che Guevara on television, and that the CIA was going to assassinate her. These delusions led to paranoia and alcohol abuse. Ann currently receives psychotherapy and medication and attends self-help groups. She “runs light” on her medications so she can remain in a hypomanic state at all times. Interesting segments include her discussion of how one feels during a manic episode and the perceived benefits of being manic.

DISCUSSION QUESTIONS: 1. What symptom is most associated with Bipolar I Disorder? a) Mania b) Depression c) Psychosis d) Insomnia Answer: a.

A diagnosis of Bipolar I Disorder requires either a manic or mixed episode. Depressive episodes are very common as well, however. Psychosis and/or insomnia may appear as well, but are not required for diagnosis. .

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2. What are some ways in which mania has negatively affected Ann’s life? Suggested answers: loss of job/relationships, insomnia, racing thoughts, tension, etc.

3. What are some ways in which Ann feels mania affected her life positively?

Suggested answers: high energy, ability to see connections in business, creativity, etc.

4. How does Bipolar I Disorder differ from Bipolar II Disorder?

Answer: Bipolar I Disorder requires at least one Manic Episode or Mixed Episode. Bipolar II Disorder requires at least one Major Depressive Episode and at least one Hypomanic Episode.

CLASS ACTIVITY: 1. Although not all people with Bipolar I Disorder have a wide range of symptoms, Ann’s symptomatology was multifaceted. Discuss the symptoms Ann had and put them into diagnostic groups.

Suggested answers: MANIC SYMPTOMS: energy, hyperactivity, substance use, etc.; DEPRESSED SYMPTOMS: sadness, etc.; PSYCHOTIC SYMPTOMS: delusions (e.g., thinking her office was bugged, thinking she was in line for university presidencies), etc.

Virtual Case Study simulations available on MyPsychLab.com SIMULATION BACKGROUND: Virtual Case Studies, found in Pearson’s MyPsychLab, is a new, science-based, interactive simulation where students can explore how a number of risk factors and protective factors may impact the development of a psychological disorder. Virtual Case Studies engages students through captivating narratives that they advance, allowing students to explore and critically think about the influence of biological, psychological, social and cultural factors in the development or regression of a disorder.

Virtual Case Study: Mood Disorders http://staging.allthingsmedia.com/pearson/virtual_case/src/vc_01.html

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CHAPTER EIGHT SUBSTANCE-RELATED AND ADDICTIVE DISORDERS Learning Objectives 8.1 Identify the major types of substance related disorders in the DSM-5 and describe their general features.

8.2 Describe nonchemical forms of addiction or compulsive behavior.

8.3 Explain the difference between physiological dependence and psychological dependence.

8.4 Identify common stages in the pathway to addiction.

8.5 Identify the major categories of psychoactive drugs and specific drugs in each category, and describe the effects of these drugs and the risks they pose.

8.6 Describe the major theoretical perspectives toward understanding substance disorders.

8.7 Explain how cocaine affects the brain.

8.8 Evaluate methods of treating substance use disorders.

8.9 Describe the basic features of gambling disorder and evaluate ways of treating it.

Chapter Outline I. Classification of Substance-Related and Addictive Disorders A. Substance Use and Abuse B. Nonchemical Addictions and Other Forms of Compulsive Behavior C. Clarifying Terms D. Pathways to Addiction II. Drugs of Abuse A. Depressants B. Stimulants C. Hallucinogens III. Theoretical Perspectives A. Biological Perspectives B. Learning Perspectives C. Cognitive Perspectives D. Psychodynamic Perspectives E. Sociocultural Perspectives IV. Treatment of Substance Use Disorders A. B. C. D. E. F. G.

Biological Approaches Culturally Sensitive Treatment of Alcoholism Nonprofessional Support Groups Residential Approaches Psychodynamic Approaches Behavioral Approaches Relapse-Prevention Training

V. Gambling Disorder A. Compulsive Gambling as a Nonchemical Addiction B. Treatment of Compulsive Gambling

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VI. Summing Up

Chapter Overview Classification of Substance-Related Disorders The DSM-5 classifies substance related disorders in two major diagnostic categories—substance-induced disorders, which are repeated episodes of drug intoxication or development of a withdrawal syndrome, and substance use disorders, which are maladaptive use of a substance leading to psychological distress or impaired functioning. The DSM-5 draws the line between substance use and substance abuse as being the point at which a pattern of substance use significantly impairs the person’s occupational, social, or daily functioning or causes significant personal distress.

Gambling Disorder is a non-chemical form of addiction that has been categorized as such in the new DSM-5 system. Compulsive gambling, compulsive shopping, and even compulsive internet use share some hallmark features of drug addiction or dependence.

Drugs of Abuse Depressants include alcohol, sedatives and minor tranquilizers, and opioids. Effects of alcohol include intoxication, impaired coordination, slurred speech, and impaired intellectual functioning. Chronic alcohol abuse has been connected with disorders such as alcohol-induced persisting amnestic disorder (Korsakoff’s 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.

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.

The 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.

Theoretical Perspectives Biological perspectives focus on uncovering the biological pathways that may explain mechanisms of physiological dependence. The disease model treats problems of substance abuse and dependence as disease processes.

Learning theorists view substance abuse disorders as learned patterns of behavior that, in principle, can be unlearned. They focus on the roles of classical and operant conditioning and observational learning.

Cognitive perspectives have focused on 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 theorists view problems of substance abuse, such as excessive drinking and habitual smoking, as signs of oral fixation. They believe the features contribute to what is termed an oral.

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dependent personality.

Sociocultural perspectives have focused 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.

Treatment of Substance Abuse and Dependence Biological approaches to substance abuse disorders include detoxification, the use of disulfiram, methadone, naltrexone, antidepressants, and nicotine replacement therapy. Residential treatment approaches include hospitals and therapeutic communities. Nonprofessional support groups, like Alcoholics Anonymous, promote abstinence within a supportive group setting.

Regardless of the initial success of a treatment technique, relapse remains a pressing problem in treating people with substance abuse problems. Relapse-prevention training employs cognitive-behavioral techniques to help ex-abusers cope with high-risk situations and to prevent lapses from becoming relapses by helping participants to interpret lapses in less damaging ways.

Psychodynamic therapists focus on uncovering the inner conflicts originating in childhood that are believed to be at the root of substance abuse problems. Behavior therapists focus on helping people with substance-abuse-related problems change problem behaviors through such techniques as self-control training, aversive conditioning, and skills training approaches.

The sociocultural perspective holds that substance use is determined, in part, by where we live, whom we worship with, and the social or cultural norms that regulate our behavior. Cultural attitudes can encourage or discourage substance abuse.

Gambling Disorder Examples of compulsive gambling include excessive wagering on horse races or in card games and casinos, betting on sporting events, and chancy stock picks. About 0.4 percent to 1.0 percent of the general population develops a gambling disorder at some point in their lives. Compulsive gambling has been on the rise in recent years, ostensibly due to the increasing spread of legalized forms of gambling.

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 .

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significance with respect to psychoactive drugs, especially psychedelic and hallucinogenic substances.

2. Alcohol use and abuse. Ask students where they draw the line between the use and abuse of alcohol.

Do their responses focus more on the amount or type of alcohol used? Review the DSM-5 criteria distinguishing use from abuse. How does one determine if the pattern of substance use significantly impairs the person’s occupational, social, or daily functioning or causes significant personal distress?

3. Binge drinking among college students. Consuming alcohol during college has almost become a rite of passage and normative part of the college experience. Similarly, binge drinking is on the rise, as are the number of injuries and deaths related to binge drinking. Binge drinking is defined as 4+ drinks (for women) or 5+ drinks (for men) on one occasion. Based on this definition, it is estimated that 40 percent of college students engage in this behavior during college. Ask students what they think of this definition.

How many know at least one person who has met the criteria for binge drinking? Do students believe binge drinking is as problematic as is claimed, or are the potential risks overblown? Challenge attempts to rationalize the behavior as acceptable simply because it is common.

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. 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 the age of 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. 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.

5. Relationships with drugs. In their book, Chocolate to Morphine, Andrew Weil, 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 dependent users believe they can take it or leave it when it is abundantly clear to those around them that they are drug dependent. (4) Freedom from adverse effects on health and behavior. 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 behavior is another characteristic of drug abuse.

6. AIDS and intravenous drug use. Acquired Immunodeficiency Syndrome (AIDS) has greatly increased the urgency of modifying behaviors associated with drug addiction; sharing needles for intravenous drug use results in an exchange of contaminated blood and is a leading mode of transmission .

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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: (1) IV drug users need basic information about HIV transmission before they change their needle-sharing behavior; (2) information is not sufficient; means for behavior change (such as sterilized needles or bleach for sterilizing) must be readily available for change to occur; and (3) sustained reinforcement for risk reduction behaviors, especially new peer norms favoring safer behavior, 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. What are the parallels and differences in legalizing drugs today compared to the prohibition of alcohol in 1920 and later relegalization of alcohol in 1933? Have students review the states currently considering decriminalization or medically approved marijuana. How has the legalization of medical marijuana affected the states that presently do allow medical marijuana?

8. Drug education. Discuss the effectiveness of drug education today. How early in school should such a program begin? Do students believe they received adequate information on newer forms of harmful drug use, such as sniffing fumes, crystal methamphetamine, crack cocaine, and Ecstasy? 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? Discuss the research that has been done on the efficacy of the D.A.R.E. program. Review the changes in the program that have come about as the result of criticism.

9. Smoking. Surveys indicate that, after years of steady declines, cigarette smoking among young people has increased significantly in recent years. 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 there 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 the crime wave that occurred during the prohibition of alcohol in the 1920s?

Think About It Does someone you know show evidence of any nonchemical forms of addiction, such as compulsive shopping, gambling, or sexual behavior? How is this behavior affecting his or her life? What can he or she do about overcoming it? This is a personal experience question. Students need to appreciate the different forms of addiction.

Do you use alcohol? How does it affect you physically and mentally? Have you drunk alcohol and driven? How do you feel about that? Have you ever done anything under the influence of alcohol that you later regretted? What? Why? This is a personal experience question. Students are encouraged to probe the impact of alcohol use in their lives.

Do you think it is wise to use alcohol in moderation to reduce the risk of cardiovascular disease?

Why or why not? This is a personal opinion question. Students should be familiar with the research on the health benefits of moderate drinking.

Speculate on the reasons that smoking is more prevalent among poorer and less educated segments of the U.S. population and why smoking is on the rise among teenagers. What kinds of public health .

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messages might be effective at reaching these at-risk groups? The more educated and higher socioeconomic classes have gotten the message that smoking is bad for your health. Perhaps the poorer, less educated classes in the U.S. population feel they have less to lose. Peer pressure is important to teens, so public health messages that focus on the idea that smoking is not “cool” might help.

Do you believe that illicit drugs should be legalized or decriminalized? Why or why not? This is a personal opinion question. The pros and cons of drug legalization should be explained clearly with logical evidence.

How has your cultural background affected your attitudes and your use of drugs such as alcohol and tobacco? This is a personal experience question. It assumes that students are in touch with their cultural backgrounds.

Do you know anyone who has received treatment for a drug abuse problem? What was the outcome? This is a personal experience question. Students may or may not have personal experience on this issue, but they certainly can comment on celebrities in the media.

What do you think of the concept of using methadone, a narcotic drug, to treat addiction to another narcotic drug, heroin? What are the advantages and disadvantages of this approach? Do you believe the government should support methadone maintenance programs? Why or why not? This is a personal opinion question. Students need to be familiar with the philosophy of methadone maintenance treatment programs.

Many teenagers today have parents who themselves smoked marijuana or used other drugs when they were younger. If you were one of those parents, what would you tell your kids about drugs?

This is an opinion question. Students may have direct experience from the vantage point of being a kid.

Activities/Demonstrations 1. The most commonly used drugs. Instruct students to list the three most commonly used drugs among people ages 15–30. Have them rank in 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 diverse products such 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 alcohol abuse. Have students complete the inventory adapted from the National Council on Alcoholism’s self-test. Then, 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. Drugs and other addictive behaviors in college. Similar to the National Council on Alcoholism’s self-test, have students complete substance use and abuse inventories for drugs and other addictive behaviors (e.g., compulsive gambling). Students may be surprised to discover that behaviors that appear normative in a college environment, such as excessive drinking or marijuana use, are potentially problematic and may warrant a substance-related diagnosis.

4. 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, .

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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 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 whitewater 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.

5. 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 behavior of those under the influence of a drug. How might expectancies influence other responses to alcohol or to other drugs? What are the expectancies about the effects of cigarette smoking, marijuana use, or psychedelics?

6. 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?

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

8. 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.

9. Alcoholic stereotypes. Present the following scenario to students. “You are walking down the street in a major city. You see a person as you walk by and think to your self, that person is an alcoholic.” Have the students jot down on a sheet of paper the imaginary person’s age, gender, socioeconomic level, and appearance. Compile the data on the board using age categories of 0–20, 21–40, 41–60, 61+; malefemale; socioeconomic level—white collar, blue collar, unemployed; note appearance such as well groomed, disheveled, etc.

Results should be obvious stereotypes. Alcoholics are usually considered to be male, in the 21–40 age range, blue collar or unemployed with disheveled appearance. This always leads to a good discussion on stereotypes. You can counter with the percent of women, elderly, and young alcoholics. It’s always powerful to note that it’s not them (other), it’s us.

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Media Resources Speaking Out Videos in Abnormal Psychology Chris: Alcoholism (3:12) Video available on MyPsychLab.com VIDEO BACKGROUND: In this interview, Chris discusses the course of alcoholism during his life and the impact it has had. He began using alcohol at the age of 12 and began experimenting with marijuana soon thereafter. All this led to harder drugs until he was spending $1,000 per week on his cocaine habit and drinking twelve-packs within thirty minutes to be able to sleep. He discusses his attitude about the goal of drinking, which was to get drunk to the point of having frequent blackouts, and the pain he experienced from past sexual abuse. His alcoholism led him to physical fights (one of which shattered his face) and being kicked out of college, among other things. He also engaged in infidelity largely due to his alcoholism, which caused serious problems in his marriage. Of particular interest in this video is that even after these negative events occurred, he was unable to see the problems stemming from his alcoholism.

DISCUSSION QUESTIONS: 1. Which of the following means a person requires more and more of a substance to achieve the same sensation? a) Withdrawal b) Tolerance c) Stamina d) Addiction Answer: b.

As a person increasingly uses a substance, he or she requires more and more of the substance to achieve the same high. This is tolerance. Withdrawal is a reaction to the removal of a substance from one’s system.

2. If a person regularly partakes in a substance, requires more and more of it over time to achieve the same highs, has physiological reactions when the substance is removed, and has difficulty at work because of the substance, what is the best diagnosis? a) Substance use disorder b) Substance withdrawal disorder c) Substance dependence disorder d) Substance tolerance Answer: a.

Substance use disorders are patterns of maladaptive use of psychoactive substances that lead to significant levels of impaired functioning or personal distress.

3. What are common problems for people with Substance Use? .

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Suggested answers: Failure to fulfill obligations at work, school, or home; substance use in hazardous situations; recurrent substance-related legal problems or continued use despite problems in social or interpersonal functioning due to the substance, etc.

4. Chris discusses the difficulty he had during withdrawal. What are some common symptoms of withdrawal?

Suggested answers: An autonomic hyperactivity, increased hand tremor, insomnia, nausea or vomiting, transient visual, tactile or auditory hallucinations or illusions, psychomotor agitation, anxiety, grand mal seizures, etc.

CLASS ACTIVITY: 1. In this interview, Chris notes that he used both alcohol and other drugs in unison. Discuss how Chris’s alcohol and other drug problems interrelated.

Suggested answer: Chris began with alcohol use, then began experimenting with other soft drugs (e.g., marijuana) before moving on to hard drugs, then began using alcohol to counteract the strong effects of the hard drugs. Review Pathways to Addiction in the text (p. 296).

Substance Abuse: Dr. Jean Obert (3:11) Jean Obert, clinical director of the Matrix Center, a substance abuse clinic, is interviewed about the effects of drugs and alcohol. In this segment, she highlights heroin as a particularly difficult drug to give up because of the illicit culture associated with it Video available on MyPsychLab.com Virtual Case Study simulations available on MyPsychLab.com SIMULATION BACKGROUND: Virtual Case Studies, found in Pearson’s MyPsychLab, is a new, science-based, interactive simulation where students can explore how a number of risk factors and protective factors may impact the development of a psychological disorder. Virtual Case Studies engages students through captivating narratives that they advance, allowing students to explore and critically think about the influence of biological, psychological, social and cultural factors in the development or regression of a disorder.

Virtual Case Study: Substance Use Disorders http://staging.allthingsmedia.com/pearson/virtual_case/src/vc_01.html

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CHAPTER NINE EATING DISORDERS AND SLEEP-WAKE DISORDERS Learning Objectives 9.1. Describe the key features of three types of eating disorders: anorexia nervosa, bulimia nervosa, and binge-eating disorder.

9.2. Describe causal factors involved in anorexia nervosa and bulimia nervosa.

9.3. Evaluate methods used to treat eating disorders.

9.4. Identify health risks associated with obesity.

9.5. Identify factors linked to obesity.

9.6. Identify and describe specific types of sleep-wake disorders.

9.7. Evaluate methods used to treat sleep-wake disorders.

9.8. Apply your knowledge of healthy sleeping habits to steps you can take to develop more adaptive sleep habits.

Chapter Outline I. Eating Disorders A. Anorexia Nervosa B. Bulimia Nervosa C. Causes of Anorexia Nervosa and Bulimia Nervosa D. Treatment of Anorexia Nervosa and Bulimia Nervosa E. Binge-Eating Disorder II. Sleep-Wake Disorders A. Treatment of Sleep-Wake Disorders III. Summing Up

Chapter Overview Eating Disorders Two major types of eating disorders, anorexia nervosa and bulimia nervosa, tend to begin in adolescence. They affect many more girls than boys and involve preoccupations with weight control and maladaptive ways of trying to keep weight down. Anorexia nervosa involves maintenance of weight at least 15 percent below normal levels, intense fears of becoming overweight, distorted body image, and, in females, amenorrhea. Bulimia nervosa involves preoccupation with weight control and body shape, repeated episodes of binge eating, and regular purging to keep weight down.

Obesity: A National Epidemic About one-third of Americans are obese and about another third are overweight. The causes of obesity include genetic factors and psychological factors. Treatment approaches to obesity include behavior modification (to alter problem eating habits) and appetite-suppressant drugs (to curb appetite). Longterm success depends on making lasting changes in dietary and exercise patterns.

Binge-Eating Disorder Binge-eating disorder (BED) involves engaging in repeated binge-eating episodes but with no .

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compensatory behavior (e.g., laxative use, vomiting, and exercise) afterward to reduce the caloric intake or weight gain. BED is more common than either anorexia or bulimia, affecting about 3.5 percent of women and 2 percent of men at some point in their lives. Although people with bulimia nervosa typically fall within a normal weight range, many (but not all) BED patients are either overweight or obese.

Sleep-Wake Disorders The term “sleep-wake disorders” replaces the earlier DSM term “sleep disorders.” The change underscores the fact that these disorders involve problems occurring during sleep or at the threshold between sleep and wakefulness. These disorders include insomnia disorder, hypersomnolence disorder, narcolepsy, breathing-related sleep disorders, circadian rhythm sleep-wake disorders, and parasomnias.

The DSM-5 characterizes abnormal behavior patterns associated with partial or incomplete arousals as parasomnias. This category of sleep-wake disorders is further divided into disorders associated with REM sleep and those associated with non-REM sleep. The major types of parasomnias associated with non-REM sleep are sleep terrors and sleepwalking. Those associated with REM sleep are rapid eye movement sleep behavior disorder and nightmare disorder.

The most common form of treatment of sleep disorders involves the use of antianxiety or hypnotic drugs. However, use of these drugs should be time limited because of the potential for psychological and/or physical dependence, among other problems associated with their use. Cognitive-behavioral interventions have produced substantial benefits in helping people with chronic insomnia.

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 weightloss programs generally include behavioral 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 behaviors 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 common to see high schoolers and even middle schoolers showing behaviors 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. Calories absorbed during binge and purge episodes. Many may wonder why those with bulimia nervosa manage to maintain a normal weight despite eating relatively small amounts of food outside of binges. Dr. Kaye and colleagues developed an interesting study to investigate this topic. In a naturalistic, but controlled environment, they allowed women with bulimia nervosa to binge as they would normally and calculated the number of calories consumed. They then had the women purge into plastic buckets and measured the calories remaining in the vomited material. They determined that participants retained approximately 1,150 calories during a binge despite purging relatively quickly after .

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eating. This is up to 75 percent of the recommended calorie intake for women for an entire day. Even if restricting their caloric intake the rest of the day, on average they would consume enough calories to maintain their body weight.

Kaye, W. H., Weltzin, T. E., Hsu, L. K. G., McConaha, C. W., Bolton, B. (1993). Amount of calories retained after binge eating and vomiting. American Journal of Psychiatry, 105 (6), 969–971).

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? Make parallels between smoking (which is a serious and avoidable risk to health) to obesity. Do smokers face the same degree of discrimination as the obese? Has society made obesity one of the last acceptable domains for discrimination?

5. Weight loss surgery as a treatment option for obesity. Many people have strong opinions about the appropriateness of surgery as a treatment option for obesity. Unfortunately, most people know very little about the actual procedures, surgery options, risks, and benefits. Weight loss surgery (WLS) was first introduced in the 1950s and the procedure has evolved considerably since that time. Currently, options are numerous and include: open or laparoscopic surgery; cutting a section of the stomach to form a new pouch about the size of an egg or golf ball, having a band inserted that surrounds the stomach that creates an artificial pouch, or having an adjustable band the individual can control; and bypassing much of the intestines so that caloric absorption is reduced or leaving the connection to the intestines intact. Although the mortality rate is considered high (approximately 1–2 percent) many deaths are isolated to those with such severe complications due to their obesity that they were already at high risk of death. Moreover, recent studies demonstrate that patients keep 60–80 percent of the lost weight off 10 years later and greatly reduce or eliminate comorbid disorders such as diabetes, sleep apnea, and high blood pressure. Have students research both the positives and negatives of WLS as a treatment option for obesity. Have them take sides and then present an argument for/against WLS. Encourage students to consider long-term insurance costs, quality of life, success of non-surgery options, populations the surgery should be restricted to (e.g., teens versus adults), etc.

6. 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 reverses, the muscle loss and stiffening associated with aging. It also seems to counteract anxiety and depression and helps people effectively cope with stress.

7. 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. .

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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.

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 are not moving and incorporates that fact into the dream itself.

8. Learning to control your nightmares. In some cultures, nightmares are not considered to be random torments beyond one’s control. Rather, they are seen as a part of our psyche that we can learn to have power over as we mature into adulthood. Children are actively encouraged to revisit nightmares and determine strategies for conquering the object of their fears and learning to overcome adversity. Is this a strategy students have ever tried? How effective is this strategy? If students have tried it, they probably realize how challenging it can be to conquer fears in nightmares and the discipline needed to do so regularly.

9. Sleep and depression. Discuss the connection between sleep 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. I've heard this problem called "student sleep syndrome" by many of my college counseling center colleagues, 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. I have had students who are very relieved to know that this condition is not unique to them, but reflects their situation and will usually disappear when their stress levels are reduced. I always caution students, however, that their physician should check out any physical condition that is not normal for them.

10. Home remedies for insomnia. Ask students to list some common home remedies for battling insomnia. Among the methods I've heard commonly mentioned are counting sheep, making one's mind go blank by thinking of nothing, focusing on slow, deep, relaxed breathing, and so forth. Point out that most of these methods involve 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 sleep he or she really needs.

11. Milk as a sedative. 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 sugar (such as coffee with a sugar donut).

12. Personal accounts of sleep disorders. I have found that when I discuss sleep disorders with my classes, 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 .

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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.

Think About It Why do you think that people with anorexia and bulimia continue their destructive behaviors in spite of the medical complication of these conditions? This is an opinion question. Students should be familiar with the symptoms and features of anorexia and bulimia.

Encourage them to 1) maintain a skeptical attitude, 2) consider the definitions of the terms, 3) weigh the assumptions or promises on which arguments are based, 4) bear in mind that correlation is not causation, 5) consider the kinds of evidence on which conclusions are based, 6) do not oversimplify, 7) do not overgeneralize.

How do sociocultural and psychosocial issues interact to cause eating disorders? How might we as a society change the social influences that lead many young women to develop disordered eating habits? Sociocultural theorists point to societal pressures and expectations placed on young women in our society as contributing to the development of eating disorders. The pressure to achieve an unrealistic standard of thinness, combined with the importance attached to appearance in defining the female role in our society, can lead young women to become dissatisfied with their bodies. Evidence shows that eating disorders are less common, even rare, in non-Western countries where there is not the weightobsessed culture of the United States. Although cultural pressures to conform to an ultra thin female ideal play a major role in eating disorders, other factors must be involved. Psychosocial factors such as body dissatisfaction and cognitive factors such as perfectionist attitudes also play a role. We could change the culture of thinness in our society. Super thin models, Barbie doll fascination, media hype, all contribute to unrealistic expectations of feminine beauty. Not so long ago, the ideal women’s form was a voluptuous, buxom beauty.

Do you know anyone who has suffered from an eating disorder? What factors discussed in the text might help you to better understand the causes of the person’s problem? This is a personal experience question. Students need to know the symptoms and features of anorexia and bulimia.

How does binge-eating disorder differ from anorexia and bulimia? In what ways is it similar to substance abuse? People with binge-eating disorder have recurrent eating binges but do not purge themselves of the excess food afterwards. Unlike bulimia, binge-eating disorder is more commonly found among obese individuals. People with binge-eating disorder tend to be older than those with anorexia or bulimia. It may fall within the broader domain of compulsive behaviors such as pathological gambling and substance disorders due to the impaired control over maladaptive behaviors.

Why is obesity considered a major health risk? Why is it difficult to control? Obesity has been linked to serious, chronic diseases such as heart disease, diabetes, and some forms of cancer. The old adage “eat less, exercise more” sounds simple, yet it is very difficult to do. The problem is that change in diet, eating habits, and exercise patterns that lead to initial weight loss are not carried over into changes in lifestyle that would promote maintenance of weight loss. People seeking to lose excess weight and keep it off need to make a lifelong commitment to following a sensible, calorie-sparing diet and engaging in regular exercise.

Do you believe that obesity results from a lack of will power? Why or why not? This is a personal opinion question. Students should be familiar with the theoretical causes of obesity. .

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What are the drawbacks of relying on sleep medications to combat chronic insomnia? The most common method for treating insomnia in the United States is the use of sleep medications called hypnotics. The major problem with these drugs is that they all can produce dependence if taken over time. Sleep inducing drugs tend to suppress REM sleep, which may interfere with the restorative effects of sleep. They can also lead to a carry over “hangover” the next day, which is associated with daytime sleepiness and reduced performance. Rebound insomnia can also follow discontinuance of the drug, causing worse insomnia than was originally the case. The drugs quickly lose effectiveness at a given dosage level, so progressively larger doses must be used to achieve the same effect. High dosages can be dangerous, especially if they are mixed with alcohol at bedtime. Regular use can lead to dependence.

Once dependence is established, withdrawal symptoms following cessation of use may occur, including agitation, tremors, nausea, headaches, and in severe cases, delusions or hallucinations.

Do your sleep habits help or hinder your sleeping patterns? Explain. This is an experience question.

Students need to be familiar with their own sleep patterns and habits.

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

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

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

3. The Body Mass Index. Have students calculate their body mass index. While some students may not want to publicly disclose their results, others might be more than willing to volunteer theirs, and you can use this as a springboard for discussing whether or not students believe these standards are too stringent, too lenient, or fairly realistic.

4. Standards of beauty and Body Mass Index. Use a picture of a woman (or a live person if possible) that most would agree is slim/average weight and provide her BMI. Then demonstrate that this person would need to lose another X number of pounds to achieve the average BMI = 22 for Miss America winners in the 1920s. Repeat this for the BMI = 20 by the 1960s and the recent average of a BMI = 18 for Miss America winners in the 1990s. Students may be shocked to discover how thin someone needs to be to achieve this standard of beauty. Having a picture or an actual person that is already slim/average makes this point even more shocking for students.

5. 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. I'd expect that those students who engage in more structured rituals have the longer sleep latencies and perhaps more fitful sleep patterns. Of course, this doesn't establish causal patterns—sleep rituals may be a response to underlying sleep disturbances rather than vice versa.

6. Sleep center field trip. Plan a field trip to a local sleep center. Most medical centers and many community hospitals now have them. Ask for a tour of the sleep lab. Students can get a first-hand view of all the physiological equipment needed to track a night’s sleep. Print-outs of EEG’s may be available .

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for review.

7. College students and sleep deprivation. Poll students on their sleep-related behaviors. Ask questions, such as how many of the students have ever pulled an “all-nighter,” how many days in a row have students gone without sleep, how many get less than 7 hours a night regularly, and what consequences they have noticed as a result. Students may be more readily familiar with the effects of several nights without sleep, but may be surprised by the consequences associated with chronic sleep deprivation, even if mild, such as 4–5 hours a night.

Media Resources Jessica: Eating Disorders (3:41) Video available on MyPsychLab.com VIDEO BACKGROUND: In this interview, Jessica discusses her struggle with anorexia nervosa, which began around age nineteen. As a performer in a competitive New York dance program, Jessica found herself attempting to become thinner as a means of standing out, maintaining control, and coping with stress and other emotions. She engaged in restrictive eating, excessive exercise, and the use of diet pills and laxatives regularly. She also discusses the shame and guilt she faced after the rare instances when she purged. Of particular interest in this interview is Jessica’s discussion of her goals of dieting: to “surpass human boundaries” for weight. Additionally, Jessica notes that, “No matter how thin I got… I was never going to be thin enough.” Notice how she equated thinness with perfection. Lastly, her mention of body image distortion is another hallmark of anorexia nervosa.

DISCUSSION QUESTIONS: 1. What anorexic tendencies did Jessica use to keep her weight down? a) Eating low calorie foods b) Restricting her food intake c) Eating “safe foods” d) All of the above Answer: d.

All three choices were behaviors in which Jessica engaged, and all three are common to anorexia nervosa.

2. Adult women with anorexia nervosa: a) gain large amounts of weight. b) undergo amenorrhea. c) eat one large meal per day. d) binge on high calorie foods.

Answer: b.

Women with anorexia nervosa do not gain large amounts of weight or usually binge on high calorie foods, as they must fail to maintain a body weight of 85 percent to meet diagnostic criteria. Anorexic .

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women may eat one meal per day, but this is only a possibility. Women who meet anorexia nervosa diagnostic criteria stop having their regular menstrual cycle: amenorrhea.

3. What are the symptoms of anorexia nervosa?

Suggested answers: refusal to maintain body weight at 85 percent of expected level, fear of gaining weight, disturbance in body image, amenorrhea (loss of three menstrual cycles).

4. How did the people around Jessica react to/influence her anorexia?

Suggested answers: Her family and friends often did not know about her eating disorder.

Some people would say she looked “good,” but Jessica took this as an insult because it implied she looked normal. Some of her classmates and teachers gave her positive feedback for being so thin. Any comments made about her weight, both positive and negative, were internalized and fed into her disorder.

5. What are the two subtypes of anorexia nervosa and how are they different?

Suggested answers: restricting type (has not regularly engaged in binge eating or purging behaviors) and binge-eating/purging type (has regularly engaged in binge eating or purging behaviors).

CLASS ACTIVITIES: 1. Discuss the body image distortions that Jessica had.

Suggested answer: The more weight she lost, the fatter she perceived herself to look, etc.

2. Anorexia Nervosa seems to be growing more common in the United States, especially in teenage girls. What reasons can you think of for this?

Suggested answers: television, movies, magazines, shifting ideals of beauty, peer pressure, etc.

Speaking Out: Mali: Living with a Sleep Disorder–Narcolepsy (7:09) A woman is interviewed about living with narcolepsy and how she copes with the disorder.

Video available on MyPsychLab.com Virtual Case Study simulations available on MyPsychLab.com SIMULATION BACKGROUND: Virtual Case Studies, found in Pearson’s MyPsychLab, is a new, science-based, interactive simulation where students can explore how a number of risk factors and protective factors may impact the development of a psychological disorder. Virtual Case Studies engages students through captivating narratives that they advance, allowing students to explore and critically think about the influence of biological, psychological, social and cultural factors in the development or regression of a disorder.

Virtual Case Study: Eating Disorders http://staging.allthingsmedia.com/pearson/virtual_case/src/vc_01.html

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CHAPTER TEN DISORDERS INVOLVING GENDER AND SEXUALITY Learning Objectives 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 10.9 10.10

Describe the key features of gender dysphoria.

Explain the difference between gender dysphoria and homosexuality.

Describe the major theoretical perspectives on transgender identity.

Define the term sexual dysfunction and identify three major categories of sexual dysfunctions and specific disorders within each type.

Describe the causal factors involved in sexual dysfunctions.

Describe the methods used to treat sexual dysfunctions.

Define the term paraphilia and identify the major types of paraphilic disorders.

Describe the theoretical perspectives on paraphilias and the underlying causal factors.

Describe methods for treating paraphilic disorders.

Identify the major types of rape, describe the effects of rape, and identify the factors involved in rape.

Chapter Outline I. Gender Dysphoria A. Sex Reassignment Surgery B. Theoretical Perspectives on Transgender Identity II. Sexual Dysfunctions A. Prevalence Rates of Sexual Dysfunctions B. Types of Sexual Dysfunctions C. Theoretical Perspectives D. Treatment of Sexual Dysfunctions III. Paraphilic Disorders A. Types of Paraphilias B. Theoretical Perspectives C. Treatment of Paraphilic Disorders IV. Rape A. Types of Rape B. Theoretical Perspectives V. Summing Up

Chapter Overview Gender Dysphoria Gender dysphoria pertains to people who find their anatomic gender to be a source of persistent and intense distress. People with the disorder may seek to change their sex organs to resemble those of the opposite gender, and many undergo gender reassignment surgery to accomplish this purpose. Unlike people with gender dysphoria, people with a gay male or lesbian sexual orientation have a gender identity .

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that is consistent with their biologic sex.

Sexual Dysfunctions Sexual dysfunctions include sexual desire disorders (hypoactive sexual desire and sexual aversion disorder), sexual arousal disorders (female sexual arousal disorder and male erectile disorder), orgasm disorders (female and male orgasmic disorders and premature ejaculation), and sexual pain disorders (dyspareunia and vaginismus). 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). Sex therapy focuses on directly modifying problematic sexual behavior by enhancing selfefficacy expectancies, teaching sexual competencies, improving sexual communication, and reducing performance anxiety.

Paraphilias Paraphilias are sexual deviations involving patterns of arousal to stimuli such as nonhuman objects (for example, shoes or clothes), or to humiliation or the experience of pain in oneself, one’s partner, or children. Paraphilias include exhibitionism, fetishism, transvestic fetishism, voyeurism, frotteurism, pedophilia, sexual masochism, and sexual sadism. Although some paraphilias (such as fetishism), are essentially harmless, others, such as pedophilia and sexual sadism, often harm nonconsenting victims.

Paraphilias may be caused by the interaction of biological, psychological, and social factors. Efforts to treat paraphilias are compromised by the fact that most people with these disorders do not wish to change.

Rape A recent national survey found that nearly one in five women reported being raped or experiencing an attempted rape. Based on this survey, the estimate of the number of women who suffer rape or attempted rape is 1.3 million women annually. Although women are much more likely to be raped, recent estimates indicate that 1 percent to 3 percent of men are victims of rape at some point during their lives.

Rape is classified as stranger rape, acquaintance rape, date rape, marital rape, and male rape. Nearly twothirds of all rapes are committed by an acquaintance. Among college women,,15.4 percent reported that they had been the victims of rape or attempted rape. The national college survey reports that the great majority of rapes of college women were committed by men with whom the women were acquainted.

Those who have been raped may experience depression, posttraumatic stress, sexual dysfunction, physical injury, sexually transmitted infections, and other health-related illnesses. Theoretical perspectives on rape focus on male dominance and desires for power, sexual arousal being paired with aggression, social attitudes, rape myth endorsement, and sociocultural beliefs regarding women as key issues contributing to this form of violence.

Lecture and Discussion Suggestions 1. Sexual survey methods. 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 come only 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 on the .

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basis of 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, where students are the 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 behavior may not be representative of sexual behavior 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 their 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 the 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.

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; more lengthy 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 behavioral sex therapy, involving teaching techniques known to help alleviate particular sexual dysfunctions. The suggestions are tailored to 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 .

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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 may 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.

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 come from arrest records and that 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 behavior than females do. Thus, women may wear either skirts or pants, but men who don skirts are regarded as abnormal by our culture.

8. Attitudes toward homosexuality. Men and women hold different attitudes toward homosexuality.

Women are more lenient and accepting of homosexual behavior among men. What might account for the difference in attitudes about homosexual behavior among males?

9. Tomboys and sissies. The terms “tomboy” and “sissy” denote similar concepts: children of one gender who engage in behaviors 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 American society. How do students feel about this issue? Is gay bashing any different than other forms of prejudice? Is it ever justified? What, if anything, can be done to help alleviate this problem?

11. Performance anxiety. Some 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. .

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12. Should committing rape be a DSM-5 disorder? The DSM-5 and its predecessors have often been criticized for diagnosing the victims of traumatic events and violence, but failing to diagnose perpetrators.

For example, victims of racism and sexism may develop conditions that are diagnosable, such as depression and posttraumatic stress, but there are few options for diagnosing most people who might commit racist or sexist acts (with the exception of those severe enough to warrant a diagnosis of Conduct Disorder or Antisocial Personality Disorder). However, it could be argued that committing a violent act with potential severe social and legal consequences for perpetrators is a reckless act similar to driving while under the influence. Ask students to discuss why these forms of violence are not readily diagnosable. Should they be?

Think About It Where should we draw the line between normal and abnormal sexual behavior? What criteria should we use? Our conception of what is normal and what is not is clearly influenced by sociocultural factors. Sexual behavior may be considered abnormal if it is self-defeating, deviates from social norms, harms others, causes personal distress, or interferes with one’s ability to function.

What is the difference between gender dysphoria and a gay male or lesbian sexual orientation? Our gender identity is our sense of being male or female. In gender dysphoria, there is a conflict between one’s anatomic gender and one’s gender identity. Gender identity should not be confused with sexual orientation. Gay males and lesbians have erotic interests in members of their own gender, but their sense of being male or female is consistent with their anatomic sex. They do not desire to become members of the opposite gender. Nor do they despise their own genitalia, as do people with gender identity disorder.

Do you think that anyone requesting a sex change operation should be entitled to receive one? If not, what criteria should be applied? This is a personal opinion question. Students should know the issues surrounding gender dysphoria.

Do you believe that exhibitionists, voyeurs, and pedophiles should be punished, treated, or both? Do you think that people with these different types of paraphilias should be treated differently by society? Explain. This is a personal opinion question. Students need to know the symptoms and features of the different types of paraphilias.

Why do you think that most people with paraphilias are men? Paraphilias are sexual disorders in which the person experiences recurrent sexual urges and fantasies involving nonhuman objects, inappropriate or nonconsenting partners, or painful or humiliating situations. The majority of those with paraphilia are male. Perhaps, it is a biological issue such as more testosterone that makes the difference; or perhaps it can be traced to psychodynamic reasons, for example, poor resolution of the Oedipal conflict. Perhaps, again, it lies in sociocultural explanations; for example, males are powerful and dominant in sexual relations. For whatever reason, it is extremely rare to see females with paraphilias.

When does a sexual problem become a sexual dysfunction? Sexual dysfunctions involve problems with sexual interest, arousal, or response. They interfere with the initiation or completion of the sexual response cycle. A sexual problem is a dysfunction at the point that it interferes with life. People can go for many years without acknowledging that a sexual problem is really dysfunctional.

Can you think of examples in your own life in which you have been hampered by performance anxiety of one kind or another? What did you do about it? This is a personal experience question.

Students need to be comfortable sharing their experiences with anxiety as applied to a sexual context.

If you had a sexual dysfunction, would you be willing to seek help for it? Why or why not? This is a .

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personal opinion question. Students need to know the symptoms and features of the sexual dysfunctions and be comfortable in sharing their opinions.

Activities/Demonstrations 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 behaviors and have students rate how normal each is. A good example is found in Kite (1990). Students first complete the survey, and then break into groups. The task of each group is to build a definition of what is normal sexual behavior and what is not.

Let the groups present their definitions for class discussion. Kite reports that students have difficulty separating normal from abnormal sexual behavior. Remind students that paraphilias are not the same as a paraphilic disorder. For a paraphilic disorder to be diagnosed, the paraphilia must cause personal distress or impairment in important areas of daily functioning, or involve behaviors presently or in the past in which satisfaction of the sexual urge involved harm, or risk of harm, to other people.

3. Is engaging in internet sex an addiction? Cybersex addiction is currently being considered as a disorder for the next edition of the DSM. It is suggested that brain changes associated with chemical abuse may also occur with the compulsive use of internet sexual materials. Sexual arousal and orgasm reinforce the behavior. Tolerance has been noted in cases as well. Have students discuss what defines addictive behavior and if cybersex addiction is worthy of inclusion in the next DSM. 4. 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 behavior. 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.

5. Sexuality laws. Many paraphilias are illegal. Have students collect information on the laws in your area. What sexual behaviors 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 on societal views of sexual behavior in general and on the paraphilias in particular.

6 Other paraphilias. Students are quite interested in learning about the “other paraphilias.” These are listed in the DSM-5, as other specified paraphilic disorders or as other unspecified paraphilic disorders.

It is fun to simply put the names on the board and have students guess what they might be. Care should be taken not to offend students’ sensibilities by being too cavalier. The atypical paraphilias include zoophilia (animals), coprophilia (using feces), klismaphilia (enemas), mysophilia (filth), necrophilia (dead bodies), telephone scatalogia (obscene phone calls), and urophilia (urine). .

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7. Rape, gender role stereotyping, and rape myth acceptance. Have students take the quiz on rape myth endorsement in the text at p. 399 (called Beliefs That Create a Climate That Supports Rape). In class, go through the items and deconstruct the societal beliefs that contributed to item endorsement. Ask students to offer hypotheses on how these ideas develop, debate whether they are now (or once were) helpful and necessary, and how they are harmful to all people, not just women.

8. Societal responses to end rape. If they are comfortable, ask students to discuss how the fear of rape impacts their daily lives (e.g., always parking under lights at night, having pepper spray on key rings, avoiding going out at night, etc.). Is the burden of protecting themselves from rape unfairly placed on women? Should the focus address more of the social issues contributing to rape versus the individual responsibility to stay safe? Is there enough emphasis on perpetrators of rape? In what ways can men be allies in fighting rape?

Media Resources Gender Identity Disorder: Denise (5:33) Denise is a transsexual interviewed about her earlier life. Raised the youngest boy in a family of seven, Denise chose to reassign her sex from male to female as a young adult. She describes years of crossdressing and disgust with her own genitals.

Video available on MyPsychLab.com Sexual Disorders (1:13) In this interview with a sex therapist, he discusses three common sexual disorders: sexual response disorders, gender-identity problems, and paraphilias.

Video available on MyPsychLab.com

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CHAPTER ELEVEN SCHIZOPHRENIA SPECTRUM DISORDERS Learning Objectives 11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.8 11.9

Define the term schizophrenia.

Describe the course of development of schizophrenia.

Describe the key features of schizophrenia.

Describe the psychodynamic and learning theory viewpoints on schizophrenia.

Describe the biological bases of schizophrenia.

Describe the role of family factors in schizophrenia.

Apply the diathesis-stress model to the development of schizophrenia.

Evaluate the methods used to treat schizophrenia.

Describe the general features of other disorders in the schizophrenia spectrum.

Chapter Outline I. Schizophrenia A. Course of Development B. Prevalence of Schizophrenia C. Diagnostic Features D. Perceptual Disturbances E. Theoretical Perspectives F. Treatment Approaches II. Other Schizophrenia Spectrum Disorders A. Brief Psychotic Disorder B. Schizophreniform Disorder C. Delusional Disorder D. Schizoaffective Disorder III. Summing Up Chapter Overview Schizophrenia Schizophrenia is a chronic, debilitating disorder that touches every facet of the affected person’s life.

Nearly one million people in the United States are treated for schizophrenia each year, with about a third of them requiring hospitalization. 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.

Among the more prominent features of schizophrenia are disorders in the content of thought (delusions) and form of thought (thought disorder), as well as the presence of perceptual distortions (hallucinations) and emotional disturbances (flattened or inappropriate affect). There are also dysfunctions in the brain that regulate attention to the external world. Schizophrenia is often discussed in terms of the presence of positive symptoms (such as hallucinations and delusional thinking) and negative symptoms (representing the absence of behaviors such as loss of motivation and lack of emotions or emotional expression). Many .

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patients with schizophrenia exhibit an eye movement dysfunction, such as having difficulty tracking a slow-moving target across their field of vision.

Theoretical 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 behavior and give rise to hallucinations and delusions.

Learning theorists propose that some form of schizophrenic behavior 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 behavior may explain some schizophrenic behaviors in the hospital setting.

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. Environmental factors also play a role in schizophrenia, and many researchers have adopted the diathesis-stress model to account for the interaction between a genetic predisposition (diathesis) and environmental factors. Most researchers today 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 dysfunction and structural damage in schizophrenia is accumulating, but researchers are uncertain about causal pathways.

Family factors, such as communication deviance and expressed emotion, may act as sources of stress that increase the risk of development or recurrence of schizophrenia among people with a genetic predisposition toward the disorder.

Treatment 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 have not been shown to be effective in treating schizophrenia. Learning-based approaches, such as token-economy systems and social skills training, have achieved some successes in increasing adaptive behavior among people with schizophrenia. Psychosocial-rehabilitation approaches help people with schizophrenia adapt more successfully to occupational and social roles in the community. Family intervention programs help families cope with the burden of care, communicate more clearly, and learn more helpful ways of relating to the patient.

Schizophrenia Spectrum Disorders In addition to schizophrenia, the DSM-5 classifies psychological disorders within the schizophrenia spectrum. These disorders range from milder forms of disorganized or unusual thinking and difficulties relating to others to frankly psychotic disorders. These disorders include brief psychotic disorder, schizophreniform disorder, delusional disorder, and schizoaffective disorder.

A person carrying the diagnosis of brief psychotic disorder experiences psychosis that lasts from a day to one month. These episodes are often linked to significant stressors in the person’s life. The diagnosis of schizophreniform disorder is assigned to an individual who meets the basic criteria for a diagnosis of schizophrenia but whose behavior does not yet justify the diagnosis of schizophrenia. People with .

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delusional disorder hold delusional beliefs that are apparently plausible and less bizarre than schizophrenic delusions. The delusion itself is often the only clear sign of abnormality, whereas schizophrenic delusions are embedded within a more general pattern of disturbed thoughts, perceptions, and behaviors. Persons with a diagnosis of schizoaffective disorder present with the psychotic features associated with schizophrenia but also evidence a major mood disorder.

Lecture and Discussion Suggestions 1. Famous schizophrenics. Students, like the general public, often think that 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 bipolar 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.

Famous individuals currently living with schizophrenia include John Nash, a Nobel Prize winner in Economics (subject of the movie “A Beautiful Mind”) and law professor Elyn Saks. Professor Saks has given many talks about living with schizophrenia that can be accessed through the internet. Her memoir, The Center Cannot Hold: My Journey Through Madness (2007) is a read many students will find inspiring and fascinating.

2. “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? Discuss Szasz’s view (p. 422) of mental illness as a myth.

3. Is schizophrenia a myth? Discuss Thomas Szasz’s idea (p. 422) that mental illness, including schizophrenia, is a myth. That is, schizophrenia is properly regarded as a problem 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?

4. The diathesis-stress model. This model (p. 426), which views psychological disorders 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 the model to integrate the vast amount of research findings into meaningful patterns to identify 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, the 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 child rearing. For instance, an individual born to a single parent who experienced severe schizophrenia, who had been in and out of hospitals, and who expressed little .

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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.

5. Outlook for recovery. Numerous studies have identified a group of factors that appears to be associated with a more favorable course of schizophrenia as follows: a. Premorbid adjustment. The more adequately a person functions prior to the active phase of the disorder, the better will be the outcome. b. 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. c. Sudden onset. The more acute the onset, the better the prognosis. d. Age of onset. The later in life the initial schizophrenic episode occurs, the better are the chances of recovery. Men are more at risk before the age of 25; women are more at risk after 25. e. Affective behavior. The presence of anxiety and other emotions, including depression, is a favorable sign. A state of hopelessness not accompanied by depression is a poor sign. f.

Type of schizophrenia. Paranoid schizophrenia with an acute onset generally offers a more favorable outcome than undifferentiated schizophrenia with a chronic course.

g. 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. h. 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 is the outlook.

6. The concept of schizophrenia: History and future directions. 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 (associations, affect, ambivalence, and autism) and secondary symptoms (hallucinations and delusions). Kurt Schneider distinguished between first-rank symptoms that define the disorder, such as hallucinations and delusions, and second-rank symptoms that occur in schizophrenia and other disorders (e.g., disturbances in mood and confused thinking). Given the emerging evidence of genetic and biological linkages to schizophrenia, differences in the structure of the brain, and even gender differences, future classifications and understanding of schizophrenia may continue to evolve. Ask students to speculate on new directions for the classification and understanding of schizophrenia and psychotic disorders.

7. 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 .

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violence. Is this, however, really the case? Frankly, it is a difficult question, and the answer you get depends upon whom you ask. Scott Lilienfield has assembled two opposing works on the subject, and he describes the complexities involved 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 mirror 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 percent of future psychiatric patients commit a violent act prior to hospitalization; from 25–30 percent of released male patients with a past history of violence commit another such act within a year of release.

Who is right? Lilienfield 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?

Lilienfield, S. (1995). Seeing Both Sides: Classic Controversies in Abnormal Psychology. Pacific Grove, CA: Brooks/Cole.

Monahan, J. (1992). “Mental disorder and violent behavior: 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.

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 who 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 to apply research findings, not just speculate.

9. 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 “nervous breakdown” applicable only to schizophrenia and other psychotic disorders, or can it be used with anxiety disorders and affective disorders as well?

10. Erotomania and other forms of delusional disorder. Erotomania is one form of delusional disorder (pg. 434). Typically, the delusion is that someone of higher social status, often a movie star or political figure, is in love with you. These people often harass the presumed loved one with visits, phone calls, gifts, and stalking of their movements. Both genders can have this problem. Often, males are more visible, since they appear to use more forceful and illegal means to try to reach their “loved one,” which frequently results in arrest. Among females, the object of affection is sometimes a superior at work or some other less-famous figure. .

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Another delusional disorder is experienced by the grandiose type. These people believe they have a special and often unrecognized talent or link to someone powerful. Sometimes they believe they have some brilliant new invention, and you might find the grandiose type in a patent attorney’s office or otherwise seeking recognition. Another possible place for such people is as leaders of religious cults, where the presumed talent is construed as a special link to the deity.

The persecutory type believes that others are trying to impede, obstruct, or harass him or her. The persecutory type often strikes back through tactics such as filing lawsuits. Delusions perceived by the persecutory type are unlike those perceived by a paranoid schizophrenic in that the people the persecutory type believes to be harassing others are real people, who could feasibly do what the person with persecutory delusions believes is being done.

It is useful to ask the class for examples they might have known or read about that illustrate these delusional disorders. Generally, they find this topic interesting given the high profile of some of the incidents with religious cults or stalking of film stars.

Think About It What is schizophrenia? How is it diagnosed? How is schizophrenia distinguished from other disorders within the schizophrenic spectrum? Schizophrenia is a major mental illness that takes the form of a thought disorder. Two or more of the following symptoms must be present for a diagnosis of schizophrenia: 1) delusions, 2) hallucinations, 3) speech that is either incoherent or characterized by marked loosening of associations, 4) disorganized or catatonic behavior, and 5) negative features (e.g., flattened affect). These symptoms must be present for a significant portion of time over the course of a one-month period. Some people have persistent patterns of unusual thinking or emotional responses that seem to lie within the broader spectrum of schizophrenic problems but that may not fit the stringent definition of schizophrenia. The distinction between schizophrenia and schizophrenia-spectrum disorders may be more of a matter of degree than kind.

Do the prevalence data for schizophrenia suggest that it is or is not a biologically based disorder?

Explain your answer. The prevalence of schizophrenia has remained constant at approximately one percent across all cultures, probably at all times. The constant rate and the universality across all cultures suggest a biological component. Genetics are probably at play when a disease rate remains constant.

The authors make the statement that schizophrenia is perhaps the most disabling type of psychological or mental disorder. What makes it so? Schizophrenia so profoundly affects a broad range of functions, including thought, speech, motivation, perceptions, and movement, that it is probably the most disabling mental disorder. Residual deficits in cognitive, emotional, and social areas of functioning persist between acute episodes. Although we have better treatments than ever before, there is still no clear cause or cure.

Summarize briefly the evidence that supports a genetic component to the development of schizophrenia. How strong is the genetic component? What other factors might be involved? Is the evidence that having a father over the age of 50 is a risk factor an argument for or against a genetic component? Schizophrenia tends to run in families. First-degree relatives have about a ten-fold greater risk of developing schizophrenia than do members of the general population. Adoption and twin studies all point to a strong genetic component in schizophrenia. Evidence to date strongly suggests a genetic component in schizophrenia; however, genetics alone does not determine the risk. The prevailing view today is the diathesis-stress model, which holds that schizophrenia involves a complex interplay of genetic and environmental factors. There is evidence, for example, that fathers who are over the age of 50 .

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when their child is born have a three times higher chance of having a child develop schizophrenia than do fathers under the age of 25.

What have we learned about the biological bases of schizophrenia? What don’t we know? What might you say to critics who claim that schizophrenia is not a disease because no one has yet found any specific disease process in the brain that accounts for it? We have learned that schizophrenia is a brain disorder. The brains of schizophrenics are different in a number of ways and yet we are still asking the question, where is the pathology? The clearest evidence of structural damage is enlarged ventricles, which suggests loss of brain tissue. There is also evidence of abnormalities in the prefrontal cortex.

Prefrontal abnormalities may explain why schizophrenics have trouble organizing their thoughts. There also seem to be disturbances in the subcortical regions of the brain. Such disturbances may cause neurotransmitter imbalances or faulty connections between neurons that could contribute to disturbances in thinking, attention, and emotions associated with schizophrenia. We just don’t know whether the changes in brain tissue are the cause or result of the disease process. To those critics who say that schizophrenia is not a disease because no one has found the specific disease process that accounts for it, think of the many other diseases in the same circumstance. Is Alzheimer’s less of a disease because we are not sure of the specific cause?

Have you known anyone diagnosed with schizophrenia? What information do you have about the person’s family history, family relationships, and stressful life events that might shed light on the development of the disorder? This is a personal experience question. Students should be familiar with the symptoms and features of schizophrenia.

How does the diathesis-stress model try to account for the development of schizophrenia? What evidence supports the model? The diathesis-stress model suggests that certain people possess a genetic predisposition to schizophrenia that is expressed behaviorally only if they are reared in stressful environments. Schizophrenia is seen in terms of an interaction or combination of a diathesis, in the form of a genetic predisposition to develop the disorder, with environmental stress that exceeds the individual’s stress threshold or coping resources. Several lines of evidence support the diathesis-stress model. One is the fact that schizophrenia tends to manifest itself in late adolescence or early adulthood around the same time that young people are trying to develop a separate identity or role in life. The other evidence is that psychosocial stress, such as harping criticism, tends to exacerbate symptoms of schizophrenia, increasing the risk of relapse.

What are the relative risks and benefits of antipsychotic medication? Why is medication alone not sufficient to treat schizophrenia? Do you believe that people with schizophrenia should be treated indefinitely with antipsychotic drugs? Why or why not? This is a personal opinion question. Students need to know the various drugs used in the treatment of schizophrenic disorders.

What psychosocial interventions are useful in the treatment of schizophrenia? What limitations are there in current treatment models? Since people with schizophrenia often have difficulty functioning in social and occupational roles, a number of self-help clubs and more structured psychosocial rehabilitation centers have sprung up to help schizophrenics find a place in society. The clubhouse movement, started in the late 1940s, serves as a model of psychosocial support. Multiservice rehabilitation centers typically offer housing as well as job and educational opportunities. Unfortunately, no single treatment approach meets all the needs of people with schizophrenia. These interventions need to be long term and must be coordinated in an integrated, comprehensive manner.

Activities/Demonstrations 1. Focusing through the voices. Ask students to speculate on what it would be like to live with auditory .

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hallucinations common to schizophrenia. It is often difficult to truly empathize with the challenge of this experience. The following exercise offers a small glimpse into the challenge of focusing one’s attention within the context of auditory hallucinations.

Exercise: Ask for six volunteers from the class. Without telling the rest of the class, tell the volunteers that they will each represent a ‘voice’ in the mind of someone with schizophrenia. Ask them each to pick a topic they will discuss in front of the class. It works best if one or two students choose to make a noise or say a word repeatedly (e.g., “boom”), one tries to give a running dialogue on everything s/he sees happening in the classroom, and another makes random comments about ancillary events (such as the weather). Instruct them that they will stand in front of the class and begin to talk simultaneously and get louder over time as if fighting to be heard. Ask students to try and keep notes on what the group is saying (or you can try to lecture during this and ask students to keep notes on your lecture). Let this continue for approximately one minute.

After it is done, have students reflect on this experience. Were they frustrated? Did they notice physical and emotional responses to the experience and their frustration? This is a brief exercise. What would it be like to live with auditory hallucinations most of the time?

2. Schizophrenia and personal space. Explain to the class that one interesting aspect of schizophrenia is the misperception of personal space. For example, schizophrenics often misjudge the proper distance for social conversation. Ask for a student volunteer to come up in front of the class. You play the schizophrenic. Face the student; hold both hands out, so that you are two arm lengths away. Ask the student if he or she feels comfortable. Then slowly encroach on their personal space by walking closer and closer until you are in their face. Explain that schizophrenics misperceive social cues and may not be aware of their intrusion. The opposite effect can be demonstrated from behind. Schizophrenics tend to be over-sensitive to those approaching from behind. You can play with this idea to see what the “normal” comfortable bubble is. This can lead to a demonstration of behavioral therapy or social skills training.

After you have set the “normal” boundaries, try teaching your student volunteer (who should now play the role of a schizophrenic) how to start and end a conversation, how to stand the appropriate distance, etc.

3. 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. Next, ask students to identify those factors, both dispositional and environmental, which 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?

4. Range of schizophrenia-spectrum disorders. Draw a continuum on the chalkboard, with normal behavior at the far left end and schizophrenia at the extreme right. Then ask the class to place the various disorders discussed in this chapter at the appropriate place on the continuum. You might point out that it would be a challenge for anyone to do this, because of the complexities in diagnosing the various disorders. Yet, the exercise of doing so may be helpful in clarifying the distinctions between the various disorders. During the exercise and discussion you might list several of the identifying characteristics beneath each disorder. In discussing the disorders toward the right end of the continuum, point out that there must be continuous signs of the disturbance for at least six months before the diagnosis of schizophrenia can be made, whereas in schizophreniform disorder, by definition, the duration of the illness is less than six months. In discussing the less disabling disorders on the continuum, you might point out that schizoid personality disorder denotes a chronic personality style characterized by social withdrawal without odd or peculiar thought, whereas schizotypal personality disorder involves the .

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additional feature of odd or peculiar ideation.

5. 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?

6. Biographies of 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.

7. 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 the speech to memory and coming into class talking that 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.

8. The Three Christs of Ypsilanti. There are many literary and professional works that provide in-depth histories of schizophrenic behavior. 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, each maintaining 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.

Media Resources Schizophrenia: The Case of Georgina (3:04). Georgina is a young woman diagnosed with schizophrenia. She is interviewed about the beginning stages of her illness and some of her past delusions.

Video is available on MyPsychLab.com.

Speaking Out: Larry: Schizophrenia (4:06) Video is available on MyPsychLab.com .

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VIDEO BACKGROUND: In this interview, Larry discusses his life with schizophrenia and the impact it has had on his functioning.

Note that Larry discusses his auditory hallucinations as “fictional and non-fictional friends”—characters that have emerged from his imagination or history and communicate with him. One of the most striking examples of this is his creation of imaginary baseball characters with whom he conversed. Problems began to emerge for him in late high school and early college, requiring hospitalization. In addition to his hallucinations, Larry has also experienced paranoid thoughts, and this leads him to having difficulty with new people. A particularly touching moment is Larry’s discussion of stigma and how he wishes he were able to have a family (specifically a son). Now Larry has two volunteer positions that involve his interest in history.

DISCUSSION QUESTIONS: 1. Which are common symptoms of schizophrenia? a) Positive symptoms b) Negative symptoms c) Disorganized symptoms d) All of the above Answer: d.

Schizophrenia is often divided into symptom categories of positive and negative.

2. In this interview, Larry discussed his fictional and non-fictional friends. These friends were a manifestation of what symptom of schizophrenia?

Answer: Hallucinations.

3. How do delusions and hallucinations differ?

Suggested answer: A delusion is a distortion of thought content (e.g., believing the CIA is listening to everything a person says). A hallucination is a distortion of perception (e.g., seeing or hearing people who are not real).

CLASSROOM ACTIVITIES: 1. In this video, Larry discusses the perceived stigma of having a mental illness. How does the stigma of mental illness affect people’s lives on a daily basis?

Suggested answers: difficulty with friends, family, work, housing, prejudices of people, self-fulfilling prophecies and “acting sick,” etc.

2. How are people with schizophrenia portrayed in movies and on television? Do you think Larry fits those characterizations?

Suggested answers: People with schizophrenia are often portrayed as “crazy,” violent, homeless, etc. A notable exception to this is the portrayal of Dr. John Nash in A Beautiful Mind. Larry seems to be relatively high functioning, able to hold occupational positions, friendly, and intelligent. It does not seem that he fits the usual media characterization of a person with schizophrenia. .

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Josh: Schizoaffective Disorder (3:40) Video is available on MyPsychLab.com.

VIDEO BACKGROUND: In this interview, Josh discusses his schizoaffective disorder and how it has affected his life. During the course of his illness, he had auditory and visual hallucinations as well as paranoid delusions. His auditory hallucinations mostly involve hearing voices that he notes are “speaking to me but they don’t make any sense—there’s no language at all.” His visual hallucinations include seeing patients with cleavers chasing hospital staff. His delusions include thinking he has seen one of the FBI’s Most Wanted in his apartment and that the mafia is after him. Note the paranoid nature of his delusions. His mood is cyclical, vacillating between the highs of mania and the lows of depression in daily, weekly, and seasonal patterns. He notes that when he is feeling manic, he stays up late organizing things and has a lot of energy. During his depressed times, he does not even shower. Particularly interesting segments include the discussion of his traditionally schizophrenic symptoms coupled with his traditionally bipolar symptoms. Additionally, his dialogue about stigma and just wanting to feel loved are touching.

DISCUSSION QUESTIONS: 1. Schizoaffective Disorder seems to be a combination of which of the following disorders? a) Schizophrenia and Mood Disorders b) Schizophrenia and Schizotypal Personality Disorder c) Schizoid Personality Disorder and Affective Disorder d) Schizophrenia, Mood Disorders, and Borderline Personality Disorder Answer: a.

Schizoaffective disorder has both psychotic and mood components. The word itself yields a clue: “Schizo” is related to schizophrenia and “affect” is related to mood and emotion.

2. Josh’s feelings that the mafia was chasing him and his looking out the window and seeing patients chasing doctors with cleavers were examples of what, respectively? a) Intrusive thoughts, hallucinations b) Hallucinations, intrusive thoughts c) Delusions, hallucinations d) Hallucinations, delusions Answer: c.

Note that Josh believed these things to be real. The first was a nonreal belief and thus a delusion. The second was a nonreal perception, and thus a hallucination.

3. What are the two main symptom groups that a person with schizoaffective disorder has?

Suggested answer: psychotic symptoms (i.e., hallucinations, delusions) and mood symptoms (i.e., major depressive, manic, or mixed episodes).

4. In relation to the mood symptoms, when must the psychotic symptoms be present? Why is this necessary for diagnosis?

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Suggested answer: The psychotic symptoms must be present when the mood symptoms are present and when the mood symptoms are not present. One reason for this is that there are sometimes psychotic features that arise from mood disorders. By requiring psychotic symptoms to be present simultaneously and non-simultaneously with mood symptoms, a diagnosis of schizoaffective disorder can be differentiated from one of a mood disorder with psychotic features.

5. How is schizoaffective disorder similar to and different from schizophrenia?

Suggested answer: Generally, mood symptoms in schizophrenia are brief relative to the total duration of the psychotic features, occur only in the prodromal or residual phases, or are not sufficient to meet full criteria for a mood episode.

CLASS ACTIVITY: 1. Discuss how a person with schizoaffective disorder might be affected differently by his or her mental illness than a person with schizophrenia or a mood disorder.

Suggested answers: Schizoaffective disorder, as it combines features of both schizophrenia and mood disorders, can often be conceptualized as more complex and possibly more severe. Although there are sometimes mood disturbances that occur during schizophrenia and sometimes psychotic features that occur during mood disorders, a person with schizoaffective disorder must deal with both.

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CHAPTER TWELVE PERSONALITY DISORDERS AND IMPULSE-CONTROL DISORDERS Learning Objectives 12.1 12.2 12.3 12.4 12.5 12.6 12.7 12.8 12.9

Define the concept of personality disorders.

Identify the three major categories of personality disorders.

Describe the key features of personality disorders characterized by odd or eccentric behavior.

Describe the key features of personality disorders characterized by dramatic, emotional, or erratic behavior.

Describe the key features of personality disorders characterized by anxious or fearful behavior.

Evaluate the problems associated with the classification of personality disorders.

Describe the major theoretical perspectives on understanding personality disorders—the psychodynamic, learning, cognitive, family, biological, and sociocultural perspectives.

Evaluate methods used to treat personality disorders.

Define the concept of impulse control disorders and describe the features of several major types.

Chapter Outline I. Types of Personality Disorders A. Personality Disorders Characterized by Odd or Eccentric Behavior B. Schizotypal Personality Disorder C. Personality Disorders Characterized by Dramatic, Emotional, or Erratic Behavior D. Antisocial Behavior and Criminality E. Personality Disorders Characterized by Anxious or Fearful Behavior F. Problems with the Classification of Personality Disorders II. Theoretical Perspectives A. Psychodynamic Perspectives B. Learning Perspectives C. Family Perspectives D. Biological Perspectives E. Sociocultural Perspectives III. Treatment of Personality Disorders A. Psychodynamic Approaches B. Cognitive-Behavioral Approaches C. Biological Approaches IV. Impulse-Control Disorders A. Kleptomania B. Intermittent Explosive Disorder C. Pyromania V. Summing Up

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Chapter Overview Types of Personality Disorders Maladaptive or rigid behavior 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 labeled A, B, and C. A fourth group, other personality disorders, includes personality changes that occur as the result of a medical condition and also provides a specified and unspecified category for individuals who meet some, but not all, of the criteria for a personality disorder classified in clusters A–C. 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 behavior, but not to the degree found in schizophrenia.

Antisocial personality disorder describes people who persistently engage in behavior that violates social norms and the rights of others and who tend to show no remorse for their misdeeds. Borderline personality disorder 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 behavior, 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.

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 overattention to detail, but are without the true obsessions and compulsions associated with obsessive-compulsive (anxiety) disorder.

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 behavior and abnormal behavior, underlying sexist biases in certain categories, and confusion of labels with explanations.

Theoretical 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 theorists view personality disorders in terms of maladaptive patterns of behavior, 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.

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 .

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parental modeling of antisocial behavior. Cognitive theorists have focused on the role of encoding strategies in explaining tendencies of antisocial adolescents to presume that others mean them ill.

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 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 behavior patterns.

Treatment Therapists from different schools of therapy try to assist people with personality disorders to gain better awareness of their self-defeating behavior patterns and learn more adaptive ways of relating to others.

Despite the difficulties of working therapeutically with these clients, promising results are emerging from the use of relatively short-term psychodynamic therapy and cognitive-behavioral treatment approaches.

Impulse Control Disorders Impulse control disorders are characterized by failure to control impulses, temptations, or drives, resulting in harm to oneself or others. Impulse-control disorders in the DSM-5 are grouped in a broader category of disruptive, impulse-control, and conduct disorders that also include conduct disorder and oppositional defiant disorder. The text focuses on three types of impulse control disorders: kleptomania, intermittent explosive disorder, and pyromania. .

Lecture and Discussion Suggestions 1. 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.

2. Psychopaths and society. Given that people with psychopathy are, by definition, people who repeatedly engage in antisocial behavior, and given also that they do not seem to learn from experience or respond to therapy, how should society treat them? Should they be punished the same as other lawbreakers? Would students consider the death penalty for psychopaths more appropriate (given that rehabilitation is less likely) or less appropriate (given that they have a mental disorder) than for other criminals? Should they be considered insane and committed to treatment 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 to protect society from their depredations, especially given the low success rates in “curing” them?

3. 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-IV-TR includes two categories of antisocial behavior. One is antisocial personality disorder, in which antisocial behavior is presumed to be a function of psychological disturbance. The other category is adult antisocial behavior, in which the .

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deviant behavior 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 behavior without getting into trouble with the law. Accordingly, the emphasis in the DSM-IV-TR is on specifically undesirable behaviors, such as lying, cheating, or criminal behavior; and the single best predictor of criminal behavior is past criminal behavior, rather than the diagnosis of antisocial personality disorder.

4. Adopting the child of a psychopath? Should adoptive parents be told if the child they are about to adopt is the offspring of a psychopath? 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 for ways to prevent psychopathy by intervening in childhood.

5. Antisocial personality versus psychopath. There was some controversy when DSM-III changed the way antisocial personality was defined. That change, which is very similar to the present DSM-IV-TR, moved away from the view of psychopathy articulated by Hervey Cleckley. That view, which was the basis of DSM-III, focused less on illegal behaviors 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 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 DSMIV-TR antisocial personality disorder have 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 behavior 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 (specifically early onset of aggressive, violent, and irresponsible behavior and inconsistent or nonexistent discipline) and adult antisocial behavior.

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. Reconsidering the story of Sampson and Delilah. Discuss the biblical story of Sampson and Delilah and debate whether or not Sampson had antisocial personality disorder. Have students read the story while attending to diagnostic considerations and then make an argument for or against the diagnosis. .

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Generally, students will not be able to determine whether or not his antisocial behaviors began prior to age 15, but otherwise, enough information is available for students to assess his condition and determine the appropriateness of the diagnosis.

8. 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. Selfcentered 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.

Hans 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 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.

Discuss with the class the implications that come when we label some behaviors as abnormal and fail to label others because of the concerns of specific subgroups. 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? 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.

9. 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 the chances of success are often minimal? What conditions make this therapeutic effort more justifiable?

10. 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 behavior a disorder excuse it and allow the individual not to take responsibility for his or her behavior (as some have asserted regarding the controversial proposed diagnosis, sadistic personality disorder)? What trait, if it was maladaptive and interfered with functioning, wouldn’t qualify as a personality disorder?

11. Paranoid personalities? 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 behavior. Would they qualify under the DSM-5 for having paranoid personality disorder? Or, given the government’s alleged mishandling of the .

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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 behaviors 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.

Think About It Which behaviors or ways of relating to others do you view as intrinsic parts of yourself, or ego syntonic? Do you believe they are changeable? Why or why not? This is a personal opinion question.

Students need to be comfortable sharing part of their personality.

Encourage them to 1) maintain a skeptical attitude, 2) consider the definitions of the terms, 3) weigh the assumptions or promises on which arguments are based, 4) bear in mind that correlation is not causation, 5) consider the kinds of evidence on which conclusions are based, 6) do not oversimplify, 7) do not overgeneralize.

Distinguish between schizoid and schizotypal personality disorder by giving examples of some ways in which a person with each disorder might behave. The distinguishing feature of schizoid personality disorder is social withdrawal. A schizoid personality isolates, preferring to be alone. A classic example would be a computer nerd, who prefers machines to people. He would not be involved in any social activities, may be withdrawn and aloof, but would prefer things that way. In schizotypal personality disorder a person would seem odd or eccentric. They may have peculiarities of speech; even their own private language. They might not have much social interaction but it is not because they don’t like people, others just find them odd. Despite the DSM’s grouping of schizotypal behaviors with personality disorders, the schizotypal behavior pattern may fall within the schizophrenic spectrum. Schizotypal personality disorder may actually share a common genetic basis with schizophrenia.

How is antisocial personality disorder distinguished from criminal behavior? People with antisocial personality disorder persistently violate the rights of others and often break the law. We may tend to think of antisocial behavior as synonymous with criminal behavior. Although a strong relationship does exist between the two, not all criminals are antisocial and not all antisocial personalities become criminal.

Many are law abiding and quite successful in their chosen careers, yet they possess a personality style characterized by a callous disregard of the interest and feelings of others.

We have referred to characters in movies in our illustrations of personality disorders characterized by emotional and erratic behavior. You can probably think of other examples of characters that manifest the traits of these disorders. Why are these characters so frequently encountered in entertainment media? What is the attraction for dramatists, actors, and viewers? This is a personal experience question. Students need to be familiar with the various personality disorders that demonstrate emotional and erratic behavior.

Are some personality disorders more likely to be diagnosed in men or in women because of societal expectations rather than because of real underlying pathology? Have you ever assumed, for example, that women are “just dependent or hysterical” or that men are “just narcissists or antisocial”? What kinds of problems do these underlying assumptions pose for clinicians and researchers? This is a personal experience question. Students should demonstrate knowledge of the different personalities that demonstrate emotional and erratic behavior.

What are the major points of controversy concerning the classification of personality disorders?

Explain the problems that result from using labels as explanations of behavior. Have you ever been “labeled” in this way? What kinds of real-life problems can this cause? This is a personal experience .

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question. Students need to grasp the controversies regarding diagnosis of personality disorders.

What further research is needed to support psychodynamic theories about the development of personality disorders? Psychodynamic theory provides a rich theoretical basis for the understanding of the development of several personality disorders. But some critics contend that theories of disorders such as borderline personality and narcissistic personality disorders are based largely on inferences drawn from behavior and retrospective accounts of adults rather than on observations of children. We may also question whether direct comparisons should be made of normal childhood experiences and abnormal behaviors in adulthood. Further direct observational research with children could be of great help in illuminating psychodynamic theories.

What features do the psychodynamic and family perspectives on personality disorders have in common? How do they differ? Many theorists have argued that disturbances in family relationships underlie the development of personality disorders. Consistent with psychodynamic formulations, researchers find that people with borderline personality disorder remember their parents as having been more controlling and less caring than other research subjects with other disorders. Another consistency in the psychodynamic perspective is the fact that family factors such as parental overprotection and authoritarianism have been implicated in the development of dependent personality traits. The major difference between the two theories is the psychodynamic belief in the importance of the unconscious.

Family perspectives focus on the social environment rather than intrapsychic unconscious processes.

Consider the current state of knowledge about biological causes of antisocial personality disorder.

What social-policy issue does this information raise, if it is confirmed by further research? Research supporting biological causes of antisocial personality disorder suggests there may be a lack of emotional responsiveness, craving for stimulation, and certain brain abnormalities at the root of antisocial personality. For example, studies using sophisticated brain imaging techniques link antisocial personality to abnormalities in the prefrontal cortex of the brain. If there were biological markers of antisocial personality, then it would be easy to influence social-policy in a prevention-treatment mode. If potential antisocial personalities could be diagnosed before they wreak havoc in society, treatment programs could be targeted to prevent the crime and heartache.

Have you known anyone who you believe might fit the profile of the antisocial personality? What factors do you believe may have shaped this particular individual’s personality development? How did the individual’s personality affect his or her relationships with others? This is a personal experience question. Students need to be well versed in the symptoms and features of antisocial personality.

What factors make it difficult to treat people with personality disorders? If you were a therapist, how might you attempt to overcome these difficulties? The primary difficulty in treating people with personality disorders is that they do not seek treatment. People with personality disorders usually see their behaviors, even maladaptive, self-defeating behaviors, as natural parts of themselves. They usually do not seek help on their own because they do not see their own behaviors as causative. As a therapist, it would be extremely difficult to overcome these obstacles. Therapists often must lower their expectations in the treatment of personality disorders.

Activities/Demonstrations 1. Assessing personality disorders. Have a colleague or student knowledgeable about personality disorders to play the role of a client. As the clinician, assess the “client” using the Structured Clinical Interview for DSM-5 Personality Disorders (SCID-PD). a). The SCID-PD is designed to assess and classify personality disorders. Once you have completed the assessment, ask students to provide the diagnosis they believe is most appropriate with a rationale. Ask students to reflect on the types of .

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questions asked, how they were asked, as well as any other interesting factors they noticed in the assessment.

2. Normal and narcissistic self-interest. 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 effects of such behavior. Have students reflect on the extent to which self-interest may enhance our personal and social adjustment, 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.

3. Sensation-seeking. Have students check their responses to the items in the abbreviated sensationseeking scale presented in this chapter (p. 468), 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 behavior. Then, have students reflect on their scores and the extent to which they engage in any of the related behaviors 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, drive fast, prefer exotic foods, and gamble.

4. 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 behaviors that have antisocial elements.

5. Name that disorder. Compile a list of celebrities or television and movie characters. Tell your students you are going to play, “Name that Disorder.” Present a description of the character’s background, family relationships, and current behavior. Name the character only at the end. Have your students name the personality disorder that most closely matches their behaviors. Use examples such as: Richard Nixon—Paranoid Personality Marilyn Monroe—Borderline Personality Charles Manson—Antisocial Personality Media Resources Speaking Out: Liz: Borderline Personality Disorder (3:34) Video available on MyPsychLab.com VIDEO BACKGROUND: In this interview, Liz discusses her life with borderline personality disorder and the difficulties it has caused her. Her symptoms include anger management issues as well as irrational cognitions relating to stress. She also deals with feelings of extreme loneliness and jealousy, and her disorder makes her fear loss or rejection, have suicidal thoughts, and experience a heavy burden on her relationships with friends and lovers. Of particular interest in this video is Liz’s discussion of her relationship with her exboyfriend. He was leaving to go to flight school (which caused her severe stress due to her abandonment issues) when she found an “innocent” email from another girl, which led Liz to believe that he would cheat on her, they wouldn’t get married, they wouldn’t have a family, and she would not be able to get a job. She says that within the course of five seconds, she had lost all interest in living. In addition, Liz’s .

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discussion of her rapid mood swings (especially to extreme anger and sadness) highlights another important characteristic of borderline personality disorder.

DISCUSSION QUESTIONS: 1. Borderline personality disorder is often associated with which of the following symptoms? a) Inappropriate displays of anger b) Shifting, severe emotions c) Deliberate self-harm d) All of the above Answer: d.

Borderline personality disorder encompasses a wide range of symptomatology as can be seen in the choices here.

2. What is the best example of borderline personality disorder behavior? a) Liz being happy with her new fiancé b) Liz being excited to get married c) Liz occasionally being annoyed with her parents d) Liz almost driving into a car because of road rage Answer: d.

Choice d shows the anger associated with borderline personality disorder. The other choices, while possibly also present in a person with borderline personality disorder, seem normal.

3. What are people with borderline personality disorder often trying to avoid?

Suggested answers: Abandonment and loneliness.

4. Borderline personality disorder is often described as a pattern of instability. What are some characteristics that are often unstable?

Suggested answers: Interpersonal relationships, self-image, affect, etc.

5. List some of the emotions often felt by people with borderline personality disorder.

Suggested answers: Anger, sadness, fear of abandonment, worthlessness, emptiness, paranoia, etc.

CLASS ACTIVITIES: 1. Cognitions are an important part of borderline personality disorder. While most people might feel a little concerned if they found an email sent to their partner, Liz’s thoughts were extreme. Discuss her thoughts and note how they differ from the way you might react.

Suggested answer: She was very jealous and angry, she felt this email meant her boyfriend would cheat on her, they would not get married, they would not have a family, she could not get a job, and she wanted to kill herself. These thoughts seem like unwarranted severe conclusions resulting from a relatively innocent event. .

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2. People with borderline personality disorder are afraid of being abandoned by the people they love.

However, to keep these people in their lives they often resort to angry outbursts, moodiness, and threatened/actual self-harm. How effective do you think these behaviors are at preventing abandonment by loved ones?

Suggested answer: They are probably not very effective. It is likely that the loved ones are often bothered by this behavior and leave because of it. Those loved ones who do not leave may be staying simply to prevent future negative behavior.

Janna: Borderline Personality Disorder (2:04) In this interview, Janna discusses her life with borderline personality disorder and the difficulties it has caused her. Her symptoms include self-handicapping, fear of relationships, and commitment issues.

Video available on MyPsychLab.com

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CHAPTER THIRTEEN ABNORMAL BEHAVIOR IN CHILDHOOD AND ADOLESCENCE Learning Objectives 13.1

Explain the differences between normal and abnormal behavior in childhood and adolescence and the role of cultural beliefs in determining abnormality.

13.2 13.3 13.4 13.5

Describe the effects of child abuse.

Describe key features of autism spectrum disorder and ways of understanding and treating it.

Describe the key features and causes of intellectual disability.

Identify the types of deficits associated with learning disorders and describe ways of understanding and treating learning disorders.

Define the concept of communication disorders and identify specific types.

Describe the key features of attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder.

Describe causal factors in ADHD and evaluate treatment methods.

Describe the key features of anxiety and depression in children and adolescents.

Identify risk factors for suicide among adolescents.

Describe the key features of elimination disorders and evaluate methods of treating bed-wetting.

13.6 13.7 13.8 13.9 13.10 13.11

Chapter Outline I. Normal and Abnormal Behavior in Childhood and Adolescence A. Cultural Beliefs about What Is Normal and Abnormal B. Prevalence of Mental Health Problems in Children and Adolescence C. Risk Factors for Childhood Disorders II. Autism and Autism Spectrum Disorder A. How Common Is Autism Spectrum Disorder?

B. Features of Autism C. Theoretical Perspectives on Autism D. Treatment of Autism III. Intellectual Disability A. Causes of Intellectual Disability B. Interventions IV. Learning Disorders A. Understanding and Treating Learning Disorders V. Communication Disorders A. Language Disorder B. Problems with Speech C. Social (Pragmatic) Communication Disorder VI. Behavior Problems: Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, and Conduct Disorder A. Attention-Deficit/Hyperactivity Disorder B. Conduct Disorder C. Oppositional Defiant Disorder .

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VII. Childhood Anxiety and Depression A. Separation Anxiety Disorder B. Understanding and Treating Childhood Anxiety Disorders C. Childhood Depression D. Understanding and Treating Childhood Depression E. Suicide in Children and Adolescents VIII. Elimination Disorders A. Enuresis B. Encopresis IX. Summing Up Chapter Overview Normal and Abnormal Behavior in Childhood and Adolescence In differentiating between normal and abnormal behavior in childhood and adolescence, we consider children's ages, genders, family and cultural backgrounds, and developmental levels. Approximately four in ten adolescents (40.3 percent) have experienced a diagnosable mental disorder during the past year; one in four (23.4 percent) are presently affected and one in ten children suffer from a mental disorder severe enough to impair development.

Autism and Autism Spectrum Disorder The DSM-5 identifies Autism Spectrum Disorders (ASD) on the basis of a common set of behaviors representing persistent deficits in communication and social interactions and restricted or fixated interests and repetitive behaviors. The diagnoses of Asperger’s disorder and childhood disintegrative disorder were used in the previous edition of the DSM as separate disorders. Both are now considered as part of the autism spectrum. Estimates based on 2013 statistics indicate that one in fifty children is affected by some form of autism spectrum disorder.

Intellectual Disability About one percent of children meet DSM criteria for a diagnosis of intellectual disability. Children with ID tend to have deficits in reasoning and problem-solving ability, abstract thinking skills, judgment, and school performance. To qualify for the intellectual disability diagnosis, the disability must be apparent before age 18.

Learning Disorders Learning disorders are specific deficits in the development of arithmetic, writing, or reading skills that persist into adulthood. The DSM-5 applies a single diagnosis of specific learning disorder to encompass various types of learning disorders or disabilities involving significant deficits in skills involved in reading, writing, arithmetic and math, and executive functions. Intervention attempts mainly to remediate specific skill deficits.

Communication Disorders Communication disorders involve impaired understanding or use of language. Language disorder involves .

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impairments in the ability to produce or understand spoken language. Specific impairments include slow vocabulary development, errors in tenses, difficulties recalling words, and problems producing sentences of appropriate length and complexity for the individual’s age. In speech sound disorder there is persistent difficulty articulating the sounds of speech. Persistent stuttering has been classified in DSM-5 as a type of communication disorder called childhood-onset fluency disorder. Social (pragmatic) communication disorder is a newly recognized disorder in DSM-5. The diagnosis applies to children with difficulties communicating verbally and nonverbally with other people.

Behavior Problems: Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, and Conduct Disorder In earlier editions of the DSM, Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, and Conduct Disorder were grouped together as disruptive behavior disorders. These three disorders are now listed in separate categories in the DSM-5. ADHD is characterized by impulsivity, inattention, and hyperactivity. Stimulant medication is generally effective in reducing hyperactivity, but it has not led to general academic gains. Children with conduct disorders intentionally engage in antisocial behavior.

Childhood Anxiety and Depression Children with separation anxiety disorder show excessive anxiety when separated from their parents.

Some have excessive or unrealistic anxieties and worries.

Depressed children, especially younger children, may not report or be aware of being depressed.

Depression may also be masked by seemingly unrelated behaviors, such as conduct disorders. Although rare, suicide in children does occur and threats should be taken seriously. Risk factors for adolescent suicide include gender, age, geography, race, depression, past suicidal behavior, strained family relationships, stress, substance abuse, and social contagion.

Elimination Disorders Enuresis and encopresis are not due to organic causes and are more common among boys. The bell-andpad method conditions enuretic children to respond to bladder tension.

Lecture and Discussions Suggestions 1. Overcontrolled and undercontrolled children. A helpful way of viewing childhood problems is to distinguish between overcontrolled and undercontrolled behaviors. Using a factor analysis of reported behavior problems in children, T. M. Achenbach and C. S. Edelbock (Psychological Bulletin, 1987, 85) classify children’s psychological problems into two main categories: overcontrolled and undercontrolled.

Problems in the undercontrolled category tend to be manifested externally and include aggressive, actingout behaviors. 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 behavior. Included here would also be the anxiety disorders, phobias, eating disorders, and affective disorders. The fact that a greater proportion of boys exhibit undercontrolled behaviors and are more likely to express their difficulties in outward behavior 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 undercontrolled, externalized behavior.

2. Difficulty distinguishing abnormality in childhood and adolescence. Experienced clinicians have long realized that it is more difficult to distinguish between normal and abnormal behavior during .

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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 behavior in terms of the following questions: a. b. c. d. e. f.

Has the problem lasted beyond the expected age?

Does such behavior resist ordinary efforts to change it?

How frequently is it displayed?

Does the behavior interfere with school?

How seriously does it interfere with the adolescent's relationships with peers and adults?

If such behavior 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 behavior: 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 selfreliant in mastering new tasks. In contrast, preschool children of authoritarian parents were withdrawn, were 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.

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 that just noted, may be the problem. Some believe that 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. Suicide is rare in childhood and early adolescence but becomes more common in late adolescence and early adulthood. Among persons in the 15- to 24-year-old age group, suicide is the third most common cause of death, after accidents and homicides. Factors associated with heightened risk of suicide in children and adolescents include the following: stressful life events, family problems, .

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substance abuse, depression and hopelessness, previous suicidal behavior and social contagion (cluster suicides in communities). Females make more suicidal attempts but males have a higher mortality.

6. The scope of PL 94–142. It is worth informing students of the broad scope of PL 94–142 and its influence on education in the eighteen years since its implementation. 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 mental retardation and autism. The law greatly mandated the responsibility of the public school system for educating all children and has required school districts require programs for both assessing the needs of special-needs children and providing specialized education when indicated, either within a normal classroom, through a separate classroom within the public school, or through providing funds for a specialized private classroom.

7. 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.

8. 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 exhibiting restlessness, searching for stimulating activities, and manifesting a need for constant companionship.

9. Use of stimulants with children. The use of stimulant medications, such as Ritalin, has developed into one of the more effective treatments for attention-deficit/hyperactivity disorder. The drugs reduce activity-level problems, thereby making the child more manageable at home and in the classroom. The drugs appear to work in about 65 percent of children with overactive behavior symptoms. As indicated in the text, however, long-lasting effects, such as academic improvement and increased 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 behavior. How would students develop a procedure to ensure that only children with critical levels of behavior impairment received the medication?

10. Adolescent violence. This chapter provides another opportunity to discuss the issues surrounding adolescent violence, which has gotten so much coverage because of recent shootings at schools, such as the incident at Virginia Tech. Why, according to the students, are these shootings 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?

Think About It Why have behavioral approaches been found to be the most effective for children with autism spectrum disorder? Children with autism spectrum disorder respond well to behavioral approaches; no other treatment approach has yielded results so favorable. Behavioral approaches are based largely on operant conditioning methods in which rewards and punishments are systematically applied to increase the child’s ability to attend to others, to play with other children, to develop academic skills, and to .

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eliminate self-mutilating behavior. Because children who suffer from autism show behavioral deficits, a central focus of behavior modification is the development of new behavior.

Do you think children with mental retardation should be mainstreamed within regular classes?

Why or why not? This is a personal opinion question. Students need to be familiar with the symptoms and features of mental retardation. Encourage them to 1) maintain a skeptical attitude, 2) consider the definitions of the terms, 3) weigh the assumptions or promises on which arguments are based, 4) bear in mind that correlation is not causation, 5) consider the kinds of evidence on which conclusions are based, 6) do not oversimplify, and 7) do not overgeneralize.

Why might children with learning disabilities be at high risk for other disorders, such as depression? Children with learning disabilities are often at high risk for other disorders, especially depression. Learning disorders tend to be chronic disorders that continue to affect development into adulthood. Children with learning disorders tend to perform poorly in school. Their teachers and their families often view them as failures. It is not surprising that most of them develop low expectations and problems with self-esteem. These problems can lay the framework for later disorders such as depression.

Do you think people with learning disorders should be given special consideration when given standardized tests, such as the Scholastic Aptitude Test (SAT)? Should we give these students extra time? Why or why not? This is a personal opinion question. Students need to know the symptoms and features of learning disorders.

What are the risks and benefits of using stimulant medication, like Ritalin, in treating ADHD in children? If you had a child with ADHD, would you consider using these drugs? Why or why not?

This is a personal opinion question. Students should be aware of the various treatment methods in attention-deficit/hyperactivity disorder.

What elements of Billy’s treatment (pp. 507–508) do you believe contributed to its effectiveness?

Would this type of approach be likely to be as effective with a girl? This is a personal opinion question. Students should read the case study on oppositional defiant disorder and be familiar with its treatment.

Where would you draw the line between “normal” childhood fears and specific phobias? This is a personal opinion question. Students need to know about depression and anxiety in children and relate that knowledge to the norm.

What behaviors in children might be masking unrecognized depression? Childhood depression is not necessarily expressed as it is in adults. It can be masked by behaviors that do not appear directly related to depression. Conduct disorders, academic problems, physical complaints, and even hyperactivity may stem from unrecognized depression. Among adolescence, aggressive and sexual acting out may also be signs of underlying depression.

What types of cognitive biases are linked to problems of anxiety and depression in childhood?

Why? Like their adult counterparts, children and adolescents who are depressed tend to hold more dysfunctional attitudes toward themselves and the future. The distorted cognitions include 1) expecting the worst (pessimism), 2) blowing out of proportion the consequences of negative events, 3) assuming personal responsibility for negative outcomes, even when it is unwarranted, and 4) selectively attending to the negative aspects of events. You can see how these negative views of self and situation could promote depression. Children may become depressed due to a depressive mind-set.

Considering the risk factors presented in the text, do you know anyone who is at high risk of .

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committing suicide? What could be done to lower the risk of that person? This is a personal experience question. Students should feel comfortable in sharing their views and experiences related to suicide.

Do you know any children who were treated for a psychological disorder? What treatments did they receive? What were the outcomes? This is a personal experience question. Students should be aware of all the possible treatments for childhood psychological disorders.

Activities/Demonstrations 1. Is psychopharmacological treatment appropriate for children? Ask students to examine resources about the short- and long-term effects of various medications for the treatment of psychological disorders (e.g., Prozac, Luvox, Lithium, Strattera, Concerta, Ritalin). Encourage students to examine both the efficacy and possible impact on physical and psychological developmental on children and adolescents.

With this information, ask students to consider the possible side effects against the possible social, emotional, educational, and developmental consequences of leaving a child untreated.

2. 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 states, many of them live in group homes and participate in supervised activities in the community.

Students in human service and social work often have experience with this population. Having someone who is working in this area and who can speak from first-hand experience often gives students a more concrete, tangible account of the possibilities and problems for this segment of the population.

3. Child observation. Again, 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 then write a one- or twopage 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 the fact 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.

4. What is normal development? Clinicians often lose sight of what is normal in the development of children after they have been in the field for a long time. You can help your students recognize normal child development to be contrasted later with child psychopathology. Divide your class into five groups.

Give each group a sheet of paper with one of Erikson’s first five stages of psychosocial development. The stages are as follows: 1) 2) 3) 4) 5)

Trust versus Mistrust Autonomy versus Shame and Doubt Initiative versus Guilt Industry versus Inferiority Identity versus Role Confusion

Have the students brainstorm about their assigned psychosocial crisis. How old should a child be when wrestling with these issues? What would a child be like who resolved the crisis positively? Negatively?

Which childhood disorders would fit in the assigned category? What is the job of a child in the assigned stage? How would you know if a child was abnormal? Have a group spokesperson report back to the class on the findings. .

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Media Resources Speaking Out: Xavier: Autism (3:13) Video available on MyPsychLab.com VIDEO BACKGROUND: In this interview, Xavier’s mother talks about her discovery of Xavier’s autism, his behavior, and the impact it has on his functioning. At one and a half years old, Xavier’s mother noticed he was not developing speech and even as a baby had some unusual characteristics (e.g., not liking to have his feet and hands touched). Xavier did not begin speaking until age four. Note now that he is older, his speech is still very infrequent and difficult to understand. Although he is affectionate and does not seem withdrawn, Xavier tends to have some behaviors associated with Autistic Disorder such as poor communication.

Xavier also shows repetitive behaviors, such as watching particular scenes from movies over and over and talking about the same topic for up to three hours at a time. Of particular interest in this video is the way Xavier communicates with the interviewer. Note how well his mother is able to communicate with him and also the type of education he receives.

DISCUSSION QUESTIONS: 1. People with autism spectrum disorder typically show symptoms in what area(s)? a) Social interactions b) Communication c) Repetitive behaviors, interests or activities d) all of the above Answer: d.

Autism spectrum disorder often affects social interaction and relationships, communication, behaviors, interests, and activities.

2. The age of onset must be: a) early childhood. b) during adolescence. c) during adulthood. d) all of the above.

Answer: d.

Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).

3. How are social interactions impaired in people with autism spectrum disorder?

Suggested answer: They often have impaired nonverbal behaviors, inappropriately developed peer relationships, and a lack of shared enjoyment, interests, achievements, and emotional and social reciprocity.

4. Discuss typical language deficits in autism spectrum disorder. .

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Suggested answers: Spoken language is often delayed or nonexistent, the person may lack the ability to initiate or sustain a conversation, may dwell on the same topic at length, etc.

5. How does Xavier’s behavior watching a movie differ from that of other children? Suggested answers: Xavier engages in typical autistic repetitive behavior by watching the same movies repeatedly and watching the same scene over and over.

CLASS ACTIVITIES: 1. Discuss ways in which a child with an autism spectrum disorder would need educational accommodations different from that of typically developing children.

Suggested answers: They may go year-round, they are often in special classes, they often learn through drills (e.g., language drills) that repeat vital information over and over, they often take learning in small steps associated with a lot of positive reinforcement, etc.

2. Discuss ways in which the autistic people you might have known behaved. What effects did these behaviors have on their families?

Suggested answers: poor communication and social skills, repetitive behaviors, etc. This can be a strain for parents and siblings may be confused or jealous of the attention given to the child with autism spectrum disorder.

Speaking Out: Jimmy: ADHD (3:54) Video available on MyPsychLab.com VIDEO BACKGROUND: In this interview, Jimmy and his mother discuss his ADHD and the effect it has had on him and the family. Note that although Jimmy seems to have average verbal abilities for his age, his speech is incomprehensible at times due to its rapidity. Also, notice that he has physical agitation at some points, moving his hands or body. Jimmy’s mother discusses his problems paying attention in school and working on large projects that require extended periods of concentration. Jimmy notes that he does not usually have difficulty concentrating with his friends though, especially when they are engaged in imaginative play. In addition to his school difficulties, Jimmy is also impatient and disorganized and tends to drift into his “own world” and “tune out” everything else. Interesting things to point out include the rapidity of Jimmy’s speech, his motor agitation, his problems concentrating and remembering certain information, and the strategies he and his mother use to overcome these difficulties.

DISCUSSION QUESTIONS: 1. Blurting out answers in class by a student with ADHD is an example of: a) hyperactivity-impulsivity. b) attentional deficits. c) inattention. d) poor social skills.

Answer: a.

A hyperactive-impulsive child will be unable to show patience in a classroom setting, such as raising his or her hand before speaking.

2. Difficulty focusing on a homework assignment is an example of: .

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a) hyperactivity. b) inattention. c) impulsivity. d) disorganized thoughts.

Answer: b.

Inattention is the difficulty many people with ADHD have focusing and concentrating on a particular thing.

3. Jimmy’s mother notes the success of what treatment modality in positively changing Jimmy’s behavior? a) Medication b) Psychotherapy c) Dietary regulation d) Social-skills training Answer: a.

Medication is a very popular and often successful method of treatment for ADHD. 4. What are the two clusters of symptoms in ADHD? Answer: inattention and hyperactivity-impulsivity.

5. What are some common examples of inattention?

Suggested answers: not being able to pay attention to details, tasks or play activities, when being directly spoken to, etc.

CLASS ACTIVITY: 1. Jimmy showed various ADHD-style behaviors in his interview including fast speech and motor agitation. Before the diagnosis of ADHD existed, parents often had difficulty understanding and dealing with these and other symptoms of ADHD (such as inattention and impulsivity). To parents, is the diagnosis of ADHD helpful, detrimental, or both?

Suggested answer: probably helpful or both. Although there is a certain stigma attached to all mental disorders, ADHD has become well accepted by the population as a whole. Certainly knowing that one’s child has a certifiable disorder would relieve beliefs that the child is “not applying himself” or “badly behaved.”

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CHAPTER FOURTEEN NEUROCOGNITIVE DISORDERS AND DISORDERS RELATED TO AGING Learning Objectives 14.1 Define the concept of neurocognitive disorder and identify three major types.

14.2 Describe the key features and causes of delirium.

14.3 Describe the key features and causes of major neurocognitive disorder.

14.4 Describe the key features of mild neurocognitive disorder.

14.5 Describe the key features and causes of Alzheimer’s disease and evaluate current treatments.

14.6 Identify and describe other types of neurocognitive disorders.

14.7 Identify other psychological disorders related to aging.

Chapter Outline I. Neurocognitive Disorders A. Delirium B. Major Neurocognitive Disorder C. Mild Neurocognitive Disorder D. Subtypes of Major and Mild Neurocognitive Disorders E. Neurocognitive Disorder Due to Alzheimer’s Disease F. Vascular Neurocognitive Disorder G. Frontotemporal Neurocognitive Disorder H. Neurocognitive Disorder Due to Traumatic Brain Injury I. Substance/Medication-Induced Neurocognitive Disorder J. Neurocognitive Disorder With Lewy Bodies K. Neurocognitive Disorder Due to Parkinson’s Disease L. Neurocognitive Disorder Due to Huntington’s Disease M. Neurocognitive Disorder Due to HIV Infection N. Neurocognitive Disorder Due to Prion Disease II. Psychological Disorders Related to Aging A. Anxiety Disorders and Aging B. Depression and Aging C. Sleep Problems and Aging IV. Summing Up Chapter Overview Neurocognitive Disorders The category name of these disorders was changed from cognitive to neurocognitive in DSM-5 to better reflect the fact that cognitive functions such as thinking, memory, and attention are closely linked to particular brain regions and neural pathways in the brain. Neurocognitive disorders are not psychologically based; they are caused by physical or medical conditions or drug use and withdrawal that affect the functioning of the brain. Nevertheless, psychological and environmental factors play key roles in determining the impact and range of the symptoms.

Major neurocognitive disorders or dementias are disabling and degenerative brain disease processes. The .

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developers of the DSM-5 chose to rename the dementias as neurocognitive disorders as the prior is a pejorative term that carries an unfortunate stigma. Alzheimer’s disease (AD) is the most well-known of these disorders. Other causes include brain diseases such as Pick’s disease, and infections or disorders affecting the functioning of the brain, such as meningitis, HIV infection, and encephalitis.

Mild neurocognitive disorder is a newly recognized disorder in DSM-5 that applies to people who suffer a mild or modest decline in cognitive functioning from their prior level. People with mild neurocognitive disorder or MCI are able to function independently and complete tasks of daily living at home and on the job, but may experience difficulty completing tasks that used to come more easily.

Vascular neurocognitive disorder (formerly called vascular dementia or multi-infarct dementia) is a form of major or mild neurocognitive disorder resulting from cerebrovascular events (strokes) affecting the brain. Vascular neurocognitive dementia ranks second to Alzheimer’s Disease (AD) as being the most common form.

Frontotemporal Neurocognitive Disorder is characterized by deterioration (thinning or shrinkage) of brain tissue in the frontal and temporal lobes of the cerebral cortex. This disorder typically takes the form of progressive dementia symptomatically similar to AD. Neurocognitive Disorder Due to Traumatic Brain Injury Head traumas may injure the brain by jarring, banging, or cutting brain tissue. Neurocognitive impairment is more likely to occur from multiple head traumas than from a single incident. Delirium, agitation, and amnesia may result from severe concussions. Contusions can lead to coma, cognitive impairment, and emotional problems. Lacerations can be lethal or lead to permanent major cognitive impairment.

Substance/Medication-Induced Neurocognitive Disorders are caused by the use of, or withdrawal from, psychoactive substances or medications which can impair brain functioning. The most common example is Korsakoff’s syndrome, which involves irreversible memory loss due to brain damage resulting from deficiency of vitamin B1 (thiamine).

Neurocognitive disorder with Lewy bodies is among the most common types of progressive dementia. It accounts for about 10 percent of dementias in older adults. The disease has features of both AD and Parkinson’s.

Parkinson's disease is characterized by involuntary shaking or tremors, motor disabilities, and possible cognitive impairment. Parkinson's disease involves destruction of brain tissue in the substantia nigra of the brain, which plays a role in controlling body movements. The disease also involves reductions in the level of dopamine in the brain.

Huntington's disease is a genetically transmitted disease that involves progressive deterioration in the basal ganglia, which primarily affects neurons that produce ACh and GABA. The symptoms usually first appear between the ages of 30 and 50 and involve involuntary, jerky movements of the face (grimaces), neck, limbs, and trunk, or so-called choreiform movements, which are accompanied by neurocognitive decline. The disease is progressive and death usually occurs within 15 years of the onset of symptoms.

Human immunodeficiency virus (HIV) can attack the central nervous system, causing progressive decline in mental and motor functioning. Few develop HIV-related dementia without having full-blown AIDS, but 25 percent of those with AIDS develop cognitive impairment that can develop into a neurocognitive disorder. .

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Prion disease can cause brain damage when clusters of abnormal prion molecules spread within the brain.

Creutzfeldt-Jakob disease is caused by a slow-acting virus. A variant of Creutzfeldt-Jakob disease is related to mad-cow disease, a fatal illness spread by eating infected beef.

Psychological Disorders Related to Aging Generalized anxiety disorder and phobic disorders are the most commonly occurring anxiety disorders among older people. Depression is common among people in later life and may be associated with memory deficits that can lift as depression clears, which is not the case in the more progressive dementias, such as those caused by Alzheimer's disease. Certain sleep disorders, such as insomnia and sleep apnea, are also common among older people.

Lecture and Discussion Suggestions 1. Diagnosing Alzheimer's disease. Because there is not yet a clear-cut definitive test for Alzheimer's disease; the diagnosis at present is properly given after various causes of neurocognitive decline have been eliminated. Thus, diagnosticians try to rule out other medical conditions that give rise to similar symptoms, as well as abnormal behavior patterns that might account for impaired thinking and memory loss. In the past, a confirmatory diagnosis of Alzheimer's disease could be made only upon a biopsy or autopsy. In 2012, a new brain scanning technology became available, allowing doctors for the first time to diagnose AD based on brain scans showing plaques associated with the disease together with clinical evidence of memory loss (Kolata, 2012). Brain scanning techniques may soon be available to predict which patients with MCI are likely to progress to AD. 2. Happy and sad stroke victims. How people are affected psychologically by a stroke depends not only on the severity of the blockage or leaks in the blood vessels that feed the brain but also on the area of the brain in which the rupture occurs. The left hemisphere is more important for feeling and expressing happy emotions, while the right hemisphere is more significant for feeling and expressing sad emotions. Thus, damage to the left hemisphere, resulting in an under activity of this part of the brain, is more apt to tip the balance toward depression. By contrast, damage to the right hemisphere is more likely to tip the balance toward the happier side of things. In one study, researchers examined extreme cases of individuals who either cried or laughed uncontrollably. They found that those who cried uncontrollably had suffered damage in the left brain, whereas those who laughed uncontrollably had suffered right-brain damage (H. A. Sackeim, et. al. Archives of Neurology, 1982, 39, 210–218). The same researchers examined cases of crying and laughing during epileptic seizures, in which the brain is overactive, and found the opposite results. That is, seizures in the left hemisphere are likely to cause uncontrollable laughing while seizures in the right hemisphere are more likely to cause uncontrollable crying.

3. Psychosurgery. Robert W. White and Norman F. Watt (The Abnormal Personality, 1981, New York: Wiley and Sons) described the results of prefrontal lobotomies. In this procedure, some of the neural connections between the frontal lobes and the rest of the brain are severed. It was used frequently from 1935 until 1952 with patients who were tense and anxious in an effort to induce greater relaxation.

The results showed that lobotomized people behaved similarly to those who had naturally occurring frontal lobe syndrome. Among the changes noted by White and Watt (1981) were impairment in accuracy, ability to profit from past mistakes, and planning ahead. Affect became shallow and patients showed less drive and self-concern. They also became stimulus-bound to environmental cues. With the advent of major and minor tranquilizers, the use of lobotomy all but ceased.

Psychosurgery is still used today. The number of psychosurgeries performed has dropped so that only an estimated 300 are performed in the United States each year. They are usually a last resort intervention .

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after other treatments have failed. Psychosurgery seems to be most successful in treating chronic depression, excessive panic disorders, and persistent obsessive-compulsive disorders. The rather radical procedures of prefrontal lobotomies are rarely used. Instead, stereotactic surgery involving implantation of fast-decaying radiological substances and electrocoagulation of blood supply to particular neurons are the interventions of choice. Given the questions still unanswered about localization of function and interdependence of brain function, many neuropsychologists feel that psychosurgery is still a crude procedure.

4. Psychosurgery II. As a follow-up to lecture suggestion 3, have students discuss whether it was ethical to subject clients to procedures such as prefrontal lobotomy that could interfere with their ability to feel, judge, have foresight, and engage in self-criticism. Invite students to discuss under what conditions they would be willing to accept psychosurgery on themselves as an intervention technique.

5. Caring for Alzheimer's patients. Discuss the most humane way for family members to take care of an Alzheimer's patient. Is a nursing home the only alternative? Or would it be more humane (and less expensive to insurers) to keep many of these patients at home during the early stages of their illness, provided that adequate financial assistance was available? What may be the financial and psychological costs to families with either choice?

6. Wearing helmets. Discuss whether there should be a state law requiring bikers to wear helmets to reduce incidents of severe head trauma when accidents occur. What are the pros and cons of this issue?

Several county and local governments across the United States have passed laws requiring bicyclists to wear helmets. Is it fair and reasonable to expect bicyclists, including children, to follow the same rules imposed on motorcyclists?

7. Risks of getting Alzheimer's disease. Discuss whether students would want to know if they were at high risk for getting Alzheimer's disease if such a test were available. Point out that even though there is such a test for Huntington's disease, which runs in families, many individuals at risk prefer not to know.

What are the pros and cons of knowing or not knowing?

8. Social stigma. Many psychological disorders carry a stigma. In most cases, those disorders have no easily identifiable cause, which means that it is possible the patient may or may not have played a role in his or her own problems. Is there a similar stigma surrounding the cognitive impairment disorders, where organic factors are clearly the paramount causes? Ask students if there is such a stigma. To aid in discussion, especially if they say there is no such stigma, ask the students to consider their responses to the following situations: a. A group home for neurocognitively impaired patients will be built or established on your street. b. The new people next door include a physically active Alzheimer's patient. c. The new worker you just hired tells you she has epilepsy. d. The patient you work with as a nursing home volunteer is found to actually have neurocognitive disorder due to HIV infection.

9. 40 years from now. By the year 2050 it is estimated that there will be more old people than children or adolescents. Medical science and other factors will swell the ranks of those over 65, in whom the greatest risk of neurocognitive issues lies. Unless cures or treatments, which are presently elusive, are found, the number of dementia patients will increase dramatically in the twenty-first century. What will be the ramifications for society? Given the intensive supervision needed for these patients, who will pay for that? Currently, many of these patients end up on public support sooner or later. Discuss with your students options for the future. What sacrifices, if any, will society be willing to make to provide care for .

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these future patients?

Think About It What are neurocognitive disorders? What role does social support play in determining the adjustment of people affected by neurocognitive disorders? Neurocognitive disorders involve disturbances in thinking or memory that represent a marked change from the individual’s prior level of functioning. These disorders are caused by physical or medical conditions that affect functioning of the brain. Although they are biologically based, we can see that psychological and environmental factors play key roles in determining the impact and range of disabling symptoms as well as determining the individual’s ability to cope with deterioration of cognitive and physical abilities. Social support becomes crucial in these disorders. People who suffer from neurocognitive disorders may become completely dependent on others to meet basic needs in feeding, toileting, and grooming.

Do you expect people to become senile as they age? If so, what is the basis of your opinion? This is a personal opinion questions. Students should be aware of the theories of normal aging. Encourage students to 1) maintain a skeptical attitude, 2) consider the definitions of the terms, 3) weigh the assumptions or promises on which arguments are based, 4) bear in mind that correlation is not causation, 5) consider the kinds of evidence on which conclusions are based, 6) do not oversimplify, and 7) do not overgeneralize.

Why do you suppose that depression is so common among older people? To what extent might it be related to the diminished expectations that are placed on older people in our society? In what ways might society provide more meaningful social roles for people as they age? This is a personal opinion question. Students should know the various psychosocial aspects related to aging and depression.

What is Alzheimer’s disease? What have we learned about the biological underpinnings of the disease? What don’t we know? Alzheimer’s disease is the most common neurocognitive disorder. It is a progressive and irreversible, degenerative brain disease that is characterized by loss of memory and other cognitive functions. Although it is strongly connected with aging, it is not a consequence of normal aging.

We know that the plaques that form in the brains of people with Alzheimer’s are composed of a material called beta amyloid, which consists of fibrous protein fragments. These plaques may be responsible for destroying adjacent brain tissue, which, in turn, may lead to memory loss, confusion, and other symptoms of the disease. We don’t know what causes Alzheimer’s disease, how to prevent it, or how to cure it.

What treatments are available for Alzheimer’s disease? What are their limitations? Although there is no cure for Alzheimer’s disease, there is treatment. Alzheimer’s patients show reduced levels of the neurotransmitter acetylcholine. Presently, there are several drugs available that produce modest results in slowing the cognitive decline in Alzheimer’s. These drugs all work by inhibiting the breakdown of Ach, thereby increasing the availability of the chemical in the brain. The drugs may slow the progression of the disease, but are far from a cure.

How might your underlying attitudes toward older people affect the ways in which you relate to them? How might societal attitudes toward older people affect the allocation of funds for social services and for medical research? This is an opinion question. Students should be aware of the social theories of aging and the underlying social attitudes.

The availability of a genetic test for Huntington’s disease means that a child of someone with Huntington’s can find out whether he or she carries the gene that will eventually lead to the disease.

If you faced this situation, do you think you would want to know whether you carried the gene?

Why or why not? This is an opinion question. Students need to be familiar with the genetic basis of Huntington’s chorea. .

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Activities/Demonstrations 1. Nursing home visit. Ask for volunteers to visit a local nursing home and interview several patients.

You might give extra credit for this assignment. If possible, have students talk with patients who are experiencing some symptoms discussed in this chapter, such as memory loss, impaired cognitive ability, or occasional disorientation. Encourage them to try and interview an Alzheimer's patient. Then, have students share the results of their visit with the class.

2. Grandparenting programs. Many communities have begun "grandparenting" programs in which children from a local school or preschool "adopt" an elderly person from a local nursing home or retirement center and visit him or her regularly. These programs have often proved beneficial to both children and elderly persons alike. Ask students if they are aware of or have ever been involved in one of these programs. What do they think of the usefulness of programs such as this? Would they want their children involved in this type of program?

3. Case studies. Many students have case examples to contribute in this area. Grandparents, other relatives, and family friends have had strokes or other neurocognitive disorders. Ask students to think about any examples they have, and reserve part of a class to allow those who wish to describe the behaviors of people in their lives, as well as the reactions of caretakers, family, and friends. This can be an excellent supplement to the text descriptions of these conditions.

4. Support resources. Many communities have referral centers and various support resources for patients with cognitive impairments and for the families. Support groups are common for Alzheimer's, Parkinson's, Huntington's, and other disorders. Have students investigate what resources are available in your area for a family who discovers that one of its members now has a serious dementia or other problem. The students can collect phone numbers, group meeting sites, referral networks, etc. and share these with each other. Encourage students to also examine the availability of Internet resources for families and caretakers.

5. Geriatric assessment. Obtain a copy of the Mini Mental Status Exam adapted from Folstein, M.F., Folstein, S.E. & McHugh, P.R. (1975) “Mini-Mental State: A practical method for grading the cognitive state of patients for the clinician.” Journal of Psychiatric Research, 12, 89–198. Give the exam to the class as an exercise in what clinicians look for in cognitive assessment. Explain that although many of the questions seem painfully easy, people with dementia have great difficulty in accurately completing the orientation items.

Media Resources Speaking Out: Alvin: Living with Dememtia (11:13) An interview with a man living with the early onset of dementia. His caregivers discuss how he has changed as a result of the disease.

Video available on MyPsychLab.com Connie: Head Injury (1:59) A woman with a traumatic brain injury discusses memory loss, impaired reasoning, and other difficulties she has faced.

Video available on MyPsychLab.com

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CHAPTER FIFTEEN ABNORMAL PSYCHOLOGY AND THE LAW Learning Objectives 15.1 Explain the difference between civil commitment and criminal commitment.

15.2 Evaluate the ability of mental health professionals to predict dangerousness.

15.3 Identify major court cases establishing the rights of mental patients.

15.4 Define the duty to warn and evaluate the dilemma it poses for therapists.

15.5 Describe the history of the insanity defense, citing specific court cases.

15.6 Describe the guidelines proposed by the American Law Institute for determining the legal basis of insanity.

15.7 Describe the legal basis for determining length of criminal commitment.

15.8 Describe the legal basis for determining competency to stand trial.

Chapter Outline I. Civil Commitment and Patients’ Rights A. Predicting Dangerousness B. Patients’ Rights II. The Insanity Defense A. The Aftermath of the Hinckley Case B. Legal Bases of the Insanity Defense C. Determining the Length of Criminal Commitment D. Perspectives on the Insanity Defense E. Competency to Stand Trial III. Summing Up

Chapter Overview 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. Factors that may account for the failure to predict dangerousness include (1) the observation that recognizing violent tendencies post hoc is easier than predicting them, (2) the observation that generalized perceptions of violent tendencies may not predict specific acts of violence, (3) a lack of agreement in defining violence or dangerousness, (4) base-rate problems, (5) the unlikelihood of direct threats of violence, and (6) the observation that predictions based on hospital behavior may not generalize to community settings. .

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Landmark court cases have clarified patients’ rights in psychiatric facilities. In Wyatt v. Stickney, a court in Alabama imposed a minimum standard of care. In O’Connor v. Donaldson, the U. S. Supreme Court ruled that non-dangerous mentally ill people could not be held in psychiatric facilities against their will if such people could be maintained safely in the community. In Youngberg v. Romeo, the U. S. Supreme Court ruled that involuntarily confined patients have a right to less restrictive types of treatment and to receive training to help them function. Court rulings such as that of Rogers v. Okin in Massachusetts have established that patients have a right to refuse medication, except in case of emergency.

The Insanity Defense Three court cases established legal precedents for the insanity defense. (1) In 1834, a court in Ohio applied a principle of irresistible impulse as the basis of an insanity defense. (2) The M’Naghten 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. (3) The Durham rule was based on a case in the United States in 1954 in which it was held that persons did not bear criminal responsibility if their criminal behavior was the product of “mental disease or defect.” Another set of standards developed by the American Law Institute that combines the M’Naghten and irresistible impulse principles has been adopted in some form in 22 states.

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 of assisting in their own defense can be found incompetent to stand trial and sent to a psychiatric facility. In the case of Jackson v. Indiana, the U. S. Supreme Court placed restrictions on the length of time a person judged incompetent to stand trial could be held in a psychiatric facility.

Lecture and Discussion Suggestions 1. The fundamental attribution error. Social scientists tend to regard human behavior 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 behavior, social scientists are well aware of the biases in the way we interpret behavior, depending mainly on whether it is our own or someone else’s behavior. According to the fundamental attribution error, we tend to overemphasize personal, or dispositional, causes in accounting for other people’s behavior, but underemphasize these causes in accounting for our own behavior. Expressed differently, we readily excuse our behavior because of unfavorable circumstances, while jumping to unwarranted conclusions about other people’s motives in similar behaviors and circumstances. Thus, in 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 in 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, 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-defense (situational influences).

2. The impact of malpractice litigation. The exorbitant rise in insurance rates since the 1980s and the increased frequency of malpractice cases brought against professionals have had 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 .

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the professional. However, 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 behaviors. 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.

3. 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 who meet regularly to discuss 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 problem, whether it be alcoholism, obesity, or bereavement. 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 behaviors or 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 and view their problems more objectively.

4. 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 behaviors and without a prior history of violent behavior 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 behavior from a patient being considered for release into the community?

5. 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 defense entirely?

Do students feel that most people who are accused of crimes get off on the insanity defense? In fact, they don’t! Only a small percentage of criminals use the defense (approximately one percent), and only a small percentage of these use the defense successfully (about 20 percent of those who try the defense are successful). In the end, only .2 percent of all cases successfully use this defense! 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 issue, you might mention that one state legislature passed a bill requiring that psychiatrists and psychologists giving testimony in court cases wear a tall conical hat and wave a “magic” wand during their 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?

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Think About It Do you believe that schizophrenia patients who wander city streets mumbling to themselves and living in cardboard boxes should be hospitalized against their will? Why or why not? This is a personal opinion question. Students need to be aware of the issues associated with the psychiatric homeless. Encourage them to 1) maintain a skeptical attitude, 2) consider the definitions of the terms, 3) weigh the assumptions or promises on which arguments are based, 4) bear in mind that correlation is not causation, 5) consider the kinds of evidence on which conclusions are based, 6) do not oversimplify, and 7) do not overgeneralize.

Do you believe that we should abolish psychiatric commitment? Why or why not? This is a personal opinion question. Students should be aware of commitment proceedings in their state.

If you were called on to evaluate whether an individual posed a danger to himself or herself or to others, on what criteria would you base your judgment? This is a personal opinion question. Students need to know what constitutes danger to oneself or others.

Do you believe that therapists should be obligated to breach confidentiality in cases in which their patients make threats against others? Why or why not? What concerns have therapists raised about the duty to warn? Do you believe their concerns are warranted? What constitutes a sufficient threat to warrant breaching patient-doctor confidentiality? This is a personal opinion question.

Students should be familiar with the implications of the Tarasoff decision.

Under what circumstances do you think someone should be confined to a mental hospital? What rights should patients have under such circumstances? This is a personal opinion question. Students need to have knowledge of the patients’ bill of rights.

What legal rights do individuals have regarding obtaining or refusing treatment? Generally speaking, the history of abuses in the mental health system, as highlighted in such popular books and movies as One Flew Over the Cuckoo’s Nest, have led to a tightening of standards of care and the adoption of legal guarantees to protect patients’ rights. In the classic 1972 case of Wyatt v. Stickney, the courts established that mental hospitals must, at a minimum, provide 1) a humane psychological and physical environment, 2) qualified staff in numbers sufficient to administer adequate treatment, and 3) individualized treatment plans. The 1975 Donaldson case was a landmark for the refusal of treatment. The court held that mental illness alone cannot justify a state’s locking a person up against his or her will and keeping the person indefinitely in simple custodial confinement.

Describe how the test for legal insanity has changed over time. How does this reflect changing ideas about mental illness and abnormal behavior? The public grossly overestimates the number of cases in which the insanity defense is used and how often it succeeds. In modern law, we can find three major court rulings that bear on the insanity defense. The first involves an 1834 case in which it was ruled that people could not be held responsible if they are compelled to commit criminal actions because of impulses they are unable to resist. The second major ruling is known as the M’Naghten rule and is based on an 1843 English case of a man who had intended to assassinate the prime minister of England. The court ruled that people do not bear criminal responsibility if, by reason of a mental disease or defect, they are unable to tell right from wrong. The third major ruling that helped lay the foundation for the modern insanity plea is the 1954 Durham decision. The judge held that the accused person is not criminally responsible if his or her unlawful act was the product of mental disease or defect. Unfortunately, jurors were expected to decide not only whether the accused suffered from a mental disease but also whether this mental condition was causally connected to the criminal act. By 1972, the Durham rule had failed and was replaced by two legal guidelines: 1) A person is not responsible for a criminal act if at the time of .

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such conduct, as a result of mental disease or defect, he or she lacks the capacity to appreciate the wrongfulness of his act, and 2) the terms “mental disease or defect” do not include an abnormality manifested only by repeated criminal conduct.

Explain in your own words why there are different standards for legal sentencing and for legal commitment. Legal sentences are meant to fit the seriousness of the crime. In criminal commitment, however, persons acquitted of their crimes by reason of insanity are guiltless in the eyes of the law. They must be treated, not punished, until such time as their mental status has improved to allow them safe entry back into society.

Do you believe the insanity verdict should be abolished? Should it be replaced with another type of verdict, such as the guilty-but-mentally-ill verdict? Why or why not? This is a personal opinion question. Students need to be aware of the complex legal decisions that have contributed to the current view of the insanity plea.

What is the difference between the concept of competency to stand trial and the legal defense of insanity? The concept of competency to stand trial should not be confused with the legal defense of insanity. A defendant can be held competent to stand trial but still be judged not guilty by reason of insanity. The test for competency is simply the ability to understand the proceedings and confer with counsel.

Activities/Demonstrations 1. Predicting dangerousness. Select a relatively recent act of violence, such as a murder, assault, or act of terrorism that has received wide publicity in the media. Then, invite class members to help you analyze it in terms of six factors which make it difficult for professionals to predict dangerous behavior. Discuss each factor one at a time, making a brief summary of the case at the end of the exercise. The six factors that may lead to inaccurate predictions presented in the text (pp. 552–556) are as follows: a. The Post Hoc Problem: It is easier to recognize violent tendencies after a violent event than to predict them ahead of time. b. The Problem in Leaping From the General to the Specific: Generalized perceptions of violent tendencies may not predict specific acts of violence. c. Problems in Defining Dangerousness: There’s a lack of agreement in defining violence or dangerousness. d. Base-Rate Problems: The relative rarity of violent events like murder makes it difficult to predict such events. e. The Unlikelihood of Disclosure of Direct Threats of Violence: Direct threats of violence as precursors to actual acts of violence are unlikely. f. The Difficulty of Predicting Behavior in the Community From Behavior in the Hospital: Predictions based on hospital behavior may not generalize to community settings.

2. The law and sex offenders. When psychology and the law are discussed, it is generally in the context of issues like competency to stand trial and the insanity defense; however, the role of psychology in the legal system extends much further. One current example involves laws regulating sex offenders. Many states have now adapted registration programs where, after serving their sentence, sex offenders must notify the police if they move into an area or plan to travel into a new area, and most states have regulations that limit where sex offenders can work. Nearly all states now have computer databases with pictures of sex offenders and details of the crime each committed. These databases are open to the public and accessible to everyone, often online. Many states now have a computer-based system where .

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employers can search the database to determine if a potential employee has been convicted of a sex-based crime. Many applaud these efforts, particularly since the ability to effectively treat sex-offenders is admittedly poor. Others believe that these efforts open the door for greater legal and governmental oversight into the lives of those determined to be deviant in one way or another. Ask students to consider the implications of these regulations for public safety as well as the possible costs for the individual and eventually society as a whole. Ask students to ponder the level of legal intervention desired in the name of public safety and whether or not these efforts represent a legal “slippery-slope” that may eventually go too far.

3. Interviews of homeless people. Since many homeless people suffer from mental illness and would have been institutionalized thirty years ago, they are a population suitable for discussion in this unit. Have several members of the class 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 the notion that 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.

4. 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, including 8 to 10 of the patients’ rights affirmed in Wyatt v. Stickney and discussed in this chapter of the text (p. 557). Then ask for several volunteers to administer this quiz to a sample of students who are not taking abnormal psychology. Finally, the volunteers should 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 that are false. Some suggested filler items are as follows: a. b. c.

All patients have the right to at least one weekend at home each month if they should desire it.

Patients may not refuse to perform work that is done for the maintenance of the hospital facility if they are physically and mentally capable of performing the work.

Patients have the absolute right to choose their own therapists.

5. Locating community resources. Have students look in your community or area 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.

Encourage students to also consider Internet resources. Given the time constraints of caretakers and the availability of the Internet, many caretakers, as well as those with mental illnesses, may use Internet support groups and informational sources.

6. 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. See what your students can learn about the types of behavior problems police officers encounter. 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 behavior, abusive situations, and so on?

Perhaps an officer can speak to the class about the police role in the mental health system.

7. Commitment laws. Have students investigate the procedures for involuntary commitment in your area. 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 .

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they go about it?

8. Legalities of current events. Pick a couple of local or national news items relating to mental illness in the law. Consider the cases of James Homes and Jared Loughner or any other recent case involving a defendant with alleged mental illness. Students should be assigned to small groups and complete a review of the background of the selected cases. Each case could be presented to the class for a discussion from the perspective of their assigned case about the ethics of the insanity defense, the competency to stand trial, and the evaluation of danger to oneself or others.

Media Resources Ill Treatment at Developmental Center (2:25) An interview about the treatment of a mentally ill family member.

Video is available on MyPsychLab.com Special Topics: Ethics in Psychological Research (5:27) This video explores ethical concerns related to research in psychology and details what regulations researchers need to follow.

Video is available on MyPsychLab.com

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