Abnormal Psychology Pearson New International Edition, 15E James N Butcher Solution Manual by Ace Test Banks

Abnormal Psychology Pearson New International Edition, 15E By James N. Butcher

Email: Richard@qwconsultancy.com

Table of Contents Preface

A Sample Syllabus

Chapter 1 Abnormal Psychology: An Overview

Chapter 2 Historical and Contemporary Views of Abnormal Behavior

Chapter 3 Causal Factors and Viewpoints

Chapter 4 Clinical Assessment and Diagnosis

Chapter 5 Stress and Physical and Mental Health

Chapter 6 Panic, Anxiety, and Their Disorders

111

Chapter 7 Mood Disorders and Suicide

131

Chapter 8 Somatoform and Dissociative Disorders

153

Chapter 9 Eating Disorders and Obesity

173

Chapter 10 Personality Disorders

188

Chapter 11 Substance-Related Disorders

205

Chapter 12 Sexual Variants, Abuse, and Dysfunctions

229

Chapter 13 Schizophrenia and Other Psychotic Disorders.

248

Chapter 14 Neurocognitive Disorders

266

Chapter 15 Disorders of Childhood and Adolescence

281

Chapter 16 Therapy

302

Chapter 17 Contemporary and Legal Issues in Abnormal Psychology

321

The final grade is calculated by adding the total number of points the student achieves. Points 677–750 604–676 531–603 458–530 000–457

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

NOTE TO THE STUDENTS: To be successful in this course: 1. 2. 3. 4. 5. 6. 7. 8.

Read the chapters in the text prior to discussing them in class. This allows you to interact in class about the content and pose any questions that you may have. Complete your Learning Objectives prior to each class. Complete your Key Terms prior to each class. Participate in each In-class exercise. Attend all classes. Ask questions. Take notes. Review the course material.

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

ASSIGNMENTS

ANALYSIS PAPERS Students are required to complete two assignments: 1.

“Diagnosing the Celebrities” —Select any “celebrity” or famous person who you believe has a clinical disorder. Select someone personally intriguing and famous, such as a musician, movie star, politician, historical figure, or criminal. Please DO NOT select a family member, friend, professor, or anyone else in the local community. Gather data from a variety of sources, including books, popular magazines, Internet sites, television interviews, articles, scholarly resources, etc. Make up a reason for your referral, as well as any material for the mental status examination. However, this material should be congruent with existing evidence (i.e., magazines, books, etc.) about the person’s behavior and symptoms. Before you begin the project, review your ideas with the professor to eliminate overlap in assessment subjects. Before you begin typing your paper, include the following disclaimer: “This document is entirely fictional, the person named in the evaluation was never actually evaluated, and the report author is not qualified to conduct psychological evaluations.” DUE 11/5 Worth: 100 points Your essay should be 3–4 typed pages (points will be taken off if you do not meet the minimum page requirement), and double spaced with no larger than 12 point, Times New Roman font; summary of each assignment is required.

For each class, you will write weekly journal entries based on the readings and how the subject matter was presented (PowerPoint presentation, speakers, in-class discussion, activities, videos, etc.) Your journal can be kept in a spiral-ring notebook or something of your choosing. Toward the end of the semester turn your journal into your own “Personal Memoir of Being in an Abnormal Psychology Class.” Organize the entries by looking at themes: did your perception of abnormality change, what did you find particularly interesting or not interesting, did you find you wished you had the opportunity to explore something else in detail, etc. This is where you can use your creativity. Then design your own journal cover, dedication page, title page, table of contents, abstract, and the main text; you may also include an appendix with pictures or actual journal entries. Again this is where you can use your own personal style and creativity. DUE 11/24 Worth: 130 points

CASE STUDY Students are to: 1. 2. 3. 4. 5. 6. 7. 8.

Read the case study, given by the professor, of a fictional patient describing his/her medical history. Assess the symptoms. Assess any other potential problematic areas of the person’s life, such as social, spiritual, emotional, cognitive, work/education level, physical. Provide diagnostic criteria based on the DSM. Identify stressors. Recommend treatment. Assess the prognosis. Summarize the results in a written statement.

Your written statement should be 3–4 typed double-spaced pages, no larger than 12 point, Times New Roman font. Points will be deducted if you do not meet the minimum page requirements.

DUE 10/1 Worth: 130 points

IN-CLASS ORAL PRESENTATIONS Students will make two in-class oral presentations: 1.

Students will learn about several different AXIS I (i.e,. serious) mental disorders. After learning the diagnostic criteria according to the DSM-IV-TR, treatment options, medication, therapy, and how each psychological model views the disorder, the student will use their own creativity to come up with their own AXIS I mental disorder. What is the criterion to be diagnosed with this disorder, what does it look like, what would be the wording of the disorder according to the DSM-IV-TR, who is typically diagnosed with this, how does society view this disorder, and what are the best treatment options? DUE 10/29 Worth: 10 points

Students will explore abnormal behavior and the various different psychiatric diagnoses. Using their creativity and personal interests, have the students select a song that can be related to abnormal behavior, mental illness, psychiatric disorders, therapy, treatment, or the field of psychology, etc. Then examine the song lyrics and/or music video. What message is the song sending about abnormal psychology? Is it positive, negative, stereotyping, etc.? What specifically is the song trying to get across, and how would you use this to teach someone or a class about a specific disorder, treatment, the field of psychology, etc.? Students may use their textbook as a source to reflect clinical knowledge with “pop culture” knowledge. DUE 11/19 Worth: 10 points

COURSE OUTLINE ABNORMAL PSYCHOLOGY—PSY 266 Date 8/25–Syllabus, 8/27

Topic Intro, Syllabus, Abnormal Psychology: An Overview

Readings Chapter 1

Assignments

9/1, 9/3

Historical and Contemporary Views of Abnormal Behavior

Chapter 2

9/8, 9/10

Causal Factors and Viewpoints

Chapter 3

9/15, 9/17

Clinical Assessment and Diagnosis

Chapter 4

9/22, 9/24

Stress and Physical and Mental Health

Chapter 5

9/29, 10/1

Panic, Anxiety, and Their Disorders

Chapter 6

Case Study due

10/6, 10/8

Mood Disorders and Suicide

Chapter 7

Test 2

10/13, 10/15

Somatoform and Dissociative Disorders

Chapter 8

10/20, 10/22

Eating Disorders and Obesity

Chapter 9

10/27, 10/29

Personality Disorders

Chapter 10

AXIS I activity due

11/3, 11/5

Substance-Related Disorders

Chapter 11

Diagnosing the Celebrities due

11/3, 11/5

Sexual Variants, Abuse, and Dysfunctions

Chapter 12

Test 1

11/10, 11/12

Schizophrenia and Other Psychotic Disorders

Chapter 13

Test 3

11/17, 11/19

Neurocognitive Disorders

Chapter 14

Song Lyric evaluation due

11/24,

Disorders of Childhood and Adolescence

Chapter 15

Personal Memoir due

Therapy

Chapter 16

Oral Presentations/ In-Class Exercise

11/26–NO CLASS– THANKSGIVING 12/1, 12/3

Test Review 12/8

12/14–12/18

Contemporary and Legal Issues in Abnormal Psychology

Chapter 17

Test 4

FINAL EXAMS

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

CHAPTER 1: Abnormal Psychology: An Overview Teaching Objectives Explain the authors’ approach to the study of abnormal psychology. Discuss common topics and issues relevant to abnormal psychology. Explain why we need to classify mental disorders, and the advantages and disadvantages of classification. Summarize the proposed DSM-5 definition of mental disorders, illustrating several problems with this approach. 5. Identify how cultural issues can influence the definition of abnormal psychology as well as culture-specific disorders. 6. Identify the professionals responsible for working on the mental health “team.” 7. Explain the difference between the prevalence and the incidences of mental disorders. 8. Discuss the prevalence rates for mental disorders. 9. Summarize current trends in patient care, including inpatient and outpatient treatment. 10. Describe the scientific inquiry process. 11. Describe the importance of hypotheses in the research process. 12. Identify the critical elements of sampling and generalization. 13. Compare and contrast correlational design research strategies, experimental research designs, and single-case experimental designs. 14. Illustrate how research designs allow psychologists to make statements about the efficacy of treatment. 15. Discuss the importance of animal research to understanding abnormal behavior. 16. Identify the basic principles behind the text’s study of abnormal psychology. 1. 2. 3. 4.

Chapter Overview/Summary Encountering instances of abnormal behavior is a common experience for all of us. This is not surprising given the high prevalence of many forms of mental disorder. A precise definition of abnormality is still elusive. Even though we lack consensus on the precise definition of abnormality, there are clear elements of abnormality: suffering, maladaptiveness, statistical deviancy, violations of society’s standards, social discomfort, irrationality or unpredictability, and dangerousness. These elements allow for the adoption of a prototype model of abnormality. Although this model is helpful, we have the additional problem of changing values and expectations in society at large. Currently, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders is in the fourth edition, a text revision that is referred to as the DSM-IV-TR (APA, 2000). The DSM-5 is expected to be published in 2013 and has already received criticism. The proposed DSM-5 definition of a mental disorder focuses on a behavior or psychological pattern, reflects psychobiological dysfunction, causes clinical distress and disability, is not an expectable response to a stressor or loss, and does not result from deviating from socially acceptable norms. Despite these difficulties, psychologists continue to classify mental disorders for several reasons: classification systems provide a nomenclature that allows us to structure information in a more helpful way, research on etiological factors, treatment decisions, social and political implications, and insurance reimbursement. There are also many disadvantages to classifying mental disorders: loss of information, stigma, stereotyping, and labeling. With the influence of such things as labeling and stereotyping, it was first thought that the public could be educated that mental illnesses are indeed real disorders of the brain. This has not been the case, but with the public’s increased awareness, some of the stigma associated with mental health issues has decreased. Some interesting research has shown that although people realize the impact of neurobiology as a cause of mental illness, it does not mean that the level of prejudice has decreased. Society and culture are vital in determining what defines what is normal versus abnormal, and culture can Copyright © 2013 Pearson Education, Inc. All rights reserved. 1

also influence the presentation of clinical disorders. For instance, karo-kari is a form of honor killing in Pakistan wherein a woman can be murdered for disgracing her family. There are also certain disorders, such as taijin kyofusho or ataque de nervios, that appear to be highly culture specific. Additionally, beyond disorders, we have different superstitions. For example, in Christian countries the number 13 is viewed as unlucky. In Japan, on the other hand, the number four is viewed as bad because in Japanese the word for “four” pronounced in a similar manner to the word death. The DSM opts for a categorical classification system similar to that used in medicine. Disorders are regarded as discrete clinical entities, although not all clinical disorders are best considered in this way. Even though it is not without problems, the DSM provides us with a working set of criteria that helps clinicians and researchers to identify and study specific and important problems that affect people’s lives. Although it is far from a “finished product,” knowledge of the DSM is essential to a serious study of the field. The extent of mental disorders may be surprising. Several epidemiological studies have been conducted in recent years. The lifetime prevalence of having a DSM-IV disorder is 46.4%. In addition, there is significant comorbidity, especially among those individuals who have severe disorders. Unfortunately not all people with mental disorders receive treatment. Some may deny or minimize their problems, and others may try to cope with their problems on their own. Even when the problems are recognized, many delay seeking treatment or seek assistance from a primary health care provider such as a physician. There are numerous forms of treatment for psychological disorders, such as medication, various types of psychotherapy, and outpatient care, but for more intensive treatment, hospitalization and inpatient care are preferred. In an ideal case, the mental health team, composed of professional and paraprofessionals, may gather information from a variety of sources, process and integrate all the available information, arrive at a consensus diagnosis, and plan the initial phase of treatment. Some examples of the different professionals in the mental health field would be clinical social workers, counselors, psychiatric nurses, occupational therapists, pastoral counselors, community mental health workers, alcohol or drug-abuse counselors, clinical psychologists, counseling psychologists, school psychologists, psychiatrists, and psychoanalysts. To avoid misconception and error, we must adopt a scientific attitude and approach to the study of abnormal behavior. This requires a focus on research and research methods, including an appreciation of the distinction between what is observable and what is hypothetical or inferred. To produce valid results, research must be done on people who are truly representative of the diagnostic groups to which they purportedly belong. Research in abnormal psychology may be observational, correlational, or experimental. Some of the identified sources of information would be case studies, self-report data, and observations. Observational research studies things as they are. Experimental research involves manipulating one variable (the independent variable) and seeing what impact this has on another variable (the dependent variable). Mere correlation between variables does not allow us to conclude that there is a causal relationship between them. Simply put, correlation does not imply causation. Although most experiments involve studies of groups, single case experimental designs (e.g., ABAB designs) can also be used to make causal inferences in individual cases. Analogue studies, also known as laboratory studies, provide an approximation to the human disorders of interest, by studying animals in the place of humans (e.g., animal research). Although generalization can be a problem, animal research in particular has been very informative. Research starts with asking a question to make sense of behavior by generating a hypothesis. The next part is to decide who should be a part of the study. This is done by using a technique called sampling, which is when people are selected who have similar abnormalities of behavior. One of the goals of research in the field of abnormal psychology is to learn the causes of different mental disorders. When assessing correlational research, it is important to evaluate the statistical significance or the probability that the correlation would simply occur by chance. The effect size is the number used to assess the association between two variables of the sample size. However, when the researchers want to review the past Copyright © 2013 Pearson Education, Inc. All rights reserved. 2

findings from other research studies, they conduct a meta-analysis that calculates and combines the effect sizes from the studies selected. Some strategies often applied in correlational research are either retrospective or prospective approaches. A retrospective research strategy identifies the potential factors that might have been associated with the onset of the disorder. A prospective research strategy identifies individuals that would be considered at risk for developing a psychological disorder.

MyPsychLab Resources The current edition of MyPsychLab offers yet more assets and resources to aid you in teaching with this text. It offers many videos, activities, and even short PowerPoint presentations to clarify points in the text. Go to www.MyPsychLab.com to register for access. Contact your book rep for the access codes for this text. Your students will also need to register using their e-mail address, course ID, and a student access code (provided with student’s textbook or in a student access card/kit available from your campus bookstore). If you assign any of the simulations or activities, students will need them to access the site. If you would like to show videos, only you will need access. To select videos, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. You can select a particular chapter or “All Chapters,” and then select “Watch” in the Media Type field to bring up a list of video offerings.

Detailed Lecture Outline Lecture Launcher 1.1: Why Are You Taking This Course? Teaching Tip 1.1: General Tips for Students on Studying I.

What Do We Mean By Abnormality?

First begin the in-class discussion onthe various ways in which abnormal behavior is defined and classified so that researchers and mental health professionals can communicate with each other about the people they see. Again, as a reminder, the textbook defines abnormal behavior as encompassing: suffering, maladaptiveness, statistical deviancy, violation of the standards of society, social discomfort, irrationality and unpredictability, and dangerousness. Handout 1.1: Begin this discussion by having students take a few minutes to fill out Handout 1.1: “Is it Abnormal?” You then want to discuss some of the students’ answers in relation to how difficult it is to define “abnormal” behaviors. Activity 1.1: Defining Abnormality A comprehensive definition of abnormality has several elements. A.

The Elements of Abnormality 1. Suffering—personally defined psychological suffering (e.g., you can’t leave your house because you need to wash your hands 1,000 times). This is one of the most important aspects according to the APA. 2. Maladaptiveness—any behavior that is maladaptive for the individual or toward society (e.g., anorexia); starving oneself is maladaptive. 3. Statistical deviance—abnormal is defined as “away from the normal.” Also, just because something is statistically common or uncommon does not reflect abnormality (e.g., having an intellectual disability, although statistically rare, represents a deviation from the normal). 4. Violation of the standards of society—all cultures have rules, and some of these are viewed as laws. Those who fail to follow the conventional social and moral rules of their cultural group may be viewed as abnormal (e.g., the Amish of Pennsylvania not driving a Copyright © 2013 Pearson Education, Inc. All rights reserved. 3

car or watching television). Social discomfort—occurs when someone breaks a social rule and then those around this individual experience some discomfort (e.g., you are sitting in a movie theater with rows of empty seats and then someone comes and sits directly next to you). Irrationality and unpredictability—people are expected to behavior in socially acceptable ways and abide by those social rules (e.g., if someone next to you started screaming and yelling obscenities at nothing, this behavior would be viewed as unpredictable, disorganized, and irrational). Dangerousness—this represents someone who is clearly a danger to himself or herself or to another person. This is also known as exhibiting DTO (e.g., danger to others) and DTS (e.g., danger to self) behaviors (e.g., therapists are required to hospitalize suicidal clients, but someone who engages in high-risk sports such as free diving or base jumping is not immediately considered mentally ill).

Lecture Launcher 1.2: Evolutionary Psychology 8. 9.

Deviancy—statistically unusual behaviors. Again, point out this is not comprehensive (e.g., depression is in no way statistically unusual). Violation of the standards of society—this gets at failure to follow the conventional social and moral codes of an individual society (e.g., taking ones clothes off in public).

Lecture Launcher 1.3: Evolving Conceptualizations of Homosexuality 10. 11.

Causing social discomfort—related to the above violation of social norms but results in others’ discomfort. Irrationality and unpredictability—related to behavior that cannot be expected and/or behaviors that appear to be irrational (e.g., washing one’s hands 1,000 times).

The Proposed DSM-5 Definition of Mental Disorder 1. A behavioral or psychological syndrome or pattern that occurs in individuals. 2. Reflects an underlying psychobiological dysfunction. 3. Consequences that cause clinically significant distress or disability. 4. Must be beyond the expectable response to common stressors and losses. 5. Is not primarily a result of social deviance or conflicts with society. (The DSM-5 is expected to be published in May 2013)

Lecture Launcher 1.4: Abnormality as “Harmful Dysfunction” 6. C.

DSM-5 is a work-in-progress and is already the subject of much controversy and debate.

Why Do We Need to Classify Mental Disorders? 1. Advantages: a. Sciences rely on classification. b. Provides a nomenclature, a naming system. c. Enables us to structure information. d. Delimits the domain of professional expertise. e. Allows us to study different disorders. f. Lets us learn about causes but also treatment. D.

What Are the Disadvantages of Classification? 1. Overall have to do with negative consequences for the individual. 2. Loss of information/detail due to the information being in shorthand form. 3. As we simplify through classification we lose personal details about the actual person with the disorder. Copyright © 2013 Pearson Education, Inc. All rights reserved. 4

Stigma is still associated with having a psychiatric disorder.

Lecture Launcher 1.5: Stigma Progress? 5.

Stereotyping are those automatic beliefs concerning other people based on trivial factors. For example, people who wear glasses are more intelligent.

Activity 1.2: Stereotypes and the Media 6.

Labeling—classification should be of disorders, not of people. Once a person receives the “diagnostic label,” it can be hard to lose this label even after an individual has made a full recovery. The diagnostic classification system does not classify people, but classifies the disorders that people have. For example, when previously individuals were called “manic-depressives,” this type of language shows that the person is the diagnosis. If you use more people-first language, you would state that the person had been diagnosed with manic depression.

Lecture Launcher 1.6: What’s Your Frame of Reference? Teaching Tip 1.2: Students with Disabilities E.

How Does Culture Affect What Is Abnormal? 1. Culture shapes the clinical presentation of disorders.

Activity 1.3: Cultural Relativity F.

II.

Culture-Specific Disorders 1. Certain forms of psychopathology are culture-specific: a. taijin kyofusho: Japan—marked fear of giving offense b. ataque de nervios: Caribbean—distress triggered by a stressful event c. karo kari: Pakistan—a form of honor killing whereby a woman is murdered by a male relative because she has disgraced her family 2. Nevertheless, certain unconventional actions and behaviors such as hearing voices, laughing at nothing, defecating in public, drinking urine, and believing things that no one else believes are almost universally considered to be the product of mental disorder

How Common Are Mental Disorders? A. Prevalence and Incidence 1. Frequencies of particular disorders are of great interest to professionals. a. Research efforts are guided by frequencies. b. Allocation of treatment resources depends upon the extent of the disorder. 2. Epidemiology—the study of the distribution of diseases, disorders, or health-related behaviors in a given population. 3. Prevalence—the number of actual, active cases in a given population during any given period of time—typically expressed as a percentage. 4. Point prevalence—at any instant. 5. One-year prevalence—during an entire year. 6. Lifetime prevalence—full lifespan—tends to be higher than other prevalence rates. 7. Incidence—a rate, specifically the number of new cases occurring over a period of time (usually one year).

Lecture Launcher 1.7: Rates of Incidence B.

(Baltimore, New Haven, St. Louis, Durham, and Los Angeles). The National Comorbidity Survey: sampled the entire United States. One-year prevalence—based on the replication of the National Comorbidity Survey: a. 18.1% anxiety disorder (see Table 1.1) b. 26.2% any disorder (see Table 1.1) 4. Lifetime prevalence of having a DSM-IV disorder: 46.4%. a. May be an underestimate as did not assess for eating disorders, schizophrenia, autism, or most personality disorders. b. Disorder with the highest lifetime prevalence—major depressive disorder (see Table 1.2). c. Although the lifetime prevalence is high, the duration may be brief or severity may be mild. 5. Comorbidity is especially high in people who have severe forms of mental disorders (50%) in comparison to those who have milder forms of mental disorders (7%). Treatment 1. Not all people with disorders get treatment. a. Some deny or minimize their problems. b. Some fear the stigma of diagnosis. c. Some try to cope on their own. d. Some spontaneously recover. e. Some see general practitioner physicians. f. Many delay treatment, even if they recognize they need help. 2. Inpatient and outpatient treatment a. Inpatient hospitalization is declining. b. Budget cuts. c. Even if hospitalized, stays tend to be shorter and people are referred for additional outpatient treatment. d. Effective medications. e. Deinstitutionalization (Chapter 2). f. Half of individuals with depression delay seeking treatment for more than 6–8 years. g. For anxiety disorders, the delay ranges from 9–23 years. 2. 3.

MyPsychLab Resource 1.1: Video on “Recent Trends in Treatment” D.

The Mental Health “Team” (The World around Us 1.3) 1. In both mental health clinics and hospitals, people from several fields may function as an interdisciplinary team. 2. Professional a. Clinical psychologist b. Counseling psychologist c. School psychologist d. Psychiatrist e. Psychoanalyst f. Clinical social worker g. Psychiatric nurse h. Occupational therapist i. Pastoral counselor 3. Paraprofessional a. Community mental health worker b. Alcohol- or drug-abuse counselor

Teaching Tip 1.3: Careers in Psychology III.

IV.

1. Acute—a disorder where the symptoms are short term. 2. Chronic—the symptoms of a disorder that appear long in duration. 3. Etiology—the cause of a disorder. Sources of Information A. Case Studies 1. Emil Kraepelin (German psychiatrist) and Eugen Bleuler (Swiss psychiatrist) described cases of schizophrenia. 2. Alzheimer described a case of Alzheimer’s disease. 3. Sigmund Freud described cases of phobia and obsessive-compulsive disorder. 4. Cases may be idiosyncratic and results not generalizable. 5. Bias can happen in case studies because the writer of the case study selects which information to include. 6. Generalizability—when you are able to draw conclusions about other cases when individuals experience similar abnormalities.

Lecture Launcher 1.8: Issues with Case Studies B.

Self-Report Data 1. Self-report data may be misleading but is when research participants complete questionnaires. Observational Approaches 1. Overt behavior. 2. Psychophysiological variables. 3. Brain imaging technology allows us to observe how the brain works. 4. Direct observation would be used, for example, if you were trying to observe aggression in children’s behavior. Observers would record the number of times children hit, bite, push, punch, or kick their peers.

Forming and Testing Hypotheses 1. Hypothesis—an effort to explain, predict, or explore something that starts after a question has been developed. 2. Careful observation can suggest interpretations requiring scientific testing. 3. Cases and prior data are good sources of hypotheses. 4. Various perspectives explain the same behavior differently. 5. Causal hypotheses shape treatment strategies we use.

Lecture Launcher 1.9: On Being Sane in Insane Places A.

Sampling and Generalization 1. Studies that examine groups of people are valued over single cases. 2. May identify multiple causes for disorders. 3. Can generalize results to other cases. 4. Sampling is the careful selection of a sub-group that is representative of a larger population for close study. a. The more representative the sample, the more able we are to generalize. b. Ideally, we would like to be able to use random sampling to avoid potential biases. c. Erroneous conclusions can emerge from faulty sampling.

Lecture Launcher 1.10: Sampling Issues in Abnormal Psychology B.

Internal and External Validity 1. External validity—being able to generalize results beyond the current study. 2. Internal validity—how confident you are in the current study’s results. Criterion and Comparison Groups Copyright © 2013 Pearson Education, Inc. All rights reserved. 7

1. 2.

VI.

People with the disorder are the criterion group. Control groups (sometimes called comparison groups)—typically healthy people—are used for comparisons.

Research Designs A. Studying the World as It Is: Correlational and Experimental Research Designs (see Figure 1.4) 1. Experimental studies of etiological factors are unethical and impractical. 2. Observational research requires no manipulation of key variables. 3. Study natural groups (e.g., depressed people). 4. Correlational research design takes things as they are to see if a relationship exists between them. B. Measuring Correlation 1. A correlational coefficient statistic that ranges from -1 to +1 with a 0 in between. Correlations of +1 or -1 means the two variables are directly related. A correlation of 0 means there is no relationship between the two variables. (See Figure 1.3 for a scatterplot example.) The number, denoted by r, tells the strength of the relationship between the two variables. 2. A positive correlation means the two variables hang together—as variable A goes up or down, variable B goes up or down with it (e.g., watching violent media and committing aggressive acts, or smoking and lung cancer, or students who miss a lot of class tend to do poorly in class). 3. A negative correlation indicates that as variable A goes up or down, variable B does the opposite (e.g., having a low score in golf means you are doing well, or having a lot of money decreases the risk for schizophrenia). 4. Can provide a rich source of inference—may suggest hypotheses and occasionally provide crucial data that confirm or refute these hypotheses. C. Statistical Significance 1. P <.05 is the level of statistical significance. This indicates that there is roughly a 5% probability the correlation would happen by chance. The size of the correlation dictates how strong the correlation is. 2. Effect size reflects the size of association between two variables. 3. Meta-analysis is an approach that calculates and then combines the effect sizes from all of the studies. D. Correlations and Causality 1. Correlation or association of variables is not evidence of causation. a. A might cause B or B might cause A. b. A and B might both be caused by C. c. A and B are involved in a complex web of relationships with other variables. d. Third variable problem is when a third variable might be the causing both events to happen. E. Retrospective versus Prospective Strategies 1. Retrospective research strategy—memories can be both faulty and selective. 2. Such a strategy may increase the odds that investigators discover what they expect to discover. 3. Prospective research strategy—often focuses on high-risk populations before they develop the disorder. 4. Identification of differentiating variables. 5. When hypotheses correctly predict behavior, we are much closer to establishing a causal relationship. 6. Longitudinal design is a study that follows people over time. F. Manipulating Variables: The Experimental Method in Abnormal Psychology 1. Scatterplots of positive, negative, and zero correlation. 2. Scientific control of all but one variable. 3. Independent variable is manipulated. 4. Dependent variable is observed for experimentally induced changes. Copyright © 2013 Pearson Education, Inc. All rights reserved. 8

5. 6.

Direction of effect problem is when researchers are unable to draw any conclusions. Experimental research is used to draw conclusions about causality

Handout 1.2: Research Methods: Is it an experiment or is it a correlation? Experiment: independent variable—treatment condition; dependent variable—level of depression G.

Studying the Efficacy of Therapy 1. Random assignment to treated or untreated group. 2. Untreated (“waiting list”) control group. 3. Ethics of withholding effective treatment may lead to an alternative research design in which two or more treatments are compared. 4. Comparative-outcome research: comparing new versus established treatment. 5. Random assignment—every research participant has an equal chance of being placed in the treatment or the no-treatment condition. Single-Case Experimental Designs 1. Many observations of one subject. 2. ABAB design. 3. Single-case-research design—the same individual is studied over a period of time.

Activity 1.4: Single-Case Experimental Design I.

Animal Research 1. Permits experimental manipulation. 2. Ethical considerations still apply. 3. “Analogue” of human conditions. 4. Findings from animal research provided impetus for learned helplessness model of depression. 5. Analogue studies may involve humans but are used when animals are studied to find an approximation to how something would apply to humans.

Lecture Launcher 1.11: Ethics in Scientific Research Activity 1.5: Journal Browsing VII.

The Focus of This Book A. A Scientific Approach to Abnormal Behavior 1. Clinical picture 2. Causal factors 3. Treatments B. Openness to New Ideas 1. Biological 2. Psychosocial (e.g., psychological and interpersonal) 3. Sociocultural (e.g., culture and subculture) C. Respect for the Dignity, Integrity, and Growth Potential of All Persons

VIII.

Unresolved Issues: Are We All Becoming Mentally Ill? The Expanding Horizons of Mental Disorder A. There Is Constant Pressure to Expand DSM to Encompass More 1. Economic interests of mental health professionals support expansion. 2. For instance, “road rage” B. Too Much Expansion Would Make DSM Scientifically Useless

Key Terms ABAB design abnormal psychology acute analogue studies bias case study method chronic comorbidity comparison or control group correlation correlation coefficient correlational research criterion group dependent variable direct observation direction of effect problem effect size epidemiology etiology experimental research external validity generalizability incidence independent variable

internal validity labeling lifetime prevalence longitudinal design meta-analysis negative correlation nomenclature observational research one-year prevalence point prevalence positive correlation prevalence prospective research random assignment retrospective research sampling self-report data single-case research design statistical significance stereotyping stigma third variable problem

Lecture Launchers Lecture Launcher 1.1: Why Are You Taking this Course? Students taking abnormal psychology often have a variety of reasons for doing so. These range from satisfying a degree requirement to a desire for enhanced personal insight. The expectations of the students regarding the course, and what they may or may not get out of it, are interesting issues to explore at the very outset. Students should be encouraged to volunteer their reasons for enrolling in the course. Common answers that usually arise include: to learn more about my own behavior, to understand others, and to learn about the different mental health professions. Hearing other peoples’ answers to this question can also help students expand their ambitions in the course beyond the ones they originally held. This discussion can also provide a good opportunity to present the rationale behind studying abnormal psychology and how the scientific tradition assists in increasing our understanding of behavior and its determinants. After this discussion, students should have a clear understanding of the demands and expectations of this course and how their expectations fit into the course design. Students can also write one reason anonymously on a piece of paper and designate a couple of students or the professor to read them aloud. Lecture Launcher 1.2: Evolutionary Psychology If you have a background that includes evolutionary psychology, you may want to discuss adaptive value and ask students to generate possible reasons why we would see maladaptive behaviors not die out. Because one of the main tenets of evolutionary psychology is that behaviors that persist must in some way be or have been adaptive, how does this explain the disorders we see today? One example can be built on the example above on the “adaptive value” of schizophrenia. Ask students if someone lived in a remote tribe in South America or Africa and they reported talking to God, how would their village receive them? Could there be other situations with other disorders where some of these behaviors are actually adaptive in some way? Lecture Launcher 1.3: Evolving Conceptualizations of Homosexuality Prior to the publication of DSM-III in 1980, homosexuality was considered a mental illness. In DSM-III it was Copyright © 2013 Pearson Education, Inc. All rights reserved. 10

considered a disorder only if the homosexual person was emotionally troubled by it—that is, only if it was egodystonic. In DSM-IIIR (1987) it moved into a general category of sexual disorders “not otherwise specified,” where it was recast as “persistent and marked distress about one’s sexual orientation,” for ego-dystonic heterosexuality as well as homosexuality. These transitions were not driven by scientific research but by evolving societal norms and political pressure. Evolving conceptualizations of homosexuality provide interesting material for discussing diagnosis, science, and politics. It is also sometimes quite interesting to discuss the kinds of research that could be conducted to establish the diagnostic status of behaviors, including homosexuality. Are there data that would certify behaviors as abnormal, or are societal values absolutely necessary? Lecture Launcher 1.4: Abnormality as “Harmful Dysfunction” An interesting article that can be used for a brief lecture and discussion session is one by J. Wakefield published in 1998 (“Diagnosing DSM-IV: DSM-IV and the concept of disorder.” Behavior Research and Therapy, vol. 35, 633– 649). The author suggests that the DSM-IV is overinclusive of its diagnostic criteria. The DSM does not distinguish between harmful conditions due to internal dysfunction from harmful conditions that are not disordered or cause problems in living. The author recommends a dimensional approach to diagnosing mental disorders. Students can be asked about the value of having a diagnostic system, such as the DSM-IV, that does not examine the context of the individual’s life. The events that trigger mental disorder would have a more meaningful place in the dimensional approach than in the DSM classification system. Students can be asked to discuss the events that may lead to problems in living conditions that are harmful to the individual, yet don’t cause internal dysfunction. Would there be different outcomes for the different situations? Have students list the problems of living that may cause dysfunction in life. Should a person be diagnosed with a mental disorder if experiencing these situations? Lecture Launcher 1.5: Stigma Progress? Using an overhead transparency, a PowerPoint slide, a whiteboard, or a chalkboard, write the following question, “Your city is planning to create a half-way house for adult men who have been hospitalized for paranoid schizophrenia. Where would be the best place to put this home? A. Next door to your home, B. In your neighborhood, C. Anywhere in town would be fine, D. In the next town.” Asking students to answer privately on their own paper prior to beginning any discussion of this topic is typically necessary. Lecture Launcher 1.6: What’s Your Frame of Reference? The concept of social labeling provides an excellent topic for a lecture/discussion session. Any number of cultural groups can be used as examples to provide contrasts in how societies label pathology. Students can be asked to generate their own examples of social labeling, using experiences with subcultural groups. The behaviors found among different age groups are often labeled as abnormal by the dominant age group in our society. For instance, street slang may be evaluated as maladaptive by the school system, yet it provides rich communication in its own subcultural context. The behavior of adolescents may be labeled as pathological by adults who see the behavior as maladaptive (an example from the text is body piercing or tattooing). Students should find the discussion of social labeling an interesting one, because they can contribute experiences from their own subcultural group. In-class lecture can illustrate that, although social labeling can be a powerful process, some behaviors (such as depression) are generally assumed to be maladaptive in all subcultures and societies. Students can be asked to identify other behaviors whose maladaptiveness transcends cultural boundaries. An easy way to begin a discussion of this type might be to ask students the number of piercings that they have. Tally the number of students who report 0, 1, 2, 3, 4, 5 or more piercings, and talk about how the acceptance of piercing has changed in the past few years in our culture. Lecture Launcher 1.7: Rates of Incidence Here you may want to again discuss the issue of the rates of incidence with students. Do they feel these numbers include everyone? What about gender differences? Do they think one gender may be diagnosed more? Why or why not? Perhaps one sex is more likely to seek help? What about disorders like substance abuse? Will everyone be represented in the data? Lecture Launcher 1.8: Issues with Case Studies This is a good time to point out the problems with case studies. For example, Alex the African parrot (see clip at: www.youtube.com/watch?v=c4gTR4tkvcM). Despite many attempts, researchers have never replicated these results. Keep in mind, although case studies can be dead on (e.g., early descriptions of schizophrenia, the role of the Copyright © 2013 Pearson Education, Inc. All rights reserved. 11

amygdale in Phinneus Gage’s uncontrolled emotions, Piaget’s observations of his children), they can also be very wrong (e.g., Alex the parrot, some of Freud’s assumptions based on his case studies). Also, remind students that although there are significant limitations to case studies, many times it is the only way, for example, when only a handful of people have a condition, or in cases of brain damage. Lecture Launcher 1.9: On Being Sane in Insane Places Rosenhan (1973) published a classic abnormal psychology study in the extremely high-profile journal Science (vol. 179, pp. 250–258). This study raises many interesting questions about research methods, definitions of abnormality, and the ability of mental health professionals to distinguish actual from feigned mental illness. In this study, eight healthy volunteers, several of them psychologists and psychiatrists, went to mental hospitals and complained of hearing voices saying “empty,” “hollow,” or “thud.” These pseudo-patients acted normally in every way except for the reported auditory hallucinations. As soon as they were admitted, they stopped complaining of these symptoms. Although many of the real hospitalized patients suspected the pseudo-patients were faking, none of the hospital staff apparently did. All pseudo-patients were labeled schizophrenic and their stays ranged from 7 to 52 days, with an average stay of 19 days. Originally, this was taken as evidence of how important labels and expectations affect interpretations of people’s behavior. However, it is worth envisioning a control group of pseudo-patients who report equally severe physical symptoms to physicians. Indeed, people with some kinds of somatoform disorder (Chapter 8) succeed in getting fairly dramatic treatments, including surgery, in the absence of genuine organic pathology. It is also worth noting that many pseudo-patients were diagnosed with atypical subtypes of schizophrenia, suggesting that the hospital staff recognized that there was something quite different about these patients. The Rosenhan study also raises questions about securing informed consent from research participants, draining precious treatment resources, and how long it is reasonable to observe an apparently recovered psychotic person to ensure that relapse is not imminent. These, and other design, ethical, and statistical matters, many of which were published in a subsequent issue of Science (1973, vol. 180, pp. 1116–1122), qualify the interpretation of this classic report substantially. Lecture Launcher 1.10: Sampling Issues in Abnormal Psychology Discuss with students where the data in this area comes from. Is it from Intro to Psych students like data in Social? Is it from schools and education data clearinghouses like Developmental? Here you are generally looking at what sample? Who’s included? Who’s excluded? By getting students to think about where the data comes from and if it excludes many people, students should be able to think about how good is the data in this area and if there are ways to get better data. Lecture Launcher 1.11: Ethics in Scientific Research This is a great time to discuss the ethical treatment of subjects, both human and animal. Point out to students that drug studies, for example, involve both humans and animals. Regardless of the long-term pay off, the cost to a subject can be high; where should the line be drawn? You may want to show a brief 3-minute clip on “Before Informed Consent: Robert Guthrie,” discussing the Tuskegee Study, a highly unethical example of human research. Once logged in to MyPsychLab, select “Intro to Psychology Materials,” then select “Intro Psych Media Materials,” then click on “All Pearson Intro Psych Videos,” and then scroll down to “Before Informed Consent: Robert Guthrie.” You can do this either as an in-class demo (if your room has a computer set-up)—or as an extra learning exercise for them to do on their own. There are questions throughout the clip so that you can further discuss the points being made. Classroom Activities, Demonstrations, and Assignments Activity 1.1: Defining Abnormality Students can be introduced to the numerous definitions of abnormality described in The World around Us 1.2: The Elements of Abnormality by trying to formulate their own definition of what is abnormal. The question “How would you define abnormal behavior?” can be used to initiate the discussion. A number of different answers will be generated, and these should be recorded on the blackboard. The instructor will have to challenge each of the answers in order to illustrate the concepts expressed in the text. The responses generated by the students can then be categorized into the different areas identified in Chapter 1—for example, the view that abnormality is always dangerous or that mental disorder is something to be scorned. Through the course of the discussion, students should Copyright © 2013 Pearson Education, Inc. All rights reserved. 12

come to appreciate the problem in defining abnormal behavior and gain an insight into factors affecting the labeling of abnormality. Activity 1.2: Stereotypes and the Media Stereotypes and stigma often originate in media portrayals of both the mentally ill and the professionals who treat and study them. Television and the movies consistently use psychological labels to describe unpleasant and dangerous characters. The written media likewise often use lurid descriptions of crimes, including psychological diagnoses and terms. Most students in the class will be able to cite examples of such portrayals from their own experience. An excellent way to combat erroneous beliefs about abnormal psychology is to rebut these salient portrayals. Asking students to bring examples to class can readily accomplish this. Each student can be required to bring at least one newspaper or magazine article, video clip, or even Web site portraying some aspect of abnormal psychology. The class can be asked to comment on these materials before the instructor points out what is generally representative and accurate, given the scientific literature on the topic, versus what is not representative or even inaccurate. For instance, a student might bring a clip from A Beautiful Mind, which provides vivid images of visual hallucinations, even though these are much less common in schizophrenia than auditory hallucinations. This film also provides a good opportunity to discuss medications and the prospects for overcoming schizophrenia through mere effort of will. Large classes can be broken into groups that can compile materials and present their observations and questions to the rest of the class. Activity 1.3: Cultural Relativity Students sometimes view stigma, cultural relativity, and social causation as rather weak compared to biological factors and cultural universals. The force of cultural and social phenomena can be established experientially by assigning students to violate an innocuous norm in a way that would be inconsequential elsewhere. Caution them to avoid illegal activities or ones that infringe on the rights of others. For instance, if social and interpersonal forces are innocuous, it should be inconsequential to wear a football helmet all day or to carry around a houseplant adorned with Christmas ornaments. Activity 1.4: Single-Case Experimental Design James Carr and John Austin (1997) developed a demonstration of single-case experimental design that can easily be used in a classroom setting. Students are instructed on how to take their own pulse rate and record these data for five, 1-minute intervals. This constitutes baseline. The treatment phase then begins by asking students to stand up and do jumping jacks for 20 seconds. The students then sit and take their pulse rate again for one minute. Students repeat the treatment phase four additional times. Following the collection of the five pulse rates during “treatment,” the students once again sit and record five resting pulse rates in 1-minute intervals. Students could repeat the treatment phase if the instructor wished to demonstrate an ABAB design. Once the data is collected, each student could draw a graph of his or her results and attempt to draw some conclusions regarding how “treatment” impacted heart rate. Activity 1.5: Journal Browsing Students can gain a greater appreciation for scientific approaches to the study of abnormal psychology by perusing current issues of some of the more rigorous journals in the field. Either individually or in groups, students can be sent to the library to browse recent issues of Journal of Abnormal Psychology, Journal of Consulting and Clinical Psychology, Archives of General Psychiatry, and American Journal of Psychiatry to find at least one article of interest. They can then be asked to present this article to the class, summarizing its purpose and main findings. It can also be instructive to ask that students make some general classifications of the research design. Is the selected study correlational or experimental? Retrospective or prospective? What diagnosis is under consideration? Does the article address etiology, descriptive psychopathology, or treatment? Is there a control group? A historical perspective can be encouraged by randomly assigning students to study articles from various decades.

MyPsychLab Resources MyPsychLab Resource 1.1: Video on “Recent Trends in Treatment” You may want to show a brief 2-minute video on current trends in treatment. To access this video, log in to MyPsychLab, select the front cover of this textbook, and then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 16, Therapy. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Recent Trends in Treatment” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set-up—or assign as a suggested exercise.

Teaching Tips Teaching Tip 1.1: General Tips for Students on Studying Teaching abnormal psychology poses some interesting issues because it attracts a wide variety of students. Often the class includes both freshman and seniors as well as majors from all different areas. Because of this I often spend a little more time discussing the qualifications of different areas of the fields. I also encourage students to spend time on studying. Many students seem to erroneously feel that they know much of the material from TV and movies and thus may not study enough. Under the MyPsychLab assets, go to www.coursecompass.com and log in. Select “Intro to Psychology Materials,” then select “Intro Psych Media Materials,” and select “All Pearson Intro Psych Videos.” Go to “it video: more tips for effective studying,” a brief (under 3-minute) video on studying habits. Also, there is an “it video: Why is cramming an ineffective study method.” Teaching Tip 1.2: Students with Disabilities You may want to consider asking students with disabilities to come in and do a short discussion on what it is like for many of the students on your campus with disabilities. The discussion of labeling and stereotyping lends itself well to more general discussions on labeling of all forms. Many students in abnormal psychology classes, more so than other classes, often self-disclose diagnoses and other forms of personal information. This discussion may make students more sensitive to others in the class who have been “labeled” and how that in and of itself has affected them. Teaching Tip 1.3: Careers in Psychology Make a copy of The World Around Us 1.3 and review with students. You may also want to take this opportunity to briefly discuss the different graduate degree programs and also that students should make themselves aware of the requirements for licensing in the state they wish to eventually practice. If your department has someone who regularly schedules seminars for students to review graduate programs in psychology, then you may want to announce in class when the next one is. Additionally, you can direct students to such professional organizations as the American Psychological Association, the American Psychiatric Association, or the American Counseling Association as a way to locate an accredited program to obtain a degree.

Handout Descriptions Handout 1.1: Is It Abnormal? Have students fill out the handout and then discuss some of their answers in relation to how difficult it is to define “abnormal” behaviors. Both 1 and 6 involve similar behaviors but one would be far more acceptable than the other—why? Students should point out that gender may play a role, or maybe the situation or context of the behavior. Both 2 and 9 are both about persons talking to themselves. Again, the context makes all the difference. Both 3 and 7 further highlight the issue of culture and context in how we interpret behaviors. This is also a good time to discuss religion and religious behaviors. (The APA steers clear of most religious behaviors because it gives rise to issues of religious freedom.) Ask students what behaviors done in a religious context would seem “abnormal” outside of one. Copyright © 2013 Pearson Education, Inc. All rights reserved. 14

Both 4 and 10 refer to hearing voices. Again, it continues the discussion above because #10 involves religious freedom. You can also use this one to discuss the perhaps “adaptive value” of schizophrenia. For example, even today in a remote non-industrialized setting (e.g., the Amazon), if you think you are talking to God it is most likely a plus. Here in the United States, not so much. Both 5 and 8 have to do with superstitious behaviors. Ask students what superstitious behaviors they perform, or know of behaviors that others do. How different is that from some of the rituals you see in OCD? It is important to point out to students at the end of this discussion that there are many issues to defining abnormal behavior. What’s appropriate for one gender, or in one context, or in one culture, may be profoundly “abnormal” in another. Handout 1.2: Research Methods: Is it an experiment or is it a correlation? You may want to either assign students to do this on their own and then go over it in class, or uses this in class as examples of the concepts you’ve just covered. For each example, state if the study described is an experiment or a correlation. If it is an experiment, identify the independent and dependent variables. If it is a correlation, identify if it is a positive or negative correlation. 1. Researchers are interested in whether eating disorders are related to childhood abuse. They looked at females both diagnosed with eating disorders and no diagnoses of eating disorders and compared it to self-reports of abuse in childhood. They found that females with a history of abuse were slightly more likely to develop an eating disorder than females in the general population. Positive correlation You again could point out the actual rate is about 25%—it is significant, but in no means does A predict B. You may want to point out that ice cream sales and violent crime are also correlated—this does not mean eating ice cream causes violence, rather it means that in the summer both go up. 2. Dr. Benzo is interested in developing a new anti-anxiety drug with less side effects and risk of dependency than the current leading treatments. She gets one group of subjects that take her new super-drug A, one group that takes a placebo, and one group that takes the currently prescribed treatment. She then measures which group has the lowest levels of anxiety. Experiment: independent variable—treatment type; dependent variable—anxiety level 3. Researchers notice what they feel is a connection between an external locus of control and sustaining injuries in a tornado. They find that for people in Alabama, there is a relationship between having an external locus of control and dying in a tornado. Positive correlation 4. Drs. Dre and Snoop are interested in the effects of smoking marijuana on memory. They predict that smoking marijuana will decrease short-term memory. They expose 100 rats to marijuana smoke three times a day, 100 rats to marijuana smoke one time a day, and 100 rats to no marijuana smoke ever. After 1 week of this condition, they teach the rats to run a maze and measure how many trials it takes each group of rats to learn the maze. Experiment: independent variable—exposure level to marijuana; dependent variable—memory of maze 5. Researchers are interested in the rates of incidence of schizophrenia and socioeconomic status (SES). They compare SES and diagnoses of schizophrenia and find that as SES increases, the likelihood of being diagnosed schizophrenic decreases. Copyright © 2013 Pearson Education, Inc. All rights reserved. 15

Negative correlation 6. Researchers are interested in the efficacy of cognitive behavioral therapy (CBT) in treating depression. They give some people pharmaceuticals, some CBT, and some both. They found that patients receiving both are less depressed then either of the other two groups. Experiment: independent variable—treatment condition; dependent variable—level of depression.

Video / Media Sources Curry, A. (News Anchor). (2008, August 29). Serbia’s horrific institutions a relic of the past [Television broadcast Parts 1–3]. Belgrade, Serbia: Dateline MSNBC. Inside Serbia’s Mental Institutions, Part One (2008, 4.55 minutes, Dateline MSNBC). ✓ One of a 3-part series depicting current-day Serbian mental institutions that mirror ancient-time asylums. Retrieved from http://www.msnbc.msn.com/id/21134540/vp/26447010#26447026 on February 12, 2012. Inside Serbia’s Mental Institutions, Part Two (2008, 9.53 minutes, Dateline MSNBC). ✓ The second part of a 3-part series showing the inhumane treatment of the mentally ill in Serbia. Retrieved from http://www.msnbc.msn.com/id/21134540/vp/26447010#26447041 on February 12, 2012. Inside Serbia’s Mental Institution, Part Three (2008, 6.52 minutes, Dateline MSNBC). ✓ The last part of the series reflecting common-day practices regarding mental health in Belgrade, Serbia. Retrieved from http://www.msnbc.msn.com/id/21134540/vp/26447010#26447026n February 12, 2012. Kids and psychiatric drugs (2007, 2.29 minutes, CBS Evening News). ✓ This video discusses the controversies surrounding children and the prescribing of psychotropic and antipsychotic medications for mental illness. Retrieved from http://www.cbsnews.com/video/watch/?id=2556317nn February 12, 2012. Looking at abnormal behavior (1992, 58.34 minutes, Alvin H. Perlmutter, Inc. and Toby Levine Communications). Retrieved from http://www.learner.org/vod/vod_window.html?pid=776 on July 24, 2009. ✓ Gives an overview of the field of abnormal psychology and shows case examples. Wallace, K. (News Anchor). (2007, March 10). Kids and psychiatric drugs [Television broadcast]. New Jersey: CBS Evening News. 2.29 minutes

Web Links Web Link 1.1: www.sfasu.edu/sfapsych/links.html This site provides psychology associations (APA, APS, Psi Chi, etc.), academic departments, journals, licensing information, and other items of interest to students of Abnormal Psychology. Web Link 1.2: www.psychopathology.org/index.cgi Official Web site of the Society for Research in Psychopathology, the premier organization for psychologists studying psychopathology. Web Link 1.3: www.apa.org Official Web site of the American Psychological Association; offers information for students, interesting psychological topics, research, and career information. Web Link 1.4: www.nami.org Home page for the National Alliance for the Mentally Ill (NAMI), a nonprofit, grassroots, self-help, and support and advocacy organization of consumers, families, and friends of people with severe mental illnesses. Web Link 1.5: www.psych.org Web site for the American Psychiatric Association, publisher of the DSM, founded by Benjamin Rush.

Handout 1.1: Is it Abnormal? Using the following scale, please answer if the behavior described is abnormal. 1

Not at all abnormal

5 Very abnormal

1. You are in a bar late at night with your friends playing a game of pool and a girl climbs on the bar, takes off her shirt, and starts dancing. _____ 2. You are walking in a parking lot on your way to a restaurant and you see a homeless person talking to himself. _____ 3. You are in a Pentecostal church and a person raises his hands and starts speaking in a nonsensical language. _____ 4. A person says her dog is telling her to do things to others, but it’s OK because God is talking through the dog. _____ 5. A 16-year-old boy playing basketball has to wear his lucky underwear because he believes he needs it to help him “win the big game.” _____ 6. You are in class and the student next to you starts to take off his clothes. _____ 7. You are in a store shopping and a person next to you starts speaking in a made-up language. _____ 8. A person must wash his hands 500 times before he can leave his house. _____ 9. You are walking through the grocery store mumbling to yourself what was on the grocery list you left at home. _____ 10. A priest tells his parishioners that God speaks through him. _____

Handout 1.2: Research Methods Is it an experiment or is it a correlation? For each example, state if the study described is an experiment or a correlation. If it is an experiment, identify the independent and dependent variables. If it is a correlation, identify if it is a positive or negative correlation. 1. Researchers are interested in whether eating disorders are related to childhood abuse. They looked at females both diagnosed with eating disorders and no diagnoses of eating disorders and compared it to self-reports of abuse in childhood. They found that females with a history of abuse were slightly more likely to develop an eating disorder than females in the general population. 2. Dr. Benzo is interested in developing a new anti-anxiety drug with less side effects and risk of dependency than the current leading treatments. She gets one group of subjects that take her new superdrug A, one group that takes a placebo, and one group that takes the currently prescribed treatment. She then measures which group has the lowest levels of anxiety. 3. Researchers notice what they feel is a connection between an external locus of control and sustaining injuries in a tornado. They find that for people in Alabama, there is a relationship between having an external locus of control and dying in a tornado. 4. Drs. Dre and Snoop are interested in the effects of smoking marijuana on memory. They predict that smoking marijuana will decrease short-term memory. They expose 100 rats to marijuana smoke three times a day, 100 rats to marijuana smoke one time a day, and 100 rats to no marijuana smoke ever. After one week of this condition, they teach the rats to run a maze and measure how many trials it takes each group of rats to learn the maze. 5. Researchers are interested in the rates of incidence of schizophrenia and socioeconomic status (SES). They compare SES and diagnoses of schizophrenia and find that as SES increases, the likelihood of being diagnosed with schizophrenia decreases. 6. Researchers are interested in the efficacy of cognitive behavioral therapy (CBT) in treating depression. They give some people pharmaceuticals, some CBT, and some both. They found that patients receiving both are less depressed then either of the other two groups.

CHAPTER 2: Historical and Contemporary Views of Abnormal Behavior Teaching Objectives

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

11. 12. 13. 14. 15. 16. 17.

Explain why in ancient times abnormal behavior was attributed to possession by a demon or god, and describe how shamans and priests administered exorcism as the primary treatment for demonic possession. Describe the important contributions from 460 BC to 200 AD of Hippocrates, Plato, Asclepiades, Aristotle, and Galen to the conceptualization of the nature and causes of abnormal behavior. Discuss how mental disorders were viewed during the Middle Ages. Describe the work of Avicenna and the differences between conceptions of mental health in Europe and the Middle East during the Middle Ages. Give examples of mass madness or mass hysteria and summarize the explanations offered for this unusual phenomenon. Outline the contributions in the late Middle Ages and early Renaissance of Paracelsus, Johan Weyer, and St. Vincent de Paul, all of whom argued that those showing abnormal behavior should be seen as mentally ill and treated with humane care. Describe the inhumane treatment that mental patients received in early “insane asylums” in Europe and the United States. Describe the humanitarian reforms in the treatment of mental patients that were instigated by Philippe Pinel, William Tuke, Benjamin Rush, and Dorothea Dix. Review how mental disorders were viewed during the 19th Century and the 21st Century. Explain how both the discovery of a biological basis for general paresis and a handful of other disorders (such as the senile mental disorders, toxic mental disorders, and certain types of mental retardation) contributed in a major way to the development of a scientific approach to abnormal psychology as well as to the emergence of modern experimental science, which is largely biological. Distinguish between biological and nonbiological versions of medical-model thinking about psychopathology. Trace the important events in the development of psychoanalysis and the psychodynamic perspective. Contrast the biological and psychodynamic views of abnormal disorders. Describe how the techniques of free association and dream analysis helped both analysts and their patients. List the major features of the behavioral perspective. Discriminate between classical and operant conditioning. Explain the problems associated with interpreting historical events.

Chapter Overview/Summary Progress in understanding abnormal behavior over the centuries has not been smooth or uniform. The steps have been uneven, with great gaps in between. Unusual, even bizarre, views or beliefs have often sidetracked researchers and theorists. The dominant social, economic, and religious views of the times have had a profound influence over how people view abnormal behavior. In the ancient world, superstitions were followed by the emergence of medical concepts in places such as Egypt and Greece; many of these concepts were developed and refined by Roman physicians. With the fall of Rome near the end of the fifth century (AD), superstitious views dominated popular thinking about mental disorders in Europe for more than a thousand years. The more scientific aspects of Greek medicine survived only in the Islamic counties of the Middle East. As late as the 15th and 16th centuries it was still widely believed, even by scholars, that some mentally disturbed people were possessed by a devil, and the primary treatment for demonic possession was for an exorcism to be conducted. Great strides have been made in our understanding of abnormal behavior. For example, during the latter stages of the Middle Ages and early Renaissance, a spirit of scientific questioning reappeared in Europe, and several noted physicians spoke out against inhumane treatments. There was a general movement away from superstitions Copyright © 2013 Pearson Education, Inc. All rights reserved. 20

and “magic” toward reasoned, scientific studies. During the times of the Greek and Romans, the Greek physician known as Hippocrates (460-377 B.C.) (now referred to as the father of modern medicine) was one of the first to state that the brain can also be diseased. He classified all mental disorders into three basic categories of mania, melancholia, and phrenitis. He further espoused that illness was also due to an imbalance of four essential fluids (blood, phlegm, bile, and black bile). During the Middle Ages, some of the ancient views and treatment methods were still present and scientific thinking was not as important. With the recognition of a need for the special treatment of disturbed people came the founding of various “asylums” toward the end of the 16th century. However, with institutionalization came the isolation and maltreatment of mental patients. Although these asylums had good intentions initially, they later became warehouses for mental patients. Slowly this situation was recognized, and in the 18th century, further efforts were made to help afflicted individuals by providing them with better living conditions and humane treatments, though these were likely the exception rather than the rule. The development of the mental hospital movement continued into the 20th century. However, over the last four decades of the century, there was a strong movement to close mental hospitals and release people into the community. This movement remains controversial. The 19th and early 20th centuries witnessed a number of scientific and humanitarian advances. The work of Philippe Pinel in France, William Tuke in England, and Benjamin Rush and Dorothea Dix in the United States prepared the way for several important developments in contemporary abnormal psychology. Among these were the gradual acceptance of mental patients as afflicted individuals who needed and deserved professional attention; the success of biomedical methods as applied to disorders; and the growth of scientific research into the biological, psychological, and sociocultural roots of abnormal behavior. In the 19th century, great technological discoveries and scientific advancements were made in the biological sciences that aided in the understanding and treatment of disturbed individuals. A major biomedical breakthrough, for example, came with the discovery of the organic factors underlying general paresis—syphilis of the brain—that had been one of the most serious illnesses of the day. Our modern scientific views of abnormal behavior have several historical branches. Four main themes were highlighted in this chapter: (1) the biological, (2) the development of a classification system, (3) the psychodynamic, and (4) the psychological research viewpoints. These viewpoints will be addressed further in chapter three. In the early part of the 18th century, knowledge of anatomy, physiology, neurology, chemistry, and general medicine increased rapidly. These advances led to the identification of the biological, or organic, pathology underlying many physical ailments. The development of a psychiatric classification system by Kraepelin played a dominant role in the early development of the biological viewpoint. Kraepelin’s work (a forerunner to the DSM system) helped to establish the importance of brain pathology in mental disorders and made several related contributions that helped establish this viewpoint. The first major steps toward understanding psychological factors in mental disorders were taken by Sigmund Freud. During five decades of observation, treatment, and writing, he developed a theory of psychopathology, known as psychoanalysis, which emphasized the inner dynamics of unconscious motives. Over the last half-century, other clinicians have modified and revised Freud’s theory, evolving new psychodynamic perspectives. Scientific investigation into psychological factors and human behavior also began to make progress in the latter part of the 19th century. The end of the 19th and early 20th centuries saw experimental psychology evolve into clinical psychology with the development of clinics to study, as well as intervene in, abnormal behavior. Two major schools of learning paralleled this development, and behaviorism emerged as an explanatory model in abnormal psychology. The behavioral perspective is organized around a central theme—that learning plays an important role in human behavior. Although this perspective was initially developed through research in the laboratory, unlike psychoanalysis, which emerged out of clinical practice with disturbed individuals, it has been shown to have important implications for explaining and treating maladaptive behavior. Understanding the history of viewpoints on psychopathology, with its forward steps and its reverses, helps us understand the emergence of modern concepts of abnormal behavior.

Detailed Lecture Outline I.

Historical Views of Abnormal Behavior A. Demonology, Gods, and Magic 1. Abnormal behavior attributed to demonic possession a. Differentiated good vs. bad spirits based on the individual’s symptoms b. Religious significance of possession 2. Treatment for possession through exorcism B. Hippocrates’ Early Medical Concepts 1. Hippocrates insisted mental disorders due to natural causes–believed brain was the central organ of intellectual activity and that mental disorders were due to brain pathology 2. Hippocrates also emphasized the importance of heredity and predisposition; pointed out that head injuries could lead to sensory and motor disorders 3. Classified all mental disorders into three categories based on detailed clinical observations: a. Mania b. Melancholia c. Phrenitis (brain fever) 4. Doctrine of the four essential fluids (Hippocrates and, later, Galen) a. Blood (sanguis) b. Phlegm c. Bile (choler) d. Black bile (melancholer) e. Treatments were designed for the specific classifications and recognized the importance of the environment f. Some treatments during this time were regular and tranquil life, sobriety from all excesses, a vegetable diet, celibacy, exercise, and bleeding 5. Many misconceptions were perpetuated a. Hysteria caused by a wandering uterus, pinning for a child where marriage was the cure b. Four bodily fluids out of balance c. Delirium was used to describe symptoms of mental disorders that result from fever or physical injury

Lecture Launcher 2.1: Are We Smarter than Hippocrates? C.

Early Philosophical Conceptions of Consciousness 1. Plato (429-347 B.C.) 2. Greek philosopher who studied individuals with mental illness who has committed criminal acts a. Claimed diminished criminal responsibility for mentally ill b. Emphasized in The Republic the role of sociocultural factors in etiology and treatment c. Despite this, believed that mental disorders were partly divinely caused 3. Aristotle a. Largely Hippocratic in views b. Rejected importance of frustration and conflict in causing mental disorders c. Described role of consciousness d. Greek philosopher (384-322 B.C.) e. Student of Plato Later Greek and Roman Thought 1. Greek and Roman thought influenced medical thought in Alexandria, Egypt a. Environmental factors considered important Copyright © 2013 Pearson Education, Inc. All rights reserved. 22

b. c.

Wide range of treatments provided Ascleplades (c. 124-40 B.C.) was a Greek physician born in Asia Minor who practiced medicine and developed a theory of disease based on the flow of atoms through the pores in the body 2. The Greek physician Galen (A.D. 130-200) a. Elaborated upon anatomy of the nervous system based on animal dissection b. Divided causes of psychological disorders into physical and mental categories 3. Roman medicine a. Pragmatic approaches b. Treatment via contrariis contrarius (opposite by opposite)—for instance, giving chilled wine while patient was in warm tub Early Views of Mental Disorders in China 1. Early Chinese medicine based on the belief that illness was naturally based; for example, yin and yang, a division of positive and negative forces—when balanced, overall health; when imbalanced, illness results 2. Treatments here focus on restoring balance 3. Chung Ching in AD 200 argued like Hippocrates that organ pathologies were the primary reason for illness but added that stressors could lead to organ pathologies Views of Abnormality During the Middle Ages 1. Islamic countries preserved some scientific aspects of Greek medicine a. First mental hospital established in Baghdad in AD 792 b. Avicenna, the “prince of physicians,” wrote the Canon of Medicine, which may be the most widely studied medical work ever written 2. European attitudes toward mental disorder were marked by superstition a. Mental disorders were prevalent in this period b. Supernatural explanations of abnormality grew in popularity c. Sin was seen as a cause of only a minority of cases 3. Mass madness—widespread occurrence of group behaviors disorders that were cases of hysteria (1) Tarantism—uncontrollable impulse to dance often attributed to the bite of the southern European tarantula or wolf spider, related to episodes in Italy; Saint Vitus’s Dance elsewhere in Europe (2) Lycanthropy—belief in possession by wolves, affected many rural residents (3) Oppression, disease, and famine maintained the mass hysterias (4) Plague (Black Death) seen as engendering mysticism, killed 50% of the population in Europe (5) Occasionally mass madness is seen even today (a) April 1983 West Bank Palestinian girls (b) 1992 in Nigeria – Koro 4. Exorcism and witchcraft a. Exorcisms were performed by the gentle laying on of hands (1) Management of mentally disturbed left largely to clergy (2) Treatment occurred mainly in monasteries and was relatively kind (3) Although we used to think that a connection between witchcraft and mental illness was common during the Middle Ages, it now appears substantially overestimated (4) Recently, there has been a resurgence of belief in supernatural forces as the cause of psychological problems and exorcism as the appropriate treatment

Lecture Launcher 2.2: How Could They Think That? II.

Paracelsus (1490-1541), Swiss physician, was an early critic of mental illness as possession a. Formulated the idea of psychic causes for mental illness b. Advocated treatment by “bodily magnetism,” later called hypnotism c. Believed in astral influences on behavior 2. Johann Weyer (1515-1588), German physician, is considered a founder of modern psychopathology a. Rebutted Malleus Maleficarum b. First physician to specialize in mental disorders c. Scorned by his peers and his works were banned by the church until the 20 th century 3. St. Vincent de Paul declared mental disease no different than physical The Establishment of Early Asylums 1. Early asylums were simply places to warehouse troublesome people 2. First hospital in Europe was probably the Valencia mental hospital in Spain in 1409 3. 1547–monastery of St. Mary of Bethlehem in London was officially made into an asylum by Henry VIII a. “Bedlam” and its deplorable conditions b. More violent patients were exhibited to the public for one penny a look c. More harmless inmates forced to seek charity on the streets 4. Proliferation of asylums across Europe and the Americas 5. Harsh tactics used to control unruly or excited patients 6. Asylums—sanctuaries or places of refuge meant solely for the care of individuals with mental illness 7. In the U.S., the Pennsylvania Hospital in Philadelphia completed under the guidance of Benjamin Franklin in 1756 Humanitarian Reform (late 18th century) 1. Pinel’s experiment (1792 at La Bicetre in Paris) a. Removed chains from mental patients as an experiment b. Patients treated with kindness, as sick people would be c. Fortunately, the experiment was a success with increased peace and order d. Recent evidence suggests that Pinel’s predecessor at La Bicetre, Jean-Baptiste Pussin, may have begun the process of removing the chains and treating the patients with more kindness e. Philippe Pinel (1745-1826) 2. Tuke’s work in England—the York Retreat a. Based on Quaker principles b. Sparked the growth of more humane mental health treatment c. Hitch introduced trained nurses and trained supervisors d. Not only improved care for patients but changed public attitudes e. William Tuke (1732-1822) 3. Rush and moral management in America a. Benjamin Rush founded American psychiatry (1) Encouraged more humane treatment (2) Wrote first systematic treatise on psychiatry in America (3) First American to organize a course in psychiatry (4) Despite these advances, he believed in astrology, bloodletting, and purgatives (5) Rush invented the “tranquilizing chair” (6) Benjamin Rush (1745-1813)

MyPsychLab Resource 2.1: Video on “Asylum: History of the Mental Institution in America” Lecture Launcher 2.3: How Can Social Progress Be Accelerated?

Moral Management—wide-ranging method of treatment that focuses on social, individual, and occupational needs (1) Achieved a high degree of effectiveness (2) Nearly abandoned by the late nineteenth century (a) Ethnic prejudice that came with rising immigrant population (b) Failure to train replacements (c) Overextension of hospital facilities (d) Rise of Mental Hygiene movement condemned patients to dependency (e) An emphasis on physical basis of mental illness countered moral treatment Dix and the mental hygiene movement (1841–1881) a. Aroused worldwide awareness of inhumane treatment for the mentally ill b. Established 32 mental hospitals in the United States, Canada, Scotland, and other countries c. Movement can be criticized as leading to the warehousing of the mentally ill in overcrowded facilities d. Mental hygiene movement—advocated for a method of treatment that focused almost exclusively on the physical well-being of mental health patients e. Benjamin Franklin’s early work with electricity accidently lead to the exploration to use electricity to treat mental illness

Activity 2:1: The History Channel 5.

The military and the mentally ill—alcohol was viewed as a key cause of psychological problems among soldiers

Nineteenth-Century Views of the Causes and Treatment of Mental Disorders 1. In the early part of the 19th century: a. Mental hospitals essentially controlled by lay persons for the treatment of “lunatics” b. Psychiatrists, known as “alienists,” played little to no role in caring for the mentally ill c. Effective treatments not available 2. By latter part of 19th century, alienists were in control of insane asylums and incorporated the traditional moral management therapy 3. Emotional problems came to be viewed as a result of expenditure of energy, depletion of bodily energies, or shattered nerves—this came to be known as neurasthenia”

Handout 2.1: Connecting Treatment to Etiology E.

Changing Attitudes Toward Mental Health in the Early 20th Century 1. Asylums viewed by public as eerie, strange, and frightening 2. Attitudes toward mental health began changing at the beginning of the 20th century with the publication of Clifford Beer’s book, A Mind That Found Itself Mental Hospital Care in the 21st Century 1. Substantial growth in numbers of hospitals in first half of century a. Lengthy hospital stays b. Little effective treatment 2. 1946—Changing views of mental health services a. Mary Jane Ward published The Snake Pit b. The National Institute of Mental Health is organized c. The Hill-Burton Act is passed funding community mental health agencies 3. 1961—Goffman published Asylums, which provided a detailed account of the neglect and maltreatment of patients in mental hospitals Copyright © 2013 Pearson Education, Inc. All rights reserved. 25

4. 5. 6.

Community Health Services Act of 1963 helped to create outpatient psychiatric clinics to treat individuals with mental illness Development of effective medications, such as lithium and phenothiazines Deinstitutionalization a. Replacement of inpatient hospitals by community-based care, day treatment hospitals, and outreach programs b. Impetus for this movement was that it was considered more humane, and cost effective, to treat mental disorders outside of hospitals, thereby preventing the learning of negative behaviors acquired as people adapted to institutionalization c. International movement d. Failure of deinstutionalization illustrated by homeless mentally ill may be due, in part, to the failure of society to develop ways to fill the gaps in mental health care

Teaching Tip 2.1: Deinstitutionalization III.

The Emergence of Contemporary Views of Abnormal Behavior A. Biological Discoveries: Establishing the Link Between the Brain and Mental Disorder 1. General paresis and syphilis a. General paresis produced paralysis and insanity; typically causing death within two to five years b. 1917—von Wagner-Jauregg introduced the malarial fever treatment of syphilis; the high fever associated with the malaria killed off the bacteria c. Early malarial treatment represented the first clear-cut conquest of a mental disorder by medical science d. Raised hopes that medical science would uncover organic bases for all mental disorders 2. Brain pathology as a causal factor a. Von Haller, Elements of Physiology (1757) b. Griesinger, The Pathology and Therapy of Psychic Disorders (1845) c. Alzheimer established the brain pathology in cerebral arteriosclerosis and in the senile mental disorders d. Identified organic pathologies underlying the toxic mental disorders, certain types of mental retardation, and other mental illnesses e. Important to note that although this has led us to understanding “how” these disorders are caused, we don’t always know “why” disorders afflict one person and not another B. The Development of a Classification System 1. Emil Kraepelin 2. Textbook, Compendium der Psychiatrie, published in 1883 3. Recognizing symptom patterns was a forerunner of the modern DSM-IV-TR C. Development of the Psychological Basis of Mental Disorder 1. Sigmund Freud (1856-1939) 2. Psychoanalytic perspective—emphasizes the inner dynamics of unconscious motives 3. Psychoanalysis—the methods used to study and treat patients from a psychodynamic point of view 4. Mesmerism a. Mesmer believed that the planets affected a universal magnetic fluid in the body—the distribution of this fluid determined health or disease b. Paris, 1778: Mesmer opened a clinic where he treated all kinds of diseases through “animal magnetism” c. Branded a charlatan by medical colleagues and an appointed body of noted scholars including Benjamin Franklin

The Nancy School—viewed hysteria as self-hypnosis a. Ambrose August Liebeault (1823-1904) used hypnosis successfully in his practice b. Jean Charcot clashed with the Nancy School (1) Believed that degenerative brain changes led to hysteria (2) Eventually was proven wrong and the Nancy School triumphed (3) First recognition of a psychologically cased mental disorder The Beginnings of Psychoanalysis a. Nancy School believed in hysteria and that those symptoms could be removed through hypnosis

Handout 2.2: The Impact of Early Relationships b.

Discovery of the unconscious (1) Breuer—unlike others using hypnotism, Freud and Breuer allowed their patients to talk freely about their problems while under hypnosis (2) Catharsis—this emotional release not only helped patients but revealed to the therapists the nature of the problems that had brought about the symptoms (3) Unconscious—the portion of the mind that contains experiences of which a person is unaware (4) Free association—involved having patients talk freely about themselves providing information about their feelings, motives, etc. (5) Dream analysis—involved having patients record and describe their dreams

Activity 2.3: Catharsis and Writing about Trauma (6)

Patients, however, did not see any connection, upon awakening from the hypnosis, between their problems and their symptoms (7) Led to formation of the notion of the unconscious (8) Free association and dream analysis The Evolution of the Psychological Research Tradition: Experimental Psychology

Lecture Launcher 2.5: Schizophrenia in Historical Perspective 1.

The early psychology laboratories a. 1879 Wilhelm Wundt at University of Leipzig b. J. McKeen Cattell brought Wundt’s methods to the U.S. c. 1896 Witmer’s psychological clinic at University of Pennsylvania (1) Clinic focused on the problems of mentally deficient children (2) Witmer seen as the founder of clinical psychology d. Other clinics soon established (1) Chicago Juvenile Psychopathic Institute in 1909 by William Healy (2) Healy was the first to view juvenile deviancy as a symptom of urbanization; first to recognize environmental, or sociocultural, factors e. Rapid and objective communication of scientific findings with the publication of journals (1) 1906–Prince–Journal of Abnormal Psychology (2) 1907–Witmer–The Psychological Clinic

Handout 2.3: Modern Non-Science and Pseudo-Science 2.

human behavior a. Classical conditioning—antecedent stimulus conditions and their relation to behavioral responses (1) Pavlov, conditioned reflex (2) Watson, psychology should study overt behavior Handout 2.4: Associative Learning–Classical Conditioning b.

Operant conditioning—consequences of behavior influence future behavior (1) Thorndike (2) Skinner (3) Pavlov (4) Watson (5) Behaviorism-study of overt behavior

MyPsychLab Resource 2.2: Video on “Skinner Biography” IV.

Unresolved Issues: Interpreting Historical Events A. “Tenacity of Historical Information” 1. Case of Little Albert 2. Psychological theorizing can be advanced by greater use of historical data 3. Collective memory and negative reaction 4. There is an absence of direct observation, so we must rely on written accounts 5. Written accounts may be incomplete a. Historical articles are from the context of the times b. We do not know the author’s purpose in writing the document c. A propaganda element may be present in them B. Current Viewpoints Color Our Interpretation of Past Events 1. Conclusions are only working hypotheses 2. Need to search for “new” historical documents

Lecture Launcher 2.5: Why Do Bad Ideas Persist? Teaching Tip 2.2: Science versus Intuition C.

Witchcraft and Mental Illness: Fact or Fiction? 1. Witch hunts during the 15th and 16th centuries 2. Controversies concerning extent of the witch hunts 3. Schoeneman’s contention that mental disorder was not viewed as witchcraft 4. Problems in the historical record confused the issue

Key Terms asylums behavioral perspective behaviorism catharsis classical conditioning deinstitutionalization dream analysis exorcisms free association insanity lycanthropy

mass madness mental hygiene movement mesmerism moral management Nancy School operant conditioning psychoanalysis psychoanalytic perspective Saint Vitus’s dance tarantism unconscious

Lecture Launchers Lecture Launcher 2.1: Are We Smarter than Hippocrates? Hippocrates’ “Doctrine of the Four Humors” often strikes students as quaint, at best, or obviously wrong at worst. The general idea, though, that imbalances in bodily fluids cause mental illness, is commonly held to this day, though we discuss imbalances in brain neurotransmitters rather than imbalances in blood, phlegm, and yellow and black biles. It might be objected that today we know about these imbalances from direct observations of the relevant substances in contrast to Hippocrates and Galen, who made claims about them in the absence of direct empirical scrutiny. It must be pointed out, though, that we do not have such data available with respect to neurotransmitters either. Such data would require conducting neurotransmitter assays from samples taken from the brains of living people—a procedure simply impossible with presently available technology. Some students might mention that blood tests are often taken during the course of pharmacotherapy. These tests, however, do not pertain to brain neurotransmitters. Instead, they track plasma levels of the medication as well as monitoring for side effects by observing white blood cells and liver enzymes, among other things. If we really had a way to establish neurotransmitter imbalances, then surely there would be a diagnostic test for psychiatric disorders that used this procedure. Instead, we infer neurotransmitter problems from the therapeutic effects of neurotransmitter-altering medications. This might seem to be a reasonable inference to students until they ponder the fact that bloodletting, for example—particularly when done to extreme degrees—was also claimed to be therapeutic, notably for its “calming” effect on patients! Lecture Launcher 2.2: How Could They Think That? The appeal to supernatural causes of mental illness strikes many students as rather incomprehensible. This is an interesting opportunity to ask whether they think people today are smarter than they were 500, 1,000, or more years ago. It is probably not too much of a stretch to assert that smart people of every age make use of the best of contemporary thinking to inform their efforts in their own fields. Prevailing views about the causes of physical events like earthquakes and astrological events would then be good sources for ideas about the causes of psychological events. Viewed in this light, early speculations about the causes of mental disorders seem much more comprehensible. Lecture Launcher 2.3: How Can Social Progress Be Accelerated? In 1758, a physician, Tissat, proposed that the loss of seminal fluid during masturbation resulted in a number of disorders, including insanity. Tissat felt that a “life force” would be used up too soon if one masturbated frequently or engaged in excessive sexual intercourse. Once the life force was depleted, insanity would ensue. This theory produced an obvious treatment approach in which the goal was to stop excessive sexual activity. Benjamin Rush’s tranquilizing chair was a form of restraint used for those exhibiting excessive masturbation. Severe forms of treatment were also developed and used including severance of the dorsal nerve in the penis and removal of the clitoris. A discussion in class can center around how attitudes concerning masturbation have changed and not changed in our society. What other behaviors that have been previously labeled as abnormal are now gaining approval? What helps to maintain such beliefs? What can speed the change in societal approval of previously rejected behaviors in the area of sexuality? Lecture Launcher2.4: Mesmer and Hypnotism Copyright © 2013 Pearson Education, Inc. All rights reserved. 29

Today, many people falsely believe that Mesmer was the inventor of hypnotism. While Mesmer was responsible for laying some of the groundwork for Freud in terms of hysteria and neuroses, most argued his cures were nothing more than “snake oil.” That said, Mesmer’s influence was still felt well into the 19th century and gave rise to work on hypnotism, hence the myth that he is responsible for it. There is a movie made in 1994 starring Alan Rickman called Mesmer that is about his life if you would like to show a clip. Lecture Launcher 2.5: Why Do Bad Ideas Persist? One explanation for the enduring nature of erroneous accounts for mental illness throughout history is the irrefutable manner in which they were framed. This would be an opportune time to describe the desirability of refutability as a property of theory development. Other reasons erroneous accounts persist can also be introduced profitably at this point in the course. Among these are placebo effects, “Barnum”-type predictions, selective perception, the power of authority, and the lack of familiarity with relatively rare forms of psychopathology. The advantages of choosing science as the ultimate frame of reference for the acquisition of one’s beliefs about mental illness can also be debated in an effort to expose and challenge objections that could interfere with student appreciation for the text and course.

Classroom Activities, Demonstrations, and Assignments Activity 2.1: The History Channel Have students simulate a modern television talk show with volunteers playing “guests” drawn from the history of abnormal psychology. The class would choose the format of the show. Would someone play Oprah, or would the “Jerry Springer” format be more interesting? Perhaps a late-night talk show would be more suitable? Or maybe a PBS-type program or extended documentary-type interview format would work best. In any event, some of the more flamboyant members of the class could be asked to play the roles of various figures discussed in chapter 2. They might want to do some additional research to help flesh out their portrayals. The class might also discuss who would be interesting to see appearing together—say, Rush and Dix–for purposes of facilitating debate. The instructor might serve as moderator in order to ensure important points are drawn out of these celebrity appearances. Activity 2.2: Hospital Field Trip A field trip to a local mental health center with inpatient facilities is a classic means for students to gain first-hand exposure to current treatment practices. Such a visit can provide a fertile ground for later classroom discussion. The students’ attention can be focused on the general living conditions of the patients and what privileges and/or opportunities exist for them. Students can be asked how they would feel living in an institution and what improvements they would like to see take place. Also, students should be sensitized to observe any present conditions that may still be influenced by attitudes and practices from the historical record. It is very important to prepare students for such a visit by discussing professional behavior, confidentiality, and any special requests offered by administrators of the facility. This can be an excellent way for facilities to secure volunteer assistance and for students to gain experiences that inform and bolster their applications for advanced study in the various mental health fields. Activity 2.3: Catharsis and Writing about Trauma Breuer, Freud, and others have been impressed with the cathartic effects of emotional self-disclosures in therapy. Recently, researchers have shown many positive effects of simply writing about emotional or traumatic events. Students could be asked to undertake such an exercise on their own, writing a detailed account of a personally traumatic or emotional event, especially one that they have not shared with others. Students can be asked to leave their names off of these essays to ensure their anonymity. If records of having completed the assignment are desired, students can be asked to write their name on someone else’s essay so that those completing the assignment can be credited without their disclosures being identified. Later, students can be asked to write about or discuss their experience following the essay assignment. It would be expected that students would feel slightly worse following the writing task but feel better in the longer term. Why this is such a fascinating topic for discussion, and how one gets from observing these effects to an elaborate theory about the dynamics of the unconscious, is also worth contemplating in anticipation of learning about Freud’s theories in the next chapter.

MyPsychLab Resources MyPsychLab Resource 2.1: Video on “Asylum: History of the Mental Institution in America” You may want to show this brief video clip that discusses the old asylums and includes video footage from an asylum. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 2, Historical and Contemporary Views of Abnormal Behavior. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Asylum: History of the Mental Institution in America” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 2.2: Video on “B.F. Skinner Biography” You may want to show this three-minute video on B.F. Skinner. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 2, Historical and Contemporary Views of Abnormal Behavior. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Skinner Biography” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise.

Teaching Tips Teaching Tip 2.1: Deinstitutionalization This is a great time to discuss with students the real effect of deinstitutionalizing—the increase in the homeless population. It’s an excellent discussion starter into ethical issues of forced treatment and free choice. Typically, at least one student will suggest that forcing medication on people who need it is OK. This can lead to larger discussions on whether we should forcibly prevent someone with high cholesterol from eating at McDonalds or force that person to take statins. Reminds students that having a mental health issue does not necessarily remove the basic human rights of a person. Teaching Tip 2.2: Science versus Intuition Although last chapter you stressed the importance of research, this is an ideal time to reiterate. As we can see based on the fields past, it is often very easy for both laypersons and experts to get it wrong. Remind students that a large focus of scientific thinking is reasoning and critical thinking. By asking questions about the validity of a theory or perspective, they are actually strengthening that perspective if it is valid. Sometimes, things that seem obvious are wrong, and everything should be viewed in the historical context in which the theory originated.

Handout Descriptions Handout 2.1: Connecting Treatment to Etiology Use Handout 2.1 as a small group exercise that enables students to review how attitudes affect the treatment of mental disturbance by designing treatment strategies for disorders “caused” by different things. Once students have been divided into small groups, present them with the task of contrasting treatment approaches for (a) a mental disorder blamed on weakness of character, (b) a mental disorder blamed on sinfulness, (c) a mental disturbance caused by poor heredity, (d) a mental disorder developed because of poor and faulty learning situations, (e) a mental disorder due to some physical illness, and (f) a mental disorder created by a poor social environment. Students are not expected to develop professional types of treatment but rather to be able to identify those attitudes that could affect how one person with mental disturbance would be treated considering the cause of the condition. Following the group activity, discussion can focus on relating past and present activities concerning mental disorder to the student ideas.

Handout 2.2: The Impact of Early Relationships The psychoanalytic perspective suggests that our early relationships carry forward into our lives by influencing current friendships. Have students describe the characteristics of people influential in their early childhood, e.g., parents, grandparents, or elementary school teachers. Next, have the students provide descriptions of recent friends. Do students select friends or dating partners based upon similarities with past significant others? Are friendship choices the result of conscious choices or is there some unconscious directive? Students can be asked to rate the similarity of current friends to past relationships using a numerical scale for dominant traits. Handout 2.3: Modern Non-Science and Pseudo-Science We have already discussed science as the final arbiter of theoretical conflicts about the origins of mental illness. Many will accept this posture relatively uncritically and wonder why it needs to be advanced at all. In order to enliven the need to promote this idea, it is interesting to have students collect contemporary examples of unscientific ideas about behavior. The self-help section of the local bookstore or library is fertile ground for gathering such examples. Newspapers also are prone to report alternative approaches to health and emotional wellness. Unconventional religious practices, occult groups, astrology, and dietary recommendations are also frequently packaged along with obviously unscientific explanations. A bit more challenging, but pedagogically superior, is the collection of pseudo-science material. These would be things that are at pains to look scientific but actually are not. Bogus science detection is an invaluable skill in modern society and inculcation of the habits of thinking that support it are a terrific aspiration for teachers of abnormal psychology. Handout 2.4: Associative Learning–Classical Conditioning This is a great way to not only illustrate the practicality of classical conditioning but also to ensure that students understand the concepts. The behavioral perspective takes the stance that everything is learned. For example, look at the case of Little Albert. Albert was a young child who was conditioned to fear white rats. The association of fear to rat was learned via classical conditioning. That is, Albert was exposed to a rat (neutral stimuli) then a loud noise (UCS and an aversive stimuli). He showed a fear response to the aversive stimuli by jumping up and crying (UCR). After many trials, Albert showed the fear response (CR) to the stimuli of rat (CS). This is classical conditioning. For the following examples, fill in the unconditioned stimuli and response as well as the conditioned stimuli and response. 1. Bethany is sitting outside sunbathing when a spider crawls on her leg and bites her. She jumps up and yells in pain. Now when she sees a spider, she jumps and yells. UCS: spider bite UCR: jumps up and yells in pain CS: spider CR: jumps and yells 2. Ramon is in the mall parking garage when a man holding a gun to his head attacks him. He screams in fear. Now Ramon shudders with fear whenever he sees a parking garage. UCS: being attacked at gun point UCR: scream and fear CS: parking garage CR: fear 3. Simone was only five when she was on a plane that almost crashed. She remembers the plan landing very hard and bouncing all over the runway and being very afraid. Now when Simone thinks about flying, she becomes very afraid. UCS: bad landing for plane UCR: being afraid CS: thinking about flying CR: being afraid

4. Tamika lives in an old dorm on campus that has a plumbing issue. One day, she was taking a shower when someone flushed the toilet and all the cold water went out and the hot water burned her. She yelled and jumped out of the way. Now when she is in the shower, if someone flushes, she jumps out of the way. UCS: getting burned UCR: yell and jump away CS: toilet flushing CR: jump away 5. Dave was out with his friends one day when they decided to go white water rafting. Unfortunately, the boat immediately overturned, and Dave wound up on the wrong side of the river, away from everyone else and with no access. It took hours for rescuers to cross to him and rescue him. While he waited he became anxious and fearful. Now when his friends suggest any activity on the river, Dave becomes anxious and fearful. UCS: waiting to be rescued after rafting accident UCR: anxious and fearful CS: river related activities CR: anxious and fearful (You may also want to use this to discuss backward conditioning and systematic desensitization.)

Video / Media Sources Abnormal Behavior: A Mental Hospital, 28 min. CRM/McGraw-Hill Films, 110 15th Street, Del Mar, CA 92014. Portrays life in a modern mental hospital, including views of schizophrenics and of a patient receiving ECT. Abnormal Psychology, 29 min. Coast Telecourses. This shows the difficulties distinguishing between normal and abnormal behavior in reference to DSM criteria. Asylum, 60 min. Direct Cinema Limited. A documentary that focuses on one hospital, St. Elizabeth’s in Washington, and the changes in treatment that have occurred over time. Is Mental Illness a Myth? 29 min. NMAC-T 2031. Debates whether mental illness is a physical disease or a collection of socially learned behaviors. Panelists are Thomas Szasz, Nathan Kline, and F.C. Redlich. Keltie’s Beard: A Woman’s Story, 9 min. FL. (1983). A video about a woman with heavy facial hair that she chooses not to cut. This can be useful in discussing the criteria for abnormal. Little People, 58 min. FL. (1985). This video focuses on the discrimination and difficulties of access for people with dwarfism. It is good for discussing the definition and meaning of abnormal.

Web Links Web Link 2.1: www.trepan.com Lest students conclude that trephining is merely a historical, if slightly humorous, artifact of prehistorical ignorance, it is worth pointing out that it survives to this day. At this website, students will learn that the International Trepanation Advocacy Group is dedicated to accumulating the largest base of information about trepanation ever before assembled. I-TAG is interested in presenting all the information about trepanation. Web Link 2.2: www.cwu.edu/~warren/today.html This is the search engine for the Historical Database of the American Psychological Association. Keyword (e.g., “bedlam”), name (e.g., Dorothea Dix), and date (e.g., June 1) searches are permitted. Web Link 2.3: http://psychclassics.yorku.ca Here you will find full-text copies of a large number of historical documents from the history of psychology with over 200 articles and 25 books—with links to many more at other sites. Freud, Janet, Jung, Szasz, and Witmer are among the many authors represented. All documents are in the public domain. Web Link 2.4: www.psych.yorku.ca/orgs/resource.htm Web resources about the history and philosophy of psychology.

Handout 2.1 Treating the Cause of Mental Disorder

Group 1:

Mental disorder due to weak character

Group 2:

Mental disorder due to sinfulness

Group 3:

Mental disorder due to genetics

Group 4:

Mental disorder due to poor parenting

Group 5:

Mental disorder due to physical illness

Group 6:

Mental disorder due to social interactions with peers

Handout 2.2 Childhood Role Models

Select a person who was most influential in your early years of psychological development. Describe the characteristics and traits of that individual. Role Model

Traits and Characteristics

Select friends from high school and college and list them below. Describe their characteristics and traits. Friend 1

Traits and Characteristics

Friend 2

Traits and Characteristics

Friend 3

Traits and Characteristics

Friend 4

Traits and Characteristics

Rate the level of similarity of each friend to the childhood role model. Use the scale 1-10, where “1” is not at all similar and “10” is extremely similar. Ratings: Friend 1: _____,

Friend 2: _____,

Friend 3: _____,

Friend 4: _____.

Handout 2.3 Pseudoscience Detection Michael Shermer gives a Carl Sagan-inspired “Baloney Detection Kit” in the journal Scientific American (2001, November and December). Use his ten questions to evaluate allegedly scientific claims.

How reliable is the source of the claim?

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

Have the claims been verified by other sources?

How does the claim fit with what we already know?

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

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

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

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

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

10.

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

Handout 2.4 Associative Learning–Classical Conditioning The behavioral perspective takes the stance that everything is learned. For example, look at the case of Little Albert. Albert was a young child who was conditioned to fear white rats. The association of fear to rat was learned via classical conditioning. That is, Albert was exposed to a rat (neutral stimuli) then a loud noise (UCS and an aversive stimuli). He showed a fear response to the aversive stimuli by jumping up and crying (UCR). After many trials, Albert showed the fear response (CR) to the stimuli of rat (CS). This is classical conditioning. For the following examples, fill in the unconditioned stimuli and response as well as the conditioned stimuli and response. 1. Bethany is sitting outside sunbathing when a spider crawls on her leg and bites her. She jumps up and yells in pain. Now when she sees a spider, she jumps and yells. UCS: UCR: CS: CR: 2. Ramon is in the mall parking garage when a man holding a gun to his head attacks him. He screams in fear. Now Ramon shudders with fear whenever he sees a parking garage. UCS: UCR: CS: CR: 3. Simone was only 5 when she was on a plane that almost crashed. She remembers the plan landing very hard and bouncing all over the runway and being very afraid. Now when Simone thinks about flying, she becomes very afraid. UCS: UCR: CS: CR: 4. Tamika lives in an old dorm on campus that has a plumbing issue. One day, she was taking a shower when someone flushed the toilet and all the cold water went out and the hot water burned her. She yelled and jumped out of the way. Now when she is in the shower, if someone flushes, she jumps out of the way. UCS: UCR: CS: CR: 5. Dave was out with his friends one day when they decided to go white water rafting, unfortunately, the boat immediately overturned and Dave wound up on the wrong side of the river, away from everyone else and with no access. It took hours for rescuers to cross to him and rescue him. While he waited he became anxious and fearful. Now when his friends suggest any activity on the river, Dave becomes anxious and fearful. UCS: UCR: CS: CR:

CHAPTER 3: Causal Factors and Viewpoints Teaching Objectives 1.

2. 3. 4. 5. 6.

Discuss the different conceptual approaches to understanding the causes and risk factors of abnormal behavior. These approaches will include: (a) necessary, sufficient, and contributory causes; (b) feedback and bidirectionality model; and (c) the diathesis-stress model. Summarize the biological theories and causes of abnormal behavior, including neurotransmitter/hormonal imbalances, genetic vulnerabilities, temperament, and physical damage to brain structures. Outline the major psychological theoretical approaches to abnormal behavior, including the psychodynamic, behavioral, and cognitive-behavioral perspectives. Review the causal factors of abnormal psychology from a psychological view, such as early deprivation or trauma, parenting styles, marital problems, divorce, and maladaptive peer relationships. Describe the sociocultural perspective and its contributions to understanding abnormal behavior. Explain why the field needs a unified viewpoint and how the biopsychosocial viewpoint may fulfill that need.

Chapter Overview/Summary Usually the occurrence of abnormal or maladaptive behavior is considered to be the joint product of a person’s vulnerability (diathesis) to disorder and of certain stressors that challenge his or her coping resources. In considering the causes of abnormal behavior, it is important to distinguish between necessary, sufficient, and contributory causal factors, as well as between relatively distal causal factors and those that are more proximal. Regardless of the theory used, several factors are considered in the etiology of abnormal behavior. The concept of protective factors is important for understanding why some people with both a diathesis and a stressor may not develop a disorder but may remain resilient. Both the distal and proximal (immediate) causes of mental disorder may involve biological, psychosocial, and sociocultural factors. These three classes of factors can interact with each other in complicated ways. This chapter discusses biological, psychosocial, and sociocultural viewpoints, each of which tends to emphasize the importance of causal factors of the same type. In examining biologically based vulnerabilities, we must also consider genetic endowment, biochemical and hormonal imbalances, temperament, and brain dysfunction and neural plasticity. Investigations in this area show much promise for advancing our knowledge of how the mind and the body interact to produce maladaptive behavior. The oldest psychological viewpoint on abnormal behavior is Freudian psychoanalytic theory. For many years, this view was preoccupied with questions about libidinal energies and their containment. More recently, psychodynamic theories have shown a distinctly social or interpersonal thrust under the influence, in part, of objectrelations theory that emphasizes the importance of the quality of very early (pre-Oedipal) mother-infant relationships for normal development. The originators of the interpersonal perspective were also defectors from the psychoanalytic ranks that took exception to the Freudian emphasis on the internal determinants of motivation and behavior. They instead emphasized that important aspects of human personality have social or interpersonal origins, especially unsatisfactory relationships in the past or present. Psychoanalysis and closely related therapeutic approaches are termed psychodynamic in recognition of their attention to inner, often unconscious, forces. The behavioral perspective on abnormal behavior, which was rooted in the desire to make psychology an objective science, was slow in overcoming the dominant psychodynamic bias of the time, but in the last 30 years, it has established itself as a major force. Behaviorism focuses on the role of learning in human behavior, and it views maladaptive behavior either as a failure of learning appropriate behaviors, or learning maladaptive behaviors. Adherents of the behavioral viewpoint attempt to alter maladaptive behavior either by extinguishing it and/or by training new, more adaptive, behaviors. Initially a spin-off from (and in part a reaction against) the behavioral perspective, the cognitive-behavioral viewpoint attempts to incorporate the complexities of human cognition and how it can become distorted into understanding the causes of psychopathology. Adherents of the cognitive-behavioral viewpoint attempt to alter maladaptive thinking and improve a person’s abilities to solve problems and to plan. People’s schemas and self-schemas play a central role in the way that they process information and in the kinds of attributions and values concerning the world that they have. A schema is what contributes to how one acts, thinks, and feels based on temperament, abilities, and experiences. The efficiency, accuracy, and coherence of a person’s schemas and self-schemas appear to provide an important protection against psychopathology. Sources of psychosocially determined vulnerability include early social deprivation or severe emotional trauma, inadequate parenting styles, marital discord and divorce, and maladaptive peer relationships. The sociocultural viewpoint is concerned with the social environment as a contributor to mental disorder because sociocultural variables are important sources of vulnerability, or, conversely, of resistance. Although many serious mental disorders are fairly universal, the prevalence and form that some disorders take varies widely among different cultures. Low socioeconomic status, unemployment, and being subjected to prejudice and discrimination are associated with greater risk for various disorders.

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

Detailed Lecture Outline I.

Causes and Risk Factors for Abnormal Behavior A. Necessary, Sufficient, and Contributory Causes 1. Etiology is the causal pattern of abnormal behavior. 2. Necessary cause is a condition that must exist for a disorder. 3. Sufficient cause of a disorder is a condition that guarantees the occurrence of a disorder. 4. Contributory causes increase the probability of a disorder. 5. A condition that must exist for a disorder to occur is a necessary cause. 6. A sufficient cause guarantees the occurrence. 7. A contributory cause increases the probability. 8. Distal causal factors are causal factors occurring relatively early in life that do not show their effects for years. 9. Proximal causal factors are causal factors that operate shortly before the occurrence of the symptoms of a disorder. 10. A reinforcing contributory cause is a condition that maintains maladaptive behavior.

Handout 3.1: Partitioning Causal Variance B.

Feedback and Bidirectionality in Abnormal Behavior 1. When more than one causal factor is involved, a causal pattern is found. 2. Simple cause-and-effect sequences are rare in abnormality. 3. Complex systems of feedback produce patterns of interaction and circularity. 4. Causal pattern is when more than one factor is involved in the cause. Diathesis-Stress Models 1. A predisposition toward a given disorder is termed a diathesis or vulnerability. 2. Diathesis can derive from biological, psychosocial, and sociocultural causal factors. 3. Diathesis may be perceived as the distal necessary or contributory cause; a more proximal undesirable event or situation (the stressor) produces the disorder in someone with the distal necessary or contributory cause. 4. Diathesis-stress-models—when mental disorders develop when some kind of stressor operates on a person 5. Stress is a response to an adjustment demand. 6. Several models of how diathesis and stress may combine to produce a disorder: a. Additive model: diathesis and stress together must reach a particular level; may reach this level with only diathesis or stress but easier if both are present b. Interactive model: some amount of diathesis and stress required; if both are not present, the disorder will not develop 7. Protective factors are influences that modify a person’s response to environmental stressors making it less likely that the person will experience the adverse consequences of the stressors. a. Having at least one parent who is warm and supportive b. Exposure to moderate stressful experiences dealt with successfully c. Girls are less vulnerable than boys d. Other protective attributes: easygoing temperament, high self-esteem, high intelligence and school achievement e. Protective factors may lead to resilience—the ability to cope successfully with very difficult circumstances 8. Diathesis-stress models are multicausal developmental models emphasizing that we must know what is normal development to understand what constitutes abnormal development (developmental psychopathology).

Teaching Tip 3.1: Diathesis Stress Models Lecture Launcher 3.1: Implicit Theoretical Orientations

Activity 3.1: Etiological Thought Experiments II.

III.

Viewpoints for Understanding the Causes of Abnormal Behavior A. Viewpoints help organize observations, provide a system of thought in which to place the observed data, and suggest areas of focus for research and treatment. B. The understanding and treatment of abnormal behavior has moved from biological, to unconscious psychological forces, to sociocultural influences on behavior. Today the field takes a more inclusive interactionist perspective. C. The biopsychosocial viewpoint incorporates the biological, psychological and sociocultural factors and looks at how nature and nurture interact to produce mental health issues. The Biological Viewpoint and Biological Causal Factors

Lecture Launcher 3.2: Is Crying Biological? Activity 3.2: Is Crying Biological? A. B.

Mental disorders are viewed as disorders of the central nervous system, the autonomic nervous system, and/or the endocrine system that are inherited or caused by some pathological process. Imbalances of Neurotransmitters and Hormones (see figure 3.1) 1. Imbalances of neurotransmitter systems 2. Neurotransmitter—chemical substances that are released into the synapse by the presynaptic neuron a. May be excessive production and release of the neurotransmitter substances into the synapses b. Synapse—a tiny fluid-filled space between neurons c. Dysfunction may occur in how neurotransmitters are deactivated d. May be a problem with receptors in the postsynaptic neuron e. Norepinephrine, dopamine and serotonin are monoamines (each synthesized from a single amino acid) that have been extensively studied 3. Hormonal imbalances (see figure 3.4 for a diagram of the endocrine system) 4. Pituitary gland—the master gland of the body which produces a variety of hormones 5. Hypothalamic-pituitary-adrenal-cortical axis (HPA axis) 6. Cortisol—stress hormone Genetic Vulnerabilities

MyPsychLab Resource 3.1: Explore “Building Blocks of Genetics” 1. 2. 3. 4. 5.

6. 7. 8. 9. 10.

Abnormalities in the structure or number of chromosomes Genes-very long molecules of DNA Chromosomes—chain-like structures within a cell nucleus that contain genes Vulnerabilities to mental disorders are almost always polygenic, which means multiple genes influence them. Genes affect behavior indirectly; expression is not a simple outcome of the information encoded in the DNA but is the end product of a process that is influenced by the internal and external environment. The relationship of genotypes to phenotypes Polygenic—mental disorders that are influenced by multiple genes Genotype—a person’s total genetic endowment Phenotype—the interaction of the genotype and the environment Genotype-environment correlations occur when the genotype shapes the environmental experiences a child has. a. Passive effect b. Evocative effect c. Active effect

11. 12.

13.

People with different genotypes may be differentially sensitive or susceptible to their environment; this is known as genotype-environment interactions Methods for studying genetic influences, used by those in the field of behavior genetics, includes: a. Behavior genetics-the field that focuses on studying the heritability of mental disorders (1) Pedigree or family history method (2) Twin method (3) Concordance rate (4) Adoption method Separating genetic and environmental influences a. Shared environmental influences are those that would affect all children in a family similarly. b. Nonshared environmental influences are those in which children in the same family differ.

Teaching Tip 3.2: Genotype-Environment Interactions and Nature Nurture Effects 14.

Linkage analysis and association studies a. These studies attempt to determine the actual location of genes for certain disorders. b. Linkage analysis—studies mental disorders on known chromosomes of genes for inherited physical characteristics c. Linkage analysis has proven successful with Huntington’s disease but not conclusively with any psychological disorders. d. Association studies are proving to be more promising, starting with two large groups of individuals—one group with and one group without a given disorder.

Lecture Launcher 3.4: Would It Clone? D.

Temperament 1. Refers to a child’s reactivity and characteristics of self-regulation 2. Approximately five dimensions of temperament have been identified: a. Fearfulness b. Irritability or frustration c. Positive affect d. Activity level e. Attentional persistence

Activity 3.3: Temperament, Applying the Diathesis Stress Model 3.

Temperamental characteristics seem to be related to three important dimensions of adult personality: a. Neuroticism or negative emotionality b. Extraversion or positive emotionality c. Constraint (conscientiousness and agreeableness) 4. May set the stage for various forms of psychopathology later in life 5. Behaviorally inhibited—label for children who are fearful or hypervigilant in unfamiliar situations. Brain Dysfunction and Neural Plasticity 1. Considerable neural plasticity or flexibility of the brain in making changes in organization and function in response to pre- and post-natal experiences, stress, diet, disease, drugs, maturation, etc. 2. Animal studies clearly document that both positive and negative events can lead to changes in the structure and functioning of the brain. Copyright © 2013 Pearson Education, Inc. All rights reserved. 44

Recent evidence suggests that unstimulating, deprived environments can cause retarded development in humans. 4. Developmental systems approach acknowledges not only the genetic activity influences on neural activity but also how the environment also impacts psychopathology. 5. Recent research emphasizes the importance of a developmental systems approach— genetic activity influences neural activity which in turn influences behavior which in turn influences the environment but also that these influences are bidirectional. (See figure 3.6 for Gottlieb’s concept of epigenisis.) The Impact of the Biological Viewpoint 1. Host of new drugs has brought attention to biological viewpoints 2. Gorenstein points out that it is illusory to say biological differences signal illness. 3. Gorenstein also points out that psychological causes can be distinguished from biological causes only prior to their entry into the central nervous system. 4. Mediated—psychological events are controlled through the activities of the CNS.

Lecture Launcher 3.5: Pills or Skills for ADHD? IV.

The Psychological Viewpoints A. The Psychodynamic Perspectives 1. Sigmund Freud founded the psychoanalytic school, which emphasizes the role of unconscious motives and thoughts. 2. Fundamentals of Freud’s psychoanalytic theory a. The structure of personality: id, ego, superego (1) Life instincts and libido (2) Death instincts (3) Pleasure principle (4) Primary process thinking (5) Secondary process thinking (6) Reality principle (7) Intrapsychic conflicts (8) Libido—the basic emotional and psychic energy of life (9) Pleasure principle—id operates on this engaging in selfish and pleasureoriented behavior (10) Primary process thinking—realistic actions needed to meet instinctual demands (11) Ego—second part of the personality that mediates between the id and the realities of the real world (12) Secondary process thinking—ego’s adaptive measures (13) Reality principle—ego operates on this (14) Superego—the third part of personality, conscience (15) Intrapsychic conflicts—inner mental conflicts that lead to mental disorders b. Anxiety, defense mechanisms, and the unconscious (1) Ego-defense mechanisms—irrational protective measures to defend a bruised ego.

Activity 3.4: Own Your Mechanisms of Defense Handout 3.2: Freudian Defense Mechanisms

(2) Freud believed that anxiety played a key causal role in most forms of psychopathology. (3) Neurotic and moral anxiety, because they are unconscious, cannot be dealt with rationally thus the ego resorts to irrational protective mechanisms referred to as ego-defense mechanisms (see Table 3.1). Psychosexual stages of development

(1) Oral stage (2) Anal stage (3) Phallic stage (4) Latency period (5) Genital stage d. The Oedipus Complex and the Electra Complex (1) Castration anxiety (2) Penis envy 3. Newer psychodynamic perspectives a. Ego psychology—when the ego does not function adequately b. Object-relations theory focuses on individuals’ interactions with real and imagined other people and on the relationships that people experience between their internal and external objects. c. The interpersonal perspective views psychopathology as rooted in unfortunate tendencies we have developed while dealing with our interpersonal environments. d. Attachment theory emphasizes the importance of early experience, specifically the quality of parental care to the development of secure attachments. 4. Impact of the psychoanalytic perspective a. Development of therapeutic techniques such as free association and dream analysis leading to recognition and influence of the unconscious, early childhood experiences, and sexual factors. b. Problems develop as failed coping strategies c. Two important criticisms (1) Failure to recognize scientific limits of personal reports of information. (2) Lack of scientific evidence to support many of its assumptions or the effectiveness of traditional psychoanalysis. 5. Impact of newer psychodynamic perspectives a. Increasing scientific rigor b. More focus on documenting effectiveness of treatment c. Enormous amount of research generated by attachment theory. The Behavioral Perspective 1. Learning—the modification of behavior as a consequence of experience 2. Classical conditioning (see Figure 3.8) a. Unconditioned stimulus b. Unconditioned response c. Conditioned stimulus d. Conditioned response e. Stimulus-stimulus expectancy f. Extinction g. Spontaneous recovery h. Interoceptive cues

Teaching Tip 3.3: An Example of a Learned Fear Response 3.

Instrumental (or operant) conditioning a. Reinforcement b. Response-outcome expectancy c. Conditioned avoidance response

Lecture Launcher 3.6: Why Is It So Hard to Quit Smoking? 4. 5. 6.

Generalization and discrimination Observational learning Impact of the behavioral perspective a. Dollard and Miller’s classic publication Copyright © 2013 Pearson Education, Inc. All rights reserved. 46

Maladaptive behavior is viewed as essentially the result of: (1) Failure to learn necessary adaptive behaviors or competencies (2) Learning of ineffective or maladaptive responses c. Focus of therapy is to change specific behaviors and emotional responses d. Hailed for precision and objectivity, wealth of research, and for its demonstrated effectiveness in changing specific behaviors e. Criticized by many for focusing on specific behaviors and for the misconception that it simplifies human behavior The Cognitive-Behavioral Perspective 1. Bandura stressed that human beings regulate their behavior by internal symbolic processes—thoughts—or internal reinforcement. 2. Cognitive-behavioral perspective focuses on how thoughts and information processing can become distorted and lead to maladaptive emotions and behaviors 3. Believed that treatment works by improving self-efficacy, the belief that one can achieve one’s desired goal. 4. Schemas and cognitive distortions a. Today, the cognitive or cognitive-behavioral perspective focuses on how thoughts and information processing can become distorted and lead to maladaptive emotions and behavior. b. Schema—underlying representation that guides current processing of information and leads to distortions c. Aaron Beck developed the concept of a schema or underlying representative of knowledge that guides the current processing of information and often leads to distortions in attention, memory, and comprehension. d. Beck: (1) Has received widespread support (2) Traditional behaviorists remain skeptical, as cognitions are not observable; must rely on client report. (3) Research studies documenting effectiveness of cognitive-behavioral techniques. e. Self-schemas include our views about who we are, what we might become, and what is important to us. f. Assimilation and accommodation g. Different maladaptive schemas that have developed as a function of adverse early learning experiences characterize different forms of psychopathology. h. Information may be processed nonconsciously, outside of our awareness as evidenced by implicit memories. 5. Attributions, attributional style and psychopathology a. Attribution—simply process of assigning causes to things that happen. b. Self-serving bias 6. Cognitive therapy 7. The impact of the cognitive-behavioral perspective What the Adoption of a Perspective Does and Does Not Do 1. No one viewpoint accounts for the complex variety of maladaptive behaviors 2. Perceptions influenced by viewpoint

Psychological Causal Factors

Activity 3.5: Predictable and Controllable A.

Early Deprivation or Trauma (See Figure 3.10) 1. Institutionalization a. Many children institutionalized in infancy or early childhood show severe emotional, behavioral, and learning problems and are at risk for disturbed attachment relationships and psychopathology.

Adoption can lead to significant improvement; the earlier the adoption, the better the children did. 2. Neglect and abuse in the home a. Among infants, gross neglect may be worse than abuse. b. Abused children may be overly aggressive, suffer difficulties in linguistic development, and develop significant problems in behavioral, emotional, and social functioning, including conduct disorder, depression, anxiety, and impaired relationships with peers. c. Atypical patterns of attachment are common—most often a disorganized and disoriented style. d. These early experiences may never be overcome. e. There is a 30% chance of intergenerational transmission. f. Improvements may be seen when the caregiving environment changes. 3. Separation Inadequate Parenting Styles 1. Parent-child relationships are always bidirectional. 2. Parental psychopathology a. Parents suffering from schizophrenia, depression, antisocial personality disorder, or alcoholism tend to have children at heightened risk for a wide variety of developmental difficulties. b. Effects do not seem to be due simply to genetic variables. c. Importance of protective factors such as a warm and nurturing relationship with an adult, having good intellectual skills, having social and academic competence, and being appealing to adults 3. Parenting styles: warmth and control (Figure 3.12 depicts the four types) a. Authoritative parenting b. Authoritarian parenting c. Permissive/indulgent parenting d. Neglectful/uninvolved parenting e. Styles vary in the degree of parental warmth and in the degree of parental control f. Restrictiveness can protect children growing up in high-risk environments.

Activity 3.6: The Parental Authority Questionnaire C.

Marital Discord and Divorce 1. Marital discord a. When marital discord is long-standing, may lead to frustrating, hurtful, and generally damaging effects on both adults and children b. Effects may be buffered if one parent is warm, prone to praise and approval, and able to inhibit rejecting behavior toward child or if child has supportive peers. 2. Divorced families a. Effects of divorce on parents b. Direction of the causal relationship—overrepresentation among psychiatric patients c. Effects of divorce on children (1) Long-lasting modest negative effects documented. (2) Effects of divorce are often more favorable than the effects of remaining in a home with marital discord. (3) Children living with stepparents—especially very young children—are at increased risk for physical abuse. Maladaptive Peer Relationships 1. Despite attitudes against bullying, most children do nothing to discourage bullying; 20%30% of children actually encourage the bully.

Sources of popularity versus rejection a. Popular children tend to be either prosocial or antisocial b. Rejected children tend to be too aggressive or too withdrawn.

VI.

The Sociocultural Viewpoint A. Uncovering Sociocultural Factors through Cross-Cultural Studies 1. Universal and culture-specific symptoms of disorders a. Controlled experimentation is difficult in sociocultural investigation b. Sociocultural factors appear to influence which disorders develop, the forms that they take, how prevalent they are, and their courses. c. Depression is seen across cultures but in varying rates and in different forms—in China, for example, there is a relatively low rate of depression, decreased reporting of guilt, and the effects of stress are more typically manifested in physical problems. 2. Culture and over- and undercontrolled behavior (see Table 3.4) a. Children in Thailand show greater prevalence of overcontrolled problems such as shyness, anxiety, and depression as compared to American children. b. Also found differences in likelihood of parents referring children for treatment with Thai parents less likely than their American counterparts.

VII.

Sociocultural Causal Factors A. Low Socioeconomic Status and Unemployment 1. Correlation between psychopathology and low socioeconomic status; strength of correlation varies by disorder. 2. Stressors are common. 3. Lower SES families tend to have more problems. 4. Unemployment associated with enhanced vulnerability and elevated rates of psychopathology 5. Underemployed people show rates of depression comparable to those seen in unemployed individuals. B. Prejudice and Discrimination in Race, Gender, and Ethnicity 1. Stereotypes are demoralizing 2. Two primary types of discrimination: a. Access discrimination b. Treatment discrimination 3. In addition to discrimination, women have also suffered from sexual harassment in the workplace. C. Social Change and Uncertainty 1. Numerous adjustments demanded by change in our society 2. Helplessness engendered by events such as September 11, 2001. D. Urban Stressors: Violence and Homelessness 1. Annually 3.5 million people worldwide die from violence. 2. Domestic violence impacts physical health, lost productivity, and increases rates of anxiety, PTSD, depression, and suicide. 3. One-third of homeless people suffer from mental illness. E. The Impact of the Sociocultural Viewpoint 1. Broadened view from a focus on the individual to include a concern with societal, communal, familial, and other group settings 2. Led to design of programs 3. Led to community facilities 4. Changes in the DSM system

VIII.

Unresolved Issues: Theoretical Viewpoints and the Causes of Abnormal Behavior A. Advantages of Having a Theoretical Viewpoint 1. Consistent approach Copyright © 2013 Pearson Education, Inc. All rights reserved. 49

2. 3. B.

However, may also blind researchers to other approaches Corrective interpretations attempt to update theoretical perspectives but may not always be accepted The Eclectic Approach 1. Accepting working ideas from several viewpoints and incorporating whatever is found to be useful. 2. Works best in clinical practice rather than at a theoretical level. The Biopsychosocial Unified Viewpoint 1. Attempt at an unified perspective 2. Particular combination of factors may be unique for each individual.

Key Terms adoption method association studies attachment theory attribution behavior genetics biopsychosocial viewpoint castration anxiety chromosomes classical conditioning cognitive-behavioral perspective concordance rate contributory cause cortisol developmental psychopathology developmental systems approach diathesis diathesis-stress models discrimination ego ego psychology ego-defense mechanisms Electra complex etiology extinction family history (or pedigree) method generalization genes genotype genotype-environment correlation genotype-environment interaction hormones hypothalamic-pituitary-adrenal-cortical axis

id instrumental (or operant) conditioning interpersonal perspective intrapsychic conflicts learning libido linkage analysis necessary cause neurotransmitters object-relations theory observational learning Oedipus complex phenotype pituitary gland pleasure principle polygenic primary process thinking protective factors psychosexual stages of development reality principle reinforcement resilience schema secondary process thinking self-schema spontaneous recovery stress sufficient cause superego synapse temperament twin method

Lecture Launchers Lecture Launcher 3.1: Implicit Theoretical Orientations Students of abnormal psychology love case studies, and it is helpful to introduce such studies early and often. At this point in the course, though, students do not necessarily have the knowledge of disorders necessary to make cases educational as far as the disorders themselves are concerned. Nevertheless, students are quite willing to speculate about the causes of psychopathology in individual cases and in doing so they can expose the implicit theoretical orientations they will have to be mindful of throughout the course. Therefore, giving a fairly straightforward case study of a common disorder, like depression, can prompt an interesting class discussion. Most students will be familiar with the basic features of depression, and they are likely even to have an opinion about what causes it and how it ought to be treated. This is also a good opportunity to introduce something about your own background, mentioning how the case is one of your own or where you learned about it. Alternatively, many excellent cases are available to you from among the many case studies given in the text or other case study resources, like journals, books, and even newspapers and magazines or celebrity autobiographical articles. In any event, after describing the case, students are asked to come up with as many explanations as they can and then to reflect upon the ones that seem most plausible to them. What kinds of explanations do they gravitate toward? Which ones do they dislike? Why? Are there background experiences or factors coming into play? Are they being overly influenced by something they read or saw on TV? Lecture Launcher 3.2: Is Crying Biological? At this point in the course, students are ordinarily not equipped to discuss causal factors and viewpoints with respect to specific disorders. However, they are able to apply these ideas to more familiar phenomena. For instance, the lecture could begin with a discussion of the various components of crying, setting the stage for later discussion of the ideas students offer. That is, it would be typical to have crying explained by students as involving components that are cognitive (“I realized I wouldn’t get into medical school”), interpersonal (“My best friend betrayed me”), biological (“Tears clear debris from the eye and come from special tear ducts”), and sociocultural (“Everyone started crying at the same time”). These could be named as they come out. Then, there would be some foundation for the components when they are covered subsequently in the lecture. Alternatively, the various causal factors and viewpoints can be covered first; then they could later be applied to crying. If not crying, other topics might include love, joy, anger, and jealousy. Students could also be asked to name psychological phenomena that baffle them. These could then be analyzed according to the principles described in the chapter and lecture on causal factors and viewpoints. It is very helpful to emphasize early in the course that it is not a matter of which viewpoint is “right” or “best.” Rather, all the viewpoints are necessary, and the challenge of the course is an integrative understanding of disorders. Just as biological components of crying do not negate cognitive ones, neither do biological components of schizophrenia negate social ones. A companion activity to this discussion topic is given below as activity 3.2. Lecture Launcher 3.3: Developmental Trends in Genotype-Environment Interactions You may want to point out to students that there are specific trends in these three effects. Passive effects should decrease as you get older. That is, mom and dad should not be picking out your clothes and friends today. Active effects should decrease in concourse with passive decreasing. That is, now your students pick their own friends, clothes, and where they go to school. Evocative effects tend to stay constant, assuming there is no gross environmental harm. Ask students what they think about this. If someone is a pretty child, does it necessarily mean that can’t change? If so, how does it affect the person (if at all). If someone is a smart five year old, will he or she be a smart 20 year old? Lecture Launcher 3.4: Would It Clone? Another way to expose students’ ideas about the distribution of causes of psychopathology is to ask whether a clone of someone with the disorder or personality would be the same, insofar as the characteristic under consideration is concerned. Point out that this is not entirely an academic thought experiment because throughout the text there are citations to how similar genetic clones are to people with the various disorders. That is because identical twins are genetic clones, and the concordance rates for identical, or monozygotic, twins give the concordance to be expected with a clone. The two highest concordance rates—in the .75 range for bipolar mood disorder and just under .50 for schizophrenia—might surprise students, especially if you point out that this means the identical twin or clone of a person with schizophrenia most likely won’t be schizophrenic.

Lecture Launcher 3.5: Pills or Skills for ADHD? Without needing a detailed understanding of the disorder, a fairly active discussion can usually be started by asking students about treatments for attention-deficit hyperactivity disorder (ADHD). Most of them know people who take psychostimulants and many have taken them themselves. The accelerating prescribing rate of psychostimulants has given rise to many media examinations of the wisdom and necessity of this therapy in contrast with more behavioral approaches or no treatment at all. It is not worth debating the effectiveness of various treatments, as these are empirical questions students are not yet equipped to analyze. Therefore, it is probably worth stipulating, at least for purposes of the discussion, that the treatments are for the most part are equally effective for the primary ADHD symptoms/behaviors. Some careful management of the discussion may be necessary to avoid offending students who have been treated themselves in ways others might find objectionable. Of course, treatment preferences are another clue to implicit theoretical orientations. Lecture Launcher 3.6: Why Is It So Hard to Quit Smoking? Students often see cigarette addictions as very clearly biological in nature. It is of course the body’s acquired need for the chemical nicotine that causes people to smoke, even though they vow not to. Right? The question to pose about this is why, then, nicotine patches and gum don’t work perfectly. If one can get nicotine into one’s system, one ought to eliminate the need for the cigarette, right? This can often produce insights about “doing something with one’s hands,” “coping with stress,” “automatic cigarettes, say, after meals,” “looking cool,” and “not caring about one’s health.” A related discussion can be conducted concerning alcohol, though there is not as clean a substitute for the molecule in question. Nevertheless, the multiple determinants of otherwise apparently strict chemical addictions are evident for alcoholism as well. Note that students will be challenged throughout the term to integrate behavioral theory and operant conditioning—that is, smoking as a negative reinforcer—in consideration of the various forms of psychopathology presented in the text.

Classroom Activities, Demonstrations, and Assignments Activity 3.1: Etiological Thought Experiments A good way to get students thinking about the potentially powerful role played by the various etiological factors emphasized within each of the causal viewpoints given in this chapter is to conduct etiological “thought experiments.” Either on their own or in groups, students are given the task of designing a program to cause a form of psychopathology using the principles emphasized by a particular causal viewpoint. For instance, students can be asked to describe the creation of the cognitive conditions necessary for a random person to be clinically depressed. What would they do to such a person? What would they want to cause them to believe? How would they get them to believe such things? Would any person who was caused to believe such things then be depressed? What if you could only manipulate their interpersonal world? Or what if you only had access to their biology? What would you do to cause depression? What would you do to cause social phobia? If students can develop procedures they believe would work in principle, they might be more amenable to imagining such things happening in reality, especially once one considers that various causal factors can combine and that some people carry extra vulnerabilities. Activity 3.2: Is Crying Biological? A good way to get students working together in groups is to give each group a different assignment. Then the resulting group projects can be integrated via a classroom discussion to which all students contribute. A notable advantage of this approach is that all the students are well prepared for the classroom discussion because of their prior small-group participation. This facilitates the early socialization to participation every instructor strives for. In terms of the present chapter, groups can be formed for the purpose of analyzing a psychological phenomenon such as crying (or love, enthusiasm, violence, fear, etc.) from a single perspective. Then the individual perspectives developed by each group can be integrated into a comprehensive biopsychosocial model via classroom discussion. Activity 3.3: Temperament, Applying the Diathesis Stress Model If you have a computer in class, go to www.apa.org/helpcenter/shyness.aspx for an article on “Painful Shyness: In Children and Adults.” It provides a nice layout of how temperament interacts with several other factors to result in shyness. Activity 3.4: Own Your Mechanisms of Defense Table 3.1 in the textbook gives a nice compact description and summary of Freud’s mechanisms of defense. Although we are often in the worst possible position to recognize these in ourselves, it is enlightening to Copyright © 2013 Pearson Education, Inc. All rights reserved. 53

contemplate their application to our own lives. A good individual exercise in self-exploration that also teaches the mechanisms of defense is to ask students to replace the example column from table 3.1 with ones from their own lives. Those who are unable to do so, of course, are just too well defended! If it is too difficult to do with respect to one’s self, students can be asked to do so with respect to people they know well. Activity 3.5: Predictable and Controllable When studying psychosocial causal factors, the extent to which negative events are predictable and controllable seem to be critical in understanding how much stress a child experiences and how likely the child is to develop anxiety and depression. Illustrating the importance of these variables to students may be extremely difficult. One way of emphasizing this issue is to create an unpredictable classroom setting where the actions of the students lead to no control over what happens to them. For the first 15 minutes of class, the professor can engage in seemingly unpredictable behavior. Lecturing from the back of the classroom, speaking only in a whisper, or speaking in a foreign language can all be used effectively to increase unpredictability. To create the sense of events being out of students’ control, a simple exercise is to assign extra credit points for seemingly no reason: the first student to use the word “red” gets an extra credit point, any student wearing green gets an extra credit point, etc. Of course, the instructor would not reveal the system being used until after the exercise is completed. Following the 15 minutes of unpredictable and uncontrollable conditions, explore with the students what the experience was like and how growing up under such conditions would impact a child. Activity 3.6: The Parental Authority Questionnaire (PAQ) To further illustrate the typology, go to faculty.sjcny.edu/~treboux/documents/parental%20authority%20questionnaire.pdf for a copy of the PAQ, including scoring. Students will enjoy taking the survey and are rarely surprised at the results. Activity 3.7: Bullying and American Culture Your book notes that American adolescents have higher scores than Thai adolescents on behaviors like fighting, bullying, and disobedience at school. Given the highly publicized school shootings such as those at Columbine, the fact that American adolescents score higher in these areas is of serious concern. Place students in small groups and ask each group to determine what sociocultural factors in the United States might contribute to American adolescents scoring higher in these areas. Once students have completed this task, have groups share their answers with the class. Finish by asking students to think about what changes would have to occur in our society for the incidence of fighting, bullying, and disobeying in school to decrease.

MyPsychLab Resources MyPsychLab Resource 3.1: Explore “Building Blocks of Genetics” You may want to assign students to complete one of the MyPsychLab exercises on “Building Blocks of Genetics.” To access this Explore, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pulldown menu next to “Chapter,” select chapter 3, Causal Factors and Viewpoints. In the Media Type field, select “Explore,” then click the “Find Now” button at the bottom. “Building Blocks of Genetics” will appear as one of your Explore offerings. You can either use this Explore as an in-class demo—if your room has a computer set up— or assign as a suggested exercise.

Teaching Tips Teaching Tip 3.1: Diathesis Stress Models One example that can be used to illustrate the diathesis stress model could be the neurodevelopmental hypothesis of the etiology of schizophrenia. This argument is that early in development (most likely prenatal) something goes awry with the development of the central nervous system. Then at some later point in life (adulthood), if the person is exposed to stressors, schizophrenia can develop. The argument here is that you have a diathesis, or predisposition, early in development, but that alone will not cause the disorder. A stressor needs to be introduced for the trait to be expressed.

Teaching Tip 3.2: Genotype-Environment Interactions and Nature Nurture Effects You may want to point out to students how the Scarr and McCartney Genotype-Environment effects relate here as well. Ask students how many of them have siblings. Ask how many of them would say they are “very much” like their siblings, how many are “somewhat like” their siblings, and how many “wonder if they were switched at birth.” Generally, you’ll get most of the class choosing the “separated at birth” response. Point out that if nature and nurture should make us similar, we would predict that siblings should be a lot more similar than random people because they have shared nature and nurture. Then point out that when you’ve talked about nature/nurture to this point, nurture has been clumped together. Now the field further separates nurture into shared (this would be the Scarr and McCartney passive effects) and nonshared (the Scarr and McCartney active and evocative effects). Thus, the reason you are more like your friends than family may be due to evocative effects—for example, being mom’s favorite because of your sense of humor—and active effects, reacting to the environment and choosing behaviors that make you different from your siblings. Another good example of this is to ask students how many of them have a sibling (it may even be themselves) that remembers a far different childhood than the rest of the family. Nonshared environmental factors account for these types of effects. Teaching Tip 3.3: An Example of a Learned Fear Response As was discussed last chapter, you may want to discuss the case of Little Albert one more time. This conditioning shows how a fear response can be conditioned. Another example could be a fear of hypodermic needles. One should only show fear or discomfort if one had been conditioned to do so.

Handout Descriptions Handout 3.1: Partitioning Causal Variance Especially with respect to one’s self, but also with respect to the other activities and discussion points given in this chapter, it is well to keep in mind that causes combine and that risk factors are not necessarily causal factors. Also, the outcome of a wide variety of complex processes may appear uniform. Therefore, it is important to keep the chapter’s distinction between necessary, sufficient, and contributory causes, as well as the general diathesis-stress formulation, in mind throughout the course. This process can be supported by frequently asking students whether they believe or the evidence suggests that something can, at least in principle, serve in each capacity—that is, as a necessary cause, a sufficient cause, and a contributory cause. Keeping a worksheet with these concepts available and asking students to support their claims can sharpen their awareness of the issue. Handout 3.2: Freudian Defense Mechanisms For each of the following, state which of Freud’s defense mechanisms is being described. 1. Because Raul often lies, he assumes others are often lying as well. Projection 2. After getting into an argument with her co-worker, Lucinda comes home and starts yelling at her boyfriend. Displacement 3. Marcella goes to therapy because she is struggling with an eating disorder. The therapist suggests that she was sexually abused as a child and that is why she has the eating disorder. The therapist is suggesting what? Repression 4. When Louis’s girlfriend says she doesn’t want to go out, he pitches a temper tantrum. Regression 5. Because he enjoys hurting people, Liam becomes a dentist. Sublimation 6. Mary tells people she failed her test because the professor was a jerk instead of reporting that she didn’t study. Rationalization 7. Because Sebastian has difficulties with his negative feelings towards Hispanics, he dates someone from Puerto Rico. Reaction Formation 8. Cheri smokes because she wasn’t breast-fed. Fixation

9. When Caleb is feeling aggressive, he goes to the gym. Sublimation 10. Because you don’t like your coworker Zoe, you tell all your friends that she doesn’t like you. Projection

Video / Media Sources B.F. Skinner and Behavior Change: Research, Practice, and Promise, (1975, 45 minutes,RP). Behavioral interventions in various settings, including fear of dental procedures, learning social skills at a youth center, controlling epilepsy in a hospital, and working with a developmentally disabled child at home. Behavior Therapy: An Introduction, (1978, 23 minutes, Harper & Row). Demonstrates three basic behavioral procedures, including contingency management, counter-conditioning, and role playing, as applied to three individuals. Being Abraham Maslow, (1968, 30 minutes, , black and white, FLMLIB). Excerpts from an interview with Maslow in which he discusses his life and theory. The Brain, Mind, and Behavior, 8 parts, (2007, 60 minutes, each, color, PBS Video). One part on the "Enlightened Machine" focuses on the mysteries of consciousness and the brain. Another part, on "Rhythms and Drives," examines the effects of the brain and hormones on behavior. Dialogues, Dr. Carl Rogers, Parts I and II, 100 min. UCEMC (1966). Wide-ranging interview with Dr. Rogers. Discovering Psychology: The Responsive Brain, 30 min., color. Annenberg/CPB Collection (1990). Looks at the interaction of the brain, behavior, and the environment. Also shows how brain structure and function are changed by behavioral and environmental factors. Freud under Analysis, 58 min. (1987). MINN. Deals with Freud's beliefs and the scientific evidence. Kids and Psychiatric Drugs, (2007, 2.29 minutes, CBS Evening News). This video discusses the controversies surrounding children and the prescribing of psychotropic and antipsychotic medications for mental illness. Retrieved from http://www.cbsnews.com/video/watch/?id=2556317non July 19, 2011. Looking at Abnormal Behavior, (1992, 58.34 minutes, Alvin H. Perlmutter, Inc. and Toby Levine Communications). Retrieved from www.learner.org/vod/vod_window.html?pid=776 on July 19, 2011. Gives an overview of the field of abnormal psychology with some case vignettes. The Humanistic Revolution: Pioneers in Perspective, 32 min., black and white. PEF (1971). Interviews with Maslow, Murphy, Rogers, May, Tillich, Perls, Frankl, and Watts Mysteries of the Mind, 58 min. Films for the Humanities and Sciences (1988). Examines the neurochemical and genetic components in various disorders. Rollo May on Humanistic Psychology, 24 min. PEF (1971). May describes the historical development and general characteristics of humanistic psychology What Makes Them Tick? 42 min. Films for the Humanities and Sciences (1999). Examines the relationship between genes and environment in the formation of personality for adolescents.

Web Links Web Link 3.1: www.nal.usda.gov/awic/pubs/primates/4n4laule.htm This Animal Welfare Information Center Newsletter provides a wonderful introduction to the use of behavioral management techniques to reduce or eliminate abnormal behavior in animals. Web Link 3.2: psychclassics.yorku.ca Classics in the History of Psychology links out to the full texts of over 25 books and 150 articles from the scholarly literature of psychology and allied disciplines. The site also contains links to nearly 200 relevant works posted at other sites. Web Link 3.3: www.gestalt.org/yontef.htm This online essay by Gary Yontef provides an excellent overview of the Gestalt assumptions and approach to abnormality and therapy. Web Link 3.4: www.freudarchives.org The Sigmund Freud Archives provides many links to personal papers, photos, correspondence, and memorabilia relating to Freud and the psychodynamic theory as well as access to essays and original publications.

Handout 3.1 Necessary, Sufficient, and Contributory Causes

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

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

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

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

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

Handout 3.2 Freudian Defense Mechanisms For each of the following, state which of Freud’s defense mechanisms is being described.

1. Because Raul often lies, he assumes others are often lying as well. 2. After getting into an argument with her co-worker, Lucinda comes home and starts yelling at her boyfriend. 3. Marcella goes to therapy because she is struggling with an eating disorder. The therapist suggests that she was sexually abused as a child and that is why she has the eating disorder. The therapist is suggesting what? 4. When Louis’s girlfriend says she doesn’t want to go out, he pitches a temper tantrum. 5. Because he enjoys hurting people, Liam becomes a dentist. 6. Mary tells people she failed her test because the professor was a jerk instead of reporting that she didn’t study. 7. Because Sebastian has difficulties with his negative feelings towards Hispanics, he dates someone from Puerto Rico. 8. Cheri smokes because she wasn’t breast-fed. 9. When Caleb is feeling aggressive, he goes to the gym. 10. Because you don’t like your coworker Zoe, you tell all your friends that she doesn’t like you.

CHAPTER 4: Clinical Assessment Teaching Objectives 1. 2. 3. 4. 5. 6. 7.

8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.

Identify the basic elements of clinical assessment and explain the relationship between assessment and diagnosis. Describe the types of information sought in a clinical assessment and how the clinician would go about obtaining this information. Define the importance of incorporating culture into the assessment process. Describe how clinicians with different professional orientations might individualize their assessment process. Discuss the importance of reliability, validity, and standardization in assessment. Explain what is meant by rapport between the clinician and client, and outline the components of a relationship that leads to good rapport. Summarize the conditions under which a medical evaluation might be necessary. Describe the various approaches to assessment of physical problems, including the general physical examination, the neurological examination, and the neuropsychological examination. Explain why an individual would receive an EEG, a CAT scan, a MRI, a PET scan, or a functional MRI. List types of psychosocial assessments and explain their appropriate use. Discriminate between structured and unstructured interviews for the assessment of psychosocial functioning, and evaluate the relative merits of the two. Discuss various approaches to the clinical observation of behavior and identify the advantages of each. Explain the importance of rating scales in clinical observations. Describe the major intelligence tests. Discuss the advantages and disadvantages of projective personality tests. Discuss the advantages and disadvantages of objective personality tests. Discuss the advantages and disadvantages of a computerized personality assessment. Summarize the process of integrating assessment data into a model for use in planning or changing treatment. Explain the ethical issues involved in assessment. Explain the purpose and outline the advantages and disadvantages of classification systems for abnormal behavior. Discuss reliability and validity as they relate to a classification system. Distinguish between signs and symptoms. Describe the differing models of classification. Explain the diagnostic classification of mental disorders. Explain how the new DSM-5 will impact assessment and diagnosis.

Chapter Overview/Summary Understanding and appropriately treating psychological disorders depends, in large part on the adequacy of clinical assessment. The assessment process typically involves interviews, observations, and psychological tests that are then integrated to develop a summary of the client’s symptoms and problems. Assessment results are frequently used to establish a baseline of client behavior from which subsequent behavior can be judged in the process of clinical diagnosis—that is, classifying a disorder according to a clearly defined system such as the DSM-IV TR or the ICD-10 (International Classification of Disease). Even after this initial assessment and diagnosis, continued assessment is critical to determine the course and effectiveness of treatment procedures. Psychological assessment uses tests, observations, and interviews. Clinical diagnosis is when the clinician arrives at a disorder based on the DSM-IV-TR. There are several basic elements of clinical assessment. Identification of the presenting problem or the major symptoms and behavior is most likely the first step in the assessment process. Providing a diagnosis may assist in treatment planning and may be required for insurance purposes. Clinically, assessment will most likely involve collecting information about the client’s behavioral history, intellectual functioning, personality Copyright © 2013 Pearson Education, Inc. All rights reserved. 60

characteristics, and environmental pressures and resources. The precise nature of the information collected will, of course, depend on the nature of the presenting problem. Because a wide range of factors may contribute to maladaptive behavior, assessment may also include medical evaluation. A general medical examination may be followed by a more comprehensive neurological examination that could involve neuropsychological testing or, in some circumstances, neurological tests–such as an EEG or a CAT, PET, or MRI scan—to aid in determining the site and extent of organic brain disorder. The precise nature of tests administered during this assessment process may be influenced by the theoretical orientation of the clinician. For example, a more biologically oriented clinician may be more apt to focus on assessment procedures aimed at determining underlying organic malfunctioning, while a more cognitively oriented clinician may focus on dysfunctional thoughts. In order for any assessment procedure to be effective, however, the client must feel comfortable with the clinician. The clinician should explain the purpose of the assessment process and must help the client understand the limits of confidentiality. Psychosocial assessment methods focus on providing a realistic picture of how the client interacts with his or her social environment. Data is gathered, allowing the clinician to form hypotheses that are confirmed, modified, or discarded as the clinician proceeds. The most widely used and most flexible psychosocial assessment methods are the clinical interview and behavior observation. These methods provide a wealth of clinical information and can vary from highly structured and reliable procedures to more unstructured and less reliable procedures. Psychological tests represent a more indirect method of assessing psychological characteristics. The tests used by psychologists compare the client’s responses to standardized stimuli with the responses of other people with similar demographic characteristics, usually through established test norms or test score distributions. For all psychological tests, the competence of the person administering, scoring, and interpreting the test will dictate their value. This issue becomes even more important when computerized administration, scoring, and interpretation of psychological tests have become widespread. Psychological tests can be divided into two major categories: intelligence tests and personality tests. The most common intelligence tests are the individually administered Wechsler scales (WISC-III and WAIS-III) and the Stanford Binet Intelligence Scale. Personality tests can be subdivided into two additional categories based on their approach: 1) projective tests, such as the Rorschach, in which unstructured stimuli are presented to a subject who then “projects” meaning or structure on to the stimulus, thereby revealing “hidden” motives, feelings, and so on; and (2) objective tests, or personality inventories, in which a subject is required to read and respond to itemized statements or questions. Objective personality tests, such as the MMPI-2 and MMPI-A, provide a cost-effective, reliable, and valid means of collecting a great deal of personality information rapidly. Assessment also allows clinicians to engage in classification, which aids in communication, research, gathering statistics, and meeting the needs of insurance companies. Classification, however, is a constantly evolving process that is subject to human error. All classification systems depend on reliability and validity. Currently, there are three basic classification systems used in abnormal psychology: the categorical (adopted for use in the DSM-IV TR), the dimensional, and the prototypal. The categorical system has been questioned in recent years, as the categories do not always result in within-class homogeneity or between-class discrimination. This, in turn, can lead to high levels of comorbidity among disorders. Several possible solutions to this problem include dimensionalizing the phenomena of mental disorder and the adoption of a prototypal approach to the organization of the field. For all of its problems, however, knowledge of the DSM-IV-TR is essential to serious study in the field of abnormal behavior. There are two major classification systems used today. One, the ICD-10, is used widely is Europe. The DSM-IV TR is used in the United States. Both systems are similar in that they focus on symptoms and define problems into different facets. In the DSM-IV TR, for example, behavior can be diagnosed along five axes. The present DSM is the result of a long process that began with the publication of the first DSM in 1952. The first two DSMs were more narrative and jargon-laden. With the publication of the DSM-II a radically new approach was Copyright © 2013 Pearson Education, Inc. All rights reserved. 61

introduced. Operational definitions were adopted requiring a specific number of signs or symptoms from a designated list prior to diagnosis. This allowed for diagnosis to be more reliable and valid than in previous years, especially with the introduction of structured clinical interviews. Although the DSM system is standard in the United States, there are many who do not like providing any diagnosis for a client. The DSM-5 will be published in 2013 and is already the subject of much controversy. One of the major objections to any such diagnostic classification is the problem of labeling. In the final analysis, any such classification should only be seen as a first step, subject to revision, in the overall process of understanding and treating abnormality.

Detailed Lecture Outline I.

The Basic Elements in Assessment A. Psychological assessment—refers to a procedure by which clinicians use tests, observations, and interviews B. Clinical diagnosis—the process by which the clinician arrives at an diagnosis C. Presenting problem—major symptoms or behaviors the client is experiencing D. The Relationship Between Assessment and Diagnosis 1. Formal diagnoses are needed for insurance purposes 2. Planning for treatment follows from diagnosis 3. It is essential for administrative purposes E. Taking a Social or Behavioral History

Activity 4.1: What Is “Abnormal”? Handout 4.1: Intake Interviews 1.

Personality factors a. Descriptions of long-term personality characteristics are included. b. How has the person responded to different situations? 2. The social context a. Environmental stressors and supports are identified. b. Conflicting information is integrated, leading to understanding of what may drive the person (what some call a dynamic formulation). c. Hypotheses about future behavior are derived. d. Decisions about treatment are made with consent of the client. e. Coordination of physical, psychological, and environmental procedures is needed in assessment, Ensuring Culturally Sensitive Assessment Procedures 1. Cultural competence issues in both clinical and court-related multicultural assessments are important when dealing with culturally diverse populations. 2. APA recommends psychologists consider things like language and differences in cultural situations when looking at test scores.

Lecture Launcher 4.1: Cultural Formulation and Culture-Bound Syndromes G.

The Influence of Professional Orientation 1. Psychiatrists are biologically oriented practitioners. 2. Psychoanalytically oriented clinicians may use unstructured assessment methods. 3. Behaviorally oriented clinicians determine the functional relationships between environmental events, consequences, and behaviors. 4. Cognitively oriented clinicians focus on dysfunctional thoughts. 5. Humanistically oriented clinicians may use interview techniques to uncover blocked or distorted personal growth. 6. Interpersonally oriented clinician may use behavioral observations to identify problematic relationships. Reliability, Validity, and Standardization 1. Reliability is a term describing the degree of consistency in a measurement. 2. Validity is the extent to which a measurement measures what it purports to measure. 3. Standardization is the process by which a psychological test is administered, scored, and interpreted in a standard way. 4. T score distribution is the distribution of scores.

MyPsychLab Resource 4.1: Simulation on “Overview of Clinical Assessment Methods”

II.

Trust and Rapport Between the Clinician and the Client 1. Clients should understand the underlying rationale of assessment 2. Assurances of confidentiality 3. Motivation of client for being assessed 4. Importance of providing feedback to client 5. Court-ordered versus voluntary treatment Assessment of the Physical Organism A. The General Physical Examination 1. A medical history is obtained. 2. This medical exam is needed when presenting problems include physical symptoms, especially when clients may be experiencing somatoform, addictive, or organic brain disorders. 3. Such medical exams may eliminate costly and ineffective treatments. B. The Neurological Examination 1. Electrocencephalogram-EEG to assess brain wave patterns in awake and sleeping states, which reveals dysrhythmia. 2. Anatomical brain scans a. Computerized axial tomography (CAT scan) can reveal diseased parts of the brain. Technique involves computer analysis of x-rays. b. Magnetic resonance imaging (MRI) allows visualization of the interior of the brain. Images are typically much sharper with the MRI, and the MRI is less complicated to administer and does not expose the client to ionizing radiation. Only major problem is that some clients have a claustrophobic reaction. 3. PET scans: A metabolic portrait a. Positron emission tomography (PET scan) appraises how an organ is functioning rather than simply the anatomical structure like those above. PET scans work by tracking natural compounds such as glucose as they are metabolized. Unfortunately, the pictures produced are of low-fidelity and the equipment is fairly expensive. 4. The functional MRI (fMRI) measures changes in local oxygenation of specific areas of brain tissue allowing a “map” of brain activity to be developed. This technique may lead to more detailed information of how psychological disorders develop but at this time, there are significant problems with the procedure. a. Aphasia—a disorder in which there is a loss of ability to communicate verbally C. The Neuropsychological Examination 1. Measurement of alteration in behavioral or psychological functioning involves neuropsychological assessment. 2. Neuropsychologists may administer a standard test battery or, more frequently, administer a highly individualized array of tests depending on the particular client’s problems. 3. The two most common test batteries are the Halstead-Reitan and the Luria-Nebraska. 4. Halstead Category Test measures a subject’s ability to learn and remember material. 5. Tactual Performance Test measures a subject’s motor speed. 6. Rhythm Test measures attention and sustained concentration through an auditory perception task. 7. Speech Sounds Perception Test determines whether an individual can identify spoken words. 8. Finger Oscillation Task measures the speed at which an individual can press a level with index finger.

Handout 4.2: What Do Neuropsychologists Do? III.

Psychosocial Assessment

Assessment Interviews 1. Structured and unstructured interviews a. Structured formats have been developed to guide questions b. Structured assessment interview yields far more reliable results than the flexible format c. Unstructured assessment interview is typically subjective and does not follow a predetermined set of questions d. Rating scales help focus inquiry and quantify the interview data e. Reliability increases with structured interviews f. All interviews need specific goals g. Rating scales can increase interview reliability h. Interviews are subject to error as they rely on human judgment i. Emphasis on observable criteria The Clinical Observation of Behavior 1. Direct observation a. Should occur ideally in the natural environment b. Analogue or contrived situations are designed to yield information about the person’s adaptive strategies c. Role-playing—the event reenactment, family interaction assignments or a think-aloud procedures d. Self-monitoring or self-observations and objective reporting of behavior are often used in the natural environment, can also be used in determining the kinds of situations in which maladaptive behavior is likely evoked. e. The client can be an excellent source of information. f. Methods such as electronic beepers to remind clients to record thoughts are also being developed. 2. Rating scales a. Help to organize observations and increase reliability b. Ratings may be made not only as part of an initial evaluation but also to check on the course or outcome of treatment. c. The Brief Psychiatric Ratings Scale (BPRS) is widely used to record observations for clinical research. d. Comparisons to other clients’ symptoms can be made. Psychological Tests 1. Psychological tests are standardized procedures to sample behavior a. A client’s responses are compared to the responses of others who have taken the same test b. Often more precise and reliable than interviews or some observational techniques c. Many tests are available in a computer-administered and computer-interpreted format d. Their value depends on the competence of the clinician administering them 2. The value of the test frequently depends on the competence of the tester Intelligence tests a. Wechsler Intelligence Scale for Children-Revised (WISC-IV) b. Stanford-Binet Intelligence Scale c. Wechsler Adult Intelligence Scales-Revised (WAIS-IV) d. These tests are used when detailed information about cognitive functioning is required 3. Intelligence tests—widely used to measure intelligence abilities in children and adults a. . Vocabulary (verbal)—subtest that consists of a list of words to define that are presented orally to the individual b. Digital Span (performance)—test of short-term memory a sequence of numbers is administered orally. 4. Projective personality tests Copyright © 2013 Pearson Education, Inc. All rights reserved. 65

b. c. d.

Underlying assumption in using projective techniques is that people “project” their own problems, motives and wishes onto the vague, unstructured stimuli (1) The Rorschach Inkblot Test-named after the Swiss psychiatrist Hermann Rorschach as a personality assessment. (2) The Thematic Apperception Test (TAT)-introduced in 1935 by Morgan and Murray of the Harvard Psychological Clinic which uses simple pictures where subject are constructed to make up stories (3) Sentence Completion Test-these tests have been designed for children, adolescents, and adults which is related to free association in where the client is asked freely based on the answers the examiners can pinpoint the individual’s problems, attitudes, and symptoms through the interpretation of his or her responses Interpretation of these tests is generally subjective, unreliable, and difficult to validate Administering and scoring these tests is frequently time consuming and requires advanced skills These tests have an important place particularly in clinical settings where it is important to obtain information about one’s personality and psychodynamic functioning

Activity 4.2: Projective Assessment 5.

Objective personality tests a. More structured than projective techniques leading to greater precision, typically use questionnaires, self-report inventories, and rating scales (1) MMPI: The Minnesota Multiphasic Personality Inventory MMPI is the most widely used personality test in the United States (See Table 4.1 for a chart of the scales of the MMPI-2) (2) The clinical scales of the MMPI were developed through empirical keying (3) Clinical scales measure tendencies to respond in psychologically deviant ways (4) Validity scales designed to detect whether a patient has answered the questions in an honest manner (5) Special problem scales have also been developed (6) Criticisms of the MMPI led to MMPI-2 (7) Advantages and limitations of objective personality tests (8) Advantages include being cost-effective, highly reliable and objective (9) Disadvantages include some believing they are too mechanistic to portray the complexity of human behavior and the tests require the client to be literate and cooperative (10) Minnesota Multiphasic Personality Inventory-2 (MMPI-2) (11) The MMPI-2 has replaced the original MMPI (12) The MMPI-2 is used in same way as the original (13) Validity scales detect dishonesty and lack of cooperation (14) Computer interpretation of objective personality tests (15) Actuarial procedures used where descriptions of the actual behavior or other established characteristics of many subjects with particular test scores have been stored in the computer (16) Difficulty in collecting sufficient actuarial data (17) Computer cannot integrate conflicting findings (18) Well-trained professional is required to interpret and monitor

Activity 4.3: Developing Your Own Test IV. The Integration of Assessment Data A. Integration of assessment data prior to treatment allows the clinician to formulate a plan for treatment and allows for the discovery of gaps or discrepancies in knowledge about the client. Lecture Launcher 4.2: Too Much Information B. C. D.

Additional assessment data collected during treatment can allow clinician to determine how effective treatment is and allow for modification to improve success. The information gathered may lead to a tentative diagnosis. Ethical Issues in Assessment 1. Potential cultural bias of the instrument or the clinician 2. Theoretical orientation of the clinician 3. Underemphasis on the external situation 4. Insufficient validation 5. Inaccurate data or premature evaluation

Lecture Launcher 4.3: What Do You Do If…? Activity 4.4: What’s My Diagnosis? IV.

Classifying Abnormal Behavior

Lecture Launcher 4.4: Can You Treat without Knowing the Cause of a Disorder? A. B. C. D.

Classification allows communication, improves research, and is required by many insurance companies for reimbursement Classification is important in any science and involves the intent to delineate meaningful subvarieties of maladaptive behavior Classification systems are ongoing works-in-progress as new knowledge allows more precision Reliability and validity

Teaching Tip 4.1: Reliability and Validity Activity 4.5: When to Be Impressed by Agreement E.

Differing Models of Classification 1. The dimensional approach 2. The prototypal approach Formal Diagnostic Classification of Mental Disorders 1. Two major systems in use today are the International Classification of Disease System (ICD-10) used mainly in Europe and the Diagnostic and Statistical Manual of Mental Disorders (DSM) used mainly in the United States. 2. DSM was designed as a categorical system but is actually a prototypical system. 3. Symptoms—refers to the patient’s subjective description and the complaints he or she is experiencing 4. Signs—objective observations that the diagnostician may make either directly or indirectly

Teaching Tip 4.2: Issues with DSM Data 5.

The evolution of the DSM

6. 7. 8. 9.

Criteria used consist of symptoms (subjective description of the client) and signs (objective observations) The DSM has evolved over the past 5 decades from a vague, jargon-laden description of disorders to the present “operational” method Limitations of the DSM classification system a. Still exist especially in relation to the artificial, categorical systems adopted The five axes of DSM-IV-TR a. Axis I—clinical syndromes or other conditions that may be a focus of clinical attention such as major depression, generalized anxiety disorder b. Axis II—personality disorders and mental retardation, know known as intellectual disability such as Borderline Personality Disorder or Down syndrome c. Axis III—general medical conditions relevant to understanding or managing the case, such as diabetes d. Axis IV—psychosocial and environmental problems during the past year such as legal, family, social, educational, etc. problems e. Axis V—global assessment of functioning (GAF) a numerical rating scale where a clinician rates the patient’s current level of functioning at that given time 0100

MyPsychLab Resource 4.3: Explore “The Axes of the DSM” 10.

Main categories of Axis I and Axis II disorders a. Acute—used to describe disorders of short duration b. Chronic—refers to long-standing and often permanent disorders c. Mild, moderate, and severe—reflect the dimensions of how severe the symptoms are d. Episodic and recurrent—used to describe unstable disorder patterns that tend to come and go with some mood and psychotic disorders 11. The problem of labeling a. Labeling may lead to a closing off of further inquiry, create preconceptions about a person, or even lead the person to act in ways consistent with his or her view of how a person with that label “should” act Lecture Launcher 4.5: What’s Right and What’s Wrong with Diagnosis? 12.

13. 14.

Limited usefulness of diagnosis a. Diagnosis is only the beginning step of a comprehensive evaluation and treatment Unstructured diagnostic interviews a. Allow the examiner to pursue “leads” but reduce reliability Structured diagnostic interviews a. The Structured Clinical Interview for DSM Diagnosis (SCID) and others have substantially improved diagnostic reliability

VI. Unresolved Issues A. The DSM-V: What Comes Next? 1. Many argue there are issues with the categorical nature of the DSM as the categories appear to be unable to distinguish between classes of disorders. Thus there is a high comorbidity between disorders. 2. One argument is to add dimensions and prototypes. 3. The DSM is a constantly evolving work in progress, and the DSM-5 is proposed to published in 2013. Lecture Launcher 4.6: Is Everybody a Little Crazy? Activity 4.6: “Dump the DSM?” A Point Counterpoint Exercise Copyright © 2013 Pearson Education, Inc. All rights reserved. 68

Key Terms actuarial procedures acute aphasia Brief Psychiatric Rating Scale (BPRS) chronic clinical diagnosis comorbidity computerized axial tomography (CAT scan) dysrhythmia electroencephalogram (EEG) episodic forensic functional MRI (fMRI) intelligence test magnetic resonance imaging (MRI) mild Minnesota Multiphasic Personality Inventory (MMPI) moderate neuropsychological assessment objective personality tests personality tests

positron emission tomography (PET scan) presenting problem projective personality tests psychological assessment rating scales recurrent reliability role playing Rorschach Inkblot Test self-monitoring sentence completion test severe signs standardized structured assessment interview symptoms T score distribution Thematic Apperception Test (TAT) unstructured assessment interviews validity

Lecture Launchers Lecture Launcher 4.1: Cultural Formulation and Culture-Bound Syndromes DSM-IV-TR gives an appendix of information about multicultural aspects of diagnosis. It is divided into two sections. The first section is an “outline for cultural formulation” that is intended to supplement the multiaxial diagnostic assessment and to address complexities that arise when applying DSM-IV criteria in a multicultural environment. It systematically reviews peoples’ cultural background, the role of cultural context in symptomatology, and also cultural differences between the patient and clinician. The second section is a glossary of “culture-bound syndromes.” For instance, hwa-byung (also known as wool-hwa-byung) is a Korean folk syndrome attributed to the suppression of anger. Its symptoms include insomnia, fatigue, panic, fear of impending death, dysphoric affect, indigestion, anorexia, dyspnea, palpitations, generalized aches and pains, and a feeling of a mass in the upper middle region of the abdomen. What aspects of culture are diagnostically important to consider? How about gender? What customs or behaviors do your students have that might be perceived as odd to others? What about them separates them from actual symptoms of psychopathology? Should different criteria, cutoffs, or standards be applied when diagnoses are made of different cultural groups? Would this inappropriately eliminate genuine group differences? Lecture Launcher 4.2: Too Much Information Clinicians are sometimes reluctant to disclose to their clients all of the information gathered during a comprehensive assessment. In fact, they are usually taught to release only summary information and to retain raw data unless communicating with a professional who is trained to interpret the raw data. Do you think withholding information is sensible? How about information that is not germane to the treatment? Imagine a client presenting for treatment of depression who scores high on a measure of paranoia, though not reaching a clinical level. Is it worth expending session time disclosing this information and explaining its meaning to the client, or would it be best to focus on other things? If you were this client, would you want to know everything learned in the assessment? How do you balance the client’s right to know against the expense of communicating information that may not be useful, especially when the meaning of some test scores requires substantial education to grasp–indeed, entire graduatelevel courses are necessary—to understand scores well? Lecture Launcher 4.3: What Do You Do If…? Ethical principles seem relatively straightforward to students until they try to apply the principles. Beginning the lecture with an overhead transparency or PowerPoint slide with the following questions facilitates students learning how to apply these principles. Possible questions to use may include: What should I do if the client tells me she or he is being abused? What should I do if the client tells me she or he is suicidal? What should I do if the client tells me that his or her child is being abused? What should I do if the client wants me to reveal his or her IQ score? What should I do if the client refuses to take a test? What should I do if the client wants testing that I don’t know how to give? What should I do if the parent of the client insists on tests unrelated to the client’s problem? What should I do if the computer-generated report doesn’t match my own interpretation of the test? What should I do if I believe a client needs a particular test but the person’s insurance company refuses to pay for it? Lecture Launcher 4.4: Can You Treat Without Knowing the Cause of a Disorder? Inasmuch as DSM is atheoretical, making a DSM diagnosis does not tell one what caused the diagnosed disorder. This situation is quite different from many medical diagnostic situations, in which diagnoses are made only once etiology is known (e.g., positive test for Strep infection). An etiologically informed diagnosis has obvious advantages over etiologically silent ones when it comes to choosing a course of treatment, but etiology is not always necessary for successful treatment, even of biological conditions. “Take two aspirin and call me in the morning” is often pretty effective. And oftentimes treatments are so general that the specific nature of the condition need not be established before prescribing one (e.g., antibiotics). Essentially, the implication is that DSM disorders, like depression, can be successfully treated without knowing exactly what caused them. Asking whether headache is an aspirin deficiency can further emphasize the disconnection between treatment and etiology. Lecture Launcher 4.5: What’s Right and What’s Wrong with Diagnosis? It is said that nobody likes to be pigeonholed, but that is what a diagnosis does. Clearly, any time an object or person is assigned to a category, there is a loss of information about that object or person. The rest of the course is predicated upon the acceptance of the idea that for most purposes the benefits of diagnosis outweigh their costs.

Nevertheless, it is a good idea to spend some time early in the course recognizing these costs and benefits. Avoid putting up a list of costs and benefits for the class to copy down. Instead, lead the class to see them for themselves by asking students to offer some. Lecture Launcher 4.6: Is Everybody a Little Crazy? According to most reports, as many as 46% of Americans will be diagnosed with a psychological disorder during their lifetime. This figure does not include people with symptoms of a disorder who do not receive a diagnosis. Are psychological disorders being over-diagnosed? Have the criteria for psychological disorders become so broad that anyone can be seen as having a disorder?

Classroom Activities, Demonstrations, and Assignments Activity 4.1: What Is “Abnormal”? The most fundamental issue for students of abnormal psychology is the delineation of the scope of the topic. That is, where do you draw the line between normal and abnormal? The DSM contains one such definition, and others appear in various scholarly journals. Nevertheless, the issue is far from settled, and this seemingly innocuous question can quickly turn into a very lively debate about the abnormality of various behaviors. Stepping into traffic is abnormal, but skydiving or willingly going into combat is not? Why is hyposexuality abnormal but hypersexuality not? What about the person who has strange thoughts and perceptions but does not disclose them to others, or only does so through critically acclaimed art? Or people who are geniuses in a field like science or music but are interpersonally so strange that they might be hospitalized were it not for their phenomenal abilities? If enough people experience something like depression does it become normal? Why is PTSD a disorder when it is explained by the trauma causing it? Activity 4.2: Projective Assessment Ask students to write their responses to a TAT-like picture that you have found in a magazine. Display the picture and ask them, “What are the people in this picture doing?” “What are they saying to each other?” and “How do you think the situation will turn out?” Then ask students to share their responses with the class, emphasizing that there is no magical interpretation or insight that can be revealed by responses to a single picture. Only after responding to many cards might patterns of interpretation emerge, and even then there is significant disagreement when it comes to making sense of the themes. The purpose of the exercise is not to expose students’ underlying psychopathology but, rather, to emphasize the wide variety of responses people make. It is the open-ended response format that makes tests “projective.” “Objective” tests give only a few response options, the scoring of which are clerical and algorithmic in nature. Activity 4.3: Developing Your Own Test Split students into groups and allow them to create their own diagnostic test. Allow groups to decide if they wish to develop an objective personality test, a projective personality test, or a structured clinical interview. Tell all students that the test they construct must allow for the clinician to determine whether a person is depressed. Have each group share its test with the class. Talk about reliability and validity. Activity 4.4: What’s My Diagnosis? A classic abnormal psychology activity, which is as entertaining as it is educational, is to pin diagnoses on students’ backs and have them interview others until they discover what they have by asking questions such as: “Would I likely be taking medication or being hospitalized at some point?” or “Are my symptoms more emotional, behavioral, perceptual, or cognitive?” Once students have a little experience with this exercise, they are in a better position to talk about what a standard set of questions might look like for use in making efficient diagnoses in a structured manner with a wide variety of people. Activity 4.5: When to Be Impressed by Agreement How much agreement between diagnosticians is impressive? 75%? 85%? 95%? It depends. Among other things, it depends on how often each diagnostician makes the diagnosis in question. What percent agreement do we expect to observe between tosses of two fair coins? There are four possible outcomes; heads-heads, heads-tails, tails-heads, and tails-tails, each occurring 25% of the time. The two coins will therefore “agree” on a “diagnosis” of heads 25%

of the time by chance alone. Similarly, they will agree on a diagnosis of tails 25% of the time, giving an overall agreement rate of 50%. Now substitute depression and schizophrenia for heads and tails, and it is easy to see that rates near 50% are mostly due to chance. Now consider a university counseling center in which few people are diagnosed with schizophrenia. Let’s say that 90% are not people diagnosed with schizophrenia. By chance alone, there will be 81% agreement that people being seen at the counseling center are not diagnosed with schizophrenia. Bottom line: Percent of diagnostic agreement is not a meaningful indicator of the quality of diagnoses being made. Percent of agreement is only meaningful if you know the base rates of the diagnosis for each of the diagnosticians. Students benefit from working out a few examples of chance agreement in order to really understand the idea and its application to diagnostic reliability. Activity 4.6: “Dump the DSM?” A Point Counterpoint Exercise Have students read Genova (2003), Dump the DSM: www.psychiatrictimes.com/display/article/10168/47316, and then the article by First & Spitzer (2003), The DSM: Not Perfect, but Better Than the Alternative: www.psychiatrictimes.com/display/article/10168/48541. Have students write a brief paragraph on each of the articles arguments and then a third paragraph discussing which article makes the most convincing argument. Activity 4.7: Conducting a Clinical Observation For this activity, see Handout 4.4. You will need to split the students up into small groups or pairs. Then tell the students they will be conducting an observation on campus for ten minutes. During this ten-minute observation, they will be asked to record everything they experience from each of their senses. Give them a timeframe to return and then ask them to answer the information listed on the handout. This activity can be used as an introduction to observations or used after the fact as a way to illustrate how observations are conducted. Activity 4.8: A Measurement Comes to Life Before class, go ahead and prepare some large pieces of paper with the following on them: strongly agree, agree, neutral/undecided, disagree, or strongly disagree. Then place these large pieces of paper around the room where students will move to the perspective area based on how they would answer the question. Below is a list of statements you can make—or you can always modify these or come up with your own.

1. I would rather be labeled different than abnormal. 2. It is more acceptable to visit a psychiatrist instead of a psychologist. 3. I would much rather suffer from an anxiety disorder than a substance abuse disorder. 4. Stigma exists for individuals diagnosed with a mental disorder. 5. Children should not be prescribed psychotropic medications. 6. I would rather be diagnosed with a mental disorder in childhood instead of adulthood. 7. I would prefer medicine over psychotherapy. 8. Society is looking for a magical pill to cure all. 9. Media causes eating disorders. 10. Marijuana should be prescribed for medicinal purposes. Activity 4.9: Guess My Axis of the DSM Guess Which Axis I Fall Under: Have several large index cards with different terms on them, then ask the students to put the terms under the correct Axis of the DSM-IV-TR. This activity can be done as a class, or you can have several different sets of the cards for students to work in small groups. The following are what should be on the large note cards as the categories: Axis I Axis II

Axis III Axis IV Axis V

Then here are some examples you can use for the rest of the notes cards to go under each specific category:

Divorce, problems related to the legal system, no health care insurance, no social supports, psychosocial, environmental, occupational, and educational stressors, unemployed, Gender identity disorder (GID), Bipolar Disorder, major mental illness, Anorexia nervosa, Bipolar disorder, Generalized anxiety disorder (GAD), Schizophrenia, personality disorders and mental retardation, antisocial, borderline, narcissistic, avoidant, severe symptoms 41-50 suicidal ideation, severe obsessional rituals, and serious impairment in Axis IV, Global Assessment of Functioning (GAF), 91-100 superior functioning no symptoms, 11-20 DTO/DTS, frequently violent, poor hygiene, and impairment in communication, report based on clinician’s judgment of an individual’s overall level of functioning, 0 not enough information to conclude a GAF score, complications of pregnancy or childbirth, cancer, AIDS/HIV, injury or poisoning, high blood pressure, other general medical conditions, dependent, and drop out of school. Activity 4.10: Personality Test For Fun The Pig Personality Profile: This assessment tool is not scientifically based, but it is a good way to begin lecture, especially for the discussion on validity and reliability of measurement and assessment tools. There are many variations of this activity such as draw a pig, draw a mountain, etc. You can access a detailed description of the “Pig personality profile” at http://www.uri.edu/volunteer/PDF/Pig_personality.pdf. This activity gives some information about personality characteristics based on how the student draws a pig. After completing the activity, ask for the students’ thoughts on the assessment as it relates to perceived views of one’s personality, relationships, interpersonal skills, and communication style. Cotton, G. (2011). The pig personality profile. Retrieved from http://www.uri.edu/volunteer/PDF/Pig_personality.pdf on February 15, 2012.

MyPsychLab Resources MyPsychLab Resource 4.1: Simulation on “Overview of Clinical Assessment Methods” This is a brief overview of the different types of assessment approaches. You may want to use it in class or assign students to do the simulation. The simulation first reviews the different approaches of assessment based on theoretical approaches. They then show five clips of different assessment methods and ask students questions about what kind of theoretical background is being taken. To access this simulation, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select chapter 4, Clinical Assessment and Diagnosis. In the Media Type field, select “Simulate,” then click the “Find Now” button at the bottom. “Overview of Clinical Assessment Methods” will appear as one of your Simulate offerings. You can either use this simulation as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. There is also a pdf file. MyPsychLab Resource 4.2: Simulation on “Overview of Clinical Assessment Tools” This is a brief overview of the different types of assessment tools. The simulation covers a number of assessment techniques, including structured interviews, psychological tests, MRI, projective tests, sentence completion tests, and personality tests (including examples of items on the MMPI). For each, they show a clip of different assessment tools and then ask students questions about the method. To access this Simulate, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select chapter 4, Clinical Assessment and Diagnosis. In the Media Type field, select “Simulate,” then click the “Find Now” button at the bottom. “Overview of Clinical Assessment Tools” will appear as one of your Simulate offerings. You can either use this simulation as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 4.3: Explore “The Axes of the DSM” You may want to assign a brief drag-and-drop quiz on the five Axes of the DSM. To access this Explore, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pulldown menu next to “Chapter,” select chapter 4, Clinical Assessment and Diagnosis. In the Media Type field, select “Explore,” then click the “Find Now” button at the bottom. “The Axes of the DSM” will appear as one of your Explore offerings.

Teaching Tips Teaching Tip 4.1: Reliability and Validity Students often have difficulty grasping the importance of these concepts. I typically use the example of a scale. If you have a scale that is under by 10 pounds, is it reliable? Why? It is a consistent measure, and it has good test-retest reliability. Now ask students if the measure is valid. They should know that it is not. Meaning, it is not doing what it says it’s going to do, which is measure your weight. So in this example it is reliable but not valid. Now ask students which they would rather have in a measure. Ideally, a measure has both. Teaching Tip 4.2: Issues with DSM Data You may want to remind students that the S in DSM stands for statistics. That said, there are some concerns about the data represented in the DSM that you might want to point out. First, whose data is in the DSM? Ask students if they think everyone is represented there. What of persons who go to their primary care physician and are placed on an antidepressant? What about prison populations? What effect does that have on the data in the DSM? Activity 4.10 has a video clip on how women are more likely to seek medical attention in general—what effect does that have on the data? I find that by pointing out some of these thinking questions, students are more likely to think critically as they read about rates of incidence throughout the text. Handout Descriptions Handout 4.1: Intake Interviews Students are fascinated with the interviewing process. After lecturing about intake interviews, offer students the opportunity to conduct one. Tell students that a client, “Bill” or “Helen,” will be coming to class for them to interview. Break the group into smaller groups of four or five and allow each group to develop questions they might like to ask the client. Provide each group with a copy of the handout so they know what types of decisions they will need to make based on the interview. The client, of course, will be the instructor. Think through what symptoms you wish to present. Actually writing out the symptoms is easiest for your first time of portraying a client. After the client leaves, the groups should discuss the interview and complete the handout. Allow the students to use their text to arrive at a possible diagnosis. Once each group is finished, allow groups to share their results with the entire class. Handout 4.2: What Do Neuropsychologists Do? Neuropsychological assessment involves the use of various testing devices to measure a person’s cognitive, perceptual, and motor performance as clues to the extent and location of brain damage. Strub & Black (1999) have published a wonderful text outlining the Mental Status Examination in Neurology and the Mini-Mental Status Examination, commonly used tools in this area. Place students in pairs and allow them to administer the Mental Status Examination provided on the handout. Handout 4.3: Diagnosing Mrs. Simon For this exercise, divide students into small groups and ask them to make a differential diagnosis of "Mrs. Simon." Because Mrs. Simon's case is somewhat ambiguous, making the diagnosis is not straightforward. The exercise helps students appreciate various aspects of diagnosis, including how to assess symptoms, how to apply inclusion/exclusion criteria, the necessity of obtaining accurate information about the patient, and the sometimes unavoidable ambiguity of diagnostic categories.

Video / Media Sources ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Assessing Diverse Populations. Assessment and Evaluation: Developing Tools to Measure Effectiveness Series. Princeton, NJ: Films for the Humanities and Social Sciences. Assessment, Intervention, and Treatment. Psychotropic Medications: Caring for Patients with Psychiatric Disorders Series. Irvine, CA: Concept Media. Basic Interviewing Skills for Psychologists. New York, NY: Insight Media. Behavioral Interviewing with Couples. Champaign, IL: Research Press. Bitter Potion: Psychological Profiling. Allyn & Bacon Video Library. Diagnosis According to the DSM-IV. Diagnosis According to the DSM-IV Series. Princeton, NJ: Films for the Humanities and Social Sciences. Interview and Assessment. Substance abuse: Assessment and Intervention Series. Irvine, CA: Concept Media. Interviewing for Child Sexual Abuse: A Forensic Guide. New York, NY: Guilford Publications. Testing and Intelligence. Discovering Psychology Series. South Burlington, VT: Annenberg/CPB Multimedia Collection. Assessment, Intervention, and Treatment, Psychotropic Medication: Caring for Patients with Psychiatric Disorders Series. Irvine, CA: Concept Media. The Clinical Psychologist (24 minutes, Insight Media: 2162 Broadway, New York, NY: 10024/1800-233-9100) Assessment and Diagnosis of Childhood Psychopathology (26 minutes, Penn State University)

Web Links Web Link 4.1: www.apa.org/science/programs/testing/index.aspx This is the “Testing and Assessment” site of the American Psychological Association’s Science Directorate. It includes a “Frequently Asked Questions” resource as well as information about standards for tests, links to other testing websites, and specific test resources. Web Link 4.2: www.unl.edu/buros The Buros Institute of Mental Measurements has published critical reviews of tests and testing for over six decades. Their Mental Measurement Yearbook has long been the standard testing and assessment reviews reference in the field. Web Link 4.3: www.apa.org/science/programs/testing/committee.aspx The Joint Committee on Testing Practices was established in 1985 by a group of major national associations with an interest in testing. The Joint Committee provides “a means by which professional organizations and test publishers can work together to improve the use of tests in assessment and appraisal.” Their website provides an assortment of their publications on fair and responsible test use, test user qualifications, rights and responsibilities of test takers, and so on. Web Link 4.4: www.apa.org/science/programs/testing/standards.aspx The APA’s “Standards for Educational and Psychological Testing” address professional and technical issues of test development and use in education, psychology and employment. It is an extremely important reference for test developers, publishers, users, policymakers, employers, and students in psychology. Web Link 4.5: emedicine.medscape.com/article/317596-overview This site provides an article written describing the purposes of neuropsychological testing, the conditions Copyright © 2013 Pearson Education, Inc. All rights reserved. 76

under which such testing might be appropriate, a detailed discussion of the various types of tests used in neuropsychological testing, and the information obtained from such testing. This would be an excellent resource for the instructor unfamiliar with neuropsychological testing or a site to which students could be directed for more information on this topic. Web Link 4.6: psychcentral.com/resources/Psychology/Assessment_and_Testing/ This site provides an array of information related to resources and different links reviewing assessment and testing in the field of psychology. Web Link 4.7: www.apa.org/ This site reviews different research studies conducted in abnormal psychology using various assessment and testing materials.

Handout 4.1 University Psychology Clinic Intake Diagnostic Assessment Form A. Patient Summary:

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

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

Handout 4.2

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

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

Repeat after me (Pause one second between numbers): 3, 4, 8 _________________ 2, 6, 4, 7 _________________ 1, 3, 2, 7, 4 _________________ 2. 5. 6. 9. 3. 8 _________________ What should come next? X, O, X, ____, _____, _______ bird 1234 / shirt 56237 / rat 387 / bash _ _ _ _

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

Using your left hand, touch your right knee. Using your right hand, point to my left hand.

Handout 4.3 Mrs. Simon, a 37-year-old elementary teacher who was referred for therapy by her principal. Although Mrs. Simon has been teaching for the past three years, her performance has always been problematic. Mrs. Simon misses two to three days per month because she simply “can’t get out of bed.” Mrs. Simon reports that she is tired all of the time, even when she goes to bed early, and that she rarely sleeps all night, typically awakening no later than 3 am. Upon questioning, Mrs. Simon denied being depressed but reported that she “feels down” all the time and frequently finds herself crying for no reason. Mrs. Simon reports that she doesn’t enjoy any activities and believes that her life will always be this way. She went on to report that she has great difficulty concentrating on her responsibilities at school and was dismayed to discover that she had taught the students the wrong material on several occasions. Diagnostic Criteria for a Dysthymic Disorder A. Depressed mood for most of the day, for more days than not for at least two years B. While depressed, reports two (or more) of the following: 1. Poor appetite or overeating 2. Insomnia or hypersomnia 3. Low energy or fatigue 4. Low self-esteem 5. Poor concentration or difficulty making decisions 6. Feelings of hopelessness C. During the two-year period of the disturbance, the person had never been without symptoms for more than two months at a time D. No major depressive episode has been present during the first two years of the disturbance, and there has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria have never been met for cyclothymic disorder E. Not due to an organic or physical cause Diagnostic Criteria for a Major Depressive Episode A. At least five of the following symptoms are present every day for a period of at least two weeks and represent a change from a previous level of functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure: 1. Depressed mood 2. Loss of interest or pleasure in usual activities, or a decrease in sexual drive 3. Poor appetite with weight loss, or increased appetite with weight gain 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Loss of energy or fatigue 7. Feelings of worthlessness, guilt, self-reproach 8. Complaints or evidence of a decreased ability to concentrate (slow thinking, indecisiveness) 9. Recurrent thoughts of death, wishes to be dead, suicide attempt B. None of the symptoms of schizophrenia are present (see above) C. Not due to an organic or physiological cause

Handout 4. 4 Conducting a Clinical Observation Have the students work in pairs or small groups of three to four. Then ask them as a group to pick a place on campus to conduct an observation with each group member recording everything they see, hear, smell, etc. for ten minutes. Allow for time to conduct the observation and time to return to class. Then once they return to class ask them to define the following: 1. Names of Group Members 2. Location where observation was conducted 3. Two to three words to describe this place, such as peaceful, calming, etc. Have the students share the different observations verbally with other group members. Note the similarities and differences among the observations. 1. Categorize the data. For example, after asking the students to verbally share their individual observations, note some common themes. As a group, come up with three different categories with at least two examples under each. Some examples I usually give are: Age Ethnicity child White adolescent Hispanic young adult African-American older adult Asian

Clothing casual fitness/workout clothing business causal professional

This also provides a time you can discuss the two types of observation—naturalistic or laboratory, as well as the advantages and disadvantages of each, the importance of more than one observer, observer bias, and observer effect.

CHAPTER 5: Stress and Physical and Mental Health Teaching Objectives 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

Define stress, and learn about how stress presents as a psychiatric disorder. Differentiate and provide an example of a stressor, stress, and coping; describe the basic categories of stressors, and discuss factors that increase or decrease a person's vulnerability to stress. Review ways to measure life stress and discuss the importance of resilience. Explain the role cortisol and other hormones play in stress reaction and why extended contact can be problematic over the longer term. Explain the interactions between the nervous system, the immune system, and behavior, and describe psychoneuroimmunology's relationship to all three. Explain what cytokines are, how they work, and why researchers are so excited about them. Discuss the connection between the mind and body when it comes to health. Explain why negative emotional states can impair the functioning of the immune system and the cardiovascular system. Explain the correlation between stress, depression, and the immune system functioning. Review the treatment modalities for stress-related physical disorders. Characterize the DSM-IV diagnosis of adjustment disorder and describe three major stressors and the consequences that increase the risk of adjustment disorder. Characterize the phenomenon of combat-related stress and of PTSD in connection with battlefield stress. Summarize what is known about the major features of reactions to catastrophic events. Explain the risk factors in the development of PTSD. Understand PTSD from a sociocultural point of view. Outline the factors that appear to influence combat-related stress problems and describe the long-term effects of PTSD. Summarize the approaches that have been used to treat or to prevent stress disorders and evaluate their effectiveness. Discuss the issue of using psychotropic medications to treat PTSD. Discuss the process of psychological debriefing and the challenges faced when studying disaster victims. Review the impact trauma has on one’s physical health. Outline the proposed DSM-5 remedy for the current diagnostic criterion for PTSD.

Chapter Overview/Summary Health psychology is the sub discipline of the field of psychology that focuses on the effects of stress and other psychological factors in the development and maintenance of physical health problems. Behavioral medicine is an approach to physical illness that is concerned with how psychological factors cause physical health problems. Stress is an inevitable part of life; all situations, positive and negative, can be stressful. Stressors can be placed into one of three categories: frustrations, conflicts, and pressures. A person’s response to stressful situations depends not only on the severity of the stressor but also on the person’s perceptions, preexisting stress vulnerabilities, and amount of external resources and social supports. Conflict situations can be characterized as approach-avoidance, doubleapproach, or double-avoidance. People’s stress responses can be viewed as task-oriented or defense-oriented. Among the consequences of extreme or prolonged stress can be extensive physical and psychological problems. When we are stressed, the autonomic nervous system responds in a variety of ways. One consequence of stress is increased production of cortisol. High levels of this stress hormone may be beneficial in the short term but problematic if the levels remain high over the longer term. In the immune system, specialized white blood cells called B-cells and T-cells work together to respond to antigens such as viruses and bacteria. T-cells are assisted by macrophages.

Psychoneuroimmunology, an exciting and developing new field, is concerned with the interactions between the nervous system, the immune system, and behavior. Cytokines are chemical messengers that allow the brain and the immune system to communicate with each other. Some cytokines respond to a challenge to the immune system by causing an inflammatory response. Other cytokines, called anti-inflammatory cytokines, dampen the response that the immune system makes when it is challenged. Negative emotional states, such as being under stress or having low social support, can impair the functioning of the immune system and the cardiovascular system, leaving a person more vulnerable to disease and infection. Damaging habits and lifestyles, such as smoking or lack of exercise, also enhance risk for physical disease. Many physical illnesses seem to be linked to chronic negative emotions such as anger, anxiety, and depression. Hostility is well established as an independent risk factor for CHD. The same is true of depression. When assessing the treatment methods for stress-related disorders, you can look at serious medical treatments as well as psychological interventions such as emotional disclosure, biofeedback, relaxation and meditation, and cognitive-behavioral therapy. Factors such as genetic vulnerabilities and excessive autonomic reactivity remain important in our understanding of the causes of physical diseases. They must also be a part of treatment considerations whenever physical disease occurs, regardless of strong evidence of psychological contributions to its development. A common factor in much psychosocially mediated physical disease is inadequacy in an individual’s coping resources for managing stressful life circumstances. Cognitive-behavior therapy, in particular, shows much promise in alleviating this type of health-endangering problem. Adjustment disorders can be caused by relatively common life events, such as unemployment, loss of a loved one through death, or marital separation or divorce. PTSD is the response to more severe trauma or excessively stressful situations such as rape, military combat, imprisonment, being held hostage, forced relocation, or torture. PTSD may include such symptoms as intrusive thoughts and repetitive nightmares about the event, intense anxiety, avoidance of stimuli associated with the trauma, and increased arousal manifested as chronic tension, irritability, insomnia, impaired concentration and memory, and depression. When PTSD symptoms occur within six months of the traumatic event, the diagnosis is acute stress disorder; if symptoms are delayed by six months or more after the traumatic event, the diagnosis is classified as delayed PTSD, a diagnosis that is more difficult to make and that is more controversial. Many factors contribute to breakdown under excessive stress, including the intensity or harshness of the stressful situation, the length of the traumatic event, the person’s biological makeup and personality adjustment prior to the stressful situation, and the ways in which the person manages once the stressful situation is over. In many cases, symptoms remit with the removal of the stressor, especially with the help of psychotherapy. In extreme cases, there may be residual damage or symptom-onset itself may be delayed until well after the trauma is over. Among the most important treatments for PTSD are the following: prevention by reducing the frequency of traumatic events; prevention of maladaptive responses to stress by preparing people in advance; stress-inoculation training; telephone hotlines; crisis intervention; psychological debriefing; medication and cognitive-behavioral treatments.

Detailed Lecture Outline I.

What Is Stress? A. Stressors are external demands. B. Stress is the effect caused by stressors C. Efforts to deal with stress, which are the effects created in an organism, are coping strategies— the efforts to deal with the stress 1. All situations, positive and negative, that require adjustment can lead to stress. 2. Hans Selye—stress can be positive (eustress) or negative (distress) B. Stress and the DSM 1. Role of stressors in symptom development is formally emphasized in the DSM-IV TR on Axis IV 2. Axis I disorders implicated in stress are adjustment disorder, acute stress disorder, and PTSD C. Factors Predisposing a Person to Stress 1. The individual’s stress tolerance a. People vary greatly in overall vulnerability to stressors. b. Children are particularly vulnerable. c. Stress tolerance refers to a person’s ability to withstand stress without becoming severely impaired. d. Early traumatic experiences can increase or decrease future vulnerability. e. Recently, the 5HT-TLPR gene has been indicated as partially responsible for stress response. 2. The experience of crisis a. When a stressful situation exceeds the adaptive capacities of a person or group 3. Measuring life stress a. Social Readjustment Rating Scale assesses the measurement of life stress 4. Resilience a. The healthy psychological and physical functioning after a potentially traumatic event b. Same events are interpreted differently by people c. Stress is different depending upon how competent a person feels to handle the stressor d. Unanticipated stressors may place a person under severe stress e. Realistic expectations for stressful events helps f. Being able to perceive some benefit from a stressor (the silver lining) may moderate the effects of a trauma g. High levels of optimism, high self-esteem, good social support, and greater selfcontrol are all positively correlated with resilience. These traits and coping styles may be heritable.

Handout 5.1: Disaster Plan 5. MyPsychLab Resource 5.1: Video on “Learned Optimism” Lecture Launcher 5.1: Emotional vs. Instrumental Support D.

Characteristics of Stressors 1. Nature of the stressor a. The impact of the stressor depends upon importance, duration, cumulative effect, multiplicity, and imminence Copyright © 2013 Pearson Education, Inc. All rights reserved. 84

b. Traumatic events influence those closest to the situation The experience of crisis a. Crisis occurs when stressful situations approach or exceed adaptive capacities b. Crisis intervention—providing psychological help in times of severe and special stress—may allow person to emerge from crisis stronger than before Life changes a. Even positive life changes place demands on us and thus may be stressful b. Holmes and Rahe, 1967—Social Readjustment Rating Scale

Handout 5.2: Holmes & Rahe Social Readjustment Rating Scale MyPsychLab Resource 5.2: Simulation “How Stressed Are You?”

II.

c. Horowitz, Wilner, & Alvarez, 1979—Impact of Events Scale Personal growth in the face of tragedy a. Being able to perceive some benefit from a disaster (e.g., being closer to your family), moderates the effect of trauma and appears to be adaptive.

Stress and the Stress Response

Activity 5.1: Migraines A.

The stress response system 1. Stress response involves a cascade of biological changes 2. Sympathetic adenromedullary (SAM) system is designed to mobilize resources and prepare for a fight-or-flight response 3. Stress response begins in the hypothalamus, stimulating the SNS, the hypothalamuspituitary-adrenal (HPA) system- (see figure 5.1). This causes the adrenal glands to secrete adrenalin and noradrenalin increasing heart rate. Hypothalamus also releases a corticotrophin-releasing hormone that stimulates the pituitary gland. The pituitary secretes ACTH, which induces the adrenal cortex to produce glucocorticoids, specifically cortisol. 3. Cortisol prepares body for “fight or flight” and inhibits the immune response. 4. Cortisol, if not shut off, can damage cells in the hippocampus and stunt growth. Biological Costs of Stress 1. Biological cost of adapting to stress is called the allostatic load. 2. Focus is not just on major stressors, but also on daily stressors. The Mind-Body Connection 1. Psychoneuroimmunology—the study of the interaction between the nervous system and the immune system 2. Immunosuppression—when a person’s behavior and psychological state affect immune system functioning Understanding the Immune System 1. Established link between stress and lowered immune system reactivity 2. Elements of the human immune system a. The immune system maintains bodily integrity and protects the body from viruses and infections. b. White blood cells (leukocytes or lymphocytes) are the core of the body’s defenses. c. There are two types of leukocytes: B-cells and T-cells. d. B-cells mature in the bone marrow and produce specific antibodies that respond to specific antigens. When an antigen is recognized, B-cells divide and produce antibodies that circulate in the blood.

f. g.

T-cells mature in the thymus and circulate through the blood and lymph glands in an inactive form. Each T-cell has specific receptors that recognize one type of antigen. T-cells become activated when macrophages detect antigens (foreign bodies such as viruses and bacteria) and start to engulf and digest them. Macrophages release interleukin-1 Cytokines are chemical messengers that appear to be crucial for health.

Activity 5.2: Illness and Stress E.

The Importance of Cytokines 1. Cytokines are small protein molecules that serve as chemical messengers and allow immune cells to communicate with each other 2. Interferon is an example of a cytokine given to patients with Hepatitis C 3. The play an important role in mediating the inflammatory and immune response 4. They are divided into main categories: proinflammatory cytokines and anti-inflammatory 5. Cytokines communicate with the immune system functioning and they also send signals to the brain, these cytokines can stimulate the HPA axis 6. Downstream effect which means that problem with the immune system may lead to some behavioral changes and psychiatric problems 7. Bruce and Peebles (1904) findings with white blood cells were abnormal in type and number for those individuals with mental illness living in a mental asylum. Stress, Depression, and the Immune System 1. Strong association found between dysphoric mood and compromised immune function 2. Depressed affect associated with lowered numbers of white cells following challenge by a foreign protein, with lowered natural killer cell activity, and with lowered quantities of several varieties of circulating white cells 3. Findings also true with: students undergoing final examinations. sleep deprivation, marathon running, space flight, being the caregiver for a patient with dementia, and death of a spouse, a. Chronic stress and depression may trigger the production of proinflammatory cytokines such as interleukin-6 b. Increases in interleukin-6 have been found to be associated with aging, certain cancers, cardiovascular disease, being overweight, smoking, and having a sedentary lifestyle 4. Positive psychology focuses on human traits and resources such as humor, gratitude, and compassion that might have direct implications for our physical and mental well-being

MyPsychLab Resource 5.3: Video “Stress and Wellness” G.

Stress and Physical Health 1. Optimism a. Hopelessness accelerates progression of atherosclerosis b. Optimism seems to serve as a buffer against disease 2. Negative affect a. Depression associated with measurable and undesirable changes in immune functioning, greater risk of having a heart attack, increased mortality from all causes, heighten the risk for osteoporosis, decline in muscle strength b. Anxiety has also been associated with development of coronary heart disease c. Chronic anger and hostility can be risk factors for coronary heart disease

Lecture Launcher 5.2: Is Laughter the Best Medicine 3.

a. b. c.

Laughter is associated with enhanced immune functioning Psychological benefits to forgiving people who have wronged us Placebo effect

MyPsychLab Resource 5.4: Video on “Positive Psychology” Lecture Launcher 5.3: Sick Days IV.

Cardiovascular Disease A. Hypertension 1. Hypertension is defined as having a persistent systolic blood pressure of 140 or more and a diastolic blood pressure of 90 or higher. (see figure 2.3 for new standards) Essential hypertension (no specific physical cause) is a risk factor for heart disease and stroke 3. Hypertension and a. Higher rates and more severe hypertension found among African Americans b. Factors may include: inner city living, economic disadvantage, exposure to violence, race-based discrimination, lifestyle factors (women more likely to be overweight and both men and women less likely to exercise) c. Biological reasons including excessive retention of ingested sodium, renin processed differently, nitric oxide produced in lower levels in the blood vessels, specific genes B. Coronary Heart Disease (CHD) 1. Chief clinical manifestations are: a. Myocardial infarction b. Angina pectoris c. Disturbance of the heart’s electrical conduction C. Risk and Causal Factors in Cardiovascular Disease 1. Chronic and acute stress a. Everyday stressors increase the risk of CHD and death 2. Personality a. The Type A behavior pattern (Friedman and Rosenman) (1) Characterized by (a) Excessive competitive drive (b) Extreme commitment to work (c) Impatient and time urgent (d) Hostility expressed in manner and speech (e) Not all components of Type A are equally predictive of heart disease. It has become clear that the hostility component including anger, contempt, scorn, cynicism, and mistrust is most closely associated with coronary heart disease.

Lecture Launcher 5.4: More Reasons Not to Be Type A Handout 5.3: Type A Traits Handout 5.4: Type A Questionnaire Recent development is the identification of the “distressed” or Type D personality (see Figure 5.5 for a chart of the characteristics of Type D) (1) Tendency to experience negative emotions and to feel insecure or anxious (2) Initial results indicate Type D is associated with coronary heart disease Depression a. Those with heart disease are three times more likely to be depressed. b.

b. c. d. e.

Being depressed at the time of a heart attack or shortly afterward places a person at greater risk for future coronary events and death. Those who had suffered major depression were found to be four times more likely to have a heart attack. Evidence points to the importance of hopelessness and vital exhaustion (fatigue, irritability, and demoralization) as risk factors for CHD. Why should depression and CHD be linked? (1) Two mechanisms have been proposed: (a) Depressed people may engage in more behaviors known to put people at risk for CHD (b) Depression ay be linked to CHD through various biochemical mechanisms

Anxiety a. Association between phobic anxiety and increased risk for sudden cardiac death. b. No association was found between anxiety and nonfatal attacks. Social isolation and lack of social support a. Those who have a relatively small social network or who consider themselves to have little emotional support are more likely to develop CHD b. For those who already have CHD, low social support predicts future cardiac events and death d. Chronic and acute stress (1) Some types of stress have a large subjective element; others appear universal (such as earthquakes) (2) Everyday forms of stress, such as workplace stress, can elevate risk for CHD (3) Key factors for negative effects of stress in the workplace are highly demanding job and little control over decision making (see figure 5.6) (4) Experiences of discrimination have been linked to a number of bad health outcomes, including increased blood pressure and signs of cardiovascular disease (5) CRP is a protein synthesized in the liver and the researchers Lewis and colleagues found that there was an increase of CRP in African Americans that had experienced discrimination (6) Emotion regulation-hostility, depression, and anxiety are all linked to CHD it is beneficial to be able to regulate one’s emotions

Treatments of Stress-Related Physical Disorders A. Biological Interventions 1. Begin with appropriate biological treatments 2. Patients treated with SSRIs were much less likely to die or have another heart attack B. Psychological Interventions 1. Emotional disclosure a. “Opening up” and writing expressively about life problems in a systematic way does seem to be effective. b. Psychosocial interventions can decease depression, systolic blood pressure, heart rate, and cholesterol levels 2. Biofeedback a. Useful for treating headaches, muscular skeletal pain b. Effects tend to be small and could be obtained in simpler ways such as systematic relaxation training

Activity 5.3: Biofeedback Demonstration 3.

a. b.

Effective for simple tension headaches and essential hypertension Increasing interest in meditation as a way to reduce blood pressure

Activity 5.4: Progressive Muscle Relaxation MyPsychLab Resource 5.5: Video “Relaxation” 4.

Cognitive-behavioral therapy a. Effective for headache and other types of pain b. CBT techniques also used for stress management

Handout 5.5: Biological or Psychological? Activity 5.5: Sociocultural Factors in Physical Illness VI.

Psychological Reactions to Stress A. Adjustment Disorder 1. Diagnosed when response to a common stressor such as divorce or childbirth is maladaptive and occurs within 3 months of the stressor 2. Considered maladaptive if unable to function as usual or if reaction is excessive 3. Maladjustment will lessen when the stressor has subsided or the individual learns to adapt. If symptoms persist past 6 months, diagnosis will change 4. Mildest diagnosis a therapist can assign to a client 5. Adjustment disorder caused by unemployment a. Unemployment is particularly an issue for young minority males. b. Rates of unemployment for young black males is twice those for young white males. 6. Adjustment Disorder Caused by Divorce or Separation a. The loss of intimate an relationship is a potent stressor b. Major source of vulnerability to psychopathology c. The loss is a multifaceted event d. Readjustment to life has new demands and stresses e. Even when divorce is relatively agreeable, coping is necessary

VII.

Posttraumatic Stress Disorder (PTSD)

Lecture Launcher 5.4: Date Rape Handout 5.6: Date Rape A.

Acute Stress Disorder 1. A diagnostic category that can be used when symptoms develop shortly after experiencing a traumatic event and last for at least two days. 2. People with this disorder do not have to wait a whole month to be diagnosed with PTSD. 3. People can receive treatment as their symptoms begin. If the symptoms continue for longer than four weeks, symptoms can progress into PTSD. Clinical Description 1. Traumatic event is re-experienced 2. Person has experienced a traumatic event 3. Response involved intense fear, helplessness, or horror 4. Recurrent distressing dreams 5. Avoidance of stimuli associated with stress 6. Increased tension/arousal, often accompanied by insomnia and sensitivity to noise 7. Impaired concentration and memory Copyright © 2013 Pearson Education, Inc. All rights reserved. 89

8. 9.

Feelings of depression leading to social withdrawal DSM-5 new proposed category which would move PTSD from anxiety disorders to a Trauma-and Stressor-Related Disorders, disorders that would be included is PTSD, ASD, and Adjustment disorder

MyPsychLab Resource 5.6: Video on “Post Traumatic Stress Disorder: Sara” C.

Prevalence of PTSD in the General Population 1. National Comorbidity Survey-Replication suggests that the lifetime prevalence rate in the U.S. is 6.8% and that these rates are higher for women 2. Over the course of their lives, 9.7% of women and 3.6% of men will develop PTSD. 3. Original cases limited to war veterans and disaster victims. 4. U.S. National Comorbidity study estimates the rate at about 6.8% lifetime prevalence 5. Women tend to have more severe symptoms. 6. Women are more likely to be exposed to certain kinds of trauma like rape . Rates of PTSD After Traumatic Experiences

MyPsychLab Resource 5.7: Video on “Post Traumatic Stress Disorder” 1. 2. 3. 4. 5. 6.

Many people who experience car accidents with injury, extreme hurricanes, and violent crime suffer from PTSD even a year later. More than 900 earthquakes with a magnitude between 5 and 8 on a Richter scale occur annually. Tsunamis devastate coastal villages; tornadoes and floods destroy lives. Shalev and Freedman (2005) found that PTSD rates were higher in those that survived a terrorist attack than those who had survived a bad car accident. Rescue workers who respond to disasters or other traumatic events usually develop PTSD at the rate of 5 to 10%. The trauma of military combat a. WWI traumatic reactions were termed “shell-shocked”—coined by Col. Frederick Mott b. Considered to be organic conditions produced by minor brain hemorrhages c. Resulted from the general combat situation—physical fatigue, constant threat of death or mutilation, and severe psychological shocks d. During WWII, traumatic reactions were known as operational fatigue and war neuroses e. During Korean and Vietnam wars, this became known as combat fatigue or combat exhaustion and impacted 10% of troops f. Figures were greater than officially reported—many soldiers received supportive therapy in their battalion and immediately returned to combat g. The trauma of military combat produced the greatest loss of personnel during WWII h. A study by the Department of Defense found that 92% of Army soldiers and Marines in Iraq report they have been attacked or ambushed and 86% report knowing someone who has been killed i. Among Iraq and Afghanistan war veterans found that 21.8%received the diagnosis of PTSD and 17.4% were diagnosed with depression j. A report evaluating Marines found that 17.1% of them reported symptoms of PTSD after deployment in Iraq or Afghanistan k. 12% to 16% of veterans of Vietnam War developed PTSD l. This data highlight the importance of mental health screenings prior to deployment m. From 2005 to 2009, 1,100 members of the armed forces have committed suicide

Teaching Tip 5.1: Combat Stress Prisoners of war and Holocaust survivors a. Almost 40% of the American prisoners in Japanese POW camps during WWI died; even higher proportion of prisoners in Nazi concentration camps died b. Survivors of Nazi concentration camps sustained residual organic and psychological damage (anxiety, insomnia, headaches, irritability, depression, nightmares, impaired sexual potency, and functional diarrhea) along with lowered tolerance to any stress c. Survivors of POW camps showed impaired resistance to physical disease, low frustration tolerance, substance abuse, irritability, and emotional instability d. 50% of POWs were found to meet criteria of PTSD in the year following their release; nearly a third met PTSD criteria 40 to 50 years later e. Several studies have documented higher risk of death in those returning from war—even years later f. Some of these effects may be due to harsh treatment and malnutrition 6. Psychological trauma among victims of torture a. Intense suffering and lifelong dread may result from torture b. 38% of Burmese political dissidents who escaped to Thailand had been tortured before their escape c. Many studies have unrepresentative samples and cannot be generalized d. Recent study of African refugees from Somalia and Ethiopia was able to obtain a substantial representative sample: (1) 45% of men and 43% of women were tortured (2) 55% of Ethiopians and 36% of Somalians were tortured e. Psychological symptoms have been well documented, including night terrors, nightmares, depression, suspiciousness, social withdrawal and alienation, irritability, and aggressiveness f. Cognitive control (being able to predict and ready themselves for the pain) of situations reduces negative consequences D. Causal Factors in Posttraumatic Stress Disorder 1. Level of stress and personality variables account for development of PTSD—at high enough stress levels, almost everyone will develop symptoms 2. PTSD is caused by experiencing trauma 3. Double victimization, with victims of trauma also being stigmatized and being blamed for the troubles that they have 4. Not everyone that is exposed to a traumatic event will develop PTSD 5. The nature of the traumatic stressor and how directly it was experienced can account for much of the differences in stress response E. Individual Risk Factors 1. Those who work with people undergoing traumatic events, such as police officers, soldier, firefighter, and aid workers, also are at high risk for developing symptoms 2. Being male, having less than a college education, having conduct problems in childhood, having a family history of psychiatric disorders, , and scoring high on measures of extroversion and neuroticism 3. Rates of exposure to traumatic events are higher for African Americans than White counterparts 4. Being female also puts an individual at a greater risk 5. Prompt treatment following a traumatic event can prevent this conditioned fear from establishing itself and becoming resistant to change 6. High IQ, high on measure of cognitive ability, and the ability to create meaning from the traumatic event all seem to act as buffers. 7. Biological factors

a. b.

VIII.

Women with PTSD have higher levels of cortisol than men. In combat veterans, males with PTSD have smaller hippocampuses (responsible for memory) than veterans without PTSD. c. MZ twin studies reveal that it is most likely hippocampal volume that may contribute to vulnerability. d. Cortisol tends to be lower in people with PTSD who have experienced physical or sexual abuse. e. Gene-environment interactions such as how people with a particular form of the gene 5HTTLPR or serotonin supporter transporter gene Sociocultural Factors 1. Psychosocial factors a. Reductions in personal freedom b. Frustrations c. Separation from home and loved ones d. Constant fear e. Prolonged harsh conditions f. Unpredictability g. Necessity of killing h. Personal immaturity—sometimes stemming from parental overprotection i. Past personality instability 2. Sociocultural variables a. Clarity and acceptability of war goals b. Identification with combat unit c. Esprit de corps—influence morale and adjustment to extreme circumstances d. Leadership quality e. Returning to an unaccepting social environment can increase a soldier’s vulnerability to post-traumatic stress f. Families of returning soldiers can develop secondary traumatic stress responses g. Being a part of a minority group Long-Term Effects of Posttraumatic Stress 1. Symptoms may persist for a sustained period 2. Delayed PTSD somewhat controversial a. Difficult to relate directly to combat stress as they may have had other adjustment problems b. Increased diagnosis may reflect increased popularity more than increased incidence

Prevention and Treatment of Stress Disorders

Handout 5.7: Institutional Stress Reduction / Student Stress and Coping A.

Prevention 1. “Stress—inoculation training” using cognitive-behavioral techniques can be effective in cases where the person is facing a known traumatic event. a. Information provided about the stressful situation and ways people can cope with dangers b. Self-statements promoting effective adaptation are rehearsed c. Person practices self-statements while being exposed to a variety of egothreatening or pain-threatening stressors—allows person to practice the new coping skills. 2. Can’t prepare for most traumatic situations as they are unpredictable and uncontrollable. Treatment for Stress Disorders 1. Telephone hotlines

Teaching Tip 5.2: Crisis Intervention Hotlines 2. C.

Psychological Debriefing

Lecture Launcher 5.5: Is Help Necessary? 1. 2. 2. 3.

C. D.

IX.

Short-term crisis therapy involving face-to-face discussion and an active therapist Debriefing sessions—often controversial Postdisaster debriefing sessions have increased over the past 20 years Research has yet to identify the efficacy of this treatment. In fact, in some studies, people who received such treatment fared worse than controls. 4. Psychotropic medications a. Antidepressants may be helpful in alleviating symptoms of depression, intrusive thoughts, and avoidance b. Since symptoms fluctuate, medication needs to be closely monitored. 5. Cognitive-behavioral treatments a. Direct exposure therapy for continuing symptoms b. Behaviorally oriented techniques involving repeated or extended exposure, either in vivo or in the imagination, to objectively harmless but feared stimuli c. Relaxation training and assertiveness training may also be recommended d. Prolonged exposure—the patient is asked to vividly recall the traumatic event over and over until there is a decrease in his or her emotional response Challenges in Studying Crisis Victims 1. Impossible to study scientifically as you cannot create an “awaiting disaster” study. Trauma and Physical Health 1. In a study looking at HIV-positive people, childhood trauma was highly predictive of death. 2. A history of trauma predicts mortality rate.

Unresolved Issues: Will DSM-5 Remedy Problems with the Diagnostic Criteria for PTSD? A. In the DSM IV TR, the definition of PTSD has expanded to include the experience of the victim— not the event itself, this was first introduced as exposure to a traumatic event that was “outside the range of usual human experience” and that would cause “significant symptoms of distress in almost everyone” 1. One study found that 89.6% of its sample had been exposed to an event (typically death of a loved one) that would qualify them for PTSD. 2. Some argue that the overly broad definition has lead to an increase in diagnosis and potential problems. 3. The DSM-5 wants to eliminate indirect and informational exposure and to remove the requirement of how a person responds with intense fear, helplessness, or horror 4. Tightening the above could mean that only people whom have experienced very traumatic events would meet diagnostic criteria.

Teaching Tip 5.3: Revisiting the DSM IV TR

Key Terms acute stress disorder adjustment disorder allostatic load antigens B-cell behavioral medicine coping strategies cortisol crisis crisis intervention cytokines debriefing sessions distress essential hypertension health psychology hypertension hypothalamic-pituitary-adrenal (HPA) system

immune system immunosuppression leuocytes lymphocytes positive psychology posttraumatic stress disorder (PTSD) prolonged exposure psychoneuroimmunology resilience stress stress-inoculation training stress tolerance stressors sympathetic-adrenomedullary (SAM) system T-cell Type A behavior pattern Type D personality

Lecture Launchers Lecture Launcher 5.1: Emotional vs. Instrumental Support What level of support does a cancer patient desire from family, friends, and health professionals? This question was examined by Rose (1990) in her study of 64 nonhospitalized cancer patients (American Journal of Community Psychology, vol. 18, pp. 439-464). She found that emotional and instrumental functions of support were distinct and required separate examination. Family and friends were preferred sources for dealing with emotional concerns. A classroom discussion can center on the actual behaviors and situations that may be helpful to the cancer patient. What factors may contribute to the development and course of the disease? Rose (1990) presents a good categorization of support functions that can guide classroom discussions. Lecture Launcher 5.2: Is Laughter the Best Medicine? The role of positive emotions in the promotion of good physical health has been demonstrated most dramatically by Norman Cousins (Anatomy of an Illness). Following diagnosis of a terminal illness, Cousins surrounded himself with stimuli to facilitate a positive effect. For instance, he watched taped re-runs of the television program Candid Camera. It was found that laughter was producing beneficial physiological effects in addition to psychological ones. His recovery began soon after his self-treatment was implemented. What physiological changes could have been affected by his positive mood and laughter? Were his changes a placebo effect or just luck? What does a case study like this prove? Do Cousins’ claimed results put unrealistic pressure on other sick people to heal themselves? Lecture Launcher 5.3: Sick Days Numerous studies (e.g., Crane & Martin, 2002) have documented that parental reinforcement of childhood sick behavior occurs. Prior to beginning the lecture on psychosocial factors as general causal factors in physical illness and disease, ask students to jot down what they did when they were kept home from school due to illness as a child. After allowing students to share some of their experiences (common experiences might include being allowed to watch television, being read to by a parent, spending time with Mom or Dad), ask them whether they believe this may lead to an increase in sick behavior. This allows for a nice discussion of classical and operant conditioning. Lecture Launcher 5.4: More Reasons Not to Be Type A An interesting lecture can be developed around the study of Karlberg and associates (1998). They examined the Type A behavior in relation to automobile accidents. Although Type A characteristics of impatience, competitiveness, hostility, and time pressure have been extensively studied as a risk factor for coronary heart

disease, this is the first study to look at automobile accidents and Type A factors. The study was completed in Europe examining Swedish drivers. The authors found time pressure to be a significant factor. A discussion could be designed to consider other situations where Type A characteristics could have a negative impact. (Behavioral Medicine, vol. 24, pp. 99-106). Lecture Launcher 5.4: Date Rape Although the text focuses on veterans and PTSD, you may also want to discuss date rape and violent crime with the class. Roughly 20% of female college students report having been forced to have sexual intercourse, and this becomes the most frequent cause of PTSD in women. Although the data varies somewhat between stranger rape (fear of physical harm and death) and acquaintance rape (fear and betrayal), both age and life circumstances moderate reactions to rape. For many young women, self-esteem may increase conflicts over independence, and their parents may encourage victims to regress (move back home, etc). This leads to enhanced vulnerability. It can also lead to issues with a husband or boyfriend. Long-term effects depend upon past coping skills, resiliency in dealing with problems, and level of psychological functioning Lecture Launcher 5.5: Media Trauma Especially following the extensive television coverage of the events of September 11, 2001, and the war in Iraq, students have a good sense of how the media can make traumatic events quite immediate to a global audience. Cable and satellite television have expanded coverage to 24 hours and provide specialized channels and programs that make it a relatively simple matter to see fairly gruesome footage from battlefields, horrific natural disasters, terrorist attacks, and even medical procedures that can leave a lasting impression. Some movies, such as Saving Private Ryan, come to be well known for their realistic depictions of traumatic events. Whether clinically diagnosable posttraumatic stress disorder can be acquired via televised exposure is not known, but it is clear that some people become quite upset by what they see, even to the point of experiencing sleep disturbances, concentration difficulties, and intrusive imagery. Efforts are made to shield children from some of this material, and surely there are images that broadcasters judge to be too disturbing even for adults. A classroom discussion of media presentation of traumatizing images can be started by simply asking students whether they have ever been traumatized by what they’ve seen on TV or in a movie. Follow-up questions can then center on who is responsible for these experiences, whether our senses are dulled by exposure of this type, whether that is a bad thing or not, how far broadcasters will go in depicting real or realistic events that may be traumatic to the audience, why viewers are attracted to this material, etc. Lecture Launcher 5.6: Is Help Necessary? Although many people were severely traumatized by the terrorist attacks of September 11, 2001, it was quite surprising to many in the mental health professions how relatively few presented for treatment. The magnitude of the expressed need for professional care was widely perceived as low in proportion to the magnitude of the precipitating events. In retrospect, however, this may not be surprising. Throughout history, humans have coped with extremely traumatic events, many that were much worse than September 11, and they have done so without mental health professions even existing. One explanation for this phenomenon emphasizes the role of family and community support. An interesting class discussion can center on the question of what mental health professionals can provide that family and community cannot. Or perhaps it is the case that the mental health professional’s role in disaster relief is to provide the family and community supports for those who otherwise would have none.

Classroom Activities, Demonstrations, and Assignments Activity 5.1: Migraines Many people suffer from migraine and tension headaches. A student project can involve having the students interview people who experience such conditions. The students could focus questions on such issues as: How long has the person been experiencing the symptoms? How do the symptoms affect his or her daily functioning? What treatment methods have been used effectively? Do physicians advise their patients of possible psychological factors when a diagnosis is made? Has the person been able to identify factors that aggravate the disorder? Are other family members affected with the same disorder? How are they diagnosed? Has the person visited a neurologist about his or her headaches? Are there different tests and different procedures for managing different types of headaches? Activity 5.2: Illness and Stress As part of the discussion of stress and its measurement, a “student stress” checklist could be developed, and a checklist of various physical symptoms could also be compiled (e.g., headache, runny nose, skin rash). If there are about 30 items on each list, then the two checklists could be administered together either to the entire class, if the class is relatively small, or to a group of about 20 students. A simple count of the stressors and of the physical symptoms would be all that is necessary to calculate the illness and stress correlation. Various weighting schemes have not outperformed simple counts in the research literature on this topic. The actual calculation of the correlation coefficient is fairly tedious to do in front of the entire class, but plotting of the data on a scatterplot goes fairly quickly and can help students to visualize the meaning of the correlation coefficient. Activity 5.3: Biofeedback Demonstration Biofeedback techniques are widely used in the treatment of disorders such as hypertension. If the instruments are available, present a portable biofeedback for classroom demonstration. An EMG or thermal unit would be most useful to demonstrate how biofeedback works. A student volunteer can be used for the illustration. Following the activity, a classroom discussion can focus on the applications and limitations of biofeedback for the disorders. Activity 5.4: Progressive Muscle Relaxation Systematic or progressive muscle relaxation is a commonly used, and very effective, procedure in the treatment of many disorders including headaches and hypertension. Progressive muscle relaxation (PMR), as developed and described by Jacobson in the 1930s, involves focusing one’s attention on muscle activity levels in order to release muscular tension. There are numerous websites where the precise procedures can be learned. One such site is http://www.innerhealthstudio.com/progressive-muscle-relaxation-exercise.htmlDemonstrating this procedure in class can then lead to a discussion of how the procedure is used and benefits as well as the limitations of the procedure. Activity 5.5: Sociocultural Factors in Physical Illness Transparency T-63 illustrates the death rate from coronary heart disease in people between 55 and 64 in 21 different countries. Depending on the number of students in your class, assign students, in groups, to one of these 21 countries. You may use more or less countries to suit your class characteristics. Instead of researching coronary heart disease, have students research another physical illness—AIDS, lung cancer, or diabetes, for example—and then create a graph similar to the one found on the transparency. Discuss what sociocultural variables might explain similar and differing rates found between countries. Activity 5.6: Create An Assessment Tool Create an assessment tool for acute stress disorder, posttraumatic disorder, adjustment disorder, or impact of stress on physical health: Divide the students into small groups to create an evaluation tool the university could use to evaluate if a student is experiencing one of the issues listed above. On several small pieces of construction paper, write down the different disorders from each of the above categories and pass one disorder out per small group. Then, ask the group members to work together using their notes, textbook, or Internet if available; knowledge of the disorder; and creativity to come up with a simple assessment tool that could be used to identify whether or not the student is experiencing the signs and symptoms of the assigned disorder. After the students have had time to create their assessment tool, allow time for sharing with the class. This can lead into a discussion of prevention of trauma exposure, treatment methods, at risk groups, and examples of trauma. Copyright © 2013 Pearson Education, Inc. All rights reserved. 96

Activity 5.7: Guest Speaker on EMDR, virtual reality therapy, somatic experiencing, or a play therapist that specializes with children that have experience trauma It is helpful for students to see an actual professional discuss how trauma presents in real-life people. Also, this provides a chance for students to hear about the opportunities in the profession and what it takes to work with individuals that have experienced trauma. If you contact your local psychological association, board of behavioral health examiners, EMDRIA, or your state’s local association for play therapy, you should be able to track down one of the professionals listed above.

MyPsychLab Resources MyPsychLab Resource 5.1: Video on “Learned Optimism” You may want to show a two-minute video on Martin Seligman discussing how learned helplessness is related to optimism. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select chapter 5, Stress and Physical and Mental Health. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Learned Optimism” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up— or assign as a suggested exercise. MyPsychLab Resource 5.2: Simulation “How Stressed Are You?” This is a brief overview of the different types of stressors. It involves a quiz that students can take to see how many stressors are occurring in their lives right now. You may want to assign it for students to do outside of class. To access this Simulate, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pulldown menu next to “Chapter,” select chapter 5, Stress and Physical and Mental Health. In the Media Type field, select “Simulate,” then click the “Find Now” button at the bottom. “How Stressed Are You?” will appear as one of your Simulate offerings. There is also a pdf file that can be downloaded at the end. MyPsychLab Resource 5.3: Video on “Stress and Wellness” You may want to show a one-minute video on stress and wellness to explore lifestyle habits. The video provides questions at the end that you can use as an in-class demo. You can also have students e-mail you the answers. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pulldown menu next to “Chapter,” select chapter 5, Stress and Physical and Mental Health. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Stress and Wellness” will appear as one of your video offerings. MyPsychLab Resource 5.4: Video on “Positive Psychology” You may want to show a two-minute video on Martin Seligman discussing how positive psychology can be applied. The video provides questions at the end that you can use as an in-class demo. You can also have students e-mail you the answers. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select chapter 5, Stress and Physical and Mental Health. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Positive Psychology” will appear as one of your video offerings. MyPsychLab Resource 5.5: Video on “Relaxation” You may want to show a two-minute video on relaxation. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select chapter 5, Stress and Physical and Mental Health. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Relaxation” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. Copyright © 2013 Pearson Education, Inc. All rights reserved. 97

MyPsychLab Resource 5.6: Video on “Post Traumatic Stress Disorder: Sara” You may want to show this four-minute video on PTSD and domestic violence. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select chapter 5, Stress and Physical and Mental Health. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Post Traumatic Stress Disorder: Sara” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 5.7: Video on “Post Traumatic Stress Disorder” You may want to show a two-minute video on a 9/11 survivor getting treatment. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select chapter 5, Stress and Physical and Mental Health. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Post Traumatic Stress Disorder” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise.

Teaching Tips Teaching Tip 5.1: Combat Stress Students can gain insight into the stresses of military combat by hearing first-hand descriptions. Local veteran organizations can be contacted to supply a person willing to speak about combat-related stresses. The speaker could also provide valuable information concerning the problems in adjusting to civilian life after combat experience. The special stresses associated with war could then be related to those factors that may modify or help a combatant handle the stress successfully. After hearing such a speaker, students could discuss how the real-life experience of military combat compares to the way it is portrayed in films and television. As part of a class discussion, excerpts from various combat movies may be shown that illustrate the stresses associated with war. Teaching Tip 5.2: Crisis Intervention Hotlines Many students, psychology majors especially, have volunteered to work on crisis-intervention or suicide hotlines. If there are any in your class, ask them to tell the rest of the class about the experience. In particular, get a description of the major points emphasized during training. Students may even have various handouts and educational material you could copy and distribute. If there are no students in the class with such experience, a small group of students interested in the topic could research the available resources, interview staff and administrators, and collect answers to class-generated questions about the service. You may also want to consider asking a representative from the crisis center on campus to visit the class to give a presentation. Actual case examples are always well received, though care must be taken to mask the identities of clients. It may also be a good time to discuss HIPPA with students. Teaching Tip 5.3: Revisiting the DSM IV TR The text discusses some of the problems that broadening the definition of PTSD could have. This is a good time to draw the analogy to autism. By redrawing the boundaries of the “autism spectrum disorder” what was one result? An increase in diagnosis, perhaps lack of a prototype, and maybe even a reconceptualizing of the disorder itself. You may want to discuss with students what the end result of this was. Is it a good thing to broaden a definition, or should the DSM be tightening its definition? This is a discussion that will illustrate to students again how such changes affect the statistics in the DSM as well as how one operationalizes a definitional term can have dramatic effects. This can also be an opportunity to address the proposed changes in the DSM-5 related to the diagnostic criterion for PTSD.

Handout Descriptions Handout 5.1: Disaster Plan One way to reduce stress is to feel prepared. Most universities have detailed disaster plans. Although such plans often emphasize physical safety and material logistics, they also incorporate more psychological components directed at preventing and managing panic and providing for people’s emotional needs once the disaster is over. A representative of the university office of public safety could be invited to discuss psychological aspects of the university’s disaster plan with the class. Alternatively, students could be asked to go through the process of creating such a plan for their university, focusing primarily on psychological aspects. Most cities also have disaster plans, so if the university office of public safety is not available or appropriate, perhaps a representative of the city can be invited instead. It may also be helpful to contact someone from your local Red Cross that is a disaster mental health professional to come out to speak to your class about the local, national, and international efforts that the Red Cross provides. Handout 5.2: Holmes & Rahe Social Readjustment Rating Scale The Holmes and Rahe Social Readjustment Rating Scale (1967) is frequently used to measure stress. It includes both negative and positive events because it views stress as anything requiring “social readjustment.” Despite its popularity, the Holmes and Rahe Scale has often been criticized. Targets of criticism include its out-of-date items (e.g., a $10,000 mortgage), the failure to cover stressors relevant to various populations of interest (e.g., college students), and the specific weights. A greater appreciation for the complexity of stress can be achieved via a classroom discussion of how to improve this measure. Students could discuss how to reword items to make them more current; different weights or research methods for deriving weights; the role of positive events on the list; what items should be added to make it more relevant to college-age people; how to improve the coverage of items weighted in the 70s, 80s, and 90s; and what might be a good anchor item with a weight of “100.” Using Handout 5.2, ask students to rate their own level of stress on Holmes & Rahe’s classic scale. You may use the following scale to provide students the meaning of their score: Score 300+: Be extremely careful—you are at a greatly increased risk of serious illness (reduce stress now!). Score 150-299+: Be cautious—your risk of illness is moderate (reduced by 30% from the above risk). Score 150-: Be glad—you only have a slight risk of illness (but still need to take care of yourself!). Handout 5.3: Type A Traits Have students complete the Type A behavior pattern questionnaire before lecturing on its relationship to coronary heart disease. Then discuss how Type As might change their behavior. Oftentimes, Type As themselves will express reluctance to change, making a variety of arguments about its adaptiveness for them. It can be helpful to discuss such ideas from a problem-solving standpoint. Type As are usually quite willing to undertake challenges, including the challenge of achieving the same ends without being Type A about it! The question to ask is whether the ends achieved via Type A behavior can be equally well achieved another way. This may be even more effective than challenging the validity of the goal itself. Ironically, Type As in treatment often will try to be your very best patient, push to get more assignments, and demand constant feedback about their rates of progress. Handout 5.4: Type A Questionnaire Here is a brief seven item, eight point Likert scale measure looking at Type A traits. It has been adapted from Bortner, R.W., & Rosenman, R.H. (1967). The measurement of Pattern-A behaviour, Journal of Chronic Disorders, 20, 525-533. You can either hand it out or post it for students to take on their own.

Handout 5.5: Biological or Psychological? You can either use Handout 5.4 as a Lecture Launcher or an activity. Place students in small groups and have each complete Handout 5.4 individually and then discuss their answers as a group. Once groups have had a chance to discuss their answers, have one spokesperson from each group share their answers with the class. Students enter the classroom with many preconceptions about what causes illness. A useful way to begin a lecture is to expose some of these beliefs. Using Handout 5.5 as an overhead transparency or a PowerPoint slide, have students respond as to whether biology or psychology would be more important in explaining what causes each of the disorders listed. It may be necessary to talk with the students about what is included under psychology. This activity works best if students include lifestyle factors under psychological factors. Handout 5.6: Date Rape—Myths or Reality? Since Mary Koss and her colleagues published information about date or acquaintance rape in the mid-1980s, awareness of this issue has grown exponentially. Unfortunately, college students frequently have erroneous beliefs concerning this topic. Using Handout 5.6 provide students with a copy of the myths or convert Handout 5.6 to an overhead transparency. Begin class by allowing students to read through the myths and then discuss what they have learned that dispel the myths. Handout 5.7: Institutional Stress Reduction / Student Stress and Coping Stress reduction is often a goal in organizational settings, not only to improve morale, employee retention, and productivity, but also to reduce healthcare costs associated with stress-related disease. The nature of stress, coping, and social policy implications can all be illustrated via a conversation in which college is treated as an organization that could benefit from stress-reduction efforts. Toward that end, students can be asked to list the most common and problematic stressors associated with being a college student. Then, they can be asked about the most effective means of coping with these stressors on one’s own. Finally, they can be asked about what could be done at an institutional level to relieve the stresses identified earlier, particularly the ones that do not yield as well to individual coping strategies.

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Abused Women Who Fought Back: The Framingham Eight. Princeton, NJ: Films for the Humanities and Social Sciences. Age is no Barrier. New York, NY: Filmmakers Library. AIDS Research: The Story So Far. Princeton, NJ: Films for the Humanities and Social Sciences. Bereavement Issues. Caring for the Dying Patient Series. Irvine, CA: Concept Media. Brain-Body Connection. Allyn & Bacon Video Library. Breaking Silence. Sherborn, MA: Aquarius Health Care Videos. Breathing Away Stress. Beyond Stress Series. Princeton, NJ: Films for the Humanities and Social Sciences. Can’t Slow Down. Allyn & Bacon Video Library. Caught in the Speed Trap: Information Age Overload. Allyn & Bacon Video Library. Cognition and the Immune System: Mind/Body Interaction—Vol. 4, The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection. Coping with Stress. Allyn & Bacon Video Library. Dealing with Doctors and Controlling Pain Through Self-Hypnosis. Berkeley, CA: University of California Extension Center for Media and Independent Learning. Dealing with Pain. Princeton, NJ: Films for the Humanities and Social Sciences. Focusing the Mind. Beyond Stress Series. Princeton, NJ: Films for the Humanities and Social Sciences. Grief and Healing. Allyn & Bacon Video Library. Handling Stress: Today and Tomorrow. Princeton, NJ: Films for the Humanities and Social Sciences. Kids and Stress. Princeton, NJ: Films for the Humanities and Social Sciences. Managing Stress. Allyn & Bacon Video Library. The Nature of Stress—Vol. 2, The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection. Off Limits. New York, NY: The Cinema Guild. A One and a Two. New York, NY: Filmmakers Library. One Nation Under Stress. Allyn & Bacon Video Library. Pain Management. Allyn & Bacon Video Library. Post-Traumatic Stress Disorder. Princeton, NJ: Films for the Humanities and Social Sciences. Post-Traumatic Stress Disorder—#1 ABC News and Client Interviews. Allyn & Bacon Abnormal Psychology Video. Post-Traumatic Stress Disorder—Anxiety-Related Disorders: The Worried Well Video Series. Princeton, NJ: Films for the Humanities and Social Sciences. Post-Traumatic Stress Disorder: The Woman’s Perspective. Princeton, NJ: Films for the Humanities and Social Sciences. Psychological Factors and Physical Illness—Vol. 4, The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection. Reducing Stress. Princeton, NJ: Films for the Humanities and Social Sciences. The Relaxation Response. Beyond Stress Series. Princeton, NJ: Films for the Humanities and Social Sciences. Relaxing Muscle Tension. Beyond Stress Series. Princeton, NJ: Films for the Humanities and Social Sciences. A Room Full of Men: Therapy for Abusive Men. New York, NY: Filmmakers Library. Running Out of Time: Time Pressure, Overtime, and Overwork. Princeton, NJ: Films for the Humanities and Social Sciences. The Session. Beyond Stress Series. Princeton, NJ: Films for the Humanities and Social Sciences. Sexual Harassment. Princeton, NJ: Films for the Humanities and Social Sciences. Stress and Emotion. The Brain Series. South Burlington, VT: Annenberg/CPB Collection. Stress: Keeping Your Cool. Allyn & Bacon Video Library. Stress: Locus of Control and Predictability—The Brain Teaching Modules Video Series. South Burlington, VT: Annenberg/CPB Collection. Stress, Trauma, and the Brain. Allyn & Bacon Video Library. Stress and Sudden Cardiac Arrest—#5 ABC News and Client Interviews. Allyn & Bacon Abnormal Psychology Video. Copyright © 2013 Pearson Education, Inc. All rights reserved. 101

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Strong at the Broken Places: Turning Trauma into Recovery. Cambridge, MA: Cambridge Documentary Films.

Web Links Web Link 5.1: www.istss.org The International Society for Traumatic Stress Studies homepage provides society-published fact sheets about traumatic stress and a wide variety of other materials for professionals, media, and the general public. Web Link 5.2: www.aaets.org/arts/art13.htm The American Academy of Experts in Traumatic Stress homepage provides articles and information on traumatic events. Web Link 5.3: http://www.ptsd.va.gov/ The National Center for PTSD sponsors this website, which serves as an educational resource concerning PTSD and other enduring consequences of traumatic stress. Web Link 5.4: www.emedicine.com/med/topic3348.htm This website provides a brief summary of treatments for adjustment disorder. Web Link 5.5: www.healthpsych.com/library/links.html This is the Health Psychology Library of healthpsych.com. In it you will find books, journals, organizations, disorders, legal issues, psychological testing, education, medical news, research, and treatment information. Web Link 5.6: www.heart.org The American Heart Association website is a terrific source of authoritative information about coronary heart disease as well as related conditions such as stroke. The patient handouts are especially nice. There is also an informative section on science. Web Link 5.7: www.healthpsych.com This website contains information and viewpoints about the interaction between psychological factors and various medical conditions, including information about psychological difficulties that can be caused by medical conditions, as well as psychological factors that can complicate or delay recovery from medical conditions. Web Link 5.8: www.healthy.net/scr/column.asp?id=187 This article provides a good overview of the research conducted on the benefits of humor. The article also provides practical suggestions for increasing humor in daily life. Web Link 5.9: www.apa.org This is the APA website. It has many articles students can access for free or that you can use for assignments. Web Link 5.10: www.apahelpcenter.org This is the APA help center. It has many articles students can access for free, or that you can use for assignments. Web Link 5.11: www.psychiatrictimes.com/resources This is the site for the Psychiatric Times. It has many articles students can access for free, or that you can use for assignments. Web Link 5.12: www.emdria.org This is the site for the Eye Movement Desensitization and Reprocessing International Association. It provides helpful information related to trauma and how trauma impacts individuals, explains the use of EMDR, and reviews training on how to become an EMDR provider,

Handout 5.1 Disaster Plan

Interview civic, institutional, or facility authorities about their disaster plans. 1.

What training is given for crisis intervention?

What services are available for people following a crisis?

What use is made of volunteers?

What are the most common problems encountered?

What are the typical outcomes following services?

Are there any special or unique issues requiring special handling within your disaster plan?

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43.

Handout 5.2 The Social Readjustment Rating Scale Death of a spouse ................................................. 100 Divorce................................................................. 73 Marital separation ................................................ 65 Jail term................................................................ 63 Death of a close family member .......................... 63 Personal injury or illness ...................................... 53 Marriage ............................................................... 50 Fired from work ................................................... 47 Marital reconciliation ........................................... 45 Retirement ............................................................ 45 Change in health of family member..................... 44 Pregnancy............................................................. 40 Sex difficulties ..................................................... 39 New family member ............................................ 39 Business readjustment .......................................... 39 Change in financial state ...................................... 38 Death of close friend ............................................ 37 Change to a different line of work ....................... 36 Change in number of arguments with spouse ...... . 35 Mortgage over $10,000 ........................................ 31 Foreclosure of mortgage or loan .......................... 30 Change in responsibilities at work ....................... 29 Child leaving home .............................................. 29 Trouble with in-laws ............................................ 29 Outstanding personal achievement ...................... 28 Spouse begins or stops work ................................ 26 Begin or end school ............................................. 26 Change in living conditions ................................. 25 Revision of personal habits .................................. 24 Trouble with boss................................................. 23 Change in work hours or conditions .................... 20 Change in residence ............................................. 20 Change in schools ................................................ 20 Change in recreation ............................................ 19 Change in church activities .................................. 19 Chance in social activities .................................... 19 Mortgage or loan less than $10,000 ..................... 17 Change in sleeping habits .................................... 16 Change in number of family get-togethers .......... 15 Change in eating habits ........................................ 15 Vacation ............................................................... 13 Christmas ............................................................. 12 Minor violations of the law .................................. 11

From: Holmes and Rahe (1967)

Handout 5.3 Type A Traits

List the major Type A traits and characteristics, then provide possible positive and negative consequences for each. Where the positives outweigh the negatives, think of alternatives to Type A traits that achieve the same positive effects without the deleterious consequences of the Type A version. Traits and Characteristics

Positive Aspects

Negative Aspects

Alternative Behaviors

Handout 5.4 Type A Questionnaire

Circle the number on the scale below that best characterizes your behavior for each trait: 1. Casual about appointments

1-2-3-4-5-6-7-8

Never late

2. Not competitive

1-2-3-4-5-6-7-8

Very competitive

3. Never feel rushed

1-2-3-4-5-6-7-8

Always rushed

4. Take things one at a time

1-2-3-4-5-6-7-8

Try to do many things at once

5. Slow doing things

1-2-3-4-5-6-7-8

Fast (eating, walking, etc.)

6. Express feelings

1-2-3-4-5-6-7-8

“Sit” on feelings

7. Many interests

1-2-3-4-5-6-7-8

Few interests outside work

Scoring Key: Total your score on the seven questions. Now multiply it by three. A total of 120 or more indicates you’re a hard-core Type A. Scores below 90 indicates you’re a hard-core Type B. Points 120 or more 106-119 100-105 90-99 Less than 90

Personality Type A+ A AB+ B

Adapted from: Bortner, R.W., & Rosenman, R.H. (1967). The measurement of Pattern-A behaviour, Journal of Chronic Disorders, 20, 525-533.

Handout 5.5 Biological or Psychological?

For each of the conditions listed in the first column, determine if biological or psychological factors are the primary cause. If for example, you believe the actions of the person, the person’s psychological makeup, or the person’s lifestyle choices are NOT important in determining the cause of the condition listed in column one, check biological factors. Biological Factors are Primary Causes

Psychological Factors are Primary Causes

Cancer Heart Disease Depression Suicide Eating Disorders Stomach Ulcers Colds Headaches

Handout 5.6 Date Rape—Myths or Reality? •

A woman who gets raped usually deserves it, especially if she has agreed to go to a man's house or park with him.

•

If a woman agrees to allow a man to pay for dinner, drinks, etc., then it means she owes him sex.

•

Acquaintance rape is committed by men who are easy to identify as rapists.

•

Women who don't fight back haven't been raped.

•

Intimate kissing or certain kinds of touching mean that intercourse is inevitable.

•

Once a man reaches a certain point of arousal, sex is inevitable and he can't help forcing himself upon a woman.

•

Most women lie about acquaintance rape because they have regrets after consensual sex.

•

Women who say “No” really mean “Yes.”

•

Certain behaviors, such as drinking or dressing in a sexually appealing way, make rape a woman's responsibility.

Handout 5.7 Institutional Stress Reduction

Many institutions are trying to reduce or eliminate stress wherever possible. This effort begins with a process of identifying the sources of stress by consulting the people who ought to know—the people experiencing the stress. At your school, that’s you! Imagine that your school wants to eliminate unnecessary stress. What should it focus on, and how should it go about this? 1.

What are some major sources of stress at your school?

On a scale from 1–10, where “1” is not at all stressful and “10” is extremely stressful, weight the stressfulness of each of the items listed in #1 above.

Starting with the most stressful and working your way down to the least stressful, briefly describe how your school could deal with the stressors you’ve identified. Try to think of stress reduction programs that reduce stress without altering the fundamental nature of the activities.

CHAPTER 6: Panic, Anxiety, and Their Disorders Teaching Objectives 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Compare and evaluate the merits of Freud’s use of the concept of anxiety in the etiology of the neuroses versus the descriptive approach used in DSM since 1980. Distinguish between fear and anxiety. Describe the major features of phobias, identify and differentiate the different subtypes of phobia, explicate the major etiological hypotheses, and discuss the most effective treatment approaches. List the diagnostic criteria for panic disorder, contrast panic attacks and other types of anxiety, and explain the association with agoraphobia. Summarize prevalence, age of onset, and comorbidity. Describe recent findings on the biological, behavioral, and cognitive influences for anxiety proneness. Summarize the evidence that anxiety sensitivity constitutes a diathesis for the development of panic attacks. Describe how safety behaviors and cognitive biases help to maintain panic. Compare and contrast the major treatment approaches for panic disorder and agoraphobia. Summarize the central features of generalized anxiety disorder, and distinguish among psychoanalytic, conditioning, and cognitive theories of etiology. Identify the central nervous system processes and structures associated with generalized anxiety disorder, and evaluate treatments for the disorder. Describe the defining features of obsessive-compulsive disorder, summarize theories of etiology along with supporting evidence (or the lack thereof), and outline the treatment of OCD. Provide several examples of sociocultural effects on anxiety disorders.

Chapter Overview/Summary Although anxiety disorders were initially considered neuroses, this term has been largely abandoned ever since DSM-III (1980). The anxiety disorders have panic or anxiety or both at their core. Today anxiety impacts 25%–29% of Americans. Anxiety is defined as an anticipation for possible future danger and fear is in response to immediate danger. Panic is a basic emotion that involves activation of the fight-or-flight response of the autonomic nervous system. Anxiety is more diffuse, including blends of high levels of negative affect, worry about possible threat or danger, and a sense that threats are unpredictable or uncontrollable. Although everyone has identifiable, rational, realistic sources of anxiety, people with anxiety disorders, by definition, have irrational sources of, and unrealistic levels of, anxiety. Mood-congruent information processing, such as attentional and interpretive biases, seem to maintain all anxiety disorders. Specific phobias are intense and irrational fears of specific objects or situations accompanied by avoidance of the feared object. Stimuli may acquire phobic properties through conditioning or other learning mechanisms or through activation of constitutional predispositions. Because stimuli such as heights and menacing animals that posed a threat to our early ancestors are better able to become the target of phobias, it is thought that we are biologically “prepared” to associate them with trauma. Phobia subtypes include: (1) animals—the fear of snakes, spiders, dogs, insects, and birds; (2) natural environment—fear of storms, heights, and water; (3) blood-injectioninjury—fear of seeing blood or an injury, receiving an injection, or seeing a person in a wheelchair; (4) situational— fear of public transportation, tunnels, bridges, elevators, flying, driving, and enclosed spaces; and (5) other—phobias associated with choking, vomiting, or “space phobias.” Social phobia, also known as social anxiety disorder, involves disabling fears, or even panic attacks, in one or more social situations, usually out of fear of negative evaluation by others or fear of acting in an embarrassing or humiliating manner. Social stimuli signaling dominance and aggression from other humans, including facial expressions of anger or contempt, appear “prepared” in the evolutionary sense to elicit phobic responses. The preoccupation with negative self-evaluative thoughts characteristic of social phobia tends to interfere with the ability to interact in socially skillful ways. Panic disorder involves unexpected panic attacks that often create a sense of stark terror, which usually subsides in a matter of minutes. The fear of future panic attacks is known as “anxious apprehension.” Many people with panic disorder also develop agoraphobic avoidance of situations in which they Copyright © 2013 Pearson Education, Inc. All rights reserved. 111

fear they might have an attack and would find it difficult to escape or would be especially embarrassing. According to the conditioning theory of panic disorder, interoceptive bodily symptoms associated with early stages of prior attacks come themselves to be able to elicit panic attacks. According to the cognitive theory of panic disorder, it is the catastrophic misinterpretation of these bodily cues that produces panic attacks, especially among those with high levels of preexisting anxiety sensitivity. Biological theories of panic disorder emphasize biochemical abnormalities in the brain as well as abnormal activity of the neurotransmitter norepinephrine and probably also serotonin. The area of the brain known as the amygdala is thought to be an especially important source of panic attacks. Another anxiety disorder is panic disorder, which involves recurrent and unexpected attacks wherein the individual worries about having more attacks. The average panic attack lasts around ten minutes. A panic attack usually includes feelings of heart racing, sweating, shaking, shortness of breath, and so on as just some examples. About 85% of people who experience a panic attack think it is a heart attack and may show up at the emergency room. Agoraphobia is the fear of public places such as crowded spaces, shopping malls, and movie theaters. Panic disorder with agoraphobia means that someone has recurrent panic attacks and presence of agoraphobia. Agoraphobia without a history of panic disorder has the presence of agoraphobia but the person has not met the diagnostic criterion for panic disorder. Panic disorder without agoraphobia is when one has recurrent panic attacks, worry about having more attacks, and the absence of agoraphobia. Generalized anxiety disorder (GAD) involves chronic and excessive worry about a number of events or activities and high levels of psychic and muscle tension. People with GAD may have extensive experience with unpredictable and/or uncontrollable life events as well as having schemas through which strange and dangerous situations promote automatic thoughts focused on possible threats. The neurobiological bases of GAD differ from those related to panic disorder, involving the neurotransmitter GABA and the limbic system of the brain. Obsessive-compulsive disorder (OCD) involves unwanted and intrusive distressing thoughts or images usually accompanied by compulsive behaviors designed to neutralize those thoughts or images. Checking and cleaning rituals are most common. Genetic, brain function imaging, and psychopharmacological studies all suggest significant biological contributions to OCD. The anxiety-reducing qualities of the compulsive rituals may help maintain OCD. Medical treatments of people with anxiety disorders often include anti-anxiety and anti-depressant medications. These medications suppress anxiety symptoms, have high addiction potential, and tend to be associated with high relapse rates once the medications are discontinued. Behavioral and cognitive therapies are effective for anxiety disorders. Behavior therapies involve prolonged exposure to feared situations to allow fear or anxiety to habituate. With OCD, the rituals also must be prevented following exposure to the feared situations. Cognitive therapies focus on getting clients to understand their underlying automatic thoughts, which often involve cognitive distortions such as unrealistic predictions of catastrophes that in reality are very unlikely to occur, and to change these thoughts and beliefs through cognitive restructuring.

Detailed Lecture Outline I.

The Fear and Anxiety Response Patterns A.

Fear and Panic Activate the “Fight or Flight” Response 1. Cognitive/subjective components. 2. Physiological components in the absence of any external danger. 3. Behavioral components. 4. Anxiety—involves feeling of apprehension about possible future danger. 5. Fear—a response to immediate danger. 6. Panic Attack—a response that occurs. When the fear response occurs in the absence of any obvious external danger

Lecture Launcher 6.1: Thrills or Chills? B.

II.

to the Future and Much More Diffuse than Fear 1. Adaptive value. 2. Has cognitive/subjective, physiological, and behavioral components. Unconditional versus Learned Sources of Fear and Anxiety 1. Conditionability of fear. 2. External versus internal (interoceptive) cues.

Overview of the Anxiety Disorders A. B.

Unrealistic and Irrational Fears of Disabling Intensity DSM-IV-TR Recognizes Seven Anxiety Disorders 1. Specific phobia 2. Social phobia or social anxiety disorder. 3. Panic disorder with or without agoraphobia and agoraphobia without panic. 4. Generalized anxiety disorder. 5. Obsessive-compulsive disorder. 6. Acute stress disorder . 7. Post traumatic stress disorder. Anxiety Disorders are Relatively Common 1. Most common group of disorders among women. 2. Comorbidity is typical. 3. Phobias are the most common of the anxiety disorders. 4. Commonalities in causes across these disorders: a. Common genetic vulnerability is the personality trait of neuroticism. b. Brain structures most commonly involved are generally in the limbic system. c. Most common neurotransmitters involved are GABA, norepinephrine, and serotonin. d. Classical conditioning is common. e. People with perceptions of lack of control over their environment and their emotions are more vulnerable. 5. Commonalities across effective treatments: a. Graduated exposure is the single most effective treatment. b. Cognitive restructuring. c. Benzodiazepines and anti-depressants.

MyPsychLab Resource 6.1: Video on “Overcoming Fears and Anxieties” III.

Specific Phobias (See Table 6.1 for a brief overview)—a person is diagnosed with a specific phobia when she or he shows a persistent fear that is excessive and unreasonable A.

Blood-Injection-Injury Phobia 1. Occurs in about 3%–4% of the population. 2. Disgust is as typical a response as fear. 3. Initial heart acceleration followed by a drop in rate and pressure. 4. Nausea, dizziness, and fainting. Prevalence, Age of Onset, and Gender Differences 1. Common in women. 2. Animal phobias—about 90%–95% are women. 3. Lifetime prevalence rate is about 12%. 4. Animal, dental, and blood-injection-injury phobias begin in childhood. 5. Agoraphobia and claustrophobia begin in adolescence and early adulthood. Psychological Causal Factors 1. Psychoanalytic viewpoint: a. View of phobia as defense against anxiety via repression of id impulses; anxiety is then displaced onto some external object or the situation is symbolically Copyright © 2013 Pearson Education, Inc. All rights reserved. 113

linked to the real object of the anxiety. Phobias as learned behavior: a. Classical conditioning and generalization. b. Direct traumatic conditioning. c. Vicarious conditioning of phobic fears. d. Prepared learning—when primates and humans acquire fears of certain objects or situations that posed real threats.

Lecture Launcher 6.2: The Transmission of Fear Responses e.

Sources of individual differences in the learning of phobias: (1) History of previous positive experiences reduces the likelihood of a phobia developing. (2) Events during conditioning such as inescapable and uncontrollable events. (3) Experiences after a conditioning event such as the inflation effect. (4) Cognitive factors maintaining phobias. f. Evolutionary preparedness for the development of fears and phobias. Biological Causal Factors 1. Affect the speed and strength of conditioning of fear. 2. Behavioral inhibition and fear—high levels in early development correlate with developing multiple specific phobias by 7–8 years of age. 3. Twin studies indicate modest heritability—but nonshared factors play a larger role. Treatments 1. Exposure therapy—involves controlled exposure to the stimuli or situations that elicit phobic fear. 2. Participant modeling. 3. Virtual reality environments. 4. Cognitive and pharmacological treatments are ineffective. 5. Some evidence that anti-anxiety medications may interfere with the positive effects of exposure therapy.

Activity 6.1: Systematic Desensitization Exercise Activity 6.2: Roller Coasters IV.

Social Phobias or Social Anxiety Disorder

MyPsychLab Resource 6.2: Video “Steve Social Phobia” A.

Prevalence, Age of Onset, and Gender Differences 1. Approximately 12% of the population qualifies for a social phobia. More than half of these suffer from one or more additional anxiety disorder during their lives. 2. 60% of individuals are female. 3. Starts in early or middle adolescence—early adulthood. 4. The disorder results in lower employment rates and lower SES. Psychological Causal Factors 1. Social phobias as learned behavior a. Direct or vicarious conditioning, such as experiencing or witnessing a perceived social defeat or humiliation, or being or witnessing someone else being the target of anger or criticism. b. 92% of an adult sample of those with social phobia recalled severe teasing as a child. c. Those with social phobia are also more likely to have grown up with parents who were socially isolated and avoidant. Copyright © 2013 Pearson Education, Inc. All rights reserved. 114

Social fears and phobias in an evolutionary context a. Proposes that social phobias are a by-product of dominance hierarchies. b. Evolutionarily based predisposition. Perceptions of uncontrollability and unpredictability a. Lead to submissive and unassertive behavior. b. Likelihood increases if person has experienced an actual social defeat. c. Diminished sense of personal control that may, in part, have developed from overprotective parents. Cognitive biases a. Danger schemas concerning others. b. Expect they will behave in an awkward and unacceptable way resulting in rejection. c. Preoccupied with bodily responses and negative self-images in social situations. d. A negative attribution bias may also come into play here.

Teaching Tip 6.1: Incorporating Social Psychology C.

Biological Causal Factors 1. Genetic and temperamental factors a. Modest genetic contribution—about 30% due to genes. b. Behavioral inhibition—those high on behavioral inhibition between 2–6 years of age are three times more likely (22%) to be diagnosed with a social phobia even in middle childhood. Treatments 1. Cognitive and behavioral therapies a. Exposure. b. Challenge of negative, automatic thoughts. c. Cognitive restructuring—review the faulty beliefs. 2. Medications a. Antidepressants may also be effective. b. Monoamine oxidase inhibitors (MAOIs). c. Selective Serotonin Reuptake Inhibitors (SSRIs). b. One study found that cognitive behavioral therapy was more effective than medication and had better long-term results.

Handout 6.1: Commonalities among Social Phobias V.

Panic Disorder with and without Agoraphobia A. Panic Disorder—defined as the occurrence of panic attacks

Lecture Launcher 6.3: “False Alarms” 1. 2.

As many as 85% seek help from an emergency room or doctor’s office. Case of Mindy Markowitz.

MyPsychLab Resource 6.3: Video on “Panic Disorder” MyPsychLab Resource 6.4: Video “Panic Disorder: Jerry” B.

Agoraphobia 1. Conceptualized as a complication of repeated panic attacks in varied situations. 2. Case of John D. 3. Most commonly avoided situation is crowded places and streets (see Table 6.2)

Agoraphobia without Panic 1. Usually a gradually spreading fearfulness. 2. Extremely rare in clinical settings. Prevalence, Age of Onset, and Gender Differences 1. Prevalence increasing with younger generations. 2. Onset most common between 15–24 years. 3. Twice as common in females, probably for sociocultural reasons (see Table 6.3 for chart of gender differences in anxiety disorders). Comorbidity with Other Disorders 1. High comorbidity with other anxiety disorders. 2. 30%–50% will experience serious depression. 3. 83% of people with panic disorder also have at least one comorbid disorder. Timing of a First Panic Attack 1. Frequently follows feelings of distress or a highly stressful life situation. 2. Panic attacks more common (23% of population) than panic disorder. Biological Causal Factors 1. Genetic factors a. Only moderate heritability. b. Liability is probably for panic disorder and phobias. 2. Panic and the brain a. Amygdala—a collection of nuclei in front of the hippocampus in the limbic system of the brain, which is key in the interpretation of fear. b. Abnormally sensitive fear network. c. Hippocampus implicated in conditioned anxiety. d. Higher cortical centers mediate cognitive symptoms. 3. Biochemical abnormalities a. Biological challenge procedures suggest that no single neurobiological mechanism is implicated. b. Noradrenergic and serotonergic systems are implicated. c. GABA recently shown to be implicated in anticipatory anxiety. d. Panic provocation procedures—something that produces panic attacks in panic disorder. Psychological Causal Factors 1. Comprehensive learning theory of panic disorder a. “Fear of fear” hypothesis and process of interoceptive and extereoceptive conditioning. b. Anxiety conditioned to internal and external cues. c. Panic attacks themselves are likely conditioned to certain internal cues. d. Constitutional and experiential vulnerabilities.

Teaching Tip 6.2: Fear of Fear 2.

The cognitive theory of panic (see Figure 6.2) a. Catastrophic interpretations of bodily sensations. b. Automatic thoughts become the triggers of panic. c. Evidence that cognitive therapy for panic works supports the prediction that changing cognitions about bodily symptoms may reduce or prevent panic. Learning and cognitive explanations of results from panic provocation studies a. Catastrophic cognitions are not needed in conditioning theory. b. Cues can be unconscious. c. Learning theory is better than cognitive model at explaining nocturnal panic attacks and panic attacks that occur without any preceding negative (catastrophic) automatic thoughts. Anxiety sensitivity and perceived control Copyright © 2013 Pearson Education, Inc. All rights reserved. 116

Anxiety sensitivity is a trait—like belief that certain bodily sensations may have harmful consequences. b. Anxiety sensitivity predicted the development of spontaneous panic attacks during a highly stressful period. c. Psychological manipulations, such as having a sense of perceived control or having a “safe” person, may block panic. 5. Safety behaviors and the persistence of panic a. Disconfirmation does not occur because people with panic disorder engage in “safety behaviors” such as breathing slowly. b. Safety behaviors believed to prevent catastrophe. c. Safety behaviors need to stop for effective treatment. 6. Cognitive biases and the maintenance of panic a. People with panic disorder interpret ambiguous bodily sensations and situations as threatening. b. Attentional bias toward threat cues. c. Memory bias favoring threatening information. Treatments 1. Medications a. Benzodiazepines/anxiolytics, e.g., xanax or klonopin (1) Rapid effects. (2) Addictive. (3) Withdrawal must be gradual. (4) Rebound panic and relapse. (5) Interfere with cognitive therapy. b. Antidepressants (primarily the tricyclics and the SSRIs) (1) Non-addictive. (2) Slow effects—may take up to 4 weeks. (3) Side-effect problems—SSRIs better tolerated. (4) High relapse rates. 2. Behavioral and cognitive-behavioral treatments a. Prolonged exposure is effective in 60%–75% of patients. b. Interoceptive exposure. c. Integrative cognitive-behavioral techniques. d. Combined medication and cognitive-behavior therapy seems to always lead to greater relapse.

Lecture Launcher 6.4: Overcoming Phobias VI.

Generalized Anxiety Disorder A. General Characteristics 1. Future-oriented mood state of chronic worry and “anxious apprehension.” 2. Restless, easily fatigued, poor concentration, irritable, tense, indecisive. 3. Worry experienced as uncontrollable. 4. The “basic” anxiety disorder. 5. Subtle avoidance such as procrastination and checking. 6. High vigilance, muscle tension, and sleep disturbance. 7. A graduate student with GAD. B. Prevalence, Age of Onset, and Gender Differences 1. Relatively common. 2. Twice as common in women. 3. Most continue to function despite symptoms. 4. Age of onset difficult to determine with as many as 60%–80% report being anxious all their lives. C. Comorbidity with Other Disorders 1. Seen with other Axis I disorders, especially other anxiety and mood disorders. Copyright © 2013 Pearson Education, Inc. All rights reserved. 117

2. D.

Excessive use of tranquilizing drugs, sleeping pills, and alcohol complicates the clinical picture. Psychological Causal Factors 1. The psychoanalytic viewpoint a. Unconscious conflict between id and ego. b. Defenses broken down or never developed. c. No object to displace upon. d. Theory is not testable and has basically been abandoned. 2. Perceptions of uncontrollability and unpredictability a. Cognitive processes associated with prior aversive events. b. Unpredictability of important past events generalizes to future ones c. Lack of safety signals. 3. A sense of mastery: The possibility of immunizing against anxiety a. “Master” and “yoked” infant monkeys, rhesus monkeys. b. “Masters” coped better with stress when older. c. Suggests that early experiences with control and mastery can immunize the individual against the harmful effects of stressful situations. 4. The central role of worry and its positive functions a. Five benefits of worry identified by people with GAD: superstitious avoidance of catastrophe, actual avoidance of catastrophe, avoidance of deeper emotional topics, coping and preparation, motivating device. b. Suppression of emotional and aversive physiological responding may serve to reinforce the process of worry. c. Worry impairs the processing of the event, thereby preventing fear from being extinguished. 5. The negative consequences of worry a. Worrying is itself not pleasant. b. Attempts to control thoughts and images actually increase them. 6.

Cognitive biases for threatening information a. Attention is drawn toward threat cues. b. Interpret ambiguous stimuli as threats.

Activity 6.3: Cognitive Restructuring E.

Biological Causal Factors 1. Genetic factors a. Small to modest heritability. b. Inherited predisposition is to neuroticism (proneness to experience negative mood states); shared with major depression. 2. Neurotransmitters and neurohormonal abnormalities a. A functional deficiency of GABA. b. The corticotrophin-releasing hormone system and anxiety. 3. Neurobiological differences between anxiety and panic a. Biology of panic and GAD are not the same. b. Amygdala and fight-or-flight for fear and panic, limbic system for GAD. Treatments 1. Medications a. Benzodiazepines not as effective as believed by public. b. Busipirone is a new, non-addictive, non-sedating, but slow drug. c. Antidepressants are useful. 2. Cognitive behavioral treatment a. Therapy involves applied muscle relaxation and cognitive restructuring, is quite effective.

Handout 6.2: Progressive Muscle Relaxation VII.

Obsessive-Compulsive Disorder

MyPsychLab Resource 6.6: Video “Dave: Obsessive Compulsive Disorder” MyPsychLab Resource 6.7: Video “Margo: Obsessive Compulsive Disorder” A.

Characteristics of OCD 1. Types of obsessive thoughts a. Obsessions—Contamination fears, harming self or others, lack of symmetry, pathological doubt, sexual obsessions, and obsessions concerning religion or aggression. b. Obsessions rarely carried out. 2. Types of compulsions a. Compulsions—Five primary types: cleaning, checking, repeating, ordering/arranging, and counting. b. Performance of act brings feeling of reduced tension and satisfaction, as well as a sense of control. 3. Consistent characteristics a. Anxiety is the affective symptom.

Teaching Tip 6.3: The ABCs of Psychology b. c. d.

Fear that something terrible will happen to them or to others because of them. Compulsion reduces anxiety in the short term. “What if” illness; this tendency to judge risks unrealistically is very common among those with OCD.

Prevalence, Age of Onset, and Gender Differences 1. Not as rare as once thought, 2.3% lifetime prevalence. 2. More than 90% of those who present for treatment experience both obsessions and compulsions; if include mental rituals and compulsions, this jumps to 98%. 3. Divorced and unemployed people overrepresented. 4. Little or no gender difference. 5. Typically begins in late adolescence or adulthood but is not uncommon in children. 6. Early onset more common in boys and is usually associated with more severe symptoms. 7. Gradual onset and chronic once serious. Comorbidity with other disorders 1. Depression is especially common, up to 80% may experience significant depressive symptoms. 2. Body dysmorphic disorder also rather common as a comorbid disorder. Psychological Causal Factors 1. OCD as learned behavior a. Mowrer’s two-process theory of avoidance learning. b. Several classic experiments have supported this theory. c. Core of the most effective form of behavior therapy for OCD. d. Does not explain development of obsessions or abnormal assessments of risk. 2. OCD and preparedness a. Some fears have occurrence rates that seem nonrandom. b. Obsessions also adaptive in evolutionary terms. 3. Cognitive causal factors a. The effects of attempting to suppress obsessive thoughts (1) Thought suppression may lead to paradoxical increase in those thoughts later. Copyright © 2013 Pearson Education, Inc. All rights reserved. 119

(2) b. c.

Normal and abnormal obsessions differ in degree to which they are resisted. Appraisals of responsibility for intrusive thoughts (1) Inflated sense of responsibility may lead to thought-action fusion. Cognitive biases and distortions. (1) Problems inhibiting cognitive processing. (2) Predisposition to thought suppression. (3) Nonverbal, but not verbal, memory deficits.

Handout 6.3: Superstitious Behavior and Compulsions E.

Biological Causal Factors 1. Genetic influences a. Moderately high heritability. b. Higher rates if sub-clinical obsessive-compulsive symptoms and tic-related OCD is included. 2. OCD and the brain a. Abnormally active metabolic levels in the orbital frontal cortex, caudate nucleus, and cingulate cortex. b. Brain functions normalize after behavior or pharmacotherapy. c. Dysfunction of the cortico-basal-ganglionic-thalamic circuit leading to inappropriate behavioral responses that are normally inhibited. d. Orbital frontal cortex is responsible in the obsessions. 3. Neurotransmitter abnormalities a. Anafranil (clomipramine) and prozac often effective. b. Drugs must be taken at least 6–12 weeks before changes noted. c. Leads to a functional decrease in availability of serotonin. Treatments 1. Behavioral and cognitive-behavioral treatments a. Behavioral treatment that combines exposure and response prevention is most effective. b. Success in 50%–70% of patients; this is superior to medication. 2. Exposure and response prevention—the treatment involves having OCD clients develop a hierarchy of upsetting stimuli 3. Medications a. Serotonin-reuptake inhibitors. b. Relapse rates high (up to 90%) following medication discontinuance. c. Combining medication with behavioral treatment has not been shown to be more effective in adults; one study showed promise in children. d. Neurosurgery being investigated once again. e. Antipsychotic medications.

Lecture Launcher 6.5: Medications VIII.

Sociocultural Causal Factors for all Anxiety Disorders A. Cultural Differences in Sources of Worry 1. Yoruba culture in Nigeria indicates three clusters of symptoms: worry, dreams, bodily complaints. 2. Culturally related syndrome in China is called Koro. 3. Caribbean cultures and ataque de nervios. B. Taijin Kyofusho 1. Anxiety disorder symptoms unique to Japanese cultural patterns. 2. Fear of blushing, making eye contact, emitting an offensive odor.

IX.

Compulsive Hoarding: Is it a Subtype of OCD? 1. When considered a subtype of OCD, hoarding accounts for 10%–40% of diagnosed persons. 2. Generally, these individuals are for more disabled than those with OCD and are at greater risk for fire and health risks. 3. Recent studies indicate that the brain scans of hoarders is different than those of persons with OCD that don’t hoard. 4. Many persons with hoarding do not respond to the medications that work on those with OCD.

Key Terms agoraphobia amygdala anxiety anxiety disorder anxiety sensitivity blood-injection-injury phobia cognitive restructuring compulsions exposure and response prevention exposure therapy exteroceptive conditioning fear generalized anxiety disorder (GAD)

interoceptive conditioning obsessions obsessive-compulsive disorder (OCD) panic attack panic disorder panic provocation procedures phobia prepared learning social phobia specific phobia

Lecture Launchers Lecture Launcher 6.1: Thrills or Chills? Bungee jumping, riding roller coasters, participating in extreme sports, scary movies, and parachuting all produce physiological reactions extraordinarily similar to panic attacks. Of course, they are not panic attacks, and this is likely to be related to the fact that the sensations being experienced are expected and, indeed, even sought after. Nevertheless, they are also frequently described as very fear provoking—and that’s a big part of their appeal! A classroom discussion of fear-seeking and fear-avoidance can help illustrate how cognitive and environmental factors can influence the experience of fear to a remarkable degree. Lecture Launcher 6.2: The Transmission of Fear Responses This is a great time to again discuss conditioning theories. You may want to refer back to Handout 2.4 from Chapter 2 on classical conditioning. This demonstrates how classical conditioning accounts for at least part of the learning aspect of fear. Ask students to discuss fear responses they have and how they could have been classically, operantly, or socially learned. One example could be the fear of dogs; it could be classically conditioned (e.g., you’ve been bitten by a dog and now fear all dogs) or vicariously conditioned (e.g., mom and dad always show a fear response to dogs so now you do too). Lecture Launcher 6.3: “False Alarms” The comprehensive learning theory of panic emphasizes the reactions to initial panic attacks. A variety of external circumstances can lead up to initial attacks, but if people experiencing attacks fail to attribute the attacks to external circumstances, they might be left to imagine they are having heart attacks, dying, or going crazy instead. For instance, one might run up the stairs to get to an important meeting but nevertheless attribute physiological symptoms to cardiac problems, neglecting to consider the roles of upcoming meeting stress and of bounding up the stairs. Similarly, one might attribute feelings of dizziness and disorientation to “going crazy” when it might be more accurate to attribute these feelings to, say, a missed lunch and physical exertion. These points can be emphasized through a discussion of why pregnant women rarely experience panic attacks. One likely explanation is that pregnant women have a readily available attribution for any physiological symptoms they experience—the physiological changes associated with pregnancy. If students appreciate the role of attributions, they should be able to offer this explanation with fairly minimal prompting. It can further emphasize elements of the theory to discuss ambiguous circumstances, where ready attributions to external circumstances are not available to anyone. That is, even people prone to appropriately attribute panic symptoms to external circumstances might sometimes fail to identify any. In these ambiguous circumstances, any particular attribution is arbitrary, and the preference for catastrophizing attributions is what sets those prone to panic disorder apart from those who are not. The class might be asked to brainstorm benign alternatives to catastrophic interpretations. This would also be a good time to Copyright © 2013 Pearson Education, Inc. All rights reserved. 122

emphasize that medical rule-outs are always necessary before pursuing such psychological aspects of panic disorder. Lecture Launcher 6.4: Overcoming Phobias Students are often more comfortable talking about their phobias when asked how they defeated them. Alternatively, they can be asked how they intervened with their fears before they became full-blown phobias. For instance, they might be asked whether they recall things that made them fearful initially but about which they later became at ease. How did the initial apprehension come about? What did they think about it? Was there anything they did deliberately to combat the fear? What worked and what didn’t? These informal attempts can be compared to the more formal ones described in the book, and the characteristics of effective and ineffective self-help strategies can be explored in the context of therapeutic principles drawn out in the text. Lecture Launcher 6.5: Medications A variety of issues about medications are nicely illustrated in the context of anxiety disorders. For one, students often associate medication with “cure” and are surprised to learn that once anxiety medications are discontinued, the underlying physiology of the disorder returns. That is, these medications control but do not cure the disorders for which they are being taken. Another medication issue concerns the way medications can undermine the effectiveness of behavior therapy for panic disorder. This can be used to re-examine the important features of effective behavior therapy. When students are asked why medication might undermine behavior therapy, they should recognize that medications can weaken exposure experiences and that medications provide complicating additional targets to which attributions about fear can be made and to which therapeutic progress can be credited.

Classroom Activities, Demonstrations, and Assignments Activity 6.1: Systematic Desensitization Exercise Systematic desensitization is a popular technique to demonstrate in the classroom. To demonstrate systematic desensitization, a volunteer must be secured from the class or else a “guest” can be brought in especially for this purpose. The demonstration begins with a brief interview to determine what is anxiety-provoking for this person (simulated symptoms are suitable). Prompt the person for as many details as possible about the circumstances surrounding the fear; when it occurs, where it occurs, who else is there, coping strategies, how long it lasts, how it feels, and so on. Write each scenario onto a separate index card. Then, you construct a fear hierarchy of about 15 specific fear situations, ordered in terms of how anxiety provoking they are. Tell the subject to signal you with a raised finger anytime anxious feelings occur. When the subject seems and reports being very relaxed, begin by describing the least anxiety-provoking situation from the hierarchy. Pause and let the subject imagine it for about 10 seconds. Then ask the volunteer to stop imagining this situation and to relax once again. Proceed to the next scene from the hierarchy in the same way. If the person signals anxiety, ask him or her to stop visualizing the scene and to relax. If this is difficult to do, it might help to pre-arrange a relaxing scene to visualize. Once the volunteer is relaxed again, start with the image one step lower on the hierarchy than the one that prompted the anxiety and proceed as before. If the next step again provokes anxiety, it may be necessary to construct an intermediate step to soften the transition. Activity 6.2: Roller Coasters Working individually, have each student imagine him or herself waiting in line to ride a roller coaster. Each student is to record the physical sensations they would experience while waiting to get on the ride. Warn students that you are interested only in physical sensations and that they are not to list their emotional reactions or thoughts. Once students have completed this task, have volunteers read their physical sensations. Make a list on the board or use an overhead projector. Once again, eliminate any descriptors that interpret their physical sensations such as emotional reactions or thoughts. Once a thorough listing has been created that represents the responses of all students, have students raise their hands to indicate if they like roller coasters or dislike them. Point out that their physical sensations are identical. Use this activity as a launching point to discuss cognitive appraisal and the importance of past experiences in interpreting events. Activity 6.3: Cognitive Restructuring For this exercise, ask the class to report the automatic thoughts associated with the various anxiety disorders. It can be helpful to select one disorder or else to structure the task by going through the disorders one-by-one. Student responses often feed off of each other and fairly comprehensive sets of thoughts are fairly quickly produced. Once a Copyright © 2013 Pearson Education, Inc. All rights reserved. 123

detailed set of these dysfunctional thoughts is produced, students can brainstorm therapeutic “challenges” to these thoughts as well as more functional coping thoughts. Alternatively, once the dysfunctional thoughts are listed, students can be asked to write them down and to generate challenges and replacement thoughts on their own as a homework assignment. Activity 6.4: Stressors and Worries from the letter A to Z Defining stressors and coping strategies The exercise is designed to allow students to use their creativity and critical thinking to analyze the impact of stress and ways of coping. Before beginning the activity, split the class into small groups of three to four students. Then ask the students to work together as a group and come up with a list of stressors, starting with every letter of the alphabet from A–Z, and then come up with an additional list of ways to cope with stressors, again using every letter of the alphabet A–Z. Ask each group to pull out two separate sheets of notebook paper and designate a group member to be the recorder. The coping techniques can be positive or negative ways to deal with stress. You may also get more specific, asking the students to make a list using every letter of the alphabet from A–Z of anxietyprovoking events, situations, or objects as well. You could also designate certain letters of the alphabet like B, C, D, R, S, T, L, A, and D. After every group has completed the activity, allow time for an in-class discussion of the various stressors and ways to cope with stress. Was it easier to come up with a list of stressors or was it easier to come up with the list of ways to cope? Can stress lead to anxiety disorders? Why or why not? At what point does a worry turn into anxiety? This can also be a time to discuss the stress and anxiety that college brings, and it also offers a chance to normalize this experience for students, as it shows a sense of universality.

MyPsychLab Resources MyPsychLab Resource 6.1: Video “Overcoming Fears and Anxieties” You may want to show a brief, 3-minute video discussing treatment options for anxiety disorders. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 6, Panic, Anxiety, and Their Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Overcoming Fears and Anxieties” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 6.2: Video “Steve Social Phobia” You may want to show a brief, 3-minute video case study on Steve who has social anxiety disorder. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 6, Panic, Anxiety, and Their Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Steve Social Phobia” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 6.3: Video “Panic Disorder” You may want to show a brief, 1-minute video on panic disorder brain imaging and the role of serotonin in panic disorder. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 6, Panic, Anxiety, and Their Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Panic Disorder II” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 6.4: Video “Panic Disorder: Jerry” You may want to show a brief, 2-minute video on a case study on panic disorder. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 6, Panic, Anxiety, and Their Disorders. In the Media Type field, select “Watch,” then click the “Find Copyright © 2013 Pearson Education, Inc. All rights reserved. 124

Now” button at the bottom. “Panic Disorder: Jerry” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 6.5: Video “Phobias” You may want to show a brief 2-minute video case study of an agoraphobic. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 6, Panic, Anxiety, and Their Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Phobias” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 6.6: Video “Dave: Obsessive Compulsive Disorder” You may want to show a brief, 3-minute case study on Dave who has OCD. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 6, Panic, Anxiety, and Their Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Dave: Obsessive Compulsive Disorder” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 6.7: Video “Margo: Obsessive Compulsive Disorder” You may want to show a brief, 2-minute case study on Margo who has OCD. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 6, Panic, Anxiety, and Their Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Margo: Obsessive Compulsive Disorder” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise.

Teaching Tips Teaching Tip 6.1: Incorporating Social Psychology You may want to draw the connection here between social cognition, specifically attribution and social facilitation, and how these processes may have gone awry or be more sensitively set in some than others. For example, in social facilitation, tasks like public speaking become easier or more difficult based on if there is an audience present. A study by Zajonc, Heingartner and Herman (1969) found that even cockroaches show this effect, suggesting that this is a very basic response. In the case of social phobias, some individuals may be reacting to a larger extent than the average. It is also a good time to remind students that much of abnormal psychology are processes, like anxiety and attribution, that all of us have but are stronger or set more sensitively in some than others. This should further illustrate the adaptive values of many of these traits and faculties. Teaching Tip 6.2: Fear of Fear Many students fail to recognize how easy it could be to condition a fear to being in public spaces. You may want to help illustrate this point with the following example. Say you were at the mall shopping when you suddenly had a panic attack for no apparent reason. The next time you are at the mall you begin to worry that you might have another panic attack because the first one was not in response to any specific event or stimuli. Now because you are worried you leave the mall and start to feel better. It would not be surprising for you to not be eager to return to the mall anytime soon. Why? Initially, you associate mall and panic attack via classical conditioning then it becomes maintained via operant conditioning. This almost guarantees that you will avoid the mall. If your brain starts to think the panic can occur in other social contexts, generalization will occur. Thus, it could be quite easy for someone to become agoraphobic after even one panic attack at the mall. Teaching Tip 6.3: The ABC’s of Psychology This is a great time to cover how affect, behavior, and cognition are intertwined. Remind students that this Copyright © 2013 Pearson Education, Inc. All rights reserved. 125

relationship is epigenetic and bidirectional. Affect effects both cognition and behavior. Behavior effects both affect and behavior. And of course cognition affects both affect and cognition. Functioning or change on one level necessarily affects the others.

Handout Descriptions Handout 6.1: Commonalities among Social Phobias Social phobias are characterized by a fear of being humiliated or embarrassed in a public setting. These types of fears are quite common among college students. Using Handout 6.1, have each student find three people with different religious, cultural, or socioeconomic backgrounds to interview. Each person interviewed should be able to describe a social fear they have that might be similar to a social phobia. Once the information is collected, have students share their findings with other students in a small group setting. Finally, have groups share what they found as similar features of social fears and describe how these commonalities cut across the different individuals they interviewed. Handout 6.2: Progressive Muscle Relaxation Progressive muscle relaxation (PMR) can be conducted on the entire class while they remain in their seats or else they can lie on the classroom floor if the room is suitable. Emphasize that PMR is a skill and that once people are skilled at relaxation they are well equipped to benefit from many anxiety-reducing therapies, such as systematic desensitization. Students often have many comments about the experience immediately after you complete the demonstration. An alternative approach to this exercise involves pairing students up and having them take turns being the therapist and client. Handout 6.3: Superstitious Behavior and Compulsions The behaviorist B. F. Skinner compared the compulsions observed in OCD with superstitious behavior he produced in pigeons under fixed-time schedules of reinforcement. These pigeons acted as if whatever they were doing before reinforcement had actually produced the reinforcement, even though their behavior was in fact irrelevant. Students will often admit to superstitious behaviors, like using their “lucky” exam pencil, wearing a special hat when their favorite sports team is playing, or avoiding stepping on sidewalk cracks. They are also likely to know some of the many superstitious behaviors engaged in by professional athletes and celebrities. What do superstitious behaviors and compulsions have in common? How are they different? Why don’t they extinguish? How do “popular” superstitions spread to many people? This might also be a good place to remind the students about negative reinforcement, which is the name given to increases in behavior due to the removal of a stimulus. Superstitious behaviors and compulsions both might appear to be negatively reinforced inasmuch as bad things don’t happen after they are engaged in. The compulsive cleaner can point to a long history of not catching deadly diseases in the same way the superstitious athlete can point to a long history of not failing.

Video / Media Sources ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Anxiety Disorders—DSM-IV: New Diagnostic Issues Videotape Series. Allyn & Bacon Video Library. Body Dysmorphic Disorder—Anxiety-Related Disorders: The Worried Well Video Series. Princeton, NJ: Films for the Humanities and Social Sciences. Challenge Cases for Differential Diagnosis. Differential Diagnosis in Psychiatry Series. Princeton, NJ: Films for the Humanities and Social Sciences. Chronic Anxiety in the Elderly. Princeton, NJ: Films for the Humanities and Social Sciences. Cognitive Therapy for Panic Disorder. Psychotherapy Videotape Series II: Specific Treatments for Specific Populations. Washington, DC: American Psychological Association. Coping with Phobias. Princeton, NJ: Films for the Humanities and Social Sciences. Getting Anxious. New York, NY: Insight Media. Mixed Anxiety and Depression: A Cognitive-Behavioral Approach with Dr. Donald Meichenbaum. Assessment and Treatment of Psychological Disorders Series. Princeton, NJ: Films for the Humanities and Social Sciences. Obsessive-Compulsive Disorder: An Alternative Treatment. Allyn & Bacon Video Library. Obsessive-Compulsive Disorder—Anxiety-Related Disorders: The Worried Well Video Series. Princeton, NJ: Films for the Humanities and Social Sciences. Copyright © 2013 Pearson Education, Inc. All rights reserved. 126

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Obsessive-Compulsive Disorder: Pharmacotherapy and Psychotherapy—Treatments of Psychiatric Disorders Videotape Series. Allyn & Bacon Video Library. Obsessive-Compulsive Disorder, Tanya—Patient Interview Video for Abnormal Psychology (12th ed.). Allyn & Bacon Video Library. OCD Clinic—#2 ABC News and Client Interviews. Allyn & Bacon Abnormal Psychology Video. Panic. Sherborn, MA: Aquarius Health Care Videos. Panic. Princeton, NJ: Films for the Humanities and Social Sciences. Panic Attacks—Anxiety-Related Disorders: The Worried Well Video Series. Princeton, NJ: Films for the Humanities and Social Sciences. Panic Attacks: Causes and Treatments. Princeton, NJ: Films for the Humanities and Social Sciences. Phobias: Overcoming the Fear. New York, NY: Filmmakers Library. Secret Fears: Phobias. The Nature of Things Series. New York, NY: Filmmakers Library. Sedatives. Drugs: Uses and Abuses Series. Princeton, NJ: Films for the Humanities and Social Sciences. Self-harm. Anxiety-Related Disorders: The Worried Well. Princeton, NJ: Films for the Humanities and Social Sciences. Step on a Crack: Obsessive Compulsive Disorder. Boston, MA: Fanlight Productions. The Anxiety Disorders—Vol. 3, The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection.

Web Links Web Link 6.1: http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml National Institute of Mental Health brochure on anxiety disorders, covering symptoms and treatment of the major anxiety disorders. Also lists organizations to contact for further information. Web Link 6.2: www.lexington-on-line.com/naf.html The National Anxiety Foundation homepage provides information and links about panic disorder and obsessivecompulsive disorder. Web Link 6.3: http://familydoctor.org/handouts/137.html The American Academy of Family Physicians “Panic Attacks and Agoraphobia” fact sheet. Web Link 6.4: www.mentalhelp.net/poc/center_index.php?id=1 Mental Help Net provides an enormous amount of basic information as well as many Web links for anxiety disorders. Web Link 6.5: www.apa.org This is the APA website. It has many articles that students can access for free, or that you can use for assignments. Web Link 6.6: www.apahelpcenter.org This is the APA help center. It has many articles students that can access for free, or that you can use for assignments. Web Link 6.7: www.psychiatrictimes.com/resources This is the site for Psychiatric Times. It has many articles that students can access for free, or that you can use for assignments. Web Link 6.8: www.ocfoundation.org This site provides education, resources, and support for those suffering from OCD and for family and friends with loved ones with OCD.

Handout 6.1 Social Fears and Phobias Characteristics of person

Description of fear

1. What problems has this fear caused the person? 2. Does the person avoid certain activities? 3. Does the person experience any physical symptoms?

Interview # 1

Interview # 2

Interview # 3

How does the person attempt to cope with this fear?

Handout 6.2 Progressive Muscle Relaxation The idea behind Progressive Muscle Relaxation (PMR) is that muscle relaxation is incompatible with anxiety. In addition, PMR is a skill that can be learned. Therefore, it is important to pay very close attention to the differences between muscle tension and relaxation. We will walk through a series of muscles. As we focus on each, you will flex each muscle for 7–10 seconds, in a smooth, strong squeeze. Do not strain or squeeze as hard as you can. Take special care when squeezing painful or injured parts of the body. Continue breathing throughout the lesson. After flexing each muscle group, abruptly let the muscle go completely limp, as limp as you can possibly get it, for about 15–20 seconds, focusing especially carefully on how it feels as you go from tense to relaxed. As you let the muscle go completely limp, think to yourself “Re-laaaax.” • • • • • • • • • • • • • • • • • • • •

Start with three deep abdominal breaths, exhaling very slowly each time. As you exhale, imagine that tension throughout your body is already flowing away. Clench your fists tightly. Hold for 7–10 seconds and then release for 15–20 seconds. Use these same time intervals for all other muscle groups. Tighten your biceps by drawing your forearms up toward your shoulders and “making a muscle” with both arms. Hold . . . and then relax. Tighten your triceps—the muscles on the undersides of your upper arms—by extending your arms out straight and locking your elbows. Hold . . . and then relax. Tense the muscles in your forehead by raising your eyebrows as far as you can. Hold . . . and then relax. Imagine your forehead muscles becoming smooth and limp as they relax. Tense the muscles around your eyes by clenching your eyelids tightly shut. Hold . . . and then relax. Imagine sensations of deep relaxation spreading all around your eyes. Tighten your jaws by opening your mouth so widely that you stretch the muscles around the hinges of your jaw. Hold . . . and then relax. Let your lips part and allow your jaw to hang loose. Tighten the muscles in the back of your neck by pulling your head way back, as if you were going to touch your head to your back (be gentle with this muscle group to avoid injury). Focus only on tensing the muscles in your neck. Hold . . . and then relax. Take a few deep breaths and tune in to the weight of your head sinking into whatever surface it is resting on. Tighten your shoulders by raising them up as if you were going to touch your ears. Hold . . . and then relax. Tighten the muscles around your shoulder blades by pushing your shoulder blades back as if you were going to touch them together. Hold the tension in your shoulder blades . . . and then relax. Tighten the muscles of your chest by taking in a deep breath. Hold for up to 10 seconds . . . and then release slowly. Imagine any excess tension in your chest flowing away as you exhale. Tighten your stomach muscles by sucking your stomach in. Hold . . . and then release. Imagine a wave of relaxation spreading through your abdomen. Tighten your lower back by arching it up. (You should omit this exercise if you have lower back pain.) Hold . . . and then relax. Tighten your buttocks by pulling them together. Hold . . . and then relax. Imagine the muscles in your hips going loose and limp. Squeeze the muscles in your thighs all the way down to your knees. You will probably have to tighten your hips along with your thighs, since the thigh muscles attach at the pelvis. Hold . . . and then relax. Feel your thigh muscles smoothing out and relaxing completely. Tighten your calf muscles—by pulling your toes toward you. Hold . . . and then relax. Tighten your feet by curling your toes downward. Hold . . . and then relax. Mentally scan your body for any residual tension. If a particular area remains tense, repeat one or two tense-relax cycles for that group of muscles. Now imagine a wave of relaxation slowly spreading throughout your body, starting at your head and gradually penetrating every muscle group all the way down to your toes.

The entire progressive muscle relaxation sequence should take you 20–30 minutes the first time. With practice you may decrease the time needed to 15–20 minutes. You can record the above exercises on an audio cassette to expedite your early practice sessions. Or you may wish to obtain a professionally made tape of the progressive muscle-relaxation exercise. Some people always prefer to use a tape, whereas others have the exercises so well learned after a few weeks of practice that they prefer doing them from memory. Adapted from Goldfried, M. R., & Davison, G. (1994). Clinical behavior therapy (expanded edition). New York: Wiley.

Handout 6.3 Superstitious Behavior List common superstitious behaviors. Provide a possible reason for the development of the behavior. Superstition

Reasons for the superstition

Prevention of behavior

CHAPTER 7: Mood Disorders and Suicide Teaching Objectives 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

Describe the types of mood disorders. Discuss the prevalence of mood disorders in the United States as well as in other parts of the world and subgroup differences in prevalence rates. Describe unipolar mood disorders. Differentiate depressions that are not mood disorders from those that are. Describe how dysthymia differs from major depressive disorder. Describe criteria for diagnosing major depressive disorder and the subtypes. Identify the major biological and psychosocial etiological theories, and describe the best explanation for how depressions occur. Differentiate between cyclothymia, bipolar I disorder, and bipolar II disorder. Identify the major biological and psychosocial etiological theories in the bipolar disorders. Explain how various sociocultural factors affect unipolar and bipolar disorders. Trace the history of the development of antidepressants, explaining how one class of antidepressants was replaced by another. Present evidence for the effectiveness of biological and nonbiological treatments for unipolar depression. Identify what treatment(s) might be most supported. Identify the most effective treatment package for bipolar disorders. Discuss prevalence rates of suicide among people with mood disorders. Describe who is likely to attempt suicide and who is likely to complete suicide. Describe the various motives for suicide. Explain the sociocultural and biological variables that affect suicide. Identify prevention and treatment methods for suicide. Evaluate the ethical issues involved in the right to die.

Chapter Overview/Summary Mood disorders (formerly called affective disorders) are those in which extreme variations in mood —either low or high—are the predominant feature. We all experience such variations at mild to moderate levels in the natural course of life, but for some people the extremity of moods in either direction becomes seriously maladaptive, even to the extent of suicide. The vast majority of people with mood disorders have some form of unipolar depression–dysthymia or major depression. In these disorders, the person experiences a range of affective, cognitive, motivational, and biological symptoms including persistent sadness, negative thoughts about the self and the future, lack of energy or initiative to engage in formerly pleasurable activities, too much or too little sleep, and gaining or losing weight. Unipolar depression may have multiple causes; traditional biological explanations have increasingly been shown to interact with more psychosocial factors. Among biological causal factors for unipolar depression, there is evidence of a moderate genetic contribution to the vulnerability for major depression, but probably not for dysthymia. Moreover, major depressions are clearly associated with multiple interacting disturbances in neurobiological regulation, including neurochemical, neuroendocrine, and neurophysiological systems. Disruptions in circadian and seasonal rhythms in depression are also prominent features of depression. Among psychosocial theories of the causes of unipolar depression are Beck’s cognitive theory and the reformulated helplessness and hopelessness theories, which are formulated as diathesis-stress models where the diathesis is cognitive in nature (e.g., dysfunctional beliefs and pessimistic attributional style, respectively) and stressful life events are often important in determining when those diatheses actually lead to depression. Personality variables, such as neuroticism, may also serve as diatheses for depression. Psychodynamic and interpersonal theories of unipolar depressions emphasize the importance of early experiences (especially early losses and the quality of the parent-child relationship) as setting up a predisposition for depression. In the bipolar disorders (cyclothymia and bipolar I and II disorders), the person experiences episodes of both depression and hypomania or mania. During manic or hypomanic episodes, the symptoms are essentially the opposite of those during a depressive episode.

For bipolar disorders, biological causal factors probably play an even stronger role than for unipolar disorders. The genetic contribution to bipolar disorder is among the strongest of any psychiatric disorders. Biochemical imbalances, abnormalities of the hypothalamic-pituitary-adrenal axis, and disturbances in biological rhythms all play a role in bipolar disorder. Stressful life events may be involved in precipitating manic or depressive episodes. It is unlikely that they cause the disorder, but rather affect the timing and frequency of episodes of illness. Treatment of unipolar depression may be successfully accomplished through cognitive-behavioral therapy (CBT), behavioral activation therapy, interpersonal therapy, antidepressant drugs, and electroconvulsive therapy (ECT). The biologically based treatments are more likely to lead to negative side effects, sometimes severe, and to result in greater chance of relapse or recurrence. Married couples in which one partner is experiencing depression are probably best treated with marital therapy. Bipolar disorder is most frequently treated with mood stabilizing drugs such as lithium or one of the newer anticonvulsant drugs. Increasingly, however, psychosocial treatments are also being used with good effectiveness, especially in reducing the incidence of relapse or recurrence. Suicide is a constant danger with depressive syndromes of any type or severity. Accordingly, an assessment of suicide risk is essential in the proper management of depressive disorders. A small minority of suicides appears unavoidable—chiefly those where the person really wants to die and uses a highly lethal method. However, a substantial amount of suicidal behavior (e.g., taking nonlethal or slow-acting drugs where the likelihood of discovery is high) is motivated more by a desire for indirect interpersonal communication than by a wish to die. Somewhere between these extremes is a large group of people who are ambivalent about killing themselves and who initiate dangerous actions that they may or may not carry to completion, depending on momentary events and impulses. Suicide prevention (or intervention) programs generally consist of crisis intervention in the form of suicide hotlines. Although these are undoubtedly effective in some cases in averting fatal suicide attempts, the long-term success of treatment aimed at preventing suicide in those at high risk is much less clear at the present time.

Detailed Lecture Outline I.

Mood Disorders: An Overview A. Types of Mood Disorders 1. Unipolar depressive disorders. 2. Bipolar disorders. 3. Major depressive episode. 4. Manic episode. 5. Mood disorders—severe alterations in mood for long periods of time. 6. Hypomanic episode. B. Prevalence of Mood Disorders 1. Mood disorders occur with alarming frequency, at least 15–20 times more frequently than schizophrenia at almost the same rate as anxiety disorders. 2. Lifetime prevalence rates of unipolar major depression is nearly 17%. 3. Women are overly represented in unipolar depression 2:1. This is found cross-culturally 4. Major types: unipolar major depressive disorder and bipolar disorder.

Lecture Launcher 7.1: Evolutionary Impact? II.

Unipolar Mood Disorders A. Depressions that Are not Mood Disorders 1. Loss and the grieving process a. Bowlby identified four phases of normal response to the loss of a spouse or close friend. b. Four phases include: numbing and disbelief; yearning and searching for the dead person; disorganization and despair; reorganization. c. Depressive symptoms tend to peak 2–6 months after the loss. d. Recent studies of bereaved individuals have found that about 50% exhibit genuine resilience. 2. Postpartum “blues” a. May occur in new mothers or fathers.

b. It was believed postpartum major depression in mothers was common but more recent evidence states that only “postpartum blues” are common. c. Symptoms include changeable mood, crying easily, sadness, and irritability, often intermixed with happy feelings. d. 50%–70% of women experience the “blues” within 10 days of giving birth e. Rare to have accompanying psychotic features. f. Especially likely if new mother lacks social support, has difficulty adjusting to new demands, or if there is a history of depression. g. Hormonal readjustment and alterations in serotonin and noradrenaline functioning may play a role in the onset of postpartum blues and depression. Dysthymic Disorder 1. Depressed mood of mild to moderate intensity. 2. Primary hallmark is chronicity a. Average duration is four to five years. b. Chronic stress increases the severity of symptoms. c. Must be persistently depressed mood for most of the day for more days than not. d. Is common, with 2.5%–6% lifetime prevalence rates. e. Begins in adolescence, 50% of those seeking treatment have an onset before the age of 21 and 74% recover within 10 years. 3. Half relapse, usually occurs at 71% after the 3-year follow up.

Lecture Launcher 7.2: PMS in DSM-V? C.

Major Depressive Disorder

MyPsychLab Resource 7.1: Video “Helen: Major Depressive Disorder” MyPsychLab Resource 7.2: Video “Major Depression: Everett” 1.

Cognitive, motivational, and biological symptoms a. Intense symptoms marked with sadness, insomnia, diminished cognitive capacity, and low self-esteem. b. Also known as major depression. c. To receive a diagnosis one must be experiencing a major depressive episode. d. Lethargy and lack of motivation. e. Anxiety symptoms are common. f. Must experience a depressed mood most of everyday and must also have three to four of the following symptoms: feelings of worthlessness, guilt, thoughts of suicide, fatigue, physical agitation, changes in appetite and sleep.

MyPsychLab Resource 7.3: Video “Depression/Deliberate Self Harm: Sarah” 2.

3. 4.

Depression as a recurrent disorder a. Single (initial) vs. recurrent (preceded by one or more previous) episodes. b. Recurrence vs. relapse. c. 40%–50% may experience recurrence. Depression throughout the life cycle Specifiers for major depression a. Major depressive episode with melancholic features (see Table 7.1 for chart). b. Specifiers—different patterns of symptoms or features. c. Severe major depressive episode with psychotic features: (1) Mood congruent (2) Mood incongruent d. Major depressive episode with atypical features. e. Major depressive episode with catatonic features. f. Major depressive episode with seasonal pattern. Copyright © 2013 Pearson Education, Inc. All rights reserved. 133

III.

g. Seasonal affective disorder. Double Depression (1) Major depression coexists with dysthymia. (2) May be extremely common among those with dysthymia.

Causal Factors in Unipolar Mood Disorders A. Biological Causal Factors 1. Genetic influences: a. Two to three times more common among blood relatives. b. Hippocrates hypothesized that depression was caused by an excess of black bile (400 B.C.). c. The monozygotic twin of a person with unipolar depression is twice as likely to develop unipolar depression as is a dizygotic twin. d. 31%–42% of the variance in unipolar depression is due to genetics. e. Serotonin transporter gene, the short allele (s) and the long allele (I). f. Geno-type-environment interaction. 2. Neurochemical factors: a. Focus on two neurotransmitters of the monoamine class: norepinephrine and serotonin—monoamine hypothesis. b. Failure of research to support monoamine hypothesis. c. Focus now is on the interaction of neurotransmitters and how they affect cellular functioning. 3. Abnormalities of hormonal regulatory and immune systems: a. Hypothalamic-pituitary-adrenal (HPA) axis (1) Blood plasma cortisol levels elevated in 20%–40% of depressed outpatients and 60%–80% of severely depressed hospitalized patients. (2) Elevations in cortisol may be due to failure of feedback mechanisms— dexamethasone. (3) Recent evidence suggests that dexamethasone nonsuppression may be a general indicator of mental distress rather than specific to depression. b. Hypothalamic-pituitary-thyroid axis (1) 20%–30% of depressed people who have normal thyroid functioning show dysregulation in this axis. (2) Using drugs to increase thyroid hormone levels can lower depression in these individuals. (3) Prolonged elevations of cortisol lead to cell death in the hippocampus. (4) Hypothyroidism, which is low levels of thyroid, is often discovered. 4. Neurophysiological and neuroanatomical influences a. Depressed individuals show lower levels of EEG activity in the left hemisphere and higher levels in the right hemisphere. b. May be able to use this to identify persons at risk for unipolar depression. c. Several regions: orbital prefrontal cortex, dorsolateral prefrontal cortex, hippocampus, anterior cingulated cortex, and the amygdala have all been shown to play a role in depression. 5. Sleep and other biological rhythms a. Sleep: Sleep problems range from early morning awakening, periodic awakening during the night, and difficulty falling asleep. (1) Enter the first period of REM after only 75–80 minutes and show greater amounts of REM sleep. (2) Five states of sleep: stages 1 to 4 of non-REM sleep, and REM sleep make up a sleep cycle. (3) Rapid Eye Movement (REM) Sleep—rapid eye movements, dreaming, and bodily changes. (4) Patients who are depressed have early morning waking, periodic waking, and difficulty falling asleep. b. Circadian rhythms Copyright © 2013 Pearson Education, Inc. All rights reserved. 134

(1) (2) (3)

Size or magnitude of the circadian rhythm may be blunted. Circadian rhythm becomes desynchronized. These control sleep, body temperature, REM sleep, and secretion of cortisol, thyroid, and growth hormone. c. Sunlight and seasons (1) Typically show increased appetite and hypersomnia. (2) Clear disturbances in circadian rhythm. (3) Majority of people diagnosed with seasonal affective disorder become depressed in the fall and winter, and normalize in the spring and summer. (4) Therapeutic use of light therapy. d. Biological explanation for sex differences (1) For females, hormones play a crucial role with the onset of puberty, before menstrual cycles, postpartum period, and menopause. (2) Women have a greater genetic predisposition. 6. Summary of biological causal factors a. Moderate genetic contribution is mediated by environmental factors. b. Stress response system is chronically overactivated. c. Severe depression is linked to multiple interacting disturbances in neurochemical, neuroendocrine, and neurophysiological systems. Those with less severe depressions may show few, if any, biological abnormalities. Psychological Causal Factors

Activity 7.1: Antidepressant Behavior Activity 7.2: Sex Differences in Antidepressant Behavior 1.

Stressful Life Events as Causal Factors a. Stressful life events involved in precipitating depression include: loss of a loved one, serious threats to important relationships or one’s occupations, severe economic or health problems, events involving humiliation. b. Independent life events vs. dependent life events. c. Severely stressful life events play a causal role in about 20%–50% of cases. d. Mildly stressful events and chronic stress. e. Minor events may play more of a role in the onset of recurrent episodes than in the initial episode. f. Vulnerability and invulnerability factors in response to stressors. (1) Vulnerability and invulnerability factors: (a) Genetics. (b) Living in poverty. (c) Chronic life stress. Different Types of Vulnerabilities for Unipolar Depression a. Personality and cognitive diathesis (1) Neuroticism or negative affectivity. (2) Introversion. (3) Negative patterns of thinking: internal, stable, and global. b. Early adversity and parental loss as a diathesis (1) Parental loss when followed by poor care. (2) Early environmental adversity such as abuse, family turmoil, parental psychopathology, and so on. (3) Low self-esteem and insecure attachment with a caregiver. (4) Can lead to “stress inoculation” if adversity is moderate rather than severe and mediated by strengthening socio-emotional and neuroendocrine resistance. c. Summary of different types of vulnerabilities. Psychodynamic theories Copyright © 2013 Pearson Education, Inc. All rights reserved. 135

a. b.

1917—Mourning and Melancholia. Regression to the oral stage followed by incorporation of the lost person—anger turned inward. c. Later psychodynamic theorists such as Klein and Jacobson emphasized the quality of the early mother-infant relationship. d. Bowlby—attachment theory. Behavioral theories a. Depression occurs when an individual’s responses no longer produce positive reinforcement or when the rate of negative reinforcement increases. b. Not very influential as an etiological theory. Beck’s cognitive theory (See Figure 7.4 for a model of Beck’s Cognitive Model of Depression) a. Depressogenic schemas/dysfunctional beliefs (1) Beliefs predispose a person to depression. (2) Develop during childhood and adolescence as a function of one’s negative experiences with parents and significant others. (3) Activated by current stressors or depressed mood creating a pattern of negative automatic thoughts. (4) Negative cognitive triad: self, one’s experiences and the surrounding world, one’s future (see Figure 7.5 for model of the negative cognitive triad).

Handout 7.1: Thought Worksheets b.

Negative cognitive biases or errors maintain the negative cognitive triad (1) Dichotomous or “all or none” reasoning. (2) Selective abstraction. (3) Arbitrary inference. Evaluating Beck’s theory as a descriptive theory (1) Nondepressed people show a large positivity bias in attributions. (2) Stressors are not necessary to activate negative cognitive triad; simple depressed mood can activate negative cognitive triad. (3) Teasdale—vicious cycle of depression. Evaluating the causal aspects of Beck’s theory (1) Results mixed. (2) Recent studies suggest that those with high levels of dysfunctional attitudes and high stress are more likely to develop major depression than those with low stress or low dysfunctional attitudes and high stress.

Lecture Launcher 7.3: Treating Depressed People Dishonestly 6.

The Helplessness and Hopelessness Theories of Depression a. Learned helplessness in laboratory dogs proposed as useful model of human depression.

Lecture Launcher 7.4: Learned Helplessness and Control b.

Reformulated Helplessness Theory (1) Attributions: internal/external, global/specific, stable/unstable. (2) Pessimistic attributional style associated with depression. (3) Mixed results in testing whether this causes depression. (4) Many studies demonstrated that depressed people do indeed have a more pessimistic attributional style.

IV.

The hopelessness theory of depression (1) Revision of reformulated helplessness theory. (2) Hopelessness expectancy: one has no control over what will happen and something bad will happen. (3) Internal/external dimension not important. (4) Proposed two new dimensions: other likely negative consequences will occur and negative inferences about the implication of the event for the self-concept. (5) Initial research supports this conceptualization. d. The ruminative response styles theory of depression (1) Focusing intently on how you feel and why you feel that way often leads to periods of depression more so than those who don’t feel that way. (2) Rumination—involves a pattern of repetitive and relatively passive mental activity. (3) Those with negative cognitive styles tend to ruminate and more likely to develop depression. (4) 7.1 Developments in Research Why Do Sex Differences in Unipolar Depression Emerge During Adolescence? Interpersonal Effects of Mood Disorders a. Lack of social support and social skills deficits. b. The effects of depression on others. c. Marriage and family life (1) High correlation between marital dissatisfaction and depression. (2) Marital distress increases relapse for depression. (3) Parental depression increases problems for children. (4) 7.2 Developments in Thinking: Comorbidity of Anxiety and Mood Disorders.

Bipolar Disorders A. Distinguished from unipolar disorders by the presence of manic or hypomanic episodes (See Figure 7.7 for a description of the manic-depressive spectrum. B.

Cyclothymia 1. Cycles between hypomania and depression are signs of cyclothymia. 2. Cyclothymic disorder—a less serious version of the full-blown bipolar disorder 3. May be a mild form of major bipolar disorder. Bipolar Disorders (I and II)

MyPsychLab Resource 7.4: Video “Nathan: Bipolar Disorder” MyPsychLab Resource 7.5: Explore “Bipolar Disorder” 1. 2.

Kraepelin—1899—manic-depressive insanity Bipolar I disorder a. One episode of mania or a mixed episode is needed for diagnosis. b. Mania shows elevated mood, irritability, increases in activity, and a “flight of ideas.” c. A mixed episode, once thought rare but increasing in occurrence, is characterized by symptoms of both full-blown manic and major depressive episodes for at least 1 week, where the symptoms are mixed or alternating rapidly every few days. Bipolar II disorder a. Hypomanic episodes and major depressive episodes with atypical features. b. More common than bipolar I, 2%–3% of the U.S. population. Features of bipolar disorder: Copyright © 2013 Pearson Education, Inc. All rights reserved. 137

a. b. c. d. e. f. g.

Symptoms during depressive episodes of bipolar disorder are identical to depressive symptoms in unipolar major depression. Suicide attempts may be more common than in unipolar. Average age of onset is 18–22 years old. May be misdiagnosed until first manic episode appears. Some drugs used to treat unipolar depression may actually trigger manic episodes in patients who have been misdiagnosed. Rapid cycling in 5%–10% of patients. 24% relapse within 6 months; 77% have a new episode within 4 years; 82% by 7 years.

MyPsychLab Resource 7.6: Video “Bipolar Mood Disorder with Psychotic Features: Ann” V.

Causal Factors in Bipolar Disorder A. Genetic Influences 1. Genes show that 8%–10% of the first-degree relatives of a person with bipolar I can be expected to also have bipolar I. 2. About 70% of the genetic liability for bipolar is distinct from unipolar. 3. Polygenic transmission; have not identified precise genes.

Handout 7.2: What’s my Diagnosis?—Bipolar Disorder or ADHD? B.

VI.

Neurochemical Factors 1. Monoamine hypothesis of unipolar disorder extended to bipolar. 2. Increased levels of dopamine may be related to manic symptoms. 3. Abnormalities in how ions (such as sodium) are transported across the neural membranes (lithium may substitute for sodium ions). C. Abnormalities of Hormonal Regulatory Systems 1. Similar abnormalities as in unipolar with the hypothalamic-pituitary-adrenal axis and the hypothalamic-pituitary-thyroid axis. 2. PET scans reveal that blood flow to the right frontal and temporal regions is reduced during manic episodes. 3. More changes in subcortical structures than in unipolar, including enlarged basal ganglia and amygdale. 4. Disturbances in circadian rhythms. D. Neurophysiological and Neuroanatomical Influences 1. Blood flow to the left prefrontal cortex is decreased during depression and increased during mania. 2. Positron emission tomography (PET) have shown variations in the brain glucose metabolic rates in depressed and manic states of individuals. 3. As with unipolar, there are deficits in the anterior cingulated cortex. 4. In bipolar the basal ganglia and the amygdala are enlarged; in unipolar they are decreased in size. 5. The decrease in the hippocampus found in unipolar is absent in the case of bipolar. 6. Increased activation in the subcortical brain regions. E. Sleep and Other Biological Rhythms 1. During manic episodes individuals sleep very little, in depressed states, too much sleep. F. Psychosocial Causal Factors 1. Stressful life events. 2. Other psychological factors in bipolar disorder: a. Low social support, b. Personality and cognitive variables: neuroticism, high levels of achievement striving, increased sensitivity to rewards in the environment, pessimistic attributional style. Sociocultural Factors Affecting Unipolar and Bipolar Disorders

Cross Cultural Differences in Depressive Symptoms (See Figure 7.8 for the prevalence rates for depression across several nations) 1. China and Japan—psychological symptoms of depression are low; somatic and vegetative manifestations are higher. 2. As Asian cultures have incorporated Western values, rates of depression have increased. 3. Adolescents from Hong Kong were shown to have higher rates of depression than adolescents in the United States.. Cross-Cultural Differences in Prevalence 1. Varies tremendously; Taiwan – 1.5%, whereas United States and Lebanon – 17% to 19% 2. Need to identify risk factors in each culture. Demographic Differences in the United States 1. No large racial differences identified. 2. Inversely related to socioeconomic status in unipolar depression; bipolar is more common in higher socioeconomic classes. 3. Mania or hypomania may facilitate the creative process; intense negative emotional experiences of depression provide material for creative activity. 4. African Americans might display chronic course of depression compared to white Americans. 5. Native Americans have a higher rate of depression than white Americans.

Lecture Launcher 7.5: Rates of Mood Disorders among Writers and Artists VII.

Treatments and Outcomes A. Only about 40% of people with mood disorders receive minimally adequate treatment, with the other 60% receiving no treatment or inadequate care. B. Pharmacotherapy 1. First category of antidepressant drugs developed in the 1950s were the monoamine oxidase inhibitors (MAOIs). 2. Treatment of choice from 1960s–1990 was one of the tricyclic antidepressants such as imipramine. 3. Selective Serotonin Re-uptake Inhibitors (SSRIs) 4. Recently several atypical antidepressants (Wellbutrin, Serzone, Remeron) have become popular because they have fewer side effects or are more effective with severe depression. 5. The course of treatment with antidepressant drugs: a. Require 3–5 weeks to take effect. b. 50% do not respond to first drug tried. c. Discontinuing drug may lead to relapse. d. 25% of patients relapse while on drugs. 6. Lithium and other mood-stabilizing drugs a. Lithium (1) 75% of patients show at least partial improvement on lithium. (2) Some unpleasant side effects can be seen such as lethargy, decreased motor coordination, and GI difficulties; long-term use can cause kidney damage. (3) Compliance is a major problem. b. Anticonvulsants (carbamazepine, divalproex, and valproate) (1) Often effective in those who do not respond to lithium. (2) Risk for attempted and completed suicide increases 2 to 3 times on anticonvulsants compared to lithium. C. Alternative Biological Treatments 1. Electroconvulsive therapy a. Severely depressed patients who present an immediate and serious suicidal risk would be most appropriate for ECT. b. Typical treatment involves 6–12 sessions administered every other day. c. Varying levels of amnesia may persist. Copyright © 2013 Pearson Education, Inc. All rights reserved. 139

d. Has also been found to be of use in manic episodes. Transcranial magnetic stimulation (TMS) a. Noninvasive technique allowing focal stimulation of the brain in awake patients. b. Brief, but intense, pulsating magnetic fields which induce electrical activity in certain parts of the cortex are delivered. c. Some studies have shown TMS to be more effective than antidepressants without the side effects of ECT. 3. Deep brain stimulation a. Used for individuals with refractory depression who have not responded to other treatments such as medication, psychotherapy, and ECT. b. Involves implanting an electrode in the brain and then stimulating that area of the brain with an electrical curren.t 4. Bright light therapy a. Originally used only for seasonal affective disorder. b. Recently shown to be effective for nonseasonal depression. Psychotherapy 1. Cognitive-behavioral therapy a. Focuses on here-and-now problems; teaches people to evaluate their beliefs and negative automatic thoughts systematically as well as to challenge their underlying depressogenic assumptions. b. Equally, or more, effective as antidepressants and more effective in preventing relapse. c. Cognitive therapy, originally developed by Beck and colleagues. 2. Behavioral activation treatment is relatively new a. Focuses on getting patients to become more active and engaged with their environment and their interpersonal relationships. b. May be even more effective, and easier to administer, than CBT. d. Modified form of CBT may be effective with bipolar as well. e. Mindfulness-based cognitive therapy: developed for highly recurrent depression; involves training in mindfulness meditation techniques aimed at increasing awareness of unwanted thoughts and feelings and sensations so they are accepted as simply thoughts and not reality; found effective in two studies . 3. Interpersonal therapy (IPT) a. Not as extensively studied or used. b. Research suggests it is as effective as CBT or antidepressants. c. Focuses on current relationship issues, trying to help the person understand and change maladaptive interaction patterns. d. Adapted for treatment of bipolar disorders by focusing on stabilizing daily life 4. Family and marital therapy a. For some types of bipolar disorder, reducing the level of expressed emotion or hostility and increasing coping information has been shown to be effective in preventing relapse. b. For unipolar, focusing on marital discord is as effective as CBT. c. Stressors in the patient’s life may lead to recurrent depression and require longer treatment. 5. Conclusions 2.

MyPsychLab Resource 7.7: Video “Recent Trends in Treatment” VIII.

Suicide

Activity 7.3: Suicide Test /Myths A.

2. 3. 4. 5.

Ranks among the 10 leading causes of death in most Western countries. 90% of people who either attempted or committed suicide had some psychiatric disorder. Most people who commit suicide are ambivalent and are alone and in a state of severe psychological distress and anguish. Suicide—taking one’s own life.

Lecture Launcher 7.6: Predicting Suicide B.

The Clinical Picture and the Causal Pattern 1. Who attempts and who commits suicide? (See Figure 7.11 for chart of U.S. suicide rates by age, gender, and race). a. Until recently the peak age for suicide attempts was 25–44; now the peak age is 18–24 with three times as many women attempting suicide compared to men. b. Highest rate of completed suicides is in the elderly (65 and over), particularly those who are divorced, widowed, or suffer from chronic illness. c. Methods of suicide vary between the genders. d. 7th leading cause of death for men and 15th leading cause of death for women. e. High-risk groups include the depressed, those suffering from schizophrenia, alcoholics, divorced persons, certain professionals (highly creative or successful scientists, physicians and psychologists, businessmen, composers, writers, and artists), people living alone, and people from socially disorganized areas. 2. Suicide in children a. Rates have been increasing, suicide under the age of 10 is rare. b. Ages 10–14: suicide is 5% of deaths. c. Increased risk if child has lost a parent or has been abused. 3. Suicide in adolescents and young adults a. Third most common cause of death in ages 15–19. b. For people ages 15–24 suicide has tripled from the mid-1950s to the mid-1980s. c. Second leading cause of death among college students. d. Increases in suicide rates for adolescents observed worldwide. e. Known risk factors for adolescent suicide: (1) Mood disorder, conduct disorder, and substance abuse (especially alcohol). (2) Treatment with antidepressants. (3) Media exposure to suicides. (4) For college students, the combined stressors of academic demands, social interaction problems, and career choices. (5) 7.3 The World Around Us: Warning Signs for Student Suicide. 4. Other psychosocial factors associated with suicide: a. Personality traits such as impulsivity, aggression, pessimism, and negative affectivity. b. Associated with negative life events. c. Hopelessness about the future may be a good predictor of suicide within one to two years. d. Predictors of immediate suicide among the depressed: severe psychic anxiety, panic attacks, severe anhedonia, global insomnia, delusions, and alcohol abuse. e. Shneidman—suicide is an escape from pain. f. Psychosocial causes: combination of family psychopathology, child maltreatment, and family instability associated with low self-esteem, hopelessness, and poor problem-solving skills. 5. Biological causal factors: a. Concordance rate in monozygotic twins about 3 times higher than in fraternal twins. b. Reduced serotonergic activity. c. People who are hospitalized with low levels of serotonin are 10 times more likely to kill themselves in the next year than are those without low serotonin levels. Copyright © 2013 Pearson Education, Inc. All rights reserved. 141

d. Having one or two copies of the short allele. Sociocultural factors: a. Whites have much higher suicide rates than African Americans except among young males where rates are similar. b. United States: 11 per 100,000 people. c. Rates vary from one society to another (Hungary is the highest: 40 per 100,000 people). d. Western countries with high suicide rates (20 per 100,000) are Switzerland, Finland, Austria, Sweden, Denmark, and Germany. e. 30% of suicides worldwide occur in China and India. f. Religious beliefs are important determinants of suicide rates (Catholics and Islamic countries are low). g. Japan is one culture that sanctions certain suicides; Muslim extremists are another. h. Subgroup differences exist within societies. i. Durkheim’s view of group cohesiveness as a factor in suicide. Suicidal Ambivalence 1. Ambivalence a. Some wish to communicate a message to others. b. Some are seemingly intent on ending their lives. c. Some are ambivalent and leave death to chance. d. Following an attempt there is a reduction in emotional turmoil. e. In the year after a suicide attempt repetition occurs in 15%–25%. 2. Communication of suicidal intent a. 40% communicate suicidal intent in very clear and specific terms; an additional 30% had talked about death and dying. b. 50% had never seen a mental health professional. c. Among inpatients hospitalized for suicidal ideation or intent, nearly 80% denied suicidal ideation the last time they spoke with a clinician. 3. Suicide notes a. Only about 15%–25% leave notes. b. Suicide notes are typically coherent and legible; some include statements of love and concern; occasionally suicide notes contain very hostile content. c. Most notes do not provide significant insights into the suicidal mind. Suicide Prevention and Intervention 1. Crisis intervention a. Treatment of mental disorders. b. Crisis intervention (1) Suicide prevention centers try to avert an actual suicide attempt. (2) Primary objective is to help people regain their ability to cope with their immediate problems as quickly as possible. (3) Emphasis is placed on: (a) Maintenance of supportive contact with person. (b) Helping the person to realize that distress is impairing judgment. (c) Helping the person see that present distress is not endless. (4) Establishment of suicidal hotlines since the 1960s—not much information to document success in reducing suicide rates. 2. Focus on high-risk groups and other measures a. Broad-based programs are needed to alleviate life problems. b. Involving older men in social and interpersonal activities that help others. c. 10 sessions of cognitive therapy for those who have already attempted suicide once has proved beneficial in reducing further attempts. 6.

Teaching Tip 7.2: Suicide Prevention

IX.

Unresolved Issues: Is There a Right to Die? A. Ethical Issues in Suicide Prevention 1. Should people be allowed to take their own lives? 2. Terminally ill people are asking for the “right to commit suicide.” a. Ancient Greeks provided hemlock to those who had received permission to commit suicide due to illness. b. Some Western European countries allow terminally ill people to commit suicide. c. Oregon Death with Dignity Act in 1994 allows physician-assisted suicide. d. Dr. Jack Kevorkian (1928–2011). B. Suicide Intervention is a Neutral Moral Stance 1. Refers to interceding without the implication of preventing the act. 2. May encompass the possibility of facilitating the suicidal person’s objective C. Moral problems associated with involuntary hospitalization. 1. Personal items removed; medication may be forcibly administered. 2. Practitioners take a cautious and conservative path to avoid legal repercussions on both sides. 3. This may lead to some people being institutionalized based upon limited clinical justification.

Handout 7.3: Suicidal Friend or Relative

Key Terms attributions behavioral activation treatment bipolar disorder with a seasonal pattern bipolar disorders bipolar I disorder bipolar II disorder cognitive-behavioral therapy( CBT) (cognitive therapy) cyclothymic disorder depression depressogenic schemas double depression dysfunctional beliefs dysthymic disorder electroconvulsive therapy (ECT) hypomanic episode interpersonal therapy (IPT) learned helplessness lithium major depressive disorder major depressive episode major depressive episode with a seasonal pattern major depressive episode with atypical features major depressive episode with catatonic features major depressive episode with melancholic features

mania manic episode mixed episode monoamine oxidase inhibitors (MAOIs) mood congruent mood disorders negative automatic thoughts negative cognitive triad pessimistic attributional style rapid cycling recurrence relapse rumination seasonal affective disorder selective serotonin reuptake inhibitors (SSRIs) severe major depressive episode with psychotic features specifiers suicide tricyclic antidepressants unipolar depression

Lecture Launchers Lecture Launcher 7.1: Evolutionary Impact?

Mood disorders appear to be counterproductive and yet have not been eliminated by natural selection. Why? Presenting this question to the students on an overhead or PowerPoint slide (CD-ROM PowerPoint Topic 6: Slide 35) is an easy way to encourage students to consider this seeming contradiction. Most students are already familiar with Darwin and the basic principles of selection. However, it may be necessary to quickly review these principles prior to beginning this discussion. Lecture Launcher 7.2: PMS in DSM-V? Should PMS be in DSM? An extremely distressing and psychosocially debilitating form of PMS, called premenstrual dysphoric disorder, has been proposed for inclusion in DSM. This controversial proposal pits the stigma of mental illness and systematic pathologizing of women against the desire to make access to healthcare easier by providing a reimbursable diagnostic category. What do students think of a disorder that can be diagnosed only in women? Is that so different from other categories that functionally apply only to men (e.g., transvestic fetishism)? Is premenstrual dysphoric disorder a psychiatric problem or a gynecological one? What process should be used to resolve controversies such as this one? Lecture Launcher 7.3: Treating Depressed People Dishonestly People who are depressed are characteristically pessimistic and hopeless about the future. Extreme hopelessness can even lead to suicide. Clinicians treating depressed people have to take special care not to endorse this hopelessness in any way whatsoever because their clients would then be even worse off than they were without treatment. This is fairly simple if one keeps in mind that depressed people have distorted perceptions of their circumstances and their situations are never as bleak as they make them sound. Sometimes, however, the facts surrounding particular cases are bleak. In these cases, clients may cling to the erroneous hope that their view is distorted. After all, they have enough hope to be in treatment. But if their psychologist suggests that the situation is indeed hopeless, then their distrust of their own thinking is eliminated, they have a professional certification for hopelessness, and as a result they are worse off than before. The first line of defense against this iatrogenic effect is to genuinely believe there is always hope, even for clients in the most desperate of situations. When this fails, however, it is a matter of professional responsibility to avoid concurring with clients’ pessimism, even if it is not entirely honest. Lecture Launcher 7.4: Learned Helplessness and Control You may want to discuss the relationship between locus of control (LOC) and learned helplessness in other contexts as well. Students are often already familiar with internal and external locus of control and the relationship to learned helplessness. One particularly interesting study was done by Sims & Bauman (1972), The Tornado Threat: Coping Styles of the North and South, Science 176 (4042),1386–1392. There is a link to the full text article at: www.sciencemag.org/cgi/content/citation/176/4042/1386. This study looks at survival rates from tornados in the South and Midwest. They found that LOC, specifically an external LOC, is positively correlated with death. This can lead to an interesting discussion on LOC and learned helplessness. An example students might well relate to would be if they studied (really studied) for their first exam in this class and then failed it. What if it happened on exam 2? How would they react? Now tie it in to poverty. You may want to point out that learned helplessness is not because a person is weak, rather it is a learned response based on experiences with your world. Much like Seligman’s dogs, people too are not immune to learned helplessness if they feel they have no control. Lecture Launcher 7.5: Rates of Mood Disorders Among Writers and Artists Students are typically very interested in discussing the incidence of mood disorders amongst those considered “creative.” For many students, Van Gogh is their prototype of bipolar. There is some evidence that this is not an illusory correlation. Research indicates that there is a relationship between mood disorders and creativity. Recent research has reveled that children of bipolar parents are more creative. See article at: http://med.stanford.edu/news_releases/2005/november/bipolar.html. The big question is in what direction does this correlation go? Is one creative because you have a mood disorder, or does having a mood disorder somehow make one more creative? Lecture Launcher 7.6: Predicting Suicide Although every suicide is a tragedy, the base rate of suicide is low, especially in the general population. This makes the challenge of predicting suicide even greater than it otherwise might be. If, hypothetically speaking, the rate of suicide in your university’s counseling center was a high 1%, then you would be correct in the “prediction” of suicide 99% of the time if you simply always predict “no suicide.” Any method of improving on your predictions will then have to exceed 99% correct, surely a daunting challenge. Copyright © 2013 Pearson Education, Inc. All rights reserved. 144

Lecture Launcher 7.7: How to Die in Oregon HBO Documentary by Peter D. Richardson If you can gain access to the documentary that won awards in the Sundance film festival, this is a disturbing but eyeopening film about a woman’s journey with terminal cancer and her choice toward physician-assisted suicide. The following link is just the HBO trailer for the film, “How to Die In Oregon,” http://www.youtube.com/watch?v=IbhoYK5inaE&feature=related. This movie is very powerful to create a great discussion on death, dying, suicide, and the use of physician-assisted suicide.

Classroom Activities, Demonstrations, and Assignments Activity 7.1: Antidepressant Behavior Everyone experiences minor episodes of depression. Though clearly not to be confused with major depression, these episodes probably represent a stage through which all those progressing to major depression must pass. Therefore, it is not entirely insignificant to think about what can be done to beat the more common minor depressive episodes. In fact, minor depressions are problems in their own right, worth limiting as best one can. Along these lines, many students have pretty clearly laid plans for dealing with their own depressions. Others are not quite so deliberate but can, upon some reflection, recall the kinds of things they have done when depressed. A compendium of such techniques can be assembled as a class project. In doing so, one would want to emphasize antidepressant behaviors that actually work as opposed to listing out anything one does when depressed whether they are helpful or not. Activity 7.2: Sex Differences in Antidepressant Behavior Susan Nolen Hoeksema (1990, 2001) argues that sex differences in depression are at least partly due to the way men and women react differently to stress. Whereas men tend to distract themselves through activities such as work, sports, or even drugs and alcohol, women tend to become less active, ruminating about the causes of their stress. It is the difference in coping with stress, then, that gives rise to the different rates of depression between men and women. If students in your class have undertaken Activity 7.5, then it would be a fairly simple matter to compare the responses of men and women. Alternatively, you can ask students to briefly list a few things they do when depressed and discuss these. In any event, it could be interesting to ask students where they got their ideas about how to cope with stress. In particular, it would be fascinating to see who socialized the men and women in class to expect their way of coping to be appropriate (e.g., parents, media, school, friends). Activity 7.3: Suicide Test/Myths Lists of myths about suicide can readily be converted into pre-test questionnaires students that can complete before covering this topic in class. For instance, the idea that asking about suicide can trigger someone into actually doing it could be placed on such a pre-test, which could then be self-scored during a lecture that systematically covers the content of the pre-test. A simple list of such myths can be found on the CD-ROM PowerPoint Topic 6: Slide 33. You may convert the slide into a questionnaire or present the slide to the class. Activity 7.4: Should Physician-Assisted Suicide Be Legalized? Divide the students into two separate groups randomly, and then assign them a side either for or against this argument. Ask them to work together using their books, Internet, their phones, and so on to come up with some information to support their side of the argument. Then allow the students to debate their respective side back and forth. Activity 7.5: Conduct a Psychological Autopsy Ask each student to identify a famous person in history, politician, actress, actor, and so on who has committed suicide. Note that it will be easier to find more information if it is someone who has committed suicide within the last 10 years or so. I do not recommend students using Wikipedia, however this site does provide a comprehensive, alphabetized list of famous individuals who have committed suicide. You can access this site at http://en.wikipedia.org/wiki/List_of_suicides. If you do not have access to enough computers in your classroom, book a computer lab, or you can offer this as an assignment. If you view the Web site http://www.angelfire.com/ga4/suicideawareness/18.html, you will also find out more information on the purpose, Copyright © 2013 Pearson Education, Inc. All rights reserved. 145

what information is included, and so on to complete a psychological autopsy. Provide the students with the information from the Web sites or just the links and ask the students to compile a summary about the individual they have selected, touching on the personal information, details of the death, family and medical history, personality, precipitating factors or triggers, changes, life events, method of lethality, and who was the informant.

MyPsychLab Resources MyPsychLab Resource 7.1: Video “Helen: Major Depressive Disorder” You may want to show a brief video case study on Helen, diagnosed with major depressive disorder. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 7, Mood Disorders and Suicide. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Helen: Major Depressive Disorder” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 7.2: Video “Major Depression: Everett” You may want to show a brief video case study on Everett, diagnosed with childhood onset major depressive disorder. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 7, Mood Disorders and Suicide. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Major Depression: Everett” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 7.3: Video “Depression/Deliberate Self Harm: Sarah” You may want to show a brief video case study on Sarah, a cutter. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the lefthand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 7, Mood Disorders and Suicide. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Depression/Deliberate Self Harm: Sarah” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 7.4: Video “Nathan: Bipolar Disorder” You may want to show a brief video case study on Nathan, diagnosed with bipolar disorder. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 7, Mood Disorders and Suicide. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Nathan: Bipolar Disorder” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 7.5: Explore “Bipolar Disorder” This is a brief true/false quiz on bipolar disorder. To access this Explore, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 7, Mood Disorders and Suicide. In the Media Type field, select “Explore,” then click the “Find Now” button at the bottom. “Bipolar Disorder” will appear as one of your Explore offerings. You can either use this Explore as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 7.6: Video “Bipolar Mood Disorder with Psychotic Features: Ann” You may want to show a brief video case study on Ann, diagnosed with bipolar disorder and suffering from delusions. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select chapter 7, Mood Disorders and Suicide. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Bipolar Mood Disorder with Psychotic Features: Ann” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room Copyright © 2013 Pearson Education, Inc. All rights reserved. 146

has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 7.7: Video “Recent Trends in Treatment” You may want to show a brief video on current trends in treatment. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the lefthand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 16, Therapy. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Recent Trends in Treatment” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise.

Teaching Tips Teaching Tip 7.1: Positive Psychology This is a good time to point out that Seligman has gone onto do much research in the area of positive psychology. Students often find it interesting that his work has taken him from shocking dogs in learned helplessness studies to the polar perspective of what makes some more resilient. His Web site is: www.authentichappiness.sas.upenn.edu/default.aspx Teaching Tip 7.2: Suicide Prevention You may want to contact the student counseling center at your school and ask them to send someone over to discuss suicide prevention measures on campus. Many students may not realize that most universities have not only counseling centers but also peer counseling, support programs, and many have crisis centers. Because many of the mental disorders described in the text have an age of onset around college age, many schools have devoted resources to these issues. This will not only give students a different perspective, but may also alert them to services on campus.

Handout Descriptions Handout 7.1: Thought Worksheets Thought Worksheets are often used in therapy to help people identify and challenge their depressogenic thinking patterns between sessions. Students can do thought diaries using the same kind of worksheet, completing them once a day for a week, or else they can simply reflect on times they have felt badly, listing the thoughts that came to mind at that time and how to challenge them. Students frequently understand this assignment better after viewing Transparency T115. The foundation for this exercise is the essential cognitive theory of depression that negative moods have their origin in distorted thinking. Therefore, the instructor will want to fairly firmly state that behind every negative mood is a series of automatic thoughts, the validity of which seems clear at the time but which are actually of dubious merit. For instance, one could feel bad and think “Nobody cares about me.” The apparent depth of this belief notwithstanding, it is clearly untrue, and thinking this kind of thought would clearly be upsetting to anyone. Fortunately, thoughts such as these are never literally true. Monitoring one’s own thoughts can be a useful exercise as a matter of good mental hygiene. Handout 7.2: What’s my Diagnosis?—Bipolar Disorder or ADHD? Recently, the field has been undergoing a debate on if it is possible to have bipolar disorder in childhood. Some argue it is impossible and others argue that some cases of ADHD may actually be bipolar disorder. To help students understand the complexities of this diagnostic, and treatment, dilemma, students may be placed into small groups (4–5 students per group) and provided a case description of a child or adolescent who is experiencing difficulties. Also provide each group with the diagnostic criteria for ADHD and bipolar disorder. Each group should decide which diagnosis best describes the case. Class discussion should include a consideration of children who are diagnosed as ADHD initially, receive stimulant treatment, and then, later, are determined to have bipolar disorder. Handout 7.3: Suicidal Friend or Relative—Preventing Suicide? Should people who want to die be prevented from killing themselves? Most health care professionals, and a variety of people in other occupations as well, are obligated to try to prevent people from killing themselves. Laws require them to treat suicidal people in essentially the same manner they would treat homicidal people, even to the extent of breaking doctor-patient confidentiality to do so. At the other extreme are people like Jack Kevorkian, MD, a physician who believed doctors ought to help their patients commit suicide when asked. What do students think Copyright © 2013 Pearson Education, Inc. All rights reserved. 147

about suicide laws and the requirement that mental health professionals intervene to prevent suicide even when it goes against the wishes of their clients and their professional codes of ethics (viz. confidentiality)? Might awareness of these laws cause clients to refrain from discussing their suicidal feelings?

Video / Media Sources ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

After a Suicide. New York, NY: Filmmakers Library. Between the Lines. Boston, MA: Fanlight Productions. Bipolar Disorder —#3 ABC News and Client Interviews. Allyn & Bacon Abnormal Psychology Video. Bipolar Disorder, Tony—Patient Interview Video for Abnormal Psychology (12th ed.). Allyn & Bacon Video Library. Brainstorm: The Hidden Epidemic of Depression. New York, NY: Filmmakers Library. Breaking the Dark Horse: A Family Copes with Manic Depression. Boston, MA: Fanlight Productions. Depression. Sherborn, MA: Aquarius Health Care Videos. Depression and Anxiety. Psychotropic Medications Series. Irvine, CA: Concept Media. Depression: Beating the Blues. Allyn & Bacon Video Library. Depression: The Biology of the Blues. Princeton, NJ: Films for the Humanities and Social Sciences. Depression and Manic Depression. Princeton, NJ: Films for the Humanities and Social Sciences. Depression: Moving On. Allyn & Bacon Video Library. Depression in Older Adults: The Right to Feel Better. Sherborn, MA: Aquarius Health Care Videos. Depression: The Storm Within. Washington, DC: American Psychiatric Association. “Don’t Kill Yourself”: One Survivor’s Message. Princeton, NJ: Films for the Humanities and Social Sciences. Gender Differences in Depression: A Marital Therapy Approach. New York, NY: Guilford Publications. Intervention Strategies. Suicide in Inpatient Settings Series. Irvine, CA: Concept Media. A Journey Back: Coping with a Parent’s Suicide. New York, NY: Filmmakers Library. Major Depression, Bob—Patient Interview Video for Abnormal Psychology (12th ed.) Allyn & Bacon Video Library. Manic. New York, NY: Filmmakers Library. Manic Depression/Brain Tumor, Steve—Patient Interview Video for Abnormal Psychology (12 th ed.). Allyn & Bacon Video Library. Me Depressed? Don’t Make me Laugh. Boston, MA: Fanlight Productions. Mood Disorders—DSM-IV: New Diagnostic Issues Videotape Series. Allyn & Bacon Video Library. Mood Disorders: Hereditary Factors—Vol. 32, The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection. Mood Disorders: Mania and Depression—Vol. 31, The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection. Mood Disorders: Medication and Talk Therapy—Vol. 33, The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection. Mood Disorders—Vol. 8, The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection. Nature’s Antidepressant: St. John’s Wort. Allyn & Bacon Video Library. No More Shame: Understanding Depression. Princeton, NJ: Films for the Humanities and Social Sciences. Overview and Assessment. Suicide in Inpatient Settings Series. Irvine, CA: Concept Media. Prozac Diary. Princeton, NJ: Films for the Humanities and Social Sciences. Strategies and Tactics in the Treatment of Mood Disorders—Treatments of Psychiatric Disorders Videotape Series. Allyn & Bacon Video Library. Suicide: A Guide for Prevention. Allyn & Bacon Video Library. Suicide: Dead Is Forever. Allyn & Bacon Video Library. Treating Depression: Electroconvulsive Therapy—Vol. 34, The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection. Understanding Depression. No More Shame: Understanding Schizophrenia, Depression and Addiction Series. Princeton, NJ: Films for the Humanities and Social Sciences. Understanding Depression: Through the Darkness. Princeton, NJ: Films for the Humanities and Social Sciences. Unmasking Depression. Princeton, NJ: Films for the Humanities and Social Sciences. Copyright © 2013 Pearson Education, Inc. All rights reserved. 148

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When the Blues Won’t Go Away: Women and Depression. Allyn & Bacon Video Library. Women and Depression. Allyn & Bacon Video Library. Women and Depression: When the Blues Won’t Go Away. Princeton, NJ: Films for the Humanities and Social Sciences.

Web Links Web Link 7.1: www.dbsalliance.org The Depression and Bipolar Support Alliance is a patient-directed support organization whose purpose is to educate people about mood disorders. Their extensive site provides consumer and advocacy information as well as help and support. Web Link 7.2: www.depression.org The National Foundation for Depressive Illness seeks to inform the public about mood disorder research, treatment, and education. Web Link 7.3: www.nmha.org The National Mental Health Association works to promote mental health through advocacy, education, research, and services. Web Link 7.4: www.psycom.net/depression.central.html Depression Central is a very large clearinghouse of information about mood disorders. Many different aspects of mood disorders get attention, including the elderly, getting free medication, first person accounts, ECT, famous people with mood disorders, and so on. Web Link 7.5: www.nimh.nih.gov NIMH is the national institute of mental health. They have the latest research on everything to do with mental health issues and is a trusted resource for information. Web Link 7.6: www.apa.org This is the APA website. It has many articles that students can access for free, or that you can use for assignments. Web Link 7.7: www.apahelpcenter.org This is the APA help center. It has many articles that students can access for free, or that you can use for assignments. Web Link 7.8: www.psychiatrictimes.com/resources This is the site for Psychiatric Times. It has many articles that students can access for free, or that you can use for assignments.

Handout 7.1 Thought Worksheet Depressed feelings are the product of irrational or distorted thoughts. Whenever you feel depressed, there is an underlying automatic thought of this sort. Use this worksheet to track the role of cognitive processes in your negative moods. Whenever you have a negative mood, complete a row of this sheet.

Situation

Emotion

Automatic Thought

Cognitive Distortion

Rational Responses

Outcome

Handout 7.2 What’s my diagnosis?

John is a 10-year-old child who is currently repeating the third grade. His teachers have requested that his parents have John evaluated for possible ADHD. At school, John talks excessively, is frequently out of his seat, and his teacher describes him as, at times, so difficult to control that she “can’t get a word in edgewise.” His teacher reports that when John is very active it is as if he has a “motor” inside. He can also be somewhat irritable, “fidgety,” and has difficulty not interrupting the other children. His teacher notes that she likes the fact that when John is like this that he believes he can be the best student in her class and focuses more on his assigned tasks. At home, his parents report few problems. They acknowledge that he is extremely active at times but report that they send him outside to play and that he will eventually “wear himself out.” His parents report that John sometimes has difficulty playing by himself quietly. Once again, when this is a problem, they simply send him outside to play. Finally, they report that John may simply be one of those children who doesn’t need much sleep. When he is very active he may sleep only a few hours each night, spending the rest of the time working on his “special projects” to catch up at school.

Handout 7.1 Suicidal Friend or Relative

How should you deal with a close friend or relative whom you think may be thinking about suicide? This is a common question, and one that is the topic of many helpful Internet resources. Write down a list of questions you would ask an expert if you found yourself in this situation. Then research answers using the Internet. Sites about suicide and depression are probably good starting points as are university counseling centers. 1.

Questions you want answered:

Advice on dealing with someone who is possibly suicidal:

CHAPTER 8: Somatoform and Dissociative Disorders Teaching Objectives 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Explain the historical usage of the term neurosis and why this term is no longer used by the DSM system. Describe how somatoform disorders differ from physical conditions. List the primary presenting symptoms of somatization disorder and hypochondriasis, and note the similarities of and differences between these closely related disorders. Explain what is meant by a pain disorder. What is meant by describing pain as a “subjective experience?” Characterize the symptoms of conversion disorder, trace the history of the concept of “conversion,” and describe the likely cause and chain of events in the development of a conversion disorder. Differentiate somatoform disorders from malingering and factitious disorders. Discuss the etiological contributions of biological, psychosocial, and sociocultural factors to the somatoform disorders. Explain what is meant by the diagnosis body dysmorphic disorder. Compare and contrast the treatments for somatoform disorders. What is known regarding their effectiveness as compared to no treatment at all? Compare the major features of dissociative amnesia and fugue, dissociative identity disorder, and depersonalization disorder. Discuss the causal factors that contribute to the dissociative disorders, and note the critical difficulty caused by the fallibility of memory in determining the contribution of childhood abuse to these disorders. Describe the most appropriate treatments for the dissociative disorders, as well as the limitations of biological and psychological treatments. Describe the issues related to DID and recovered memories.

Chapter Overview/Summary Somatoform disorders are comprised of hypochondriasis, somatization disorder, pain disorder, conversion disorder, and body dysmorphic disorder. In somatoform disorders, psychological problems are manifested in physical disorders (or complaints of physical disorders) that often mimic medical physical conditions, but for which there can be found no evidence of corresponding organic pathology. In hypochondriasis, one of the most commonly seen somatoform disorders, there is an anxious preoccupation with having a disease based on a misinterpretation of bodily signs or symptoms. Medical reassurance does not help. Somatization disorder is characterized by many different complaints of physical ailments in four symptom categories spreading over several years. The symptoms need not actually have existed as long as they were complained about. Pain disorder is characterized by pain severe enough to cause life disruption. Although a medical condition can contribute to the pain, psychological factors must be judged to play an important role in the onset, severity, exacerbation, or maintenance of the pain. Conversion disorder involves patterns of symptoms or deficits affecting sensory or voluntary motor functions, leading one to think there is a medical or neurological condition, even though a medical examination reveals no physical basis for the symptoms. Body dysmorphic disorder involves obsessive preoccupation with some perceived flaw or flaws in one’s appearance. Compulsive checking behaviors (such as mirror checking) and avoidance of social activities, because of fear of being rejected, are also common. Dissociative disorders occur when the normal processes regulating awareness and the multichannel capacities of the mind apparently become disorganized, leading to various anomalies of consciousness and personal identity. Depersonalization disorder occurs in people who experience persistent and recurrent episodes of derealization (losing one’s sense of reality) and depersonalization (losing one’s own sense of self and one’s own reality). Dissociative amnesia involves an inability to recall previously stored information that cannot be accounted for by ordinary forgetting and seems to be a common initial reaction to stressful circumstances. The memory loss is primarily for episodic or autobiographical memory. In dissociative fugue, a person not only goes into an amnesiac state but also leaves his or her home surroundings and becomes confused about his or her identity, sometimes assuming a new one. In dissociative identity disorder (DID), the person manifests at least two or more distinct identities or personality states that alternate in some way in taking control of behavior. Alter identities may differ in many ways from the host identity. There are many controversies about DID, including whether it is real or faked, Copyright © Pearson Education, Inc. All rights reserved. 153

how it develops, whether memories of childhood abuse are real, and, if the memories are real, whether the abuse played a causal role.

Detailed Lecture Outline I. A.

Somatoform Disorders Somatoform disorders are a group of conditions that involve physical symptoms and complaints suggesting a medical condition 1. Soma—means body. 2. Malingering—a person intentionally produces physical symptoms and is motivated by external incentives. 3. Factitious disorder—a person intentionally produces symptoms and has no external incentives.

B. Hypochondriasis 1. Major characteristics a. Vague and ambiguous physical symptoms are common. b. Sincere in their conviction that the symptoms represent illness. c. Around 2%–7% of general medical practice patients are hypochondriacs. d. Case study: An “abdominal mass.” 2. Major characteristics a. Highly preoccupied with bodily functions, minor physical abnormalities, and ambiguous physical sensations. b. Have intrusive thoughts where they attribute physical symptoms to a suspected disease. c. They are not malingering or consciously faking symptoms to achieve specific goals. 3.

Causal factors in hypochondriasis a. Minimal information available. b. May be closely related to the anxiety disorders. c. Called health anxiety. d. Misinterpretations of bodily sensations are seen as a causal factor in cognitive conceptualizations. e. Past experiences lead to a set of dysfunctional assumptions. f. Attentional bias for illness-related information. g. Role of secondary reinforcements. h. Hypochondriacal occurrences reduced by onset of serious medical conditions.

Handout 8.1: Body Log 4.

Treatment of hypochondriasis a. Cognitive-behavioral treatments have been found to be quite effective. b. SSRIs may also be effective. c. Behavioral techniques. d. Group therapy.

Lecture Launcher 8.1: Is Hypochondriasis an Anxiety Disorder? B.

Somatization Disorder 1. Somatization disorder. a. Seen most often in primary medical care. b. Symptoms: (1) Four pain symptoms. (2) Two gastrointestinal symptoms. Copyright © Pearson Education, Inc. All rights reserved. 154

(3) One sexual symptom. (4) One pseudoneurological symptom. Case study: Not-Yet-Discovered Illness.

Handout 8.2: Secondary Gain for Somatic Symptoms 2.

Demographics, comorbidity, and course of illness a. Begins in adolescence. b. Seen in patients in primary medical care settings. c. Complaints not faked. d. 3–10 times more common among women. e. Occurs more often in lower socioeconomic classes. f. Co-occurs with major depression, panic disorder, phobic disorders, and generalized anxiety disorders (GAD). g. Complaints of physical ailments over several years before age 30. h. Considered a chronic condition. 3. Causal factors in somatization disorder a. Uncertain about developmental course and specific etiology. b. Familial linkage between antisocial personality disorder in men and somatization disorder in women. c. Interaction of personality, cognitive, and learning variables. d. Selectively attend to bodily sensations as somatic symptoms. e. People high on neuroticism. 4. Treatment of somatization disorder a. Identification of one physician who integrates patient care and reduces medications and unnecessary testing. b. Primary care physicians experience a great deal of uncertainty and frustration when working with these individuals. c. See patients on a regular basis. d. Medical management is more effective if combined with cognitive-behavioral therapy focused on promoting appropriate behavior such as better coping and personal adjustment, and discouraging inappropriate behavior and preoccupation with physical symptoms. e. CBT. f. Reducing secondary gain is critical. g. 8.1 The World Around Us: DSM-5 Proposed Revisions: renamed to somatic symptom disorders, medically explained symptoms, combination into a single disorder, conversion disorder, and body dysmorphic disorder. Pain Disorder 1. Pain disorder a. The subjectivity of pain b. Persistent and severe pain in one or more areas. c. Diagnosed more frequently in women. d. Comorbid with anxiety and mood disorders. e. An invalid lifestyle can result. f. Social isolation. g. Often unable to work, fatigue, and loss of strength. h. Pain could be viewed as acute (less than six months) or chronic (more than six months). 2. Treatment of pain disorder a. Cognitive–behavioral treatment is successful. b. Treatment programs include: relaxation training, support and validation that the pain is real, scheduling of daily activities, cognitive restructuring, and reinforcement of “no-pain” behaviors. c. Tricyclic antidepressants also reduce pain intensity. Copyright © Pearson Education, Inc. All rights reserved. 155

d. SSRIs. Conversion Disorder 1. Conversion disorder a. Physical malfunction or loss of control is the central feature. b. Hysteria was an early term for the disorder. c. Freud used the term conversion hysteria to represent his belief that the symptoms were an expression of repressed sexual energy. d. La belle indifference— French for the beautiful indifference—occurs in only about 20% of cases. 2. Precipitating circumstances, escape, and secondary gain a. Physical symptoms as a socially acceptable means of escaping form negative responsibilities. b. Primary and secondary gain. 3. Decreasing prevalence and demographic characteristics a. Common during World Wars. b. 1%–3% of all disorders referred for treatment. c. Prevalence in general population may be only about 0.005%. d. Decreasing prevalence may be closely related to increasing sophistication about medical and psychological disorders. e. More common among rural populations from lower socioeconomic circles f. “Outbreak” of cases among five Amish girls. g. 2–10 times more common among women. h. Generally rapid onset after a significant stressor; often resolves within 2 weeks if stressor is removed. 4. Range of conversion disorder symptoms a. Sensory symptoms or deficits (1) Today symptoms are most often in the visual system, in the auditory system, or in the sensitivity to feeling (anaesthesias). (2) Glove anesthesia is one of the most common. (3) Sensory input appears to be received but screened from conscious recognition—implicit perception. b. Motor symptoms or deficits (1) Usually confined to a single limb; loss of function is usually selective. (2) Aphonia (talking only in a whisper) is the most common speech-related conversion disturbance. c. Seizures (1) Typically do not show any EEG abnormalities. (2) Do not show confusion and loss of memory following the seizure. (3) Often show excessive thrashing about and writhing; rarely injure themselves in falls or lose control over their bowels or bladder. 5. Important issues in diagnosing conversion disorder a. Symptoms do not conform clearly to the particular disease or disorder simulated. b. Selective nature of the dysfunction. c. Accurate diagnosis can be extremely difficult. d. Medical tests. e. Hypnosis or narcosis (sleeplike state induced by drugs) can remove dysfunction. 6. Treatment of conversion disorder a. No well-controlled studies have been conducted. b. Motor conversion symptoms have been successfully treated with behavioral therapy and reinforcements. Distinguishing Conversion from Malingering and from Factitious Disorder a. Malingering diagnosed when symptom production is intentional to gain an external goal. b. Factitious disorder diagnosed when symptom production is intentional to maintain a sick role (see 8.2 The World Around Us). Copyright © Pearson Education, Inc. All rights reserved. 156

Severe and chronic forms of factitious disorder have been called Munchausen’s syndrome. d. Difficult diagnostic challenges. Body Dysmorphic Disorder (BDD) 1. Body dysmorphic disorder a. Most common locations for perceived deficits are: (1) Skin—73%. (2) Hair—56%. (3) Nose—37%. (4) Stomach—22%. (5) Breasts/chest/nipples—21%. (6) Eyes—20%. (7) Face size/shape—12%. (8) Case Study: The Elephant Man. (9) See Table 8.1 Interference in Functioning. 2. Prevalence, gender, and age of onset a. No official estimates of prevalence, perhaps 1%–2% of the general population, 8% of people with depression. b. No gender differences. c. Men more likely to obsess about genitals, body build, and balding. d. Women tend to obsess more about skin, stomach, breasts, buttocks, hips, and legs. e. Age of onset is usually adolescence. f. Estimate 50% comorbid with depression. g. Often leads to suicide or attempted suicide. h. More than 75% seek nonpsychiatric treatment such as from a dermatologist and cosmetic medical treatments. 3. Relationship to OCD and eating disorders a. May be viewed as an obsessive-compulsive spectrum disorder: prominent obsessions, variety of ritualistic-like behaviors such as reassurance seeking, mirror checking, comparing themselves to others, and camouflage. b. Same brain structures have been implicated in both OCD and BDD. c. Same treatments are effective with OCD and BDD. d. Some overlapping features with anorexia nervosa: distorted body image, excessive concerns and preoccupation with physical appearance, and dissatisfaction with one’s body. 4. Why now? a. BDD has existed for centuries. b. Western culture emphasizes “looks as everything.” c. Imaginary defect disorder. d. Suffer in silence to seek treatment from dermatologist or plastic surgeon. e. Prevalence may have increased. f. Sufferers rarely seek psychological treatment. g. Increased media attention to BDD. 5. Causal factors: A Biopsychosocial Approach to BDD a. Suggestion that there is a partially genetically based personality predisposition. b. Sociocultural context—focus on attractiveness; self-schemas. c. Reinforced as children for appearance; teased or criticized for appearance. d. Biased attention and interpretation of information relating to attractiveness. 6. Treatment of body dysmorphic disorder a. SSRIs produce moderate improvement. b. Cognitive-behavioral treatment emphasizing exposure and response prevention leads to marked improvement in 50%–80% of patients. c.

II.

Dissociative Disorders

III.

Dissociation Refers to the Human Mind’s Capacity To Engage in Complex Mental Activity

IV.

Group of Conditions Involving Disruptions in a Person’s Consciousness, Memory, Identity, or Perception

Activity 8.1: Cultivating Dissociation A.

Depersonalization Disorder 1. Depersonalization Disorder a. Depersonalization (loss of self or one’s own reality) and derealization (one’s sense of the reality of the outside world). b. Reality testing remains intact. c. Implicit memory. d. Implicit perception. e. Out-of-body experiences can occur. f. Acute stress triggers the reactions. g. Personal reactions to the symptoms. h. The experience is usually frightening. i. Comorbid anxiety and mood disorders. j. Average age of onset is 23. k. Chronic course in 80% of cases. l. Differential diagnosis is important. m. Depersonalization symptoms can signal decompensation. n. Psychotic states often show early depersonalization symptoms. o. Case Study: A Foggy Student. Dissociative Amnesia and Dissociative Fugue 1. Retrograde amnesia involves the partial or total inability to recall or identify previously acquired information or past experiences; anterograde amnesia is the partial or total inability to retain new information. 2. Dissociative amnesia is also known as psychogenic amnesia.

Teaching Tip 8.2: Clive Waring 3.

Types of retrograde amnesia found in dissociative amnesia a. Localized—specific period. b. Selective—forgets some but not all of what occurred during a specific period. c. Generalized—loss of all life history, including identity. d. Continuous—remembers nothing beyond a certain point until the present. Typical symptoms associated with amnestic episodes a. Amnestic episodes typically last between a few days and a few years. b. Basic habit patterns—such as reading, talking, performing skilled work—are maintained. c. Most commonly impacts episodic (experienced events) or autobiographical memory, leaving intact semantic (language and concepts), procedural (how to do things), and short-term storage. Dissociative fugue a. New identities may be assumed. b. Fugue may last for days, weeks, or years. c. French for flight. Patterns of defense for amnesia and fugue are similar to conversion disorder a. Threatening information becomes inaccessible. b. Suppression is involved in memory loss. Copyright © Pearson Education, Inc. All rights reserved. 158

Memory and intellectual deficits in dissociative amnesia and fugue a. Little systematic research. b. Semantic knowledge appears to be intact. c. Primary deficit is compromised episodic or autobiographical memory. d. When presented with autobiographical information, show reduced activation in their right frontal and temporal brain areas. e. Implicit memory generally intact (e.g., when asked to dial numbers randomly, one man dialed his mother’s number). f. Compared with related deficits in explicit perception that occurs in conversion disorder.

Lecture Launcher 8.2: Does Dissociative Amnesia Exist? Activity 8.2: Dissociative Amnesia C.

Dissociative Identity Disorder (DID)

MyPsychLab Resource 8.1: Video “Dissociative Identity Disorder: The Three Faces of Eve” MyPsychLab Resource 8.2: Video “Dissociative Identity Disorder: Doctor Holliday Milby” 1.

Dissociative identity disorder a. Two or more personality systems are created from stressful precipitating events. b. Personalities are dramatically different. c. Formerly known as multiple personality disorder (MPD). d. Influence of Chris Seizmore and Three Faces of Eve in 1975. e. Needs inhibited in one personality are displayed in another. f. Personality most frequently encountered and who carries the person’s real name is known as the host identity. g. Alter identities represent fragments of a single person; some alters may have more knowledge than others. h. Switches between alters and host may occur very quickly or may be more gradual. i. People with DID may also show depression, self-mutilation, and frequent suicidal ideation and attempts. j. Usually starts in childhood; diagnosis is typically not until teens, 20s, or 30s. k. See 8.3 Developments in Thinking: Should Conversion Disorder Be Classified as a Dissociative Disorder?

Lecture Launcher 8.3: Developmental Variability in Dissociative Disorders l. m. n.

3 to 9 times more common in women. Females tend to have more alters than males. Believed this gender difference is due to the greater proportion of childhood sexual abuse among females. o. Case Study: Mary and Marian. p. Number of alters has increased over time; 50% now show more than 10 identities; increasing multiplicity suggests the importance of social factors. q. Another recent trend is bizarre and unusual identities. r. Host unaware of alters but alters know one another. s. See 8.4 DID, Schizophrenia, and Split Personality: Clearing Up the Confusion. Prevalence—Why has DID been increasing? a. Prior to 1979 only about 200 cases reported. b. Prevalence increasing dramatically in recent years; by 1999, more than 30,000 cases reported in North America alone Copyright © Pearson Education, Inc. All rights reserved. 159

(1) (2) (3) (4)

Increased public awareness through books and movies. Increased professional acceptance of disorder. Decreased misdiagnosis of cases as schizophrenia. Increases are artifactual—occurred because therapist suggested the existence of alter identities to patients or therapists have reinforced patients for producing alter identities.

Activity 8.3: Film Screening and Discussion: Sybil 3.

Experimental studies of DID a. Only a small number of experimental studies have been conducted. b. Traditionally, assumed that what one alter learns is not necessarily transmitted to other alters—interpersonality amnesia; at least one study has challenged this finding, documenting at least partial transfer of explicit and implicit memory across alters . c. Emotional reactions learned by one identity are also transferred across identities. d. Putnam found differences in brain waves between identities, and that these differences were larger than found between actors simulating different identities. e. Tsai and colleagues, using fMRI brain-imaging techniques, found changes in hippocampal and medial temporal lobe activity during the switch from one identity to another. Causal factors and controversies about DID a. Is DID real or is it faked? (1) Use of DID as a criminal defense; deliberate faking in Bianchi trial. (2) Factitious and malingering cases of DID are rare.

Handout 8.3: Is DID Real? Activity 8.4: Is DID Real? Activity 8.5: Do You Have Multiple Personalities? Activity 8.6: Self-Monitoring b.

If DID is not faked, how does it develop: posttraumatic theory or sociocognitive theory? (1) Posttraumatic theory (a) More than 95% of DID patients report memories of severe abuse. (b) DID is an attempt to cope with an overwhelming sense of hopelessness and powerlessness. (c) Escape—dissociation—occurs through a process like selfhypnosis. (d) Since only some abused children develop DID it leads to a diathesis-stress model i) Children prone to fantasy. ii) Easily hypnotizable. (e) DID as a variant of PTSD. (2) Sociocognitive theory (a) DID develops when a highly suggestible person learns to adopt and enact the roles of multiple identities due to therapist suggestions and reinforcement, and because the different identities allow the individual to achieve their personal goals. (b) Unintentional process. (c) Spanos and colleagues demonstrated that normal college Copyright © Pearson Education, Inc. All rights reserved. 160

students can be induced by suggestion under hypnosis to show DID symptoms. Handout 8.4: Absorption Scale (d)

This theory is consistent with evidence of no clear DID symptoms prior to entering therapy and the fact that the number of alters increases as therapy progresses. (e) Theory is also consistent with increased DID when therapists became more aware of condition. Are recovered memories of abuse in DID real or false? (1) Repressed memories may be false, a product of highly leading questions and suggestive techniques. (2) Difficulty in determining which memories of abuse are real and which are false. (3) Independent verification of abuse has been attempted but in many cases the verification has been very loose and suspect. If abuse has occurred, does it play a causal role in DID? (1) Childhood abuse tends to occur in families with many other sources of adversity and trauma. (2) It may be that people with DID who have experienced childhood abuse are more likely than those who did not experience childhood abuse to seek treatment. (3) Childhood abuse is associated with many forms of psychopathology; may play a nonspecific causal role. Comments on a few of these controversies about DID (1) Seems likely that some cases of DID are not due to social enactment roles. (2) Multiple different causal pathways are probably involved.

Lecture Launcher 8.4: Was Freud Right the First Time? D.

Sociocultural Factors in Dissociative Disorders 1. Prevalence is influenced by the degree to which they are accepted or tolerated by the surrounding cultural context. 2. Identified in all racial groups, socioeconomic classes, and cultures where it has been studied. 3. Dissociative trance disorder. 4. Possession trance. 5. Cross-cultural variations such as Amok. Treatment and Outcomes in Dissociative Disorders 1. Little is known about dissociative amnesia, fugues, and depersonalization. 2. No systematic controlled research has been conducted. 3. Dissociative identity disorder treatment is focused on integration; treatment is typically psychodynamic and insight-based. 4. Outcome studies are few. 5. Studies biased for good outcomes. 6. 8.5 The World Around Us: Dissociative Disorders: Proposed Revisions for DSM-5— the criterion for DID will be broadened and the criterion for depersonalization will be altered.

Lecture Launcher 8.5: Dissociative Identity Disorder or Schizophrenia? II.

Unresolved Issues: DID and the Reality of “Recovered Memories” A. “Believers” Are Usually Practitioners 1. View sexual abuse as the cause of DID. 2. Recovered memories are accurate; before treatment, such memories were repressed. B. “Disbelievers” Come from Academics and Science-oriented Professionals 1. Challenge that sexual abuse is the cause of DID. 2. DID is due to the social enactment of roles encouraged or induced by misguided therapy. 3. Recovered memories are inaccurate; human memory is malleable, constructive, and subject to modification. C. False Memory Syndrome Foundation

Lecture Launcher 8.6: Repressed or False Memories of Abuse? Activity 8.7: Is repression real?

Key Terms alter identities body dysmorphic disorder (BDD) conversion disorder depersonalization depersonalization disorder derealization dissociation dissociative amnesia dissociative disorders dissociative fugue dissociative identity disorder (DID) factitious disorder host identity

hypochondriasis hysteria implicit memory implicit perception malingering pain disorder posttraumatic theory (of DID) primary gain secondary gain sociocognitive theory (of DID) soma somatization disorder somatoform disorders

Lecture Launchers Lecture Launcher 8.1: Is Hypochondriasis an Anxiety Disorder? The difficulties inherent in organizing something as complex as the DSM can be underscored via a discussion about where hypochondriasis should be placed. Nominally, it is related to perceived aberrations of bodily function, making it a somatoform disorder. It actually shares many features of anxiety disorders, however, and might better be placed in that category. Hypochondriacs are fearful of disease and dysfunction to a degree that exceeds the magnitude of the actual risk, just as phobic fear is unreasonable. In fact, hypochondriasis might be seen as a disease phobia. Complicating things a little is the fact that hypochondriacs view their fears as reasonable, whereas many phobics do not. Nevertheless, fear is the primary emotion. It is also worth offering to the class that panic disorder, which is clearly an anxiety disorder, is rather like an acute fear response to interoceptive cues of pending physical calamity. Hypochondriasis is a more chronic fear of the same thing. Lecture Launcher 8.2: Does Dissociative Amnesia Exist?

Ask students to read this section prior to coming to class. At the start of class, ask students if they think it is possible to see this level of memory deficit in individuals who have not suffered some traumatic brain injury (like Clive Waring). Under what circumstances would they expect someone to develop a case of dissociative amnesia? Lecture Launcher 8.3: Developmental Variability in Dissociative Disorders Although the etiology of the dissociative disorders is unclear, there are tantalizing clues that are interesting to discuss. The relation of dissociative disorders to childhood sexual abuse is examined in detail in the text. Students may have some of their own thoughts about this relation, particularly on the issue of why most abused children do not become afflicted adults. It is also of interest to discuss why dissociative disorders are more common among women. Finally, the relation to individual differences in suggestibility and hypnotic susceptibility are worth discussing. Lecture Launcher 8.4: Was Freud Right the First Time? Freud’s initial investigations of hysteria suggested that childhood sexual abuse was common. Later, he dismissed reports of such abuse as fantasies because they started to seem far too frequent to be plausible. Now, however, there is increasing recognition of high rates of childhood sexual abuse in society, and its role in somatoform and dissociative disorders has become the subject of etiological theorizing once again. By some estimates (Cutler & Nolen-Hoeksema, 1991), between 7%–19% of females and between 3%–7% of males were sexually assaulted in childhood. Even though there is clearly a very high rate of childhood sexual abuse in the histories of adults with somatoform and dissociative disorders, it is worth emphasizing that most people who are sexually abused as children do not grow up to suffer from these disorders. Indeed, childhood sexual assault also increases the risk for depression (Weiss et al., 1999). Therefore, other factors must be taken into consideration. It is interesting to speculate about how Freud’s ideas would have developed had he not abandoned his initial ideas about actual sexual abuse. Lecture Launcher 8.5: Dissociative Identity Disorder or Schizophrenia? Dissociative identity disorder (a.k.a., multiple personality disorder) is often confused with schizophrenia, even though there is no relationship at all between the two disorders. This is probably because the term “schizophrenia” evokes an image of splitting of the mind/personality, coming as it does from Greek words for “split” and “mind.” For instance, if a country’s foreign policy is called schizophrenic because it penalizes some human rights violators but not others, then the policy is actually better compared to dissociative identity disorder than to schizophrenia. Even dictionary definitions of schizophrenia support the conflation between these disorders, but this just won’t do for purposes of this course. Once this is pointed out, it is not unusual for a student to ask “Well, then, what IS schizophrenia?” revealing the depth of the confusion on this point. Schizophrenia will be described in detail later in the course, but for now it is reasonable to offer that the “split” in schizophrenia is between reality, perceptions, emotions, ideas, and behaviors—not between separate personalities. You might also tell students that if they would like to show off their erudition, they should henceforth describe contradictory actions of single entities as “dissociative identity disordered” not “schizophrenic”! Lecture Launcher 8.6: Repressed or False Memories of Abuse? During the late 1980s and throughout the 1990s the U.S. legal system struggled to deal with recovered memories of childhood sexual abuse. Often elicited via hypnosis and other highly suggestive techniques by poorly trained therapists, these memories of events occurring decades previously were the basis of a wave of lawsuits against parents, friends, and relatives of people, mostly women, who were now adults and who believed various symptoms and life difficulties they were currently experiencing were the result of these previously forgotten episodes. The backlash against this trend, often termed the false memory syndrome, was quite vigorous (e.g., Gardner, 1993, Skeptical Enquirer). In retrospect, it appears that earnest and well-meaning therapists who truly believed their techniques were effective got caught up in the perceived pervasiveness of the phenomenon they were discovering, failing to recognize the limitations of their techniques.

Classroom Activities, Demonstrations, and Assignments

Activity 8.1: Cultivating Dissociation Many people can report dissociative experiences, such as walking into another room but forgetting why, dialing the phone number of one friend when intending to call another, “reading” a paragraph only to realize the words weren’t processed, reaching for the stick shift in an automatic transmission car, being able to dial a phone number without being able to state it, and so on. Ask students to describe their own dissociative experiences. Then talk about the dissociative continuum and how dissociative disorders are at the extreme end of that continuum. Some artists are described as being capable of cultivating dissociative experiences for artistic purposes. Students can try this through automatic writing, in which they try to let the words come automatically rather than deliberately, or through drawing, letting their hands move with minimal guidance from their conscious mind. Students who succeed in cultivating dissociation will gain a greater appreciation for its potential use as a way to cope with severe trauma, particularly for young children. Activity 8.2: Dissociative Amnesia Ask students to do a search for newspaper articles on cases of individuals with dissociative amnesia and bring them to class. Although many will have duplicates, you should be able to get possibly 10 cases. Ask students what they think about these cases. Do they think they are real? Activity 8.3: Film Screening and Discussion: Sybil Most students in Abnormal Psychology are aware of Sybil, either the best-selling 1973 book or the movie that was later based on the book. As the result of childhood abuse, Sybil purportedly developed 16 distinct personalities who did things without her knowledge. The book and movie cover how therapy with psychiatrist Cornelia Wilbur helped Sybil eventually overcome her disorder. Along with The Three Faces of Eve, Sybil is probably the most famous depiction of dissociative identity disorder and is worth screening for students, perhaps in an optional evening class meeting. Recently, psychologist Robert Rieber reported that taped conversations between Wilbur and the book author, Flora Rheta Schreiber, both deceased, show the story is incorrect. In fact, the psychiatrist and author appear themselves to have been “not totally unaware” that the story they told was wrong. Rieber’s report suggests that there was as much self-deception as deception of others going on between Wilbur and Schreiber. Wilbur was a colleague of Rieber’s at John Jay, and she gave him the tapes of her interactions with Schreiber. Rieber forgot about it for 25 years. Herbert Spiegel hypnotized Sybil and concluded that her so-called personalities actually arose from Wilbur’s therapeutic technique of giving names to various emotional states Sybil experienced. Wilbur then mistakenly came to believe that they really were distinct personalities. For example, when discussing something with Spiegel, Sybil asked whether she should be “Helen,” as Dr. Wilbur preferred. When he said no, she said, “Fine, I’d prefer it that way.” Activity 8.4: Is DID Real? A great source for some case studies on DID that had been misdiagnosed can be found in: Freeland, A, Manchanda, R., Chiu, S., Sharma, V., & Merskey, H. (1993). Four Cases of Supposed Multiple Personality Disorder: Evidence of Unjustified Diagnoses. Canadian Journal of Psychiatry, vol. 38(4), 245–247. And online at http://fmsfonline.org/four_cases_MPD.html. These could be incorporated into lecture or you could place students into small groups and assign each group a case and have them determine how they were misdiagnosed. Activity 8.5: Do You Have Multiple Personalities? Most college students report that they revert in many ways when they return home for vacations. Surely, their table manners vary depending on the circumstances. And who wouldn’t put their best foot forward for a job interview? Nobody is perfectly consistent. With this minimal orientation to the idea of normal multiple personalities, a student volunteer can then be solicited to participate in a brief exploration of the topic. In doing so, the instructor can demonstrate how multiple personalities can be encouraged iatrogenically in therapy. First, the student volunteer is asked about his or her different personalities. Then, the contradicting behaviors are grouped into categories, like “neat” vs. “messy,” “responsible” vs. “irresponsible,” “serious” vs. “fun-loving.” If contradictions are not immediately evident, they can be elicited by questions like “yes, but isn’t the opposite also sometimes true?” Then ask the student to give a new name to each of these different personalities. The neat, responsible, and serious side can be given one name and the messy, irresponsible, and fun-loving side can be given another name. Then, the instructor can ask to talk to just one side. This “personality” can then be elaborated upon in detail, followed by a similar elaboration upon the other personalities. Although the instructor has made clear that there is normal contradiction within all normal personalities, ask what effect it might have on a person to be told that the degree of Copyright © Pearson Education, Inc. All rights reserved. 164

personality elaboration “discovered” through this interview is abnormal and that one actually “has” multiple personality disorder? Activity 8.6: Self Monitoring Dissociative identity disorder appears very strange and exotic indeed, but an analogous phenomenon is probably quite familiar to students in your class. Who doesn’t behave in different ways with different people or in different situations? This is self-monitoring. The Snyder (1974) Self Monitoring Scale can be found at: http://pubpages.unh.edu/~ckb/SELFMON2.html. Activity 8.7: Is Repression Real? Elizabeth Loftus is one of the key researchers in the area of false memory creation. Her now influential Lost at the Mall studies has changed the way the field views memory systems and has shaped the way the legal world views eyewitness testimony. Have students read the following article: Loftus, E. (1997). Creating False Memories. Scientific American, vol. 277(3), 70–75. Or online at: http://faculty.washington.edu/eloftus/Articles/sciam.htm. Have students read the article and then find a criminal court case involving false memories (for example the McMartin trial). Then have them write two paragraphs on the Loftus article, one paragraph describing the case they found and another applying Loftus’s work to the criminal case. If your university has a law school and you get students who are prelaw as well as psych majors, you may want to modify the assignment and have them read the following article instead of the Loftus article. Piper, A., Lillevick, L., Kritzer, R (2008). What's wrong with believing in repression?: A review for legal professionals. Psychology, Public Policy, and Law, vol 14(3), 223–242.

MyPsychLab Resources MyPsychLab Resource 8.1: Video “Dissociative Identity Disorder: The Three Faces of Eve” You may want to show a brief video case study on classic footage of Eve White, Eve Black, and Jane, a young woman with what was then known as multiple personality disorder and today is known as dissociative identity disorder. This is the original case in which the Hollywood film starring Joanne Woodward was based. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 8, Somatoform and Dissociative Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Dissociative Identity Disorder: The Three Faces of Eve” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 8.2: Video “Dissociative Identity Disorder: Doctor Holliday Milby” You may want to show a brief video case study on 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. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 8, Somatoform and Dissociative Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Dissociative Identity Disorder: Doctor Holliday Milby” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise.

Teaching Tips Teaching Tip 8.1: The Relationship between BDD and Plastic Surgery Individuals with BDD often seek plastic surgery to “fix” the problem area(s). Some plastic surgeons have argued that approximately 7% –10% of their patients most likely suffer from BDD. Unfortunately, even that does not quell the BDD. Many suggest that the surgery may even result in new problems afterwards and greater dissatisfaction. There is also a relationship between eating disorders and BDD that students often confuse. Whereas someone with an eating disorder may be concerned with their entire body, individuals with BDD have issues with specific parts. Teaching Tip 8.2: Clive Waring

You may want to discuss the case of Clive Waring. If you Google the name, you can usually find the video clips on YouTube. Clive lost his hippocampus and suffered other traumatic brain injury in the mid-1980s after a severe case of encephalitis. Although he lost his episodic memories and suffers from both anterograde and retrograde amnesia, he still retains much semantic knowledge about his life. His memory is about 2 minutes long and students often find it fascinating that this exists not just in movies like “50 First Dates.” It is good to point out that there are welldocumented cases of these types of severe memory deficits.

Handout Descriptions Handout 8.1: Body Log Is it that hypochondriacs experience more bodily symptoms than other people, or is it that they attach excessive importance to the same symptoms experienced by everyone? Perhaps we all experience enough bodily symptoms to be hypochondriacs; we just ignore them. To test this hypothesis, it is of interest to survey the bodily symptoms that normal people experience if they are instructed to attend more carefully to them. For this activity, students can be asked to keep a “body log” that tracks the physical symptoms they experience at various times throughout one week. Alternatively, one body log can be collected during class. Students might be surprised at the wide range of aches, pains, itches, numbness, dryness, palpitations, dizziness, and other symptoms that are observed without alarm by themselves and their classmates. Handout 8.2: Secondary Gain for Somatic Symptoms Somatic symptoms are internal to the person experiencing them, but they can have external motives and even etiologies. These external reinforcements are called secondary gain, and they complicate physiological treatments because they tend to maintain symptomatology. It takes practice to recognize secondary gain from illness, but students often have some intuitions about what this involves. Ask them to reflect on various symptoms, describe the secondary gain associated with the symptoms, and think of ways to counteract secondary gain. Handout 8.3: Is DID Real? A lively debate on this issue can be found in the following point–counterpoint–point exchange between Putnam and McHugh debating whether DID is a valid condition. If your library has it have students read: McHugh, P. (1995). Resolved: multiple personality disorder is an individually and socially created artifact. Journal of the American Academy of Child and Adolescent Psychiatry, vol. 34(7), 957–962. Then the rebuttal: Putnam, F. (1995). Negative rebuttal: Putnam. Journal of the American Academy of Child and Adolescent Psychiatry, vol. 34(7), 957–962. And finally the affirmative rebuttal: McHugh, P. (1995). Affirmative rebuttal: McHugh. Journal of the American Academy of Child and Adolescent Psychiatry, vol. 34(7), 957–962. All three can be found online at: www.astraeasweb.net/plural/debate.html. Then have students read all three and answer the questions on Handout 8.3 as an assignment. This could also be used in a small class (around 16 students max) as a debate in class. Handout 8.4: Absorption Scale Hypnotic susceptibility and suggestibility can be rather abstract concepts. Therefore, it is helpful to show students some concrete examples of the traits that make up these constructs. In fact, students may enjoy gauging their standing on one such measure. Tellegen’s Absorption Scale (1982) is given in the last section of this Instructor’s Manual. Note that all the items are keyed true and that the mean/standard deviation for men is 21.4/6.9 and for women is 19.6/7.3.

Video/Media Sources Body Dysmorphic Disorder. Anxiety-related Disorders: The Worried Well Series. Princeton, NJ: Films for the Humanities and Social Sciences. Broken Bond: Munchausen Syndrome by Proxy. Medical Detectives Series, Part 3. Princeton, NJ: Films for the Humanities and Social Sciences. The Case of the Hillside Strangler. Mind of a Murderer Series. Princeton, NJ: Films for the Humanities and Social Sciences. Challenge Cases for Differential Diagnosis. Differential Diagnosis in Psychiatry Series. Princeton, NJ: Films for the Humanities and Social Sciences. Deception: Munchausen’s Disorder. New York, NY: Filmmakers Library. Copyright © Pearson Education, Inc. All rights reserved. 166

Lost in the Mirror: Women with Multiple Personalities. Princeton, NJ: Films for the Humanities and Social Sciences. The Madness of Children. New York, NY: Filmmakers Library. Many Faces of Marsha. New York, NY: Insight Media. Multiple Personality. The Brain Teaching Modules Video Series. South Burlington, VT: Annenberg/CPB Collection. Multiple Personality Disorder: In the Shadows. Princeton, NJ: Films for the Humanities and Social Sciences. Multiple Personality Puzzle. Allyn & Bacon Video Library. Neurotic, Stress-Related, and Somatoform Disorders. Allyn & Bacon Video Library.

Web Links Web Link 8.1: www.psychological.com/somatofom_disorders.htm The Web site of a practitioner in Atlanta, GA; gives summary information about many disorders. This link takes you to the page on somatoform disorders. Web Link 8.2: www.issd.org The International Society for the Study of Dissociation is a nonprofit professional association. It networks clinicians and researchers, provides education, and promotes dissociation theory, research, and training. The Web site has an interesting FAQ section that describes, among other things, what to do if someone close to you has a dissociative disorder. Web Link 8.3: www.depersonalization.info This site explores the world of depersonalized people through their stories and interaction. It also gathers new treatment information. It describes itself as a place “where people who have been diagnosed with Depersonalization Disorder, and people who feel that they may have the condition, can reach out to each other and share information about symptoms and treatment.” Web Link 8.4: www.psychiatrictimes.com/resources The site for Psychiatric Times. It has many articles that students can access for free, or that you can use for assignments. Web Link 8.5: www.nsf.gov/discoveries/disc_summ.jsp?cntn_id=100658 A great NSF article looking at how memory works and how false memories come into play. Web Link 8.6: http://fmsfonline.org/about.html The site for the False Memory Syndrome Foundation—contains many links to articles and research on false memories. Web Link 8.7: www.npr.org/templates/story/story.php?storyId=4123031 An interesting article by M. Trudeau on the biological basis for false memories.

Handout 8.1 Body Log

For each Body Log entry, focus as closely as you can on each specific part of your body, noting any sensations or feelings whatsoever. Try to make at least one comment about each area. Skin: itchy, dry, tight, oily, crusty, etc.

Muscles: sore, tense, weak, tender, etc.

Heart: pounding, fluttering, etc.

Stomach: heavy, sour, weak, etc.

Breathing: shallow, labored, etc.

Bones/Joints: stiff, sore, painful, tender, weak, etc.

Glands: swollen, heavy, painful, etc.

Eyes/Vision: dry, crusted, blurred, hazy, etc.

Mouth: dry, cottony, pasty, painful, etc.

Feet/Hands: cold, clammy, sweaty, hot, itchy, sore, etc.

Back: uncomfortable, sore, stiff, tight, twisted, knotted, etc.

Throat: dry, sore, acidic, raw, scratchy, etc.

Other bodily sensations:

Handout 8.2 Secondary Gain for Somatic Symptoms

What are some of the ways that a person receives reinforcement for being ill? Develop a list of possible symptoms. Then describe the secondary gain that a person may receive. Finally, provide ways to remove secondary gain. Symptoms/Illness

Secondary Gain

Counteracting Secondary Gain

Handout 8.3 Is DID Real? A lively debate on this issue can be found in the following point–counterpoint–point exchange between Putnam and McHugh debating the issue of if DID is a valid condition. Read: McHugh, P. (1995). Resolved: multiple personality disorder is an individually and socially created artifact. Journal of the American Academy of Child and Adolescent Psychiatry, vol. 34(7), 957–962. Then read the rebuttal: Putnam, F. (1995). Negative rebuttal: Putnam. Journal of the American Academy of Child and Adolescent Psychiatry, vol. 34(7), 957–962. And finally the affirmative rebuttal: McHugh, P. (1995). Affirmative rebuttal: McHugh. Journal of the American Academy of Child and Adolescent Psychiatry, vol. 34(7), 957–962. Now answer the following questions: 1. What are the major tenets of the point article? 2. What are the main points of the rebuttal? 3. What are the main problems or issues with the argument that the point article makes? That is, does the author make any fallacies in thinking? 4. What are the main problems or issues with the argument that the rebuttal article makes? That is, does the author make any fallacies in thinking? 5. Do you feel that this argument is theoretical or semantic? 6. In sum, do you feel that the point and affirmative rebuttal author has done a good job of expressing their argument? Why? 7. In sum, do you feel that the rebuttal author has done a good job of expressing his argument? Why? 6. In your opinion, which article makes a more convincing argument and why?

Handout 8.4 Absorption Scale Instructions: Indicate whether each of the following items is either “True” (if it is true or mostly true) or “False” (if it is false or mostly false as applied to you): 1.

Sometimes I feel and experience things as I did when I was a child.

I can be greatly moved by eloquent or poetic language.

While watching a movie, TV show, or play, I may become so involved that I forget about myself and my surroundings and experience the story as if it were real and I were taking part in it.

If I stare at a picture and then look away from it, I can sometimes “see” an image of the picture almost as if I were still looking at it.

Sometimes I feel as if my mind could envelop the whole world.

I like to watch cloud shapes change in the sky.

If I wish, I can imagine (or daydream) some things so vividly that they hold my attention as a good movie or story does.

I think I really know what some people mean when they talk about mystical experiences.

I sometimes “step outside” my usual self and experience an entirely different state of being.

10.

Textures—such as wool, sand, wood—sometimes remind me of colors or music.

11.

Sometimes I experience things as if they were doubly real.

12.

When I listen to music I can get so caught up in it that I don’t notice anything else.

13.

If I wish, I can imagine that my body is so heavy that I could not move it if I wanted to.

14.

I can often somehow sense the presence of another person before I actually see or hear her/him.

15. The crackle and flames of a wood fire stimulate my imagination. 16.

It is sometimes possible for me to be completely immersed in nature or in art, and to feel as if my whole state of consciousness has somehow been temporarily altered.

17. Different colors have distinctive and special meanings for me. 18.

I am able to wander off into my thoughts while doing a routine task and actually forget that I am doing the task, and then find a few minutes later that I have completed it.

19.

I can sometimes recollect certain past experiences in my life with such clarity and vividness that it is like living them again or almost so.

20.

Things that might seem meaningless to others might make sense to me.

21.

While acting in a play, I think I could really feel the emotions of the character and “become” her/him for the time being, forgetting both myself and the audience.

22.

My thoughts often don’t occur as words but as visual images.

23.

I often take delight in small things (like the 5-pointed star shape that appears when you cut an apple across the core or the colors in soap bubbles).

24.

When listening to organ music or other powerful music, I sometimes feel as if I am being lifted into the air.

25.

Sometimes I can change noise into music by the way I listen to it.

26.

Some of my most vivid memories are called up by scents and smells.

27.

Some pictures remind me of changing color patterns.

28.

I often know what someone is going to say before he or she says it.

29.

I often have “physical memories,” for example, after I have been swimming I may still feel as if I am in the water.

30.

The sound of a voice can be so fascinating to me that I can just go on listening to it.

31.

At times I somehow feel the presence of someone who is not physically there.

32.

I find that different odors have different colors.

33.

I can be deeply moved by a sunset.

Scoring: One point for each item marked “True.” Mean/Standard Deviation for men is 21.4/6.9 and for women 19.6/7.3. From Tellegen (1982).

CHAPTER 9: Eating Disorders and Obesity Teaching Objectives 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Define anorexia nervosa, and describe the two subtypes. Define bulimia nervosa. Compare and contrast anorexia nervosa, binge-eating/purging subtype, and bulimia nervosa. Identify other forms of eating disorders such as EDNOS and BED. Describe the medical complications of the various eating disorders. Explain the comorbidity of eating disorders with other forms of psychopathologies. Discuss age, gender, and prevalence rates of eating disorders in this culture and across cultures. Describe the biological, sociocultural, individual, and family risk and causal factors associated with eating disorders. Explain the various methods used for treating eating disorders, and be able to evaluate each one. Define obesity, and identify risk and causal factors. Discuss prevention and treatment methods for obesity. Review the eating disorder not otherwise specified (EDNOS) diagnosis.

Chapter Overview/Summary DSM-IV-TR recognizes three different forms of eating disorders: anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified (EDNOS). A fourth type of eating disorder, binge-eating disorder (BED), is listed in the Appendix and is not yet part of the formal DSM. Both anorexia nervosa and bulimia nervosa are characterized by an intense fear of becoming fat and a drive for thinness. Patients with anorexia nervosa are seriously underweight. This is not true of patients with bulimia nervosa. Eating disorders are more common in women than they are in men. They can develop at any age, although they typically begin in adolescence. Anorexia nervosa has a lifetime prevalence of around 0.9%. Many more people suffer from less severe forms of disturbed eating patterns. Genetic factors play a role in eating disorders, although exactly how important genes are in the development of pathological eating patterns is still unclear. The neurotransmitter serotonin has been implicated in eating disorders. This neurotransmitter is also involved in mood disorders, which are highly comorbid with eating disorders. Sociocultural influences are important in the development of eating disorders. Our society places a heavy value on being thin. Western values about thinness may be spreading, helping explain why eating disorders are now found throughout the world. Finally, individual risk factors, such as internalizing the thin ideal, body dissatisfaction, dieting, negative affect, and perfectionism are implicated in the development of eating disorders. Anorexia nervosa is very difficult to treat. Treatment is long-term and many patients resist getting well. Current treatment approaches include re-feeding, family therapy and cognitive-behavioral therapy (CBT). Medications are also used. The treatment of choice for bulimia nervosa is CBT. CBT is also helpful for binge-eating disorder. Obesity is defined as having a body mass index (BMI) of 30 or above. Being obese is associated with many medical problems and increased risk of death from heart attack. Obesity is not viewed as an eating disorder or a psychiatric condition. A tendency to being thin or heavy may be inherited. However, unhealthy lifestyles are the most important cause of obesity. People are more likely to be obese if they are older, female, and from a low SES group. Being a member of an ethnic minority group is also a risk factor for obesity. Obesity is a chronic problem. Medications help patients to lose small amounts of weight; drastic weight loss usually requires bariatric surgery. Because obesity tends to be a lifelong problem and because the treatment of obesity is so difficult, there is now a focus on trying to prevent people from becoming obese in the first place. Many recommendations will require major changes in social policy.

Detailed Lecture Outline I.

Clinical Aspects of Eating Disorders

MyPsychLab Resource 9.1: Video “Eating Disorders” A.

Anorexia Nervosa 1. An intense fear of gaining weight or becoming fat, coupled with a refusal to maintain minimal weight, body weight less than 85% of expected. 2. Disturbance in body weight or shape. 3. First reports in early religious literature. 4. Usefulness of amenorrhea criterion questioned, proposed change with DSM-5 to do away with amenorrhea. 5. Binge—out of control consumption of food. 6. Purge—efforts to remove food from the body. 7. Two types identified: a. Restricting type. b. Binge-eating/purging type.

MyPsychLab Resource 9.2: Video “Anorexia Nervosa: Binge-Eating/Purging Type: Jessica” MyPsychLab Resource 9.3: Video “Anorexia Nervosa: Tamora” Lecture Launcher 9.1: What Kind of Disorder Is Anorexia? B.

Bulimia Nervosa (see Table 9.2 for a comparison chart) 1. Characterized by binge eating and weight gain efforts such as self-induced vomiting and excessive exercise. 2. The term, bulimia, was first proposed in 1979. 3. Argument has been made that the binge-eating/purge subtype of anorexia (severely underweight) should be considered a subtype of bulimia (normal or slightly above normal weight). 4. Anorexia and bulimia share a common fear of being or becoming “fat.” 5. Binging increases food costs and may result in stealing food. 6. Bulimia comes from Greek word bous, means ox and limos hunger. 7. During an average binge one may consume as many as 4,800 calories. 8. Bulimia begins with restricted eating motivated by the desire to be slender. 9. Preoccupied with shame, guilt, self-deprecation, and efforts at concealment. Other Forms of Eating Disorders 1. Eating disorder not otherwise specified. 2. Binge-eating disorder. 3. Distinguishing among diagnoses a. Diagnosis complicated by high numbers of women who are on a “diet.” b. Some argue that there is no distinction between anorexia and bulimia. c. Most will transition from one eating disordered diagnosis to another over the lifespan. Age of Onset and Gender Differences 1. Although these disorders are considered modern, they actually date back several centuries. 2. 15–19 is the most common age of onset for anorexia; 20–24 is the most common age of onset for bulimia. 3. Eating disorders are 10:1 more common in females. Prevalence of Eating Disorders 1. Despite media impressions, the lifetime prevalence of anorexia is about 0.9% for females and 0.3% for men, and the lifetime prevalence of bulimia is about 1.5% for women and 0.5% for men. Copyright © 2013 Pearson Education, Inc. All rights reserved. 174

2. 3. 4. F.

Binge-eating disorder may be more common—3.5% of women and 2% of men. Many more women have disordered eating patterns that do not reach a diagnosable level. Increased cases of both anorexia and bulimia may be due to changing norms regarding the “ideal” size. Medical Complications of Anorexia Nervosa and Bulimia Nervosa (see Figure 9.2) 1. Anorexia a. Hair and nails are thin and become brittle. b. Dry skin. c. Highest mortality rate of any psychiatric disorder, 12 times higher than mortality rate of females 15–24, 3% of females with anorexia nervosa die. d. Downy hair called lanugo grows on face, neck, arms, back, and legs. e. Yellowish tinge to skin. f. Hair on scalp thins. g. 10%–60% abuse laxatives. h. Damage to bowels and gastrointestinal tract. i. Sensitive to cold. j. Low blood pressure leading to feeling tired, weak, dizzy, and faint. k. Thiamin deficiency may lead to depression and cognitive changes. l. Heart arrhythmias due to hypokalemia. m. Electrolyte imbalances. n. Kidney damage. 2. Bulimia o. Electrolyte imbalances. p. Hypokalemia (low potassium) leading to heart problems. q. Damage to heart muscle from ipecac syrup. r. Calluses on hands. s. Tears to the throat. t. Mouth ulcers and dental cavities. u. Small red dots around eyes. v. Swollen salivary glands—chipmunk cheeks. w. Mortality rate 2 times the general population, less lethal.

Activity 9.1: Medical Consequences of Eating Disorders G.

Course and Outcome 1. Difficult to treat with high relapse rates. 2. 3%–23% attempt suicide. 3. Frequent binges, more shape concerns, and longer duration of illness. 4. Medical complications and suicide cause the most common deaths, 1 out of 5 commit suicide for anorexia nervosa. 5. Substance abuseis associated with poorer outcome. 6. Even when “well,” still suffer from residual food issues: excessively concerned about shape and weight, restrict their dietary intakes, overeat and purge in response to negative mood states. Cognitive-Behavioral Therapy Recovered Diagnostic Crossover 1. One 7-year study found that the majority of patients show diagnostic crossover, meaning once someone has been diagnosed with an eating disorder, they are more likely to be diagnosed with another eating disorder—for example, transitioning between the two subtypes of anorexia. (See Figure 9.3 for a chart of diagnostic crossover.) Association of Eating Disorders with Other Forms of Psychopathology 1. 68% of those with anorexia nervosa and 63% of those with bulimia nervosa are also diagnosed with depression, with 50% diagnosed with binge eating disorder. 2. Other common comorbid diagnoses include: obsessive-compulsive disorder, substance abuse disorders (except for restricting anorexia), personality disorders (avoidant cluster for anorexics and Cluster B for bulimics). 3. More than one third have engaged in self-harming behaviors. Copyright © 2013 Pearson Education, Inc. All rights reserved. 175

4. BED has comorbidity with anxiety disorders 65%, mood disorders 46%, and substance abuse disorders 23%. 5. 2/3 of those with anorexia report being rigid and perfectionistic, even as children. Eating Disorders across Cultures 1. Most research conducted in the United States and Europe. 2. Eating disorders documented in South Africa, Japan, Hong Kong, Taiwan, Singapore, India, Iran, China, and Korea. 3. Being white is also associated with the type of subclinical problems that places people at high risk for eating disorders: body dissatisfaction, dietary restraint, and a drive for thinness. 4. Asian women exhibit similar pathological eating like white females. 5. African American are less at risk than their white counterparts. 6. Assimilation into white culture determines prevalence rates among minority women. 7. Clinical features of diagnosed eating disorders vary by culture a. 58% of anorexics in Hong Kong are not excessively concerned about fat but “stomach bloating.” b. Young women in Ghana emphasized religious ideals of self-control and denial of hunger. c. Japanese women report lower levels of perfectionism and less of a drive for thinness. 8. Anorexia nervosa occurs in all cultures; bulimia nervosa is a culture-bound syndrome.

II.

Risk and Causal Factors in Eating Disorders A. Biological Factors 1. Genetics a. Risk of anorexia for relatives is 11.4 times greater than for the relatives of normal controls. b. Mood disorders and eating disorders cluster together. c. Genetics after puberty and the role of the hypothalamus. d. Risk of bulimia for relatives is 3.7 times greater than for the relatives of normal controls. e. Restricting anorexia has been associated with chromosome 1; bulimia has been associated with chromosome 1. 2. Set points—weight that an individual’s body tries to defend. 3. Serotonin a. Neurotransmitter implicated in obsessionality, mood disorders, and impulsivity; also modulates appetite and feeding behavior. b. Those with anorexia and bulimia show low levels of 5-HIAA (metabolite of serotonin); higher levels than normal during recovery. c. Increased activity of the serotonin receptors is more characteristic of the bulimia type of anorexia than the restricting type. d. Research is complicated by being unable to tell whether serotonin alterations are due to the eating disorder, rather than the altered serotonin causing the eating disorder. B. Sociocultural Factors

Lecture Launcher 9.2: Race and Eating Disorders 1. 2. 3. 4. 5. 6.

Peer and media influences. Influence of Kate Moss “rexy,” hybrid of anorexic and sexy. Influence of Vogue and Cosmopolitan. Social pressure to be thin more powerful in higher SES backgrounds. 1960s—Twiggy. Becker—research in Fiji a. Initial research found an absence of eating disorders; being fat was associated with being strong, able to work, and being kind and generous; being skinny was associated with being sickly, incompetent, or having somehow received poor treatment. b. When reassessed in 1998 after television was introduced, found that women were dieting and expressing concern about their bodies/weight.

Lecture Launcher 9.3: Why Is the Thin Message So Effective When Others Are Not? C.

Family Influences 1. One third of patients report that family dysfunction contributed to the development of their anorexia. 2. No “typical” family profile with anorexia. 3. Associated family behaviors for anorexia include: rigidity, parental overprotectiveness, excessive control, and marital discord. 4. Many parents of anorexics have the same issues: preoccupied with the desirability of thinness, dieting, and good physical appearance. 5. Bulimic family characteristics include: a. High parental expectations. b. Other family members’ dieting. c. Critical comments from other family members about shape, weight, or eating. d. Extent family members made comments about a woman’s appearance and focused on her diet. e. Role of family conflict. Copyright © 2013 Pearson Education, Inc. All rights reserved. 177

f. Families less cohesive Individual Risk Factors 1. Gender—higher in females. 2. Internalizing the thin ideal is associated with: a. Body dissatisfaction. b. Dieting. c. Negative affect. 3. Perfectionism a. May be an enduring personality trait of people who are susceptible to eating disorders. b. More common in women. 4. Negative body image (See Figure 9.4 for body ideal image) a. Incongruence between the ideal image and how they perceive themselves.

Handout 9.1: Eating Disorders in Men—Bigorexia Nervosa? Activity 9.2: Body Size Ratings Activity 9.3: Measuring Body Image Distortion 5. 6. 7.

Dieting. Negative emotionality a. Depression and negative affect are both predicative of later eating disorder. Childhood sexual abuse a. Research inconsistent; one prospective study found no link between early sexual abuse and binge eating whereas retrospective studies have found a weak relationship. b. Causal pathway may be indirect.

MyPsychLab Resource 9.4: Video on “College Students & Eating Disorders” III.

Treatment of Eating Disorders A. Treating Anorexia Nervosa 1. Patients are generally pessimistic about recovery, view the disorder as chronic, and have a high drop-out rate. 2. Few controlled studies. 3. Must restore weight—may require hospitalization and tube feeding. 4. Short-term aggressive efforts may lead to temporary improvements but long-term problems. 5. In randomized controlled trials where patients are treated with family therapy for one year, after five years have 75%–90% full recovery. 6. Nutritional counseling. 7. Maudsley Model, 10–20 sessions spaced over 6–12 months. 8. Medications a. No strong evidence that medications are helpful; antidepressants and antipsychotic medications such as olanzapine are sometimes used . 9. Family therapy a. Family therapy considered the treatment of choice with adolescents who had developed anorexia before the age of 19 and who had been ill for less than 3 years.

Handout 9.2: Focus on the Family 10.

Cognitive-behavioral therapy a. Cognitive-behavioral treatment has been shown to be effective for older patients with more long-standing problems. Copyright © 2013 Pearson Education, Inc. All rights reserved. 178

Treating Bulimia Nervosa 1. Medications a. Use of antidepressants is common; seem to decrease the frequency of binges as well as improving mood and preoccupation with shape and weight. 2. Cognitive-behavioral therapy is the treatment of choice: a. Most current CBT approaches based on the work of Fairburn. b. Multiple controlled studies show the CBT is superior to medications and interpersonal therapy. c. Behavioral components focus on: meal planning, nutritional education, ending binging and purging cycles by teaching the person to eat small amounts more frequently. d. Cognitive element focuses on challenging dysfunctional thought patterns. Treating Binge-Eating Disorder 1. Little information is available. 2. High comorbidity with depression. 3. Sibutramine. 4. Interpersonal psychotherapy (IPT). 5. Antidepressants, appetite suppressants, and anticonvulsant medications have been used. 6. Marcus—suggested adapting CBT techniques.

MyPsychLab Resource 9.5: Video “Eating Disorders: Nutritionist Alise Thresh” Teaching Tip 9.1: Student Health Services IV.

Obesity

Lecture Launcher 9.4: Is Obesity an Eating Disorder? A.

Widespread Epidemic 1. In the United States, 68.3% of the adult population is overweight; 33.9% of these are considered obese. 2. Reduced life expectancy by 5–20 years. 3. Body mass index a. Below 18.5 = underweight. b. 18.5–24.9 = normal. c. 25–29.9 = overweight. d. 30 or above = obese. 4. Other risk factors include: low parental education, children who are seriously neglected. 5. Associated with: diabetes, joint disease, high blood pressure, coronary artery disease, sleep apnea, cancer. 6. Obesity is not an eating disorder, obesity and the DSM-5 Food Addiction. 7. By 2030, costs for obesity will exceed $850 billion. 8. Obesity is more prevalent in minority ethnicities. 9. Higher in men than women. 10. High-income women are less likely to be obese. 11. Black and Mexican American men with high incomes are more likely to be obese. Risk and Causal Factors in Obesity A. Role of Genes 1. Genes associated with thinness and leanness have been found in certain animals. 2. Genetic mutation associated with binge eating is found in only 5% of obese population; all of the obese people with the gene reported problems with binge eating whereas only 14% of obese people who did not have the genetic mutation had a pattern of binge eating. B. Hormones Involved in Appetite and Weight Regulation 1. Leptin acts to reduce our intake of food; inability to produce the hormone leptin associated with morbid obesity.

People who are overweight tend to have high levels of leptin but are resistant to its effects. 3. The hormone grehlin, produced by the stomach, is a powerful appetite stimulator; in Prader-Willi syndrome, chromosomal abnormalities lead to high levels of grehlin and extreme obesity, often dying before the age of 30. Sociocultural Influences 1. Culture that encourages consumption and discourages exercise. 2. Time pressure. 3. Diathesis-stress perspective. 4. Genes. 5. Personality. 6. Junk food. 7. Lifestyle. 8. Pace of life. 9. Accessibility. 10. High caloric diets. 11. Family attitude. 12. Number and size of fat (e.g., adipose) cells. 13. Socially contagious. Family Influences 1. Family behavior patterns. 2. Eating may become an habitual means of alleviating emotional distress. 3. Overfeeding infants and young children causes them to develop more adipose cells and may thus predispose them to weight problems in adulthood. Stress and “Comfort Food” 1. When under stress, people and animals eat foods high in fat or carbohydrates. 2. Weight gain as a function of basic learning principles a. Obese people are conditioned to eat more in response to both external and internal cues than normal-weight individuals. b. Eating is reinforced because the food is pleasurable and then emotional tension is reduced. c. Means of reducing feeling.

Teaching Tip 9.2: The Eole of Conditioning: Food as Reward F.

Pathways to Obesity (see Figure 9.7 for diagram) 1. Binge eating is a predictor of later obesity. 2. Combination of genes, environment, and sociocultural factors. 3. During adolescence, starts at puberty. 4. Being heavy leads to dieting, which then leads to binge eating 5. Binge eating may be caused by:. a. Social pressure to conform to the thin ideal. b. Dieting. c. Depression and low self-esteem. Treatment of Obesity 1. Success rates are quite low. 2. Lifestyle modifications like weight-loss groups a. Many groups exist; only Weight Watchers has been shown to be effective. b. Groups tend to provide education, encourage record keeping, and provide support and encouragement. c. Popular diets. 3. Medications a. Drugs fall into two categories: appetite suppressants and those that prevent some of the nutrients form being absorbed. b. Sibutramine (Meridia): inhibits reuptake of serotonin and norepinephrine. c. Orlistat (Xenical): reduces the amount of fat that can be absorbed. Copyright © 2013 Pearson Education, Inc. All rights reserved. 180

Bariatric surgery a. Reduces the amount of food that can be consumed at any one time. b. Recovery is difficult. c. Weight loss may be quite dramatic; average loss 44–88 pounds, and 1% die from the surgery . Activity 9.4: Bariatric Surgery H.

Importance of Prevention 1. Losing weight is contrary to biology. 2. Hill and colleagues (2003) eat three fewer bites of food, take the stairs, and sleep more. 3. Brownell: Specific public policy recommendations: a. Improve opportunities for physical activity. b. Regulate food advertising directed at children. c. Prohibit the sale of fast food and soft drinks in schools. d. Subsidize the sale of healthful foods. Does DSM-5 Solve the Problem of EDNOS? 1. Most people seeking treatment are diagnosed with EDNOS. 2. Given a residual diagnosis. 3. Amenorrhea not required for anorexia nervosa. 4. Many individuals with EDNOS have BED. 5. EDNOS is not in the DSM-5. 6. Addition of purging disorder.

Activity 9.5: Local Prevention Efforts?

Key Terms anorexia nervosa binge binge-eating disorder (BED) body mass index (BMI) bulimia nervosa cognitive-behavioral therapy (CBT) eating disorder eating disorder not otherwise specified (EDNOS) grehlin hypothalamus

leptin negative affect obesity perfectionism purge serotonin set point

Lecture Launchers Lecture Launcher 9.1: What Kind of Disorder Is Anorexia? Eating disorders in general, and anorexia in particular, are diagnostically complex owing to characteristics that overlap with other sections of the DSM. Students might have already noted the similarity between obsessional thinking characteristic of OCD and the body preoccupation characteristic of anorexia and bulimia. As well, the anxiety that is caused by preventing a bulimic from purging or causing an anorexic to eat normally is similar to that evoked when phobics are exposed to their feared stimuli or compulsive OCD rituals are interrupted. Are anorexia and bulimia anxiety disorders? Alternatively, they can be viewed as mood disorders. The first clues to the possibility that some eating disorders were on the mood disorder “spectrum” were the observation that they sometimes respond to antidepressant medications. There is also some evidence that eating disorders run in families that have relatively high rates of depression. And the cognitive styles associated with some eating disorders are as distorted as those seen in depression. So the question is, should anorexia and/or bulimia be considered mood disorders? Lecture Launcher 9.2: Race and Eating Disorders Eating disorders are 7–8 times more likely in white females than among females of color. Why is that? What Copyright © 2013 Pearson Education, Inc. All rights reserved. 181

cultural factors that are less pronounced among non-white females encourage eating disorders in white females? Alternatively, what protective cultural factors enjoyed by non-white females are missing from the lives of white females? What might be done to remedy this cultural difference so that the rates of eating disorders among white females are lowered? Lecture Launcher 9.3: Why Is the Thin Message So Effective When Others Are Not? It is easy to see that the media encourages an unhealthy focus on being thin, and that it thereby contributes to eating disorders, but is there more going on here? Inherent to the media influence theory of eating disorders is the presumption that the media can profoundly affect attitudes and behaviors, causing us to do extremely unhealthy things. But if the media is powerful enough to cause people to literally starve themselves to death, why is it so ineffective at other things? Why can’t the power of the media be harnessed for good? What makes the thin message especially powerful? Conversely, how are healthy media productions such as anti-smoking campaigns being hampered? What makes the two messages different? Lecture Launcher 9.4: Is Obesity an Eating Disorder? Obesity has not been included as an eating disorder in the DSM-IV TR. Ask students to provide reasons for this decision and then to suggest possible reasons for including obesity as an eating disorder. An interesting study found that BMI is not associated with mental disorders or general psychopathologies (Lamertz, Jacobi, Yassouridis, Arnold & Henkel, 2002). Classroom Activities, Demonstrations, and Assignments Activity 9.1: Medical Consequences of Eating Disorders Many college-aged people are quite uninformed about the medical consequences of eating disorders, viewing them as rather harmless strategies to cope with pressure to be thin. They are surprised to find that anorexia is frequently fatal and that bulimia also has a wide variety of medical consequences, some of which are permanent. An excellent way to make this point is to have students research these effects themselves or to invite a physician to present a lecture on the topic. Activity 9.2: Body Size Ratings The text discusses research by Fallon and Rosen (1985) in which participants were asked to use a picture scale to identify their current body, their ideal body, the ideal body type they envision for the opposite sex, and the ideal body type they expect the opposite sex to choose for members of their own sex. For men, the four ratings were about the same, but for women, their current figure was much heavier than their own ideal, which was heavier than the ideal they perceive held by men. In fact, men’s ideal figure for women was heavier than it was expected to be by women. It is a simple matter to project these figures using an overhead or PowerPoint projector and to secure the four ratings from every member of the class, being sure to get the respondent’s sex along with the ratings. These data can then be analyzed and presented to the class later as an exercise in research methods, or else the task can simply be used to help insure student understanding of this somewhat difficult-to-describe study. The Body Image Ideals Questionnaire developed by Thomas Cash and Marcela Szymanski (1995) can also provide the basis for a class discussion (Journal of Personality Assessment, vol. 64, pp. 466–477). This measure evaluates attitudinal dimensions of the discrepancy between perceived and idealized physical characteristics. A multitude of physical characteristics is considered in addition to those that are weight related. Activity 9.3: Measuring Body Image Distortion Students can be assigned the task of gathering and analyzing various methods of assessing body image distortions. An article by Thompson and Gray (1995) is a good starting point. Thompson and Gray found 21 different approaches to assessing body image distortions in eating disorders (Journal of Personality Assessment, vol. 64, pp. 258–269). Students can divide up these methods to present to the class, perhaps administering some to their fellow students and providing information for interpretation (viz. means and standard deviations). Once the different methods are presented, students can compare their strengths and weaknesses. Activity 9.4: Bariatric Surgery Bariatric surgery has become increasingly common. As a result, most large hospitals offer the procedure. Inviting a surgeon or nurse who may be able to explain the procedure involved for those considering bariatric surgery would be very useful. Many students may be unaware of the pre-surgical education and the post-surgical lifestyle changes. Copyright © 2013 Pearson Education, Inc. All rights reserved. 182

Activity 9.5: Local Prevention Efforts? Ask students to explore the contents of the on-campus vending machines and food services. On most campuses, vending machines are filled with sodas, candy bars, and other high calorie items. Many food services on campus provide pizza, burgers, fries, and cookies. Have students create their own lists of items to include in the vending machines and to have for sale at campus food services. Students could also attempt to interest the administration in making these changes. MyPsychLab Resources MyPsychLab Resource 9.1: Video “Eating Disorders” You may want to show a brief overview on eating disorders. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 9, Eating Disorders and Obesity. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Eating Disorders” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 9.2: Video “Anorexia Nervosa: Binge-Eating/Purging Type: Jessica” You may want to show a brief video case study on Jessica discussing her struggle with anorexia nervosa. As a dancer in a competitive New York dance program, Jessica found herself attempting to become thinner as a means of standing out, control, and coping. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 9, Eating Disorders and Obesity. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Anorexia Nervosa: Binge-Eating/Purging Type: Jessica” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 9.3: Video “Anorexia Nervosa: Tamora” You may want to show a brief video case study on a young woman with anorexia nervosa who is interviewed about her problems and progress. She has been in treatment for 2 years with various therapists, a psychiatrist, and nutritionist. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select chapter 9, Eating Disorders and Obesity. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Anorexia Nervosa: Tamora” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 9.4: Video “College Students & Eating Disorders” Here is a brief video on college students and eating disorders. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 9, Eating Disorders and Obesity. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “College Students & Eating Disorders” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 9.5: Video “Eating Disorders: Nutritionist Alise Thresh” You may want to show a brief video interview with a nutrition therapist about the treatment of eating disorders. She outlines the symptoms of anorexia nervosa, bulimia, and the newest binge eating disorder. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 9, Eating Disorders and Obesity. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Eating Disorders: Nutritionist Alise Thresh” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise.

Teaching Tips Teaching Tip 9.1: Student Health Services This is a great time to have someone from student health services come in to talk about eating disorders. Because some estimates for eating disorders among college students is as high as 40%, the odds of you having students in your class with an eating disorder is high. This allows students to realize what supports on campus are available to them. Teaching Tip 9.2: The Role of Conditioning: Food as Reward Many students can relate to the “clean plate club” as well as food as reward and punishment. That is, “if you eat your dinner, you can have dessert,” or “now you’ll go to bed hungry.” Although food makes an excellent reinforcer and punisher, what message does it send to children? What about the “clean plate club”? It is important to again stress the importance of these associations with food as something other than sustenance and the message that it sends. Ask students the ways they associate food with reinforcement or punishment. This will help illustrate how all of us have ideas about food that may be problematic.

Handout Descriptions Handout 9.1: Eating Disorders in Men—Bigorexia Nervosa? Research on eating disorders focuses almost exclusively on women, but there has been a recent interest in studying men as well. With men, the issues are somewhat different because the ideal body type for men is muscular, and men who are preoccupied with their bodies are therefore trying to get bigger rather than smaller. This leads to obsessive weight-lifting, steroid use, and exercise. Men are often encouraged in this body preoccupation starting at a very young age when they are exposed to comic book heroes with unrealistic body characteristics. They can also gain encouragement from coaches and parents who want them to be successful athletes. Despite the obvious differences in what men and women are seeking to accomplish, how are men’s and women’s issues similar? How would preventive efforts target both sexes? How might they be customized for each sex? Handout 9.2: Focus on the Family A wide variety of psychological theories focus on family interactions of people with eating disorders. For instance, Hilde Bruch proposed a psychodynamic theory of anorexia as an attempt to cope with feelings of powerlessness by taking control and gaining competence in the management of one’s own weight. The need to control this one area of life is created by parents who impose too much on their children, ignoring the child’s own needs in favor of their own apparently arbitrary regulations. From a more explicitly family systems point of view, Salvador Minuchin theorized that eating disorders exist to help families avoid conflicts over other things. Families of those with eating disorders are characteristically overly enmeshed, rigid, and protective. They are poor at conflict resolution, and communication is also very poor. Cognitive behavioral theorists also focus on the family as a source of stress, in a diathesis-stress formulation, and as an important socializing influence in which preoccupation with weight can be established. For this activity, have students reflect on the way their families approached food and body image. Was food used as a reward? As a punishment? Was “comfort food” deployed to deal with negative emotions? Were students required to clean their plates? What other aspects of eating, exercise, and body image consciousness were taught in their families? How many of their current beliefs and practices have their origins in their family interactions? Do ideas about food, eating, and body image described by other class members sound strange? How resistant to change are these ideas?

Video/Media Sources ▪ ▪ ▪ ▪ ▪ ▪

An Anorexic’s Tale: The Brief Life of Catharine. Princeton, NJ: Films for the Humanities and Social Sciences. Anorexia and Bulimia. Princeton, NJ: Films for the Humanities and Social Sciences. Anorexia Nervosa/Bulimia, Client Interview (Kim)—#4 ABC News and Client Interviews. Allyn & Bacon Abnormal Psychology Video. Beautiful Piggies. New York, NY: Filmmakers Library. Belly: Overcoming Bulimia. New York, NY: Filmmakers Library. Dying to be Thin. Princeton, NJ: Films for the Humanities and Social Sciences.

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Eating Disorders. Anxiety-Related Disorders: The Worried Well Video Series. Princeton, NJ: Films for the Humanities and Social Sciences. Eating Disorders: The Hunger Within. Princeton, NJ: Films for the Humanities and Social Sciences. Eating Disorders: New Approaches to Treatment. Allyn & Bacon Video Library. Eating Disorders: When Food Hurts. Boston, MA: Fanlight Productions. Enigma of Anorexia Nervosa. New York, NY: Insight Media. Fat Chance: The Big Prejudice. Oley, PA: Bullfrog Films. Having Your Cake: Goodbye to Bulimia. Princeton, NJ: Films for the Humanities and Social Sciences. The Human Body: Appearance, Shape, and Self-Image. Berkeley, CA: University of California Extension Center for Media and Independent Learning. The Mind Awake and Asleep. Discovering Psychology Series. South Burlington, VT: Annenberg/CPB Multimedia Collection. Self-image and Eating Disorders: A Mirror for the Heart. Princeton, NJ: Films for the Humanities and Social Sciences. The Silent Hunger: Anorexia and Bulimia. Princeton, NJ: Films for the Humanities and Social Sciences. Thin at Any Cost: Treating Eating Disorders. Allyn & Bacon Video Library. Wake Up, America: A Sleep Alert. Princeton, NJ: Films for the Humanities and Social Sciences. When Food Is the Enemy: Eating Disorders. Allyn & Bacon Video Library.

Web Links Web Link 9.1: www.obesity.org This site, sponsored by the American Obesity Association, provides current information on education, prevention, treatment, childhood obesity, discrimination, and disability due to obesity. Web Link 9.2: www.anad.org National Association of Anorexia Nervosa and Associated Disorders (ANAD) provides “hotline counseling, a national network of free support groups, referrals to health care professionals, and education and prevention programs to promote self-acceptance and healthy lifestyles. All of our services are free of charge. ANAD also lobbies for state and national health insurance parity, undertakes and encourages research, fights dangerous advertising, and organizes advocacy campaigns to protect potential victims of eating disorders. ANAD stands with people and families and helps them win.” Web Link 9.3: www.nationaleatingdisorders.org The National Eating Disorders Association Web site provides eating disorders information, referrals for groups, treatment centers, doctors, and therapists, as well as educational and promotional videos, books, and pamphlets. Web Link 9.4: www.anred.com The Anorexia Nervosa and Related Eating Disorders Web site contains more than 50 pages of information about eating disorders. The information is written for a lay audience and covers warning signs, complications, causes, treatment and recovery, males and eating disorders, diabetes, pregnancy, the elderly, and myriad other lesser-known aspects of eating disorders. Web Link 9.5: www.nedic.ca The National Eating Disorder Information Center provides information and resources on eating disorders and weight preoccupation. Their Web site provides an eating disorders glossary, a questions and answers section, recommended readings, and an excellent link list that has screen shots of its offerings. Web Link 9.6: www.obesityaction.org/home/index.php The mission of the Obesity Action Coalition is to elevate and empower those affected by obesity through education, advocacy, and support. The site provides numerous resources including information, patient stories, comorbid conditions, and treatment options.

Handout 9.1 Eating Disorders in Men

Does the DSM’s delineation of anorexia, bulimia, and binge-eating disorder give adequate coverage to the kinds of eating disorders to which men might be prone?

What kinds of disordered eating are typical in men?

What would be the diagnostic criteria for an eating disorder, or disorders, that would encompass the sorts of eating problems to which men are prone?

More important than eating behaviors are the etiological factors behind the behavior. What are some of the cognitive, emotional, biological, and psychosocial factors behind men’s disordered eating?

What are some of the media influences on men’s body image? How do they differ from women’s? Are there differences in the content of the messages to which men are exposed? Differences in the pervasiveness of the message? More alternative messages available?

Who is more anatomically implausible, Barbie or G.I. Joe? Is children’s attraction to these figures what makes them popular, or does their popularity influence children’s attraction to them? What is the role of early images like these in adult body images?

Handout 9.2 Focus on the Families

In general, what are your recollections about how food and eating were approached in your family while you were growing up?

Was food used as a reward? As a punishment?

Did your family recognize “comfort foods” or in other ways tie food to either positive or negative emotions?

Were you required to eat everything on your plate?

Did your family comment on each other’s weight?

Was the dinner table a frequent place for arguments and family conflict?

How do you see your present attitudes about weight and eating connecting with your childhood family experiences?

CHAPTER 10: Personality Disorders Teaching Objectives 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

List the clinical features of the personality disorders and problems associated with the diagnosis, particularly when completing research. Review the provisional categories of personality disorders for the new DSM-5. Compare and contrast the different types of personality disorders, and identify the three clusters into which most personality disorders are grouped. Summarize what is known about the biological, psychological, and sociocultural causal factors of personality disorders. Discuss the difficulties of treating individuals with personality disorders, and describe the approaches to treatment that have been tried. Explain how changes in the family structure may have led to increasing rates of borderline personality disorder. Compare and contrast the DSM-IV concept of antisocial personality and Cleckley’s concept of psychopathy. List the clinical features of psychopathy and antisocial personality. Summarize the biological, psychosocial, and sociocultural causal factors in psychopathy and antisocial personality and the integrated developmental perspective. Explain why it is difficult to treat psychopathy and antisocial personality, and describe the most promising of the as-yet unproven approaches to treatment. Review the dimensional system of classification formerly known as a character disorder.

Chapter Overview/Summary Personality disorders appear to be inflexible and distorted behavioral patterns and traits that result in maladaptive ways of perceiving, thinking about, and relating to other people and the environment. Difficulties in diagnosing personality disorders occur because even with structured interviews, the reliability of diagnosing personality disorders is less than ideal. Moreover, most researchers agree that a dimensional approach for assessing personality disorders would be preferable to the more categorical approach taken by the DSM system. Difficulties in studying the causes of personality disorders occur because most people with one personality disorder have at least one more, making it difficult to disentangle the causes of one from the other. Three general clusters of personality disorders have been described in the DSM: • Cluster A includes paranoid, schizoid, and schizotypal personality disorders; individuals with these disorders seem odd or eccentric. Little is known about the causes of paranoid and schizoid disorders, but genetic factors are implicated in schizotypal personality disorder. • Cluster B includes histrionic, narcissistic, antisocial, and borderline personality disorders; individuals with these disorders share a common tendency to be dramatic, emotional, and erratic. Little is yet known about the causes of histrionic and narcissistic disorders. Certain biological and psychosocial causal factors have been identified as increasing the likelihood of developing borderline personality disorder in those at risk because of high levels of impulsivity and affective instability. • Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders; individuals with these disorders show fearfulness or tension, as in anxiety-based disorders. Children with an inhibited temperament may be at heightened risk for avoidant personality disorder, and individuals high on neuroticism and agreeableness, with authoritarian or overprotective parents, may be at heightened risk for dependent personality disorder. There is also relatively little research on treatments for most personality disorders. Treatment of the Cluster C disorders seems most promising, and treatment of Cluster A disorders is the most difficult. A new form of behavior therapy (dialectical behavior therapy) shows considerable promise for treating borderline personality disorder, which is in Cluster B.

Although the DSM diagnoses antisocial personality disorder (ASPD), many clinicians continue to use the diagnosis of psychopathy. A person with psychopathy is callous and unethical, without loyalty or close relationships, but often with superficial charm and intelligence. Individuals with a diagnosis of ASPD engage in an antisocial, impulsive, and socially deviant lifestyle. Genetic and constitutional, learning, and adverse environmental factors seem to be important in causing these disorders. There is some evidence that these may be distinct disorders with unique causal pathways. Psychopaths also show deficiencies in aversive emotional arousal, as well as more general emotional deficits. Treatment of ASPD and psychopaths is difficult in part because they rarely see any need for change and tend to blame other people for their problems.

Detailed Lecture Outline I.

Clinical Features of Personality Disorders A. To be diagnosed with a personality disorder, a person’s enduring pattern of behavior must be pervasive, inflexible, stable, and of long duration. The pattern of behavior must lead to clinically significant distress or impairment in functioning and must be manifested in at least two of the areas: cognition, affectivity, interpersonal functioning, or impulse control. B. Little evidence on prevalence; estimate that about 10% of the population will meet the criteria for a personality disorder at some time in their lives. C. Personality disorders are coded on Axis II of the DSM-IV TR.

Activity 10.1: Where Personality Goes Awry Handout 10.1: Personality versus Personality Disorder? II.

Difficulties Doing Research on Personality Disorders A. Difficulties in Diagnosing Personality Disorders 1. Diagnostic criteria are not as sharply defined. 2. Diagnosis relies on inferred traits or consistent patterns of behavior rather than on more objective behavioral standards. 3. Although semi-structured interviews and self-report inventories have been developed, diagnostic reliability and validity is still low. 4. Diagnostic categories are not mutually exclusive. 5. Competing dimensional views; five-factor model has become the most influential model of normal personality.

Activity 10.2: Thrill Seekers Activity 10.3: Big 5 and Job Satisfaction B.

Difficulties in Studying the Causes of Personality Disorders 1. High levels of comorbidity among disorders. 2. Very little prospective research on disorders. 3. Temperamental characteristics are possible biological factors .

Activity 10.4: Biological Bases of Personality? 4.

5. III.

Possible psychological factors include maladaptive habits and maladaptive cognitive styles that may originate in disturbed parent-child attachment relationships, parental psychopathology, ineffective parenting practices, and early emotional, physical, or sexual abuse. Possible sociocultural factors are social stressors, societal changes, and cultural values.

Cluster A Personality Disorders A. Paranoid Personality Disorder

Typical symptoms are suspiciousness, distrust of others, bear grudges, refuse to forgive insults, can display violent behaviors, rigidity, hypersensitivity, and argumentativeness. 2. The person is constantly “on guard” for attacks from others. 3. Causal factors: a. Little is known. b. Inconsistent findings on genetic transmission. c. Psychosocial factors suspected (parental neglect or abuse, exposure to violent adults). d. Heritability of high levels of antagonism and neuroticism. Schizoid Personality Disorder 1. Central symptoms are an inability to form social relationships and an indifference toward developing them. 2. This disorder has not been the focus of research. 3. Causal factors: a. Early theorists believed this was a precursor to schizophrenia. b. Failure to establish hereditary basis or any link to schizophrenia. c. Maladaptive underlying schemas with individual as a self-sufficient loner and view of others as intrusive. Schizotypal Personality Disorder 1. Extreme introversion, sensitivity, and eccentricity are the central features. 2. Pervasive social and interpersonal deficits. 3. Oddities and eccentricities in communication and behaviors. 4. Other cognitive problems, including ideas of reference, odd speech, and paranoid beliefs. 5. Oddities of thought, perception, and speech are also present and similar to schizophrenia. 6. Cognitive and perceptual deficits. 7. Hisotry of childhood abuse and early trauma. 8. Causal factors: believed to be moderately heritable with a genetic and biological association with schizophrenia a. Deficits in eye tracking. b. Attentional deficits. c. Deficits in working memory. d. Deficit in ability to inhibit attention to a second stimulus rapidly following the first stimulus.

Lecture Launcher 10.1: Personality Disorder as Exaggerated Personality IV.

Cluster B Personality Disorders A. Histrionic Personality Disorder

Lecture Launcher 10.2: Histrionics and Show Business 1. 2. 3. 4. 5. 6.

Excessive attention-seeking, emotionality, and self-dramatization are key features. Interpersonal relationships are stormy. Self-centered, vain, and overly concerned about approval. Tendency to be seductive and to eroticize situations. Prevalence in general population is 2%–3% and occurs more often in women than men. Causal factors: a. Possible genetic link with antisocial personality disorder. b. Maladaptive schemas involving need for attention to validate self-worth. c. Little research has been conducted due to the difficulty in differentiating from other personality disorders. d. Comorbidity with borderline, antisocial, narcissistic, and dependent personality disorders. e. Involves extreme versions of extraversion and neuroticism. f. Need for attention to validate sense of self worth. Copyright © 2013 Pearson Education, Inc. All rights reserved. 190

Activity 10.5: Dramatic Characters B.

Narcissistic Personality Disorder

Lecture Launcher 10.3: Narcissism: The Character of Our Times 1.

An exaggerated sense of self-importance leading to a sense of entitlement, lack of empathy, and need for attention. 2. More common among men than women. 3. Fragile self-esteem underlies grandiosity. 4. May be hypercritical and retaliatory. 5. Causal factors: a. Parental overevaluation. b. Emotional, physical, and sexual abuse. c. Intrusive, controlling, and cold parenting. d. Social learning theory: unrealistic parental overvaluation. Antisocial Personality Disorder (ASPD)

Activity 10.6: Antisocial Personality Disorder, Confusion in Definition? Handout 10.2: Antisocial Actions or Finding the Right Niche

1. Persons with this disorder violate the rights of others without remorse. 2. Intelligence and charm can be found in many antisocial personalities. 3. Show disregard for the rights of others. 4. Pattern of irresponsibility. 5. Deceitful, aggressive, or antisocial behavior. 6. Impulsivity, irritability and aggression are common features. 7. Must have symptoms of conduct disorder before the age of 15. Borderline Personality Disorder (BPD)

MyPsychLab Resource 10.1: Video “Liz Borderline” MyPsychLab Resource 10.2: Video on “Janna: Borderline Personality Disorder” 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Common symptoms include impulsivity, anger, instability, and unpredictability. These persons fail to complete the process of forming a stable self-identity. Can have a history of stormy, intense relationships. Mood is highly unstable. Impulsive self-destructive behavior such as gambling, binge eating, substance abuse, and reckless driving can take place. Engage in self-mutilation which a repetitive cutting behavior to damage tissue. 8%–10% complete suicide. 1%–2% of population meet diagnostic criterion for BPD. 75% of those diagnosed are women. Suicide attempts are usually seen as manipulative. 70%–80% report analgesia (absence of the experience of pain in the presence of a theoretically painful stimulus). 75% experience relatively short or transient psychotic-like symptoms. Comorbidity with other Axis I disorders a. Exists with disorders ranging from mood and anxiety disorders to substance abuse and eating disorders; overlap in symptomatology with depression. b. Comorbidity with other personality disorders especially histrionic, dependent, antisocial, and schizotypal. Copyright © 2013 Pearson Education, Inc. All rights reserved. 191

14.

Causal factors a. Genetic factors play a significant role; personality traits of impulsivity and affective instability are partially heritable. b. Biological (1) Lowered functioning of the neurotransmitter serotonin may explain their impulsivity–aggression. (2) Disturbances in the regulation of noradrenergic transmitters may explain their hypersensitivity to environmental changes. (3) Certain parts of 5-HTT gene is involved. (4) Reduction in both hippocampal and amygdala volume. c. Psychosocial (negative, even traumatic, childhood events). d. 90% report some type of abuse. e. Paris’s Diathesis–Stress model: high levels of impulsivity and affective instability combined with psychological risk such as trauma, loss, or parental failure. (See Figure 10.1 for a diagram of the multidimensional Diathesis–Stress model of borderline personality disorder.)

Cluster C Personality Disorders A. Avoidant Personality Disorder 1. These persons fear rejection and show extreme social inhibition, introversion, and hypersensitivity. 2. They desire affection and are lonely; desire interpersonal contact but avoid it out of fear of rejection. 3. Some hypothesize that avoidant personality disorder is a more extreme form of generalized social phobia. 4. Causal factors: a. Inhibited temperament. b. Evidence that fear of being negatively evaluated is moderately heritable. c. Emotional abuse and rejection from parents. d. Anxious and fearful attachment. e. Modest genetic influence shared with social phobia. f. Introversion and neuroticism elevated. B. Dependent Personality Disorder 1. Extreme dependency on others and panic when alone are central symptoms. 2. Self-confidence is lacking and will show clinging and submissive behavior. 3. They allow others to take over decision-making. 4. 1.5% of population; more common in women than men. 5. An indiscriminate selection of mates can take place. 6. May accept abuse in order to remain in relationship. 7. Personality traits such as neuroticism and agreeableness. 8. Comorbidity with mood and anxiety disorders. 9. Causal factors a. Small genetic influence. b. Authoritarian and overprotective parents. c. Maladaptive schemas about weakness and competence and needing others to survive. C. Obsessive-Compulsive Personality Disorder (OCPD)

Lecture Launcher 10.4: Cognitive Style of the Obsessive-Compulsive Personality 1. 2. 3.

Perfectionism and excessive concern with maintaining order and control are essential characteristics. Mental and interpersonal control is maintained. Repeatedly check work for mistakes.

VI.

Perfectionism is often dysfunctional in that they cannot finish tasks and become overly involved in details. 5. Leisure activities are sacrificed . 6. Rigidity, stubbornness, and a lack of warmth is common. 7. Differences with obsessive-compulsive disorder a. Intrusion of thoughts in OCPD. b. Extreme anxiety in OCPD due to thoughts and images. 8. Some overlap with narcissistic, antisocial, and schizoid personality disorders. 9. Causal factors a. Dimensional approach—individuals have excessively high levels of conscientiousness, high level of assertiveness, and a low level of compliance. b. Biological dimensional approach–individuals have low levels of novelty seeking and reward dependence, but high levels of harm avoidance. A. General Sociocultural Causal Factors for Personality Disorders 1. The possible factors are poorly defined. 2. Less variance across cultures than within cultures. 3. Emphasis is on impulse gratification, instant solutions, and pain-free benefits. 4. Increase in emotional dysregulation and impulsive behaviors lead to prevalence of BPD and antisocial personality disorder. 5. Change in culture’s priorities and activities may influence the development of personality disorders a. Narcissistic personality disorders more common in Western cultures. b. Histrionic less common in Asian cultures and more common in Hispanic cultures. c. Borderline is more common among Hispanic Americans than African Americans or caucasians. d. Schizotypal personality disorder is more common among African Americans than among whites. Treatments and Outcomes For Personality Disorders A. In general, personality disorders are difficult to treat 1. Personality disorders represent relatively enduring, pervasive, and inflexible patterns of behavior. 2. Different possible goals of therapy. 3. Many people with personality disorders come to therapy only at the request of someone else. 4. Many people with personality disorders (especially those with Cluster A or Cluster B diagnoses) will have difficulty forming a therapeutic relationship. B. Adapting Therapeutic Techniques to Specific Personality Disorders 1. May need to be careful not to encourage dependence. 2. Acting-out behavior may need to be constrained. 3. Specific therapeutic techniques are a central part of the cognitive approach to personality disorders; techniques include: monitoring automatic thoughts, challenging faulty logic, and assigning behavioral tasks to challenge dysfunctional assumptions and beliefs. C. Treating Borderline Personality Disorder

Activity 10.7: Therapy for Borderline Personality Disorder 1.

Biological treatments a. Controversial because using medications increases suicide risk. b. SSRIs used to treat rapid mood shifts, anger, and anxiety. c. Low doses of antipsychotic drugs. d. Mood-stabilizing drugs may reduce irritability, suicidality, and impulsive aggressive behavior. e. Consensus is that drugs offer mild benefits for borderline personality disorder. Psychosocial treatments Copyright © 2013 Pearson Education, Inc. All rights reserved. 193

Linehan’s dialectical behavior therapy (1) A promising new approach. (2) Combines individual and group components as well as phone coaching. (3) A form of cognitive and behavioral treatment that is problem-focused and based on a clear hierarchy of five goals: (a) Decreasing suicidal and other self-harming behavior. (b) Decreasing behaviors that interfere with therapy. (c) Decreasing escapist behaviors that interfere with a stable lifestyle. (d) Increasing behavioral skills in order to regulate emotions, to increase interpersonal skills, and to increase tolerance of distress. (e) Other goals the patient chooses. (f) Appears to be an efficacious treatment. Traditional treatment is psychodynamic (1) Primary goal is strengthening weak egos. (2) Focus is the defense mechanism of splitting.

VII.

Treating Other Personality Disorders 1. Treating other Cluster A and B disorders a. Antipsychotic medications have only modest success, especially with schizotypal . b. Antidepressants from the SSRI category may be useful. c. No systemic studies exist for paranoid or schizoid disorders. 2. Treating Cluster C disorders a. Active and confrontational short-term therapy shows improvement. b. Significant gains with cognitive-behavioral treatment. . c. Antidepressants and MAO inhibitors have been used. Antisocial Personality Disorder and Psychopathy A. Psychopathy and ASPD

Lecture Launcher 10.5: Adaptive Psychopathy 1.

Two dimensions of psychopathy: a. Affective and interpersonal core. b. Behavioral aspects such as antisocial, impulsive, and socially deviant lifestyle. 2. DSM focuses on behavioral factors: a. Leads to 70%–80% of prison inmates qualifying for a diagnosis of ASPD. b. Only about 25%–30% of prison inmates meet the criteria for psychopathy. c. 3% of males and 1% of females meet the diagnostic criterion. 3. Many use the Cleckley/Hare psychopathy diagnosis rather than the DSM-IV TR ASPD diagnosis. 4. Need for stimulation, peer behavior control, irresponsibility, and a parasitic lifestyle. 5. Diagnosis of psychopathy is the single best predictor of violence and recidivism. 6. ASPD may be omitting those who do not show violent behavior: a. Widom—advertisements. b. Experimental findings of possible biological differences between these two groups. Clinical Picture in Psychopathy and Antisocial Personality Disorder 1. Inadequate conscience development . 2. Irresponsible and impulsive behavior a. They take what they want. b. Prone to thrill-seeking actions. c. High rates of alcohol and other substance abuse related to ASPD but not necessarily psychopathy. Copyright © 2013 Pearson Education, Inc. All rights reserved. 194

Likewise ASPD, but not psychopathy, is related to elevated rates of suicide attempts and completed suicides. 3. Ability to impress and exploit others a. They are frequent liars. b. They understand and use the weaknesses of others. c. Rejection of authority . d. They can easily win “friends,” but seldom keep close friends. e. They can be violent toward “friends” and family. Causal Factors in Psychopathy and Antisocial Personality 1. Genetic influences. a. Moderate heritability for antisocial or criminal behavior, early signs of callous/unemotional traits. b. Genotype-environment interaction: Adopted away children of biological parents with ASPD were more likely to develop antisocial personalities if their adoptive parents exposed them to adverse environments (marital conflict or divorce, legal problems, parental psychopathology). c. Monoamine oxidase—a gene—breakdown of neurotransmitters like norepinephrine, dopamine, and serotonin. d. Significant genetic involvement in co-morbidity of alcoholism and ASPD. 2. Low Fear Hypothesis and Conditioning a. Lykken (1995)—deficient conditioning of anxiety to signals for punishment. b. This deficient conditioning of fear seems to stem from having a deficient behavioral inhibition system. c. Patrick, Bradley, & Lang (1993)—psychopaths show deficient fear-potentiated startle. d. Normal or hypernormal active avoidance of punishment (behavioral activation system) when actively threatened with it. e. Dominant response set for reward. f. Passive avoidance learning—one learns to avoid punishment by not making a response. 3. More general emotional deficits a. Reduced responsiveness to aversive visual images consistent with findings that they are low on empathy. b. Small startle responses when viewing unpleasant images might also be related to lack of empathy. c. Hare has suggested that these findings represent only a subset of a larger problem with processing and understanding the meaning of affective stimuli— “as if emotion is a second language …”. d. Dysfunction in the amygdale. 4. Early parental loss, parental rejection, and inconsistency a. Early studies pointed to early parental loss and emotional deprivation as causal agents. b. Parental rejection and inconsistency alone insufficient as causal agents. A Developmental Perspective on Psychopathy and Antisocial Personality 1. Begins in early childhood a. The number of antisocial behaviors exhibited in childhood is the single best predictor of who develops an adult diagnosis of ASPD. b. The younger the symptoms develop, the higher the risk. 2. Oppositional defiant disorder a. Early onset before 6. b. Conduct disorder by 9. c. Children who develop conduct disorder in adolescence do not typically develop ASPD. 3. Attention Deficit Hyperactivity Disorder (ADHD)

When ADHD occurs with conduct disorder, high likelihood of ASPD and even psychopathy. b. Lynam refers to these children as “fledging psychopaths.” c. Forth (2003) Psychopathy Checklist Youth Version. 4. Other psychosocial and sociocultural contextual variables also contribute: parents’ own antisocial behaviors, divorce, poverty, crowded inner-city neighborhoods, parental stress, poor and ineffective parenting skills. 5. Sociocultural causal factors and psychopathy (see Figure 10.4). a. Disorder appears in various cultures: Inuit of Northern Alaska and Yorubas of Nigeria. b. Socialization forces impact expression of aggressive impulses. c. Distinguishing between individualistic and collectivist societies. Treatments and Outcomes in Psychopathic and Antisocial Personality

Activity 10.8: Criminal Psychopaths 1. 2. 3.

VIII.

Traditional psychotherapeutic approaches are not effective. Individuals have little motivation to take medication Biological treatments. a. ECT and drugs not systematically studied. b. Lithium and anticonvulsants to treat bipolar have had some success in treating aggressive and impulsive behavior. Cognitive-behavioral treatments a. Targets: increasing self-control, self-critical thinking, and social perspective taking; victim awareness; anger management; changing antisocial attitudes; curing drug addiction. b. Interventions require a controlled situation. c. Even the best programs show only modest improvements; psychopathy more difficult to treat than ASPD. Many antisocial personalities show improvement as they age a. They achieve insight into their self-defeating actions. b. Cumulative effect of social conditioning. c. Only ASPD changes with age, not psychopathy. Prevention would seem to be more effective a. Prevention program targeted to developmental and environmental risk factors. b. Intelligence. c. Positive influence by schooling. d. Training for at risk mothers. e. Parent training.

Unresolved Issues: DSM-5: Moving Toward a Dimensional System of Classification A. Axis II Diagnoses Are Often Unreliable 1. The personality processes are dimensional in nature. 2. Arbitrary decisions are used to define the degree of a trait. 3. The diagnoses are not based upon mutually exclusive criteria. 4. Proposed revisions are most radical for DSM-5. B. Clearer Sets of Classification Rules Need to be Formulated 1. The rules need to become exhaustive and incorporate non-overlapping behaviors. 2. This process may be beyond the current capabilities of researchers. 3. A dimensional approach has been proposed, but there is no clear evidence about which system is best.

Key Terms antisocial personality disorder (ASPD) avoidant personality disorder borderline personality disorder (BPD) dependent personality disorder dialectical behavior therapy histrionic personality disorder narcissistic personality disorder

obsessive-compulsive personality disorder (OCPD) paranoid personality disorder personality disorders psychopathy schizoid personality disorder schizotypal personality disorder

Lecture Launchers Lecture Launcher 10.1: Personality Disorder as Exaggerated Personality Are all eccentrics actually schizotypic? Are all emotional people borderline? Are all self-centered people narcissistic? Clearly not, especially when distress and impairment are taken into consideration. The distinction between personality disorder and exaggerated personality can be explored two ways. First, each personality disorder can be discussed in its milder form as at the outset of this paragraph. Alternatively, various normal personalities can be discussed and extended into a pathological range. A good way to get this kind of discussion going is to ask students to describe characteristics they find annoying in others. Then, DSM diagnoses based on these personality types can be constructed. Students may find it interesting to learn that passive-aggressive personality used to be a DSM disorder but was later dropped. Lecture Launcher 10.2: Histrionics and Show Business Histrionic personality disorder is characterized by behavior that is overly dramatic and attention-seeking. Those diagnosed can be described as self-centered, overly concerned with physical appearance, and often quite shallow despite grand emotional displays. Sounds like Hollywood, doesn’t it? What better way to attract attention than to be a celebrity? Students can usually come up with quite a few names of successful histrionics. Marilyn Monroe and Liberace are classic older examples, whereas Madonna and Dennis Rodman are more contemporary ones. Are they mentally ill? Or does their ability to channel their histrionics into successful careers disqualify them? Are the private lives of celebrities in the news so often because the public is interested in them, or because their histrionic characteristics motivate them to seek attention even outside the confines of their careers? Successful entertainers who are virtually unknown outside of their professional performances suggest that histrionics are not necessary for success, but the relative rarity of this type suggests that celebrity tends to draw more generally histrionic types. Lecture Launcher 10.3: Narcissism: The Character of Our Times Narcissism has been called the characteristic of our times. Unbridled self-absorption and entitlement, reflected in our society’s predisposition to litigate when we feel wronged; materialism; and the self-esteem movement are all taken as indicators of an inward focus not too dissimilar to narcissistic personality disorder. Unabashed imageconsciousness is very nearly a literal narcissism, emulating the Greek hero’s love for his own reflection. Do students agree with this assessment of our times? What accounts for societal narcissism? Do modern child-rearing habits encourage narcissism? Is our children’s self-esteems overly emphasized? Or is it the opposite, as Kohut might have it? Are we so insecure and lacking in self-esteem that we have to construct elaborate and grandiose images of ourselves just to cope? Are we programmed by too much success or too little? Lecture Launcher 10.4: Cognitive Style of the Obsessive-Compulsive Personality Students frequently struggle to separate obsessive-compulsive personality disorder from obsessive-compulsive disorder, per se, thinking that the personality disorder is just a milder version. Instead, it is important for them to understand that obsessive-compulsive personality disorder is characterized by perfectionism and a preoccupation with minute details, orderliness, rules, schedules, etc. Such people tend to be work-oriented and to require that things be done their way. Often serious, formal, and inflexible, they evidence poor interpersonal relationships. The cognitive inflexibility that is the hallmark of the disorder is well illustrated by the following example from Shapiro’s Neurotic Styles (1965, p. 25). Perhaps students hear something familiar in this example. K:

L: K: L: K: L: K: L:

Never buy a house with a bad roof. It will cost you its price again in repairs before you’re finished. But the builder I hired to look it over did say it was in good condition otherwise. The roof is only the beginning. First it’s the roof and then comes the plumbing and then the heating and then the plaster. Still, those things seem to be all right. And, after the plaster, it will be the wiring. But the wiring. . . [interrupts with calm assurance] It will cost you double the price before you’re finished.

Lecture Launcher 10.5: Adaptive Psychopathy DSM antisocial personality disorder overlaps with both classic descriptions of psychopathy and with criminality. Cleckley (1976), Lykken (1995), and Hare (1991) have all attempted to keep psychopathy separate from criminality, and they have also emphasized certain psychopathic personality traits that may not necessarily be destructive in all cases. An especially telling example is the famous fighter-jet test pilot Chuck Yeager, whom Lykken describes as having many characteristics of a psychopath but without the antisocial tendencies that otherwise might make him a menace to society. For instance, Yeager’s apparent immunity from anxiety permitted him literally to have aircraft fall apart under him without causing him even to reconsider his line of work, much less prevent him from ever flying again—as might be the case for most of us. Given a different background, one might imagine a person like Yeager, insensitive to normal fear of negative consequences from rule-breaking, growing up to be a career criminal. What distinguishes fearless people who grow up to be criminals from those who grow up to be productive contributors to society? One factor might be the strong socializing force of institutions like the military, as in Yeager’s case. It is also possible that high IQ can permit some people to avoid legal trouble even though they have no reservations about breaking the law. A broader appreciation for psychopathic traits makes clear that these kinds of people exist in all walks of life, functioning well as business executives, politicians, lawyers, doctors, and the like, succeeding on the merits of their typically psychopathic superficial charm, lack of remorse, insincerity, and freedom from the distraction of a guilty conscience. That is why Cleckley’s book on the subject is entitled The Mask of Sanity. Incidentally, Cleckley also co-authored The 3 Faces of Eve. Are there any advantages to being a psychopath?

Classroom Activities, Demonstrations, and Assignments Activity 10.1: Where Personality Goes Awry This makes an excellent assignment for students to complete. It complements what they have learned in class, and in the text with an article describing research into a given area of personality disorder research. I have included some questions that students can answer but you can add your own based on your specific lecture as well. This can be for a portion of course grade or as extra credit. Have students read the article Where Pesonality Goes Awry (Huff, 2004) from the APA Monitor, available at www.apa.org/monitor/mar04/awry.html, and answer the following questions. 1. 2. 3. 4. 5. 6. 7.

What are some of the non-biological reasons discussed for the development of personality disorders? What research on the role of genes is described in the article? Describe the Collaborative Longitudinal Personality Disorders Study (CLPs) described in the article. What are the early findings from the CLPS data? Discuss both the positive and negative roles that parents play in the development of personality disorders. Discuss both the positive and negative roles peers play in the development of personality disorders. Based on the research described in this article, where should further research on personality disorders be focused?

Activity 10.2: Thrill Seekers When is extreme behavior normal? Should we consider obviously dangerous and thrill-seeking behavior as being abnormal? Students could interview people who are avid rock climbers, high-speed motorcyclists, and road racers to learn more about thrill-seeking experiences. Many would describe their motivations for thrill-seeking in personality terms. “I just like speed.” “I like being on the edge.” Would people who risk their lives be candidates for a personality disorder diagnosis, or is it only when their extreme behavior bothers other people that it becomes

diagnostic? A discussion of students’ own risk-taking or sensation-seeking behavior could also support examination of the role of bothering others in formulating a distinction between extremes of personality and personality disorder. Activity 10.3: Big 5 and Job Satisfaction This makes an excellent assignment for students to complete. It complements what they have learned in class and in the text with an article describing research into a given area of personality disorder research. Included are some questions that students can answer but you can also add your own based on your specific lecture. This can be for either a portion of the course grade or as extra credit. The Big 5 in personality research has been correlated with many variables and factors. The following study uses a meta-analysis procedure to evaluate the relationship between the Big 5 and job satisfaction rates: Judge, T. A., Heller, D., & Mount, M. K. (2002). “Five-Factor Model of Personality and Job Satisfaction: A Meta-Analysis.” Journal of Applied Psychology (87)3: 530, www.apa.org/psycarticles/sample.html. Using your text to help clarify the information, answer the following questions. 1. Briefly describe each of the factors that make up the Big 5 (use the text for this), and provide an example of each trait. 2. Briefly describe what a meta-analysis is. 3. In the current study, what was the overall finding for traits that correlate with job satisfaction? What was the strongest trait relationship? Make sure you describe the direction of the relationship in your own words. 4. How might core self-evaluations be related to job satisfaction? 5. How would the ABC’s (affect/emotionality, behavior, cognition) of psychology relate to these findings and/or affect these results? Please provide an example to illustrate your point. 6. Based on these results, how do you think this research could be used to help people? Activity 10.4: Biological Bases of Personality? This makes an excellent assignment for students to complete. It complements what they have learned in class, and includes an article describing research into a given area of personality disorder research. Included are some questions that students can answer but you can also add your own based on your specific lecture. This can be for either a portion of the course grade or as extra credit. The biological basis of personality has long been discussed amongst researchers. Behavioral genetics research has indicated mild to moderate levels of heritability for many traits. Read Searching for Genes That Explain Personality (Azar, 2002) at www.apa.org/monitor/sep02/genes.html and answer the following questions. 1. Using your text, briefly describe the biological bases for personality disorders. 2. From the article, describe the two genes that have thus been identified as having an effect on personality. 3. How would the research described in the article affect perspectives on “pathological” aspects of personality? 4. How do both your text and the article argue that environmental effects on personality may moderate genetic effects? 5. How might the finding that identical twins are more similar to one another than are fraternal twins be explained with something other than a biological explanation? Activity 10.5: Dramatic Characters Characters from movies, television, and theater need to be rather extreme in order to hold our interest. In fact, many would appear to qualify for diagnoses of personality disorder. Assign students the task of finding such characters and reporting on them to the class. In particular, it is crucial that students support their selections by specifying exactly how their nominees manifest the necessary symptoms. Specific behavioral examples are especially helpful. It is also valuable to focus students on popular media, such as contemporary television shows, so that their fellow students will know who they are talking about. Soap operas are an especially ripe source of examples. Extra credit might be offered for students who are able to provide video clips of prototypic behavior. Activity 10.6: Antisocial Personality Disorder, Confusion in Definition? This makes an excellent assignment for students to complete. It complements what they have learned in class, and includes an article describing research into a given area of personality disorder research. Included are some Copyright © 2013 Pearson Education, Inc. All rights reserved. 199

questions that students can answer but you can also add your own based on your specific lecture. This can be for either a portion of the course grade or as extra credit. Have students read Psychopathy and Antisocial Personality Disorder: A Case of Diagnostic Confusion (Hare, 1996), www.psychiatrictimes.com/display/article/10168/54831, and answer the following questions. 1. The author argues that one problem is the blur between DSM conceptions of ASPD and psychopathology. Describe his argument and what the author contends is the source of the problem. 2. Explain the research described on the psychopathy checklist, including the clusters found in the data. 3. In sum, what is the relationship between psychopathy and ASPD according to the data? 4. What changes were made from DSM III to DSM IV based on the research? 5. What are some of the problems or effects of the DSM IV’s ambiguity in dealing with ASPD? 6. Using your text as well as the article, briefly describe what is the relationship between criminality and ASPD. 7. Again, using your text, what is the prognosis for adolescents diagnosed with ASPD? Activity 10.7: Therapy for Borderline Personality Disorder This makes an excellent assignment for students to complete. It complements what they have learned in class and in the text with an article describing research into a given area of personality disorder research. Included are some questions that students can answer but you can also add your own based on your specific lecture. This can be for either a portion of the course grade or as extra credit. Have students read: Psychotherapy for BPD Gets Growing Evidence Base (Moran, 2007) from the Psychiatric News, http://pn.psychiatryonline.org/cgi/content/full/42/2/26, and answer the following questions. 1. 2. 3. 4. 5.

What is schema therapy, and how does it appear to work in terms of treating BPD? What are the benefits of dialectical behavior therapy? Describe what the typical process involves. When is cognitive therapy effective, according to the article? What are some of the problems of treating individuals with BPD? Using both the article and your text, how would a patient with BPD best be treated?

Activity 10.8: Criminal Psychopaths Biographies of famous criminals hold an intrinsic fascination for students, though their study of them is often unfocused. For this activity, students can be asked to nominate candidate psychopaths from history or from the news, and then to prepare a report on them that is focused on diagnostic issues. In particular, they will need to separate Cleckley/Hare-type psychopathy from DSM-type antisocial personality disorder. Among the more popular choices are Hitler, Stalin, Charles Manson, Jeffrey Dahmer, Ted Bundy, and John Hinckley. More contemporary choices might include Sadaam Hussein and Osama bin Laden. Discussion could then revolve around how certain jobs have requirements that may actually fit certain traits found in the personality disorders. Which disorders do not fit well in almost any job? Which personality disorder has characteristic traits that would be useful in the largest number of careers? If a person’s traits fit a particular career, will he or she experience a satisfying life even with a personality disorder?

Activity 10.9: Personality Disorders at a Party Have the different personality disorders defined on note cards before class. Then ask for some student volunteers and explain that each student will select a personality disorder and they will display the characteristics at a party. It is helpful to play music and have some props. After the students have been able to act out the different personality disorders, ask the rest of the class to identify the personality disorders. Activity 10.10: The Dating Game You could select one or two examples from each personality disorder cluster, or maybe you want to select one cluster such as Cluster B. Ask for five student volunteers: one to be the game show host asking the questions, one to play the contestant looking for a mate, and three mate options. Hand out the different personality disorders on note cards, and tell the student to act, think, and display emotions as if they were that personality disorder as a contestant

on the game show. Then after the role-play, have the class guess which personality disorder was whom and why. This can be a foundation to discuss the similarities and differences among the personality disorders.

MyPsychLab Resources MyPsychLab Resource 10.1: Video “Liz Borderline” 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. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 10, Personality Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Liz Borderline” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 10.2: Video on “Janna: Borderline Personality Disorder” 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. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 10, Personality Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Janna: Borderline Personality Disorder” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise.

Handout Descriptions Handout 10.1: Personality versus Personality Disorder? There continues to be disagreement about whether personality disorders are distinct from each other and from normal personality. A student or group of students can be assigned the project of researching this issue for debate. The students can present the debate to the class whose members could vote on which point of view was presented most persuasively. An article by Livesley, Schroeder, Jackson, and Jang (1994, Journal of Abnormal Psychology, vol. 103, pp. 6-17) provides important historical information on this issue and could be a good first resource for the debating students. Handout 10.2: Antisocial Actions or Finding the Right Niche The question of where abnormality begins in the personality disorders is often a difficult one to answer. Whether a person with a personality disorder will be viewed as abnormal or not depends on the circumstances in which the behavior is observed. Have students investigate this issue by selecting six or more careers or jobs and indicating how persons with different personality disorders would perform in the different endeavors.

Video / Media Sources ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Between the Lines. Boston, MA: Fanlight Productions. Beyond the Borderline. New York, NY: Filmmakers Library. Borderline Personality Disorder, Client Interview (Janna)—#6 ABC News and Client Interviews. Allyn & Bacon Abnormal Psychology Video. Borderline Syndrome: Personality Disorder of Our Time. New York, NY: Insight Media. Closet Narcissistic Disorders: The Masterson Approach with Dr. James F. Masterson. Assessment & Treatment of Psychological Disorders Series. Princeton, NJ: Films for the Humanities and Social Sciences. Cognitive Therapy for Borderline Personality Disorder. APA Psychotherapy Video Series II: Specific Treatments for Specific Populations. Washington, DC: American Psychological Association. Don’t be Shy, Mr. Sacks: Williams Syndrome. The Mind Traveller: Oliver Sacks Series. Princeton, NJ: Films for the Humanities and Social Sciences. Integrated Treatment of Borderline Personality Disorder: Pharmacotherapy and Psychotherapy. Treatments of Psychiatric Disorders Videotape Series. Allyn & Bacon Video Library. Copyright © 2013 Pearson Education, Inc. All rights reserved. 201

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Interpersonal Reconstructive Therapy for Passive-Aggressive Personality Disorder. APA Psychotherapy Video Series II: Specific Treatments for Specific Populations. Washington, DC: American Psychological Association. Mind of the Psychopath, Vol. 35. The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection. Personality Disorders. New York, NY: Insight Media. Personality Disorders. Differential Diagnosis in Psychiatry Series. Princeton, NJ: Films for the Humanities and Social Sciences. Personality Disorders. The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection. The Psychopathic Mind. Allyn & Bacon Video Library. Schizotypal Personality Disorder, Susan—Patient Interview Video for Abnormal Psychology (12th ed.). Allyn & Bacon Video Library. Treating Borderline Personality Disorder: The Dialectical Approach. Princeton, NJ: Films for the Humanities and Social Sciences. Understanding Borderline Personality Disorder: The Dialectical Approach. New York, NY: Guilford Publications.

Web Links Web Link 10.1: http://counsellingresource.com/distress/personality-disorders/foundation/index.html Originally created and maintained by the Personality Disorders Foundation, this site has preserved the original materials designed to help people better understand what personality disorders are, how they are diagnosed, the impact they have on individuals and loved ones, educational resources, and clinical services. Bibliographies of research articles, practitioner articles, books, chapters, videotapes, and audiotapes related to personality disorders are also available on the site. Web Link 10.2: http://psychcentral.com/resources/Personality This is the Personality section of PsychCentral, which gives hand-selected links to a variety of resources about personality disorders, including disorder-specific sites, FAQs, and recommended readings. Web Link 10.3: http://mentalhelp.net/poc/center_index.php?id=8 Mental Help Net includes an extensive section on personality disorders, encompassing diagnosis, treatment, organizations, book reviews, and links to other Web sites. Web Link 10.4: http://mentalhealth.about.com/cs/personaltydisordrs About.com has an extensive collection of sites on various topics, each having a human editor who chooses resources and writes about the topic of his or her expertise. This link takes you to the personality disorders section, edited by Leonard Holmes, Ph.D. Web Link 10.5: www.apa.org This is the APA Web site. It has many articles that students can access for free, or that you can use for assignments. Web Link 10.6: www.apahelpcenter.org This is the APA help center. It has many articles that students can access for free, or that you can use for assignments. Web Link 10.7: www.psychiatrictimes.com/resources This is the site for Psychiatric Times. It has many articles that students can access for free, or that you can use for assignments.

Handout 10.1 Personality versus Personality Disorder? Personality Disorder

Pros

Cons

Handout 10.2 Antisocial Actions

Consider a number of occupations that may attract people with antisocial characteristics. Then list careers that may encourage the development of antisocial behaviors.

“Antisocial” Occupations

“Antisocial” Influences

CHAPTER 11: Substance-Related Disorders Teaching Objectives 1.

2. 3. 4. 5.

6. 7. 8.

Outline the major divisions of psychoactive substance-related disorders, define alcohol abuse and alcohol dependence, summarize the many negative consequences of alcohol for both the individual and society, and indicate the prevalence and gender ratio of excessive drinking. Describe the clinical picture of alcohol abuse, including the biological and psychological effects of chronic consumption of alcohol. Review the biological, psychosocial, and sociocultural contributors to alcohol abuse and dependence. Summarize the research findings on the results of treatment and relapse prevention for alcohol-dependent persons. List the specific drugs and their effects, summarize theories of causal factors, and review treatments for the following drugs of abuse: opium and its derivatives, cocaine and amphetamines, barbiturates, LSD and other hallucinogens, marijuana, and caffeine and nicotine. Discuss the controversy surrounding controlled drinking versus abstinence. Summarize the pros and cons of including pathological gambling as an addictive behavior. Review the concept of exchanging addictions.

Chapter Overview/Summary Substance-related disorders are quite common and frequently seen in people in the limelight such as professional athletes and entertainers. Addictive disorders—such as alcohol abuse, cocaine abuse, and pathological gambling— are among the most widespread and intransigent mental health problems facing us today. Many problems of alcohol or drug use involve difficulties that stem solely from the intoxicating effects of the substances. Dependence occurs when an individual develops a tolerance for the substance or exhibits withdrawal symptoms when the substance is not available. Several psychoses related to alcoholism have been identified: idiosyncratic intoxication, withdrawal delirium, chronic alcoholic hallucinosis, and dementia associated with alcoholism. Drug-abuse disorders may involve physiological dependence on substances, such as opiates—particularly heroin—or barbiturates; however, psychological dependence may also occur with any of the drugs that are commonly used today—for example, marijuana. A number of factors are considered important in the etiology of substance abuse disorders. Some substances, such as alcohol or opium, stimulate brain centers that produce euphoria—which then becomes a desired goal. It is widely believed that genetic factors may play some role in causing susceptibility through such biological avenues as metabolic rates and sensitivity to alcohol. Psychological factors—such as psychological vulnerability, stress, and the desire for tension reduction—and disturbed marital relationships are also seen as important etiologic elements in substance-use disorders. Although the existence of an “alcoholic personality type” has been disavowed by most theorists, a variety of personality factors apparently play an important role in the development and expression of addictive disorders. Finally, sociocultural factors, such as different attitudes toward alcohol seen in different cultures, may predispose individuals to alcoholism. Possible causal factors in drug abuse include the influence of peer groups, the existence of a so-called drug culture, and the availability of drugs as tension reducers or pain relievers. Some research has explored a possible physiological basis for drug abuse. The discovery of endorphins, morphine-like substances produced by the body, has raised speculation that a biochemical basis of drug addiction may exist. The so-called “pleasure pathway” —the mesocorticolimbic dopamine pathway (MCLP)—has come under a great deal of study in recent years as the possible potential anatomic site underlying the addictions. The treatment of individuals who abuse alcohol or drugs is generally difficult and often fails. The abuse may reflect a long history of psychological difficulties; interpersonal and marital distress may be involved; and financial and legal problems may be present. In addition, all such problems must be dealt with by an individual who denies the problems exist and is not motivated to work on them. Several approaches to the treatment of chronic alcohol or drug abuse have been developed—for example, medication to deal with withdrawal symptoms and withdrawal delirium, or dietary evaluation and treatment for malnutrition. Psychological therapies, such as group therapy and behavioral interventions, may be effective with Copyright © 2013 Pearson Education, Inc. All rights reserved. 205

some alcohol or drug-abusing individuals. Another source of help for alcohol abusers is Alcoholics Anonymous; however, the extent of successful outcomes with this program has not been sufficiently studied. Most treatment programs require abstinence; however, over the past 20 years, research has suggested that some alcohol abusers can learn to control their drinking while continuing to drink socially. The controversy surrounding controlled drinking continues. Another source of controversy surrounds the use of methadone in the treatment of heroin addiction. Specifically, is the use of methadone simply a substitute for heroin or a true treatment? Addictive behavior may also be seen in those not addicted to a particular substance. One such example is pathological gambling. Many of the same characteristics seen in substance-induced addiction are also seen in pathological gambling, and these individuals show some of the same personality characteristics and responses to treatment.

Detailed Lecture Outline I.

Alcohol Abuse and Dependence (see Table 11.1 for some common misconceptions about alcohol and alcohol abuse)

MyPsychLab Resource 11.1: Video on “Alcoholism: Chris” A.

Prevalence, Comorbidity, and Demographics of Alcohol Abuse and Dependence 1. World Health Organization no longer recommends the term alcoholism but prefers the term alcohol dependence syndrome. 2. 50% of adults 18 and over currently drink and 21% are lifetime abstainers. 3. 22.2 million Americans are classified as substance dependent. 4. Substance-related disorders. 5. Addictive behaviors. 6. Substances. 7. Toxicity. 8. Substance abuse. 9. Substance dependence. 10. Tolerance. 11. Withdrawal. 12. Beer was first made in Egypt around 3000 B.C.; wine in Italy around 150 years before the birth of Christ; distillation about 800 A.D. in Arabia. 13. Alcohol abuse is associated with organic impairment, accidents, violent crimes, and suicides. 14. Comorbidity with at least one other mental disorder, especially depression. 15. Alcohol abuse and dependency include all age, educational, occupational, and socioeconomic boundaries. 16. The course of alcoholism is erratic and fluctuating. 17. Alcohol abuse results in 40% of automobile accident deaths. 18. Involved in 40%–50% of murders, 40% of assaults, and more than 50% of rapes.

Clinical Picture of Alcohol Abuse and Dependence 1. Alcohol’s effects on the brain. a. Several physiological effects are common (1) Decreased sexual inhibition. (2) Lowered sexual performance. (3) Lapses of memory (blackouts). (4) Hangover. (5) No trace of recall. (6) Alcohol intoxication. b. Low levels of alcohol stimulate brain cells, activating the brains’ pleasure areas. c. Higher levels depress brain functioning, inhibiting glutamate (leading to impaired learning, judgment, and self-control). d. Experiences a sense of warmth, expansiveness, and well-being. Copyright © 2013 Pearson Education, Inc. All rights reserved. 206

f. g.

When the alcohol content of the bloodstream is 0.08, the person is intoxicated— decreased muscular coordination, impaired speech and vision, and confused thought processes. When the blood alcohol level reaches 0.5, the entire neural balance is upset and the person loses consciousness; concentrations above 0.55 are usually lethal. Effects of alcohol vary for different drinkers, depending on physical condition, amount of food in the stomach, tolerance, and duration of drinking.

Lecture Launcher 11.1: Alcohol Myopia 2.

Development of alcohol dependence a. Progressive from early to middle to late stage. b. Fetal alcohol syndrome. Physical effects of chronic alcohol use a. Cirrhosis of the liver is found in 15%–30% of heavy drinkers. b. 40%–90% of cirrhosis deaths are related to alcohol. c. Alcohol abuse can cause stomach pains. d. 5%–10% of alcohol is eliminated through breath, urine, and perspiration. e. High caloric intake of alcohol can be detrimental as it reduces the consumption of other foods, leading to malnutrition. f. Alcohol also interferes with the body’s ability to utilize nutrients; nutritional deficiency cannot be made up by vitamin pills. Psychosocial effects of alcohol abuse and dependence a. Chronic fatigue, oversensitivity, and depression. b. Excessive alcohol use results in impaired reasoning, poor judgment, loss of responsibility, lack of pride in appearance, neglect of family. c. Brain damage may occur. Psychoses associated with alcohol abuse a. Alcohol withdrawal delirium (delirium tremens) can occur during prolonged drinking or at withdrawal. b. Severe acute psychotic reactions fit diagnostics for substance-induced psychosis.

MyPsychLab Resource 11.2: Video on “Alcohol Withdrawal” (1)

Symptoms can include disorientation, hallucinations, fear, extreme suggestibility, marked tremors, perspiration, fever, weak heart beat, coated tongue, and foul breath. (2) Can last from 3–6 days; generally followed by a deep sleep. (3) Former death rates from convulsions, heart failure, and other complications have fallen from about 10% as a result of drugs such as chlordiazepoxide. Alcohol amnestic disorder (Korsakoff’s syndrome) (1) Memory defect is its main feature. (2) Individuals with the disorder may confabulate and appear disoriented and delusional. (3) Other cognitive impairments, such as planning deficits, emotional deficits, and intellectual decline also occur. (4) Brain imaging studies document cortical lesions. (5) Symptoms may be due to vitamin B (thiamine) deficiency.

Lecture Launcher 11.2: Is Alcoholism a Disease? C.

Biological Causal Factors in the Abuse of and Dependence on Alcohol 1. Two important factors in addiction:

Ability of addictive drugs to activate areas of the brain that produce intrinsic pleasure and immediate powerful reward. b. Person’s biological make-up, including genetic inheritance and environmental influences (learning factors). 2. Neurobiology of addiction a. Routes of administration include: oral, nasal, and intravenous. b. “Pleasure pathway”—mesocorticolimbic dopamine pathway (Figure 11.1). c. Alcohol, and other drugs, produces stimulation and euphoria. d. Exposure of the brain to an addictive drug alters its neurochemical structure, resulting in behavioral effects. 3. Genetic vulnerability a. Almost 1/3 of alcoholics had a parent with an alcohol problem. b. An alcohol-risk personality has been described as one who has an inherited predisposition toward alcohol abuse and is impulsive, prefers taking high risks, and is emotionally unstable. c. Asians and Native Americans show an “alcohol flush reaction”—hypersensitive reaction that includes flushing of the skin, a drop in blood pressure, heart palpitations, and nausea following the ingestion of alcohol; found in about 50% and results from a mutant enzyme. 4. Genetics—the whole story? a. Exact role of genetics in alcoholism is unclear. b. Genetic transmission of alcoholism does not follow the hereditary pattern seen in other genetic disorders. c. Twin studies, adoption studies, and studies of high-risk groups have found no differences between those who are high risk and controls. d. McGue—mechanisms of genetic influence should be viewed as compatible rather than competitive with psychological and social determinants of alcohol abuse. 5. Genetic influences and learning a. There must be exposure to the substance in order for addictive behavior to occur. b. Development of an alcohol-related problem involves living in an environment that promotes initial as well as continuing use of the substance. c. Numerous social and intrinsic reinforcements. Psychosocial Causal Factors in Alcohol Abuse and Dependence 1. Failures in parental guidance 1. Lack of stable family relationships, substance abuse. 2. Exposure to negative models. 2. Psychological vulnerability a. Many potential alcohol abusers tend to be emotionally immature (impulsive and aggressive), expect a great deal of the world, require an inordinate amount of praise and appreciation, react to failure with marked feelings of hurt and inferiority, have low frustration tolerance, and feel inadequate and unsure of their abilities to fulfill expected male or female roles. b. Self-medication. c. Comorbid with depression, antisocial personality, and schizophrenia are disorders commonly associated with alcoholism. 2. Stress, tension reduction, and reinforcement a. Tension reduction model cannot be sole explanation because there would be more alcohol abusers. b. Alcoholism may be a learned maladaptive response. c. Motivational models of alcohol use place responsibility on the individual. d. 20%–50% of PTSD patients also have substance-abuse disorders.

Expectations of social success a. Expect alcohol to lower tension and anxiety and increase sexual desire and pleasure in life. b. Increase in popularity and acceptance by peers. c. Marital and other intimate relationship. d. Reciprocal influences model.

Lecture Launcher 11.3: Expectancy Effects Teaching Tip 11.2: Moderating Variables 5.

Marital and other intimate relationships a. Alcohol use may be related to crisis periods. b. Marital partners may behave toward each other in ways that promote or enable the spouse’s excessive drinking . c. Alcohol abuse is one of the most frequent causes of divorce. d. Six family relationship factors central to the development of alcohol abuse: (1) Presence of an alcoholic father. (2) Acute marital conflict. (3) Lax maternal supervision and inconsistent discipline. (4) Many family moves during early years. (5) Lack of “attachment” to father. (6) Lack of family cohesiveness.

Binge drinking in college a. 44% of college students in United States are binge drinkers. b. 98% of fraternity and sorority members drink every week. c. Reasons for binge drinking vary but include: (1) Expressing independence from parental influence. (2) Peer group and situational influences. (3) Developing and asserting gender role. (4) Holding beliefs that alcohol can make positive transformations. d. Consequences of binge drinking include: (1) 10 times more likely to engage in unplanned sexual activity. (2) Engaging in unprotected sex. (3) Trouble with campus police. (4) Damage property. (5) Injuries. e. Long-range consequences of college binge drinking. f. Does not predict post-college drinking. g. 11-year longitudinal study did not find heavier drinking among those who had been binge drinkers in college.

Activity 11.1: Pluralistic Ignorance and Hooking Up E.

Sociocultural Factors 1. Social drinking has reinforcing properties, particularly in Western society. 2. Seen as the “social lubricant” to reduce tension. 3. Cultural attitudes toward alcohol influence the incidence of alcoholism a. Muslims. b. Mormons. c. Orthodox Jews. d. Europe and countries heavily influenced by European culture make up less than 20% of the world’s population yet consume 80% of the alcohol. Copyright © 2013 Pearson Education, Inc. All rights reserved. 209

Behavior under the influence of alcohol also culturally influenced.

Activity 11.2: Substance Abuse, Suicide, and American Indians E.

Treatment of Alcohol Abuse Disorders 1. Refuse to admit that they have a problem before they hit bottom, and many who do go into treatment leave before treatment is completed. Lecture Launcher 11.4: Why Did Richard Feynman Quit Drinking? MyPsychLab Resource 11.3: Video on “Substance Abuse: Therapist Louise Roberts” 1.

Medications to block the desire to drink a. Disulfiram (Antabuse) causes vomiting when alcohol is ingested, and can disrupt the alcoholic cycle. b. Naltrexone reduces the craving for alcohol. Medications to reduce the side effects of acute withdrawal a. Valium and diazepam. b. Providing maintenance doses of mild tranquilizers has given rise to concerns that this practice does not promote long-term recovery and may foster addiction to another substance. c. Initial focus on detoxification. Psychological treatment approaches a. Group therapy (1) Face problems for first time. (2) Family may be invited to group. b. Environmental interventions (1) Alleviate aversive life situation. (2) Halfway houses may be important adjuncts. c. Behavior and cognitive behavioral therapy (1) Aversive conditioning methods employ noxious stimuli . (2) Marlatt—skills training procedure typically aimed at younger drinkers. (3) Self-control training techniques aimed at reducing alcohol intake but not necessarily abstaining. Controlled drinking versus abstinence a. 15% –18% of subjects are successful with controlled drinking. b. Controlled drinking is more likely to be successful with people with less severe alcohol problems . c. Despite this evidence, this is still a highly controversial approach. Alcoholics Anonymous (AA) a. Self-help group started in 1935 by two men, Dr. Bob and Bill W. in Akron, Ohio who recovered from alcoholism through a “fundamental spiritual change.” b. AA has more than 52,000 groups in the United States and Canada has 5,000, with 45,000 groups worldwide. c. Basic belief is that one is an alcoholic for life . d. Rehabilitation lifts the burden of personal responsibility. e. Affiliated movements bring family members together. f. Reported success is primarily based on anecdotal evidence. g. Objective studies—few in number—report: (1) Higher dropout rates in AA—about 50%. (2) Success with severe alcoholics is severely limited. (3) Experimental participants assigned to AA subsequently encountered more life difficulties and drank more than people in other treatment groups. (4) AA found to be better than no treatment. Copyright © 2013 Pearson Education, Inc. All rights reserved. 210

(5) Operates as a self-help counseling program. (6) AA view that one is an alcoholic for life and one is never cured, just in recovery. Outcome studies and issues in treatment a. Low rates of success among hard-core substance abusers. b. Recovery rates of 70%–90% with modern treatment and aftercare procedures. c. Favorable outcomes relate to personal motivation for change and a positive relationship with the therapist. d. Drinking Check-Up sessions during the early stages of therapy are successful in reducing drinking. e. Project MATCH: matching patients to particular treatments did not appear to be important; all treatments used had equal outcomes. Relapse prevention necessary and effective a. Recognizing indulgent behaviors. b. Recognizing abstinence violation effect. c. Clients taught to recognize apparently irrelevant decisions that serve as early warning signals of the possibility of relapse. d. One of the greatest problems in the treatment process.

Activity 11.3: How to Reduce and Avoid Drinking

II.

Drug Abuse and Dependence

III. Narcotics, Sedatives, Stimulants, Anti-anxiety Drugs, Pain Medication, Hallucinogens, and Caffeine and Nicotine Handout 11.1: Better Living through Chemistry A.

Estimated 20.1 million people in the United States aged 12 and older use psychoactive drugs (see Table 11.2 for a list of common drugs). 1. Extent of abuse is probably underestimated. 2. 1/3 quit without seeking help. 3. Drug abuse and dependence is most common during adolescence and young adulthood. 4. More common among economically depressed minority communities. 5. Employment study: a. 10.8% had illicit drugs in their system. b. 55% of this figure tested positive for marijuana. c. 36% of this figure tested positively for cocaine. d. 28% of this figure tested positively for opiates.

Handout 11.2: A Compendium of Alternatives to Substances B.

Opium and its Derivatives (Narcotics) 1. Opium is a mixture of about 18 chemical substances known as alkaloids. a. Alkaloid present in the largest amount (10%–15%) is morphine . b. Morphine is a bitter-tasting powder; serves as a powerful sedative and pain reliever. c. Morphine named after the Greek God of sleep, in Greek mythology. d. Hypodermic needle introduced in the United States in 1856 and used in the Civil War. 2. If morphine is treated with acetic anhydride, you get heroin. a. Pain relief. b. Acts more rapidly and intensely than morphine. 3. Harrison Act (1914) criminalized the unauthorized sale and distribution of certain drugs. 4. Biological effects of morphine and heroin a. Commonly smoked, snorted, eaten, “skin popped” or “mainlined.” b. Mainlined or snorted heroin causes 60-second euphoric spasm (rush) followed by a high and a subsequent lethargic, withdrawn state. c. Withdrawal occurs after extended use within 8 hours of a dose. d. Withdrawal symptoms vary; many withdraw without assistance, others experience runny nose, tearing eyes, perspiration, restlessness, increased respiration rate, and an intensified desire for the drug; more intense symptoms include chilliness alternating with flushing and sweating, cramps, vomiting, diarrhea, pain in the back and extremities, tremors, and insomnia. e. Symptoms of withdrawal decline by the fourth day. 5. Social effects of morphine and heroin a. Life becomes centered on obtaining the drug. b. Leads to lying, stealing, and associating with those who supply the drugs. c. Disruption of the immune system. d. Non-sterile instruments can lead to diseases including AIDS. e. No controls on strength and purity. 6. Causal factors in opiate abuse and dependence a. No single causal pattern. b. Three most cited reasons for beginning to use heroin: pleasure, curiosity, and peer pressure. c. May be partially influenced by genetic factors . Copyright © 2013 Pearson Education, Inc. All rights reserved. 212

d. 81% of addicts keep using heroin because of the pleasure. Neural bases for physiological addiction a. Repeated use of opiates results in changes in neurotransmitter systems. b. Endorphins are opium-like substances in the brain and are thought to be involved in pain responses; perhaps chronic underproduction of endorphins leads to a craving for narcotic drugs. 8. Addiction associated with psychopathology a. Antisocial traits may be involved. b. Lack of capacity to delay gratification is a factor. 9. Drug use associated with sociocultural factors a. Narcotics subculture. b. Isolation increases as addict group belongingness is bolstered. 10. Treatment and outcomes a. Strategies are similar to those for alcoholism. b. Withdrawal does not remove the craving for the drug. c. Methadone treatment. d. Group therapy. e. Counseling. f. Move toward total resocialization. g. Bupenorphine used as substitute with fewer side effects. h. Both methadone and buprenorphine work best when combined with behavior therapy. Cocaine and Amphetamines (Stimulants) 1. Cocaine a. Due to the expense, once considered the drug of the affluent. b. Cocaine plant product was first discovered in ancient times and widely used in pre-Columbian Mexico and Peru. c. Speeds up the central nervous system. d. During the 1980s and 1990s, prices fell and middle-to upper-income people increased use. e. “Crack” cocaine, processed from cocaine hydrochloride to a free base for smoking, is much cheaper. f. Cocaine may be ingested by sniffing, swallowing, or injecting. g. Creates a 4–6 hour euphoric state experienced as feelings of contentment and confidence. h. When cocaine is abused: acute toxic psychotic symptoms may occur, including visual, auditory, and tactile hallucinations. i. Cocaine stimulates the brain’s cortex, inducing sleeplessness and excitement as well as stimulating and accentuating sexual experiences. j. Acute as well as chronic tolerance may be found. k. Physiological dependence does occur—cocaine withdrawal involves depression, fatigue, disturbed sleep, and increased dreaming. l. Follow-up studies show increased psychosocial problems over time. m. Cocaine use in pregnancy can cause fetal crack syndrome. 7.

MyPsychLab Resource 11.4: Video on “How Cocaine Works” 2.

Treatment and outcomes a. Use of medications such as methadone and naltrexone to reduce cravings. b. Only 42% of those in one study remained in treatment for more than six sessions. c. Use of psychological therapy to ensure treatment compliance. d. Must also address feelings of tension and depression. e. Factors associated with poorer outcome: severity of abuse, poorer psychiatric functioning, presence of concurrent alcoholism. Copyright © 2013 Pearson Education, Inc. All rights reserved. 213

Problem of “dropping out.” Problems of comorbidity with antisocial personality disorder and psychosisprone personalities. h. Some improve without treatment. 3. Amphetamines a. Benzedrine (amphetamine sulfate) was first synthesized in 1927. b. Dexedrine and Methedrine (speed) was introduced in the late 1930s. c. Initially used to ward off fatigue, especially during WWII, and to suppress appetite. d. Used today for appetite suppression, treating narcolepsy, and treating ADHD. e. Controlled Substance Act of 1970 classified amphetamines as Schedule II controlled substances. 4. Effects of amphetamine abuse a. Psychologically and physically addictive. b. Body rapidly builds up a tolerance. c. Excessive dosage results in heightened blood pressure, enlarged pupils, unclear or rapid speech, profuse sweating, tremors, excitability, loss of appetite, confusion, and sleeplessness. d. Chronic use can result in brain damage and psychopathology, including amphetamine psychosis. 5. Treatments and outcomes a. Withdrawal is usually physically painless, but treatment for this is scarce. b. Withdrawal after chronic excessive use can result in cramping, nausea, diarrhea, and even convulsions. c. Depression is a psychological consequence of abrupt withdrawal. Methamphetamine, known as crystal or ice 1. Provides a quick and long-lasting high. 2. 4.9 million people have tried this substance in the United States by 1990s. 3. Relatively cheap to manufacture; often referred to as “poor people’s cocaine” 4. Can be smoked, snorted, swallowed, or injected. 5. Operates by increasing the level of dopamine in the brain; prolonged use produces structural changes in the brain. 5. Duration of use positively correlated with psychiatric problems. 6. Largest user population in the Southwest, Hawaii, and West Coast. 7. Addicted users are highly resistant to treatment. One study found that 36% of users began using again within 6 months of treatment, and more than 50% within 2 years. 8. Discontinuing use can lead to problems with learning and memory, cognitive dysfunctions, paranoid thinking, and hallucinations. Barbiturates (sedatives) 1. Effects of barbiturates a. Calm patients and induce sleep. b. Excessive use leads to tolerance and dependence; tolerance does not increase the amount needed to cause death. c. Similar to the effects of alcohol. d. Brain damage and personality deterioration may occur from prolonged ingestion. 2. Causal factors in barbiturate abuse and dependence a. Middle-aged and older persons are susceptible to dependency when used as “sleeping pills”; referred to as silent abusers. b. Alcohol is commonly used with barbiturates. 3. Treatments and outcome a. Must differentiate between barbiturate intoxication and withdrawal. b. Silent abusers: those who use in the privacy of their own home and alone. c. Withdrawal symptoms can be dangerous and severe. f. g.

(1)

Anxiety, apprehension, coarse tremors of hands and face, insomnia, weakness, nausea, vomiting, abdominal cramps, rapid heart rate, elevated blood pressure, loss of weight. (2) Acute delirious psychosis may develop. d. Withdrawal symptoms may be limited by other medications. Hallucinogens: LSD and Related Drugs 1. LSD (lysergic acid diethylamide) is the most potent of all hallucinogens. 2. Drugs that induce hallucinations a. Chemically synthesized substance first discovered by the Swiss chemist Albert Hoffman in 1938. b. Research has found it ineffective as a psychological treatment. (1) “Trips” on the drug can be pleasant or extremely traumatic. (2) Flashbacks are involuntary recurrences of hallucinations. (3) Harrowing. (4) Model psychoses. (5) Associated with raves and club culture 3. Mescaline and psilocybin a. Mescaline is derived from the disc-like growths at the top of the peyote cactus. b. Psilocybin is obtained from a variety of Mexican mushrooms known as Psilocybe Mexicana. c. Ceremonial uses among Indian groups. d. Perceptions are altered, reality distorted. Ecstasy (MDMA) 3, 4-methylenedioxymethylamphetamine 1. Both hallucinogen and stimulant. 2. Originally developed as a diet pill by Merck in 1913. 3. Later tested in the 1970s and 1980s for treatment of PTSD, phobias, psychosomatic disorders, suicidality, depression, drug addiction, and relationship difficulties. 4. No value in drug for use in psychological treatment. 5. Increasingly popular as party drug. 6. Chemically similar to methamphetamine and to the hallucinogen mescaline. 7. Recreational use is associated with impulsivity and poor judgment. 8. Negative psychological and health consequences (including death). Marijuana 1. Classified as a mild hallucinogen. 2. Comes from the leaves and flowering tops of the hemp plant, cannabis sativa. 3. Related to a stronger drug, hashish, derived from the resin exuded by the plant and made into a gummy powder. 4. Use is commonplace today; most commonly used illicit drug with 6.7% of the U.S. population using. 5. Effects of marijuana a. Vary greatly depending on the quality and dosage, personality and mood of user, user’s past experiences with the drug, the social setting, and the user’s expectations. b. Mild euphoria is produced. c. Sensory inputs are intensified, with both pleasant and unpleasant experiences. d. Time distortions are often present. e. Depressant and hallucinogenic effects are found. f. Induces memory dysfunction and a slowing of information processing. g. Withdrawal symptoms including nervousness, tension, sleep problems, and appetite change. 6. Treatment a. Psychological treatment methods are effective. b. No pharmacotherapy treatment for cannabis dependency has been shown

effective. c.

Busiprone.

Synthetic marijuana “spice.”

Activity 11.4: Emerging Trends in the Treatment of Addiction G. H.

Stimulants: Caffeine and Nicotine Both caffeine and nicotine a. Easy to abuse. b. Readily available. c. Have addictive properties. d. Difficult to quit. e. Becomes a habit. f. Cause side effects and health problems. 1. Caffeine a. Available in many drinks and foods, easy to abuse. b. Negative effects from excessive intake involve intoxication rather than withdrawal (mild headache only). c. Caffeine-induced organic mental disorder: restlessness, nervousness, excitement, insomnia, muscle twitching, and gastrointestinal complaints. 2. Nicotine a. Poisonous alkaloid. b. Nicotine dependency syndrome. c. Nicotine withdrawal disorder. d. 70.9 million Americans aged 12 or older smoke, 63% women and 53% men. 3. Treatment of nicotine withdrawal a. Social support groups. b. Replace cigarette smoking with safer forms of nicotine. c. Self-directed change. d. Professional assistance. e. Nicotine replacement therapy (NRT). f. All show about a 20%–25% success rate. g. Zyban to prevent relapse. The World Around Us 11.4: Pathological Gambling 1. Characterized by continuous or periodic loss of control over gambling, preoccupation with gambling and with obtaining money for gambling, irrational behavior, continuation of the gambling behavior in spite of adverse consequences. 2. Estimate prevalence of 1%–2% of the adult U.S. population. 3. Negative effects on social, psychological, and economic well-being. 4. Causal factors in pathological gambling: a. Learned pattern that appears very resistant to extinction (intermittent reinforcement). b. Known as compulsive gambling. c. Pathological gamblers are immature, rebellious, thrill-seeking, superstitious, antisocial, and compulsive. d. Beginners luck. e. Comorbidity with other disorders, particularly substance abuse. f. Southeast Asian refugees in the U.S. show extensive problems in this area. 5. Treatment and outcomes a. Most extensive approach is cognitive-behavioral therapy. b. Gamblers Anonymous, which is modeled after AA. c. Appears to be on the increase in the U.S..

Teaching Tip 11.3: Guest Speakers Activity 11.5: Mere Behavior Change Activity 11.6: The Role of Cognition on Substance Abuse MyPsychLab Resource 11.5: Video on “Substance Abuse: Jean Obert” III.

Unresolved Issues: Exchanging Addictions: Is This an Effective Approach? A. Methadone as an Aid to Heroin Addiction Treatment 1. Satisfies heroin craving without serious psychological impairment. 2. Facilitates psychological or social rehabilitation. 3. Addicts on methadone can function normally and hold jobs. 4. Is legal and quality controlled. 5. Negative physical symptoms (hepatitis, cognitive impairments)and social consequences (trading sex for drugs) are sometimes associated. 6. Variations in methadone programs, such as the use of additional drugs, are aimed at keeping addicts in therapy. B. Drug Abstinence Instead of Methadone Maintenance? 1. Methadone Transition Treatment a. A 180-day course of treatment. b. Involves methadone and psychosocial intervention. c. Ends with 80 days of phase out.

Activity 11.7: Develop a Better Drug Education Program

Key Terms addictive behavior alcohol withdrawal delirium alcoholic alcoholism amphetamine barbiturates caffeine cocaine delirium tremens Ecstasy endorphins flashback hallucinogens hashish heroin LSD marijuana

mescaline mesocorticolimbic dopamine pathway (MCLP) methadone morphine nicotine opium pathological gambling psilocybin psychoactive drugs substance abuse substance dependence substance-related disorders tolerance toxicity withdrawal

Lecture Launchers Lecture Launcher 11.1: Alcohol Myopia Will the true effects of alcohol please stand up? Does alcohol make you a miserable “crying in your beer” depressive or an elated, “dancing on the tables,” free-spirit? Does alcohol make you a passive, bemused observer of life swirling around you or a hypervigilant, itching-for-a-fight, pumped-up combatant? Does it make you more or less talkative? More or less sexual? It seems to depend on the circumstances, doesn’t it? Steele and Josephs (1990) argue that the apparently diverse and contradictory effects of alcohol can be understood as being the product of “Alcohol Myopia,” which is the short-sightedness that occurs under the influence of alcohol. Once more remote cues influencing behavior are removed by alcohol (e.g., moral strictures, long-term plans, concern for one’s reputation), the immediate cues to action take over. If these immediate cues are depressing, and Alcohol Myopia undermines the antidepressant effects of a broader perspective, then one will be depressed. Conversely, if the immediate cues are to elation, and depressing concerns about relatively remote issues are diminished by alcohol, then one will be elated. A wide variety of examples of seemingly contradictory behavioral effects of alcohol are explained nicely within this model and are nicely summarized in Steele and Josephs’ American Psychologist article (1990, vol. 45, pp. 921–933). Lecture Launcher 11.2: Is Alcoholism a Disease? Whether or not alcoholism is a disease always provokes good debate. Typically, this debate centers on the proper definition of disease. The American Medical Association classified alcoholism as a disease in 1956. And of course, the disease model is the foundation of Alcoholics Anonymous. Interestingly, the Supreme Court has also weighed in on this question in Traynor v. Turnage [485 U.S. 535 (1988)]. The test case was of two military veterans who were denied extensions of their Veterans’ Administration educational benefits, extensions they requested on the basis of their inability to use them owing to alcoholism-related disability. The Supreme Court ruled against the plaintiffs, finding that alcoholism was not a disease. Instead, the Court described alcoholism as a “willfully caused handicap,” thereby worthy of benefit extension denials of the sort made by the Veterans’ Administration. In support of this decision, the Court noted a variety of aspects of alcoholism that were inconsistent with it being a disease. Among these; there is no known biological defect, no clear separation from normality, loss of control is not automatic, drinking is subject to situational effects, and there are no physiological treatments. Shortly after this decision, the U. S. House of Representatives voted to overrule the Veterans’ Administration policy that had prompted the case in the first place. Lecture Launcher 11.3: Expectancy Effects Alan Marlatt has performed interesting demonstrations with students drinking in a laboratory bar. Ostensibly as a study of the effects of alcohol, he asks them to report on the symptoms, both physiological and psychological, that they experience as they ingest more and more alcohol. Once a fair number of stereotypic symptoms are reported (e.g., my face is flushing, I’m feeling a little light-headed, we are talking more and talking louder), he discloses the literally sobering fact that there has been no alcohol whatsoever in the pitchers of “beer” the students have been drinking. Most students are convinced that they themselves would not have been fooled the way the students in Marlatt’s bar were fooled, but that is exactly the message to be gotten from studies of expectancy effects on alcohol. Lecture Launcher 11.4: Why Did Richard Feynman Quit Drinking? One day as Nobel Prize-winning physicist Richard Feynman was walking along the beach enjoying a beautiful sunset, warm breeze off the ocean, and everything seemed perfect, the thought struck him that it would be nice to have a drink. At that moment he gave up drinking forever. Why might he have done that? Wouldn’t alcohol have made his experience “more perfect”? It appears that Feynman found his urge to drink scary, or perhaps pathetic, but at any rate it was a motivating reaction. Have students ever felt that way? Don’t most intrinsically exciting, moving, significant, enjoyable events involve alcohol? Why is that? Is that scary, or perhaps pathetic?

Classroom Activities, Demonstrations, and Assignments Activity 11.1: Pluralistic Ignorance and Hooking Up This makes an excellent assignment for students to complete. It complements what they have learned in class and in the text with an article describing research into a given area of personality disorder research. Included are some

questions that students can answer but you can also add your own based on your specific lecture. This can be for either a portion of the course grade or as extra credit. The role of expectations of social success definitely affects drinking on college campuses. But does it affect other behaviors as well? Read the following article and answer the following questions (you may also use your text to help clarify information): Lambert T. A., Kahn, A. S., & Apple, K. J. (2003). Pluralistic Ignorance and Hooking Up. Journal of Sex Research, http://findarticles.com/p/articles/mi_m2372/is_2_40/ai_105518215 1. According to the article, what is “hooking up”? 2. What is pluralistic ignorance? How is the “illusion of universality” related? 3. How has pluralistic ignorance on college campuses affected drinking amongst students? 4. Briefly describe the study that researchers undertook on looking at pluralistic ignorance and hooking up. 5. Briefly summarize their results. 6. Briefly describe the “Most of Us” campaign. 7. Based on the research discussed here, how would you design a program to decrease binge drinking, hooking up, and other behaviors amongst college students? Activity 11.2: Substance Abuse, Suicide, and American Indians This makes an excellent assignment for students to complete. It complements what they have learned in class and in the text with an article describing research into a given area of personality disorder research. Included are some questions that students can answer but you can also add your own based on your specific lecture. This can be for either a portion of the course grade or as extra credit. As described in the text, American Indians have had a particular issue with abuse and addiction. This article discusses the issues that may have a moderating effect on this cultural epidemic. Read the following article and answer the following questions (you may also use your text to help clarify information): Myers, L. (2007). “A Struggle for Hope,” Monitor on Psychology, 38(2), www.apa.org/monitor/feb07/astruggle.html. 1. Describe the myriad possible social issues that may have led to a widespread epidemic of substance abuse. 2. Briefly describe the role of substance abuse on the reservations. Why might some be using drugs? 3. Briefly describe the past and present issues about suicide on reservations. 4. Describe the “American Indian Life Skills” program. 5. Using both the text and the article, what would you say is the relationship, if any, between drug abuse and suicide? 6. Using both the text and the article, what would be other alternative programs to decrease abuse on reservations? Activity 11.3: How to Reduce and Avoid Drinking Peer pressure to drink is intense at college campuses, where alcohol-free socializing opportunities are exceedingly rare. Over the course of the term, there will be ample opportunity for students to experiment with ways to attend alcohol-related social activities without drinking or at least without drinking very much. As an exercise in experiential learning, ask students to attend a party at which they would ordinarily drink, but to do so without drinking at all. In making this assignment, students can be asked to brainstorm ways to be unobtrusive about it. For instance, they can tell the other partygoers they do not feel well, that they are taking medications, or even that they are simply doing what a professor told them to try. It is also fairly simple to fill one’s glass with something nonalcoholic or to carry the same drink around all evening. Bartenders will tell you that it is not all that uncommon for patrons to secretly ask them for non-alcoholic versions of drinks they order in front of their friends. Most students resist the idea that they are pawns subject to the whims of peer pressure. They recognize, however, that this assignment will be difficult—not because they are alcoholic but because peer pressure is quite strong. Activity 11.4: Emerging Trends in the Treatment of Addiction This makes an excellent assignment for students to complete. It complements what they have learned in class and in the text with an article describing research into a given area of personality disorder research. Included are some questions that students can answer but you can also add your own based on your specific lecture. This can be for either a portion of the course grade or as extra credit.

Here is an illuminating interview with Dr. Volkow, the director of the National Institute of Drug Abuse, on emerging trends in substance abuse. Read the following article and answer the following questions (you may also use your text to help clarify information): Price, M (2009). “Emerging Trends in Addiction Treatment,” Monitor on Psychology, 40(3), www.apa.org/monitor/2009/03/addiction.html 1. 2. 3. 4. 5.

What are the emerging trends in the types of substances abused? What new treatment options emerging for addiction? What are the rates of addiction in the United States? How does the researcher explain this trend? Using both the text and the article, what are the effects of peer relations on abuse? Using both the text and the article, what would be a good campaign to reduce substance abuse?

Activity 11.5: Mere Behavior Change Greater sympathy for the trouble other people have changing their behavior can be acquired through attempts to change one’s own behavior. To help make this point, the entire class can be assigned a simple behavior change they are highly likely to fail. People tend to put on their pants the same way every time; that is, by putting in their left or their right foot first. Announce that at the next class meeting you will ask which leg goes first. Then, when everyone has identified their preference, they will be assigned the task of switching to the other foot. Surely, you can ask, it doesn’t really matter which leg goes in first? Then over the course of the next few weeks, you can request a show of hands for those people who have reverted to their old way of putting on their pants. Activity 11.6: The Role of Cognition on Substance Abuse This makes an excellent assignment for students to complete. It complements what they have learned in class, and in the text with an article describing research into a given area of personality disorder research. Included are some questions that students can answer but you can also add your own based on your specific lecture. This can be for either a portion of the course grade or as extra credit. For many, the behavioral perspective has long been the dominant explanation for substance abuse. Here is an article that focuses on the cognitive component of addictive behaviors. Read the following article and answer the following questions (you may also use your text to help clarify information): Carpenter, S. (2001). “Cognition is Central to Drug Addiction,” Monitor on Psychology, 32(5), www.apa.org/monitor/jun01/cogcentral.html 1. What perspective has garnered the most empirical support in the past? 2. What evidence has the brain imaging research shown? 3. Summarize Bechara et al.’s research on the relationship between neurological imaging and decisionmaking. 4. Does Bechara et al.’s work suggest differences neurologically between different types of users? 5. Briefly describe Volkow’s argument about addiction and pleasure. 6. What does the relationship of frontal cortex and cravings suggest from a treatment perspective? 7. Using both the text and the article, if cognition is an important factor in abuse, how would one treat abuse? Activity 11.7: Develop a Better Drug Education Program It would be a rare student indeed who reached a course in Abnormal Psychology without having spent a considerable amount of time in drug education and prevention lectures and programs of various sorts. Health classes, D.A.R.E. programs, televised public service announcements, and the like are pervasive. Drug abuse and addiction is still far too common, though, so despite widespread promulgation of the relevant information, there are flaws in the system that is worth carefully examining. One approach to studying the flaws in the system is to assign students to groups to examine their experiences. First, groups should discuss what is wrong with the programs they were exposed to and then they could be asked to develop alternatives. Often students will claim that they lack the expertise to make reasonable recommendations about something as complex as drug education and prevention programming, so it might help to suggest that the people who have the knowledge of program content are often out of touch with the target audience of young people. Typical college-age students therefore have some advantages over more typical program planners. Among the kinds of questions to be addressed in groups are: What kinds of programs affected you most? What kinds of activities got your attention? What facts were most influential in your drug decision-making process? What is the best age group to target? What kinds of things undermined the

effectiveness of programs you were exposed to? How could you measure the effectiveness of these programs? How would you balance resources among education, interdiction, and treatment? Activity 11.8: The Top Three Substances Illicit or Licit that College Students Are Using Ask students to take a poll and anonymously write down on scrap sheets of paper the top three substances that they believe or have witnessed college students using. Then ask for two to four volunteers to tally the results. Identify the top three drugs, and use this activity as a springboard to the lecture and the different categories of substances. You could also talk about binge drinking and its acceptability in college.

MyPsychLab Resources MyPsychLab Resource 11.1: Video on “Alcoholism: Chris” 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, which led to harder drugs until he was spending $1000 per week on his cocaine habit. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 11, SubstanceRelated Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Alcoholism: Chris” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 11.2: Video on “Alcohol Withdrawal” This video clip looks at research on how a gene might aid in coping with withdrawal. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 11, Substance-Related Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Alcohol Withdrawal” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 11.3: Video on “Substance Abuse: Therapist Louise Roberts” This segment interviews a therapist who is an ex addict herself. She speaks about her past experiences with multiple substances, including cocaine, pills, and heroin. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 11, SubstanceRelated Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Substance Abuse: Therapist Louise Roberts” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 11.4: Video on “How Cocaine Works” This video clip interviews a neurologist discussing how cocaine affects dopamine levels. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 11, Substance-Related Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “How Cocaine Works” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 11.5: Video on “Substance Abuse: Jean Obert” 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. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 11, Substance-Related Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Substance Abuse: Jean Obert” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. Copyright © 2013 Pearson Education, Inc. All rights reserved. 222

Teaching Tips Teaching Tip 11.1: Reinforcement This is a great time to remind students that behavioral theory accounts for much of substance abuse. Ask students at what age they had their first drink? Why did they drink? Many will state high school and something relating to peer acceptance—e.g., “looking cool,” or “everyone else was doing it.” Point out that initially many begin taking substances the same way they may buy a certain brand of jeans—that is, to fit in. This makes it a positively reinforced behavior. Now ask students why many of them may smoke, drink, or engage in substances today? Is it still to fit in? Not likely; for many of them, now they need to engage in the behavior to stave off feelings of withdrawal or discomfort, that is, now it is a negative reinforcer. So now, how would they go about breaking the cycle based on what is known about operant conditioning? Teaching Tip 11.2: Moderating Variables This is a good time to review what a moderating variable is. Remind students that a moderating variable is a variable (like gender or SES) that can affect the strength and direction of the relationship between two variables. These variables can have significant effects on data and statistics. Teaching Tip 11.3: Guest Speakers A variety of interesting speakers can enliven lectures on substance use and abuse. For instance, recovering alcoholics and addicts, AA and NA representatives, physicians specializing in detoxification and addiction treatment, and addictions counselors are often fairly readily available. Most yellow page directories give resources for alcoholism and drug abuse information and treatment centers that can be consulted. It is interesting to schedule such visits after the material has been covered in class so that students can pose informed questions of the visitors. You can also check on campus with student health. Many campuses offer peer counseling as well.

Handout Descriptions Handout 11.1: Better Living through Chemistry It is difficult to attack specific substances, or patterns of substance use and abuse, when others that can seem only arbitrarily different pervade the culture. Substances exist to regulate everything from our hair color and complexion to our sleep and bowel movements. We take pills for appetite, pain, disease, depression, anxiety, upset stomach, blood pressure, to wake us up and calm us down, and myriad other things. Ask students to help you list as many of these chemical regulators as possible. Once an extensive and easily generated list is available, point out that so much of our lives is regulated chemically, it is no wonder that we think to ingest substances before we think of changing lifestyles. To what extent do students feel that the chemical culture makes lifestyle change the last resort instead of making alcohol and other drugs the last resort? Or do students see a sharp demarcation between these substances and the DSM substances of abuse and addiction? Handout 11.2: A Compendium of Alternatives to Substances For this exercise, students are asked to list all the reasons people might use and abuse substances. Ask: What do people get, and what do they avoid, by taking various substances? Then point out that it is unrealistic to ask people to give up their substances without providing another means to accomplish the same things. Therefore, they are to give an alternate means of getting, or avoiding, the items they previously listed as motivators of substance use and abuse. The only requirement is that the alternative they provide must be equally effective.

Video/Media Sources ▪ ▪ ▪ ▪ ▪

AA and the Alcoholic. Center City, MN: Hazelden Foundation. Addicted Brain—The Brain Video Series. Princeton, NJ: Films for the Humanities and Social Sciences. Addiction Caused by Mixing Medicines. Princeton, NJ: Films for the Humanities and Social Sciences. Addiction: The Family in Crisis. Princeton, NJ: Films for the Humanities and Social Sciences. Addictions and Mental Illness. Princeton, NJ: Films for the Humanities and Social Sciences.

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A Dose of Death: Ecstasy, Homeostasis, and Substance Abuse. Princeton, NJ: Films for the Humanities and Social Sciences. Advertising Alcohol: Calling the Shots, Second Edition. Cambridge, MA: Cambridge Documentary Films. Alcohol Addiction. Princeton, NJ: Films for the Humanities and Social Sciences. Alcohol Addiction: Hereditary Factors, Vol. 29. The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection. Alcohol and the Family: Breaking the Chain. Princeton, NJ: Films for the Humanities and Social Sciences. Altered States: A History of Drug Use in America. Princeton, NJ: Films for the Humanities and Social Sciences. Animated Neuroscience and the Action of Nicotine, Cocaine, and Marijuana in the Brain. Princeton, NJ: Films for the Humanities and Social Sciences. Behind the Smoke Screen: Facts about Tobacco Use. Allyn & Bacon Video Library. Binge Drinking: The Right to Party? Princeton, NJ: Films for the Humanities and Social Sciences. Bingo: You Betcha! New York, NY: The Cinema Guild. Changing Lives. Moyers on Addiction: Close to Home. Princeton, NJ: Films for the Humanities and Social Sciences. Cigarettes: Who Profits, Who Dies? Princeton, NJ: Films for the Humanities and Social Sciences. Circle of Recovery: Healing the Wounds of Drugs and Alcohol. Princeton, NJ: Films for the Humanities and Social Sciences. Cocaine: The End of the Line. Princeton, NJ: Films for the Humanities and Social Sciences. Coping Mechanisms. Substance Abuse: Assessment and Intervention Series. Irvine, CA: Concept Media. The Cronkite Report: The Dice are Loaded. Princeton, NJ: Films for the Humanities and Social Sciences. Crystal. Princeton, NJ: Films for the Humanities and Social Sciences. Cure or Wishful Thinking: Alcoholism—#7 ABC News and Client Interviews. Allyn & Bacon Abnormal Psychology Video. Disorders Due to Psychoactive Substance Abuse. Differential Diagnosis in Psychiatry Series. Princeton, NJ: Films for the Humanities and Social Sciences. Drinking Apart: Families under the Influence. Allyn & Bacon Video Library. Drinking: Are You in Control? Allyn & Bacon Video Library. Drinking Responsibly, Module X. The Total Health Video Series. EMG/Allyn & Bacon Video Library. Feelings, Alcohol, and Manhood. Men in Crisis Series. Irvine, CA: Concept Media. Fetal Alcohol Syndrome and Other Drug Use During Pregnancy. Princeton, NJ: Films for the Humanities and Social Sciences. Fetal Alcohol Syndrome: Life Sentence. Princeton, NJ: Films for the Humanities and Social Sciences. Gambling: The Chance of a Lifetime. Allyn & Bacon Video Library. Getting Help: Drugs: Profiles of Addiction and Recovery Series. Princeton, NJ: Films for the Humanities and Social Sciences. Getting Straight: New Hopes for Drug Treatment. Princeton, NJ: Films for the Humanities and Social Sciences. Here’s to You, Sister: Women and Alcoholism. Princeton, NJ: Films for the Humanities and Social Sciences. Heroin: The New High School High. Allyn & Bacon Video Library. The Hijacked Brain. Moyers on Addiction Series: Close to Home. Princeton, NJ: Films for the Humanities and Social Sciences. Hooked on Heroin: From Hollywood to Main Street. Princeton, NJ: Films for the Humanities and Social Sciences. Inhalant Abuse: Breathing Easy. Princeton, NJ: Films for the Humanities and Social Sciences. Inhalants. Drugs: Uses and Abuses. Princeton, NJ: Films for the Humanities and Social Sciences. LSD and Ergot. Princeton, NJ: Films for the Humanities and Social Sciences. Last Call: Alcoholism and Co-Dependency. Princeton, NJ: Films for the Humanities and Social Sciences. Making Choices. Drugs: Profiles of Addiction and Recovery Series. Princeton, NJ: Films for the Humanities and Social Sciences. Narcotics. Drugs: Uses and Abuses Series. Princeton, NJ: Films for the Humanities and Social Sciences. The Next Generation. Moyers on Addiction Series: Close to Home. Princeton, NJ: Films for the Humanities and Social Sciences. Copyright © 2013 Pearson Education, Inc. All rights reserved. 224

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The Opium Poppy. Princeton, NJ: Films for the Humanities and Social Sciences. PCP. Drugs: Uses and Abuses Series. Princeton, NJ: Films for the Humanities and Social Sciences. Place Your Bets. Princeton, NJ: Films for the Humanities and Social Sciences. The Politics of Addiction. Moyers on Addiction Series: Close to Home. Princeton, NJ: Films for the Humanities and Social Sciences. Portrait of Addiction. Moyers on Addiction Series: Close to Home. Princeton, NJ: Films for the Humanities and Social Sciences. The Power of Addiction. Princeton, NJ: Films for the Humanities and Social Sciences. Preventing Drug Abuse, Module XII. The Total Health Video Series. EMG/Allyn & Bacon Video Library. Psychedelics and Hallucinogens. Drugs: Uses and Abuses Series. Princeton, NJ: Films for the Humanities and Social Sciences. Recovery and Prevention of Relapse. Substance Abuse: Assessment and Intervention Series. Irvine, CA: Concept Media. The Science of Addiction. Risky Business: Teens and Addictive Behavior Series. Princeton, NJ: Films for the Humanities and Social Sciences. Smokeless Tobacco: A Wad of Trouble. Princeton, NJ: Films for the Humanities and Social Sciences. Smoking: Time to Quit. Princeton, NJ: Films for the Humanities and Social Sciences. Steroids. Drugs: Use and Abuse Series. Princeton, NJ: Films for the Humanities and Social Sciences. Stimulants. Drugs: Use and Abuse Series. Princeton, NJ: Films for the Humanities and Social Sciences. Straight Up Life. Boston, MA: Fanlight Productions. Substance Abuse Among Latinos. Princeton, NJ: Films for the Humanities and Social Sciences. Substance Abuse Disorders. The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection. Substance Abuse in the Elderly. Allyn & Bacon Video Library. Substance Abuse, Panic Disorder with Agoraphobia, Kathy—Patient Interview Video for Abnormal Psychology (12th ed.). Allyn & Bacon Video Library. The Substance in Question. Princeton, NJ: Films for the Humanities and Social Sciences. Substance Misuse. Princeton, NJ: Films for the Humanities and Social Sciences. Teen Gambling. Risky Business: Teens and Addictive Behavior Series. Princeton, NJ: Films for the Humanities and Social Sciences. Teens and Alcoholism. Princeton, NJ: Films for the Humanities and Social Sciences. THC. Drugs: Uses and Abuses Series. Princeton, NJ: Films for the Humanities and Social Sciences. Thirsty Work. Alcohol: Breaking the Habit Series. Princeton, NJ: Films for the Humanities and Social Sciences. This Buzz is Not for You: Teenage Drinking. Princeton, NJ: Films for the Humanities and Social Sciences. Tobacco Road: A Dead End. Princeton, NJ: Films for the Humanities and Social Sciences. Treating Drug Addiction: A Behavioral Approach, Vol. 30. The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection. The Two Brains. The Brain Series. South Burlington, VT: Annenberg/CPB Multimedia Collection. Unborn Addicts. Allyn & Bacon Video Library. Understanding Addiction. No More Shame: Understanding Schizophrenia, Depression, and Addiction Series. Princeton, NJ: Films for the Humanities and Social Sciences. Understanding the Risks of Tobacco and Caffeine, Module XI. The Total Health Video Series. EMG/Allyn & Bacon Video Library. A Way Back: Redefining Masculinity. Men in Crisis Series. Irvine, CA: Concept Media. Walking Through the Fear: Women and Substance Abuse. Princeton, NJ: Films for the Humanities and Social Sciences.

Web Links Web Link 11.1: www.samhsa.gov SAMHSA is the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services. The Center for Substance Abuse Prevention section is an excellent place to learn about the wide variety of prevention efforts underway.

Web Link 11.2: www.addictionresearch.com/index.cfm The America Foundation for Addiction Research seeks to fund research on addiction. Its site focuses on Internet and sex addiction. Web Link 11.3: www.addictionsearch.com/addictionsearch This is an addictions search engine that limits search results to research-related sites. Web Link 11.4: http://news.bbc.co.uk/1/hi/health/1872731.stm Interesting BBC article on the explosion of Internet gambling. Web Link 11.5: www.apa.org/topics/topicaddict.html American Psychological Association Web page on addictions, including some of the most recent information from research studies.

Handout 11.1 Better Living through Chemistry/Drugs and Society

How do drugs become outlawed in a society? What influences the selection of drugs to be regulated?

What are the political factors influencing drug control and regulation?

What are the religious factors affecting drug use and control?

Once a drug has been regulated, does society accept its deregulation? Explain.

Handout 11.2 A Compendium of Alternatives to Substances/Alternatives to Alcohol

Alcohol pervades much of our social lives. 1.

List some of the social occasions and events that commonly include alcohol:

Why is there alcohol at these events?

What would happen if there was no alcohol at these events?

Why would a lack of alcohol have this effect?

Are there alternatives to alcohol that could be provided to diminish the impact of not having alcohol?

If it seems that alcohol must be available at these events, then is there a way that abstaining can be made easier? How could you help obscure the fact that some people are not drinking? What motivates people to pressure others to drink alcohol? How can this motive be reduced?

What does it say about society that it is so hard even to reduce alcohol consumption?

CHAPTER 12: Sexual Variants, Abuse, and Dysfunctions Teaching Objectives 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Provide a number of examples of sociocultural influences in sexual practices and cultural standards and values. Define, give examples of, and describe the clinical features of the following paraphilias: fetishism, transvestic fetishism, voyeurism, exhibitionism, sadism, and masochism. Discuss the most effective treatments for paraphilias, and summarize causal factors implicated in their etiology. Define and describe the clinical features and treatment of the gender identity disorders (gender identity disorder of childhood, transsexualism). Review what is known about the frequency and nature of childhood sexual abuse. Discuss the controversies surrounding both childhood testimony regarding sexual abuse and adult “recovered memories” of childhood sexual abuse. Define pedophebephilia, and summarize what is known about pedophiles. Review what is known about the frequency and nature of incest. Summarize what is known about rape and rapists, and discuss issues regarding the frequency of rape and the motivation of rapists. Describe attempts to treat sex offenders and the recidivism of sex offenders. Define the sexual dysfunctions, describe their general features, review etiological theories, and summarize the major approaches to treatment. Knowledgeably discuss the difficulty of deciding the extent of the harm caused by childhood sexual abuse.

Chapter Overview/Summary Defining boundaries between normality and psychopathology in the area of variant sexuality is very difficult, in part because sociocultural influences on what have been viewed as normal or aberrant sexual practices abound. Degeneracy theory and abstinence theory were very influential for long periods of time in the United States and many other Western cultures, and led to very conservative views on heterosexual sexuality. In contrast to Western culture, in the Sambia tribe in Melanesia, homosexuality is practiced by all adolescent males in the context of male sexual initiation rites; they later transition to heterosexuality in young adulthood. Until rather recently, in many Western cultures homosexuality was viewed as either criminal behavior or as a form of mental illness. However, since 1974, homosexuality has been considered by mental health professionals to be a normal sexual variant. Sexual deviations in the form of paraphilias involve persistent and recurrent patterns of sexual behavior and arousal, lasting at least six months, in which unusual objects, rituals, or situations are required for full sexual satisfaction. They almost always occur in males. The paraphilias include (1) fetishes, (2) transvestic fetishism, (3) voyeurism, (4) exhibitionism, (5) sadism, (6) masochism, and (7) pedophilia. Gender identity disorders occur in children and adults. Childhood gender identity disorder occurs in children who have cross-gender identification and gender dysphoria. Most boys who have this disorder grow up to have a homosexual orientation; a few become transsexuals. Prospective studies of girls who have this disorder suggest that perhaps half of women develop a homosexual orientation and the other half may desire sex reassignment surgery. Transsexualism is a very rare disorder in which the person believes that he or she is trapped in the body of the wrong sex. It is now recognized that there are two distinct types of transsexuals: homosexual transsexuals and autogynephilic transsexuals, each with different characteristics and developmental antecedents. The only known effective treatment for transsexuals is a sex-change operation. Although its use remains highly controversial, it does appear to have fairly high success rates when the people are carefully diagnosed and participate in a lengthy readjustment program There are three overlapping categories of sexual abuse: pedophilia, incest, and rape. All three kinds of abuse occur at alarming rates today. Controversies about the accuracy of children’s testimony, and about the accuracy of recovered memories of sexual abuse that may often occur in psychotherapy, have recently arisen. Traditionally, sexual abuse has been seen as leading to both serious short-term and long-term consequences for its victims. Recent reassessments of the literature have revealed that the results of sexual abuse vary from person to person with some individuals showing little to no negative long-term consequences. What leads people to engage Copyright © 2013 Pearson Education, Inc. All rights reserved. 229

in sexual abuse is poorly understood at this time. Treatment of sex offenders has not as yet proved highly effective in most cases, although promising research in this area is being conducted. Sexual dysfunction involves impairment in the desire for sexual gratification or in the ability to achieve it, and can occur in the first three of the four phases of the human sexual response, which are the desire phase, the excitement phase, the orgasm phase, and the resolution phase. Both men and women can experience hypoactive sexual desire disorder, in which they have little or no interest in sex. In more extreme cases, they may develop sexual aversion disorder, which involves disgust about sexual activity. Dysfunctions of the arousal phase include male erectile disorder and female arousal disorder. Dysfunctions of orgasm for men include premature ejaculation and male orgasmic disorder (retarded ejaculation), and, for women, female orgasmic disorder. There are also two sexual pain disorders: vaginismus, occurring in women, and dyspareunia (painful coitus), occurring in women and men. In the past 35 years, remarkable progress has been made in the treatment of sexual dysfunctions.

Detailed Lecture Outline I.

Sociocultural Influences on Sexual Practices and Standards 1. Males place a great emphasis on a partner’s attractiveness. 2. Less than 100 years ago sexual modesty where women’s arms and legs were covered. 3. Jeffrey Dahmer was sexually aroused by killing men, having sex with them, storing their corpses, and sometimes eating them. 4. Degeneracy theory, which led to being conservative about sexual practices. A. Case 1: Degeneracy and Abstinence Theory 1. Early formation of degeneracy theory by Simon Tissot, a Swiss physician (1750s). a. Central belief was that semen is necessary for physical and sexual vigor in men and for masculine characteristics such as beard growth. b. Based on observations of eunuchs and castrated animals. c. Asserted that masturbation and patronizing prostitutes was harmful as they wasted the vital fluid (semen). 2. Sylvester Graham and abstinence theory (1830s) a. Three cornerstones were healthy food, physical fitness, and sexual abstinence. b. Kellogg—described 39 signs of the “secret vice” (masturbation) and provided treatments including sewing the foreskin with a silver wire, circumcision, burning the clitoris with carbolic acid, etc. c. Kellogg believed meat increased sexual desire and invented Kellogg’s cornflakes as an anti-masturbation food. 3. Onania, or the Heinous Sin of Self-Pollution—asserted that masturbation was the cause of insanity. 4. In 1972, the American Medical Association declared that masturbation was normal for adolescents and required no medical care.

MyPsychLab Resource 12.1: Video on “Gender vs. Sex” B.

Case 2: Ritualized Homosexuality in Melanesia 1. Semen conservation. 2. A group of islands in the South Pacific that has been studied have discovered that sexual practices for 10%–20% of Melanesian societies practice homosexuality within the context of rituals. 3. Female pollution—female body is unhealthy to males, primarily because of menstrual fluids. 4. To obtain or maintain adequate amounts of semen, young males practice semen exchange through fellatio in order to ingest sperm or by inseminating younger boys. 5. Then a gradual change occurs in adulthood, when most interactions are with women; upon the birth of the first child, with females exclusively. Case 3: Homosexuality and American Psychiatry 1. Homosexuality as a sickness. Copyright © 2013 Pearson Education, Inc. All rights reserved. 230

2003 U.S. Supreme Court struck down Texas state law banning sexual behavior between two people of the same sex. b. In 1973 homosexuality was officially removed as a psychiatric disorder from the DSM (e.g., articles such as:“Effeminate homosexuality: A disease of childhood.” c. During the sixteenth century King Henry VIII of England declared anal sex as a felony punishable by death. d. Ellis and Hirschfield—homosexuality is natural and consistent with psychological normality. e. Rado—homosexuality develops in those whose heterosexual desires were too psychologically threatening; blamed domineering, emotionally smothering mothers and detached, hostile fathers. Homosexuality as a nonpathological variation a. Kinsey—homosexuality more common than previously thought. b. Around 1950 the view of homosexuality as a sickness began to be challenged by scientists and homosexual individuals. c. 1960s—gay liberation movement. d. Openly gay psychiatrists and psychologists worked within field to have homosexuality removed from the DSM. e. Removed from the DSM by a vote of 5854 to 3810; decision seen as embarrassing as it reflects that mental health is simply a reflection of the values of mental health professionals.

Teaching Tip 12.1: Preference versus Identification Lecture Launcher 12.1: Self-Determination of Sexual Orientation Activity 12.1: Is Homosexuality Biologically Determined? Activity 12.2: Show Me Yours, and I’ll Show You Mine II.

Sexual and Gender Variants A. Paraphilias 1. Fetishism a. Recurrent, intense sexually arousing fantasies, urges, and behaviors involving the use of an inanimate object for sexual gratification. b. Female cases are rare. c. These patterns must last at least 6 months. d. Proposed distinction for the DSM between paraphilias and paraphilic disorders. e. Paraphilias are compulsive and require orgasmic release as often as 4 to 10 times per day. f. DSM-IV-TR recognizes the following paraphilias: fetishism, transvestism fetishism, voyeurism, exhibitionism, sexual sadism, sexual masochism, pedophilia, and frotteurism. g. Men have an erotic preoccupation with nonsexual body parts like feet, hair, ears, and hands. h. Masturbation often accompanies the fetishistic behavior. i. Obtaining the inanimate object may lead to criminal acts. j. Classical conditioning and social learning can be involved in its development 2. Transvestic fetishism a. Recurrent, intense sexually arousing fantasies, urges, and behaviors involving cross-dressing for sexual gratification. b. Onset occurs in adolescence and includes masturbation while wearing female clothing. c. Autogynephilia—paraphilic sexual arousal by the thought or fantasy of being a woman. Copyright © 2013 Pearson Education, Inc. All rights reserved. 231

d. e.

Hirschfeld—identified cross-dressing men who are sexually aroused by seeing themselves as a woman. Most common in men.

Lecture Launcher 12.2: Should Transvestism be a Mental Disorder? Lecture Launcher 12.3: Double Standards 3.

Voyeurism a. Recurrent, intense sexually arousing fantasies, urges, and behaviors involving observation of unsuspecting persons who are undressing, or of couples engaged in sexual activity. b. Known as “Peeping Toms.” c. Primarily seen in young men. d. Curiosity is satisfied in shy and inhibited youngsters through this behavior. e. Voyeurism meets individual’s needs while avoiding possible rejection f. A sense of power maintains the behavior. g. Permissive pornography laws may provide alternatives for the voyeur.

Lecture Launcher 12.4: What’s the Concern with Voyeurism? Handout 12.1: Reality TV = Voyeurism? 4.

Exhibitionism a. Recurrent, intense sexually arousing fantasies, urges, and behaviors involving exposure of genitals for sexual gratification. b. The exposure may occur in a secluded place like a park, church, department store, or bus. c. Typically begins in adolescence or young adulthood. d. The most common sexual offense reported by the police in the U.S., Canada, and Europe. e. Exposure is consistent in type of situation and victim. f. Usually begins in adolescence or young adulthood. g. A subtype with antisocial characteristics may be present. h. Considered a criminal offense . Frotteurism a. A Sexual excitement at rubbing one’s genitals against, or touching, the body of a non-consenting person. b. Reflects inappropriate and persistent interest in something that many people enjoy consensually. c. Co-occurs with voyeurism and exhibitionism. d. Being the victim is common on crowded buses or subway trains. e. Willingness to touch others sexually without consent means that they are at risk for more serious offending. Sadism a. Recurrent, intense sexually arousing fantasies, urges, and behaviors involving inflicting psychological or physical pain on another individual for sexual gratification. b. “Bondage and discipline” is a closely related pattern. c. Named after Marquis de Sade (1740–1814) who liked to inflict pain on his victims for sexual purposes. d. Themes of dominance, control, and humiliation. e. Sexual gratification can come from the sadistic practice alone. f. Occurs mainly in heterosexual men. g. Serial killers tend to be sexual sadists such as Ted Bundy, Jeffrey Dahmer, and Dennis Rader BTK Killer. Copyright © 2013 Pearson Education, Inc. All rights reserved. 232

h. May mentally replay the torture scenes later while masturbating . Masochism a. Recurrent, intense sexually arousing fantasies, urges, and behaviors involving the act of being humiliated, beaten, or bound for sexual gratification. b. Complementary relationships are formed. c. Named after the Austrian novelist Leopold V. Sacher-Masoch (1836–1895) whose fictional characters dwelt lovingly on the sexual pleasure of pain. d. Involves at least two people, one superior “disciplinarian” and one obedient “slave.” e. Appears to be more common than sadism and occurs in both males and females f. Dominatrixes. g. Many females who enter into these relationships were sexually or physically abused in childhood. h. More common than sadism, occurring in both men and women. i. Autoerotic asphyxia—500 to 1000 deaths per year in the United Sates.

Causal Factors and Treatments for Paraphilias 1. Usually found in males. 2. Typically begin around puberty or early adolescence. 3. When found in women, the most likely ones found are pedophilia, sadomasochistic activities, and exhibitionism. 4. Individuals, usually men, have a very strong sex drive and often masturbate numerous times a day. 5. Typically more than one found in a person. 6. Money—suggested that male vulnerability to paraphilias is due to their greater dependence on visual sexual imagery. 7. Many believe paraphilias arise as a result of classical and operant conditioning and social learning. 8. 12.1 Developments in Research Hypersexual Disorder—the idea of sex addiction or hypersexual disorder is proposed for the DSM-5.

Lecture Launcher 12.5: Why Are Paraphilias So Much More Common Among Men? Handout 12.2: An Example of Classical Conditioning of a Paraphilia 9.

Treatments for paraphilias a. Most studies conducted with sex offenders. b. Non-sex offenders rarely seek treatment. Gender Identity Disorders (GID) 1. Gender identity disorder of childhood a. Boys outnumber girls 5:1 to 3:1 for clinic-referred GID. b. Characterized by strong and persistent cross-gender identification and gender dysphoria. c. DSM-5 proposed change from GID to gender dysphoria. d. Gender identity refers to one’s sense of maleness or femaleness. e. Most common adult outcome of boys is homosexuality, rather than transsexualism. f. Argument as to whether this should be seen as a disorder. g. Generally treated psychodynamically but there is a lack of outcome studies. 2. Treatment a. Brought in by their parents for psychotherapy. b. Treatment focuses on the child’s unhappiness and strained relationship with parents.

Teaching Tip 12.2: Gender Appropriateness

MyPsychLab Resource 12.2: Video on “Gender Identity Disorder: Denise” 3.

Transsexualism a. Defined as adults with GID who desire to change their sex. b. European studies show 1 in 30,000 adult males and 1 in 100,000 adult females seek sex reassignment surgery. c. More recent data suggest 1 in 12,000 men in Western countries have actually undergone the surgery. d. Homosexual male-to-female transsexual. e. Autogynephilic transsexual—a paraphilia in which the originally male individual is attracted to thoughts, images, or fantasies of himself as a woman. f. Treatment (1) Psychotherapy is usually ineffective. (2) Surgery and hormone treatment are used. (3) Trial periods are needed before surgery. (4) Outcome studies show a success rate of 87% of 220 male-to-female transsexuals and 97 % of 130 female-male transsexuals.

Lecture Launcher 12.6: Sex Change Operations III.

Sexual Abuse A. Childhood Sexual Abuse 1. Increase in relevant research a. Childhood sexual abuse is more common than once thought. b. Sexual abuse—sexual contact that involves physical or psychological coercion or at least one individual who cannot reasonably consent to the contact. c. Possible links between childhood sexual abuse and some disorders. d. Dramatic and well publicized cases have created controversy about the validity of childhood memories and the accuracy of recovered memories. 2. Prevalence of childhood sexual abuse a. Depends on the definition of abuse and childhood. b. Data from 22 countries found that 7.9% of men and 19.7% of women had suffered sexual abuse before age 18. 3. Consequences of childhood sexual abuse a. Short-term consequences include: fears, PTSD, sexual inappropriateness, poor self-esteem; 1/3 of children show no symptoms. b. Long-term consequences include: adult psychopathology, sexual symptoms.

Lecture Launcher 12.7: Neurological Effects of Childhood Abuse 4.

Controversies concerning childhood sexual abuse a. Children’s testimony (1) McMartin Preschool case. (2) Accuracy of testimony is a crucial issue because leading or coercive questioning methods were used. (3) Concocting stories increases when interviewers ask leading questions, repeat questioning, and reinforce some kinds of answers more than others. (4) Failure to proceed with care can result in false accusations. (5) Legal case: U.S. v. Desmond Rouse (2004).

Recovered memories of sexual abuse (1) The cases of Eileen Franklin against her father and Patricia Burgus against two Chicago psychiatrists. (2) Patricia Burgus was awarded $10.6 million in 1997. (3) Bass and Davis—Courage to Heal. (4) Induction of false memories. (5) Negative consequences of recovered memories.

Activity 12.3: False Memories and Their Effects B.

Pedohebehilia 1. Recurrent, intense sexually arousing fantasies, urges, and behaviors involving sexual activity with a prepubertal child 10–13. 2. The manipulation of the child’s genitals is usually involved. 3. Proposed DSM-5 is encompassing both pedophilia and hebephilia. 4. Nearly all pedophiles are male; 2/3 of victims are girls. 5. Studies using the penile phlethysmograph. 6. Pedophiles aremore likely to believe that children benefit from sexual contact and that children initiate sexual contact. 7. Pedohebephilia usually begins in adolescence and persists throughout a person’s life. 8. Cases of pedophilia among the Catholic clergy—at least 400 priests were charged with sexual abuse during the 1980s; $400 million was paid out in damages between 1985 and the early 1990s. 9. B4UAct (Before You Act). 10. John Geoghan was found guilty of sexually molesting two boys and accused of sexually molesting dozens more in the Boston area.

Incest 1.

2. 3. 4. 5. Rape 1.

Historical and biological considerations about incest are presented, this is universally considered taboo in almost all human societies. Incidence may be underreported in our society. Brother-sister incest most common; father-daughter incest is second. Multiple patterns of incest may exist within the same family. Associated with pedophilia. Prevalence a. Studies show wildly different estimates. b. Definitions are not consistent. c. Statutory rape is sexual activity with a person is under the age of consent (see Figure 12.1). d. Variability in the way information is gathered. Is rape motivated by sex or aggression? a. Traditionally classified as a sex crime. b. 1970s—rape seen as motivated by the need to dominate, exert power, and humiliate rather than by sexual desire. c. Sexual motivation is often an important factor (1) Victims tend to be in their teens and early 20s. (2) Rapists cite sexual motivations. (3) Some rapists exhibit features associated with paraphilias and have multiple paraphilias. d. Several prominent researchers argue that all rapists have both aggressive and sexual motives. e. Classification systems for rapists; not clear which is best. Rape and its aftermath a. Repetitive, planned activity rather than a single event. b. 80% of rapists commit the act in the neighborhoods in which they live. Copyright © 2013 Pearson Education, Inc. All rights reserved. 235

c. d. e. f. g. h.

Most rapes occur in urban settings, at night, in places ranging from dark, lonely streets to elevators, hallways, apartments, and homes. Acquaintance rapes account for 2/3 of reported rapes (See Figure 12.2). Physical trauma combines with psychological factors (rape trauma syndrome). Possibility of pregnancy or sexually transmitted disease. Negative impact on victim’s intimate relationships. Myth of victim-precipitated rape; rape shield laws began to appear in the 1970s.

Teaching Tip 12.3: Peer Counselors 4.

Rapists and causal considerations a. FBI statistics indicate that rape is a young man’s crime; 60% of all rapists are under age 25, 30%–50% are married and living with their wives at the time of the crime. b. Low end of socioeconomic ladder and commonly have a prior criminal record. c. Date rapists have a different profile: often middle- to upper-class young men who rarely have criminal records. d. Both types of rapists may be characterized by promiscuity, hostile masculinity, and emotionally detached, predatory personalities. e. Some are afflicted by a paraphilia. f. Deficits in cognitive appraisal of women, social and communication skills, insensitivity to social cues or pressures, a lack of personally intimate relationships, quick loss of temper, and impulsivity. g. Only 20%–28% of rapes are reported. h. Conviction rates are low (50%); only 2/3 serve any jail time, 50% are convicted.

Activity 12.4: Rape Reporting Procedures C.

IV.

Treatment and Recidivism of Sex Offenders 1. Psychotherapies and their effectiveness 2. Megan’s Law The World Around Us 12.2 a. Therapies typically have one of four goals: (1) Modify patterns of sexual arousal typically with aversion therapy or covert sensitization; must replace deviant arousal patterns with arousal to acceptable stimuli. (2) Modify cognitions and social skills through cognitive restructuring and social skills training. (3) Change habits or behavior. (4) Reduce sexual drive. b. Sexual offenders are difficult to treat successfully; many studies show no differences between treated and untreated groups; recent meta-analysis showed that treated offenders were less likely to offend but effects were modest. c. Cognitive behavioral techniques appeared to be most effective. d. Non-pedophile child molesters and exhibitionists also found to respond better to treatment than pedophiles and rapists. 3. Biological and surgical treatments a. SSRIs have been found useful in reducing paraphilic desire and behavior but not with sex offenders. b. Controversial treatment of surgical and chemical castration. 4. Combining psychological and biological treatments. 5. Summary. Sexual Dysfunctions 1. Refers to impairment either in the desire for sexual gratification or in the ability to achieve it.

Activity 12.5: Getting Good Sex Information A.

Human Sexual Response 1. Desire phase. 2. Excitement phase or arousal. 3. Orgasm. 4. Resolution.

Teaching Tip 12.4: Empirically Validated? B.

Sexual Desire Disorders 1. Hypoactive sexual desire disorder a. Little or no sexual drive is present; most common female sexual dysfunction. b. What is “not enough” sexual interest is debatable. c. For many women, sexual desire is experienced only after sexual stimuli have led to subjective sexual arousal; linear sequence not accurate for women. d. Sustained use of bupropion improved sexual arousability and orgasm frequency in women. 2. Sexual aversion disorder. 3. Prior or current depression may contribute. 4. Treatment a. Lower levels of testosterone may be involved; however, replacing testosterone does not typically help. Sexual Arousal Disorders 1. Male erectile disorder (or erectile insufficiency) a. Barlow—cognitive distractions frequently associated with anxiety in dysfunctional people that seem to interfere with sexual arousal; preoccupation with negative thoughts. b. Formerly called impotence. c. Occur in as many as 90% of men using antidepressants. d. 18% of men ages 50–59 have some degree of erectile dysfunction. e. 37% between ages 57–85 report significant erectile difficulties. f. Vascular disease is the most common cause of erectile problems in older men. g. Untreated cases of priapism result in erectile dysfunction 50% of the time. h. Treatment (1) Cognitive-behavioral. (2) Medications such as Viagra. (3) Injections of smooth-muscle-relaxing drugs into the penile erection chambers. (4) Vacuum pump. (5) Penile implants. (6) Viagra (a) Works by making nitric oxide more available. (b) Promotes erection only if some sexual excitement is present. (c) More than 70% of men report improvement. (d) Two similar drugs introduced: Cialis and Levitra. (e) Improvements enhanced by cognitive-behavioral therapy. 2. Female sexual arousal disorder a. Involves an absence of arousal and unresponsiveness to stimulation. b. Possible causes include: early sexual traumatization, excessive and distorted socialization about the “evils” of sex, dislike or disgust with sexual partner, lowered tactile sensitivity. c. Treatment: (1) Few controlled studies have been conducted. (2) Vaginal lubricants are effective.

(3) D.

Viagra, Cialis, and Levitra not useful for women unless sexual arousal problems are due to antidepressants.

Orgasmic Disorders 1. Premature ejaculation a. Exact definition of this condition does not exist. b. Most common male sexual dysfunction at least up to age 59 c. Treatment: (1) Behavioral therapy such as the pause-and-squeeze technique. (2) Antidepressants such as Paxil and Zoloft can significantly prolong ejaculatory latency. 2. Male orgasmic disorder a. Persistent inability to ejaculate during intercourse. b. Psychological treatments emphasize the reduction of performance anxiety in addition to increasing genital stimulation. c. Specific physical problems such as multiple sclerosis and certain medications (especially the SSRIs) may be involved. d. Treatment (1) Focus on reducing anxiety over orgasm and focus on enjoying intimacy. 3. Female orgasmic disorder a. “Extra” stimulation is required for orgasm. b. No amount of stimulation can produce orgasm in lifelong orgasmic dysfunction; affects are highest in 21–24 year olds. c. Causal factors not well understood (1) Anxiety and tension. (2) Feelings of inadequacy. d. Treatment requires distinction between lifelong and situational dysfunction (1) Instruction and guidance for lifelong with high rates of success. (2) Situational more difficult to treat than lifelong.

Handout 12.3: Kegel Exercises E.

Sexual Pain Disorders 1. Vaginismus a. Defined as involuntary spasm of the muscles at the entrance to and outer third of the vagina. b. Questions about this definition; muscle tension, not spasm, is more frequently reported; perhaps pain upon penetration is more reliable diagnostic criterion. c. Relatively rare. d. Treatment (1) Banning of intercourse. (2) Training of vaginal muscles. (3) Graduated self-insertion of vaginal dilators. 2. Dyspareunia a. Painful sexual intercourse is more common in females than males, also known as painful coitus. b. Infections or structural pathology may be present. c. Some argue this should be reclassified as “pelvic pain disorder” under the pain disorder except of a sexual disorder. d. Treatment (1) Addresses specific organic or conditioned psychological responses.

Activity 12.6: Is the Cure Worse than the Disease? V.

1. Correlations between childhood sexual abuse and later problems of small magnitude. 1. Family pathology, not abuse, may be involved. 2. Incest and forced sex associated with more problems. 3. Age at which CSA was experienced unrelated to adult outcome. Controversy over study ignited by Dr. Laura Schlessinger 1. Claims were socially dangerous: giving comfort to child molesters and being insensitive to victims of CSA. 2. U.S. House of Representatives condemned the study. 3. Study not scientifically strong enough to justify conclusions a. Relied on college students; however, results confirmed with community samples. b. Statistical decisions and analyses were criticized; however, results did not change when analyzed differently. Rind has extended this discussion to adult-adolescent sexual relationships 1. Reviews evidence that current views are driven by ideology and moral panic rather than by empirical research. 2. Evidence suggests that many teenage boys see perceived benefits from such relationships in regards to their sexual confidence and self-acceptance.

Key Terms autogynephilia cross-gender identification desire phase dyspareunia excitement (or arousal) phase exhibitionism female orgasmic disorder female sexual arousal disorder fetishism frotteurism gender dysphoria gender identity disorder hypoactive sexual desire disorder incest male erectile disorder male orgasmic disorder

masochism orgasm paraphilias pedophilia premature ejaculation rape resolution sadism sexual abuse sexual aversion disorder sexual dysfunction transsexualism transvestic fetishism vaginismus voyeurism

Lecture Launchers Lecture Launcher 12.1: Self-Determination of Sexual Orientation How much choice do students in your class feel they exert over their sexual orientations? Beyond their sexual attraction to males and females, how much choice went into the kinds of material they find erotic? It is not necessary for students to disclose their sexual attractions to answer these questions. The questions are about the process of acquiring sexual desires and preferences, regardless of what they actually are. Does exposure to particular erotic stimuli enhance sexual attraction to them, or is it the prior attraction to such material that causes people to seek them out? What effect does the ready availability of erotic and pornographic material on the Internet have on people? Does it change peoples’ erotic preferences or enhance their pre-existing ones? Lecture Launcher 12.2: Should Transvestism be a Mental Disorder? A classroom discussion of the status of transvestism as a mental disorder can draw out a variety of diagnostic issues, especially the significance of “harm” and “dysfunction” as well as the role of values in demarcating normal and abnormal. Male transvestism is unusual, but statistical infrequency in and of itself is insufficient to qualify it as a mental disorder. The DSM requires distress and impairment in order to make the diagnosis, but a recent study found transvestic men to be normal on a wide variety of measures of personality, sexual functioning, and personal distress (Brown et al., 1996, Journal of Nervous & Mental Disease, vol. 184, pp. 265–273). Most peoples’ immediate reaction to descriptions Copyright © 2013 Pearson Education, Inc. All rights reserved. 239

of the disorder involve pathologizing, making this an interesting disorder to discuss with respect to the boundaries of abnormality. Lecture Launcher 12.3: Double Standards How would you know if a woman had a transvestic fetishism? In fact, the DSM-IV-TR recognizes transvestism only in males. Do class members view women who dress in men’s clothing differently than they view men who dress in women’s clothing? What would a woman have to wear to unambiguously be in male attire—a tuxedo? More generally, how are feminine males perceived compared to masculine females? Why is the term “sissy” more pejorative than the term “tomboy”? Why can women stand closer to each other and have more intimate friendships with each other than men? We often speak of the narrow social constraints placed on female gender roles, but isn’t the opposite more the case? Lecture Launcher 12.4: What’s the Concern with Voyeurism? Ask students what’s the big deal with concerns over voyeurism? What about exhibitionism? Why would APA be concerned about these behaviors? Remind students that these behaviors are largely illegal (e.g., Peeping Toms, flashers on subways), and they may also be related to criminal-escalating behaviors which would be the real concern. That is, much like drug use, tolerance increases. What starts as peeking in a neighbor’s window may eventually no longer provide sexual release for the perpetrator and eventually the individual may need to up the ante to achieve sexual release (e.g., breaking into houses). Some researchers have argued that voyeurism should not be considered a separate disorder, as most exhibitionists are also voyeurs (Langevin, 1983) Lecture Launcher 12.5: Why Are Paraphilias So Much More Common Among Men? Paraphilias are almost never diagnosed in females. Sexual masochism is the most common paraphilia found among women, but even masochism is diagnosed 20 times more frequently in men. What might account for this enormous difference? Among the possible explanations is the fact that men are generally more likely to be arrested, and their sexual misbehaviors are therefore more likely to come to the attention of authorities. Anthropologically speaking, it may be that male external genitalia have become more sexually conditionable via evolutionary pressures. Similarly, lower male investment in gestation and nursing of offspring might confer reproductive advantages on promiscuity and sexual improvisation that would not have benefited females. Finally, as described in Lecture Launcher 12.3 Double Standards, men may operate within narrower sex roles, pushing more activities outside accepted ranges. For instance, women are permitted to wear men’s clothing but not vice versa. Lecture Launcher 12.6: Sex Change Operations Sex change operations are very complicated to get, with lengthy waiting periods, extensive psychological screening, and very high cost. Why? If someone wants a sex change operation why can’t they just get one? How does this procedure differ from any other medical procedure? Is it more like cosmetic surgery or the correction of a birth defect? Should insurance pay? How would you determine whether someone is a good candidate for the procedure? What kinds of scientific data would be necessary to set policies in this area? Would you want to see data on postsurgical adjustment to being a member of the opposite sex? How strong a predictor of post-surgical adjustment would be strong enough to serve as a basis for denying someone access to the surgery—even someone willing and able to self-pay? Lecture Launcher 12.7: Neurological Effects of Childhood Abuse The Adverse Childhood Experiences (ACE) Study, which began in the mid- to late-1990s, looks at adverse early childhood experiences like abuse and adult outcome data. Early results indicate neglect and abuse has actual effects on the development of the brain. One argument is that being abused as a child may affect the development of the brain via epigenisis. That is, these early negative experiences shape the way the brain becomes wired. For example, let’s take poor exercise habits. Would sitting on the sofa watching TV or playing video games all day affect the development of the brain? One would argue yes. Further, research indicates, being aggressed against or witnessing extreme abuse of others would have a direct effect on information processing and attribution. Thus, it would have effects on behavior as well as cognition and affect. See the CDC’s Web site: www.cdc.gov/nccdphp/ACE/ for more details on the study and its findings.

Is being gay biologically based? This is a question researchers are grappling with. Unfortunately, there are camps on both sides of the issues that would either love or hate for research to show this. Why love? Ask students what are the benefits of research showing that people are gay due to biological bases? What are the negatives to research showing this? Does this explain why we don’t see much more research on this area? Have students read, “Never Ask a Gay Man for Directions” (Bering, 2009), www.sciam.com/article.cfm?id=never-ask-a-gay-man-for-directions, and answer the following questions. 1. Describe the relationship between being gay and spatial cognition. 2. The research here would argue what in relation to homosexuality? 3. How are gay men different from straight men in regards to spatial skills? What about bisexuals? 4. Does this research argue that gay men are like women? 5. Based on this and the information described in your text, what would you argue is the etiology of homosexual behavior? Activity 12.2: Show Me Yours, and I’ll Show You Mine Men’s and women’s magazines are highly honed to interest largely one or the other gender. They are designed to appeal almost exclusively to ways men and women differ from each other. Interestingly, they both provide nearly constant coverage of sex, albeit from quite different perspectives. Awareness of the differences between the portrayals requires reading examples of magazines written for the other gender. Therefore, this activity requires students to closely study sex articles in magazines written for the other sex. Men can read Cosmopolitan and Vogue or Women’s Day while women can read Maxim and GQ or Men’s Health. Bearing in mind that these articles were not written for them, ask students to reflect on how their own sex is being represented and how the material is different from what might appear in magazines written for them. Students who have not read such magazines at all before this exercise will need to investigate some from the other category to gain the comparative perspective upon which this assignment relies. Activity 12.3: False Memories and Their Effects Assign students to research the McMartin Trial or one of the other high-profile false memory cases described in the text. Have them locate a case and write a paragraph summarizing the case and then a paragraph on how Loftus argues it would be interpreted today. Activity 12.4: Rape Reporting Procedures Many rapes go unreported out of a fear about how the report will be handled. Have students investigate how rape reports are handled on campus. Are there any outreach programs to encourage reports of rape? Does the campus have a mechanism to support rape victims? What services are called into action when a rape is reported on campus? Does the campus have a rumor control service that may deal with inaccurate information following a sexual assault? Activity 12.5: Getting Good Sex Information This activity begins by asking students to jot down their questions and concerns about sex. These questions can then be collected and collated into a list that is then distributed back to students to research on their own. The research part of the activity can be done in groups or individually. The list can be divided among the students/groups if it is lengthy, or else the research can be duplicated for comparison purposes. Class time can then be devoted to going through each question and the answers students found. An important aspect of this assignment is to have students carefully observe the wide variation in the quality and authority of the sources they find. It is especially instructive to consider the sources of contradictory answers. Alternatively, the instructor can answer the questions for the class or else the questions can be forwarded to a guest expert who will be visiting the class later. It is also instructive to process the discomfort this topic can produce, and how that discomfort is often expressed with humor. Activity 12.6: Is the Cure Worse Than the Disease? People taking medications for a number of medical conditions may experience sexual dysfunction as a side effect of their treatment. How does this affect the utilization of the medications, and how does it influence the psychological adjustment of the patient? Notably, SSRI antidepressant medications frequently have sexual side effects. These can be interpreted as related to the depression itself when they are actually side effects of its treatment. Given the substantial role of cognitive processes such as “spectating” and performance concerns, is it wise to alert people taking antidepressant medications to the potential effects they might have on their sexual functioning, or that might lead to a self-fulfilling prophesy or medication non-compliance? Copyright © 2013 Pearson Education, Inc. All rights reserved. 241

Activity 12.7: What do Graham Crackers have in Common with Kellogg’s Corn Flakes? Prepare ahead of time: pieces of graham crackers and corn flakes in ramekins with lids. Then ask the students to examine the two foods and evaluate what they have in common. After the students have been able to assess the taste, smell, texture, etc. and have shared their thoughts, you can use this time to open with the abstinence theory, and the development of food like graham crackers and Kellogg’s corn flakes as a way to deter sexual appetite. Activity 12.8: Guest Speaker It is helpful to have guest speakers come into the classroom to give a personal testimonial or provide additional education on these disorders. You can check out the Web site www.aasect.org/, then click for the public, and find a professional. You could locate on this site a sex educator or sex therapist in your area that could come speak to the students. It may be helpful to prepare the questions from the students ahead of time.

MyPsychLab Resources MyPsychLab Resource 12.1: Video on “Gender vs. Sex” Here, Florence Denmark discusses the theoretical differences between the terms “gender” and “sex.” This may help clarify the difference to students. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 12, Sexual Variants, Abuse, and Dysfunctions. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Gender vs. Sex” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 12.2: Video on “Gender Identity Disorder: Denise” 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 cross-dressing and disgust with her own genitals. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 12, Sexual Variants, Abuse, and Dysfunctions. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Gender Identity Disorder: Denise” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise.

Teaching Tips Teaching Tip 12.1: Preference versus Identification It is important to make very clear to students that homosexuality is not the same thing as gender identity. One deals with sexual preference, the other with concerns about ones actual gender! Every time I cover this material, students continue to make these errors, wrongly assuming that these are not distinct concepts. Teaching Tip 12.2: Gender Appropriateness To help illustrate societal roles on how children’s behaviors are viewed, ask the class to raise their hand if, for instance, they had a 5-year-old daughter who played with cross-sex roles or activities (e.g., soccer, karate, plays with boys, plays with trucks, wants to be a fireman, etc.) Chances are few will object, some may even report they will encourage these behaviors. Now change it to sons. What if their son wants to engage in cross-sex activities or play (e.g., enjoys dance class, likes to wear sparkly shirts, plays with girls, wants to have a princess theme birthday party)? Here you will undoubtedly get a very different response, everything from laughing to outrage. One argument here is based on the research that universally, males are more strongly sex typed. This would suggest that societally, we are more concerned with males engaged in cross-sex activities and roles, and thus are more likely to take them to a doctor to determine “what’s wrong with them?” Although an issue perhaps with peer interaction, what other negative consequences can arise? Since roughly 40%–60% of GID kids are homosexual in adulthood, could this just be an unease with something that might be a biologically based preference? Teaching Tip 12.3: Peer Counselors Copyright © 2013 Pearson Education, Inc. All rights reserved. 242

Mulenhard and Linton (1987) found that 25% of college males have admitted to using sexually coercive behavior at least once in their college years. In the same study, they also found that someone they had been in a relationship with for almost a year committed most acts of sexual aggression against women. This is a cause for concern amongst the female students in your class. Although this is beyond the scope of this class, it is an excellent opportunity for you to invite the peer counselors, or the student counseling center, in to discuss incidents on your campus and what students should do if they ever feel as though something has been done against their will. You may also want to remind students that no means no. So if they are with a female who says no, even if they are acting like they mean yes, they should leave! This way, there is no risk of miscommunication. (See Figure 12.1 for a chart looking at the age of sexual assault victims, note college age is second only to high school age). Teaching Tip 12.4: Empirically Validated? Although you covered this way back, it is important to remind students that the S in DSM stands for statistics. Thus, the empirical validation of data should be of the utmost importance. Again, emphasize to students that many researchers should all be finding about the same pattern of results in their data if the psychological phenomenon is true.

Handout Descriptions Handout 12.1: Reality TV = Voyeurism? Does reality TV cater to viewers’ voyeuristic tendencies? What is the nature of its appeal? For this activity, have students select two reality TV programs and provide examples of what may encourage voyeurism. Handout 12.2: An Example of Classical Conditioning of a Paraphilia Here are two examples of how a paraphilia could be classically conditioned. You can either give students the answers, or have them do it on their own and then provide the answers. You could also ask them to generate their own example. Handout 12.3: Kegel Exercises Kegel exercises are recommended by sex therapists working with clients experiencing a variety of sexual dysfunctions. The Kegel muscle is near the pelvic floor in both men and women. The muscles are attached to the pelvic bone and act like a hammock, holding in the pelvic organs. They are also the muscles that are used to interrupt the urine stream. Students can be asked to identify this muscle by the next class period and also to learn to flex the Kegel muscle directly. Kegel exercises then involve simply flexing the Kegel muscle a certain number of times every day. Kegel exercises are also recommended for pregnant women, to improve muscle tone prior to childbirth, and for incontinence. Some even advocate doing them regularly to enhance otherwise functional sexuality.

Video/Media Sources ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Adventures in the Gender Trade: A Case for Diversity. New York, NY: Filmmakers Library. Anatomy of Desire. New York, NY: The Cinema Guild. The Blank Point: What is Transsexualism? New York, NY: The Cinema Guild. Child Abuse: It Shouldn’t Hurt to Be a Kid. Boston, MA: Fanlight Productions. Child Molestation: Sorting Out the Truth. Allyn & Bacon Video Library. Child Sex Abusers. Princeton, NJ: Films for the Humanities and Social Sciences. Child Sexual Abuse: The Clinical Interview. New York, NY: Insight Media. Date Rape. Princeton, NJ: Films for the Humanities and Social Sciences. Date Rape Drugs: An Alert. Allyn & Bacon Video Library. Date Violence: A Young Woman’s Guide. Allyn & Bacon Video Library. Fresh Talk. New York, NY: The Cinema Guild. A Journey Back: From Rape to Healing. Allyn & Bacon Video Library. Juvenile Sex Offenders: Voices Unheard. Princeton, NJ: Films for the Humanities and Social Sciences. Love, Intimacy, and Sexuality. Growing Old in a New Age Series. South Burlington, VT: Annenberg/CPB Multimedia Collection. Male Rape. Princeton, NJ: Films for the Humanities and Social Sciences.

▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Men, Women, and Sex Difference: Boys and Girls are Different. Princeton, NJ: Films for the Humanities and Social Sciences. Multiple Genders: Mind and Body in Conflict. Princeton, NJ: Films for the Humanities and Social Sciences. Pedophiles. Princeton, NJ: Films for the Humanities and Social Sciences. Rape: An Act of Hate. Princeton, NJ: Films for the Humanities and Social Sciences. Rape by Any Name. Boston, MA: Fanlight Productions. The Remarkable Story of John/Joan. New York, NY: Filmmakers Library. Sexual Brain—The Brain Video Series. Princeton, NJ: Films for the Humanities and Social Sciences. Sexual Disorders . The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection. Transgendered Cops—#8 ABC News and Client Interviews. Allyn & Bacon Abnormal Psychology Video. Viagra: A New Sexual Revolution? Princeton, NJ: Films for the Humanities and Social Sciences. When a Kiss Is Not Just a Kiss. Boston, MA: Fanlight Productions. You Don’t Know Dick. Berkeley, CA: University of California Extension Center for Media and Independent Learning.

Web Links Web Link 12.1: www.healthysex.com/ HealthySex.com is an educational site developed “to promote healthy sexuality—sex based on caring, respect, and safety.” It has information on sexual health, intimacy, communication, abuse, addiction recovery, sexual fantasy, and midlife sex. Web Link 12.2: www.aasect.org/ The American Association of Sex Educators, Counselors, and Therapists (AASECT) is a professional organization interested in promoting understanding of human sexuality and healthy sexual behavior. Their Web site has sex FAQs, links, and information about locating a therapist. Web Link 12.3: www.sexscience.org/ The Society for the Scientific Study of Sexuality is an interdisciplinary society seeking to improve the quality of sex research and its clinical applications. Web Link 12.4: www.indiana.edu/~kinsey/index.html This is the Web site of the Kinsey Institute at Indiana University–Bloomington. Web Link 12.5: www.eeoc.gov/laws/types/sexual_harassment.cfm This site, sponsored by the U.S. Equal Employment Opportunity Commission, provides definitions, statistics, and links to regulations and other information about sexual harassment. Web Link 12.6: www.emedicine.com/med/topic3127.htm This site provides a detailed article describing paraphilias, diagnostic criteria, symptoms, causes, treatments, and medications.

Handout 12.1 Reality TV = Voyeurism?

Does reality TV encourage voyeurism? Select two reality programs and provide examples of what may encourage voyeurism. Television Program

Premise of Program

Voyeuristic Characteristics

Handout 12.2 An Example of Classical Conditioning of Paraphilias

Example of arousal associated with shoes. Johnny is a 14-year-old male who is looking at one of his mom’s magazines; specifically he is looking at an advertisement for women’s shoes when he becomes aroused and spontaneously ejaculates. Now when he looks at women’s shoes he becomes sexually aroused. UCS: spontaneous ejaculation UCR: arousal CS: women’s shoes CR: arousal Now lets take one more example; arousal from exhibitionism. Tyrell is a 17-year-old male riding the subway. He has forgotten to zip his pants prior to boarding the train, thus leaving him exposed. He notices a girl sitting there laughing at him and he becomes aroused. Even once he realizes her attention is due to his unzipped fly, he is still aroused. UCS: female attention UCR: arousal CS: being exposed in public CR: arousal

In both of these cases, the arousal is misattributed to the CS instead of the UCS.

Handout 12.3 Kegel Exercises

Kegel exercises are recommended by sex therapists working with clients experiencing a variety of sexual dysfunctions. The Kegel muscle is near the pelvic floor in both men and women. The muscles are attached to the pelvic bone and act like a hammock, holding in the pelvic organs. They are also the muscles that are used to interrupt the urine stream. Next time you are urinating, identify your Kegel muscle by repeatedly interrupting the urine stream and memorizing the muscles you use to do so. Then learn to flex the Kegel muscle directly. Kegel exercises simply involve flexing the Kegel muscle a certain number of times every day. Kegel exercises are often recommended for pregnant women, to improve muscle tone prior to childbirth, and for incontinence. Some people even advocate doing them regularly to enhance otherwise functional sexuality.

CHAPTER 13: Schizophrenia and Other Psychotic Disorders Teaching Objectives 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Describe the origins of schizophrenia, and what is meant by the term schizophrenia. Define who is at risk for the development of schizophrenia. Describe what is meant by the term schizophrenia and the evolution of diagnosing this disorder. Describe and differentiate between positive, negative, and disorganized symptoms of schizophrenia. Explain why psychologists have grouped the symptoms in this manner. Compare and contrast the subtypes of schizophrenia. Describe the clinical features of other psychotic disorders. Summarize the biological, psychosocial, and sociocultural causal influences in schizophrenia. Explain how these theories may be integrated. Evaluate the various biological and psychosocial treatments for schizophrenia. Describe what might be seen as the most effective treatment approach for someone who is diagnosed with schizophrenia. Discuss current issues in treating schizophrenia, including limitations of antipsychotics and the need for expanded psychosocial intervention. Differentiate between primary, secondary, and tertiary prevention, and explain the difficulties associated with trying to prevent schizophrenia.

Chapter Overview/Summary Schizophrenia is the most severe form of mental illness. It is characterized by impairments in many domains and affects approximately 1% of the population. Characteristic symptoms of schizophrenia include hallucinations, delusions, disorganized speech, disorganized and catatonic behavior, and negative symptoms. Most cases of schizophrenia begin in late adolescence or early adulthood. The disorder begins earlier in men than it does in women. Overall, the clinical symptoms of schizophrenia tend to be more severe in men than women. Women also have a better long-term outcome. Genetic factors are clearly implicated in schizophrenia. Having a relative with the disorder significantly raises a person’s risk of developing schizophrenia. Other factors that have been implicated in the development of schizophrenia include prenatal exposure to the influenza virus, early nutritional deficiencies, and perinatal birth complications. Current thinking about schizophrenia emphasizes the interplay between genetic and environmental factors. Even though schizophrenia begins in early adulthood, researchers believe that it is a neurodevelopmental disorder. A “silent lesion” in the brain is thought to lie dormant until normal developmental changes occur and expose the problems that result from this brain abnormality. Many brain areas are abnormal in schizophrenia, although abnormalities are not found in all patients. Brain abnormalities that have been found include decreased brain volume, enlarged ventricles, frontal lobe dysfunction, reduced volume of the thalamus, and abnormalities in temporal lobe areas such as the hippocampus. The most important neurotransmitters implicated in schizophrenia are dopamine and glutamate. Patients with schizophrenia have many problems in aspects of neurocogntive functioning. They show a variety of attentional deficits (e.g., poor P50 suppression and deficits on the Continuous Performance Test). They also show eye-tracking dysfunctions. Patients with schizophrenia are more likely to relapse if their relatives are high in expressed emotion (EE). High EE environments may be stressful to patients and may trigger biological changes that cause dysregulations in the dopamine and glutamate systems. This could lead to a return of symptoms. Interestingly, both being reared in an urban environment and immigration have been shown to increase the risk of schizophrenia perhaps through the effect of stress. For many patients, schizophrenia is a chronic disorder requiring long-term treatment or institutionalization. However, with therapy and medications, about 38% of patients show a reasonable recovery. Only about 16% of patients recover to the extent that they no longer need treatment. Patients with schizophrenia are usually treated with antipsychotic (neuroleptic) medications. Secondgeneration antipsychotics cause fewer extrapyramidal (motor abnormality) side effects. Antipsychotic drugs work by blocking dopamine receptors. Overall, patients taking second-generation antipsychotics do better than patients taking conventional antipsychotic drugs. Psychological treatments for patients with schizophrenia include cognitive behavior therapy, social skills training, and other forms of individual treatment as well as case management. In

addition, family therapy is also beneficial. Family therapy focuses on reducing EE and provides families with communication skills and other skills that are helpful in managing the illness.

Detailed Lecture Outline I.

Schizophrenia A. Origins of the Schizophrenia Construct 1. Haselm, an apothecary at Bethlem Hospital in London, first described schizophrenia in the case of John Tilly Matthews in 1810. 2. Morel, 50 years later, described a case in a 13-year-old boy; called the condition demence precoce. 3. Kraepelin (1886)—careful description of what he called dementia praecox. 4. Bleuler (1911)—originated the term schizophrenia because he believed the disorder was primarily characterized by a disorganization of thought processes, a lack of coherence between thought and emotion, and an inward orientation away (split off) from reality.

Lecture Launcher 13.1: Schizophrenia in Historical Perspective B.

II.

Epidemiology of Schizophrenia (see Figure 13.1 for chart of age of onset) 1. Lifetime prevalence of about 0.7%, 1 out of every 140 people who survive at least to age 55. 2. Higher risk in certain groups: parent with schizophrenia, family with schizophrenia, older father (45–50) at time of birth, having a parent who works as a dry cleaner, people of Afro-Caribbean origins living in the U.K. 3. Vast majority of cases begin in later adolescence or early adulthood 18–30 years of age. 4. Males tend to have an earlier onset, between the ages of 20–24, and a more severe form of the disorder. 5. Brain abnormalities are more severe in men than in women. 6. More common in males, for every three men that have the disorder only two women have the disorder. 7. Estrogen levels explain the delayed onset in females.

Clinical Picture A. Delusions 1. Comes from the Latin verb ludere, which means “to play”; in essence, tricks are played on the mind, occur in 90% of patients at some point in their illness. 2. Delusions are not exclusive to schizophrenia. 3. Certain delusions are common in schizophrenia: a. Belief that one’s thoughts, feelings, or actions are being controlled by some outside agent. b. Thought broadcasting. c. Thought insertion. d. Some external agency has robbed one of one’s thoughts (thought withdrawal). e. Delusions of reference. f. Delusions of bodily changes.

Handout 13.1: The Delusion Border MyPsychLab Resource 13.1: Video on “Schizophrenia: The Case of Georgina” MyPsychLab Resource 13.2: Video on “Schizophrenia: Larry” MyPsychLab Resource 13.3: Video on “Rodney: Schizophrenia” B.

1. 2. 3.

Sensory experience in the absence of any external perceptual stimulus. Comes from the Latin verb hallucinere, meaning to wander in mind or idle talk. Auditory are the most common—75% of those with schizophrenia report auditory hallucinations. 4. Imaging studies show that hallucinating patients show increased activity in Broca’s area—area of the temporal lobe involved in speech production; suggests that auditory hallucinations occur when patients misinterpret their own self-generated and verbally mediated thoughts (inner speech or self-talk) as coming from another source. 5. 13.1 The World Around Us: Stress, Caffeine, and Hallucinations. Disorganized Speech 1. Person fails to make sense, despite seeming to conform to the semantic and syntactic rules governing verbal communication; has been referred to as “cognitive slippage,” “derailment,” “loosening of associations,” and “incoherence.” 2. Neologisms.

Activity 13.1: “The Disordered Monologue” D.

Disorganized Speech and Behavior 1. Impairment in goal-directed activity; deterioration from a previously mastered standard. 2. Deficits may appear in personal hygiene, disregard for personal safety and health, silliness or unusual dress, or a catatonic stupor. Positive and Negative Symptoms (see Table 13.1 for a list of positive, negative, and disorganized symptoms) 1. Positive vs. negative syndrome schizophrenia; disorganized symptom pattern now recognized. 2. Disorganized symptom. 3. Positive symptoms reflect an excess or distortion: delusions, hallucinations. 4. Negative symptoms reflect an absence or deficit: alogia, flat or blunted affect, avolition. 5. Research suggests that even when flat or blunted emotional expressiveness occurs, subjective reports of patients indicate they are experiencing plenty of emotion. 6. Flat affect—blunted emotional expression. 7. Alogia—little speech. 8. Avolition—inability to initiate or persist in goal-directed activities. 9. 13.2 The World Around Us: Anticipating DSM-5: Subtypes of Schizophrenia. Subtypes of Schizophrenia 1. Paranoid type a. Delusions of persecution and grandeur are common. b. The “paranoid construction” gives the person some sense of purpose and identity. c. Tend to function at a higher level and have more intact cognitive skills; prognosis generally better. 2. Disorganized type a. Earlier, more gradual onset. b. A pattern of severe disorganization, progressing into emotional indifference and infantile behavior. c. Hallucinations and delusions may be present but are not organized. d. Prognosis is poor. 3. Catatonic type a. Pronounced motor symptoms are apparent. b. Stupor and excitement phases can be seen; violent behavior can occur during excitement phase. c. Some patients may automatically obey commands, imitate the actions of others (echopraxia), or mimic their phrases (echolalia). d. Though common at one time, now uncommon except for less industrialized regions of the world. Copyright © 2013 Pearson Education, Inc. All rights reserved. 250

e. Stupor has been interpreted as patient’s way of coping or maintaining control. Undifferentiated type a. “Wastebasket” category. b. Those in the acute, early stages of schizophrenia might be diagnosed as undifferentiated . Residual type a. Suffered at least one episode of schizophrenia but not currently exhibiting any prominent positive or disorganized symptoms. b. Prominent symptoms consist only of negative symptoms.

MyPsychLab Resource 13.4: Explore: “Types and Symptoms of Schizophrenia” G.

Other Psychotic Disorders 1. Schizoaffective disorder a. Features of schizophrenia and a mood disorder. b. Bipolar and unipolar subtype possible. c. Prognosis better than for schizophrenia.

MyPsychLab Resource 13.5: Video on “Schizoaffective Disorder: Josh” 2.

Schizophreniform disorder a. Schizophrenia-like psychoses that last at least one month but not as long as six months. b. Most often seen in an undifferentiated form. c. May or may not be related to subsequent psychiatric disorder. d. Prognosis better than for schizophrenia. Delusional disorder a. Other than delusions, behave normally. b. Interesting subtype is erotomania. Brief psychotic disorder a. Sudden onset of psychotic, grossly disorganized, or catatonic symptoms. b. Often lasting only days. c. Often triggered by stress. Shared psychotic disorder (folie a deux) a. Diagnosed when a person, in a close relationship with a psychotic individual, begins to believe the same delusions. b. May spread to include an entire family.

Lecture Launcher 13.2: The Three Christs of Ypsilanti: A Psychological Study II.

Risk and Causal Factors A. Genetic Aspects (see Figure 13.2 for genetic relationship of schizophrenia) 1. Twin studies a. Higher concordance rate for schizophrenia in monozygotic twins. b. Torrey—MZ concordance rate is 28% and 6% in DZ. c. Suggests that genes play a role but genes are not sufficient for explaining schizophrenia. d. Studies of discordant MZ twin pairs reveal that children of the “well” twin are at significantly higher risk of developing schizophrenia. e. For first-degree relatives (e.g., parents, siblings, or offspring) of a proband with schizophrenia is about 10%; second-degree relatives who share only 25% of their genes with the proband is 25%, with a lifetime of 3%. f. Age-corrected incidence—at 17.4% for the offspring of the MZ twins. g. 13.3 The World Around Us: The Genain Quadruplets.

MyPsychLab Resource 13.6: Watch: “Genetic Schizophrenia” 2.

Adoption studies a. Twin studies overestimate the importance of genes by confounding environment and genes. b. Heston found higher rates of schizophrenia among adopted children of schizophrenic biological parents. Quality of the adoptive family a. Finnish Adoptive Family Study of Schizophrenia (1) 21 year follow-up. (2) Children of biological parents with schizophrenia developed more schizophrenia and schizophrenia-related disorders than did the controls. (3) Combination of genetic risk and high communication deviance was found to be problematic; children with genetic risk but low communication deviance families were healthier than the control children. b. Tienari and colleagues—recent evidence of gene-environment interaction; only children with high genetic risk and adverse family environment went on to develop schizophrenia or schizophrenia-related disorders.

Teaching Tip 13.1: Adoptee Data 4.

Molecular genetics a. Interested in uncovering the mode of genetic transmission; one method of doing this is through complicated mathematical models called segregation analysis. b. Schizophrenia probably involves multiple genes working together. c. Specific regions on chromosomes 22, 6, 8, and 1 are being investigated. d. By using known genes (DNA markers), can predict where the genes for schizophrenia might be—called linkage analysis. e. Currently looking for candidate genes: genes known to be involved in some of the processes that are thought to be problematic in schizophrenia, such as genes involved in dopamine metabolism. 5. Endophenotypes a. Endophenotypes are discrete, stable, and measurable traits that are thought to be under genetic control. b. It appears as though a cluster of specific symptoms, perceptual aberrations, working memory tasks, and magical ideation may have a predisposition to schizophrenia. Prenatal Exposures 1. Viral infection a. In Northern hemisphere, more people with schizophrenia are born between January and March. b. 1957 flu epidemic in Finland—elevated rates of schizophrenia in children whose mothers had been in their second trimester. 2. Rhesus incompatibility a. Associated with increased risk of schizophrenia. b. For males, raises risk of schizophrenia to 2.1%. c. Mechanism might involve oxygen deprivation. 3. Pregnancy and birth complications a. Birth complications increase risk of schizophrenia. b. Specifically, obstetric complications that reduce oxygen flow such as breech delivery, prolonged labor, or the cord around the baby’s neck. 4. Early nutritional deficiency a. Dutch Hunger Winter.

Children conceived during the height of the famine had a 2-fold increase in their risk of later developing schizophrenia. c. Unclear whether problem is general lack of nutrition or of a specific nutrient. 5. Maternal stress a. If a mother experiences intense stress in the first trimester or beginning of the second. b. Death of a loved one associated with 67% increased risk for schizophrenia. c. Stress hormone passed to the fetus through the placenta. Genes and Environment in Schizophrenia: A Synthesis 1. Focus on MZ twins have caused an overestimate of heritability of schizophrenia; MZ and DZ twins do not have equally similar prenatal environments. 2. 2/3 of MZ embryos are monochorionic (share placenta and blood supply). 3. Greater increase of schizophrenia in MZ twins may be due to greater chance of shared infections in monochorionic environment. 4. Only people who had a parent with schizophrenia and who had birth complications later developed brain abnormalities such as enlarged ventricles; genetic liability predisposes person to suffer more damage from environmental insults (see Figure 13.4). A Neurodevelopmental Perspective 1. Vulnerability to schizophrenia stems from a brain lesion that occurs very early in development, perhaps even before birth; lesion is dormant until normal maturation of the brain shows the problems. 2. Problem may be a result of neuronal migration. 3. Developmental precursors of schizophrenia a. Walker—family home movies (1) Preschizophrenic children showed more motor abnormalities, including unusual hand movements; less positive facial emotion and more negative facial emotion. (2) Differences frequently present by age 2. b. High-risk research (1) Unique group as 89% of patients with schizophrenia have no first- or second-degrees relatives with schizophrenia. (2) Found to exhibit deficits in attention, social competence, and motor abnormalities. c. Study of endophenotypes (1) Defined as discrete measurable traits that are thought to be linked to specific genes that might be important in schizophrenia. (2) One example might be people who score high on perceptual aberrations and magical ideation. Structural and Functional Brain Abnormalities

Activity 13.2: Erroneous Diagnostic Ideas 1. Largely unproductive until the development of modern computer-dependent technologies. 2. Neurocognition dysfunctioning a. 56%–86% of people with schizophrenia show eye-tracking dysfunction (see Figure 13.5). 3. Brain volume a. Enlarged brain ventricles; average of 3% reduction in brain volume (see Figure 13.6). b. Males more affected than females. c. Present only in a minority of those with schizophrenia and not specific to schizophrenia. d. Reductions in brain volume (cortical tissue loss) increase over time (see Figure 13.7).

Specific brain areas (see Figure 13.8 for a diagram of brain areas of interest in schizophrenics) a. Evidence of problems in the frontal and temporal lobes as well as neighboring (medial temporal) areas such as the amygdala, hippocampus, and thalamus. b. Not specific to schizophrenia and not all patients with schizophrenia show these differences. c. Abnormally low frontal lobe activity (hypofrontality) shown when patients engage in mentally challenging tasks; associated with negative symptoms. d. Left temporal lobe abnormalities may be linked with positive symptoms. e. Reduced volume of thalamus may prevent filtering out of irrelevant sensory information. Cytoarchitecture a. If cells fail to migrate properly, the organizational structure (cytoarchitecture) will be abnormal. b. Organization could also be disrupted during synaptic pruning and programmed cell death. c. Documented differences in neurons in prefrontal cortex, cortex, and hippocampus. d. Inhibitory neurons may also be missing. Brain development in adolescence a. We have an excess of synapses into adolescence. b. Pruning can reduce these synapses to decrease neuronal redundancy. c. Increase in white matter and in the volume of the hippocampus and amygdale. Synthesis a. Genes create an enhanced susceptibility to potentially aversive environmental events. b. Unlikely that schizophrenia is the result of any one problem in any one specific region of the brain. c. Subtle brain abnormalities in some key functional circuits may be involved. Neurochemistry a. Mental changes associated with LSD prompted interest in biochemical basis of schizophrenia. b. Dopamine—most important neurotransmitter implicated in the development of schizophrenia. c. Dopamine hypothesis (1) Pharmacological action of Thorazine. (2) Amphetamine-induced psychosis. (3) Give patients drugs that increase dopamine may create psychotic symptoms. (4) Dates back to 1960s. d. Dysregulated dopamine may make us pay more attention, and give more significance, to stimuli that are not relevant or important—aberrant salience. e. Numerous ways a functional excess of dopamine might be created, including receptor supersensitivity. f. Dopamine cannot be measured directly in the functioning brain; study of metabolite homovanillic acid (HVA). g. Research has uncovered no strong evidence that patients with schizophrenia are producing more dopamine than controls. h. Focus on receptor sensitivity; more D2 receptors in the postmortem brains of schizophrenics than controls; drugs used to treat schizophrenia increase postsynaptic receptor supersensitivity. i. PET scans of those with schizophrenia who have never been treated with neuroleptics are mixed in regards to an increase in D2 receptor sites. j. Glutamate, excitatory neurotransmitter, may be implicated

(1) (2)

PCP and ketamine, blocks glutamate receptors, induces positive and negative symptoms. Postmortem brains of patients with schizophrenia have lower levels of glutamate in both the prefrontal cortex and the hippocampus.

Activity 13.3: The Eden Express Activity 13.4: Perceptual Predispositions F.

Psychosocial and Cultural Aspects 1. Do bad families cause schizophrenia? a. Popular theories in the past including “schizophrenogenic mothers” and “double bind” have not been supported by evidence. b. Adverse family environments and communication deviance probably have little pathological consequence for the child who has no genetic risk for schizophrenia. 2. Families and relapse a. Brown—highly emotional family environments might be stressful to patients; went on to develop and refine the concept of expressed emotion (EE). b. EE has three main elements: criticism, hostility, and emotional overinvolvement. c. EE predicts relapse; lower EE, decreased relapse. d. Possible that when stressed, cortisol is released that triggers dopamine activity and release of glutamate leading to relapse.

Lecture Launcher 13.3: Jeffrey Dahmer and Andrea Yates Teaching Tip 13.2: Understanding the Data 3. Urban living a. Being reared in an urban environment increases risk of schizophrenia (2.75 times more likely). b. Children who spent the first 15 years of their life living in an urban environment. c. Suggests environmental causes of some types of schizophrenia. 4. Immigration a. Recent migrants have much higher risk of developing schizophrenia. b. First-generation migrants has 2.7 times the risk; second-generation migrants had 4.5 times the risk. c. No evidence that this can be explained by cultural misunderstandings. d. Migrants with black skin have a much higher risk of developing schizophrenia than do migrants with white skin; suggests that experiences of being discriminated against could lead some migrants to develop a paranoid and suspicious outlook, setting the stage for the development of schizophrenia. e. Research has found that healthy people who feel discriminated against are more likely to develop psychotic symptoms than healthy people who do not feel discriminated against. 5. Cannabis use (see Figure 13.10 for diagram of cannabis use and schizophrenia) a. People with schizophrenia are more than twice as likely to smoke pot. b. A Swedish study found that heavy pot smokers at 18 are more than 6 times more likely to develop schizophrenia 27 years later than those who never smoked. c. People with a COMT gene are at an increased risk for developing psychotic symptoms if they smoked pot in adolescence. d. The COMT gene is involved in breaking down dopamine and THC is thought to increase the synthesis of dopamine. e. The relationship exists; however, the direction of the relationship is in question. 6. Diathesis-stress model of schizophrenia (see Figure 13.12) Copyright © 2013 Pearson Education, Inc. All rights reserved. 255

a. b. c. d. e. III.

Genetic predisposition. Environmental factors. Prenatal events. Brain maturational process. Stress.

Treatment and Clinical Outcome A. Clinical Outcome 1. 15–25 years after developing schizophrenia, about 38% have a favorable outcome; does not mean a return to premorbid functioning. 2. 16% recover to the extent that they no longer need treatment. 3. 12% need long-term institutionalization. 4. 1/3 show signs of continued negative symptoms. 5. Spontaneous improvements late in life sometimes occur. 6. Mortality: men with schizophrenia in the U.K. die 14.6 years earlier. B. Pharmacological Approaches 1. First-generation antipsychotics a. Thorazine and Haldol; referred to as neuroleptics. b. Antipsychotics. c. Neuroleptics. d. Block the action of dopamine, primarily by blocking D2 receptors. e. Work best for positive symptoms. f. Common side effects include drowsiness, dry mouth, weight gain, extrapyramidal side effects (involuntary movement abnormalities such as muscle spasms, rigidity, shaking). g. African Americans and other minorities are at increased risk for extrapyramidal side effects. h. Tardive dyskinesia involves involuntary movements of the lips and tongue; females more susceptible. i. Neuroleptic malignant syndrome involves high fever and extreme muscle rigidity that can be fatal. 2. Second-generation antipsychotics a. 1980s—clozapine (Clozaril) was the first; others include Risperdal, Zyprexa, Seroquel, Geodon, and Abilify. b. Causes fewer extrapyramidal symptoms. c. Decrease both positive and negative symptoms. d. Believed to block a wider array of receptors, including D4 receptors. e. Side effects include drowsiness, weight gain, diabetes, agranulocytosis (lifethreatening drop in white blood cells). f. 13.4 The World Around Us: Using Estrogen to Help Patients with Schizophrenia (see Figure 13.13).

Handout 13.2: Antipsychotic Side Effects 3. Patient’s perspective a. Not all patients benefit. b. Those who do benefit may show only a reduction in symptoms. c. Side effects may lead to discontinuation of taking the medication. d. Psychological impact of taking these medications. C. Psychosocial Approaches 1. Family therapy a. Goal is to reduce EE. b. Involves education, improving coping and problem-solving skills, enhancing communications skills, and clarifying family communication. 2. Case management. 3. Social skills training. Copyright © 2013 Pearson Education, Inc. All rights reserved. 256

4. 5.

Cognitive remediation. Cognitive-behavioral therapy a. Goal is to decrease intensity of positive symptoms, reduce relapse, decrease social disability. b. Results are promising. Individual treatment a. Psychodynamic treatments made some patients worse. b. Hogarty—personal therapy focused on coping techniques and skills has been very effective in enhancing social adjustment and social role performance. c. 13.5 The World Around Us: A Beautiful Mind.

Lecture Launcher 13.4: Better Third World Country Outcomes Activity 13.5: “A Beautiful Mind” and John Nash III.

Unresolved Issues: What Is the Best Way to Prevent Schizophrenia? A. Aim of primary prevention is to prevent new cases: better prenatal care. B. Secondary prevention intervenes with high-risk groups. 1. Problems in identifying high-risk groups. 2. Controversy over appropriate interventions. 3. Preventing cannabis abuse in 15-year-olds. C. Tertiary prevention involves early treatment for those who already have schizophrenia.

Key Terms alogia antipsychotics (neuroleptics) avolition brief psychotic disorder candidate genes catatonic schizophrenia cognitive remediation delusion delusional disorder disorganized schizophrenia disorganized symptoms dopamine endophenotypes expressed emotion (EE)

flat affect glutamate hallucination linkage analysis negative symptoms paranoid schizophrenia positive symptoms psychosis schizoaffective disorder schizophrenia schizophreniform disorder shared psychotic disorder (folie à deux) undifferentiated schizophrenia

Lecture Launchers Lecture Launcher 13.1: Schizophrenia in Historical Perspective Schizophrenia was not adequately described until 1809, after which it seems to have appeared all over the Western world and to have increased rapidly over the next hundred years. Did schizophrenia not exist until about 200 years ago? What might be the implications of this? Are there any interpretations that might be offered? What historical events or phenomena might account for this curiously late origin? Is there a genetic mutation? Or what of a new virus like HIV? Might schizophrenia be a consequence of industrialization? Lecture Launcher 13.2: The Three Christs of Ypsilanti: A Psychological Study In The Three Christs of Ypsilanti: A Psychological Study (1964), psychologist Milton Rokeach described three patients at the Ypsilanti State Hospital, in Ypsilanti, MI, each of whom had the delusion that he was Jesus Christ. In an effort to learn about identity development, Rokeach thought it would be useful to get the three Christs together, to see how they negotiated the challenge of meeting another person claiming to be them. Verbatim session transcripts, Copyright © 2013 Pearson Education, Inc. All rights reserved. 257

especially of the initial meetings, vividly illustrate the tenacity of delusional beliefs. A side note to this fascinating work is the recent discovery of Rokeach’s notes and audiotapes of the original sessions. There was some interest in re-examining these data in light of modern conceptualizations of schizophrenia and to elaborate upon this classic of descriptive psychopathology. However, protections of human subjects concerns were raised when it was realized that the original participants—the three Christs—did not consent to this use of the data. It has been suggested that once the three Christs have all died there may be legal ways to legitimately continue the study. Of course that would presume none of them would rise from the dead! Lecture Launcher 13.3: Jeffrey Dahmer and Andrea Yates Serial killer Jeffrey Dahmer was widely held to suffer from paranoid schizophrenia but his bid for a not-guilty-byreason-of-insanity verdict failed. Essentially, the jury accepted that he was schizophrenic but that he was still culpable for his behavior. Similarly, Andrea Yates, who drowned her five children in the bathtub, was purported to be schizophrenic by one of the court’s examining psychiatrists. She, too, was held accountable for her actions, failing an NGRI bid. Does this make sense to students? How can somebody be schizophrenic and in sufficient command of their mental capacities to be culpable for their actions? Crucial to the Dahmer trial was his attempt to cover his crimes, indicating that he knew what he was doing was wrong, and his interactions with police, which showed his conduct was under his control. In the Yates case, her failure to seek the approval of others was seen as an indicator she knew her plan was wrong, and her waiting until she was alone with the children demonstrated she could control her actions. Should anyone who is schizophrenic have an automatic pass to NGRI out of criminal offenses? The definition of “insanity” is clearly spelled out in the law, and it will be reviewed in detail in Chapter 17. For now, it suffices to explain that legal and psychiatric definitions of insanity are not isomorphic. Lecture Launcher 13.4: Better Third World Country Outcomes The rate of schizophrenia is quite stable cross-culturally, but the outcomes vary considerably. Surprisingly, it appears that schizophrenics in Third World countries fare better than their counterparts in the West. This is surprising because Western medicine would appear to offer enormous advantages in technology, training, treatment options, and resources over what is available to schizophrenics in less-developed nations. Why do Third World countries have more positive outcomes? Is it because of cultural advantages? More stable families? Or is it related to EE, insofar as people in underdeveloped countries might be less critical and rejecting of people suffering from psychosis? Are there other environmental factors that might account for the difference? Classroom Activities, Demonstrations, and Assignments Activity 13.1: “The Disordered Monologue” Osberg (1992, Teaching of Psychology, vol. 19, pp. 47–48) wrote “The Disordered Monologue” as a means of demonstrating the bizarre quality of language and thought occasionally observed in people with schizophrenia. He recommends memorizing it and delivering it without any prior warning: “Okay class, we’ve finished our discussion of mood disorders. Before I go on I’d like to tell you about some personal experiences I’ve been having lately. You see I’ve [pause] been involved in highly abstract [pause] type of contract [pause] which I might try to distract [pause] from your gaze [pause] if it were a new craze [pause] but the sun god has put me into it [pause] the planet of the lost star [pause] is before you know [pause] and so you’d better not try to be as if you were one with him [pause] always fails because one and one makes three [pause] and that is the word for thee [pause] which must be like the tiger after his prey [pause] and the zommon is not common [pause] it is a zommon’s zommon. [pause] But really class, [holding your head and pausing] what do you think about what I am thinking about right now? You can hear my thoughts can’t you? I’m thinking I’m crazy and I know you [point to a student] put that thought in my mind. You put that thought there! Or could it be that the dentist did as I thought? She did! I thought she put that radio transmitter into my brain when I had the Novocaine! She’s making me think this way and she’s stealing my thoughts!” Affect is an important part of the presentation. Blunted and inappropriate affect are easily demonstrated. Loose associations, neologisms (“zommon”), perseveration (“no one is one . . . and any one who tries to be one . . . fails because one and one . . .”), and clanging (“makes three and that is the word for thee”) are all included as are

disorders of thought content, including thought broadcasting, thought withdrawal, and delusions of control. Osberg puts the text on an overhead to aid in the analysis of this confusing monologue. Activity 13.2: Erroneous Diagnostic Ideas Students may have faulty impressions concerning the diagnosis of different mental illnesses such as schizophrenia. Have students conduct surveys of other students concerning their perception of how schizophrenia may be diagnosed. Students often hear about chemical imbalances as a cause of depression and schizophrenia. Do they believe that medical testing, such as blood tests, can be used in diagnosing schizophrenia? Activity 13.3: The Eden Express The Eden Express (1975) is an autobiographical account of Mark Vonnegut’s schizophrenic breakdown. It is a classic case study of the etiology and treatment of schizophrenia. As noted by Gorman (1984, Teaching of Psychology, vol. 11, pp. 39–40), although Vonnegut himself attributes his illness to biomedical factors, there is also evidence of behavioral, humanistic, and psychoanalytic contributions. Students can be asked to write a wide variety of different kinds of book reports based on The Eden Express. For instance, they could focus on treatment, phenomenology, etiology, or symptoms. Activity 13.4: Perceptual Predispositions Students often enjoy taking brief questionnaires that relate to some topic of the course. The Attitudes about Reality Scale (Journal of Personality Assessment, 1989, vol. 53, pp. 353–365) is a 40-item measure that samples four conceptual domains. The instrument has been found to be a consistent measure of the influences on a person’s perception of reality. A person’s epistemology has a pervasive and important effect on interpersonal consequences. People distort reality in order to fit existing belief structures. This scale can provide students with some first-hand information on the factors that influence their possible distortion of reality. More extensively researched instruments include the Perceptual Aberration Scale (Schizophrenia Bulletin, vol. 6, pp. 639–653) and the Social Anhedonia Scale (Journal of Personality Assessment, vol. 56, pp. 84–95). Activity 13.5: “A Beautiful Mind” and John Nash The major motion picture A Beautiful Mind tells the story of Nobel Prize winner John Nash, who suffers from schizophrenia. It would be perhaps indulgent to watch the entire movie in class, but a selection of segments could be very worthwhile. Make sure that students are aware that the film is not an entirely accurate portrayal either of schizophrenia or of John Nash. In particular, the film’s message that schizophrenia can be overcome through sheer effort of will and that medications are a hindrance, requires clarification. The film also implies that visual hallucinations are prominent when, in fact, they are not and are in fact more prominent in other conditions (e.g., acute toxicity and withdrawal). Activity 13.6: Guest Speaker: Pharmacist to Speak on Antipsychotics and the Impact on Schizophrenia Contact a local hospital in your community to see if a pharmacist would be interested in coming to present on the various psychotropic and antipsychotic medications that are used to treat schizophrenia. The presentation can also revolve around what medications are used for positive versus negative symptoms, the side effects, and how the drugs actually work.

MyPsychLab Resources MyPsychLab Resource 13.1: Video on “Schizophrenia: The Case of Georgina” Georgiana is a young woman diagnosed with schizophrenia. She is interviewed about the beginning stages of her illness and some of her past delusions. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 13, Schizophrenia and Other Psychotic Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Schizophrenia: The Case of Georgina” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 13.2: Video on “Schizophrenia: Larry”

In this interview, Larry discusses his life with paranoid 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. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the lefthand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 13, Schizophrenia and Other Psychotic Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Schizophrenia: Larry” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 13.3: Video on “Rodney: Schizophrenia” In this interview, Rodney discusses his life with schizophrenia and the impact it has had on his functioning. Rodney has been struggling with schizophrenia since he was 13 years old. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the lefthand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 13, Schizophrenia and Other Psychotic Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Rodney: Schizophrenia” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 13.4: Explore: “Types and Symptoms of Schizophrenia” You may want to assign students to complete a drag-and-drop quiz on the subtypes of schizophrenia. To access this Explore, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 13, Schizophrenia and Other Psychotic Disorders. In the Media Type field, select “Explore,” then click the “Find Now” button at the bottom. “Types and Symptoms of Schizophrenia” will appear as one of your Explore offerings. You can either use this Explore as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 13.5: Video on “Schizoaffective Disorder: Josh” In this interview, Josh discusses his Schizoaffective Disorder and how it has affected his life since his teenage years. During the course of his illness, he had auditory and visual hallucinations as well as paranoid delusions. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 13, Schizophrenia and Other Psychotic Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Schizoaffective Disorder: Josh” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 13.6: Video “Genetic Schizophrenia” You may want to show a brief video on the link between genes and schizophrenia in mice. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 13, Schizophrenia and Other Psychotic Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Genetic Schizophrenia” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise.

Teaching Tips Teaching Tip 13.1: Adoptee Data This is a good time to discuss the limitations of adoptee data. Ask students if they think people who adopt are the same as all parents? What are some of the differences between these two groups of parents? Students will often point out money as one factor, but is that it? Point out that all adopters have to really want to have children; can we say that about parents as a group? How else do they think adoptive parents vary from non-adoptive parents?

Teaching Tip 13.2: Understanding the data Remind students that the data here can be easily misinterpreted. For many years data has consistently suggested that rich people never developed schizophrenia. Why? Ask students to generate hypotheses. Generally, the field takes the perspective that rich people can “buy” more tame diagnoses; also, behaviors of the rich may be seen differently than those of the poor. Further, remind students that even if there is a 10% increase in risk for a population, that would bring it to 10% as opposed to 1%.

Handout Descriptions Handout 13.1: The Delusion Border Members of some groups believe things that might be viewed as delusional by contemporary diagnostic standards. Have students nominate examples of these. Alien abductees, various cults and quasi-religious groups, antigovernment militia members, and practitioners of fringe health techniques are possibilities. Are these people delusional? What makes them different from hospitalized psychotics? Should they be receiving treatment as well? What is the role of mass media in some of these “delusions?” Handout 13.2: Antipsychotic Side Effects Whether or not to treat a psychotic person against his or her will often depends on the costs: benefits ratio of doing so or not. In order to prevent psychotic patients from being treated against their will, civil rights attorneys will often present an impressive litany of drug side effects that make treatment objections appear quite rational. Students can pretend that they are clerks working for an attorney trying to argue a patient’s right to refuse treatment before a judge. Have them research the side effects of a variety of antipsychotic medications.

Video / Media Sources ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪

Causation. Schizophrenia Series. Irvine, CA: Concept Media. Clozaril Case Management. East Hanover, NJ: Sandoz Pharmaceuticals Corporation. Delusional Disorder, Joe—Patient Interview Video for Abnormal Psychology (12th Ed.). Allyn & Bacon Video Library. Effective Psychoanalytic Therapy of Schizophrenia and Other Severe Disorders. APA Psychotherapy Videotape Series I: Systems of Psychotherapy. Washington, DC: American Psychological Association. First Break. Boston, MA: Fanlight Productions. Inside Schizophrenia. Boston, MA: Fanlight Productions. Losing the Thread: The Experience of Psychosis. New York, NY: Insight Media. Madness. The Brain Series. South Burlington, VT: Annenberg/CPB Multimedia Collection. Paranoia. Berkeley, CA: University of California Extension Center for Media and Independent Learning. Pharmacotherapy of Schizophrenia—Treatments of Psychiatric Disorders Videotape Series. Allyn & Bacon Video Library. Preventing Relapse in Schizophrenia. Princeton, NJ: Films for the Humanities and Social Sciences. Psychotic Disorders. New York, NY: Insight Media. Psychotic Disorders—DSM-IV: New Diagnostic Issues Videotape Series. Allyn & Bacon Video Library. Reintegration in Chronic Schizophrenia. East Hanover, NJ: Sandoz Pharmaceuticals Corporation. Schizoaffective Disorder, Allen—Patient Interview Video for Abnormal Psychology (12th Ed.). Allyn & Bacon Video Library. Schizophrenia. Boston, MA: Fanlight Productions. Schizophrenia. Princeton, NJ: Films for the Humanities and Social Sciences. The Schizophrenias. The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection. Schizophrenia and Bipolar Disorders. Psychotropic Medications: Caring for Patients with Psychiatric Disorders. Irvine, CA: Concept Media. Schizophrenia and Delusional Disorders. Differential Diagnosis in Psychiatry Series. Princeton, NJ: Films for the Humanities and Social Sciences. Schizophrenia and Depression. Princeton, NJ: Films for the Humanities and Social Sciences. Schizophrenia: Etiology. The Brain Teaching Modules Video Series. South Burlington, VT: Annenberg/CPB Collection. Copyright © 2013 Pearson Education, Inc. All rights reserved. 261

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Schizophrenia, John—Patient Interview Video for Abnormal Psychology (12th Ed.). Allyn & Bacon Video Library. Schizophrenia: New Definitions, New Therapies. Allyn & Bacon Video Library. Schizophrenia: Out of Mind. Princeton, NJ: Films for the Humanities and Social Sciences. Schizophrenia: Pharmacological Treatment. The Brain Teaching Modules Video Series. South Burlington, VT: Annenberg/CPB Collection. Schizophrenia: Symptoms. The Brain Teaching Modules Video Series. South Burlington, VT: Annenberg/CPB Collection. Schizophrenia: The Voices Within, The Community Without. Princeton, NJ: Films for the Humanities and Social Sciences. Shattered Dreams. Man Alive Series. Boston, MA: Fanlight Productions. Spinning Out. New York, NY: The Cinema Guild. Symptomatology. Schizophrenia Series. Irvine, CA: Concept Media. Through Madness. New York, NY: Filmmakers Library. Torment of Schizophrenia. Allyn & Bacon Video Library. Understanding Movement Disorders: Medication Issues in Mental Health Series. Irvine, CA: Concept Media. Understanding Schizophrenia. No More Shame: Understanding Schizophrenia, Depression and Addiction Series. Princeton, NJ: Films for the Humanities and Social Sciences. Unlocking the Secrets of Schizophrenia. Allyn and Bacon Video Library. The Voices Within: Schizophrenia—#9 ABC News and Client Interviews. Allyn & Bacon Abnormal Psychology Video.

Web Links Web Link 13.1: www.rootsweb.com/~asylums This Web site is an attempt to catalog and present some of America’s historic state hospitals. The site is searchable by state. There are many photos and historical descriptions, some of which might be of local interest. Web Link 13.2: www.nami.org This Web site is sponsored by the National Alliance for the Mentally Ill. NAMI is a very influential nonprofit, grassroots, self-help, support and advocacy organization of consumers, families, and friends of people with severe mental illnesses, such as schizophrenia, major depression, bipolar disorder, obsessive-compulsive disorder, and anxiety disorders. Web Link 13.3: www.nmha.org The National Mental Health Association is the country’s oldest and largest nonprofit mental health organization. NMHA works to improve the mental health of all Americans, especially those with mental disorders, through advocacy, education, research, and service. Their schizophrenia “fact sheet” is very useful. Web Link 13.4: www.mhselfhelp.org National Mental Health Consumers’ Self-Help Clearinghouse is a consumer-run mental health consumer movement that seeks to disseminate self-help and advocacy resources. They also offer expertise to self-help groups and other peer-run services for mental health consumers. Web Link 13.5: www.narsad.org The National Alliance for Research on Schizophrenia and Depression raises and distributes funds for scientific research into the causes, cures, treatments, and prevention of brain disorders, primarily the schizophrenias, depressions, and bipolar disorders. Web Link 13.6: www.nimh.nih.gov/publicat/schizoph.cfm This site, sponsored by the National Institute of Mental health, provides detailed information on schizophrenia, including symptoms, causes, treatments, and how to get help.

Handout 13.1 The Delusion Border

Can it be difficult to determine when a belief is delusional? Give some examples.

When does jealousy in a relationship become delusional? What are the signs?

What strongly held beliefs could be considered delusional by nonbelievers?

How can a belief system be tested to determine if it is a sign of abnormal behavior?

Handout 13.2 Antipsychotic Side Effects

Whether or not to treat a psychotic person against his or her will often depends on a costs:benefits ratio. In order to prevent psychotic patients from being treated against their will, civil rights attorneys will often present an impressive litany of drug side effects that make treatment objections appear quite rational. Pretend that you are a clerk working for an attorney trying to argue a patient’s right to refuse treatment before a judge. You have been asked to research the side effects of a variety of antipsychotic medications. Summarize your findings in the following table:

Antipsychotic Medication

Side Effects

Probability

CHAPTER 14: Neurocognitive Disorders Teaching Objectives 1. 2. 3. 4. 5.

6. 7. 8.

Discuss diagnostic issues and clinical signs of brain damage. Explain diffuse versus focal damage as it relates to brain impairment. Describe how neuropsychology and psychopathology interact. Define delirium in terms of clinical presentation and discuss clinical treatments and outcomes. Define dementia and the three disorders presented: Alzheimer’s, dementia from HIV-1 infection, and vascular dementia. Include in your description the clinical picture, prevalence, genetic or environmental aspects, treatment outcomes, and effects on caregivers. Explain how the clinical picture in amnestic disorder differs from that found in dementia. Describe the possible results of brain injury, and how brain injury can occur. Explain why the long-term consequences of brain injury are so difficult to predict. Discuss the research on the benefits of dietary supplements on brain functioning.

Chapter Overview/Summary The DSM-IV recognizes various cognitive disorders, including delirium, dementia, and amnestic disorder. Typically, these disorders result from transient or permanent damage to the brain. Chronic neuropsychological disorders involve permanent loss of neural cells. The primary causes of brain tissue destruction are many and varied; common ones include certain infectious diseases (such as the HIV-1 virus), brain tumors, physical trauma (injuries and alcohol), degenerative processes (as in Alzheimer’s disease), and cerebrovascular arteriosclerosis, often manifested as vascular dementia. There is no simple relationship between the extent of brain damage and degree of impaired functioning. Some people who have severe damage develop no severe symptoms, whereas others with slight damage have extreme reactions. Although such inconsistencies are not completely understood, it appears that an individual’s premorbid personality and life situation are important in determining his or her reactions to brain damage. The genetic APOE-4 allele may also be important. Delirium is a fluctuating condition common among the elderly. It involves a state of awareness between wakefulness and stupor or coma. It is treated with neuroleptic medications and also with benzodiazepines. Dementia involves a loss of function and of previously acquired skills. It has a slow onset and a deteriorating course. The most common cause of dementia is Alzheimer’s disease (AD). Age is a major risk factor for Alzheimer’s disease as well as other forms of dementia, such as vascular dementia. Genes play a major role in creating susceptibility and risk for Alzheimer’s disease. Genetic mutations of the APP, presenilin 1, and presenilin 2 genes are implicated in early onset AD. The APOE-4 allele of the APOE gene is also a risk factor for AD. Interestingly, substantial numbers of MZ twins are discordant for AD, suggesting that genetic susceptibility interacts with environmental factors. Environmental factors include diet, exposure to metals such as aluminum, and experiencing head trauma. The characteristic neuropathology of Alzheimer’s disease involves cell loss, senile plaques, and neurofibrillary tangles. Plaques contain a sticky protein called beta amyloid. Neurofibrillary tangles contain abnormal tau protein. Alzheimer’s disease causes a destruction of cells that make acetylcholine, a neurotransmitter important for memory. Drug treatments for AD include cholinesterase inhibitors such as donepezil (Aricept). These drugs help stop ACh from being broken down and so make more of it available to the brain. Amnestic disorders involve severe memory loss. The most common cause of amnestic disorders is chronic alcohol abuse. Head injuries can cause amnesia as well as other cognitive impairments. Retrograde amnesia is the ability to recall events before the accident. Anterograde amnesia is the inability to remember things since the accident. Any comprehensive treatment approach for cognitive disorders should also involve caregivers, who are often under a great deal of stress and have difficulties coping. They may benefit from medications as well as from support groups.

Detailed Lecture Outline I.

Brain Impairment in Adults

Teaching Tip 14.1: The Role of the Case Study A.

Diagnostic Issues 1. DSM-IV-TR presents the diagnostic coding in different and somewhat confusing ways. 2. This section is called Delirium, Dementia, and Amnestic and Other Cognitive Disorders. 3. For cognitive disorders, both the cognitive problem and medical cause are listed on Axis I; the medical condition is listed again on Axis III. 4. Brain changes due to substances are simply placed on Axis I. 5. Case study. 6. Proposed DSM-5 changes: a. New category: Neurocognitive Disorders. b. Minor neurocognitive disorder versus major neurocognitive disorder. c. Differences between minor and major will be severity levels. Clinical Signs of Brain Damage 1. For most part, cell bodies and neural pathways do not regenerate; when occurs in older children or aduls there is a loss in established functioning. 2. Impairment may involve acquired and customary skills or the capacity for realistic selfappraisal (anosognosia). 3. Impairment depends on: a. Nature, location, and extent of neural damage. b. Degree of damage. c. Premorbid competence and personality of the individual. d. Individual’s life situation. e. Amount of time since the first appearance of the condition. Diffuse versus focal damage—see Table 14.1 for a short screening for mental state (e.g., orient to time, person, place).

Activity 14.1: Mini-Mental Status Examination 1. 2. 3. 4. 5.

Attention is often impaired by mild to moderate diffuse damage, such as might be expected with moderate oxygen deprivation or the ingestion of toxic substances. Diffuse-widespread damage, may occur with loss of oxygen to the brain or ingestion of toxin-like mercury. Mild cognitive impairment can also be detected in those who have had only low-level exposure to organic solvents and other neurotoxins. Focal brain lesions are circumscribed areas of abnormal change in the brain with a number of possible consequences. Relationships between brain location and behavior can never be considered universally true, however (see Figure 14.2 for anatomy of the brain). a. Damage to frontal areas can result in one of two patterns: (1) Being unmotivated and passive, limited thoughts and ideas. (2) Impulsiveness and distractibility. b. Damage to right parietal lobe may produce impairment of visual-motor coordination. c. Damage to left parietal area may impair language, including reading and writing, as well as arithmetical abilities. d. Damage to certain structures within temporal lobes disrupts memory storage; extensive bilateral temporal lobe damage can result in no new memories being able to be stored; damage to other structures within temporal lobe can lead to disturbances of eating, sexuality, and the emotions.

Occipital damage produces a variety of visual impairments and visual association deficits (see Figure 14.2).

Handout 14.1: Chemical Damage D.

II.

III.

Neuropsychology/Psychopathology Interaction 1. Most people with a neuropsychological disorder do not have psychopathological symptoms, such as panic attacks, dissociative episodes, or delusions. 2. People with favorable life situations do better after brain injury than those who are disadvantaged. 3. Mild deficits in cognitive self- processing and regulation. 4. Psychopathological symptoms are not always predictable. 5. Never assume a psychological disorder is developed because of brain damage. 6. Involves impairment of memory and attention as well as disorganized thinking. Delirium A. Clinical Presentation 1. Delirium is an acute confused state with a sudden onset and a fluctuating state of awareness. 2. Nuances consistent with patient’s age, personality, and complete psychological situation confronting the patient. 3. Sudden onset. 4. Commonly find: cognitive changes such as impaired information-processing, hallucinations, delusions, abnormal psychomotor activity (wild thrashing), disturbances of the sleep cycle, confusion, disturbed concentration, and cognitive dysfunction. 5. See Figure 14.3. 6. Latin delirare meaning out of one’s furrow or track. 7. Can occur at any age, but elderly are at a greater risk; 10%–51% of patients who undergo surgery, particularly cardiac surgery, develop delirium; 25% of elderly with delirium die within 6 months. 8. May result from head injury, infection, drug intoxication, drug withdrawal, drug toxicity. B. Treatment and Outcome 1. Medical emergency—must identify and treat underlying cause. 2. Most cases are reversible except when caused by terminal illness and severe brain trauma. 3. Treatment involves medications (neuroleptics or benzodiazepines for drug withdrawal), environmental manipulations such as orienting techniques (calendars, staff prompting, night lights), and family support. Dementia A. Dementia 1. Decline from a previous level of functioning; onset is typically gradual. 2. Early on individuals may appear alert and fairly well tuned to the events going on in the environment. 3. Memory for recent events affected in early stage; with time, increasingly marked deficits in abstract thinking, acquisition of new knowledge or skills, visuospatial comprehension, motor control, problem solving, and judgment. 4. Often accompanied by impairment in emotional control and moral/ethical sensibilities 5. Dementia may be progressive or static. 6. Occasionally reversible if underlying cause can be treated, such as vitamin deficiency. 7. Strokes, degenerative disease (Alzheimer’s, Huntington’s, and Parkinson’s), infectious diseases (syphilis, meningitis, AIDS), intracranial tumors and abscesses, dietary deficiencies (B vitamins), head injury, anoxia, and toxic substances can produce the condition. 8. Proposed DSM-5 change: reword “dementia” to “major neurocognitive disorder,” to reduce stigma. 9. See Figure 14.4.

Activity 14.2: Early Signs of Dementia B.

Parkinson’s Disease 1. Second most common neurodegenerative disease (after Alzheimer’s). More than 75% will show signs of dementia eventually. Named after James Parkinson, first described in 1817. 2. Affects between .05%–1% of people aged 65–69 and 1%–3% over 80. That said, some develop it far earlier (e.g., Michael J Fox was diagnosed when he was 30, reveals his story in his book, “Lucky Man” (2002)). 3. Caused by loss of dopamine, causes tremors and rigid movements. 4. More common in men than women, 25%–40% show signs of dementia. 5. Mirapex prescribed as a way to increase dopamine. 6. Dopamine is key in the control of movement. 7. Can involve psychological symptoms like depression, anxiety, apathy, cognitive problems, hallucinations, and delusions. 8. Genetic and environmental factors indicated in the onset. 9. Smoking and drinking coffee may provide some protection against the development. Huntington’s Disease 1. A rare degenerative disorder affecting 1:10,000, with an average age of onset of mid40’s. Discovered in 1872 by Dr. George Huntington. 2. Characterized by chronic involuntary and irregular movements. 3. Patients develop dementia and many die within 10 years. 4. Caused by problem on chromosome 4 and highly heritable. If a parent has the disease, offspring have a 50% chance of developing the disease. 5. Affects men and women equally. 6. A genetic test is available for those who qualify but only 10% choose to take the test 7. Cognitive problems due to the loss of brain tissues are common. 8. Patients usually develop dementia, and death occurs 10–20 years after the age of onset. Alzheimer’s Disease (AD)

Handout 14.2: Living with People Who Have Alzheimer’s MyPsychLab Resource 14.1: Video on “Alzheimers and Dementia” 1.

Clinical picture a. Diagnosis based on clinical assessment but can be confirmed only after death. b. Usually begins after age 45. c. A progressive and fatal degenerative disorder named for Alois Alzheimer (1864–1915), was first described in 1907. d. Gradual and slow mental deterioration with multiple cognitive deficits. e. First sign may be withdrawal from active engagement with life followed by more self-centered and child-like thoughts and activities including a preoccupation with the functions of eating, digestion and excretion; as symptoms become more severe may see impaired memory for recent events, “empty” speech, messiness, impaired judgment, agitation, and periods of confusion. f. Delusions (paranoid and jealous) and a combative pattern occur in some patients. g. Death usually comes from lowered resistance to opportunistic infections. h. See Figure 14.5.

MyPsychLab Resource 14.2: Video on “Alzheimer’s Disease: The Case of Wilburn “John” Johnson” MyPsychLab Resource 14.3: Video on “What Happens with Alzheimer’s”

MyPsychLab Resource 14.4: Video on “Alzheimer’s Smell Test” 2.

Prevalence a. Problem is underestimated. b. AD rates double approximately every 5 years after a person reaches age 40. c. Less than 1% of the population between ages 60–64 is affected; about 40% of those over 85 are affected. d. Worldwide: 35 million people are living with AD. e. By 2030 it is estimated that 66 million will be living with AD. f. With increasing lifespan, problem grows in magnitude. g. Women have a slightly higher risk. h. Lower rates in Africa, Southeast Asia, and India, suggesting role of high fat, high-cholesterol diet. i. High levels of an amino acid homocystine increases the risk for AD and heart disease. Causal factors a. Early-onset Alzheimer’s disease (1) Progression is very rapid. (2) See Table 14.3. (3) Have identified three rare genetic mutations that can cause Alzheimer’s (about 5% of cases): (a) Mutated APP gene on chromosome 21. (b) Mutated PS1 (presenilin 1) gene on chromosome 14. (c) Mutated PS2 (presenilin 2) gene on chromosome 1. b. Late-onset Alzheimer’s disease (1) APOE (apolopoprotein) gene on chromosome 19: (a) Three alleles identified. (b) APOE-E4 significantly enhances risk for late-onset AD. (c) APOE-E2 protects against late-onset AD. (d) APOE-E4 can be detected by blood test. (e) Only 55% of those with two APOE-E4 alleles had developed AD by age 80. (2) Substantial numbers of MZ twins are discordant for AD. (3) Genetic susceptibility thought to interact with environmental factors. (4) Environmental factors include diet, exposure to metals such as aluminum, and experiencing head trauma. (5) Use of ibuprofen may be protective. (6) 14.2 Developments In Research: Depression Increases the Risk of Alzheimer’s Disease. Neuropathology (see Figure 14.6 for a diagram of a brain with Alzheimer’s disease) a. Amyloid plaques (1) Contain a sticky substance called beta amyloid. (2) Believed that an accumulation of this substance causes plaques. (3) Beta amyloid is neurotoxic. b. Neurofibrillary tangles (1) Webs of abnormal filaments within a nerve cell made up of a protein called tau. (2) Tau may be caused by accumulation of beta amyloid. c. Atrophy of the brain (1) Small holes caused by cell degeneration. (2) Leads to reduction in acetylcholine activity.

Lecture Launcher 14.1: Would You Take the Test? 5.

b. c.

d. e. f. g.

Behavioral techniques attempt to control wandering, incontinence, inappropriate sexual behavior, and poor self-care behaviors. Medications such as tacrine (Cognex) and donepezil (Aricept) inhibit the production of acetylcholinesterase, thereby increasing the availability of acetylcholine. Donepezil. Newest medication: Namenda, appears to regulate glutamate. Despite setbacks, continuing to work on developing vaccines. Prevention is needed.

Lecture Launcher 14.2: Behavior Therapy Activity 14.3: Memory Aids 6.

Early detection a. Brain-imaging techniques. b. APOE-E3 allele. c. Experience of mild cognitive impairment (MCI). d. Atrophy of hippocampus. e. 14.3 The World Around Us: Exercising Your Way to a Healthier Brain?

Supporting caregivers a. Challenging management problems as well as “social death” of the patient and their own “anticipatory grief.” b. Sandra Day O’Connor’s story. c. Caregivers are at high risk for developing depression and cortisol levels similar to people with depression. d. Providing caregivers with counseling and support has proven effective.

Lecture Launcher 14.3: Caregiver Strain E.

Dementia from HIV-1 Infection 1. Snider (1983) documented that the presence of the HIV-1 virus could itself result in the destruction of brain cells. 2. May lead to the emergence of psychotic phenomena. 3. Virus causes generalized atrophy, edema, inflammation, and patches of demyelination. 4. Damage may occur throughout the brain but seems to be localized in subcortical regions, notably the white matter, the tissue surrounding the ventricles, and deeper gray matter structures such as the basal ganglia and thalamus. 5. Between 20% –30% percent of untreated patients with HIV/AIS will develop AIDSrelated dementia; with current antiviral treatment, the rate reduces to 20%. Vascular Dementia (multi-infarct dementia) 1. A similar clinical picture to Alzheimer’s exists, although a more varied early picture. 2. Series of circumscribed cerebral infarcts cumulatively destroy neurons over expanding brain regions. 3. Tends to occur after age 50; more common in men. 4. Accounts for only about 19% of all dementia cases age 65 or older; patients are more vulnerable to sudden death from stroke or cardiovascular event. 5. Accompanying mood disorders more common than in AD. 6. “Mixed” diagnoses when patient has both vascular and AD. 7. Cerebral arteriosclerosis can be medically managed to some extent.

Lecture Launcher 14.4: Demographic Trends IV.

Amnestic Disorder

Lecture Launcher 14.5: Life without Memories A.

B. C. D. E. F. V.

Central feature is strikingly disturbed memory or amnesia 1. Immediate recall and memory for remote events usually preserved. 2. Short-term memory typically very impaired. 3. Confabulation common. Overall cognitive functioning may remain relatively intact. Root cause of brain damage typically from chronic alcohol use with its associated deficiency in vitamin B1. Other causes include: head trauma, stroke, surgery in the temporal lobe, hypoxia, brain infections. Depending on cause, may abate wholly or partially. Korsakoff’s syndrome—an amnestic disorder caused by vitamin B1 deficiencies.

Disorders Involving Head Injury A. Traumatic Brain Injury (TBI) 1. Occur frequently, affecting more than 2 million people each year in the United States. 2. Children ages 0–4, adolescents 15–19, and adults over 65 most at risk. 3. 15% of soldiers who served in Iraq war. 4. Most common cause is motor vehicle accidents followed by falls, violent assaults, and sports injuries. 5. Case of Arizona Congresswoman Gabrielle Giffords. 6. Men aged 15–24 are at greatest risk. 7. Clinical picture a. Three types of injury are distinguished: (1) Closed head. (2) Penetrating. (3) Skull fracture. b. Immediate acute reactions, such as unconsciousness and disruption of circulatory, metabolic, and neurotransmitter regulation. c. Retrograde and anterograde amnesia are commonly seen. d. Person typically passes through stupor and confusion on the way to recovering clear consciousness. e. Coma may occur. f. Presence of the APOE-E4 allele is a risk factor for increased problems after a brain injury . g. Phineas Gage. h. See Figure 14.7. i. See 14.4 The World Around Us: Can Thrill Rides Cause Brain Damage? j. See Table 14.5. k. See 14.5 The World Around Us: Brain Damage in Professional Athletes. B. Treatments and Outcomes 1. Prompt medical care is required. 2. The majority suffering mild concussion improve quickly. 3. 24% of TBI cases develop post-traumatic epilepsy, presumably because of the growth of scar tissue in the brain, seizures develop within two years of injury. 4. In a minority of cases, dramatic personality change occurs. 5. Children with severe traumatic brain injury are more likely to be adversely affected the younger they are at the time of the injury, and the less language, fine-motor, and other competencies. 6. Severe injury cases have a poor prognosis. 7. Recent evidence suggests that patients with TBI may benefit from treatment with donepezil, an acetylcholinesterase inhibitor. 8. Treatment is complex, long, and expensive. 9. Includes many interventions such as medication, rehabilitation, interventions, social skills training, vocational and recreational training, etc. 10. See Table 14.6 Predictors of Clinical Outcome After Traumatic Brain Injury. Copyright © 2013 Pearson Education, Inc. All rights reserved. 272

Handout 14.3: Class Trip to Nursing Home VI.

Unresolved Issues: Should Healthy People Use Cognitive Enhancers? A. Caffeine 1. Improves vigilance, working memory, and incidental learning. B. Nicotine 1. Enhance attention, working memory, and attention in short term. C. Prescription medication. 1. Ritalin. 2. Provigil.

Key Terms Alzheimer’s disease amnesia amyloid plaques anterograde amnesia APOE-4 allele delirium dementia early-onset Alzheimer’s disease HIV-associated dementia

Huntington’s disease Korsakoff’s syndrome late-onset Alzheimer’s disease neurofibrillary tangles Parkinson’s disease retrograde amnesia traumatic brain injury (TBI) vascular dementia

Lecture Launchers Lecture Launcher 14.1: Would You Take the Test? Presently, there is no diagnostic test for the presence of Alzheimer’s dementia, so it is quite futuristic to imagine a test that could predict Alzheimer’s disease, say via genetic assays. That makes what follows an entirely academic exercise, but where are academic exercises more appropriate than here? The question, and it actually could be raised in the context of many of the disorders covered in this class, concerns whether students would want to be tested for disorders they may later experience or whether they would prefer not to know. If students are slow to warm up to the discussion, they can be given some distance from the question by asking not what they would do but rather what are the arguments that could be made for and against getting the test(s). Alternatively, ask students to consider if they would want their unborn child tested for psychological disorders, allowing for the possibility of an abortion, if such testing was available. Lecture Launcher 14.2: Behavior Therapy Although cognitive disorders are often of organic etiology, there is still a substantial role for behavior therapies. A number of reports suggest that operant programs can be instituted to improve or maintain basic self-care, family interaction, and compliance with medical regimens. Dementia-related depression has also been shown to respond to behaviorally programmed pleasant event scheduling. Students benefit from learning about environmental approaches to treating essentially organic disorders. It combats the otherwise nihilistic view they can adopt toward what appears to be an irreversible condition. Lecture Launcher 14.3: Caregiver Strain To give a clear picture of the costs associated with Alzheimer’s disease, a lecture can be designed to show the various needs of the patients. An article by Albert, Sano, Merchant, & Stern (1998) provides a detailed account of the hours spent caring for Alzheimer’s disease patients (Gerontologist, vol. 38, pp. 704–714). A breakdown of the formal and informal care required can be presented to the students. As the disease progresses, students can be shown the shift of services toward the formal type. Lecture Launcher 14.4: Demographic Trends

The fastest growing segment of society is the elderly, particularly people in their 80s and beyond. What are the consequences of this trend for society, the healthcare system, and family life? Should younger people undertake larger roles in caring for the elderly? How could that be accomplished? How can society adjust so that older people can become more of a resource than a drain on resources? How do other cultures handle this issue? Lecture Launcher 14.5: Life without Memories What would it be like to lose many or even all your memories? This is a poignant question that in many ways gets to the heart of what it means to be who you are. Why doesn’t each day start completely fresh, a blank slate upon which you start from scratch, becoming someone new? How would you answer questions about who you are if not for your recollections about what you have done? Would it be better to lose all memory or just partial memories? Would awareness of the loss be as bad as the loss itself? What would it be like to learn about an extensive episode from your life now, about which you have no memory whatsoever? How about meeting someone with whom it is clear you once had a close relationship but of whom you have no recollection? If you had to rely on notes to yourself to remind you of who you are and what you are about as a person, what would you write down?

Classroom Activities, Demonstrations, and Assignments Activity 14.1: Mini-Mental Status Examination Students can be shown the Mini-Mental Status Examination, which was developed by Folstein, Folstein, and McHugh (1975, Journal of Psychiatric Research, vol. 12, pp. 186–198). This instrument is commonly used in the assessment of dementia. The examination can be demonstrated in class as a way to review the various impairments suffered by an Alzheimer’s disease victim. Activity 14.2: Early Signs of Dementia Students may be surprised to learn that early intervention can influence the outcome of Alzheimer’s and other types of dementia. However, achieving these benefits requires early recognition of the signs of dementia. Rather than simply telling students what these signs are, assign them the task of researching them on their own. This assures that they will be able effectively to obtain high-quality information at the time it becomes more relevant to them, perhaps as their parents age. Activity 14.3: Memory Aids People with Alzheimer’s and other types of dementia benefit from using various memory aids. Ask students to research these and to report their findings back to the class for discussion. Are memory aids for people with dementias designed specifically for the deficits characteristic of these disorders, or are they general purpose memory aids that address a variety of memory problems not necessarily those characteristic of dementias? What specific memory problems ought to be addressed? What types of things, along the lines of the memory aids currently available, would be most relevant to those with dementias of various sorts? Is memory something that can be improved with use or weakened with disuse? You may also wish to ask students to consider memory aids that they use such as notes in class, various items on the refrigerator, clocks, PDAs, etc. Activity 14.4: What Would Your Life Look Like at 75? Ask students to brainstorm and write down as a small group how they envision their life to be when they hit the age of 75. What would be different, what would be the same, what would you do for recreation, what would be easiest, what would be most difficult, etc. Then ask them to evaluate how older adults are viewed and treated by society as well as some of the typical stereotypes, stigmas, and labels. Activity 14.5: Assessment of Popular Media and Older Adults Show some short clips off of YouTube, films, etc. of older adults and ask the students to evaluate the information given about older adults, illnesses during that developmental stage, personality factors, recreational activities, etc. A very helpful tool is to evaluate a Disney film looking at the theme of what the villain usually looks like, how they treat others, and the perception of them. Activity 14.6 Neurocognitive Bingo Use the key terms as a guide and randomly place them on a grid of paper with different slots. Have at least four different versions of the Bingo card. Call out the definition and the students will be in charge of identifying the Copyright © 2013 Pearson Education, Inc. All rights reserved. 274

correct definition with the term on their Bingo card. Just like regular Bingo when they complete a diagonal, horizontal, four corners, etc., the student wins. You can increase the participation by including this as extra credit.

MyPsychLab Resources MyPsychLab Resource 14.1: Video on “Alzheimers and Dementia” This brief clip looks at the effects of Alzheimer’s and dementia on brain functioning. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 14, Cognitive Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Alzheimer’s and Dementia” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 14.2: Video on “Alzheimer's Disease: The Case of Wilburn “John” Johnson” Wilburn “John” Johnson is a retired navy chief who is in the mid-stages of Alzheimer’s disease. His wife and daughter are interviewed about the difficulty in caregiving and the sense of unfairness they feel in their own lives. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pulldown menu next to “Chapter,” select Chapter 14, Cognitive Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Alzheimer’s Disease: The Case of Wilburn “John” Johnson will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 14.3: Video on “What Happens with Alzheimer’s” This brief clip looks at autopsy results from individuals who had Alzheimer’s and more recent biological data on Alzheimer’s and the brain. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 14, Cognitive Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “What Happens with Alzheimer’s” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise. MyPsychLab Resource 14.4: Video on “Alzheimer's Smell Test” This video shows techniques designed to help the memories of people with Alzheimer’s. To access this video, log in to MyPsychLab, select the front cover of this textbook, then click on the “Multimedia Library” button on the next page in the left-hand column. A new page will appear with search criteria. In the pull-down menu next to “Chapter,” select Chapter 14, Cognitive Disorders. In the Media Type field, select “Watch,” then click the “Find Now” button at the bottom. “Alzheimer’s Smell Test” will appear as one of your video offerings. You can either watch this video as an in-class demo—if your room has a computer set up—or assign as a suggested exercise.

Teaching Tips Teaching Tip 14.1: The Role of the Case Study Remind students that much of this research is determined by case study. For some cognitive deficits in aging, there may not be many people who have a specific problem (e.g., traumatic brain injury, strokes in specific areas); thus you look at case studies. Remind students that although case studies are interesting, they cannot be used to draw any large-scale scientific conclusions because that individual may not be generalizable to the population. This chapter starts with a discussion on this issue and provides reminders about the limitations of using case studies.

Handout Descriptions Handout 14.1: Chemical Damage You can reinforce the text’s discussion of nail techs and neurological functioning by discussing how chemicals and other environmental effects can have unknown damaging effects on the brain. Ask students what environmental effects they think might have negative effects on them; many will say cell phones, power lines, and so on. Remind Copyright © 2013 Pearson Education, Inc. All rights reserved. 275

them that untold myriad factors could be having these effects. You can have students either do this as an assignment and then turn it in, or complete it and use it for class discussion. Handout 14.2: Living with People Who Have Alzheimer’s Encourage students to share any personal experiences they may have had with relatives who demonstrated disorders such as Alzheimer’s disease. How did the family deal with the disorientation and memory impairment? What major problems developed in the family when the disorder was obvious? Was institutionalized care called for? How did that affect the family? How was the decision made whether or not to institutionalize the person? How was the problem first evidenced? What kinds of treatment were used? What effect did these treatments have? Handout 14.3: Class Trip to Nursing Home Try to arrange a class trip to a nursing home that cares for people with organic brain syndrome. Alternatively, students could serve as volunteers for at least one day in order to interact with the residents. What are the major problems that members of the nursing home staff have in caring for persons with such conditions as Alzheimer’s disease?

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Advancements in Neurology and Neurosurgery. Allyn & Bacon Video Library. Advancements in Traumatic Brain Injury. Princeton, NJ: Films for the Humanities and Social Sciences. Alzheimer’s: A True Story. Allyn & Bacon Video Library. Alzheimer’s: Effects on Patients and Their Families. Princeton, NJ: Films for the Humanities and Social Sciences. Alzheimer’s: The Tangled Mind. Allyn & Bacon Video Library. Alzheimer’s Disease. Boston, MA: Fanlight Productions. Alzheimer’s Disease. The Brain Teaching Modules Video Series. South Burlington, VT: Annenberg/CPB Collection. Alzheimer’s Disease: The Long Nightmare. Princeton, NJ: Films for the Humanities and Social Sciences. Alzheimer’s Disease: How Families Cope. The Doctor is in Series. Princeton, NJ: Films for the Humanities and Social Sciences. Alzheimer’s Mystery. Allyn & Bacon Video Library. Characteristics and Behavior. The Cognitively Impaired Geriatric Patient Series. Irvine, CA: Concept Media. Code Gray: Ethical Dilemmas in Nursing. Boston, MA: Fanlight Productions. Dementia: Putting Together the Pieces of the Puzzle. Sherborn, MA: Aquarius Health Care Videos. Early Alzheimer’s Disease—#10 ABC News and Client Interviews. Allyn & Bacon Abnormal Psychology Video. Elderly Suicide. Princeton, NJ: Films for the Humanities and Social Sciences. Forget Me Never. New York, NY: Filmmakers Library. “He’s Doing This to Spite Me:” Emotional Conflicts in Dementia. Chicago, IL: Nova Films. Impact of Disorders and Trauma on the Brain. Allyn & Bacon Video Library. Intelligence. New York, NY: Insight Media. IQ Testing and the School. New York, NY: Insight Media. Lost in the Mind. Sherborn, MA: Aquarius Health Care Videos. Organic Disorders. Differential Diagnosis in Psychiatry Series. Princeton, NJ: Films for the Humanities and Social Sciences. Organic Mental Disorders. The World of Abnormal Psychology Video Series. South Burlington, VT: Annenberg/CPB Collection. A Prescription for Caregivers: Take Care of Yourself. Chicago, IL: Nova Films. Recognizing and Responding to Emotion in Persons with Dementia. Chicago, IL: Nova Films. Someone I Love Has Alzheimer’s Disease. Boston, MA: Fanlight Productions. Something Should be Done About Grandma Ruthie. Boston, MA: Fanlight Productions. Understanding Alzheimer’s Disease—Vol. 19, The Mind Teaching Modules. South Burlington, VT: Annenberg/CPB Collection. When the Mind Fails: A Guide to Alzheimer’s Disease. Allyn & Bacon Video Library. You Must Remember This: Inside Alzheimer’s Disease. New York, NY: Filmmakers Library. Copyright © 2013 Pearson Education, Inc. All rights reserved. 276

Web Links Web Link 14.1: www.neuroskills.com/index.shtml?main=/tbi/injury.html This information-packed site, sponsored by the Centre for Neuro Skills, provides detailed information, useful maps of the brain, and even video clips of what happens to the brain during various events such as a concussive impact and coup-contra-coup injuries. Web Link 14.2: www.neurologychannel.com/dementia A brief yet informative summary of information about dementia, including types, risk factors, causes, symptoms, diagnosis, and treatment. Web Link 14.3: www.merck.com/pubs/mm_geriatrics/sec5/ch40.htm Overview and fact sheet on dementia from the Merck Medical Manual. Web Link 14.4: www.alzheimers.asn.au/index.php Latest information on dementia, drug trials, research, support, and education. Web Link 14.5: www.hsph.harvard.edu/nutritionsource/vitamins.html This site, created by the Harvard School of Public Health, provides current information on which vitamins our bodies need and how these vitamins are used by the body.

Handout 14.1 Environmental/Chemical Factors

1. List at least five chemicals or environmental factors that you are exposed to daily (this would include smoking : ).

2. Do you feel that these stimuli can potentially have a long-term negative impact on your health?

3. How many people do you know with cancer or another chronic disease?

4. Now ask your parents how many people with a chronic disease they knew when they themselves were college-aged students.

5. Compare your answers for Question 3 and 4. Are they the similar or different? Why do you think that is?

6. In many of your classes faculty brings up the potential role of hormones and antibiotics in our food supply and how that may affect things like puberty. Do you think that these types of chemicals can have long-term effects?

7. Pick one of your stimuli from Question 1; what kind of study could be done to investigate whether that specific agent is harmful?

Handout 14.2 Living with People Who Have Alzheimer’s

Most people have had some experiences with a family member who developed Alzheimer’s disease. Interview such a person to determine the impact of the disease on family members.

Relationship to the Patient:

Quality of Interactions:

Behaviors Observed:

Reactions of Immediate Family:

Reactions of Extended Family:

Reactions of Community:

Interactions with Medical Providers:

Interactions with Nursing Home Staff:

Handout 14.3 Nursing Homes

From your visit to a nursing home, describe your reactions to the setting and to the services in the following categories:

Physical Characteristics:

Quality of the Environment:

Extent of Services Provided:

Characteristics of the Residents:

Personnel at the Facility:

Training Required for Employment:

Improvements Needed:

Activities for Residents:

Daily Routine for Residents: