Abnormal Psychology Perspectives, 5E David JA Dozois Instructor Manuals

INSTRUCTOR’S MANUAL ABNORMAL PSYCHOLOGY PERSPECTIVES FIFTH EDITION

David J. A. Dozois University of Western Ontario

BRIEF CONTENTS CHAPTER 1 Concepts of Abnormality throughout History CHAPTER 2 Theoretical Perspectives on Abnormal Behaviour CHAPTER 3 Classification and Diagnosis CHAPTER 4 Psychological Assessment and Research Methods CHAPTER 5 Anxiety Disorders CHAPTER 6 Dissociative and Somatoform Disorders CHAPTER 7 Psychophysiological Disorders CHAPTER 8 Mood Disorders and Suicide CHAPTER 9 Schizophrenia CHAPTER 10 Eating Disorders CHAPTER 11 Substance-Related Disorders CHAPTER 12 The Personality Disorders CHAPTER 13 Sexual and Gender Identity Disorders CHAPTER 14 Developmental Disorders CHAPTER 15 Behaviour and Emotional Disorders of Childhood and Adolescence CHAPTER 16 Aging and Mental Health CHAPTER 17 Therapies CHAPTER 18 Prevention and Mental Health Promotion in the Community CHAPTER 19 Mental Disorder and the Law

CHAPTER 1 Concepts of Abnormality throughout History I. Chapter Summary II. Case Studies:

A. Woman with obsessive-compulsive disorder B. Man displaying a paraphilia C. Man who developed schizophrenia III Case Notes: A. Religious woman with eccentricities B. Professor with strange behaviours C. Career criminal with a personality disorder

III. Attempts at Defining Abnormality A. Statistical Concept B. Personal Distress C. Personal Dysfunction and Harmful dysfunction D. Violation of Norms E. Diagnosis by an Expert F. Summary of Definitions IV. Focus 1.1 Defining disorders: The case of pedophilia V. Historical Concepts of Abnormality A. Evidence from Prehistory B. Greek and Roman Thought C. The Arab World D. Europe in the Middle Ages E. The Beginnings of a Scientific Approach VI. Focus 1.2 Treatment and mistreatment: The depiction of mental asylums in the movies VII. Development of Modern Views A. Biological Approaches B. Psychological Approaches VIII. The Growth of Mental Health Services in Canada IX. Key Points/Summary X. Key Terms XI.

Lecture Ideas/Activities

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A. Describe Hippocrates's four-fluids theory B. Movies and Mental Illness

I. Chapter Summary None of the criteria used to define abnormality are satisfactory alone; only some combination of these criteria seems to result in a reasonable definition. The history of conceptualization and treatment of behaviour problems and disorders did not follow a simple path. Humane treatment of people displaying disorders was exhibited by the early Greeks, Romans, and Arabs. In contrasting, the exorcisms during the Middle Ages in Europe were a result of supernatural explanations of mental disorder. The middle of the 19th century saw the rise of the scientific approach, so the study and treatment of the mentally ill is more rigorous and evaluative.

However, there is still a long way to go in developing a complete understanding and treatment of these problems.

II. Case Studies A. Lisa appeared at a clinic due to feelings that she had to wash the floor and bathrooms each time she took a shower, and would not let her family touch the bathroom for fear they would contaminate it.

B. Paul was sexually aroused by women’s underwear, which caused him distress. He decided to consult a therapist to deal with his unusual desires.

C. Arnold developed odd ways of perceiving the world shortly after entering university. He felt a lot of pressures and the heavy workload and responsibilities became too much for him. He began to develop odd thoughts and perceptions, and he began to behave inappropriately and do poorly in school. He was placed in hospital.

III. Case Notes A. Eileen is a young woman whose religious beliefs cause her to behave in a somewhat eccentric manner. She believes in astrology, feels that she can communicate with the dead, and believes that the world will soon end.

B. Roger is a professor at university whose social behaviour and presentation are somewhat unusual. He introduces odd ideas during his lectures with little relevance to the subject matter

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and on occasion loses students’ assignments. However, his research is well respected by his colleagues who often attempt to cover his shortcomings in other areas.

C. James has been a criminal for years. He recently became involved with a woman, with whom he had frequent conflict. James and his partner had arguments and physical confrontations around his drinking and lack of a job. One night, he lost his temper and beat his partner to death.

III. Attempts at Defining Abnormality Variability is clearly evident in the various problems classified as abnormal in both DSM-IV-TR and ICD-10. Also, many people with eccentric or strange behaviours do not meet the criteria for any diagnosable disorders. Those disorders that do meet diagnostic criteria may be described as mental illnesses, or as evidence of psychopathology, or simply as psychological disorders depending upon the person’s view of the underlying causes.

A. Statistical Concept According to the statistical definition, abnormal psychological functioning is that which occurs infrequently in the population. This, however, has limits, because some examples of unusual functioning are considered advantageous rather than problematic (e.g., high intelligence).

B. Personal Distress Personal distress is identified in DSM-IV-TR as a common feature of many disorders. However, this is not true of some psychological dysfunction, e.g., mania. Moreover, distress, is a normal part of life and is not in itself an indication of psychological dysfunction.

C. Personal Dysfunction Wakefield has suggested that harmful dysfunction is the critical feature of all people diagnosed as disordered, and that it entails negative impact on the individual. However, many individuals with diagnosable disorders are able to function in their lives. The boundaries between normal and abnormal and what is considered dysfunctional remain unclear.

D. Violation of Norms Other theorists have suggested that disordered people manifest violations in what is considered normative functioning (e.g., bizarre thoughts expressed by persons with schizophrenia).

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However, criminals, most of whom do not meet diagnostic criteria for any disorder, clearly violate norms. As well, most mentally disordered individuals are not dangerous or harmful to others. Since social norms change over time and vary across cultures, e.g., cultural relativity, violation of norms cannot be the sole criteria for defining abnormality.

E. Diagnosis by an Expert Professionals in the mental health field include psychiatrists, clinical psychologists, psychiatric nurses, and psychiatric social workers. In the final analysis, abnormality is essentially defined when diagnosticians apply the criteria for disorders as specified in DSM-IV-TR or ICD-10.

Critics such as Thomas Szasz claim that mental disorders are socially constructed to give more power to mental health professionals, and this remains an issue of discussion today.

F. Summary of Definitions There is no single definition that can on its own satisfy the multidimensionality of psychological dysfunction. To identify a person’s behaviour as abnormal, no sole criterion is necessary or sufficient, and typically some combination of criteria is used.

IV. Focus 1.1 It has been proposed that the DSM-5 add sexual attraction or behaviour towards early pubescent children to its definition of pedophilia. The term pedophilia itself would be replaced with the term pedohebephilic disorder. (In the DSM-IV-TR, sexual attraction or behaviour towards early pubescent children is not considered in the diagnosis of pedophilia).

V. Historical Concepts of Abnormality The identification of people as suffering from some psychological abnormality has a very long history. At each point in history, notions about mental illness reflected the generally held views of human functioning, as well as the social and political views of the time. If a society explains everyday events (e.g., the weather) by supernatural causes, then madness will be similarly explained, and treatment efforts will be aimed at the presumed cause. During recent times, when natural causes based on scientific evidence have predominated in our accounts of everyday events, abnormalities of psychological functioning have been explained in similar terms. The

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notions of what constitutes abnormal behaviour and explanations for abnormal behaviour have changed over time. Treatments differ over time as well, and it is important to remember that there is no necessary connection between supernatural beliefs and harsh treatment, or scientific beliefs and humane treatment.

A. Evidence from Prehistory During the Stone Age, evidence of supernatural beliefs has been found; skulls with circular sections cut out of them suggest operations called trephination were conducted, presumably to let out evil spirits that were causing the victim to engage in severely abnormal behaviour.

Egyptian papyri from nearly 4000 years ago describe supernatural explanations for various disorders and the use of magic as treatment procedures. Hunter-gatherer societies viewed both mental and physical disorders as having supernatural causes. Sadly, the view of demonological causes of mental illness still exists today.

B. Greek and Roman Thought Unlike their hunter/gatherer predecessors, the ancient Greeks and Romans preferred naturalistic explanations of madness and their treatments followed from these explanations. Hippocrates denied that psychological problems were caused by the intervention of gods or demons. He emphasized brain dysfunction, stress, and believed that dreams were important. Treatment included a quiet life, vegetarian diet, exercise, and abstinence from alcohol, or bleeding and vomiting. Although their theories now seem somewhat absurd (e.g., Hippocrates notion that disturbances in bodily fluids, or humours, caused disorders), they encouraged the beginnings of a scientific understanding of disordered behaviour and thought.

The approach of the Greeks in the last half of the millennium before the birth of Christ reflects a determination to see all phenomena in natural terms. Plato placed more emphasis on sociocultural influences on thought and behaviour. He elaborated on the function of dreams, felt that mentally disturbed people should not be held responsible for their crimes, and suggested that mentally ill people should be cared for at home. The Egyptians adopted the ideas of the Greeks and established sanatoriums for the mentally ill, which were peaceful and humane. Methodism represented a rejection of Hippocrates’ theories, which regarded mental illness as a disorder that

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resulted either from a constriction of body tissue, with the head being the primary site of affliction.

The Greeks were empirical; they provided the first clinical observations of disorders and made the first attempt at classification. Treatment was primary physical. After the Romans assumed control, physicians such as Galen continued the work of the Greeks. Both physical and mental factors were viewed as playing a role in mental disorder. Effective treatment involved comfortable surroundings and having people talk with a sympathetic listener.

C. The Arab World The Arab world retained the Greek and Roman ideas regarding treatment of psychological dysfunction. In fact, they were the first to build asylums where mad people were treated kindly.

The Islamic physician Avicenna described medicine and psychological functioning in his book The Canon of Medicine. There was an emphasis on natural causes, particularly environmental and psychological factors. His treatment emphasized care and compassion, as well as behavioural techniques.

D. Europe in the Middle Ages In Europe, from 500-1500 A.D., supernatural explanations replaced those of the Greeks and Romans. During this time, the prevailing view was that demons possessed mad people and had to be exorcised if the person was to be returned to sanity. While all exorcisms were not cruel, too often the afflicted person was made to suffer in order to make their body inhospitable to the demons. This idea applied particularly to witchcraft; many were believed to be insane, but in reality the majority were innocent victims who others wanted to be rid of. Such approaches to mental illness had critics, who were opposed to the torture and killing of witches. Paracelsus developed a new approach to mental disorders and attempted to create a new system of classification. He claimed that all mental illness resulted from disturbances in the spiritus vitae (breath of life). During the end of the Middle Ages, St. Vitus’ Dance developed, an epidemic of mass hysteria where groups of people would be hit with an urge to leap about, dancing and shouting. The general explanation was that people were possessed, but Paracelsus declared the problem to be a disease. Weyer followed Paracelsus’ ideas, advocating natural and physical treatment and rejecting exorcism. In Spain, the Moors continued the humane attitude, and the first mental institution in North America was built by the Spaniards in Mexico.

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E. The Beginnings of a Scientific Approach Through the 16th and 17th centuries, an increasing number of naturalistic theorists added their voices to the movement to replace supernatural accounts of madness. Teresa of Avila, St. Vincent de Paul, and others, challenged prevailing notions and offered accounts suggesting that physical and psychological disorders had common causes.

Asylums began to be established in Europe; often the residents were treated cruelly and lived in appalling conditions. During the 17th century, the large number of poor was seen as a serious social problem; “workhouses” were established, where the poor, the old, orphans and the insane were incarcerated. Mad people were chained to the walls and beaten. During the Enlightenment, changes occurred in the ways that the insane were viewed. Philippe Pinel, one of the leaders of this movement, insisted that the institutions be cleaned up and the treatment of mad people be more humane. He also developed a systematic and statistically based approach to the classification, management, and treatment of disorders. He emphasized the role of psychological and social factors in the development of mental disorders, and developed clear descriptions of symptomatology. He was scientific and looked only at natural causes in the development of disorders.

VI. Focus 1.2 Treatment and mistreatment: The depiction of mental asylums in the movies.

VII. The Development of Modern Views A. Biological Approaches Heredity: Benedict Augustin Morel introduced the degeneration theory, which proposed that deviations from normal functioning are transmitted by hereditary processes. The possibility that human behaviour could be seen as being passed on genetically led theorists to propose that it may be possible to identify people as potentially mentally disturbed or criminals before they developed such problems. Lombroso concluded that criminality was inherited and could be identified by the shape of the skull (phrenology), an idea that is no longer popular today.

Syndromes and the Beginning of Classification: Emil Kraepelin’s influential book, Clinical

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Psychiatry, published in 1883, attempted to classify mental illnesses. Kraepelin called groups of symptoms syndromes, and recognized that different disorders had distinct features.

Infection as a Cause of Mental Disorder: Richard Von Krafft-Ebing suggested that general paresis of the insane (GPI) might be the result of infection, and it is now known to result from untreated infections by the syphilis spirochete. The confirmation that GPI was the result of an infectious agent encouraged confidence that all mental disorders would be found to be caused by biological factors (somatogenesis), and encouraged physical approaches to treatment.

Shock Therapy: Shock therapy, of one kind or another, was applied to a whole range of disorders. German physician Manfred Sakel used it to treat withdrawal symptoms related to morphine addiction. Insulin-induced comas were used to treat schizophrenics, as were drugs that produced convulsions. Electroconvulsive therapy (ECT) was introduced by Ugo Cerletti and embraced as a treatment of schizophrenia by the psychiatric community before it was finally determined in the late 1950s that electric shock induced convulsions were beneficial only for depressed patients.

The Beginnings of Psychopharmacology: Psychopharmacology emerged in the 1950s, with several Canadians playing important roles in the introduction and development of drug therapies.

Mental illness was seen to result from disordered brain chemistry and there was a rejection of psychological perspectives. Chlorpromazine (an antipsychotic drug) radically changed the management of seriously disordered psychiatric patients and freed most of them from the restraints (e.g., straitjackets, padded rooms) that were previously thought to be necessary. More than that, these drugs allowed psychotic patients to be returned to community living far sooner than was ever possible prior to their use. A process of deinstitutionalization was set in motion.

B. Psychological Approaches Psychological treatments had been evident throughout history and obtained eminence in the latter part of the eighteenth century.

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Hypnotism and the Birth of Psychoanalysis: Anton Mesmer thought that hysteria was the result of a disturbed distribution of the magnetic fluid in the body, and believed that a magnetic force called animal magnetism would rearrange their fluids. Charcot believed that hypnotism might have value in treating hysterics and suggested that psychological factors caused hysteria.

Josef Breuer felt that patients should talk freely about unpleasant past experiences (cathartic method), and Freud developed methods to the status of a complex intrapsychic theory from which he derived his method of treatment known as psychoanalysis.

Behaviourism: In the early part of the 20th century, John B. Watson brought revolutionary ideas to psychological thought. From a behavioural (more accurately, a conditioning) perspective, Watson considered abnormal functioning to be learned, and felt that all problem functioning was the result of unfortunate conditioning experiences. His treatment procedures offered promise but were not enthusiastically until some 30 to 40 years later.

VIII. The Growth of Mental Health Services in Canada The first asylum during the early days of the settlement appeared in Quebec, housing people with all types of mental dysfunction and providing humane treatment. The growth of mental health services in the rest of Canada was evident in the increase in the number of asylums that occurred during the 19th century. However, in most of these institutions, criminals were warehoused with lunatics, and treatment was mostly absent or, when present, it was cruel. From the 1940s to the 1960s, lobotomies were performed on countless Canadians in an attempt to alleviate their suffering, despite the lack of evidence for any clear benefits. The most discouraging part of Canada’s mental health history was undoubtedly Ewen Cameron’s brainwashing and LSD studies conducted at Montreal’s Allen Memorial Hospital during the 1950s and 1960s.

Cameron’s research was offered as treatment to patients who did not realize they were guinea pigs in his CIA funded research. Over the years, many other Canadians played a role in the introduction of antipsychotic drugs, which helped alleviate the suffering of many patients, and they also contributed to the development of cognitive behavioural treatments. Recently, in a progressive move, the Federal government of Canada established the Mental Health Commission of Canada (MHCC) with the goal of developing an integrated mental health system.

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VIII. Key Points/Summary 1.

A variety of factors play a part in defining behaviours as abnormal. These include statistical rarity, personal distress, dysfunction, violations of social norms, and diagnosis by an expert.

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The early history of psychopathology reveals a struggle between supernatural and naturalistic explanations, and between harsh and sympathetic treatments.

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After the end of the Middle Ages in Europe, naturalistic approaches took over. By the late 19th century, both biological and psychological treatments based on research evidence became established as the preferred approaches.

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In Canada, the development of asylums in the 19th century marked the first steps in the mental health movement. Gradually, as elsewhere, biological and psychological interventions came to dominate, with Canadians contributing to these developments

IX. Key Terms psychological abnormality (p. 4) mental illness (p. 4) psychological disorder (p. 4) psychopathology (p. 4) culturally relative (p. 6) clinical psychologists (p. 6) psychiatrists (p. 6) psychiatric nurses (p. 6) psychiatric social workers (p. 7) occupational therapists (p. 7) supernatural causes (p. 8) natural causes (p. 8) trephination (p. 8) humours (p. 9) asylums (p. 10)

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St. Vitus’ Dance (p. 12) bedlam (p. 13) moral therapy (p. 15) mental hygiene movement (p. 15) syndromes (p. 16) general paresis of the insane (GPI) (p. 16) somatogenesis (p. 16) electroconvulsive therapy (ECT) (p. 17) deinstitutionalization (p. 18) behaviourism (p. 19) lobotomies (p. 19) Mental Health Commission of Canada (p. 20) Evidence-based practice (EBP) (p. 21)

X. Lecture Ideas/Activities 1.

Describe Hippocrates's four-fluids theory.

While technically inaccurate, you might point out that Hippocrates’s general idea of imbalances in bodily fluid causing mental illness may have been more accurate than he is generally given credit for. Point out the number of "mental" illnesses, such as some types of depression, that are clearly linked to imbalances in neurotransmitters in the brain, and other disorders, such as PMS, that are linked to hormone fluctuations and imbalances in the body. While phlegm, black bile, and yellow bile are clearly not hormones or neurotransmitters, they are similar in that both types of entity represent bodily fluids of a sort. You might also point out that not all of Hippocrates's ideas were as accurate as this one, even at a very general level. For example, his claims that hysteria in females was caused by a "wandering uterus" and could only be cured by marriage are clearly unsupported.

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Movies and Mental Illness

Films provide great opportunities to introduce and expand on the key concepts outlined throughout each chapter. Given classroom time restraints, it is best to show movie clips ranging from five to ten minutes. The utilization of popular films can be a way to capture your students’ attention by applying chapter content to real-world pop cultural settings, thus facilitating class discussion. Zimmerman (2003) listed several examples of popular feature films, both new and older releases (see films discussed and/or cited), to consider. Although Hollywood films tend to distort the realities surrounding mental health issues, they can be used as “classroom assets rather than liabilities” because films offer a visual representation as to how it would be to live with a mental disorder, including being socially excluded and experiencing discrimination. (Livingston,

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2004, p. 119).

Discuss popular videos that wildly misrepresent mental disorders. For example, in “Me, Myself, and Irene,” Jim Cary plays the role of a person with Dissociative Identity Disorder, but is labelled as schizophrenic. Many students form false beliefs about mental disorders based on what they see in the media, and some hold fast to these beliefs unless these issues are directly addressed in the classroom. This is a good opportunity to discuss the hazards of assuming that media images and depictions may be counted on to be accurate.

Livingston, K. (2004). Viewing popular films about mental illness through a sociological lens.

Teaching Sociology, 32, 119-128.

Zimmerman, J. N. (2003). People like ourselves: Portrayals of mental illness in the movies.

Laham, MD:Scarecrow Press, Inc.

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CHAPTER 2 Theoretical Perspectives on Abnormal Behaviour I. Chapter Summary II. Case Studies:

A. Teenager with major depressive disorder.

B. Little Hans who was fearful of being bitten by a horse.

C. Canadian Olympic award winning athlete recovers from depression.

III. The General Nature of Theories A. Levels of Theories B. Testing Theories: The Null Hypothesis IV. The Search for Causes

V. Biological Models A. The Role of the Central Nervous System B. The Role of the Peripheral Nervous System C. The Role of the Endocrine System D. Genetics and Behaviour VI. Psychosocial Theories A. Psychodynamic Theories B. Behavioural Theories C. Cognitive Theories D. Humanistic and Existential Theories E. Socio-cultural Influences VII. Integrative Theories A. Systems Theory B. The Diathesis-Stress Perspective C. The Biopsychosocial Model VIII. Focus Boxes IX. Key Points X. Key Terms XI. Lecture Ideas/Activities A. Psychoanalytic theory and sexism B. Which psychological perspective?

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I. Chapter Summary Theoretical views of the causes of abnormal behaviour include biological views (e.g., brain dysfunction, hormonal fluctuations, peripheral nervous system problems, or genetic errors), learning experiences, cognitive distortions, social and cultural factors, psychoanalytic processes, and integrative perspectives. Diathesis-stress models suggest disorders arise from a predisposition and a triggering stressor. The biopsychosocial model emphasizes interactions of various factors.

II. Case Studies •

When Hailey was born her mother was depressed, and she learned that others cannot be relied on. When she was 16, her boyfriend ended the relationship because he was frustrated

by Hailey’s frequent requests for reassurance. Hailey withdrew from those around her, and eventually sought treatment for depression.

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The case of “Little Hans” was brought to Sigmund Freud because of the young boy’s fear of horses. After a bad experience, “Little Hans” was so afraid of being bitten by a horse that he would not leave the house. Freud dismissed the actual experience as the cause of Han’s distress, and saw the problem as having unconscious origins.

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Clara Hughes is an Olympic cycler and skater. After her first time in the Olympics, she fell into a depression. She recovered from her depression after 2 years, and became a spokesperson for a campaign designed to reduce stigma and encourage people with mental health difficulties to seek help.

III. The General Nature of Theories From the time of the ancient Greeks through to the recent past, naturalistic theories have considered abnormal behaviour to result from either biological or environmental causes. These two main models have many theories associated with them, which tend to differ significantly in their perspective on mental disorders. Whatever position is taken, however, has implications for research, diagnosis, and treatment.

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Levels of Theories Theories that construe the cause of a given behaviour to be one single factor (e.g., a genetic disposition or a traumatic experience) are likely to be limited in their power to explain behaviour. Most current theories consider multiple factors as influences on human behaviour (interactionist explanations). In fact, research has demonstrated that biological factors and experience interact, and each may influence the other. Changes in behaviour may change biological functioning, just as biological factors may cause behavioural or psychological dysfunctions. Single-factor theories should not be seen as without value.

Testing Theories: The Null Hypothesis Scientific experiments set out not to prove a theory to be true, but rather, to reject the theory. This is referred to as testing the null hypothesis. Attempts to disprove a theory are the most rigorous tests of its value. A theory can be viewed as strong and reliable, if there are no data that contradict its main tenets.

IV. The Search for Causes The general aims of theories about mental disorders are to: explain etiology, identify the factors that maintain the behaviour, predict the course of the disorder, and design effective treatment. Many different theories have been proposed, including: biological, psychodynamic, learning (behavioural or cognitive-behavioural theories), cognitive theories, humanisticexistential theories, and socio-cultural theories. However, the view that biological, behavioural, and environmental systems operate as a whole system is gaining wide acceptance. In order to understand various theoretical approaches, it is important to understand them separately. Yet the most useful way of construing behaviour is one where it is thought of as a result of many influences -- an integration of biology and environmental experience.

V. Biological Models The Role of the Central Nervous System Biological models of abnormality take different forms. Some point to the role of structure damage to the brain, others suggest that one or another of the neurotransmitter systems is

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defective, while others suggest that hormones or the autonomic nervous system is malfunctioning. Finally, some biological theorists believe that defective genes cause abnormality. Brain damage, such as that produced by the long-term effects of syphilis, may result in disordered behaviour or cause a loss of cognitive functioning (i.e., dementia) characteristic of various disorders such as Alzheimer’s disease.

Neurotransmitters are chemicals that carry messages from one neuron to the next in complex networks within the brain. There are many types of neurotransmitters associated with various brain circuits and mediating various behaviours and cognitive processes. Difficulties can occur if a particular transmitter is over- or under-produced in the synapse, there are too many or too few receptors on the dendrites, there may be an excess or a deficit in the amount to the transmitterdeactivating substance in the synapse, or the re-uptake process may be too rapid or too slow.

Since various neurotransmitters seem to play a part in all brain activity, it is likely that the interactions of dysfunctional neurotransmitters systems play a role in disordered behaviour rather just one type of neurotransmitter. It also remains possible that environmental events, the person’s response to them, and the biological substrates all play a role in abnormal functioning. Brain plasticity, the ability of the brain to recognize its own circuitry, is influenced by large number of factors, which include environmental, hormonal, and maturational contributors. That is, influences that produce any kind of change in the brain may also leave an anatomical impact on its circuitry.

The Role of the Peripheral Nervous System The peripheral nervous system includes the somatic nervous system and the autonomic nervous system. The autonomic nervous system has two parts (the sympathetic and parasympathetic nervous systems) that act together to maintain homeostatic activity (i.e., balance) in important bodily functions, such as breathing and heart rate. During stress, the sympathetic system readies the body for action by increasing heart rate, visual acuity and breathing, while the parasympathetic system shuts down nonessential functions, such as digestion. During stress, the sympathetic nervous system goes into the “fight or flight” response, while the parasympathetic nervous system shuts down digestive processes. Overactive or under-active sympathetic or

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parasympathetic responses may play a role in various disorders. For example, the sympathetic nervous system mediates the experience of anxiety, so a chronic overactive response may dispose a person to anxiety disorders.

The Role of the Endocrine System The endocrine system interacts with aspects of the central nervous system in a feedback loop and thus functions as a self-regulatory system. This involves a complex interplay of various hormones which are chemical messengers released into the bloodstream. Since hormones play a role in many behaviours, any disturbance in their balance can cause disruptions in behaviour, thoughts and feelings. For example, Cretinism, a disorder involving a dwarf-like appearance and mental retardation, is a direct result of defective thyroid functioning. Similarly, Hypoglycemia, which results from the pancreas failing to produce balanced levels of insulin or glycogen, produces experiences that are similar to anxiety.

Genetics and Behaviour The idea that human behaviours are inherited is longstanding and has evolved over time. The search for concordance between family members for particular disorders is described as behavioural genetics, and offers insights into the biological basis of behaviour. More recent research emphasized genotype-environment interaction. Family studies, twin studies and adoption studies are types of research strategies employed by behavioural geneticists. More recently, genetic linkage studies, where a genetic marker (e.g., eye colour) is linked to the occurrence of a mental disorder, have become popular, as have research methods in molecular biology. Also in some recent approach, researchers compare specific DNA segments to identify genes that determine individual characteristics.

VI. Psychosocial Theories Psychodynamic Theories Psychodynamic theories began with Freud. His analysis of Anna O provided the basis for his complex theory that attempted to explain all human behaviour, as well as the origins of what used to be called the neuroses. Freud and Josef Breuer developed what became known as psychoanalysis as a treatment for these disorders. There are four aspects of Freud’s theory, all of

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which are interrelated in producing behaviour. First, levels of consciousness refers to Freud’s idea that the primary processes that drive behaviour reside in the unconscious, that wellpractised behaviours are activated by preconscious processes, and that consciousness is simply our awareness of the tip of the iceberg of the forces that drive our actions.

Second, the structures of personality describe the Id (instinctual drives such as sex), which operates according to the pleasure principle (primary process thinking); the Ego (whose job it is to curb the desires of the id to maximize benefits against costs), with the compromise between the id and reality referred to as secondary process thinking; and the Superego (the embodiment of society’s rules and mores).

Third, the psychosexual stages of development concern five developmental stages, during each of which specific drives must be satisfied or resolved so that problems will not develop later in life. These stages are: oral stage, anal stage, phallic stage (during which the Oedipal and Electra complex occur), the latency stage, and the genital stage. Finally, defence mechanisms allow the needs of the id to be expressed in symbolic form or serve to combat anxiety. Examples of defence mechanisms include: repression, regression, projection, intellectualization, denial, displacement, reaction formation, and sublimation.

Failure to resolve any of the psychosexual stages of development, combined with a poorly developed ego, Freud thought, would generate psychic conflict, which might overwhelm the defence mechanisms and thereby cause a breakdown. The specifics of the breakdown, or the symbolic form of the id’s desires, would reveal the particular psychosexual stage that had not been resolved. When psychoanalysis reveals this to the client, it is called insight and is thought to produce a cure.

Although Freud’s theory is largely speculative and difficult to test, his thinking has been valuable to the field. Some of his followers (e.g., Carl Jung, Alfred Adler) have reworked his theories. These new perspectives have enjoyed more acceptance, and have led to more effective treatments.

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Behavioural Theories Behavioural theories have been based on either conditioning (classical or operant) or social learning theory. John B. Watson’s original behaviourism involved the application of a classical conditioning analysis to human behaviour. He suggested that problematic behaviours resulted from the inadvertent pairing of a neutral stimulus (CS), a stimulus (UCS) that automatically elicited a response (e.g., an appetitive response or fear). After one traumatic pairing, or several sub-traumatic pairings, the CS would come to elicit on its own the UCR (i.e., the automatic response). John Watson and Rosalie Raynor took their study of Little Albert’s acquired fear to the pairing of a white rat (the CS) with a sudden loud noise (the UCS) to demonstrate that all phobias result from classical conditioning. Problems with a simple classical conditioning account led to the inclusion of operating conditioning principles to explain why phobias did not extinguish as classically conditioned fears do in the laboratory. Operant principles (behaviour changes as a result of reinforcement or punishment) were also used to explain a broad range of abnormal behaviours. Both classical and operant conditioning hare empirically based and both have generated effective treatment and management procedures.

Various elaborations on learning-based approaches have been developed, for example, Bandura and Walters' social learning theory. Social learning theory focuses on the importance of selfcontrol and self-efficacy. From the late 1960s on, Bandura and others developed social learning theory to provide a more satisfactory learning-based account of disorders and normative behaviour. Essentially, this theory claims that, while some behaviours are acquired directly by conditioning processes, most result from observing others or from information in books, television and movies. From this theory, clinicians derived cognitive-behavioural theory and treatment techniques that considered cognitions to function in the same way as behaviours; that is, they are learned and unlearned by the same procedures.

Cognitive Theories Strictly cognitive theories suggest that it is what the person perceives, remembers, and thinks that causes dysfunctional behaviours. Beck and Ellis, two of the early leading cognitive therapists, developed treatments that focused on changing what they saw as maladaptive thinking. Ellis’

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rational-emotive approach suggests that irrational thoughts guide maladaptive behaviours and must be challenged in treatment. Beck’s cognitive theory and therapy suggest that people who suffer from disorders develop dysfunctional cognitive schemata that direct their thinking and it is these deep schemata that must be changed in treatment. Different types of beliefs are believed to be related to different kinds of abnormal behaviour or what Beck referred to as contentspecificity.

Humanistic and Existential Theories Humanistic and existential theories take a phenomenological view of human behaviour.

Perceived experience shapes the people’s sense of themselves and of others, and this, along with values, provides the basis for many life choices. Behaviour is not determined by experience alone, but also by our own choices.

Humanistic Theories: Humanists like Carl Rogers and Abraham Maslow think experience provides the opportunity for us to develop our potential and it is the frustration of that development that leads to problems. Rogers took a person-centered approach and believed that abnormal behaviour results from a person’s distorted view of him or herself, which arises from an inability to trust experience. Maslow believed that people behave dysfunctionally as a result of experience. Treatment, for humanistic therapists, involves respecting the dignity of the client and fostering self-fulfillment or self-actualization.

Existential Theories: For existentialists, it is the development of meaning and the acceptance of responsibility for one’s actions that is critical. Terror of non-being (death or a meaningless existence) and a failure to take responsibility for choices, leads to angst (anxiety and distress), which can be at the heart of some disorders. Clients have to develop “the courage to be” as Tillich put it. Leading proponents include Rollo May and Viktor Frankl, who view the struggle for meaning and acceptance of responsibility as central. Treatment is directed at confronting clients with responsibility for their actions and assisting them in finding meaning.

Socio-cultural Influences Some theories take a socio-cultural view. In particular, labelling theory suggests that much of abnormal behaviour, and clinician’s responses to clients, is the result of some expert (a

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psychiatrist or clinical psychologist) labelling the person as having a disorder. The client accepts this label and responds accordingly. In addition, other people in the client’s environment treat him or her as someone one who displays all of features of that disorder.

Other socio-cultural theories emphasize the role of social support, or lack thereof, from others.

Similarly, some have stressed the role that gender stereotypes and the impact of gender expectation on the etiology and diagnosis of certain disorders. Other theorists stress race and poverty as important factors in the development of disorders.

VII. Integrative Theories Systems Theory, the Diathesis-Stress Perspective, and the Biopsychosocial Model Systems theory sees causation as the combined effect of multiple factors interacting. The diathesis-stress model suggests there is an inborn, or developed, predisposition to acquire particular disorders, can interact with environmental stress to produce the problem. The biopsychosocial model claims that biological deficits (inborn or acquired), psychological problems, and social factors, all interact to cause disorders. Both these models are integrative and do not set nature vs. nurture in trying to explain the etiology of disorders. Most theorists today adopt one of these models in some form.

VIII. Focus Boxes •

Neurotransmission: Nerve impulses are received by the dendrites of one neuron (the pre-synaptic neuron), and activate or inhibit that neuron, then travel down the axons of that neuron to activate or inhibit the electrochemical activity in the dendrites of another neuron (the postsynaptic neuron). The point of contact is the synapse, a minute space where neurotransmitters, which are contained in vesicles, are released. Some of the released neurotransmitters are reabsorbed by the axon, some are deactivated by substances in the synapse, and the remainder is taken up at receptor sites. These receptor sites only take up neurotransmitters which match their structure, making it possible to create drugs whose chemical

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structure matches these transmitters, and either block, accelerate or inhibit the action, or stimulate or reduce the release of neurotransmitters.

•

Personal genome project Canada. The University of Toronto is asking for 100,000 Canadian volunteers to provide their DNA for the Personal Genome Project Canada. The entire genome for each volunteer will be sequenced.

Volunteers will also provide medical records, health information, family medical history, and lifestyle information. All of this information – including the genome results – will be place online where the general public can see. In addition to information on physical characteristics, the genetic information will include information on intelligence, vulnerability to depression, schizophrenia, and other mental disorders. Genes related to personality traits will also be uncovered. The hope is that this information will spur research that will lead to medical breakthroughs. How much would you like to know about your own future?

Would you want to know if, for example, you were at very high risk for Alzheimer’s disease? What effects could this kind of knowledge have on the emotional well being of those who receive bad news about future illness?

IX. Key Points 1.

What purpose do theories play in science and are they value-free? What is meant by the null hypothesis and why is it a valuable concept in testing theories?

2.

Biological theories propose roles in the etiology of disorders for: damage to the CNS; over or under-active neurotransmitters; too much or too little of one of the hormones; over or under-reaction of the ANS; and the contribution of genetics.

3.

Freudian theory considers unconscious conflicts to be the basis of psychological disorders. Important concepts are: levels of consciousness, role of the id, ego, and superego, psychosexual stages of development, and defence mechanisms.

4.

Behavioural theories invoke classical and operant conditioning, or social learning processes, as the causes of abnormal behaviour, which is theorized to result from the same conditioning processes as normal behaviour.

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5.

Cognitive theories indicate that it is the person’s perceptions of events, irrational beliefs, and distorted schemata that generate dysfunction.

6.

Humanistic and existential theories similarly consider each person’s idiosyncratic perceptions and experiences to be crucial. From these perceptions and experiences, the person develops a sense of self, others, and of meaning to their life. They also generate their choices and develop, or fail to develop, responsibility for their actions.

7.

Socio-cultural influences include stereotypes of gender, race and poverty, and the effects of an expert labelling a person as disordered.

8.

Integrative theories see the interaction of biology, social and personal experience, and stress, as causing disorders.

X. Key Terms single-factor explanations (p. 23) interactionist explanations (p. 25) null hypothesis (p. 26) etiology (p. 26) neurotransmitters (p. 28) brain plasticity (p. 30) behavioural genetics (p. 32) genotype-environment interaction (p. 32) concordance (p. 33) genetic linkage studies (p. 33) molecular biology (p. 33) psychodynamic (p. 34) conscious (p. 34) preconscious (p. 34) unconscious (p. 34) id (p. 34) ego (p. 34) superego (p. 35) phallic stage (p. 35)

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Oedipal complex (p. 35) Electra complex (p. 35) defence mechanisms (p. 35) classical conditioning (p. 36) operant conditioning (p. 38) reinforcement (p. 38) punishment (p. 38) social learning theory (p. 39) cognitive-behavioural theory (p. 39) rational-emotive behaviour therapy (p. 39) schemas (p. 39) content specificity (p. 40) self-actualization (p. 42) labelling theory (p. 43) public stigma (p. 43) systems theory (p. 45) diathesis-stress perspective (p. 45) biopsychosocial model (p.46)

XI. Lecture Ideas/Activities 1.

Psychoanalytic theory and sexism.

One of the most controversial of Freud’s views involves his notions about the phallic stage of development. A particularly controversial topic within this stage is his concept of penis envy.

Briefly, Freud believes that when a little girl notices how she differs from little boys, she feels cheated. She blames her mother for her lack of a penis, and rejects mother and tries to displace her in father’s eyes -- in effect, to become “daddy’s darling.” The little girl unconsciously hopes that her father will give her a penis. When he does not, she compensates with the wish for a child. There are a number of important consequences of this process, each with applications for abnormal psychology: a.

Women have weaker superegos than males.

b.

Women feel inferior to men and contemptuous of other women.

c.

Women become passive, vain, jealous, and masochistic.

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d.

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

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

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

2.

Which psychological perspective?

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

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CHAPTER 3 Classification and Diagnosis I.

Chapter Summary

II. Case Study A. The diagnosis of panic disorder with agoraphobia and dependent personality disorder in the case of Nick.

III Why Do We Need a Classification System for Mental disorders?

IV. The Perfect Diagnostic System V. Characteristics of Strong Diagnostic Systems VI. The History of Classification of Mental Disorders VII. DSM-IV-TR: A Multiaxial Approach VIII. Categories of Disorder in DSM-IV-TR A. Disorders usually first diagnosed in infancy, childhood, and adolescence B. Delirium, Dementia, Amnesia, and other cognitive disorders C. Substance-related disorders D. Schizophrenia and other psychotic disorders E. Mood disorders F. Anxiety disorders G. Somatoform disorders H. Factitious disorders I. Dissociative disorders J. Sexual and Gender Identity disorders K. Eating disorders

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L. Sleep disorders M. Impulse control disorders N. Adjustment disorders O. Personality disorders P. Other conditions that may be a focus of clinical attention Q. Toward DSM-5

IX Focus Box X. Issues in the Diagnosis and Classification of Abnormal Behaviour A. Against Classification B. Criticisms Specific to DSM XI. Summary XII. Key Terms XIII. Lecture Ideas/Activities

A. The disadvantages of the DSM approach B. Distinguish between a psychological disorder and an illness

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I. Chapter Summary Every science includes a system for categorization of information. In abnormal psychology, diagnosis consists of a determination or identification of the nature of a person's disease or condition. Currently in psychology in North America, diagnoses are made on the basis of a diagnostic system called the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition with text revisions (DSM-IV-TR). Despite its shortcomings, the DSM has progressed with great improvement in every edition. It has made a serious attempt to apply research findings and it stresses observable behaviour and provides explicit rules for diagnosis. The fifth version of the DSM (DSM-5) is due to be published in the year 2013.

II. Case Study •

Nick, a single 30-year-old man, lives with his mother and becomes anxious when she encourages him to move out and become more independent. Due to his medical conditions, he is convinced he needs his mother’s help taking care of him. Nick also suffers from anxiety and has a history of panic attacks which has kept him mostly socially isolated and afraid of venturing outside of his mother’s home. According to a psychological assessment, Nick also has Dependent Personality Disorder.

III. Why do we Need a Classification System for Mental disorders?

A diagnostic system provides a common vocabulary for professionals to communicate with each other about individuals with mental disorders, and it provides information that is necessary when making decisions about treatment. Without a classification system we could not conduct research on disorders, and without research progress in treatment would be stalled. Finally, we need diagnostic systems in order to estimate the prevalence of disorders in the population.

IV. The Perfect Diagnostic System The perfect diagnostic system would classify disorders on the basis of sound empirical research findings on the presenting symptoms, etiology, prognosis, and response to treatment of a large number of people. Ideally, different symptom clusters would accurately signal different disorders, and a precise "cure" would be available for each disorder. Unfortunately, attaining the perfect diagnostic system is hindered by the difficulty of systematically observing and measuring

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many aspects of human functioning in a controlled fashion adhering to strict scientific principles.

Despite the shortcomings of diagnostic systems to date, a good classification system is useful for organization of information, communication, prognosis, treatment recommendations, heuristic value, and guidelines for financial support.

V. Characteristics of strong diagnostic systems In order to be useful, a diagnostic system must fulfill criterion of reliability and validity.

One important aspect of reliability of the DSM is inter-rater reliability. Concerning validity, the two most important types for the DSM are concurrent validity and predictive validity.

VI. The History of Classification In the nineteenth century Kraeplin led the way in developing a systematic classification; however, his categories and descriptors bear little relation to modern systems. The American Psychiatric Association published a classification system, the DSM-I, in 1952. The first two versions of the DSM proved highly unsatisfactory, but DSM-III (1980) and DSM-III-R (1987) were more atheoretical and pragmatic as they moved toward more precise behavioural descriptions and specific criteria. The DSM-III-R was developed to be polythetic, meaning that an individual could be diagnosed with a subset of symptoms without receiving a full diagnosis.

The advent of the DSM-IV was the result of comprehensive literature reviews, reanalysis of old data sets, and the addition of new data. Most recently, a text revision of DSM-IV has been released; DSM-IV-TR.

VII. DSM-IV-TR: A Multiaxial Approach One of the major innovations in the DSM-III and later editions was the use of multiaxial classifications that address a broad array of information that might be of concern. With the DSMIV-TR, the latest edition, clinicians assess patients under five different axes, or aspects of the person's condition. Each axis addresses different information. Axis I concerns the most obvious disorders such as schizophrenia. Axis II focuses on the presence of generally less severe longterm disturbances. Axis III covers any medical disorder that might be relevant to the understanding or management of the case. Axis IV collects information on the patient's life circumstances. Axis V measures how well a person is able to cope with the circumstances related to his or her problems. There are, however, criticisms that coding of all axes is rarely implemented.

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VIII. Categories of Disorders in DSM-IV-TR DSM-IV-TR groups all the disorder listed on either Axis I or Axis II into 15 categories.

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. Included in this broad-ranging category of disorders are the intellectual, emotional, and physical disorders that typically begin before maturity (e.g., attention deficit/hyperactivity disorder, separation anxiety disorder, autistic disorders).

Delirium, Dementia, Amnesia, and Other Cognitive Disorders. Delirium is a clouding of consciousness, wandering attention, and an incoherent stream of thought. Dementia is a deterioration of mental capacities. Amnestic syndrome involves impairment in memory with no delirium or dementia.

Substance-Related Disorders. When the use of substances that affect the central nervous system, such as alcohol or amphetamines, results in social, occupational, psychological, or physical problems, it is considered a mental disorder.

Schizophrenia and Other Psychotic Disorders. The disorders known as schizophrenia are marked by severe debilitation in thinking and perception. Individuals with such a diagnosis suffer from a state of psychosis, or a loss of contact with reality.

Mood Disorders involve disturbances in mood that do not seem to be a reasonable reaction to life events. These disorders include major depressive disorder, mania, and bipolar conditions.

Anxiety Disorders are characterized by excessive fear, worry, or apprehension. Included in this category are phobias, acute stress disorder, posttraumatic stress disorder, and obsessivecompulsive disorder.

Somatoform Disorders. The physical symptoms of somatoform disorders have no known physiological cause but seem to serve a psychological purpose. Included in this category are somatization disorder, conversion disorder, pain disorder, and hypochondriasis.

Factitious Disorders is characterized by intentional production of or complaining about symptoms, apparently because of a psychological need to assume the role of a sick person.

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Dissociative Disorders are characterized by a sudden and profound alteration in consciousness that affects an individual's memory and identity. This category includes dissociative amnesia, dissociative fugue, and dissociative identity disorder.

Sexual and Gender Identity Disorders include the three main categories of sexual dysfunctions (e.g., premature ejaculation), paraphilias (e.g., exhibitionism), and gender identity disorders.

Eating Disorders are characterized by extreme eating patterns that significantly impair functioning such as anorexia nervosa and bulimia nervosa.

Sleep Disorders. Individuals with these disorders display two major categories of sleep disturbances. In the dyssomnias, sleep is disturbed in amount, quality, or timing. The parasomnias are marked by abnormal events during sleep.

Impulse Control Disorders include a number of conditions in which people are chronically unable to resist impulses, drives, or temptations to perform acts harmful to themselves or to others such as in intermittent explosive disorder, pathological gambling, and trichotillomania.

Adjustment Disorders refer to the development of excessive emotional or behavioural symptoms such as distress and impairment in social or occupational functioning, within three months after a major stressful event.

Personality Disorders are characterized by an enduring, pervasive, inflexible, and maladaptive behaviour pattern that markedly impairs functioning or causes subjective distress. Included in this category are antisocial personality disorder and dependent personality disorder.

Other Conditions That May Be a Focus of Clinical Attention. This broad category is used for conditions that are not considered to be mental disorders but still may be a focus of attention or treatment and includes psychological factors affecting physical condition.

Towards the DSM-5

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A number of changes to the criteria for disorders in the new DSM are based on evidence-based findings. Perhaps the biggest change to the DSM involves the use of a dimensional approach in the diagnosis of personality disorder.

IX. Focus Box Research has demonstrated that comorbidity (i.e., meeting the criteria for more than one diagnostic condition at a time) may be present in more than 50% of cases. The occurrence of comorbidity leads to difficult questions about the nature of the relationship between the two disorders and how to treat them.

X. Issues in the Diagnosis and Classification of Abnormal Behaviour There are two main areas of controversy regarding the use of diagnostic systems such as the DSM in classifying abnormal behaviour. One body of opinion objects to classification in general, and the second body of opinion objects to the DSM in particular.

A. Against Classification Medical Model A substantial number of professionals argue that the whole diagnostic endeavour is flawed because of its adherence to the medical model. According to this viewpoint, medical disorders, unlike mental disorders, have a clear indication, such as a lesion, which is a recognizable deviation in anatomical structure. However, there are also many medical disorders for which there are no known lesions or anatomical abnormalities, some medical disorders are so classified on the basis of associated dysfunction alone, and at some point in the future anatomical anomalies may be found to be associated with some mental disorders.

Stigmatization Another argument against diagnosis is that it unfairly stigmatizes an individual. The label of mental illness may lead an individual to identify with that label and experience further deterioration. It has been counter argued that, even if such undesirable consequences do occur on occasion, the flaw lies not in the classification system but in people's reactions to being diagnosed.

Loss of information .

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A frequent charge against diagnosis is that information is lost through the use of labels.

However, it is also possible that the information lost by using a diagnostic label is often irrelevant to the diagnostic endeavour, and in turn this may actually facilitate intervention procedures and research.

B. Criticisms Specific to DSM Gender Bias Gender bias is still a concern in the DSM, although major improvements have been made in this area from DSM-I to the current DSM-IV-TR. Some critics claim that societal gender bias is reflected in the DSM descriptions of many psychiatric disorders, making a diagnosis more likely for women, even when no pathology is actually present.

Cultural Bias Cultural bias is another important factor that might influence the diagnostic process. Although the DSM-IV-TR has striven to be atheoretical and to take cultural differences into account, the designation of behaviour as normal or abnormal is fraught with cultural and professional assumptions, especially considering that disorders in the DSM have been determined largely by the consensus of English-speaking scientists trained primarily in North America.

Politics and the DSM There are concerns about the secrecy surrounding the DSM revision process, and about the composition of the membership of the committees that are working on DSM-5. One hundred percent of the committee members working on revisions for the categories of “Mood disorders” and “Schizophrenia and Other Psychotic Disorders” have financial ties to the pharmaceutical industry.

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XI. Summary 1. One of the improvements over earlier editions of the DSM was the addition of multiaxial classifications. With DSM-IV clinicians assess patients for the presence of major mental disorders (Axis I), personality disorders (Axis II), relevant medical conditions (Axis III), relevant life circumstances (Axis IV), and general functioning (Axis V).

2. The endeavour of diagnosing mental disorders has been criticized for its adherence to the medical model, unfairly stigmatizing an individual, and the information lost through the use of classification labels.

3. The DSM, in particular, has been criticized for its gender bias and cultural bias.

4. In terms of the DSM, inter-rater reliability refers to the extent to which two clinicians agree on the diagnosis of a particular patient and is an important requirement of any diagnostic system.

5. Validity refers to the degree to which a classification system, for example, measures what it purports to measure. The two most important types of validity for diagnostic systems are concurrent validity and predictive validity.

6. The DSM-IV-TR is the latest of an ongoing attempt to improve reliability and validity by employing more specific criteria based on empirical findings.

XII. Key Terms assessment (p. 50) reliability (p. 51) inter-rater reliability (p. 51) validity (p. 51) concurrent validity (p. 51) predictive validity (p. 51) atheoretical (p. 52) polythetic (p. 52) multiaxial (p. 52) evidence-based (p. 58) categorical (p. 59) dimensional (p. 59)

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XIII. Lecture Ideas/Activities 1.

The disadvantages of the DSM approach.

As your text notes, not everyone has been happy with the multiaxial approach and the philosophy introduced with the DSM-III in 1980. One such critic has been George Valliant, who found five problems with this DSM approach: 1. The DSM is anchored in an American system of values and does not give adequate consideration to other cultures. For example, there are no standards in place that guide therapists on how to address cultural variations in the manifestation and severity of symptoms or the cross-cultural prevalence of various diagnoses.

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

3. The DSM places too much attention on surface phenomena, while failing to attend to the longitudinal course of psychological disturbances.

4. The DSM fails to address important etiological factors that may influence the severity and course of a disorder.

5. The DSM sacrifices validity for the sake of reliability. Although use of the DSM will encourage clinicians to come up with the same diagnoses both across clinicians and over time (reliability), it does not always guarantee an accurate diagnosis (validity).

Additional concerns include: 6. The DSM does not demarcate the distinctions between disorders and presents diagnoses as if they have little overlap. In reality, many disorders are comorbid (depression and anxiety), have overlapping symptoms (e.g., sleep disturbances in Major Depressive Disorder, Posttraumatic Stress Disorder, and Bipolar I disorder), or have arbitrary distinctions (e.g., the timeframe distinction between Acute Stress Disorder and Posttraumatic Stress Disorder).

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

Ask students to discuss these criticisms. In particular, ask the class how they would design DSM-5.

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Valliant, G. E. (1984). The disadvantages of DSM-III outweigh its advantages. American Journal of Psychiatry, 141, 542-545.

2. Distinguish between a psychological disorder and an illness.

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

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CHAPTER 4 Psychological Assessment and Research Methods I. Case Study: A. Boy with disruptive behaviour II. Assessment A. Assessment Tools: Striving for the Whole Picture B. Reliability and Validity C. Clinical vs. Actuarial Prediction III. Biological Assessment A. Brain Imaging Techniques B. Neuropsychological Testing C. Case Notes – Michael, limits of diagnosis IV. Psychological Assessment A. Clinical Interviews B. Assessment of Intelligence C. Personality Assessment D. Focus 4.1 - Test Security E. Focus 4.2 – MMPI profile case F. Behavioural and Cognitive Assessment

RESEARCH METHODS V. Experimental Methods A. Controlled Experimental Research B. Quasi-Experimental Methods VI. Nonexperimental Methods A. Correlational Research B. Longitudinal research C. The Case Study D. Single-Subject Designs E. Epidemiological Research F. Studies of Inheritance G. Case Notes – Behavioural treatment of Peter, an aggressive 4 year-old boy

VII. Statistical vs. Clinical Significance VIII. Focus Box – The personal genome project IX. Summary

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X. Key Terms

XI. Lecture Ideas/Activities A. Clinical versus statistical prediction B. Ethical dilemmas involved in the use of control groups in research

1. Case Study A. Aidan was assessed by a psychologist because his behaviour in class was disruptive, and his teachers felt that he performed below his potential. He did not follow instructions well, and his behaviour in the classroom was disobedient. He was a little aggressive but not mean. Aidan’s IQ was very high, but he was found to have difficulties with concentration and impulsivity. He was also observed to be immature for his age. It was recommended that both parents and school be firm in response to his aggressive behaviour. He was placed in an accelerated classroom with only 12 children the next year, and with increased supervision and more structure, Aidan’s classroom behaviour improved, although he still displayed disruptive behaviour on the playground.

ASSESSMENT II. Assessment Diagnosing psychopathology generally results from a psychological assessment, the systematic gathering of information from an individual with suspected abnormal behaviour. Good assessment tools should be both reliable (consistent) and valid (measuring what they are intended to measure).

A. Assessment Tools: Striving for the Whole Picture The most useful understanding of an individual draws on a combination of procedures that shed light on a range of different aspects of the person’s functioning.

B. Reliability and Validity

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Several types of reliability are particularly important for psychological tests. Test-retest reliability refers to the degree to which a test yields the same results when it is given more than once to the same person. Alternate-form reliability is a method where two forms of the same test are designed and scores from each are correlated with one another.

Internal consistency refers to the degree of reliability within a test; one measure is splithalf reliability, which compares responses on odd numbers to responses on even numbers. Another method, coefficient alpha, is calculated by averaging the intercorrelations of all items on a given test.

A reliable measure is of little use if it is not valid. Face validity means that the items on a test resemble the characteristics of the concept being measured, content validity requires that the test’s content include a representative sample of behaviours believed to be related to the construct, criterion validity arises since some qualities are easier to recognize than to define, and construct validity refers to the importance of a test within a specific theoretical framework.

C. Clinical vs. Actuarial Prediction Individuals can be evaluated based on the clinical approach (clinical experience and judgment) or the actuarial approach (relying on statistical procedures). It is suggested that the actuarial approach is more efficient when making predictions in various situations.

III. Biological Assessment Medical conditions may play a role in causing abnormal behaviour; therefore, it is important that a general physical examination be conducted as part of the assessment procedure.

A. Brain imaging techniques, such as the electroencephalogram (EEG), computerized axial tomography (CAT) scans, magnetic resonance imagery (MRI), and positron emission tomography (PET) are used to provide both structural and functional

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information. The EEG measures the brain’s electrical activity and is used to detect seizure disorders, brain lesions, and tumours. In the CAT scan, X-rays projected through the head are rotated to project an image of the living brain. Data from CAT scans have supported the idea that some disorders are a result of cortical atrophy. MRI is a noninvasive technique using a magnetic field is around the patient’s head in order to measure radio wave transmission and develop a computer-generated image of the brain. PET is a combination of computerized tomography and radioisotope imaging. Various biological activities can be measured as the processes occur in the living brain. PET scans have confirmed that there are abnormal patterns of metabolic activity in people with seizures, tumours, stroke, Alzheimer’s disease, schizophrenia, and bipolar disorder.

B. Neuropsychological tests are used to determine relationships between behaviour and brain function. The Bender Visual-Motor Gestalt Test is easily administered and is used to screen children for neuropsychological impairment. Children are required to copy images from a card and then from memory, and certain types of errors are characteristic of neurological problems. However, this test produces too many false negatives.

Neuropsychological assessments now employ a battery of tests to identify the presence of cognitive and motor impairment as well as the nature and area of neurological impairment. The Halstead-Reitan and the Luria-Nebraska are widely used batteries, and can be used to discriminate between various forms of organic brain damage.

C. Case notes –limits of assessment. Michael was referred to a psychologist because he had had eight seizures within the past three months. Unfortunately, his seizures only occurred in the presence of his mother. Michael had been given a full medical and neurological examination and was healthy. The neurologist believed that he was faking to get attention or sympathy. However, it was later discovered that he suffered from a very rare and progressive brain disorder that was not diagnosable in its early stages. This is one example of a case where what appeared to be a psychological disorder was the first sign of a medical disorder.

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IV. Psychological Assessment A. Clinical Interviews The clinical interview is the oldest and most common assessment tool. It may be unstructured, semi-structured, or structured. Although different, each method attempts to gather information about the client’s functioning. Unstructured interviews are openended and allow the interviewer to pursue information that may arise during the course of the interview. The main advantage of unstructured interviews is that facilitate rapport, although this method is less reliable and valid. Structured interviews such as the Diagnostic Interview Schedule, version IV (DIS-IV), may be administered by both mental health professionals and trained lay interviewers. Although highly structured interviews may increase reliability, they tend to jeopardize rapport. Semi-structured interviews provide an outline of what to cover, while still allowing leeway, such as the Mental Status Examination and the Structured Clinical Interview for the DSM-IV-TR (SCID).

B. Assessment of Intelligence Intelligence tests such as the Wechsler Adult Intelligence Scale (WAIS), the Wechsler Intelligence Scale for Children (WISC), and the Stanford-Binet Scales measure diverse aspects of ability or intelligence using IQ or intelligence quotient. The WAIS and WISC are most widely used and contain subscales designed to measure both verbal and performance ability. On these IQ tests, the average is 100, with scores below 70 indicating mental retardation, and scores over 130 indicating exceptional intelligence.

The use of IQ tests is controversial, and while IQ tests are most often used to predict academic performance, it is important to remember that other factors influence academic and job performance. The WAIS and WISC are used to help identify intellectual giftedness, learning disabilities, mental retardation, and neurological problems.

C. Personality Assessment Various tests, questionnaires, and rating scales are offered to describe various characteristics that make up an individual’s unique personality; they are used in research, personnel selection, and diagnosis. Projective tests, such as the Rorschach inkblot test, the Thematic Apperception Test (TAT), and Sentence Completion test and

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Projective Drawings, are used to help clinicians form hypotheses about an individual’s personality. In these tests, ambiguous stimuli are presented to the individual, and it is believed that the individual will project unconscious thoughts onto that stimulus. In the Rorschach, clients are shown inkblots and asked about what they see; in the TAT individuals are asked to construct stories about cards depicting ambiguous social interactions. In the Sentence completion and Projective drawings tests, clients are asked to complete sentence stems or to draw a picture. Exner developed a standardized scoring of responses for the Rorschach in order to increase reliability and validity. Despite lack of support for the reliability and validity of these tests, they remain popular, particularly among psychodynamic clinicians, who argue that because these methods allow freedom of expression, they may shed light on areas that a questionnaire would not cover.

Personality inventories such as the widely used Minnesota Multiphasic Personality Inventory (MMPI) and the Million Clinical Multiaxial Inventory (MCMI) assess many aspects of personality and are used to assist clinicians in making diagnoses. The revised MMPI-II and MMPI-A (for adolescence) have been validated in a number of studies. The Personality Assessment Inventory (PAI) is a self-administered, objective inventory of adult personality. One limitation to self-report tests is that individuals may not give accurate reports about themselves, despite control scales designed to detect distortions.

As well, personality tests assume that an individual’s personality is stable and generalizable across situations and over time. Also, it has been argued that predicting behaviours requires knowledge of the person’s situational context, referred to as person by situation interaction.

D. Focus Box 4.1 - Test security.

In 2009 a Canadian physician posted the entire set of Rorschach inkblots, along with a list of responses, on Wikipedia. Wikipedia refused to take these down this posting.

Putting psychological tests and response into the public domain compromises the validity and usefulness of these tests.

E. Focus Box 4.2

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This is a sample analysis of an MMPI profile by an expert. The patient was referred by a physician for possible schizophrenic ideation, depression, and possible suicidal tendencies. The profile indicates that patient was experiencing a considerable amount of distress.

F. Behavioural and Cognitive Assessment Behavioural and cognitive assessments are used to assess the actual behaviour of the client. Observational techniques and ratings are used to observe behaviours directly.

Rating scales are used to assess various behaviours and changes in behaviours over time.

Researchers may also directly observe or have another individual directly observe the client’s behaviour, either in the client’s environment (in vivo observation) or in an artificial setting (analogue observational setting). However, validity of such observational methods may be undermined by several factors, e.g., reactivity, lack of generalizability across situations, inconsistency between raters, observer drift, and difficulty in terms of time, equipment, and scoring procedures.

Cognitive-behavioural assessment relies on four sets of variables, SORC (the Stimuli that precede the problem, Organismic factors, overt responses, and Consequences of the behaviour which may reinforce the behaviour).

Self-monitoring requires clients to record their own behaviours, using behaviour scales or diaries. Broad band instruments are used to measure a wide variety of behaviours, whereas narrow band instruments focus on behaviours related to single constructs. This technique is useful and cost-effective, providing the client is competent, diligent, and self-motivated.

RESEARCH METHODS Research approaches

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The primary goals of clinical research are: the description of clinical phenomena and prediction of behaviour. All scientific research can be divided into experimental methods and nonexperimental methods of investigation.

V. Experimental methods A. Controlled Experimental Methods Controlled experimental research involves manipulating certain variables (independent variables) and determining what effects this manipulation has on other variables (dependent variables). In a true experiment, subjects are randomly assigned to experimental or control groups, and the responses are analyzed using statistical methods. An experimental effect is obtained when the difference in some dependent variable are found to occur as a function of manipulations of the independent variable.

Controlled experiments allow inference concerning cause and effect, but are the most difficult to implement due to the need to control so many factors. Internal validity may be threatened if strict control cannot be achieved, and external validity, or generalizability of the results to other groups, is of concern. In order to make conclusions about outcome and whether any differences in outcome between groups was caused by the different treatment or by differences among subjects pretest and posttest descriptors are collected. Recent research has revealed that participants receiving treatment expect to get better, placebo effect. To further ensure that expectations would not influence the outcome of the study, a double-blind procedure is used, so that neither the participants nor the experimenter knew who belonged to the experimental vs. control/placebo group.

B. Quasi-experimental studies Quasi-experimental studies are ones in which the subjects in the experimental group are not randomly assigned but are selected on the basis of certain characteristics and there is no manipulation of independent variables. Control subjects are matched across all variables except the dimension being measured. Many aspects of psychological disorders, which cannot be studied by experiments, may be examined through quasi-experiments. In Quasi-experimental studies cause-effect inferences are limited and it is difficult to match subjects on all factors except for the one in question.

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VI. Nonexperimental Methods A. Correlational research allows a researcher to determine the degree of relationship between two variables. Following the measurement of variables, a correlation coefficient, represented by the symbol r and ranging from -1.00 to 1.00, is computed. A positive correlation indicates that an increase in one variable is associated with an increase in another variable, while a negative correlation indicates that an increase in one variable is associated with a decrease in another variable. A correlation of zero implies that no relationship exists between the variables. Generally, correlational values greater than 0.30 are considered interesting. Correlational research is a relatively inexpensive method of studying the relationship between naturally occurring phenomena, and may indicate whether a meaningful relationship exists between two variables, but causation cannot be established.

B. Longitudinal studies are one the ways in which to reduce ambiguity associated with the direction of correlational relationships by examining the early factors contributing to the onset of an illness.

C. Case studies are rich, detailed descriptions of the past and current functioning of single individual cases. They are useful in developing hypotheses and may provide insight into rare disorders, but may be biased and not easily generalizable.

D. Single subject designs involve observing a subject in his/her environment, avoiding the pitfalls of case studies by employing experimental methods. The ABAB design, also known as the reversal design, requires the quantification of behaviour in its naturally occurring environment prior to intervention. The A phase - baseline, B phase introduction of treatment, next A phase - reversal to original baseline conditions, next B phase - treatment provided again. However, it is ethically and practically difficult to implement some reversals and external validity may be lacking.

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E. Epidemiological research is the study of the incidence and prevalence of disorders in the population. The incidence refers to the number of new cases of a disorder in a particular population over a specified time period, whereas the prevalence refers to the frequency of a disorder in a population at a given point in time. Such information is essential for understanding factors that contribute to the health of a population and to design appropriate interventions. However, a large number of subjects are required and causation is difficult to ascertain.

F. Studies of inheritance, such as family, twin and adoption studies, are useful for determining the contribution of genetic and environmental factors to a disorder. Genetic similarity between family members tends to be greater than non-family members, and close relatives are particularly genetically similar.

In family studies, the client or patient is called the index case or proband, and if the proband and a comparison person are alike, they are said to be concordant. However, environment and heredity are confounded in family studies. That is, members of a family live in a more similar environment than found between people from different families.

Adoption studies offer researchers an opportunity to determine the separate effects of genetics and environment on the development of psychological disorders. Generally, a group of individuals who were adopted at an early age and develop a psychological disorder are studied, and rates of disorder are examined in biological and adoptive parents. If there is greater agreement between adoptees and biological parents than between adoptees and adoptive parents, a genetic link likely exists. Cross-fostering is an improvement over the traditional adoption study: one group comprises adopted children, whose biological parents have a disorder and whose adoptive parents demonstrate no psychopathology; the other group comprises adopted children whose biological parents have no disorder but whose adoptive parents develop psychopathology. It is difficult to obtain full information on biological parents, and sample sizes are often small.

Furthermore, birth difficulties cannot be controlled for, and they affect the developing fetus but are not genetically transmitted.

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The use of twin studies is a more accurate way of inferring genetic contributions to disorder. Monozygotic (MZ) twins have 100% of their genes in common, while dizygotic (DZ) twins have 50% of their genes in common - if there is greater concordance for a disorder among MZ twins than among DZ twins, a genetic basis for disorder can be inferred. However, these studies suffer from small sample sizes and environmental confounds that might be stronger for dizygotic than monozygotic twins.

G. Case Notes – Behavioural treatment of Peter, an aggressive 4 year-old boy • Peter was a 4 year old with ADHD, in a regular preschool program who behaved aggressively, both verbally and physically. The teachers and researchers decided to target his physical aggression first; each incident was recorded and he was reprimanded, but his aggression did not change. Next, each time he behaved aggressively he was given a timeout, and his aggressiveness decreased. When they went back to verbally reprimanding him, the aggressive behaviour returned. When the timeout was reinstated, his aggressive behaviour decreased even more rapidly.

VII. Statistical vs. Clinical Significance In experimental research, statistical significance is crucial. Generally, the conventional significance level is .05. Clinical significance is concerned with practical utility. To control for the potential irrelevance of statistical significance, it has been suggested that the social validity of a treatment be evaluated. Another approach, the normative comparison, compares treatment results to non-disturbed samples.

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VIII. Focus Box 4.3 Would you share the secrets of your DNA with the world?

The University of Toronto and the Hospital for Sick Children are working with a group at Harvard University on the Personal Genome Project. Researchers are hoping that 100,000 people will provide their DNA for sequencing. In addition to providing DNA, participants are being asked to provide medical records, family medical history, age, weight, height, information about occupation, lifestyle. A photo is optional. All of the information will be placed online so that scientists all over the world will have access to it. The hope is that this data will allow for medical breakthroughs in understanding and treating diseases. There is a risk that the information provided will be sufficient to identify particular individuals. Furthermore, there are no laws in place in Canada to protect individuals from insurers who may refuse insurance and prospective employers who may refuse employment on the basis of test results.

There are also concerns about how people will be affected by knowledge of the illnesses that may lie ahead in the future. What will be the impact of this information on the recipients? How will people who learn that they are at high risk for serious illness and disability in the future cope with that knowledge, and will this information trigger anxiety, depression, and other disorders in the present? http://www.personalgenomes.org/

IX. Summary

1.

Psychological assessment of individuals should include both biological and psychological methods.

2.

Research is an extremely important part of psychology and is used to describe and predict behaviour.

3.

Assessment tools should be both valid and reliable; different types of reliability and validity need to be determined.

4.

Biological assessment approaches include brain imaging techniques (EEG, CAT scan, MRI, PET) and neuropsychological testing (Bender Gestalt Visual-Motor Test

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and batteries such as the Halstead-Reitan and Luria-Nebraska). These techniques are used to examine the structure and function of the brain.

5.

Clinical interviews are designed to gather information about the functioning of the individual; they can be unstructured, semi-structured, or structured.

6.

Intelligence tests (WAIS and WISC) are widely used to distinguish between intellectually gifted, learning-disabled, and mentally retarded individuals.

7.

Assessment of personality ranges from the use of standardized tests such as the MMPI and MCMI to the presentation of ambiguous stimuli in projective tests such as the Rorschach Inkblot Test and the Thematic Apperception Test.

8.

Behavioural and Cognitive Assessment rely on observational techniques that involve rating the client’s behaviour, either by the clinician, participant observers, or the client.

9.

Controlled experiments involves the random assignment of individuals to experimental and control groups, where the experimental group is exposed to the independent variable (which is manipulated) and both groups are assessed on the dependent variables. Responses are analyzed according to statistical methods.

10. Quasi-experimental methods are those in which subjects in the experimental group are not randomly assigned but are selected on the basis of certain characteristics; independent variables are not manipulated.

11. The correlational approach assesses the degree of relationship between two variables. The case study is a description of the past and current functioning of a single individual. Single-subject designs involve the examination of specific behaviours in an individual subject.

12. Epidemiological research is the study of the incidence and prevalence of disorders in a given population 13. Family, twin, and adoption studies are valuable in determining the degree to which genetics and the environment influence a disorder.

X. Key Terms

psychological assessment (p. 67)

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test-retest reliability (p. 67) alternate-form reliability (p. 67) internal consistency (p. 67) split-half reliability (p. 67) coefficient alpha (p. 67) face validity (p. 68) content validity (p. 68) criterion validity (p. 68) construct validity (p.68) clinical approach (p. 68) actuarial approach (p.68) computerized axial tomography (CAT) (p. 69) magnetic resonance imaging (MRI) (p. 70) positron emission tomography (PET) (p.70) Bender Visual-Motor Gestalt Test (p. 71) mental status examination (p. 73) intelligence quotient (IQ) (p. 75) Stanford-Binet scales (p. 75) Wechsler Adult Intelligence Scale (p. 75) WAIS-IV (p. 75) projective test (p. 77) Rorschach inkblot test (p. 77) Exner system (p. 78) thematic apperception test (TAT) (p. 78) Minnesota Multiphasic Personality Inventory (MMPI) (p. 79) Millon Clinical Multiaxial Inventory (MCMI) (p. 80) person by situation interaction (p. 82) in vivo observation (p. 82) analogue observational setting (p.82) reactivity (p. 82) SORC (p.73)

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description (p. 85) experiment (p. 85) random assignment (p. 85) experimental group (p. 85) independent variable (p. 85) dependent variable (p. 85) control group (p. 85) experimental effect (p. 85) pretest (p. 85) post-test (p. 85) placebo effect (p. 86) placebo (p. 86) double-blind (p. 86) internal validity (p. 86) external validity (p. 86) quasi-experimental study (p. 86) confound (p. 87) correlational method (p. 87) longitudinal studies (p. 87) case study (p. 88) single-subject design (p. 88) ABAB (p. 89) reversal design (p. 89) epidemiology (p. 89) incidence (p. 89) prevalence (p. 89) proband (p. 90) concordance (p. 90) cross-fostering (p. 91) monozygotic twins (MZ) (p. 91) dizygotic twins (DZ) (p. 91)

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phenotype (p. 93) gene-environment interactions (p. 93) statistical significance (p. 93) clinical significance (p. 93) normative comparison (p. 94)

XI. Lecture Ideas/Activities A.Clinical versus statistical prediction.

Can machines do better at making accurate diagnoses? In this research area clinical judgment is pitted against statistical formulas – the same set of psychological test scores about patients is given to clinicians to think about, and is also plugged into statistical prediction formulas. Since the early 1950s, studies have shown that the formulas do at least as well as the clinicians. In fact, in more recent research, statistical techniques have actually been found to predict how the clinicians reach their decisions.

It is possible to read this research and reach three general conclusions: 1.

Clinicians rarely do better than statistical formulas.

2.

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

3.

Clinicians should be replaced by the statistical formulas.

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

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

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

B. Discuss the ethical dilemmas involved in the use of control groups in research.

Often, researchers know prior to or early into a research study that treatment subjects are getting a significantly beneficial treatment and that control subjects can never catch up

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and may suffer significant health risks or even death by getting a placebo rather than the experimental treatment. What ethical questions are raised by these situations? Similarly, is it ethical to try new drugs or experimental procedures on terminally ill patients? What ethical issues are raised by research conducted with terminally ill patients in this regard?

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CHAPTER 5 Anxiety Disorders I. Chapter Summary II. Case Studies A. University Students with symptoms of anxiety B. Woman with panic attacks C. Woman with fear of thunderstorms D. Man with fear of social situations E. Man with fear of contamination F. Man with PTSD from experiences in the military G. Woman with generalized anxiety disorder H. Woman afraid of dying in a car accident III. Applied clinical case - Hoarding IV. The Characteristics of Anxiety V. Historical Perspective VI. Etiology A. Biological Factors B. Psychological Factors C. Interpersonal Factors D. Comments on Etiology VII. The Anxiety Disorders A. Panic Disorder and Agoraphobia B. Specific Phobia C. Social Phobia/Social Anxiety Disorder D. Obsessive-Compulsive Disorder E. Post-Traumatic Stress Disorder F. Generalized Anxiety Disorder VIII. Changes in DSM-5

IX. Treatment of Anxiety Disorders A. Pharmacotherapy B. Cognitive Restructuring C. Exposure Techniques D. Problem-Solving E. Relaxation

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F. Other Techniques X. Treatment Efficacy A. Treatment of Panic Disorder B. Treatment of Specific Phobias C. Treatment of Social Phobias D. Treatment of Obsessive-Compulsive Disorder E. Treatment of Post-Traumatic Stress Disorder F. Treatment of Generalized Anxiety Disorder G. Comments on Treatments that Work XI. Canadian Research Centre XII. Key Points XIII. Key Terms XIV. Lecture Ideas/Activities A. Worry B. Gender Differences C. Are you phobic?

I. Chapter Summary

All of us experience physiological, cognitive, and behavioural aspects of anxiety. Anxiety can be adaptive in the sense that our bodies kick in a physiological response geared toward survival. When anxiety becomes extreme and interferes with the individual’s life, it is conceptualized as a disorder. Each of the anxiety disorders discussed is distinguished in terms of the main source of fear and its appraisal. Biological factors are clearly implicated in the etiology of anxiety, but it is also shaped by life experience. The most successful interventions involve cognitive-behavioural treatments.

II. Case Studies •

On the morning of a Psychology exam both Crystal and Greg are students experiencing symptoms of anxiety. Crystal’s symptoms are milder than Greg’s. Severe symptom, such as in the case of Greg, cause discomfort, and impair ability to concentrate and perform.

•

Judy was a 29-year old woman who began to experience uncued panic attacks that could occur up to 5 times per day. She also had secondary symptoms of depression. She

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experienced many symptoms including facial flushing, hyperventilation, unsteadiness and tachycardia. She also worried that she was going to die, have a heart attack, or go crazy.

•

Donna was a 42-year-old woman who had the intense fear of thunderstorms. She first experienced this fear when she was 21 years old and pregnant with her daughter. Her fear increased over the years causing considerable distress and interference with daily life. When thunderstorms occurred, Donna experienced panic attacks.

•

Tony found it extremely difficult to make friends, and was constantly anxious in social situations. His anxiety extended to eating or writing in front of others. As a result of this anxiety Tony used alcohol, drinking on average 36 beers per week.

•

Scott had extreme fear of being contaminated with germs. He constantly washed his hands, scrubbed his walls with bleach, and washed dishes and counters numerous times a day. Scott was also concerned with having properly locked the doors and turned off the stove, and consequently checked multiple times. These symptoms interfered with his performance at work.

•

Raul was born in Cuba and spent time in the Cuban army in various locations. While engaged in combat, he saw many of his friends injured and killed. After a period of working on naval ships he heard that he may be suspected of anti-government activities. He fled to Nova Scotia and was hospitalized there with flashbacks and nightmares related to his past.

•

Elizabeth describes that she was always a worrier, but that her worries became worse after experiencing a work-related injury. She became concerned about her health, as well as many aspects of her safety and the safety of others. She also worried about finances, accidents, and doing harm to her daughter. She experienced fatigue, restlessness, and sleep problems.

•

Sara developed intrusive fears about being in a car accident at the age of 18 when she moved away from home to university. She avoids driving or being a passenger in a car as much as she can. When she cannot avoid being in a car she checks it over for an hour before getting

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in. She knows that her worries and avoidance are unreasonable, but she can’t seem to stop herself.

III. Applied clinical case: Hoarding The reality TV show “Hoarders” has publicized the disorder known as hoarding. In Canada there have been at least two instances of fires associated with hoarding. In 2010, a fire in a hoarder’s apartment in downtown Toronto displaced 1100 people. In 2011, a man died in a fire in his Vancouver home when firefighters were unable to enter the home because it was so crowded with belongings. Hoarding has been considered to be a subtype of OCD, but there is a trend toward considering hoarding as a distinct disorder, separate from OCD.

IV. The Characteristics of Anxiety Anxiety is an affective state where by an individual feels threatened by the potential occurrence of a future negative event. Fear is more primitive emotion and occurs in response to a real or perceived current threat. From an evolutionary perspective, fear is an important because of the response it elicits. The behavioural response know as fight or flight response, so named because fear either prompts a person to stay an fight or to run away from a dangerous situation.

Panic is very similar to fear, making these two emotional states difficult to distinguish.

However, panic may be triggered in the absence of provoking event.

V. Historical Perspective During the 19th and early 20th centuries many psychological problems were described as neuroses. Until 1980, anxiety disorders were classified with dissociative and somatoform disorders under the heading on neuroses. Freud was one of the earliest theorists to focus on anxiety and to recognize the difference between objective fears and neurotic anxiety. Research conducted over the past few decades has greatly expanded our understanding of the nature of anxiety and its treatment. The major models today are behavioural and cognitive behavioural interventions.

VI. Etiology

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Biological Factors Genetics. Twin studies suggest a moderate level of concordance for anxiety within family members, suggesting a genetic role. The estimated heritabilities range from 30% to 40%. The genetic risk for anxiety is suggested to be non-specific and is more likely to be passed on as broader dispositional or temperamental traits. Studies also suggest that anxiety disorders arise from a combination of genetic and environmental factors.

Neurotransmitters and Neuroanatomy. The majority of what is known about the neurobiology of fear, panic, and anxiety comes from animal research. The neural fear circuit begins with the thalamus, information is then sent to parts of the amygdala, then to areas of the hypothalamus, through the mid-brain to the brain stem, and finally to the spinal cord. The latter areas are connected with various autonomic and behavioural outputs. Information transfer between the neuroanatomical structures involved in fear, anxiety is mediated by complex and interacting neurotransmitter systems. For example gamma-aminobutyric acid (GABA) is the most pervasive inhibitory neurotransmitter in the brain. Benzodiazepines are a class of anti- anxiety medications that operate primarily on GABA-mediated inhibition of fear system. The serotonin and norepinephrine systems are also involved.

Psychological Factors Behavioural Factors. The idea that anxiety and fear are acquired through learning has a long history. The two-factor model of conditioning proposes that fears are acquired through classical conditioning but maintained by operant conditioning. In other words, avoiding or escaping is a negative reinforcer that prevents classically conditioned fears from being unlearned.

This theory has limitations. First, it cannot explain the development of all phobias. Fears are sometimes acquired in the absence of conditioning, for example, some are developed by observing the reaction of other people (vicarious learning or modeling). Second, there is also evidence for biological preparedness for developing fear of some types of stimuli.

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Cognitive Factors. According to the cognitive model proposed by Aaron Beck, emotions are influenced by the way people appraise the future, themselves, and the world. This appraisal is influenced by beliefs, which are the products of prior experiences. People prone to anxiety disorders are thought to hold core beliefs that are helpless and vulnerable, and tend to focus on information relevant to their fears. Cognitive models describe schemas, information processing biases, and automatic thoughts, all thought to be relevant to the development and maintenance of anxiety.

Interpersonal Factors. Some of the cognitive styles that are characteristic of anxiety may be formed early in childhood through interactions with parents and caregivers. Parents who are anxious tend to interact with their children in less positive way, by exercising excessive control, fostering beliefs of helplessness, and failing to promote self-efficacy and independence.

Attachment theorists have shown that early child-parent interactions can lead to the development of general belief systems about relationships. An anxious-preoccupied attachment style is predictive of anxiety problems in adulthood.

Comments on Etiology. Clearly no single factor causes anxiety. Instead there is a complex and dynamic interplay among biological, psychological, and interpersonal factors. This combination of factors or vulnerabilities likely contributes to an individual’s level of anxiety when he or she is faced with life stressors.

VII. The Anxiety Disorders Panic Disorder and Agoraphobia Description. There are four defining elements of panic disorder the most important of which is the presence of unexpected panic attacks. Panic attacks are discrete periods of intense fear or discomfort accompanied by at east four of 13 symptoms outline in the DSM-IV-TR. The onset of a panic attack is sudden and often accompanied by a sense of imminent danger and an urge to flee. Diagnostically, at least one of the panic attacks must be followed by persistent concerns about the consequences of the attack or results in significant change in behaviour. In DSM-IV-TR, an individual is classified as having panic disorder with or without agoraphobia.

Agoraphobia involves avoidance of a cluster of situations such as enclosed spaces, travelling far

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from home, being alone in or outside of the home, driving on a bridge or in a tunnel, using the subway or going into public spaces. It is for the most part a fear of public, rather than open, spaces. The diagnosis of agoraphobia without panic attacks is also possible but quite rare. The onset of panic disorder is typically around early to middle adulthood, and is more common among women.

Diagnosis and Assessment. Conducting a differential diagnosis can be complicated, because panic attacks are not unique to anxiety disorders. The cardinal feature of panic disorder is uncued panic attacks and marked worry regarding the possibility of recurrence. Panic attacks associated with other anxiety disorders are cued by a particular situation (e.g., panic attack during a social function). A multiple method of assessment includes interviews, behavioural assessments, and natural observation (e.g., behavioural avoidance test).

Etiology. Cognitive theories propose that panic attacks arise from catastrophic misinterpretation of arousal-related bodily sensations. People prone to panic attacks are said to have elevated anxiety sensitivity. They catastrophically misinterpret arousal-related bodily sensations because they believe the sensations to have harmful consequences such as death, insanity or loss of control. In this model, agoraphobia is regarded as avoidance of situations that induce feared bodily sensations. Alarm theory of panic proposes that when a danger is real a true alarm occurs to mobilize our bodies to flee from the situation. In some instances, however, this system can be activated by emotional cues creating false alarms or triggering panic attacks that come to be associated with neutral cues.

Specific Phobia Description. A specific phobia is a marked and persistent fear and avoidance of a specific object or situation. Fears are adaptive reactions to threats, but phobias are excessive and unreasonable fear reactions. Prevalence rates are higher among females, with lifetime prevalence at 15.7% in women, and 6.7% in men.

Diagnosis and Assessment. For a diagnosis of phobia, the fear, avoidance and worries related to the phobic stimulus must interfere significantly with the person’s life, and the phobic reaction

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must be considered excessive. The DSM-IV-TR recognizes five subtypes of specific phobia: (1) animal phobia, (2) natural environmental phobia, (3) blood-injection-injury phobia, and (4) situational phobia, and (5) an “other” category which includes illness phobia.

Etiology. Classical conditioning explanations of phobia have been criticized for assuming that all neutral stimuli have equal potential for becoming phobias or the equipotentiality premise. The nonassociative model of phobia proposes that there exists a biological predisposition for acquiring certain phobias, such as the fear of heights. The failure to habituate to a certain stimuli and the genetic contribution to fear may predispose an individual to developing phobias. Some theories combine associative and nonassociative features and argue that biological preparedness make it more likely to fear certain types of stimuli. Recent research has focused on the role of disgust sensitivity or the susceptibility to disgust by some types of stimuli such as bugs, certain food, small animals, etc.

Social Phobia/Social Anxiety Disorder Description. People with social phobia are intensely afraid of social or performance situations in which they may be subject to scrutiny or evaluation by others. To be diagnosed as having social phobia, the fear must be considered excessive or unreasonable by the person. Typically avoided situations are being the centre of attention, public speaking, signing one’s name in public, eating in public, and using public washrooms. Non-generalized social phobia is focused on a specific situation or activity, whereas generalized social phobia involves the fear of most social settings.

A pattern of covert and overt avoidance may lead to isolation. The most recent estimates of the one-year prevalence of social phobia are around 3%, with equal rates in males and females. The onset of social phobia is usually during late childhood or adolescence and the onset of puberty may play an important role. Comorbidity is very high with other anxiety disorders, such as major depression and alcohol abuse.

Diagnosis and Assessment. Structured and semi-structured interviews are the most common tools for assessing social phobias. Some relevant diagnostic considerations include distinguishing between social and agoraphobia, or determine if both are present.

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Etiology. The etiology of social phobia includes genetic, biological, and cognitive factors.

Genetic factors appear to account for approximately one-half or more of the variance in the risk for social phobia. Behaviour inhibition (a heritable temperamental characteristic) is an early marker of risk for social phobia. Research is beginning to identify the neurocircuitry involved in social phobia. To understand the neuroanatomy of social phobia it is important to know the interactions among structures involved in fear recognition and conditioning (e.g., amygdale) arousal, and stress (e.g., hypothalamic-pituitary-adrenal axis), and areas of the brain that monitor negative affect (e.g., anterior cingulated cortex, prefrontal and orbitofronal cortex). Cognitive factors associated with social phobia involve both negative beliefs and judgments about the self and others, as well as abnormal processing of social information.

Obsessive-Compulsive Disorder (OCD) Description. Recurrent obsessions and compulsions, or both characterize OCD. Obsessions are thoughts, images, or impulses that are persistent, and markedly distressing. Compulsions are repetitive behaviours performed in response to an obsession, or according to certain rules in a stereotyped manner. They are intended to reduce the anxiety. Neutralizations are behavioural or mental acts that are used to try and prevent, cancel or undo the feared consequence. One of the more striking aspects of individuals with OCD is their excessive beliefs about personal responsibility. Thought-action fusion (TAF) refers to two types or irrational thinking: (1) thoughts are of moral equivalence to action, and (2) having a particular thought will increase its likelihood of becoming true.

Diagnosis and Assessment. It is important to distinguish between OCD and everyday worry.

Obsessions tend to be more bizarre and involve more imagery than do worries. Other criteria include that the person recognize that their obsessions are irrational, excessive, and that the symptoms significantly interfere with daily life.

Etiology. One of the most comprehensive theories of OCD is the cognitive-behavioural and neurobiological model. Most neuropsychological models of OCD implicated the basal ganglia and frontal cortex. Neurochemical theories of OCD have also been proposed. The success of selective serotonin reuptake inhibitors (SSRIs) in alleviating OCD has led many researchers to

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implicate abnormalities in serotonin neurotransmission. The cognitive-behavioural conceptualization of OCD posits that problematic obsessions are caused by the person’s reaction to intrusive thoughts, and arise from catastrophic misinterpretation of these thoughts.

Posttraumatic Stress Disorder (PTSD) Description. PTSD is characterized by three clusters of symptoms, which arise after the person is exposed to a traumatic stressor: (1) recurrent reexperiencing of the traumatic event, (2) avoidance of trauma-related stimuli and numbing of general responsiveness, and (3) persistent symptoms of increased arousal. PTSD persists for a minimum of one year following the initial trauma. In addition to the current symptoms, the DSM V may include several additional symptoms and reactions to traumatic events.

Diagnosis and Assessment. The diagnosis and assessment of PTSD generally involves the combination of a semi-structured clinical interview and the results of psychometric tests (e.g., Clinician Administered PTSD Scale. Essential to the diagnosis of PTSD is the determination of the presence of co-morbid disorders, such as substance abuse or depression. In more complex cases of PTSD personality disorders may be present.

Etiology. Traumatic life events play a role in the development of PTSD, however, a number of risk factors have been identified. Pre-event risk factors for adults include low socio-economic status, education and tested intelligence; childhood adversity including being abused as a child.

Post-event risk factors for PTSD include severity of triggering event, lack of social support, and the presence of additional traumatic experiences.

Generalized Anxiety Disorder (GAD) Description. The central difficulty in GAD is uncontrollable, chronic, and excessive worry. An estimated 3% of the population has GAD at any given time, and 5% chance of developing it at some point in life. GAD is diagnosed more frequently in women (about two thirds of persons diagnosed are female).

Diagnosis and Assessment. The primary criterion is the presence of excessive worry for more days than not for a period of at least 6 months. For a diagnosis of GAD three other symptoms

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must be present (e.g., restlessness, muscle tension, and sleep problems). It must also be determined that the source of the worry is not another Axis I disorder. GAD shares some symptoms with major depressive disorder, however anxious thinking focuses on the future, while depressive thinking focuses on the past.

Etiology. Etiological models of GAD are primarily cognitive in nature. It appears that worry may serve to decrease physiological arousal through replacing images with verbal thought. In addition, to some individuals worry seems to be a way of preparing for the future, and/or for avoiding thinking about issues of more emotional significance. Theories of cognitive vulnerability focus on a factor called intolerance of uncertainty, which refers to the individuals discomfort with ambiguity and uncertainty.

VIII. Changes in the DSM-5 Proposed changes in the next DSM include the addition of several symptoms to the disorder of PTSD, a reduction in the number of symptoms and the time that symptoms must be experienced to qualify for a diagnosis of GAD. Hoarding and agoraphobia may be designated as distinct disorders with separate criteria for diagnosis.

IX. Treatment of Anxiety Disorders Pharmacotherapy Minor tranquilizers were frequently used to treat anxiety before the development of antidepressant. These drugs have many side effects and are best used for short term relief of symptoms. Antidepressant drugs are currently the most well-used and effective medications for the treatment of anxiety disorders. The monoamine oxidase inhibitors, once widely used, are now revealed to have significant adverse effects on the digestive and cardiovascular systems. In contrast, tricyclic antidepressants are in more widespread use and function to block the reuptake of norepinephrine and serotonin. Two categories of medications have been introduced recently and seem to be effective anxiolytics and are associated with lower side effects than SSRIs: Azapirones and Venlafaxine hydrochloride.

Cognitive Restructuring

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This technique works to change a person’s faulty and maladaptive thought patterns that focus on future threat. Patients are taught how to monitor their thoughts and develop more balanced appraisals of the risks posed by stress and their ability to cope. A specific strategy involves the patient keeping a thought record in order to identify the particular thoughts that are present during or precede feelings of anxiety.

Exposure Techniques These techniques may come in the form of slowly increasing exposure to the stimuli, flooding, or in the form of response prevention. All of these techniques are aimed at confronting the person with a stimulus, which typically elicits an undesirable behaviour or an unwanted emotional response. All these techniques evoke some degree of distress, but the aim is to develop more adaptive internal representations of stimuli and their non-threatening consequences. One of the earliest forms of exposure was systematic desensitization. The patient develops a fear hierarchy or a list of fears arranged in descending order according to their fearfulness. Work begins with least feared stimuli and progressively moves to more feared stimuli. However, in vivo exposure seems to be more effective that imagined exposure. Another variation of exposure is called flooding or intense exposure which involves starting at a very high level of intensity rather than working gradually through the fear hierarchy. Exposure to internal cues or interoceptive exposure involves the induction of physical sensations.

The main treatment of OCD involves exposure and response prevention, which involves promoting abstinence from rituals used to reduce anxiety. Worry exposure, which was developed for the treatment of GAD, entails identifying the patient’s main areas of worry, and conjuring up images of worst possible outcome. After holding these images for a time, patients are then encouraged to generate alternatives. Worrying behaviour prevention involves refraining from engaging in worry behaviour. A similar strategy to response prevention is helping patients to reduce subtle avoidance, which prevents the individual from getting the full benefit of exposure.

Problem Solving

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Problem solving begins with the problem-orientation phase, in which individuals are encouraged to approach and deal with problems rather than worry. Clients are encouraged to view problems as a normal part of life. The basic problem solving strategy involves defining the problem and generating a wide range of solutions, implementing one or more of the solutions, and evaluating outcome.

Relaxation The aim of relaxation training is to decrease anxiety arousal, and can be classified into two general types: mental and physical relaxation. Techniques include the systematic tensing and relaxing of various muscle groups, positive imagery, meditation, and breathing exercises.

Other Techniques A number of additional strategies are beginning to be applied in the treatment of anxiety.

Mindfulness-based strategies combines sitting and moving (e.g., yoga, walking) meditation with a number of principles intended to promote psychological well-being. Virtual reality technology use computer environment to create exposure experiences with the feared object. Eye Movement Desensitization and reprocessing (EMDR) is primarily used for PTSD. EMDR has no obvious advantage over conventional forms of exposure and CBT.

X. Treatment Efficacy Treatment of Panic Disorder Many elements of Cognitive-behaviour therapy (CBT) for panic disorder have been shown to be as effective as drug therapy, producing powerful long-term results. CBT is also a cost- effective treatment option.

Treatment of Specific Phobias The main form of treatment is in vivo exposure, with encouraging results. Short-term and intensive treatment approaches have been effective.

Treatment of Social Phobia

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The most popular treatment is cognitive behavioural group therapy (CBGT), which integrates both cognitive restructuring and exposure. Overall, few differences exist between CBGT and medication in terms of treatment response, with individuals in CBGT appearing better protected against relapse.

Treatment of Obsessive-Compulsive Disorder The main psychological approaches involve exposure and response prevention. Cognitive therapy and ERP strategies have been the treatment of choice with impressive results. Results also support effective medication intervention.

Treatment of Posttraumatic Stress Disorder Treatment involves facing the trauma with imagined exposure and discussing it in detail. By doing so, patients begin to realize that these are memories rather than ongoing events and can make sense of them and integrate them into their lives. Another approach is psychological debriefing. This method has been used for a long time where a critical incident stress debriefing team will meet with the individual shortly after the event with purpose of preventing PTSD. Care must be taken with psychological debriefing, as intervening within one month of the trauma may in fact increase the chances of individuals developing PTSD.

Treatment of Generalized Anxiety Disorder Benzodiazepines are commonly used to treat GAD, with good short term effects but poor long term outcome. Antidepressants and azapirones have provides some positive results. A number of effective CBT approaches have been developed for treating GAD.

XI. Comments on Treatment that Work CBT is regarded as the treatment of choice for anxiety disorders. Unfortunately, only a reported 32% with mental health problems had contact with a mental health care professional. A study in Toronto shows that only 12% of those who sought help for anxiety disorders received treatment.

There is a need for increased awareness regarding effective treatments for anxiety disorders.

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XII. Canadian Research Centre •

Dr. Adam Radomsky is the president of the Canadian Association of Cognitive band Behavioural Therapies, and he is a prolific researcher. He uses cognitivebehavioural therapy in the treatment of anxiety disorders.

XIII. Key Points

1. Serotonin, GABA, norepinephrine, and in some cases dopamine and neuropeptides are linked to anxiety reactions.

2. Although many areas of the brain may be involved, the locus ceruleus and the amygdala appear to be most important.

3. Current thinking on the etiology of anxiety disorders is based on a biopsychosocial model with perceived threat, low self-efficacy, and avoidance as core features.

4. Specific phobias are characterized by a panic reaction triggered by specific cues and reinforced by avoidance behaviour.

5. Panic disordered is defined by the presence of panic attacks that often occur unexpectedly.

6. Agoraphobia is said to be the avoidance of places where panic attacks could occur, and often accompanies panic disorder.

7. The essential feature of social phobia is a fear of acting in a way that will be humiliating.

8. The defining elements of obsessive-compulsive disorder are the presence of unwanted intrusive thoughts and repetitive stereotyped behaviours.

9. Posttraumatic stress disorder develops after exposure to a traumatic event.

10. The central feature of generalized anxiety disorder is chronic worry.

XIV. Key Terms anxiety (p.97) fear (p. 97) “fight or flight” response (p. 97) panic (p. 97) neurosis (p. 97)

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two-factor theory (p. 99) vicarious learning (p. 99) panic attack (p. 100) agoraphobia (p. 101) behavioural avoidance test (BAT) (p. 102) nocturnal panic (p. 103) catastrophic misinterpretation (p. 103) anxiety sensitivity (p. 103) alarm theory (p. 103) illness phobia (p.104) equipotentiality premise (p. 104) nonassociative model (p. 104) biological preparedness (p. 105) disgust sensitivity (p. 105) obsessions (p. 110) compulsions (p. 110) neutralizations (p. 110) thought-action fusion (TAF) (p. 110) emotional numbing (p. 115) intolerance of uncertainty (IU) (p. 118) systematic desensitization (p. 121) fear hierarchy (p. 121) in vivo exposure (p. 121) worry imagery exposure (p. 121) flooding (intense exposure) (p. 122) interoceptive exposure (p. 122) ritual prevention (p. 122) subtle avoidance (p. 122) XV. 1.

Lecture Ideas/Activities

Worry.

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

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What keeps worry going so long? Borkovec believes that worry is subject to a process of incubation. Research shows that fear subsides under two types of conditions: after repeated short exposures to a fear stimulus (10 minutes or less) or after a very long exposure of over 30 minutes. In between, though, thinking about a fearful situation only intensified the fear. This is incubation. Worriers often worry in chunks of about 15 minutes, shift attention back to real life, and then go back to worrying. These moderate exposures provide fertile ground for worries to breed and grow.

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

Discuss with your students how they worry, and see if it matches Borkovec's pattern. Contrast the effects of everyday worrying with those felt by GAD patients.

Borkovec, T. D. (1985). "What's the use of worrying." Psychology Today, 59-64.

2.

Gender differences.

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

The stereotypes of the easily frightened woman abound in movies, television, and other media. Is this stereotype accurate? It is in that women score as more anxious than men on tests of anxiety, and they present themselves more often for treatment, as reflected in the preponderance of women phobics. Some authors have noted, though, that this follows the cultural expectation. A male, on the other hand, is supposed to be strong, tough, and brave. It is difficult and threatening for many men to acknowledge fear. The result, says Carol Tavris, is that men become "white knucklers." They tense up on the inside and often endure tremendous anxiety but persist in the brave front. Often they try to drown their anxiety in alcohol. When anxiety does become a

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problem, men are likely to cite physical factors as the cause rather than admit a fear.

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

Tavris, C. (1986). "Coping with anxiety." Science Digest, 12-19.

3.

Are you phobic?

Students often wonder if they themselves have an anxiety disorder.

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

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CHAPTER 6 Dissociative and Somatoform Disorders I. Chapter Summary

II. Case Studies: A. Woman experiencing multiple personality states B. Man concerned with cancer III. Historical Perspective IV. Dissociative disorders (characteristics) V. Focus 6.1 Alana sought help from a therapist due to feelings of anxiety and depression and difficulties with interpersonal relationships. She began to have vague memories of sexual abuse by her father, memories that had been repressed for years. She charged her father, who learned about false memory syndrome, in which people are induced by therapists to recall events that never occurred. The concept of repressed memory derives from Freudian theory, however, most experiences are not remembered completely accurately, and the theory that trauma causes repression has had little empirical support. Most memory researchers do not accept that significant events are likely to be forgotten for extended periods of time, but this does not mean that all recovered memories are false.

VI. Prevalence VII. The dissociative disorders A. Dissociative Amnesia B. Dissociative Fugue C. Depersonalization Disorder D. Dissociative Identity Disorder E. Etiology F. Treatment G. Applied clinical case

VIII. Characteristics of somatoform disorders

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IX. Prevalence X. The somatoform disorders A.

Conversion Disorder

B.

Somatization Disorder

C.

Pain Disorder

D.

Hypochondriasis

E.

Body Dysmorphic Disorder

F.

Etiology

G.

Treatment

XI. Focus Box- Dr. Laurence Kirmayer

XII. Summary XIII. Key Terms

XIV. Lecture ideas/activities a. Differentiating dissociative identity disorder and schizophrenia. b. Repressed memories? c. Conversion disorder or inadequate diagnosis?

I. Chapter Summary Dissociative disorders are characterized by severe disturbances of identity, memory, and consciousness. Dissociative disorders include dissociative amnesia, dissociative fugue, depersonalization disorder, and dissociative identity disorder. Somatoform disorders encompass a set of disorders in which individuals have physical symptoms for which there is no biological basis. These disorders include conversion disorder, hypochondriasis, somatization disorder, and chronic pain. Patients with somatoform and dissociative disorders are extremely common in medical practice.

II. Case Studies

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•

Kathy was a 35-year old woman who had been in and out of the mental health system for 15 years. Her history reveals an extensive history of sexual abuse. Her psychologist noticed dramatic changes in appearance form one day to the next and there were time gaps in her memory. After approximately one year of working with the psychologist, Kathy began to speak about her experience of other personalities.

•

Casey was a 30-year old man who became excessively concerned with developing cancer after his mother died of the disease. He made many visits to the doctor without receiving a diagnosis. He became increasingly frustrated and began to stay at home and chat on the internet with cancer patients in order to learn about the disease. His relationship with his family and friends became strained, and he found he was becoming increasingly isolated.

III. Historical Perspective Plato believed that a wandering womb (hysteria) caused symptoms of dissociative and somatoform disorders. Early religious beliefs conceived of dissociative stats as a kind of possession, with exorcism being the treatment of choice. Only after the decline in the belief that possession was the cause of abnormal behaviour did more psychological theories result. Freud and Breuer identified severe psychological trauma as important in the etiology of dissociation.

IV. Characteristics of Dissociative Disorders Dissociative disorders are characterized by severe disturbances or alterations of identity, memory, and consciousness. Dissociation (disruption of mental processes involved in memory or consciousness that are normally integrated) is the defining symptom. Little empirical research exists regarding these disorders, and they have been believed to be quite rare, although recently, higher rates have been reported.

V. Focus 6.1 - Repressed memory or false memory?

During therapy, with the help of a therapist a young woman remembers being sexually molested by her father. The controversy over recovered and false memories is discussed.

VI. Prevalence

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Researchers have found that as many as 15-21% of inpatients in Canada have a dissociative disorder. In the general population in New York State, researchers found that 9.1% of individuals in a representative sample of adults met the criteria for dissociative disorders.

VII. Dissociative Amnesia A. Dissociative amnesia involves a real and complete memory loss for extensive and important actions or personal information, in the absence of any physical/medical cause.

It is characterized by a sudden onset, usually in response to a traumatic or stressful experience. There are five patterns of memory loss described in DSM-IV-TR including: (1) localized amnesia, wherein a person fails to remember information during a specific time period, (2) selective amnesia, where only parts of the trauma are recalled, (3) continuous amnesia, where the person forgets information from a specific date till the present (4) systematized amnesia, where only certain categories of information are forgotten, and (5) generalized amnesia where the person forgets his or her entire life.

B. Dissociative Fugue Dissociative fugue is the loss of memory, including personal history. Persons with this disorder travel far from home and adopt new identities and occupations. Two important features for diagnosis are: sudden and unexpected travel away from home or work and the inability to recall one's past. Fugue state must be distinguished from malingering.

C. Depersonalization Disorder Depersonalization is an experience characterized by a sense of unreality and detachment from the self (derealization). Depersonalization disorder usually appears in adolescence and tends to be chronic in nature. There is no impairment in memory loss or identity confusion associated with depersonalization disorder. Brain abnormalities in perceptual pathways play a role in the process.

D. Dissociative Identity Disorder Dissociative Identity Disorder (DID), formerly Multiple Personality Disorder (MPD) is the most severe and chronic of the dissociative disorders and is characterized by the existence of two or more unique personality states that regularly take control of the patient’s behaviour. Each personality, or alter, may be very distinct and have different

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behaviours, tones of voice, age, and gender. One of these personalities is identified as “host”. Alters may or may not be aware of one another, and for DID to be diagnosed, there must be at least two alters which exert control over the person's behaviour. The transition from one alter to another is called a switching, and generally results from stress or some cue in the environment. This disorder was believed to be quite rare, although the incidence has increased.

E. Etiology There has been little systematic research into these disorders, with the exception of the finding that the vast majority of dissociative disorders are a result of intense psychological trauma. However, there is a great deal of controversy the nature and etiology of DID. Some critics suggest that it might be manufactured in therapy.

F. Treatment Little research has been conducted on the effectiveness of treatment for this disorder.

Psychotherapy involves several stages. First, a therapist must set the stage for more difficult work by establishing trust. Second, clients are assisted in developing new coping skills that will be required in order to work through their difficult histories. Finally, once a client reaches a certain level of acceptance of his/her history, therapy can move on to the final stage: integration of personalities. Hypnosis continues to be a popular treatment option for many clinicians to contact alters. Medication is generally not useful in the direct treatment DID. However, medication is helpful in treating comorbid disorders, e.g., depression.

G. Applied clinical case of Dissociative Fugue Jeff Ingram appeared at a hospital emergency ward in great distress. He had been wandering the streets with no memory of whom he is or where he came from. When his plight was publicized in the media, his fiancée turned up. Six months later he still had not recovered his memory.

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VIII. SOMATOFORM DISORDERS (characteristics) Somatoform disorders are a set of disorders where there is an occurrence of physical symptoms for which there is no known physical cause, excessive preoccupation with minor physical symptoms, or excessive concern about normal bodily functioning. Diverse Somatoform disorders are identified in the DSM-IV-TR. People with this disorder don’t consciously produce or control the symptoms. The physical symptoms can take many forms, including impairment of the sensory or musculature systems (e.g., paralysis). The DSM-IV-TR describes two conditions in which the individuals intentionally pretend to be ill: malingering and factitious disorders.

IX. Prevalence Few epidemiological studies exist on the prevalence of this disorder. However, the disorder is diagnosed in 5 to 40 percent of patients attending mental health clinics.

X. The Somatoform Disorders

A. Conversion Disorder Conversion disorder occurs when a person experiences motor symptoms or disturbances in sensory functioning that appear to be caused by a neurological problem, but for which no physical cause is present. The symptoms are usually fascinating. Motor deficits may include paralysis, impaired balance, inability to speak, urinary retention, or a sensation of lump in the throat. A classical pattern has been conversion stocking or glove anesthesia.

These disorders can be difficult to diagnose. Misdiagnosis may occur less as knowledge and diagnostic techniques improve (e.g., MRI).

B. Somatization Disorder Somatization disorder is characterized by multiple and recurring complaints of physical ailments that do not appear to have any organic basis. Patients usually attribute the symptoms to a serious medical illness and quite resistant to suggestions that psychological factors might contribute to their illness or disability. The somatization

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patterns tend to be observed early in life, with differing symptoms across cultures.

Understanding the socialization of the individual is an important feature in the diagnosis.

C. Pain Disorder Pain disorder is diagnosed using the DSM-IV-TR when psychological factors are important in the onset, exacerbation, severity, or maintenance of the patient’s pain complaints or disability. However, even if no diagnosis of pain disorder is warranted, attention to the psychological features of pain may reduce its severity. Iatrogenic, or treatment-caused problem as a result of the use of pain medications are not uncommon among these patients.

D. Hypochondriasis Hypochondriasis is defined as excessive preoccupation with fears of having a serious illness, despite assurances that these fears are groundless. It is diagnosed when an individual misinterprets minor bodily symptoms as evidence of a serious disease. Patients will often resist referrals to mental health professionals. The disorder is usually identified in early adulthood and may be associated with an early loss of a significant person or childhood illness.

E. Body Dysmorphic Disorder Body dysmorphic disorder occurs when an individual is unusually and excessively preoccupied with an imagined defect or an exaggeration of some aspect of his or her personal appearance. Individuals frequently feel that everyone else notices the 'defect' and the preoccupation causes distress or impairs functioning.

F. Etiology Over time, there has been a transformation of explanations away from psychoanalytic positions. Various possibilities exist for influences arising in the life history or the current life circumstances of people presenting with this disorder. Socialization and prior experiences with illness may also play role in the development of somatoform disorders.

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G. Treatment Current treatments focus on the affective, cognitive, or social processes that maintain excessive or inappropriate behaviour. Cognitive-behavioural approaches and treatment programs that focus on social skills training, relaxation, and scheduling activities, have been used to treat persons with Somatoform disorders.

XI Focus Box Dr. Laurence Kirmayer is a Canadian researcher and clinician who is interested in cultural psychiatry. He sees somatic disorders as illness behaviour that is triggered by psychosocial and emotional distress. Causal attributions and interpersonal processes play a central role in this process. Another area of interest is in dissociation, mental health, resilience, and healing from trauma in Aboriginal peoples.

XII. Summary 1. Dissociative and somatoform disorders have been known throughout recorded time and have been considered one of the neuroses, since anxiety is regarded as the predominant underlying feature in the etiology of these disorders.

2. Dissociative disorders are characterized by severe disturbances or alterations of identity, memory, and consciousness. These disorders include dissociative amnesia, dissociative fugue, dissociative identity disorder (formerly multiple personality disorder), and depersonalization disorder.

3. Little research has been conducted on these disorders, although the vast majority are believed to be the result of intense psychological trauma. Treatments are not welldeveloped and few attempts have been made to evaluate the success of treatments.

4. Somatoform disorders are a set of disorders that involve the occurrence of physical symptoms for which there is no known physical cause, excessive preoccupation with minor physical symptoms, or excessive preoccupation with minor physical symptoms, or excessive concern about normal bodily functioning. Somatoform disorders are: conversion disorder, hypochondriasis, somatization disorder, pain disorder, and body dysmorphic disorder.

5. It is difficult to differentiate between the various somatoform disorders, and serious problems exist with the DSM-IV criteria for these disorders.

6. Cognitive-behavioural models appear successful in treating pain, however very few systematic trials have been completed to test the efficacy of this approach.

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XIII. Key Terms hysteria (p. 129) dissociative disorders (p. 130) dissociation (p.130) repressed (p. 131) false memory syndrome (p. 131) dissociative amnesia (p. 132) dissociative fugue (p. 132) depersonalization (p. 132) depersonalization disorder (p.132) derealization (p. 132) dissociative identity disorder (DID) (p. 133) alters (p. 133) switching (p. 133) trauma model (p. 134) socio-cognitive model (p. 135) iatrogenic (p. 135) somatoform disorders (p. 136) malingering (p. 137) factitious disorders (p. 137) conversion disorder (p. 137) glove anesthesia (p.138) la belle indifference (p. 138) pain disorder (p.139) hypochondriasis (p. 140) body dysmorphic disorder (BDD) (p. 140)

XIV Lecture Ideas/Activities 1. Differentiating dissociative identity disorder and schizophrenia.

People easily confuse these two disorders, yet they are very different disorders. The term schizophrenia comes from two Greek words meaning "to split" "the mind." However, Bleuler, who proposed the term schizophrenia, was not referring to a splitting of the

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person into different personalities, as occurs in dissociative identity disorder. Instead, the split in schizophrenia occurs at the core of the person, loosening the connections between the various psychic functions. Thus, in the mind of the person with schizophrenia, ideas, perceptions, emotions, and behavior don't operate as an integral whole; rather he or she may think and act inappropriately in a given situation. Consequently, schizophrenia is a psychotic disorder that usually requires periods of hospitalization and medication as well as a prolonged time for recovery. People who have recovered from an acute episode of schizophrenia often remain loners or underemployed in the workplace. In contrast, many people with dissociative identity disorder may go unrecognized or be alternatively diagnosed for years after the initial evaluation. Some of them lead accomplished lives.

Well-functioning people with multiple personalities may elude diagnosis because clinicians are not likely to probe for evidence among those who function so well. Also, such people may have developed elaborate strategies for concealing their alternate personalities, aided by the stabilizing influences of their careers.

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

2.

Repressed memories?

The topics of dissociative identity disorder and amnesia discussed in this chapter lead well into one of the major controversies of the day – repressed memory therapy. The roots of this issue go back at least to Sigmund Freud, who originally felt that many of the problems reported to him by female patients were due to childhood experiences of incest.

These women were telling Freud, often while under hypnosis, that they had begun to remember these acts. Freud believed this for awhile, but gradually became convinced most of these incestual experiences were fantasized. This was a widely held opinion until

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about 1980, when it became clear that incestuous child abuse was much more common than thought. Then, as writer Martin Gardner tells it, "In the latter 1980s a bizarre therapeutic fad began to emerge in the United States. Hundreds of poorly trained therapists, calling themselves "traumatists" began to practice the very techniques Freud discarded."

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

There are, of course, therapists who argue that such repressed memories are real. This is an interesting topic to discuss with students. Ask students to collect examples and also to search for empirical evidence to support repressed memories. Many psychologists doubt that such repression as takes place in these cases is possible.

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

3. Conversion disorder or inadequate diagnosis?

In the 1960s, it was found that as many as 60% of patients diagnosed with conversion disorders had died or been diagnosed with neurological disorders nine years after being diagnosed with a conversion disorder. Mace and Trimble (1996) found that 11 of 56 patients from an original sample of 67 diagnosed with conversion disorder went on to receive a diagnosis of neurological disorder 10 years after being diagnosed with conversion disorder. This decrease in the incidence of false diagnosis of conversion

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disorder has been attributed to the advent of improved diagnostic techniques, such as the MRI.

If you or a loved one received a diagnosis of conversion disorder, how confident would you be that there was not an underlying neurological cause for the symptoms? At what point would you accept that there is no physiological cause for your symptoms? Given that almost 20% of the remaining sample in the Mace and Trimble (1996) study were found to have neurological disorders on follow-up, at what point would you be willing to stop looking for medical causes and enter into psychological treatment to deal with your symptoms?

Source:

Mace, C.J., Trimble, M.R. (1996). Ten-year prognosis of conversion disorder. British Journal of Psychiatry, 169(3), 282-288.

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CHAPTER 7 Psychophysiological Disorders I. Chapter Summary II. Case Studies A. Psychological evaluation revealing distress over physical condition in the case of George.

B. Stress associated illness in the case of Sarah.

C. Diagnosis of a perforated ulcer in the case of Jack.

D. John Candy’s early death due to heart disease.

III. Historical Perspective IV. Diagnostic Issues V. Psychosocial Mechanisms of Disease A. The Endocrine System B. The Autonomic Nervous System C. The Immune System VI. The Psychology of Stress VII. Psychosocial Factors That Influence Disease A. Social Status B. Controllability C. Social Support VIII. Disease States and Psychosocial Factors A. Infectious Disease B. Ulcer Disease C. Cardiovascular Disease IX. Treatment X. Focus Boxes XI. Key Points XII. Key Terms XIII. Lecture Ideas/Activities A. The hand-warming technique B. Developing good coping skills C. Personality and illness D. Personality Type A/B

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I. Chapter Summary There is a long history of attempts to explain the origin of illness and disease by psychological processes. Advances in psychological and physiological methods have lent a new credibility to these ideas. Increasingly, scientists have attempted to explain the occurrence of certain diseases by focusing on the physiological changes known to accompany psychological states. Such changes can be mediated in complex ways by the autonomic, neuroendocrine, and immune systems and their interactions. There is evidence that a number of disease states, including the common cold, ulcers, and heart disease, can be understood, at least in part, by examining psychological and psychophysiological variables.

II. Case Studies •

George, a 32-year old high school teacher, consulted his doctor 37 times about chest pains, which had caused him great anxiety because he was convinced he was having a heart attack. Psychological evaluation revealed a man obviously distressed over his physical condition, but whose agitation extended beyond that. He readily expressed grievances in many areas of his life, and claimed that his achievements as a teacher gave him no pleasure.

•

Sarah is a student in her first year of medical school. She had just finished a gruelling set of exams when she noticed the first symptoms of what she recognized as flu. By the start of the next day, she was experiencing full-blown symptoms: high temperature, aches and pains, a deep cough, and a runny nose.

•

One Sunday morning, Jack awakened with a peculiar burning sensation in his stomach. He was taken to the nearest hospital where he was diagnosed with a perforated ulcer. He attributed his ulcer to his psychological condition at the time.

•

The actor and comedian John Candy was a smoker and significantly overweight.

There was a history of heart disease in his family, and his father died of heart disease in his thirties. He tried to lose weight and quit smoking but was unsuccessful, and he lived a highly pressured life. At the age of 43, John Candy died suddenly from a myocardial embolism ( blood clot in his heart).

III. Historical Perspective

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The idea that psychological processes can have an impact on bodily states, even to the extent of producing physical disease, has a long history in the Western intellectual tradition and maybe even more deeply embedded in other cultures. Medical and psychological activities and interests converged in a branch of psychology called psychosomatic medicine concerned with psychosomatic disorders. However, the term implies a dualistic view of mind and body. In order to avoid such implication, the DSMII introduced the term psychophysiologic disorders. All these developments are covered in a branch of psychology called behavioural medicine or health psychology.

IV. Diagnostic Issues When a major element of a disorder is a diagnosable medical condition, that condition will be noted on Axis III of the DSM-IV-TR, indicating that there is a psychological factor affecting a medical condition.

V. Psychosocial Mechanisms of Disease Illness is marked by symptoms (subjective reports) whereas disease is marked by signs (objective indications). When a sign involves disturbance of bodily tissue, this is known as lesions. This distinctions between illness and disease, symptom and sign, are important because they alert us to the various ways, or mechanisms, by which psychological factors may, in principle, contribute to ill health. Psychological influences on body tissues can take place as a consequence of the effects of both behaviours and psychological processes.

The Endocrine System The endocrine system consists of a number of organs within the body that manufacture biologically active substances called hormones and, when the occasion is right, secrete these substances into the blood stream. Several endocrine hormone systems such as the hypothalamic-pituitary-adrenal-cortical (HPA) axis are known to be highly responsive to psychosocial variables.

The Autonomic Nervous System The autonomic nervous system (ANS) is also responsive to psychosocial influences. The ANS consists of two distinct parts: the sympathetic and the parasympathetic branches. In comparison to the endocrine effects which rely on the bloodstream to convey hormones to target organs, ANS are based on nervous conduction.

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The Immune System Another body system responsive to psychosocial factors is the immune system. There are three general categories of immune responses: non-specific immune responses, cellular immunity, and humoral immunity. Studies in the new field of psychoneuroimmunology have left little doubt that the immune system can be affected by learning experiences, emotional states, and personal characteristics.

VI. The Psychology of Stress The term stress has been used in three ways: (1) to refer to a stimulus, or a property of the external world, (2) to refer to a response, or (3) to refer to a transaction that mediates stimulus and response. Hans Selye proposed the first formal description and definition of stress called the general adaptation syndrome (GAS). In the first phase, alarm (adaptation challenge), and if the challenge persists then resistance (fighting or coping), and with continued challenge exhaustion (resistance fails), and the organism may succumb to disease. Richard Lazarus’ transactional model conceives of stress as an ongoing series of transactions between an individual and his or her environment, where primary and secondary appraisals are an important component.

VII. Psychosocial Factors That Influence Disease Social Status Social status refers to an individual's relative position within a social hierarchy. Social status may have an effect on longevity through some of the stress-related physiological effects with which it correlates. These effects may, in turn, depend on other psychosocial factors.

Controllability A person's actual or perceived ability to control potentially stressful events often reduces their harmful effects. There is evidence that people with an internal locus of control (rather than an external locus of control) are protected against the harmful effects of stress on their health. High strain has been shown to be associated with increased risk of morbidity and mortality due to cardiovascular disease.

Social Support One of the most pervasive and consistent psychosocial variables that has been related to health status is social support. The absence of social support also appears to exacerbate existing disease. Social support may even play a role in the impact of stressful events in nonhuman primates.

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VIII. Disease States and Psychosocial Factors Psychosocial factors have been considered possible contributors to many diseases; indeed, it has been argued that all diseases have a psychosocial component.

Infectious Disease The onset of infectious diseases such as colds or the flu has been shown to be associated with the stresses and strains of daily life. The symptoms of some infectious diseases, such as diseases mediated by the herpes viruses, often seem to be exacerbated during periods of emotional turmoil.

Ulcer So far, our knowledge of stress and its psychosocial determinants has had little effect on the treatment of ulcers. However, there have been several studies reporting association between intensely stressful life events and the development of ulcers. In recent years, considerable excitement has been aroused in the medical community by the discovery of a bacterium, Helicobacter pylori, that is believed to play a primary causal role in the genesis of ulcers. Interactions between mind and body are complex, and there is rarely a single factor that accounts for any condition.

Cardiovascular Disease Diseases of the cardiovascular system, such as ischemic heart disease and myocardial infarction, are the leading cause of death and disability in Western societies.

Cardiovascular diseases are responsible for more potential years of life lost (PYLL) than any other cause of death except cancer and injuries. The vasculature is the extensive network of arteries, arterioles, capillaries, venules and veins. The pressure of the blood flowing through the vasculature. Blood pressure is a consequence of two major variables: cardiac output (the amount of blood pumped by the heart) and total peripheral resistance (the diameter of the blood vessels). Deaths due to myocardial infarction can result from arrhythmias or atherosclerosis. High blood cholesterol and cigarette smoking are considered major controllable risk factors for cardiovascular disease. There are protective factors, such as exercise, which are thought to reduce the risk. Yet another factor that contributes to risk of cardiovascular disease is hypertension.

A simple cause could not be identified for this condition.

Numerous studies using the stress reactivity paradigm have shown that cardiovascular functions are responsive to changing psychological conditions. It has been argued that the

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risk of cardiovascular disease increased with cardiovascular reactivity. People identified as Type A were approximately twice as likely as others to die from heart disease as those identified as type B. Some studies found that hostility was the main characteristic accounting for increased risk of heart disease. Hostility might lead to health risk by various models including the psychophysiological reactivity model, psychosocial vulnerability model, transactional model, health behaviour model, or the constitutional vulnerability models. In recent years, evidence has emerged about the importance of depression in cardiovascular morbidity and mortality.

IX. Treatment A variety of psychological approaches have been developed to contribute to the treatment of physiological disorders. Broadly, there are two classes of intervention that characterize work in this field: (1) generic approaches of management of stress related to the problem, and (2) interventions directed toward specific psychosocial variables thought to play a role in the etiology of disease.

X. Focus Boxes •

Advances in our concepts and technology have made it possible to study stress in various human contexts, e.g., marital relationships. Researchers in this area found that hormones such as epinephrine, norepinphrine, and ACTH were released during marital conflicts, but were regulated better among couples who displayed less hostility.

•

Today, there is an increased acceptance that psychological factors contribute to illness; however, many psychologists continue to be extremely sceptical.

Longitudinal Studies, in which a large group of people are evaluated with respect to the existence of psychological features and the followed up to determine whether they have developed the disease. The relationship is not one of cause and effect. However, there have been several studies that supported the precedence of psychological variables.

•

The neighborhood you live in can have important effects on your health. Dr. Gillian Booth at St. Michael’s hospital in Toronto conducted a 5-year long study on residents of Toronto. She identified 1.2 million Torontonians aged 30-64 who do not have diabetes. The neighborhoods where these people lived were rated on the degree to which they are conducive to walking. “Walkable” neighborhoods

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are highly populated, have streets that connect to other streets, and are in close proximity to stores, schools, and other destinations. The risk of developing diabetes in the 5 year follow-up period was 32% higher for those living in the least walkable areas compared to those who lived in the most walkable areas in Toronto. In a similar study conducted in Utah on a sample of 650,000 residents, people who lived in older, more walkable neighborhoods had lower BMIs (Body Mass Indexes), placing them at lower risk for obesity related disorders. Some of these benefits are likely due to greater levels of physical activity, but other factors, such as more interaction with neighbors and higher levels of community involvement may also make people less susceptible to weight-related illnesses. http://www.stmichaelshospital.com/media/detail.php?source=hospital_news/2012 /20120917_hn http://www.cfah.org/hbns/archives/getDocument.cfm?documentID=1749 http://www.publichealthreviews.eu/upload/pdf_files/10/00_Lovasi.pdf XI. Key Points 1. The idea that psychological processes can have an impact on bodily states, even to the extent of producing physical disease, has a long history. Medical and psychological activities and interests converged in a new branch of psychology variously called psychosomatic medicine, behavioural medicine, or health 2.

3.

4.

5.

6.

psychology.

The endocrine system consists of a number of organs within the body that manufacture biologically active substances called hormones and, when the occasion is right, secrete these substances into the blood stream. Several endocrine hormone systems such as the hypothalamic-pituitary-adrenal-cortical (HPA) axis are known to be highly responsive to psychosocial variables.

There are three general categories of immune responses: nonspecific immune responses, cellular immunity, and humoral immunity.

The term stress has been used in three ways: (1) to refer to a stimulus, or a property of the external world, (2) to refer to a response, or (3) to refer to a transaction that mediates stimulus and response.

There is evidence that people with an internal locus of control are protected against the harmful effects of stress on their health. High strain has been shown to be associated with increased risk of morbidity and mortality due to cardiovascular disease.

One of the most pervasive and consistent psychosocial variables that has been related to health status is social support. The absence of social support also appears

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to exacerbate existing disease. Social support may even play a role in the impact of 7.

8.

9.

stressful events in nonhuman primates.

The onset of infectious diseases such as colds or the flu has been shown to be associated with the stresses and strains of daily life. The symptoms of some infectious diseases, such as diseases mediated by the herpes viruses, often seem to be exacerbated during periods of emotional turmoil.

In recent years, considerable excitement has been aroused in the medical community by the discovery of a bacterium, Helicobacter pylori, that is believed to play a primary causal role in the genesis of ulcers.

Blood pressure is a consequence of two major variables: cardiac output (the amount of blood pumped by the heart) and total peripheral resistance (the diameter of the blood vessels). Deaths due to myocardial infarction can result from arrhythmias or

atherosclerosis.

10. People diagnosed as Type A were approximately twice as likely as others to die from heart disease. Risk associated with Type A behaviour has been found to be independent of other risk factors for heart disease, such as smoking.

11. Broadly speaking, two classes of intervention characterize psychological approaches: (1) generic approaches to the management of stress and related problems and (2) interventions directed toward specific psychosocial variables thought to play a role in the etiology of disease.

XII. Key Terms dualistic (p. 146) behavioural medicine (p. 147) health psychology (p. 147) mechanism (p. 148) lesions (p. 148) nonspecific immune responses (p. 151) cellular immunity (p.151) humoral immunity (p. 152) psychoneuroimmunology (p. 152) alarm (p. 154) resistance (p. 154) exhaustion (p. 154) general adaptation syndrome (GAS) (p.154) transactional model (p. 154) appraisals (p. 154) primary appraisal (p. 154) secondary appraisals (p. 155)

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internal locus of control (p. 156) external locus of control (p. 157) longitudinal study (p. 161) ischemic heart disease (p. 163) myocardial infarction (p. 163) stroke (p. 163) potential years of life lost (PYLL) (p. 163) vasculature (p. 163) systolic blood pressure/diastolic blood pressure (p. 164) cardiac output (p. 164) total peripheral resistance (p. 164) arrhythmia (p. 164) atherosclerosis (p. 164) artherogenesis (p. 164 controllable risk factors (p. 164) protective factor (p. 164) hypertension (p. 165) stress reactivity paradigm (p. 165) cardiovascular reactivity (p. 165) Type A (p. 166) psychophysiological reactivity model (p. 165) psychosocial vulnerability model (p. 166) transactional model (p. 166) health behaviour model (p. 167) constitutional vulnerability (p. 167)

XIII. Lecture Ideas/Activities 1.

The hand-warming technique.

Norman Cousins uses this simple technique to demonstrate that each of us has greater power of the mind over the body than we realize. It is described in detail in his book Head First. The technique was developed by Dr. Elmer Green at the Menninger Clinic in Kansas for helping migraine sufferers. Students can do this exercise at home and report their results in class, or you can conduct the demonstration in class if each student has access to a fever thermometer. Have students grasp the bulb of the thermometer in one hand while you conduct the exercise. You can begin by asking students to do deep breathing exercises accompanied by mental imagery of some pleasant experiences in their lives. After several minutes of relaxation, move to the heart of the procedure.

Instruct students to concentrate on a specific place in the body, just behind the eyes or in the center of the scalp. Ask if students experience a slight warm or tingling sensation in these places. Now have students visualize their heart pumping blood to the shoulders, now across the shoulders, now down the arm, past the wrist and into their hands. Now

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have them open their eyes and look at the thermometer. Average skin temperature runs from about 76 to 82 degrees. Many individuals can increase temperature to their hands by 10 degrees or more. Demonstrating that we have the ability to move our blood around suggests we have greater control over our bodies than we realize.

2. Developing good coping skills.

When discussing stress management, students often want to know what they can do to help manage stress in their own lives. It is important to emphasize that long-term stress management involves more than a “quick fix”, such as popping a pill. It involves developing a stress-resistant lifestyle. While experts disagree about many of the specifics involved in this lifestyle, most agree on some general principles which can be helpful.

These are as follows: 1.

Self-Awareness. Learning about your stressors and how the things you do affect your stress levels. Learning what your strengths and weaknesses are and how to cope with or improve upon those weaknesses.

2.

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

3.

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

4.

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

5.

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

6.

Relaxation Activities. Developing hobbies or personal activities that you enjoy and are relaxing can provide a sense of well-being that is useful in combating stress. What the activities are doesn’t matter as long as you enjoy them. Such activities can be important stress-fighting tools if you

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make regular time in your schedule for them so you can pursue them without feeling guilty.

7.

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

3.

Personality and illness.

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

However, the idea that certain personalities are more likely to develop heart disease has been around for 2,000 years, since the time of Hippocrates. This debate was rekindled by Ronald Grossarth-Meticek, a Yugoslavian psychologist who has conducted extensive experiments on this subject for over twenty years. His work was summarized by Hans Eysenck in his article "Health's Character," in Psychology Today, 1988, 28-35.

Grossarth-Meticek claims he has devised tests that can identify cancer-prone and heartdisease prone personalities. Cancer-prone personalities are characterized by an inability to express emotions such as anger, fear, and anxiety. Also, their inability to cope with stress results in high levels of hopelessness, helplessness, and depression. Although not all the components of the Type A personality predict heart disease, the ones that stand up best are the tendencies toward anger, hostility, and aggression. Extensive longitudinal studies by Grossarth-Meticek and his colleagues have shown that among type 1 (cancerprone) personalities, 1/2 died from cancer, whereas fewer than 1/10 died of heart disease.

Among type 2 (heart disease) personalities, 1/3 died of heart disease, but only 1/5 from cancer. Types 3 and 4 personalities who can handle stress better have much lower rates of death. Luckily, there is hope. Death rates among people with cancer-prone and heart disease-prone personalities decrease after therapeutic intervention targeting those personality patterns related to cancer and heart disease.

4.

Personality Type A/B. Have your students visit the following website for an online test of their ‘type’: http://www.psych.uncc.edu/pagoolka/TypeA-B-intro.html Personality type is a modified version of the Jenkins Activity Survey. This survey was originally formulated to detect behaviors which lead to heart attacks (Jenkins, Ayzanski, Rosenman, 1971). Type A personality generally refers to hard workers who are often preoccupied with schedules and the speed of their performance. Type B personalities may be more creative, imaginative, and philosophical. The test consists of 30 multiple-choice items. Scores range from 35 to 380. Type A is associated with a high score while Type B is associated with a low score.

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CHAPTER 8 Mood Disorders and Suicide I. Chapter Summary II. Case Studies A. Lindsey became depressed after becoming a mother and her husband was deployed to Afghanistan B. Jay was diagnosed with ADHD after his mother committed suicide and was later diagnosed with pediatric bipolar disorder, from which his mother also suffered.

III. Historical Perspective IV. Diagnostic Issues

V. Unipolar Mood Disorders VI. Major Depressive Disorder A. Definition B. Prevalence and Course VII. Dysthymic Disorder VIII. Bipolar Mood Disorder A. Mania and Hypomania B. Bipolar I and Bipolar II C. Cyclothymia D. Rapid Cycling Bipolar Disorder IX.

Mood Disorder with Seasonal Pattern

X.

Mood Disorder with Postpartum Onset

XI.

Etiology

XII.

Psychological and Environmental Causal Factors A. Psychodynamic B. Cognitive Theories C. Interpersonal Models D. Life Stress Perspective

XIII.

Biological Causal Factors A. Genetics B. Neurotransmitters C. Stress and the Hypothalamic-Pituitary-Adrenal Axis D. Sleep Neurophysiology E. Neuroimaging

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IX.

Treatment A. Psychotherapy for Unipolar Depression B. Pharmacotherapy C. Combinations of Psychological and Pharmacological Treatments D. Phototherapy for Seasonal Affective Disorder E. Electroconvulsive Therapy (ECT) F. Transcranial Magnetic Stimulation (TMS) G. Vagus Nerve Stimulation (VNS)

X.

Suicide A. Definition B. Epidemiology and Risk Factors C. What Causes Suicide?

D. Prevention E. Treatment

XI.

Focus Boxes

XII.

Key Points

XIII.

Key Terms

XIV.

Lecture Ideas/Activities A. Beck’s cognitive approach to depression B. Gender and depression C. Clinical, ethical, and philosophical issues in handling suicide

I. Chapter Summary

A diagnosis of mood disorder implies interference with social and occupational function, and bodily and behavioural symptoms as well as mood change. There are two categories of mood disorders: unipolar and bipolar. Unipolar disorders involve depression followed by a return to baseline mood. Bipolar disorders involve alternating periods of depression and mania. Most researchers agree that mood disorder is multifactorial, involving the interaction of social, biological, and psychological variables. Suicide is a major social and health issue involving both social and psychological factors.

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II. Case Studies •

Lindsey began to show all the symptoms of major depression when her husband was unexpectedly deployed to Afghanistan soon after the birth of their baby daughter. She was hospitalized due to the risks she posed of harming herself and her baby.

•

When Jay was a child, his mother suffered from Bipolar I Disorder and eventually committed suicide when he was 12-years-old. In Grade 8, Jay was diagnosed with ADHD. In high school, his behaviour came to resemble that of his mother and was diagnosed with pediatric bipolar disorder.

III. Historical Perspective The Greek physician Hippocrates was the first to extend ideas on the relationship between bodily fluids and emotional temperament, including depression. The Roman physician Galen elaborated on this relationship. In Galen’s time, depression was thought to result from an excess of black bile. During the early twentieth century Freud conceptualized depression in terms of his psychodynamic theory of personality. He considered depression to be a result of fixation at the oral stage.

IV. Diagnostic Issues There are two important criteria for a clinical diagnosis of mood disorder: duration and severity.

For a diagnosis of a major depressive disorder a total of five symptoms must occur for at least two weeks. Mood disorders are classified by the DSM-IV-TR into two broad categories: unipolar (lowered mood recovering to normal mood) and bipolar (change occurs in both directions: mood lowering and mood elevation or mania).

V. Unipolar Mood Disorders If mood is to be considered along a continuum, normal moods reside primarily in the middle, with some expected normal variation. The severity and duration of mood changes required for a diagnosis is much stronger than a “normal” variation. There are two major categories of unipolar mood disorders: major depressive disorder and dysthymia.

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VI. Major Depressive Disorder (MDD) Definition. Symptoms of this disorder include persistent feelings of sadness, loss of interest or ability to feel pleasure (anhedonia), difficulty making decision or concentrating, difficulty sleeping, fatigue, difficulty concentrating, feelings of worthlessness or guilt, suicidal thoughts, and either agitation or slowing down. In the DSM-IV-TR people who are mourning a recent death are not diagnosed with depression. This will change in the DSM-5. People who are grieving a recent death will be diagnosed with depression if their symptoms meet the criteria for depression.

Prevalence and Course. It is estimated that about 5% of Canadians suffer from depression at one point in their lives. The typical age of MDD is the mid-twenties, however, more and more sufferers are having their first onset in childhood adolescence. The most frequent comorbid condition with depression is anxiety, affecting more than 50 percent of patients with MDD. These individuals experience a more severe and chronic depression and show a slower and less complete response to treatment.

VII. Dysthymic Disorder Dysthymic disorder or dysthymia manifest many of the same symptoms as major depression, except that they are less severe. Its distinguishing feature is the fact that it persists for at least two years with only brief times when mood returns to normal. Individuals with chronic depression are less likely to respond to standard depression treatment than are those with episodic major depression.

VIII. Bipolar Mood Disorders Mania and Hypomania Mania is defined as a distinct period of elevated, expansive, or irritable mood that lasts at least one week. A manic episode is such in mood that some of the thoughts associated with it are described as psychotic states. Manic individuals often display pressure of speech, excessive selfesteem or grandiosity, risky physical feats, outlandish business practices, and increased sexual behaviour. Unlike most other mental disorders, some people describe certain symptoms

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associated with mania as enjoyable. Hypomania is a less severe form of mania that involves a similar number of symptoms to mania, but need only be present for four days.

Bipolar I and Bipolar II Hypomanic episodes are similar to mania but are less extreme and have no psychotic features.

When episodes of depression alternate with episodes of mania or hypomania, this is called bipolar disorder and has been classified into two types: Bipolar I (one or more manic episodes and usually one or more depressive episodes); and Bipolar II (at least one hypomanic episode and one or more episodes of major depression). Bipolar disorder is less common than major depression with a lifetime prevalence rate of about 0.8% for bipolar I and approximately 0.5% for bipolar II. Unlike MDD, rates of bipolar disorder do not differ between men and women.

There is a growing consensus that bipolar disorder has its onset in childhood. Pediatric bipolar disorder remains a controversial issue, however, as research suggests that children and adolescents may be overdiagnosed with the disorder.

Cyclothymia It is possible for a person to experience a long-standing pattern of alternating mood episodes that do not meet the criteria for major depressive or manic episode. Criteria for a diagnosis of cyclothymic disorder, or cyclothymia, include duration of at least two years with recurrent periods of mild depression alternating with hypomania. Cyclothymia is a chronic, but less severe, form of bipolar disorder and affects about 0.4 to 1 percent of the population.

Rapid Cycling Bipolar Disorder A person who moves very quickly in and out of depressive and manic episodes may have a particularly severe type of bipolar disorder called rapid cycling bipolar disorder. These patients do not respond as strongly to pharmacotherapy, which may relieve only some of the symptoms. Rapid cycling can be induced, or made worse, by antidepressant drug medications.

IX. Mood Disorder with Seasonal Pattern

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People with SAD seem to be vulnerable to environmental changes in sunlight and show a pattern of mood problems that are cyclic and time-limited. SAD may be unipolar or bipolar. Depressions that occur in sync with seasons typically present with atypical symptoms, including oversleeping, overeating, cravings for carbohydrates, and weight gain. Patients with SAD have been treated with a light treatment that simulates the sun

X. Mood Disorder with Postpartum Onset While the birth of a new baby is often considered a happy event, up to 70% of women experience mood swings and sad feelings lasting up to two weeks after childbirth. However, in some women, the mood swings are chronic and severe enough with psychotic features and may impair functioning, and in more serious cases result in infanticide.

XI. Etiology Mood disorders are likely caused by an interaction of multiple risk factors and many levels of analysis. Mood disorders are likely due to both genetic and environmental variables.

XII. Psychological and Environmental Causal Factors Psychodynamic Theories Psychodynamic theories that consider the role of parenting and attachment in depression have been supported by research findings. People who were neglected or abused in childhood are at greater risk of developing depression.

Cognitive Theories According to Beck’s framework depressed patients see the world with a negative viewpoint because a negative schemas biases their thoughts. He also described the negative cognitive triad of depressed individuals. The triad consists of negative thoughts about the future, the world around them, and the self. Common types of cognitive distortions are: all-or-none thinking, overgeneralization, magnification, and jumping to conclusions. Beck’s model is a diathesisstress model in that negative cognitive schemas of depression-prone individuals leads them to be more vulnerable to apply such cognitive distortions to stressful life events, i.e., triggers.

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Interpersonal Models According to self-verification theory (Swann et al.), negative feedback seeking refers to the tendency for depressed individuals to seek confirmation from others that is consistent with their negative self-view, and gravitate toward individuals who will evaluate them negatively.

Depressed individuals tend to experience negative interpersonal situations. Some research has shown this difficulty to be related to the tendency of depressed persons to choose inappropriate topics of conversation. Another frequent depressive behaviour is excessive reassurance seeking (common to sociotropy), without satisfaction, and repeated requests for more reassurance.

This is consistent with the interpersonal model of depression and the stress generation hypothesis whereby depressed individuals contribute to negative social interactions due to their maladaptive interpersonal behaviours.

Life Stress Perspectives These perspectives recognize the relationship between life stress and the development of affective disorder, and view depression as developing from the interaction between a constitutional vulnerability (diathesis) and marked levels of stress. Even low levels of stress can trigger the disorder in a person who is extremely vulnerable constitutionally. Significant negative life events have consistently been shown to precede major depression. Some people may be genetically predisposed to experience depression as a result of stressful life events.

Childhood Stressful Life Events. Depression in young adulthood has been shown to be related to traumatic events, such as various forms of abuse, in early childhood and adolescence. Such life events may be related to the development of negative cognitive schemas which then serve as a diathesis for later depression.

XIII. Biological Causal Factors Genetics. Family studies contribute to our understanding of depression. First-degree relatives of people with unipolar depression are 2 to 5 times more likely to develop depression compared to individuals in the general population. This risk is even higher (7 to 15 times) for bipolar disorder.

Shared environment, however, is also likely to contribute to these higher risks. Twin and adoption studies give a clearer picture of the genetic contribution to depression.

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Heritability estimates for MDD and bipolar disorder are .36 and .75 respectively. Evidence also points to the role of the serotonin transporter gene (HTT) that regulates that action of serotonin in the brain.

Neurotransmitters. The catecholamines (especially norepinephrine) and serotonin have been implicated most directly in models of depression. Dopamine, a third monoamine neurotransmitter has also been found to regulate mood. Medications used to treat unipolar and bipolar depression in some patients have their effect by increasing levels of these particular neurotransmitters.

Stress and the Hypothalamic-Pituitary-Adrenal Axis. The hypothalamic-pituitary-adrenal (HPA) axis has been implicated in depression, as it is the brain’s principal stress response system. In particular, the function of the pituitary gland causes the release of a hormone called ACTH, which moderates the secretion of cortisol. Chronic stress results in elevated levels of cortisol which is known to kill brain cells and cause permanent damage to the hippocampus. As it has been found that depressed individuals and those exposed to severe stress show elevated levels of cortisol, treatments that reduce cortisol secretion have been proposed as treatments for individuals with mood disorders.

Sleep Neurophysiology. During episodes of major depression, people show a loss of slow-wave sleep and tend to enter REM sleep earlier than normal. Delaying the onset of REM sleep has been associated with improved mood. In 77% of bipolar patients sleep deprivation triggers the onset of mania.

Neuroimaging. Decreased blood flow and reduced glucose metabolism in the frontal lobes have been associated with mood disorders. fMRI studies also indicate that in depression the cingulated cortex may lose its ability to control the emotional processing function of the amygdala, and that this may be associated with individuals with the short allele of the serotonin transporter gene.

These factors may underlie the tendency of depressed individuals to continuously engage negative information or ruminate about depression-inducing events or information.

XIV. Treatment Psychotherapy for Unipolar Depression Cognitive Behaviour Therapy (CBT). Originally developed as cognitive therapy, this treatment focuses on the thinking that appears common in depressed individuals. CBT is a structured form

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of treatment with a focus on what can be done in the present to address depression-producing ways of thinking and behaving. CBT tends to challenge negative thinking in an effort to reduce the symptoms of depression. Some of the more common techniques used by cognitivebehavioural therapists include: Activity Scheduling, Thought Records, Behavioural Experiments, and Interpersonal Psychotherapy (IPT). IPT therapy focuses on the disruptions that occur in the person’s interpersonal world as a result of depression. IPT is a brief and structured treatment and focuses solely on the interpersonal issues in depression. The therapist examines four areas of intervention: interpersonal disputes, role transitions, grief, and interpersonal deficits.

Pharmacotherapy Medications To Treat Unipolar Depression. Tricyclics were among the first drugs to be used for specifically treating depression. Monoamine oxidase inhibitors (MAOIs) inhibit the mechanism by which neurotransmitters are broken down allowing them to stay in the synapse longer. However, MAOIs seem to have serious side effects. Selective serotonin reuptake inhibitors (SSRIs) leave serotonin in the synaptic cleft. Pharmacotherapy is generally considered effective for about 50 to 70% of people with depression.

Medications To Treat Bipolar Depression. Lithium carbonate, a naturally occurring salt, is traditionally the accepted treatment for bipolar disorder. Therapeutic levels of lithium carbonate may come close to doses of high toxicity, and must be monitored closely. Anticonvulsant drugs are prescribed alone, with lithium, or with an antipsychotic to treat mania in bipolar patients (approx. 40%) who do not respond to lithium and/or cannot tolerate its side effects.

Antipsychotic medications are also used for those patients who do not respond to lithium or anticonvulsants. Antidepressants are often used to treat the depressive phase of bipolar disorder, but because they are associated with a risk for triggering manic episodes, mood-stabilizing medications are typically used in conjunction.

Combination of Psychological and Pharmacological Treatments Combining medication with psychological intervention is becoming more popular for treating major depression. The combination of IPT and medication for severe depression has been shown to be more effective than either treatment alone. Family-focused therapy (FFT) consists of

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educating both patient and family members as an adjunct therapy for bipolar disorder.

Interpersonal and social rhythm therapy (IPSRT) combines psychoeducation with principles of IPT. Cognitive behavioural analysis system of psychotherapy combines CBT and IPT to help patients change their behaviour, build problem-solving skills, and improve their relationships. A combination of treatments is effective for both unipolar and bipolar patients with chronic depression. Cognitive therapy for bipolar disorder is similar to CBT for unipolar depression and results in fewer relapses among patients.

Phototherapy for Seasonal Affective Disorder Phototherapy is an increasingly popular treatment for SAD. Patients are exposed to very bright light for one or two hours, resulting in remission in symptoms. Light therapy is now recommended by the Canadian Psychiatric Association as a first-line treatment for SAD due its effectiveness.

Electroconvulsive Therapy (ECT) ECT was found to produce better outcome for depressed than schizophrenic patients. However side effects include loss of memory (both anterograde and retrograde). Currently, ECT is generally administered under well-defined protocols with a psychiatrist, an anesthetist, and a nurse present. This technique generally produces a generalized cerebral seizure and has been found to effectively treat patients with major mood disorders. The issue of the side effects remains hotly debated.

Transcranial magnetic stimulation (TMS) is an experimental treatment that uses magnetic fields to alter brain activity although it has been approved by Health Canada since 2002. TMS is a painless and non-invasive procedure that stimulates nerve cells in the brain, although its act mechanism of action is still not fully understood.

Vagus Nerve Stimulation (VNS) The vagus nerve travels from the brain to the major organs of the body. In vagus nerve stimulation a pulse generator is surgically implanted in the patient’s chest delivering electrical signals to the vagus nerve up to the brain. Research on its effectiveness in treating mood

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disorders to date is mixed, but there is some evidence that it may help some patients who also received standard pharmacotherapy.

XV. Suicide Definition Suicidal ideation is considered to be a set of thoughts or plans about ending one’s life. A suicidal gesture is the enactment of what appears to be a suicide attempt. Parasuicide is an unsuccessful attempt with definite potential for death. Suicide completers are those individuals that actually end their own life. Women out number men in suicide attempts (3 to 1), but men tend to complete suicide more frequently. Suicide is one of the leading causes of death in Canada and the United States, with dramatic increase since the 1950s. Suicide is the second leading cause of death for teens. Suicide is currently ranked among the 10 leading causes of death in Canada.

Epidemiology and Risk Factors The strongest risk factor for completed suicide is being male. Men in all age groups are over three times more likely than women to complete suicide, whereas women are three times more likely than men to attempt suicide. Suicide is the leading cause of death for First Nations males between the ages of 10 and 44. Rates do vary by region, both globally and within Canada and among Aboriginal populations. In Canada, Aboriginal communities have higher rates of suicide, which may be related to disintegration of traditional values and loss of cultural identity in these communities. Suicide has also been related to school failure, family violence, poverty, and substance abuse.

What Causes Suicide?

The Role of Mental Disorder. Untreated mental disorder is the number-one cause of suicide.

Approximately 15% of depressed people will complete a suicide. In studying those cases (a procedure known as psychological autopsy) it was revealed that approximately 70% of those who complete suicide suffered from major depression. Other disorders related to suicide include alcohol and substance abuse and schizophrenia.

Social Contextual Factors. Emile Durkheim was a suicide theorist and developed three reasons for suicide in society. Anomic suicide results when a person experience has a sudden change in

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their relation to society; egoistic suicide when people have been cut-off from society; and finally, altruistic suicide when people place the group ahead of their survival.

Biological Factors. There is a tendency of suicide to run in families. Although there does not appear to be a single gene, biological basis are thought to be a factor. Twin studies are too few to provide conclusions, but there is some evidence that monozygotic twins exhibit greater concordance that dizygotic twins. Serotonin has also been implicated.

Psychological Factors. According to Shneidman, psychache is the feeling of unendurable psychological pain and frustration, and is the most direct and necessary cause of suicide.

Evidence suggests that psychache is significantly more strongly related to suicide than factors such as hopelessness, previously believed to be to produce risk.

Multidimensional Model. Newer models of suicide, such as the diathesis-stress model, focus on the interaction of biological predisposition and personality vulnerabilities and environmental triggers (e.g., stressful life events).

Prevention Federal legislation was recently passed in support of a national suicide prevention strategy. The program will be based on input from the Canadian Psychological Association and the Canadian Association for Suicide Prevention (CASP). Prevention programs based on education in high schools indicates that these programs are not successful. Some researchers are concerned that these programs may actually increase the risk of suicide. More successful primary prevention techniques have focused on restricting access to the most lethal means of suicide. Secondary prevention strategies include suicide prevention centres and telephone hotlines. Although helpful for some, particularly those with suicidal ideation, such measures may have little impact on general suicide rates because of their inability to reach those most at risk, specifically young males.

Treatment A person at a high risk for suicide has a current plan that is lethal, materials that are available, and a time frame in which to carry out the act, and would warrant immediate hospitalization without that person’s consent. Usually, a suicidal patient is able to sign or agree to a “no-harm contract.” Brown and Beck have recently developed a targeted form of CBT to prevent suicide.

Research suggests this form of treatment may be beneficial at preventing reattempts at suicide.

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XVI. Focus Boxes Women are twice as likely as men to develop depression, a gender difference that appears crossculturally, and across all levels of socio-economic status, ethnicity, and marital status. Research suggests that this difference is not due to the fact that women are more likely than men to disclose their symptoms and seek treatment. Another explanation focuses on the HPA axis. That is, women may be more likely than men to react to stress with depression. Gender roles and role strain may also contribute to the traditional differences in depression between men and women.

Since the reasons for the gender disparity are not yet fully understood, future research aims to provide answers so that more effective treatment and prevention measures can be developed specifically for women.

XVII. Key Points 1.

Mood disorders are among the most common mental disorders, yet these difficulties frequently go unrecognized and untreated, even though effective interventions are available.

2.

Mood disorders can interfere with social and occupational functioning, and result in bodily and behavioural symptoms as well as mood change.

3.

Unipolar disorders involve depression followed by a return to normal mood.

4.

Bipolar disorders involve alternating periods of depression and mania.

5.

Symptoms of major depressive disorder include feeling sad or depressed most of the day, loss of interest or ability to derive pleasure from activities, weight loss, insomnia, fatigue, feelings of worthlessness or guilt, difficulty concentrating, and suicidal thoughts.

6.

Seasonal affective disorder involves mood disturbance that is cyclical and time-limited.

This disorder may be unipolar or bipolar.

7.

Bipolar disorder involves periods of depression as well as periods of mania or hypomania.

8.

People with four or more episodes of mania and/or depression in one year meet the criteria for rapid cycling depression/mania.

9.

Cyclothymic disorder is a milder version of bipolar disorder.

10.

Most researchers agree that mood disorder is multifactorial, involving the interaction of social, biological, and psychological variables.

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11.

Genetic research suggests that mood disorder, particularly bipolar disorder, has a marked heritability.

12.

Psychological treatments, such as cognitive therapy, emphasize integrative strategies of behavioural and cognitive techniques at different points in treatment.

13.

Lithium remains the treatment of choice for bipolar disorder.

XVIII. Key Terms mood disorders (p. 174) imagined loss (p. 174) unipolar mood disorders (p. 175) major depressive disorder (MDD) (p.175) dysthmic disorder (p. 177) mania (p. 177) hypomania (p. 177) bipolar I disorder (p. 179) bipolar II disorder (p. 179) cyclothymia (p. 180) specifiers (p. 180) seasonal affective disorder (SAD) (p. 181) cognitive distortions (p. 182) schemas (p. 183) cognitive triad (p. 183) diathesis-stress model (p. 183) negative feedback seeking (p. 183) excessive reassurance seeking (p. 184) stress generation hypothesis (p. 184) hypothalamic-pituitary-adrenal (HPA) axis (p. 1786) cognitive-behaviour therapy (CBT) (p. 188) interpersonal psychotherapy (IPT) (p. 190) tricyclic antidepressants (TCAs) (p. 191) monoamine oxidase inhibitors (MAOIs) (p. 191) selective serotonin reuptake inhibitor (SSRI) (p. 191)

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lithium (p. 192) family-focused therapy (FFT) (p. 193) interpersonal and social rhythm therapy (IPSRT) (p. 194) phototherapy (p. 194) electroconvulsive therapy (ECT) (p. 195) transcranial magnetic stimulation (TMS) (p. 196) vagus nerve stimulation (VNS) (p. 196) suicide (p. 196) psychache (p. 199)

XIX. Lecture Ideas/Activities 1.

Beck's cognitive approach to depression.

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

Therapeutic intervention includes helping depressed persons to identify their particular pattern of cognitive distortions and modify them accordingly. Drs. Aaron and Judith Beck have several training videos on using cognitive behavioral therapy to treat depression. Discuss Dr. Beck’s theory while interspersing video segments that demonstrate key aspects of the treatment protocol, how it links to Dr. Beck’s theory, and why it is effective in treating symptoms of depression.

2.

Gender and depression.

There have been many different explanations for the higher incidents of depression in women

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versus men. Susan Nolen Hoeksema (1987) offers an excellent review of these theories, and then offers her own. She believes that we all get depressed at times, but that the genders react to these depressions in different ways. Men try to distract themselves, such as by playing a sport, taking drugs, or doing physical work. Women, on the other hand, are less active in their response. They ruminate more about the causes of their depression. Nolen-Hoeksema believes it is this rumination that leads to helpless feelings, remembering of sad things, and self-blame. This tendency to think and ruminate is possibly socialized early in life. This theory suggests that women might respond to depression by engaging in pleasant activities and other (non-drug taking) distractions as a way to fight the mild depressions we all experience.

3.

Clinical, ethical, and philosophical issues in handling suicide.

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

Ask students what they think of Szasz's and Kervorkian's ideas and actions. What are the pros and cons of our current laws and ethical rules regarding suicide? What are the pros and cons of Szasz's approach or Kervorkian's approach? Talk about Kervorkian’s conviction and recent release from prison for his actions? What responsibilities do mental health professionals have in preventing suicide? Can they ethically support a "pro-suicide" position?

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CHAPTER 9 Schizophrenia I. Chapter Summary II. Case Studies A. Ruth B. William III. Introduction and Historical Perspective A. Prevalence, Demographic, and Socio-economic Features B. Historical perspective: the Missing Illness IV. Focus 9.1. An 18th century sculptor with schizophrenia.

V. Typical Characteristics A. Positive (Psychotic) and Negative Symptoms V. Diagnosis and Assessment A. DSM-IV-TR Diagnostic Criteria B. Symptom-Based Subtypes C. Critique of the DSM-IV-TR and Symptom-Based diagnosis D. Markers and Endophenoytpes for Schizophrenia* E. Cognitive Subtypes of Schizophrenia VI. Etiology A. Theories of Schizophrenia B. Biological Factors VII. Treatment A. Antipsychotic Medication B. Psychotherapy and Skills Training VIII. Focus Boxes A. Dr. Christopher Bowie, neurocognition and everyday function in schizophrenia IX. Summary/Key points X. Key Terms XI. Lecture Ideas/Activities A. Violence and schizophrenia

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B. The diathesis-stress model C. Schizophrenia and personal space I. Chapter Summary Schizophrenia is the most severe, challenging, and disabling form of mental illness. It is characterized by positive symptoms including hallucinations and delusions and by negative symptoms like emotional withdrawal and lack of motivation. Most theoretical attempts to explain schizophrenia include the concepts of diathesis or vulnerability and stress. In addition, current research seeks to identify biological factors that may be involved in the development of schizophrenia. Important advances have been made in treatment. These include the application of psychologically based interventions such as cognitive-behaviour therapy, family therapy, and skills training. A comprehensive approach might integrate medication with psychotherapy, family therapy, and social skills training.

II. Case Studies A. Ruth has been diagnosed with schizophrenia. She is plagued by thoughts of death and delusions of a creature wrapped around her body. Ruth does not have a difficult developmental history, and there is no history of schizophrenia in her family.

B. William believes that he is God and has a diagnosis of schizophrenia. His mother has schizophrenia, and there were signs of trouble starting in primary school when William received failing grades. He has had a turbulent life with many social and adjustment difficulties. William has had many run-ins with the law, and has various indicators of biological abnormality.

III. Introduction and Historical Perspective Schizophrenia is a complex condition characterized by heterogeneity. Individuals with very different family and personal history, varying response to treatment and prognosis, and ability to live independently are given the same diagnosis.

A. Prevalence, Demographic, and Socioeconomic Features

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The lifetime risk or prevalence of developing schizophrenia is a bout 1 percent, most frequently between 20 and 40 years of age. Men and women appear to be at equal risk, but men seem to display the symptoms earlier and more severely than women. Once diagnosed, individuals are less likely to complete their education or maintain a job and more likely to develop additional psychiatric problems, including depression and alcohol abuse. Understanding schizophrenia remains a scientific challenge.

B. Historical Perspective: The Missing Illness It is often assumed that schizophrenia always existed under other names and description, such as madness or lunacy. However descriptions of lunacy prior to the 1800s seemed to indicate that such conditions can occur at any point in the lifetime rather than in young people. In addition, auditory hallucinations, which occur in about 70% of schizophrenia patients were rarely described in cases prior to the 1700s. The lack of historical evidence seem to suggest that schizophrenia was extremely rate until the late eighteenth century. It has been speculated that industrialization and environmental changes may be related to this emergence.

IV. Focus 9.1- An historical account of a sculptor with schizophrenia •

Franz Messerchmidt, was described as a talented artist who possessed outstanding skills as a sculptor. However, he was plagued by thoughts of demons and described nightly visits by envious demons. He experienced interpersonal difficulties and became increasingly isolated. His symptoms were suggestive of a schizophrenia-like condition.

V. Typical Characteristics A. Positive (psychotic) and Negative Symptoms Positive symptoms include more obvious symptoms of psychosis, such as delusions, hallucinations, thought and speech disorder, and grossly disorganized catatonic behaviour.

Negative Symptoms refer to the absence or loss of typical behaviours such as sparse speech and withdrawal, avolition, and anhedonia.

Hallucination. Hallucinations are misinterpretations of sensory perceptions occurring while the person is awake. Hearing voices is the most commonly occurring hallucination in schizophrenia.

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These voices are perceived as distinct for the patient’s thoughts and may include instruction to carry out harmful acts.

Delusions. Delusions are implausible beliefs, and might reflect persecutory, referential, somatic, religious, or grandiose themes and meanings. Delusions of grandeur may entail a belief in having divine or special powers. Persecutory delusions, in which the individual believes they are being targeted, ridiculed, or deceived are the most common.

Disorganized Speech and Thought Disorder. Nonsensical speech often signals the presence of thought disorder. Loosening of associations and logical connections between ideas occurs in thought disordered patients.

Negative and Emotional Symptoms. Alogia and affective flattening are among the negative symptoms of schizophrenia. Many patients have flat affect or lack of emotional expressiveness, even during crises or emergencies. Negative symptoms are associated with impairment in memory, learning, attention and mental efficiency, as well as community adjustment.

Motor Symptoms and Grossly Disorganized or Catatonic Behaviour. These behaviours refer to deficits in motor functioning from ranging from agitation to immobility. Alternatively individuals with schizophrenia might engage in random, undue motor activity, or exhibit “waxy flexibility”.

VI. Diagnosis and Assessment A. DSM-IV-TR Diagnostic Criteria The diagnosis of schizophrenia is based on five diagnostic criteria which encompass a combination of symptoms and clinical features. However the DSM-IV-TR gives certain symptoms more weight. These symptoms include voices commenting on behaviour and bizarre delusions. It is important to distinguish between bizarre delusions and those that are mood congruent, which may reflect a mood disorder rather than schizophrenia.

B. Symptom-Based Subtypes The DSM-IV-TR describes five types of schizophrenia. The paranoid type is indicated by the presence of delusions or auditory hallucinations relating to a central delusional theme. The disorganized type is characterized by disorganized speech and behaviour, absence of goal orientation, and impaired daily functioning. The catatonic type is defined by acute psychomotor

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disturbance (e.g., immobility). The undifferentiated type entails patients meeting criterion A on the DSM-IV-TR but without satisfying criteria for paranoid, catatonic, or disorganized subtypes.

Residual type is diagnosed in patients with at least one prior episode and with negative symptoms and not currently experiencing an episode.

C. Critique of the DSM-IV-TR and Symptom-Based diagnosis The diagnosis currently used appears to be reliant on the patient’s presenting symptoms and history as the main indication of the illness. A significant drawback is the subjectivity of the diagnosis.

D. Markers and Endotypes of Schizophrenia Objective diagnosis is possible if measurable disease markers that occur in virtually all people with the illness can be identified. These markers could be psychological, physical, or biological characteristic or trait. Markers should have sensitivity and specificity for the disease.

E. Cognitive Subtypes of Schizophrenia Researchers have employed a variety of neuropsychological and psychophysiological tests in order to define subtypes of schizophrenia. For example, subgroups have been identified based on impairment in problem solving, as well as in terms of memory deficits.

VII. Etiology Some of the early theories implicated poor parenting and maternal rejections as possible triggers of schizophrenia. One view of social class-illness link was that cumulative exposure to poverty, crime and family disturbance led to increased cases of schizophrenia.

A. Theories of Schizophrenia In contemporary research psychiatric conditions are seen as the outcome of inherited, biologically based vulnerabilities that interact with maturation, and with environmental stresses to push individuals into developing psychosis. The assumption is that both diathesis and stress are required. Meehl’s theory proposes a diathesis stress called hypokrisia, which is the hypersensitivity of nerve cells in the brain to incoming stimulations. According to Meehl this

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causes cognitive slippage, and information becomes incoherent and causes thought disturbance.

The brain amplifies feelings of pain and weakens pleasure, causing an aversive drift or withdrawal for interpersonal relationships. A person experiencing cognitive slippage and aversive drift are termed “schizotype” in Meehl’s theory. Neurodevelopmental-diathesis stress theories suggest that early brain injury during fetal development may become a diathesis.

B. Biological Factors A familiar genetic contribution of schizophrenia has been assumed for some time. Having a biological relative with schizophrenia increases the risk. However, discrepancies between predicted and observed cases of genetic illnesses can be explained by the principle of penetrance, which states that a proportion of people with a dominant gene will not show the expected effects. Birth-related complications have been proposed as one kind of environmental and biological factor to play a role in the development of schizophrenia. Exposure to a parent with schizophrenia increases the risk of developing the disorder. Overall, the idea of cumulative liability for schizophrenia is appealing, however, research is inconclusive at this time.

Researchers studying brain abnormalities associated with schizophrenia have are interested in the frontal lobe, a part of the brain believed to impaired by the illness. Neuropsychological tests that activate the frontal regions are given as a way of assessing frontal lobe functioning.

Research supports a consistent deficiency in patient samples, however no definitive support exists for the frontal brain deficiency hypothesis. Functional imaging has also been used as a research strategy, e.g., positron emission tomography (PET). Activation studies are designed to scan the brain while mental work is being done. Functional magnetic resonance imaging (fMRI) offers the resolution of structural imaging, but indexes events like changes in flow during mental activity. Other brain regions of interest to schizophrenia are left temporal lobe and associated structures such as the amygdala and Hippocampus.

The dopamine hypothesis states that abnormal activity of dopamine, a member of catecholamine family of neurotransmitter, is involved in schizophrenia.

There are many fields which have contributed to schizophrenia research. Statistical procedures such as meta-analysis (or quantitative research synthesis) have been used to develop the overall

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picture of the significance of the findings. Effect sizes resulting from these analyses indicate that schizophrenia sufferers differ significantly on various biological and psychological indices from non-sufferers.

Focus 9.2 Cannabis use and the onset of schizophrenia Cannabis use is associated with the onset of schizophrenia. Some researchers have suggested that cannabis acts as a toxin in vulnerable individuals, causing the earlier onset of the disorder (Leeson, Verity, Harrison, Ron, Barnes, Joyce 2012). Findings from longitudinal studies suggest that the risk of contracting schizophrenia is almost doubled in those who are exposed to cannabis early (Sewell, Ranganathan, D’Souza, 2009). There is a reason to suspect that this increased rate is not due to self medication or other characteristics of people with schizophrenia. These and other findings raise the concern that cannabis use may trigger schizophrenia in individuals who, although already at risk of developing schizophrenia, may have avoided the disorder if they had abstained from using cannabis use.

Does knowing about these risks change your beliefs on the advisability of using cannabis? If there was a family history of schizophrenia in your family would this affect your thoughts on this issue?

Sewell, Ranganathan, D’Souza, ( 2009). Cannabinoids and psychosis. International Review of Psychiatry 21. 2 (Apr 2009): 152-162.

Leeson, Verity, Harrison, Ron, Barnes, Joyce (2012).

VIII. Treatment A. Antipsychotic Medication Chlorpromazine is the first genuine antipsychotic medication. Initially, the drug was thought to be useful in treating mood disorders, mania, and agitation. Later, it was discovered that its antipsychotic properties required several weeks of treatments to take effect. Improved medications such as risperidone and olanzapine that provide symptoms control with fewer side effects. It remains the case that ex-patients must struggle with many challenges including poverty, social stigma, and unemployment.

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B. Psychotherapy and Skills Training Cognitive-behaviour therapy seems to be useful in reducing the severity or frequency of psychotic symptoms in schizophrenia. More recent evidence indicates that CBT has its greatest effects in reducing negative symptoms. Social skills training and stress management is a learning-based intervention model for the treatment of functional disabilities associated with schizophrenia. Family Therapy may benefit some schizophrenia patients who have the support of family members. Treatment aims at the active involvement of the family in the therapeutic process.

IX. Key Points/Summary

1. Schizophrenia is a complex condition characterized by heterogeneity. Individuals with very different family and personal history, varying response to treatment and prognosis, and ability to live independently are given the same diagnosis.

2. Positive symptoms include more obvious symptoms of psychosis, such as delusions, hallucinations, thought and speech disorder, and grossly disorganized catatonic behaviour.

Negative Symptoms refer to the absence or loss of typical behaviours such as sparse speech and withdrawal, avolition, and anhedonia.

3. The diagnosis of schizophrenia is based on five diagnostic criteria which encompass a combination of symptoms and clinical features. However the DSM-IV-TR gives certain symptoms more weight.

4. Objective diagnosis is possible if measurable disease markers that occur in virtually all people with the illness can be identified. These markers could be psychological, physical, or biological characteristic or trait.

5. Major treatments include CBT, social skills training and stress management, as well family therapy.

X. Key Terms schizophrenia (p. 206) heterogeneity (p.206)

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prevalence (p. 207) madness (p. 207) lunacy (p. 207) auditory hallucinations (p.207) delusional thinking (p. 208) positive symptoms (p. 209) delusions (p. 209) hallucinations (p. 209) thought and speech disorder (p. 209) catatonic behaviour (p.209) negative symptoms (p.209) avolition ((p. 209) anhedonia (p. 209) persecutory delusions (p. 209) referential delusions (p. 209) delusion of grandeur (p. 210) loosening of associations (p. 210) alogia (p. 210) affective flattening (p. 210) waxy flexibility (p. 210) mood congruent (p. 212) paranoid type (p. 212) disorganized type (p. 212) catatonic type (p. 213) undifferentiated type (p. 213) residual type (p. 213) disease markers (p. 213) sensitivity (p. 214) specificity (p. 214) endophenotypes (p. 214) cognitive marker (p. 214)

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eye-tracking (p. 214) schizophrenogenic (p. 215) collective unconscious (p. 215) social drift (p. 215) diathesis (p. 216) stress (p. 216) hypokrisia (p. 216) cognitive slippage (p. 216) aversive drift (p. 216) schizotype (p. 216) genetic contribution (p. 218) familiality (p. 218) penetrance (p. 218) epigenetic (p. 218) birth-related complications (p. 218) high-risk children (p. 219) expressed emotion (p. 219) cumulative liability (p. 219) frontal lobe (p. 219) neuropsychological tests (p. 221) Wisconsin Card Sorting Test (p. 221) perseverate (p. 222) frontal brain deficiency (p. 222) structural magnetic resonance imaging (p. 222) positron emission tomography (PET) (p. 222) functional magnetic resonance imaging (fMRI) (p. 222) left temporal lobe (p. 223) amygdala (p. 223) hippocampus (p. 223) dopamine (p. 224) neurotransmitters (p. 224)

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receptors (p. 224) ligands (p. 225) dopamine-blocking drugs (p. 225) insulin coma (p. 226) psychosurgery (p. 226) frontal lobotomy (p. 226) chlorpromazine (p. 226) risperidone (p. 227) olanzapine (p. 227) social stigma (p. 227) cognitive-behaviour therapy (p. 215) social skills training (p. 228) family therapy (p. 228)

XI. Lecture Ideas/Activities 1. Violence and schizophrenia.

Discuss the idea that whenever a highly publicized act of violence is perpetrated by an ex-mental patient, people automatically think the person has schizophrenia. But how violence prone are most people with schizophrenia? Is the "violent schizophrenic" more a myth than a reality?

Clearly, the media creates the impression that "mentally disturbed" people are more prone to violence. Is this, really the case? Frankly, it is a difficult question, and the answer you get depends upon whom you ask. Scott Lilienfield has assembled two opposing works on the subject, and he describes the complexities involved drawing clear conclusions.

John Monahan notes that most reviews of the subject find a statistical association between mental illness and violence, particularly when that violence is related to delusions and hallucinations – the hallmarks of schizophrenia. Linda Teplin, however, takes issue with these findings. She argues that the data are usually based on arrest records, which can be deceptive.

Not all arrests lead to convictions, sometimes police are prone to arrest prior offenders more often than others, and arrests don't always mirror the actual crime committed. She reports a study that shows virtually no relationships between mental illness and crime. Monahan, however,

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argues that although many of the studies indeed have flaws, there is sound research supporting the association. For example, across many studies, a median of 15 percent of future psychiatric patients commit a violent act prior to hospitalization; from 25-30 percent of released male patients with a past history of violence commit another such act within a year of release.

Who is right? Lilienfield provides an excellent synthesis of this issue. Monahan offers some useful conclusions also. First, he reminds us that even with the relationship he believes to exist, the vast majority of severely disturbed people are never violent. He also makes points that will be excellent discussion topics with your students. Public education has typically stressed that the mental illness-violence relationship is a myth. If it is not, how should public education change?

What are the implications as the number of disturbed people outside of institutions has increased? How should society respond – with more treatment and community care, or with easier rules for involuntary commitment?

Lilienfield, S. (1995). Seeing Both Sides: Classic Controversies in Abnormal Psychology.

Pacific Grove, CA: Brooks/Cole.

Monahan, J. (1992). "Mental disorder and violent behavior: Perceptions and evidence."

American Psychologist, 47, 511-521.

Teplin, L. A. (1985). "The criminality of the mentally ill: A dangerous misconception.”

American Journal of Psychiatry, 142, 593-599.

2. The diathesis-stress model.

This model, which views psychological disorders in terms of the interaction of genetic vulnerability and environmental stressors, can be especially helpful in dealing with a complex disorder like schizophrenia. We can use the model to integrate the vast amount of research findings into meaningful patterns to identify the combination of factors that may increase or decrease one's vulnerability to schizophrenia. Selected factors pertaining to the dispositional vulnerability (diathesis) would include: a family history of this disorder, the degree of kinship with the schizophrenic individual, and the severity of the schizophrenic relative's disorder. In turn, these factors would be considered along with environmental factors, such as the presence of a secondary caregiver and a supportive and nurturing environment for child rearing. For instance, an individual born to a single parent who experienced severe schizophrenia, who had been in and

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out of hospitals, and who expressed little acceptance or warmth toward her child would be at relatively high risk of schizophrenia. In contrast, someone born to a mother who had experienced a brief, mild schizophrenic episode, made a good recovery, and demonstrated good nurturance toward her child would have a much lower risk of schizophrenia. In both instances, it is the combined effects or interaction of one's dispositional vulnerability with environmental stressors/supports that result in the individual's actual risk of schizophrenia.

3.Schizophrenia and personal space.

Explain to the class that one interesting aspect of schizophrenia is the misperception of personal space. For example, schizophrenics often misjudge the proper distance for social conversation.

Ask for a student volunteer to come up in front of the class. You play the schizophrenic. Face the student; hold both hands out, so that you are two arm lengths away. Ask the student if he or she feels comfortable. Then slowly encroach on their personal space by walking closer and closer until you are in their face. Explain that schizophrenics misperceive social cues and may not be aware of their intrusion. The opposite effect can be demonstrated from behind.

Schizophrenics tend to be over-sensitive to those approaching from behind. You can play with this idea to see what the “normal” comfortable bubble is. This can lead to a demonstration of behavioral therapy or social skills training. After you have set the “normal” boundaries, try teaching your student volunteer (who should now play the role of a schizophrenic) how to start and end a conversation, how to stand the appropriate distance, etc.

4. Schizophrenia and the misdiagnosis of physical ailments.

People with severe mental disorders like schizophrenia experience a disproportionate number of health issues and are less likely to receive appropriate medical care for physical ailments than those without severe mental health issues.

(Maj 2009).

To do this role-playing exercise you will need to keep half of the class waiting outside of the classroom while you give instructions, or you will need to print two separate sets of written

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instructions. Ensure that students understand that in order for the exercise to be successful they must not disclose their instructions to others. Students will work in pairs with people who received opposite instructions.

One group will play the role of G.P. (general physician) working in a drop-in medical clinic. “ Physicians” are to interview the “patient” and report whether they believe the client to have a physical illness.

The other group of students will play the role of patient. “Patients” will initially report a physical symptom to the “physician.” The symptom is that after the patient sits or lays down for a period of time, upon standing he/she experiences intense foot pain that feels like the sole of the foot is being ripped . The pain subsides after a few minutes, but returns again each time after a period of non-weight bearing. During the interview, the patient will casually mention that he/she was followed while coming to the appointment, and that there are spies everywhere recording his/her activity.

At the conclusion of the interview, ask students to report on their experience. Ask those who played the role of physician whether they felt that their patients had a foot problem, or if their description of foot pain was a hallucination and/or delusion. Ask students who played the role of patient if they felt that the “physician” listened to them and showed concern about the foot problem.

Students who play the role of doctor will commonly report that they did not believe that the foot pain was “real.” Those who play the role of patient usually indicate that they felt that their physical pain was not taken seriously, and that they were frustrated by the “physician’s” lack of concern about their pain.

Maj, Mario (2009). “Physical health care in persons with severe mental illness: a public health and ethical priority.” World Psychiatry, 8(1): 1–2.

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CHAPTER 10 Eating Disorders

I. Chapter Summary II. Case Study A. Becky began binge eating and purging after a break-up with her boyfriend.

B. Rachel lost too much weight through excessive calorie restriction and exercise.

C. Sheena’s problem with anorexia was triggered when a modeling agency told her she would be prettier if she lost weight. At the time of her death she weighed 50 pounds.

III. Introduction and Historical Perspective IV. Typical Characteristics A. Anorexia Nervosa B. Bulimia Nervosa V. Incidence and Prevalence A. Prognosis VI. Diagnosis and Assessment A. Diagnostic Criteria B. Diagnostic Issues C. Assessment VII. Physical and Psychological Complications VIII. Etiology A. Genetic and Biological Theories B. Psychological Theories C. Integrative Models IX. Eating Disorders in Males X. Treatment A. Biological Treatments B. Psychological Treatments C. Prevention XI. Focus Boxes A. Eating disorders and the media XII. Key Points/Summary XIII. Key Terms XIV. Lecture Ideas/Activities

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A. Anorexia nervosa and bulimia nervosa B. Fear of fat

I. Chapter Summary Over the past few decades there has been an increase in eating disorders such as anorexia nervosa and bulimia nervosa, and the number of people who seek help for them. Eating disorders are likely multidetermined, with different factors more important for different individuals.

Treatments for anorexia nervosa have included psychodynamic, cognitive, cognitivebehavioural, educational, and family therapy, as well as various antipsychotic and antidepressant medications. For anorexia nervosa, the most effective treatment appears to be family therapy. For bulimia nervosa, the most effective treatment appears to be cognitive-behavioural therapy. To date, attempts at preventing eating disorders have done little to change critical behaviours such as dieting.

II. Case Studies A. Becky was 18 years old when her boyfriend broke up with her. Suffering from self-esteem issues, she thought that losing a few pounds may make her feel better, which it has initially. She continued with weight loss effort, but sometimes lost control and over ate. She would then remedy this by vomiting. She began to feel as though she had no control over her eating behaviour.

Rachel is a 34 year old woman who always ate small portions and watched her weight carefully.

After her mother died, she cut back on her food intake even more, and began exercising 5-6 times a week. A friend told her that she looks unwell, and encouraged her to see a doctor. The doctor told Rachel that she has developed low blood pressure due to her weight loss, and she also learned that her irregular periods are due to her low weight. Her doctor gave her a referral to see a psychiatrist.

Sheena was encouraged by a modeling agency to lose weight when she was 14 years old. By the time she was 18, she weighed 75 pounds. Sheena’s illness progressed, and by the time she died she weighed 50 pounds. Sheena’s illness was complicated by intrusive memories of being

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sexually molested as a child and her difficult relationship with her mother. After Sheena’s death, her mother set up a not-for-profit support centre for people with eating disorders.

III. Introduction and Historical Perspective Eating disorders such as bulimia and anorexia have been described for hundreds of years. In the 1960s and 1970s, Western societies became more enamoured with thin physiques for women. In anorexia nervosa, sufferers have an extreme fear of being fat and often view themselves as fat and undeserving of food. In bulimia nervosa, periods of restriction alternate with periods of binging. The binges are followed by attempts to compensate through vomiting or purging.

IV. Typical Characteristics Anorexia Nervosa Although underweight, individuals suffering from anorexia have the impression that they are fat.

This may begin by a reduction in the total number of calories and avoidance of certain foods.

This maladaptive behaviour with respect to food increases and some engage in excessive exercise. Some anorexics also engage in purging in order to maintain weight loss.

Bulimia Nervosa Bulimia nervosa is characterized by episodes of binge eating followed by compensatory behaviours designed to prevent weight gain. Although, bulimics tend to be in the normal weight range, purging behaviours have serious medical consequences, which could include impaired renal function and arrhythmias.

V. Incidence and Prevalence Based on an Ontario sample, lifetime prevalence of bulimia is 1.1% for women and 0.1% for men. This prevalence seems to be similar to other western countries. The presence of eating disorders symptomatology tends to be twice as high as the full syndrome rates.

Prognosis Eating disorders are associated with mortality rates between 5-8%. The most common causes of death are starvation and nutritional complications, and suicide. It appears that there is a varied treatment response among individuals with eating disorders, with approximately half showing

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reduction in symptoms. More people recover after receiving treatment than exhibit spontaneous recovery without treatment.

VI. Diagnosis and Assessment Diagnostic Criteria Anorexia Nervosa. DSM-IV-TR defines it as the refusal to maintain body weight at a minimal level considered acceptable by pediatric growth charts and published life insurance tables.

Another criterion is the irrational fear of gaining weight. In order to meet diagnostic criteria, an individual must have a distortion in the experience and significance of body weight, and amenorrhea for females. The DSM-IV-TR subtypes anorexia into restricting type and bingeeating/purging type. Restricting type attain low body weight by restricting intake of food and excessive exercise, whereas binge-eating/purging type will use purging to control their weight.

Bulimia Nervosa. The current edition of the DSM defines this as recurrent episodes of objective binge eating and inappropriate compensatory behaviours such as self-induced vomiting. A person diagnosed with bulimia nervosa is further classified as purging type if purging behaviours are part of the syndrome, however, non-purging bulimics or the non-purging type use compensatory behaviours such as exercise and periods of fasting.

Eating Disorders Not Otherwise Specified (EDNOS). This form of eating disorders is more common than each of bulimia and anorexia. They are eating disorders of clinical severity that do not meet the specific criteria for anorexia or bulimia.

Diagnostic Issues Differential Diagnosis. In the case of someone with probable eating disorder, it is important to rule out medical reasons for the symptoms, as well as major depressive disorder. In addition, the typology of the eating disorder must be determined.

Validity of Diagnostic Criteria and Classification. It has been suggested eating disorders be conceptualized on a spectrum, rather than as separated diagnostic categories. Support for the spectrum view of eating disorders comes from the fact that many individuals move from one

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diagnostic category to another (and even back again) across time. There is concern about specific criteria for anorexia and bulimia, e.g., loss to below 85% of expected weight and amenorrhea.

Assessment Many researchers and clinicians use the Eating Disorder Examination (EDE) in order to aid assessment. The EDE is a structured clinical interview for diagnosing eating disorders, with good reliability and validity. An additional goal of diagnostic interviews for eating disorders is typically to assess for the presence and absence of other psychological disorders. Many interviews also include self-report component.

VII. Physical and Psychological complications Across all of the eating disorders subtypes, individuals experience a reduced quality of life and their social relationships are negatively affected. Many physical and medical complications may be associated with eating disorders, for example, osteoporosis, cardiovascular problems, decreased fertility, lethargy, dry skin and hair, hair loss, and sensitivity to cold. Lanugo, a fine downy hair may grow on the body to maintain body warmth. Individuals who induce vomiting may exhibit Russell’s sign (scrapes or calluses on the back of hands or knuckles).

VIII. Etiology A. Genetic and Biological Theories Research suggests that 50% of the variation in eating disorders can be accounted for by genetic factors. Dysfunctional neurotransmitter activity of serotonin is frequently assessed in individuals with eating disorders and has been linked to eating behaviours and satiety. Clearly, the development of eating disorders is a complex process which determined by more than biological factors. Sociocultural factors may play a role in the gender differences in eating disorders, but biological factors such as serotonergic functioning may also account for the observed gender differences.

Psychological Theories Socio-cultural Factors. According to these theories eating disorders are, in part, due to the pressures placed on women in Western societies to achieve ultra-slim body. The mass media has

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presented an increasingly thin ideal woman. Similar pressures exist for men but to a lesser extent. This pressure seems to increase body dissatisfaction among women.

Family Factors. Family has been identified as important in the development of eating disorders.

It can provide cultural transmission of pathological values, be a stressor in of itself by being a source of conflict, and through the lack of emotional support. Families who tend to focus on physical attractiveness and weight tend to have children who have a higher risk of eating disorders. Criticality and high parental expectation that are difficult for a child to meet may be associated with the development of eating disorders, especially in females.

Personality/Individual Factors. Personality traits such as perfectionism, obsessiveness, compliance, lack of awareness of internal feelings, and a sense of ineffectiveness characterized bulimia and anorexia sufferers. Low self-esteem, identity problems, depressive affect, and poor body image, may all be contributors to the development of eating disorders. Though certain personality or behavioural patterns appear to be associated with eating disorder, none are a perfect predictor.

Maturational Issues. Whereas male development involves building muscle, female development involves adding body fat, taking young women away from the ideal female shape.

Eating disorders are most likely to appear around the time of puberty, as well as body dissatisfaction.

Adverse Events. Research has found that the incidence of child sexual abuse is higher among individuals with eating disorders. Traumatic events may make some individuals more vulnerable to psychological disturbances in general.

Integrative Models Some researchers have proposed integrative models to describe the development and maintenance of eating disorders. Predisposing factors refer to events or situations that trigger the eating disorder (e.g., death of loved one). Perpetuating factors refer to physical and

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psychological symptoms that serve to maintain the disorder such as reduced basal metabolic rate, delayed gastric emptying, social isolation, and depression.

IX. Eating Disorders in Males The main features of anorexia and bulimia are similar in males and females. As in females, eating disorders in males tend to be associated with other psychiatric disorders. The etiology and symptoms of eating disorders appear to be similar in both genders. There is some evidence that homosexual males have a greater susceptibility to developing eating disorders.

X. Treatment A. Biological Treatments Bulimia sufferers are sometimes treated with antidepressant medication, namely tricyclic antidepressants and serotonin re-uptake inhibitors. These medications seemed to reduce the frequency of binging and purging, as well improve attitudes about weight, shape, and eating.

However, research indicates that patients seldom recover and many meet DSM-IV-TR criteria after pharmacological treatments.

Psychological Treatments Cognitive-Behaviour Therapy. Cognitive-behaviour therapy is considered the evidence-based treatment for bulimia. The treatment consists of 19 sessions over 20 weeks and proceeds in three phases. The first phase involves psychoeducation about normalized eating and connection between excessive control of eating and binging. This phase also involves self-monitoring to identify triggers of eating-disordered thoughts. Phase two focuses on problem-solving skills about body weight and shape. The third phase focuses on strategies to maintain change and prevent relapse.

Interpersonal Treatments. In interpersonal therapy the focus is on maladaptive interpersonal relationships. The problems of interest are grief, role transitions, interpersonal role disputes, and interpersonal deficits.

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Nutritional Therapy. The main aim is weight restoration, which can alleviate many of the symptoms, including cognitive impairment, and is thus typically a prerequisite for psychotherapy.

Family Therapy. Like interpersonal therapy, family therapy focuses on interpersonal relationships, but stresses the family. This type of therapy has received empirical support.

Self-Help. The majority of self-help manuals are based on cognitive-behaviour therapy, and can be used in a variety of ways, including: (1) make information regarding eating disorders accessible, (2) in conjunction to guidance by non-mental health professionals, (3) as a first step in stepped-care approach treatment, (4) for administration to patients on waiting lists, and (5) for facilitation of therapist administered cognitive-behaviour therapy. There treatments have not been applied to anorexia sufferers.

Prevention Evaluations of preventive intervention programs have been conducted in “high risk” environments, and have been reported to be successful. These may take the form of focus groups and psychoeducational programs.

XI. Focus Box Focus Box – Thin Ideal Media Images Make Women Feel Bad, Right?

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Research evidence support the idea that the mass media image of the ideal thin woman is associated with increased body dissatisfaction and symptoms of eating disorders. Some studies have found a correlation between mass media exposure (e.g., magazines and TV) and eating disorder symptoms, especially among young women. However, support for this hypothesis is inconsistent.

XII. Key Points 1. Eating disorders such as bulimia and anorexia have been described for hundreds of years, but increased as Western societies came to favour thin physiques for women.

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2. Although underweight, individuals suffering from anorexia have the impression that they are fat. They engage in maladaptive behaviour with respect to food and some engage in excessive exercise or calorie reduction.

3. Bulimia nervosa is characterized by episodes of binge eating followed by compensatory behaviours designed to prevent weight gain. Although bulimics tend to be in the normal weight range, purging behaviours have serious medical consequences.

4. Across all of the eating disorders subtypes, individuals experience a reduced quality of life and their social relationships are negatively affected. Many physical and medical complications may be associated with eating disorders.

5. The development of eating disorders is a complex process which determined by biological, cultural, psychological, familial and environmental factors.

6. Research evidence suggest that cognitive-behaviour therapy and interpersonal therapies are effective, whereas pharmacological treatments have been less successful.

XIII. Key Terms anorexia nervosa (p. 233) bulimia nervosa (p. 233) purging (p. 234) objective binge (p. 234) body mass index (BMI) (p. 237) amenorrhea (p. 238) restricting type (p. 238) binge eating/purging type (p. 238) purging type (p. 239) nonpurging type (p. 239) Eating Disorder Examination (EDE) (p. 242) lanugo (p. 243) Russell’s sign (p. 243) precipitating factors (p. 249) perpetuating factors (p. 249)

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XIV. Lecture Ideas/Activities 1. Anorexia nervosa and bulimia nervosa.

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

Anorexia and bulimia are also being seen more commonly among younger and younger women.

Where once they were only found in college, it is now common to see high school and even middle school children are showing behaviours associated with these disorders. Since our culture’s ultra-thin standards for attractiveness go back to the “Twiggy” era of the 1960s, why are we seeing these increases among younger women now?

2. Fear of fat.

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

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CHAPTER 11 Substance-related Disorders I. Chapter Summary

II. Case Studies: A. Man with substance abuse disorder B. Woman who became dependent on alcohol C. Young man who began using and dealing drugs III. Historical Perspective IV. Diagnosis and Assessment A. Defining Substance-Related Concepts B. Polysubstance Abuse V. Alcohol A. History of Use B. Canadian Consumption Patterns C. Effects D. Etiology E. Treatment VI. Barbiturates and Benzodiazepines A. Prevalence B. Effects C. Dependency D. Treatment VII. Stimulants A. Tobacco B. Amphetamines and Designer Drugs C. Cocaine D. Caffeine VIII. Opioids A. Prevalence B. Effects C. Dependency D. Treatment IX. Cannabis A. Prevalence B. Effects

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C. Dependency X. Hallucinogens A. Prevalence B. Effects C. Dependency XI. Focus Boxes XII. Key Points XIII. Key Terms XIV. Lecture Ideas/Activities A. Drug effects---psychological considerations B. Relationships with drugs

I. Chapter Summary Alcohol and drugs have been around since recorded history. Alcohol is the world’s number one psychoactive substance and poses a major health risk. Barbiturates are very addictive and can be fatal at high doses. Tobacco is the most widely used stimulant and likely the most addictive.

Amphetamines are very addictive and have effects similar to adrenaline. Cocaine’s effects are short-lived, but it produces intense psychological dependence and severe withdrawal symptoms.

Opioids (i.e., heroin) are depressants whose main effects are pain control and sleep inducement.

Overdoses result in coma and respiratory depression. Marijuana is the most commonly used illicit drug in Canada. Hallucinogens are not addictive, but induce perceptual and sensory distortions or hallucinations and flashbacks. Alcohol, tobacco, and illicit drugs are a major health hazard and cost to our country.

II. Case Studies •

Gareth began using alcohol, cocaine, and barbiturates to help him get through his day.

Gradually, he began to drink more and in more situations (e.g., lunch, office party, and to induce sleep. One night, his excessive drinking, lack of food intake, and a dose of sleeping

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pills led to a loss of consciousness. He was sent to the hospital and agreed to go into treatment.

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Marianne began taking alcohol along with pain medication after a car accident to help her deal with the pain. Eventually she recuperated from most of her physical injuries. However, the combination of solitary evenings and residual back pain was difficult to deal with, and she used alcohol to make herself feel better. She realized that she had a problem, but was too frightened and ashamed to admit that she needed help.

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Derek began using drugs occasionally when he was a teenager, and selling marijuana to kids around school. However, he began to smoke more frequently and his academic performance went downhill. He also began to deal more drugs, and was eventually caught and sent to prison. When he got out, he attempted to go clean, but it was difficult. He began to slip back into his old lifestyle, selling and possessing drugs.

III. Historical Perspective Alcohol and drug use has been around longer than recorded history. Mead was likely the first alcohol that humans consumed. Opium derivatives were widely used in Asian cultures, as well as Greece and Rome to relieve pain or induce sleep, but began to be widely used to enhance pleasure. Natives in the Andes chewed the leaf of the coca plant to relieve fatigue and increase endurance. The flower of the peyote cactus was used by tribes in South and Central America during religious ceremonies. The effects of substance abuse were grim as the Europeans colonized North and South America. Alcohol use resulted in many problems, particularly for aboriginal people. There was also an increase in the use of coca leaf in the Andes, since it enabled the workers to work without eating.

IV. Diagnosis and Assessment Defining Substance-Related Concepts In the DSM-IV-TR, substance intoxication refers to a reversible and temporary condition due to the recent ingestion of a substance. To receive this diagnosis, a person must demonstrate clinically significant maladaptive behavioural or cognitive changes.

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Substance abuse is used to describe a recurrent substance use that results in significant adverse consequences in social or occupational functioning. Interpersonal functioning may deteriorate and the substance may be used in dangerous situations.

Substance dependence (addiction) is a term used to describe the lack of control over substance use. Physiological dependence is defined in terms of tolerance and withdrawal. Tolerance means that the person needs increased amounts of the substance to achieve the same effect.

Withdrawal refers to unpleasant and sometimes dangerous symptoms when the addictive substance is removed from the body. Psychological dependence, or habituation, refers to being psychologically accustomed to a substance due to regular usage. Feelings of restlessness and irritability may result when the substance is not available, and time will be spent obtaining or using the substance. A core aspect of psychological dependence is impairment of control.

Polysubstance Abuse

Polysubstance abuse refers to the simultaneous misuse or dependence upon two or more substances, and appears very common, particularly among young people. Combining drugs is physically dangerous since the effects are often synergistic (combined effects of the drugs exceed or are significantly different from the sum of their individual effects). The drug that presents the most significant health problems is generally the focus of treatment. Solvent use, although not limited to Native youth, has become a serious problem in some aboriginal communities.

V. Alcohol History of Use Concern for overuse of alcohol and attempts to regulate its use date back to the earliest recordings of its use. Prohibition came into effect in the United States in 1920; although alcohol intake was reduced, there was a growth in organized crime and bootlegging. A repeal of Prohibition resulted in an increase in alcohol consumption.

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Canadian Consumption Patterns The rate of drinking is higher for males (82%) than females (77%), and highest for young adults and single people. The largest groups of drinkers are light, infrequent (39%) and light frequent (28%) drinkers. About 6% are heavy infrequent and 7% are heavy frequent drinkers. Low-risk drinking guidelines suggest daily alcohol intake should not exceed 2 drinks and weekly intake should not exceed 14 drinks for men and 9 for women. The Alcohol Use Disorders Identification Test (AUDIT) is a screening tool that indicates the relationship between an individual’s consumption and that person’s risk of alcoholism, and that cut-off scores vary by population.

Effects Ethyl alcohol reduces anxiety, produces euphoria, and creates a sense of well-being. Inhibitions are reduced, which adds to the perception that alcohol enhances social and physical pleasure, sexual performance, power, and social assertiveness. Alcohol passes directly into the bloodstream and is measured in terms of blood alcohol level. Alcohol is removed by the liver and broken down in the stomach by the enzyme alcohol dehydrogenase, which is reported to be physiologically less available to women.

Short-term effects vary with the level of concentration in the bloodstream. Alcohol has a biphasic effect; initially, it is stimulating, but eventually acts as a depressant. Alcohol causes deficits in eye-hand coordination, drowsiness, and decrease in steadiness, and decreased sensitivity to taste, smell, and pain. Also it is well documented that alcohol consumptions results in slowed reaction time. Drinking large amounts of alcohol quickly can cause memory blackouts. Symptoms of hangover may include upset stomach, fatigue, headache, thirst, depression, anxiety, and general malaise. Some believe these symptoms are a result of withdrawal from the short- or long-term addiction to alcohol, or a reaction to the congeners in alcohol. The extreme thirst is related to alcohol’s ability to cause the fluid inside the body’s cells to move outside the cells.

Long-term effects of chronic consumption include damage to many organs (liver, pancreas, endocrine glands), as well as potentially causing certain types of cancer. Factors related to severity of damage include genetic vulnerability, frequency and duration of drinking, and

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severity and spacing of binges. Heavy use has also been associated with damage to the heart, high blood pressure, and strokes, although moderate consumption may have a protective effect on the heart. Although research is mixed, long-term abuse may also result in Korsakoff’s psychosis, a chronic impairment of memory and loss of contact with reality due to nervous tissue reduction in the thalamus and hypothalamus.

Fetal Alcohol Spectrum Disorder (FASD) is caused by chronic maternal alcohol consumption, and includes growth retardation, a pattern of abnormal features of the face and head, and evidence of CNS abnormalities. It is impossible to determine whether there is any safe level of alcohol consumption for expectant mothers.

Alcohol use costs Canadians $7.5 billion a year in increased health care and law enforcement and decreased productivity. Drinking and driving is a particularly serious problem.

Etiology Alcohol abuse and dependence runs in families (studied through twin and adoption studies), although it is difficult to separate environmental from genetic effects.

Research has focused on genes involved in the sensitivity of a number of receptor sites for a number of neurotransmitters that form part of the reward system of the brain. Genes may also be involved in differences in the ability to metabolize alcohol, which affects alcohol consumption.

However, being the son or daughter of an alcoholic does not predetermine alcoholism.

Biological marker studies attempt to show that alcoholism is inherited. Sons of alcoholic fathers have higher than normal rates of the fast beta wave, and show less electroencephalogram (EEG) change after alcohol consumption. Heart rate increases are larger for men with alcoholic relatives. Low monoamine oxidase (MAO) activity has also been found in alcoholics. Low levels of serotonin have been associated with impulsivity, aggression, and antisocial behaviour.

However, none of these markers is clinically useful in diagnosing substance abuse. Biological markers can be considered an indication of vulnerability and merit further investigation.

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Psychological factors, such as certain personality characteristics are associated with alcoholism.

The trait of behavioural disinhibition is associated with alcohol problems, as is negative emotionality, although the latter may be a consequence rather than a cause of alcoholism.

The tension-reduction or anxiety-relief hypothesis suggests that drinking is reinforced by its ability to reduce negative emotions, although evidence for this is inconsistent. The alcohol expectancy theory suggests that drinking behaviour is largely determined by the reinforcement that an individual expects to receive (social and physical pleasure, increases sexual performance, etc.). In support of this hypothesis, alcoholics and non-problem drinkers have both been found to drink more when told their drinks contain alcohol, regardless of the beverages’ content.

Shep Siegel’s research has focused on the role that classical conditioning may have in producing a behavioural tolerance effect. In this model, the environment becomes associated with drug use and predicts its occurrence, leading to tolerance in that same environment, but not in novel environments, whereby the body is not cued by the surroundings, possibly leading to a fatal overdose, as has been found in the case of some heroin addicts.

Alcohol use is influenced by social and cultural factors such as family values, attitudes, and expectations. People introduced to drinking in an environment where excessive drinking is socially accepted are more likely to develop alcoholism. The patterns of alcohol abuse differ from country to country. As well, drinking patterns of adolescents often mirror that of their parents.

The exact etiology of alcohol abuse and dependence is not known, but most researchers believe it is a multidetermined disorder influenced by biological, psychological, and sociological factors.

Treatment The Minnesota model has been the most common treatment for alcohol use and dependence.

This model views alcoholism as a disease. Treatment usually begins in a hospital or detoxification clinic, followed by treatment for psychological dependence, which involves

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education, individual counselling, and group therapy. Abstinence is the goal, and participants are encouraged to attend Alcoholics Anonymous.

Pharmacotherapy, specifically, benzodiazepines, are used to assist in detoxification, and Naltrexone, an antagonist drug, is prescribed to reduce the immediate gratification associated with drinking. Acamprosate, an agonist drug has been used to reduce craving for alcohol and to reduce the distress during early abstinence. Antabuse has been used to make drinking extremely aversive.

Psychological therapy involves Alcoholics Anonymous (AA) and behavioural treatments. AA works with more alcoholics than any other treatment program. It is a self-help group, based on a disease model, with the goal being complete abstinence. AA follows a 12-step program and members rely on a Higher Power to help them stop drinking.

The behavioural approach views alcoholism as a learned behaviour. Some behavioural treatments attempt to condition an aversive response to alcohol by pairing it with an unpleasant stimulus. Contingency management has been used to manipulate reinforcement contingencies for alcohol use. For example, the Community Reinforcement Approach uses contracts between patients and program to specify rewards. This approach may involve the participation of a spouse or friend who is not a user.

Relapse prevention treatment aims to avoid relapses or to manage a relapse if it occurs. Relapse is seen as a failure of coping strategies, and often involves self-defeating thoughts. Relapse prevention techniques focus on the identification of high-risk situations and ways of dealing with them.

Marital and family therapy helps the family deal with interactions, codependency, and conflicts, which result due to the problems with alcohol. Involving the spouse and family enhances the effectiveness of treatment.

Controlled drinking, studied by Marc and Linda Sobell, found that teaching alcoholics to drink in moderation was successful. Research suggests that controlled drinking is an alternative for those

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who are not physically dependent on alcohol and have not suffered severe consequences.

Abstinence is clearly appropriate for drinkers who have a career of heavy drinking or those who have suffered severe consequences.

Brief interventions offering time-limited and specific advice regarding the need to reduce or eliminate alcohol consumption can be effective for some individuals. Motivational interviewing is an approach that can be used with clients who present with different levels of readiness to change their behaviour.

VI. Barbiturates and Benzodiazepines These drugs are depressants, which inhibit neurotransmitter activity in the central nervous system (CNS). Barbituric acid, developed in 1903, was one of the first drugs developed to treat anxiety and tension. Barbiturates (i.e., Seconal, Tuinal, Nembutal) were widely prescribed until the 1940s, when their addictive potential became known. Barbiturates are commonly known as “downers” and are usually taken as tablets or capsules. Benzodiazepines, which include Valium, Xanax, and Ativan, are generally thought to be safer alternatives to barbiturates, although they too can be addicting if misused.

Effects In small doses, mild euphoria results. Larger doses produce slurred speech, poor motor coordination, and impaired judgment and concentration. These effects are magnified in combination with alcohol. Chronic use causes symptoms similar to a constant state of alcohol intoxication, and long-term use can cause depression, chronic fatigue, mood swings, and paranoia.

Dependency Tolerance to barbiturates develops rapidly. Tolerance to benzodiazepines develops much less rapidly. A user with high tolerance to either type of drug experiences extreme withdrawal symptoms (delirium, convulsions, sleep disruptions, and symptoms similar to alcohol withdrawal) if the drug is stopped abruptly.

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Treatment Treatment is very complicated and can require prolonged hospitalization. Generally, treatment involves administering progressively smaller doses of the abused drug to minimize withdrawal symptoms. Individuals will experience abstinence syndrome, which is characterized by insomnia, headaches, and body aches. Psychological and educational programs are used as well.

VII. Stimulants Stimulants have a stimulating or arousing effect on the CNS and influence the rate of uptake of dopamine, norepinephrine, and serotonin. Stimulants are the most commonly used and abused drugs.

Tobacco Tobacco use (cigarettes, snuff, chewing tobacco, cigars, pipes) is one of the leading public health concerns in Canada. Tobacco use is extremely costly and results in a large number of deaths.

Nicotine comes from the tobacco plant nicotiniana tabacum, and Canada ranks among the top 10 tobacco-producing countries. An estimated 27% of Canadians over 15 years of age smoke cigarettes. Increased awareness of the adverse health consequences as well as cost has led to a decline in the number of people smoking. Younger people are more likely to smoke.

Nicotine is extremely potent and ingestion of only a few drops in pure form can lead to respiratory failure. The small amount present in a cigarette is not lethal and can increase alertness and improve mood. The short-term consequences are minimal, but the long-term health risks associated with smoking are significant (cancers, heart disease, respiratory illness, and other chronic conditions). Many health risks can be minimized 5 to 10 years after quitting, but lung damage is often irreversible. Second-hand smoke can be even more dangerous. Smoking during pregnancy can harm the fetus.

Nicotine dependency develops quickly, and is believed to be greater than that produced by other addictive substances. Smoking is a very difficult habit to break, although it is now banned in most public places. Psychological treatments tend to be cognitive or behavioural in nature.

Results of such interventions are mixed. Biological treatments reduce craving and other withdrawal symptoms by maintaining a steady level of nicotine in the system, and include

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nicotine gum, the nicotine patch, and nasal spray. More research is needed to ascertain the longterm efficacy of these treatments.

Amphetamines and Designer Drugs Amphetamines have effects similar to adrenaline. Common forms include: methamphetamine (speed, ice, or crystal), dextroamphetamine (Dexedrine). Other street names include ‘bennies’, ‘uppers’, ‘glass’, and ‘crank’. Methylene-dioxymethamphetamine (MDMA), or Ecstasy has become popular as well. Amphetamines were originally developed as a nasal decongestant and asthma treatment, as well as a treatment for narcolepsy, attention deficit/hyperactivity disorder, and obesity. Currently, only dextroamphetamine is legal. The rate of amphetamine and other illicit drug use in Canada is difficult to determine. Between 1950 and 1970, stimulants were widely used to increase alertness and enhance performance, but since then, amphetamine use in Canada has decreased.

At low doses, amphetamines increase alertness and attention. At higher doses they induce feelings of exhilaration, extraversion, and confidence. Very high doses can result in restlessness and anxiety. Chronic use may result in fatigue and sadness, social withdrawal, and anger.

Repeated high doses may cause hallucinations, delirium, and paranoia (toxic psychosis).

Physical effects include irregular or increased heart rate, fluctuations in blood pressure, nausea, hot or cold flashes, weakness, and dilation of pupils. At very high doses, seizures, confusion, and coma may result. Tolerance and dependence occur very quickly.

Cocaine Throughout the 1800s, cocaine was viewed as harmless and sold in various products, including Coca Cola. In the 1960s and 70s, cocaine became a popular recreational drug for middle and upper-income groups. On the street, Cocaine is usually sold in powder form, and generally snorted. Freebasing is another method of ingestion and involves purifying cocaine by heating it and smoking the residue. Crack is made by dissolving powdered cocaine in a solvent, combining it with baking soda, and heating it until it forms a crystallized substance, which can be smoked.

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The short-term effects both appear and wear off quickly. In small amounts, cocaine produces feelings of euphoria, well-being, and confidence. With high doses, poor muscle control, confusion, anxiety, anger, and aggression may result. Continuous use may result in mood swings, loss of interest in sex, weight loss, and insomnia. Physical symptoms include increased blood pressure and body temperature, and possibly chest pain, nausea, blurred vision, fever, muscle spasms, convulsions, and coma.

The restriction on cocaine use by the Canadian government in the early 1900s led to a decline in use. When amphetamine use waned in the 1950s and 1960s, cocaine’s popularity increased.

Among high school students, 4.8% report having used cocaine and 2.7% report having used crack in the past year.

Cocaine produces intense psychological dependence and severe withdrawal symptoms.

Treatment is complicated by the fact that other drugs are also likely to be used. Psychological treatments developed in the 1980s were modelled after 12-step programs. Intervention programs such as group therapy, individual counselling, and relapse prevention tend to have abstinence as the goal. Cognitive-behavioural treatment and community outpatient programs have also been used. Biological treatments such as antidepressants and dopamine-enhancing drugs are often used as adjuncts to psychological treatment in order to reduce cravings.

Caffeine Caffeine is the world’s most popular stimulant and was first isolated from coffee beans in 1820.

However, tea and coffee had been used all over the world for centuries prior to that. Canadians consume an average of 2.5 cups of coffee per day, although caffeine is also found in various other foods and over-the-counter medications.

Caffeine is less harmful than other stimulants. At low doses (100-150 mg.), caffeine can increase attention, improve problem-solving skills, and improve mood. High doses cause jitteriness, nervousness, and insomnia. At doses over 1000 mg, muscle tremors, agitation, excessive talkativeness, disorganized thinking, and rapid or irregular heartbeat result. Prolonged use of 350 mg, or more, can result in physical dependence. Cessation can cause withdrawal symptoms such as headaches, drowsiness, and irritability.

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VIII. Opioids Opioids (narcotics) are CNS depressants, with the main effects being reduction of pain and sleep inducement. Morphine and codeine are derived from opium, which comes from the seeds of the opium poppy, whereas synthetic opiates are manufactured. Opioids can be taken as tablets, capsules, syrups, or injected. Heroin can be snorted, but is usually mixed with water and injected (mainlining). Heroin, the most commonly abused opioid, was introduced in 1898 and viewed as harmless, but was discovered to be even more addictive than morphine. Morphine and codeine are still used for pain control.

Prevalence The use of heroin is quite low in Canada, although use of prescription forms of opioids is of concern.

Effects Opioids (exogenous opiates) mimic the effects of the body’s natural painkillers (endogenous opiates). Heroin is the most addictive, and causes an intense pleasurable rush, followed by dulled sensations and dreamlike sedation. At higher doses, heroin is extremely dangerous; pupils constrict, the skin may turn blue, breathing slows, and coma and respiratory depression causing death may occur. Chronic users may develop physical conditions such as chronic respiratory and pulmonary problems, as well as risk of disease through use of unsterilized needles.

Dependency Withdrawal symptoms are extremely severe and include dysphoria, dulling of senses, anxiety, increased bodily secretions, pupil dilation, fever, sweating, and muscle pain. Relapse of opioid abuse is extremely common.

Treatment

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Medications (naltrexone and methadone) are often used to alleviate symptoms of withdrawal and craving.

IX. Cannabis Marijuana and hashish come from the hemp plant Cannabis sativa. Marijuana consists of the leaves and flowers of the plant, while hashish, a much stronger form, is made from the resin of the plant. Both forms are most often smoked (a ‘joint’); they may be chewed, added to baked goods, or prepared in tea.

Prevalence Marijuana is the most commonly used and most widely available illicit drug in Canada.

Although rates of use among adults appear to be rising, use among high-school students has been stable since a rise in the 1990s.

Effects The psychoactive effects are caused by the chemical delta-9-tetrahydro-cannabinol (THC). Cannabis involves mild changes in perception and enhancement of physical experiences.

Small doses result in a feeling of well-being and relaxation. At high doses it may cause hallucinations. Effects include deficits in complex motor skills, short-term memory, reaction time, and attention. Physical effects include itchy, red eyes, increased blood pressure, and appetite. Long-term users often suffer lung problems and amotivational syndrome (apathy, profound self-absorption, detachment from friends and family, and abandonment of career and educational goals).

Therapeutic Effects of Marijuana Marijuana has been used to alleviate nausea and encourage eating in cancer and AIDS patients. It has also been used to relieve pressure within the eyes in individuals with glaucoma. In Canada, people with a terminal illness and those with severe pain can apply to the government to legally possess and/or grow the drug.

Dependency It has been believed that marijuana is not addictive, but regular use does result in mild tolerance> Withdrawal symptoms include irritability, nausea, diarrhea, loss of appetite, restlessness, sleep disturbance, and anger/aggression. Few treatment programs exist specifically for cannabis use.

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X. Hallucinogens Hallucinogens, or psychedelics (i.e., LSD, mescaline, psilocybin, and MDMA), induce perceptual or sensory distortions or hallucinations. LSD was first discovered by Albert Hoffman, from the fungus ergot, and he later extracted psilocybin from a mushroom (Psilocybe mexicana).

Prevalence In Canada, use peaked in the 1960s and current use is rare. Hallucinogen use appears to be on the rise in high school populations.

Effects The effects depend on personality as well as the individual’s expectations, amount of drug ingested, and setting. A number of sensory experiences are reported, and physical effects include excitatory effects on the CNS. Although not physiologically dangerous, one of the more frightening effects is flashbacks (unpredictable recurrences of some of the physical or perceptual distortions previously experienced).

Dependency Hallucinogens are believed to have little addictive potential, and few programs have been developed for treatment.

XI. Focus Boxes Issues related to substance abuse in Canada’s aboriginal populations are of growing social concern. Although the rate of alcohol use seems not to differ from that of other Canadians, its impact may be greater upon their communities. Solvent use among adolescents has become a serious concern among some communities. Fetal alcohol spectrum disorders are much more prevalent among aboriginal people. (p. 248).

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Mark and Linda Sobell studied a program for teaching alcoholics to drink in moderation, in contrast to complete abstinence. Results were promising, although some researchers claimed long-term results were poor. More recent evidence suggests that for some alcohol abusers moderate drinking provides them with a choice of a goal that can be helpful. For drinkers with a long-term career of heavy drinking, where drinking has become an integral part of their lifestyle or has caused them serious consequences, however, abstinence is probably the best goal. (p.

259).

Harm reduction programs focus on reducing the consequences of drug use. The best known are needle exchange programs that seek to reduce the risk of AIDS or hepatitis that accompany intravenous drug use. Some people object to the philosophy of the harm reduction approach, as no attempt is made to modify drug use, which may seem to actually support illicit drug use by providing drug paraphernalia to the abuser. (p. 270).

Pathological gamblers are preoccupied with gambling, despite negative consequences. Many parallels are noted between pathological gambling and alcohol/drug dependencies. Some pathological gamblers have difficulty quitting, and there is a frequent co-occurrence of chemical dependence and gambling. Some researchers argue for a physiological definition of dependence that requires neurophysiological changes in response to the presence of a foreign substance, while others adhere to the psychological aspects of dependence. DSM-IV-TR criteria for pathological gambling are patterned after those for substance dependence, but it remains an impulse-control disorder. (p. 274).

XII. Key Points 1. Alcohol and drug use have been around longer than recorded time, and continue to be used by people in all parts of the world.

2. The DSM-IV-TR defines criteria for substance abuse and substance dependence (with or without physiological dependence, defined by tolerance and withdrawal).

3. Polysubstance abuse is extremely common, and combining drugs is associated with higher health risks.

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4. Alcohol is a widely used drug, with serious consequences, including alcoholism, liver damage, and motor vehicle accidents. Various sociocultural, genetic, and psychological factors have been implicated in the etiology of alcoholism. Treatment includes various modalities of pharmacological and psychological interventions, for example, Alcoholics Anonymous.

5. Barbiturates are depressants, widely prescribed for anxiety until the 1940s, when their addictive potential became known. Benzodiazepines are frequently used for anxiety, although they too can be addictive.

6. Stimulants have an arousing effect on the CNS and include tobacco, amphetamines, cocaine, and caffeine.

7. Opioids (or narcotics) include morphine, codeine, and heroin. These drugs are often used for pain relief and are very addictive, with extremely severe withdrawal symptoms.

8. Cannabis (marijuana and hashish) is the most commonly used illicit drug.

9. Hallucinogens (LSD, mescaline, psilocybin) induce perceptual and sensory distortions. These drugs do not appear to be physiologically dangerous or addictive.

10. Many parallels exist between pathological gambling and alcohol/drug dependence, and a debate exists over whether addiction can occur without ingestion of a substance.

XIII. Key Terms substance intoxication (p. 246) substance abuse (p. 246) substance dependence (p. 247) physiological dependence (p. 247) tolerance (p. 247) withdrawal (p. 247) psychological dependence (p. 247) habituation (p. 247) impairment of control (p. 247) polysubstance abuse (p. 248) low-risk drinking guidelines (p. 251) ethyl alcohol (p. 251) blood alcohol level (BAL) (p. 253)

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alcohol dehydrogenase (p. 253) blackouts (p. 253) Korsakoff’s psychosis (p. 254) behavioural disinhibition (p. 257) negative emotionality (p. 257) tension-reduction (p. 257) alcohol expectancy theory (p. 257) behavioural tolerance (p. 257) Minnesota model (p. 260) antagonist drug (p. 260) agonist drug (p. 260) Antabuse (p. 260) relapse (p. 262) brief intervention (p. 262) motivational interviewing (p. 262) depressants (p. 262) abstinence syndrome (p. 263) stimulants (p. 263) nicotine (p. 264) amphetamines (p. 265) toxic psychosis (p. 266) opioids (p. 269) endogenous opiates (p. 269) exogenous opiates (p. 269) harm reduction approaches (p. 270) methadone (p. 271) cannabis (p. 271) THC (p. 272) amotivational syndrome (p. 272) hallucinogens (p. 272) flashbacks (p. 273)

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XIV. Lecture Ideas/Activities 1. Drug effects---psychological considerations.

The general effect of most drugs is greatly influenced by a variety of psychological and environmental factors. Accordingly, in determining the effect of a given drug, it may be helpful to consider three types of influences as follows: (1) Pharmacological effects. The physiological effect of a given drug is a crucial factor, with the entire field of pharmacology devoted to discovering the makeup and effects of drugs. Greater knowledge of drugs has led to specifying drug dependence by specific type, such as drug dependence of the cocaine type. (2) Mental set.

This is a collective term for a variety of psychological factors that may contribute to the effects of a drug, including the individual's personality, his or her past history of drug experience, attitudes toward the drug, motivation for taking the drug, and expectations of its effects. For instance, experiments have shown that when people believe they have drunk alcohol (when they have actually consumed only tonic water) they show increases in sexual arousal, whereas those who have actually imbibed alcohol but believe they have drunk only tonic water show decreased sexual response. (3) Setting. This refers to environmental factors, including the social influence of people. Thus, a few drinks of an alcoholic beverage may make a person feel drowsy and fatigued in some situations, whereas under different circumstances, the same amount of alcohol may psychologically stimulate and arouse that person. Set and setting are believed to be of greater significance with respect to psychoactive drugs, especially psychedelic and hallucinogenic substances.

2. Relationships with drugs.

In their book, Chocolate to Morphine, Andrew Weil M. D. and Winifred Rosen (Boston: Houghton-Mifflin, 1983) provide some guidelines for distinguishing between good and bad relationships with drugs as follows: (1) Recognition that the substance you are using is a drug and being aware of what it does to your body. People who develop the worst relationships with drugs have little understanding of the drug they are using. So, a necessary first step is to understand the nature and effects of the substances being used, including caffeine and nicotine. (2) Experience of a useful effect of the drug over time. Since the effects of a drug diminish with use, people in bad relationships with drugs tend to use them heavily but get the

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least out of them. In contrast, when the experience people like from a drug begins to fade, that is a sign they are using too much. (3) Ease of separation from using the drug. One of the striking features of drug abuse is dependence on a drug – psychological or physiological. People with a good relationship with a drug can take it or leave it. Unfortunately, many drug dependent users believe they can take it or leave it when it is abundantly clear to those around them that they are drug dependent. (4) Freedom from adverse effects on health and behavior. Some people can take a drink before dinner without it disrupting their family lives or work, while other people's drinking contributes directly to their troubles at home or work. Adverse effects on one's health and behavior is another characteristic of drug abuse.

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CHAPTER 12 The Personality Disorders I. Chapter Summary II. Case Studies A. George, who is aloof and never leaves his parents’ house.

B. Joanna, who is emotionally unstable and has had many intense failed relationships.

C. James, who, although charming, has a history of violence and sexual assault.

III. The Concept of Personality Disorder IV. Diagnostic Issues A. Gender and Cultural Issues B. Reliability of Diagnosis C. Comorbidity and Diagnostic Overlap D. Changes in the DSM-5 V. Historical Perspective VI. Etiology A. Psychodynamic Views B. Attachment Theory C. Cognitive-Behavioural Perspectives D. Biological Factors E. Summary of Etiology VII. The Specific Disorders VIII. Cluster A: Odd and Eccentric Disorders A. Paranoid Personality Disorder B. Schizoid Personality Disorder C. Schizotypal Personality Disorder IX. Cluster B: Dramatic, Emotional, or Erratic Disorders A. Antisocial Personality Disorder and Psychopathy: A Confusion of Diagnoses B. Borderline Personality Disorder C. Histrionic Personality Disorder D. Narcissistic Personality Disorder X. Cluster C: Anxious and Fearful Disorders A. Avoidant Personality Disorder B. Dependent Personality Disorder C. Obsessive-Compulsive Personality Disorder XI. Treatment A. Object-Relations Therapy B. Cognitive-Behavioural Approaches C. Pharmacological Interventions

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XII. Focus Boxes XIII. Key Points XIV. Key Terms XV. Lecture Ideas/Activities A. Antisocial personality versus psychopath B. The passive-aggressive personality

C. The self-defeating personality I. Chapter Summary Personality disorders are distinguished from normal personality traits by being rigid, maladaptive, and monolithic. People with personality traits have impaired functioning because of their disorder. The DSM-IV-TR lists 10 disorders grouped into three clusters: Odd and Eccentric Disorders (paranoid, schizoid, schizotypal), Dramatic, Emotional, or Erratic Disorders (antisocial, borderline, histrionic, narcissistic), and Anxious and Fearful Disorders (avoidant, dependent, obsessive-compulsive). Antisocial personality disorder and Borderline personality disorder are the two disorders that have received the bulk of research attention. Treatment for personality disorders in general is difficult to evaluate, because many people never seek treatment.

II. Case Studies The four cases studied in this chapter are George, Joanna, James, and Diane. George lives in his parents’ basement and has no interest in socializing. He is not shy, but prefers to be alone, acting with cold indifference to others. Joanna has been hospitalized because of repeatedly slashing her wrists. She is emotionally unstable and has had many romantic relationships with men that were tumultuous. Her romantic relationships follow a pattern of first idolizing her partner, followed by later bitter anger towards him. James is charming and engaging, yet has a long history of aggression and sexual violence. He is now an incarcerated serial rapist. Diane is an adolescent who cut herself at least 100 times, frequently burned herself, and attempted to strangle herself. She underwent Dialectical Behaviour Therapy (DBT). At follow-up, her mood was improved and her suicidal ideation had decreased.

III. The Concept of Personality Disorder

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Personality disorders are essentially maladaptive personality traits. Traits are characteristic features of a person displayed persistently over time and in various situations.

People with personality disorders tend to be rigid and inflexible; they display the same personality characteristics independent of circumstance. People with personality disorders also show a more restricted range of traits than most people. People with personality disorders can be characterized by a single dominant trait.

The DSM-IV-TR lists 10 disorders grouped into three clusters: Odd and Eccentric Disorders (paranoid, schizoid, schizotypal), Dramatic, Emotional, or Erratic Disorders (antisocial, borderline, histrionic, narcissistic), and Anxious and Fearful Disorders (avoidant, dependent, obsessive-compulsive). Antisocial personality disorder and Borderline personality disorder are the two disorders that have received the bulk of research attention.

The best estimates suggest that approximately 6 to 9% of the population will have one or more personality disorders during their life. However, this estimate is biased in that prevalence rates vary from one study to another as a function of the method used for specific diagnoses. Selfreport measures will likely yield lower estimates of certain disorders than structured interviews due to the reluctance to report negative personality traits. Prevalence among psychiatric patients is generally higher than in the community at large, and higher again among inpatients than outpatients.

Personality disorders are listed on Axis II in the DSM-IV-TR and distinct from the clinical disorders of Axis I. Those with an Axis II disorder have less impaired functioning than those patients with an Axis I disorder, but their functioning is considered egosyntonic; that is, they do not view their disorder as a problem. Individuals with an Axis I disorder are considered egodystonic, as they see their disorders as causing distress and problematic.

IV. Diagnostic Issues and the DSM-5 The etiology of personality disorders is poorly understood. Beyond that, however, there have been challenges to the DSM-IV definition of personality disorder. Canadian researchers

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have criticized the categorical approach of the DSM arguing that personality is better viewed as a constellation of traits, each of which lies along a continuum. Although there was a great deal of talk about reducing the number of personality disorders and using the dimensional model for personality disorders in the DSM-5, the DSM committee recently announced that the ten personality disorders from the DSM-IV-TR will continue to be diagnosed using a categorical system. The DSM-5 will include a separate section that uses trait-specific methodology to encourage further study on how a dimensional model can be used to diagnose personality disorders.

Gender and Cultural Issues As our population becomes increasingly culturally diverse, clinicians may misdiagnose if they do not take adequate precautions to determine whether certain attitudes and behaviours are appropriate for distinct cultures or societal subgroups. A number of authors have suggested that the diagnostic criteria for some personality disorders are gender-biased. For example, the emphasis on aggression in the criteria for antisocial personality disorder may lead to underdiagnosis in females because of gender differences in the prevalence and expression of aggression. In the same vein, clinicians have been shown to be reluctant to diagnose males as having histrionic personality disorder.

Reliability of Diagnosis Concerns about cultural and gender insensitivity underscore longstanding larger concerns about the reliability and validity of personality disorder diagnoses. Early field trials with DSMIII revealed rather poor inter-rater reliability for the personality disorders. Subsequent examinations have failed to produce any better results. Use of structured interviews and expanding the breadth of information collected can improve reliability.

Comorbidity and Diagnostic Overlap One further problem with the diagnosis of personality disorders concerns their independence from each other and from Axis I disorders. Comorbidity should be used to describe the co-occurrence in the same person of two or more different disorders. Overlap, on the other hand, refers to the similarity of symptoms in two or more different disorders. For the personality disorders the criteria remain sufficiently vague or require such inference by the

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clinician that overlap seems certain. The DSM-IV-TR encourages multiple diagnoses if appropriate. This approach makes diagnosis easier but can confuse clinicians and complicate treatment. Morey (1988) found that eight of the personality disorders diagnosed according to DSM-III-R overlapped in their diagnostic criteria with other diagnoses by as much as 50%. Also, patients diagnosed as borderline have been found to commonly have schizotypal features, and comorbidity has been observed between borderline diagnoses and other personality disorders.

V. Historical Perspective Historically, there most attention has been paid to antisocial personality disorder. One of the first written descriptions of personality disorder was made by Pinel in 1801. Pinel described what he called manie sans délire (“insanity without delirium”). British psychiatrist James Pritchard (1835) coined the term “moral insanity” to delineate a condition characterized by an absence of morality rather than madness. Kraeplin (1913) identified seven types of psychopathy. In the mid 20th century, the term “sociopath” was coined, reflecting the idea that the disorder reflected an anti-society view of life. The current conceptualization of psychopathy is founded on the observations of psychiatrist Harvey Cleckley, author of The Mask of Sanity (1941). Robert Hare of UBC has worked toward operationalizing Cleckley’s criteria, resulting in a highly reliable diagnostic tool – the Psychopathy Checklist.

VI. Etiology Psychodynamic Views Psychoanalysts see personality disorder as resulting from disturbances in the parent-child relationship, particularly in problems related to separation-individuation. Difficulties in this process result in either an inadequate sense of self or in problems in dealing with other people. In addition, there is clear evidence that personality-disordered adults are far more likely than other people to have had disrupted childhoods, including the loss of a parent through death, divorce or abandonment.

Attachment Theory Attachment theory argues that children learn how to relate to others, particularly in affectionate ways, by the way in which their parents relate to them. When the attachment bond between

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parent and child is good, the child will develop the skills and confidence necessary to relate effectively to others. When this bond is poor, the child will lack confidence in relations with others, fearing rejection, and will lack the skills necessary for intimate relationships. Evidence from the analysis of various personality disorders appears to support this hypothesis.

Cognitive-Behavioural Perspectives Cognitive-behavioural theorists argue that in the case of personality-disordered individuals, cognitive schemas become rigid and inflexible. Some theorists argue that these people come from families who consistently invalidate the child’s emotional experiences and oversimplify the ease with which life’s problems can be solved. Accordingly, they learn that the way to get their parent’s attention is by a display of major emotional outbursts. Modelling may also contribute to the learning of inappropriate personal styles.

Biological Factors Various biological theorists have claimed that personality disorders either have a genetic basis or are the result of disturbed neurotransmitters or brain dysfunction. The strongest support for these notions comes from research with antisocial personality disorder, and research also suggests a role of biological factors in schizotypal personality disorder. Research suggests a role of the prefrontal cortex in personality disorders. Twin studies suggest a substantial genetic component to personality disorders.

Summary of Etiology Biological explanations seem to dominate for Cluster A disorders. Biological and attachment theories for Cluster B disorders both have support. There has been little investigation of Cluster C disorders.

VII. The Specific Disorders Antisocial and borderline personality disorders will receive the most attention, as they have been most researched.

VIII. Cluster A: Odd and Eccentric Disorders Paranoid Personality Disorder. Primary features of patients diagnosed as having a paranoid personality disorder are a pervasive suspiciousness of other people’s motives, and a tendency to see everything others do as a personal attack. Patients are overly vigilant, consistently misread

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the actions of others as threatening or critical, and expect others to exploit them. They are typically humourless and eccentric, are seen by others as hostile, jealous, and preoccupied with power and control, and have difficulty in relationships. Paranoid people often become socially isolated, which only exacerbates their feelings of persecution. It has been suggested that paranoid personality disorder may in fact be a sub-type of schizophrenia. There also exists significant diagnostic overlap between paranoid personality and both avoidant and borderline personality disorders.

Schizoid Personality Disorder. Individuals with this disorder seem determined to avoid intimate involvement with others and they display little emotional responsiveness. Schizoid individuals are typically loners who are cold and indifferent towards others. Most lack the skills for effective social interaction, but also appear uninterested in acquiring such skills. Many studies confound schizoid and schizotypal features and do not, therefore, permit any reasonable conclusions.

Schizotypal Personality Disorder. The major presenting feature of patients diagnosed with schizotypal personality disorder is eccentricity of thought and behaviour. Such individuals typically believe in paranormal phenomenon such as telepathy and clairvoyance. While such beliefs in themselves are no sign of mental disorder, schizotypal people will create odd, idiosyncratic combinations of beliefs or interpret commonplace occurrences in bizarre ways.

Although their speech, perceptual experiences, beliefs, and behaviours are odd, they are not usually sufficiently eccentric to meet the criteria for delusional or hallucinatory psychotic experiences. There also exists considerable diagnostic overlap between schizotypal disorder and other Cluster A disorders, as well as avoidant personality disorder, and, to a lesser degree, borderline personality disorder. Generally, the long-term prognosis for schizotypal patients is poor.

IX. Cluster B: Dramatic, Emotional, or Erratic Disorders Antisocial Personality Disorder (APD). Although people with this disorder have also been referred to as psychopaths or sociopaths, it is important to note that APD and psychopathy are not the same disorder. On the surface, men diagnosed as having antisocial personality disorder appear charming and persuasive, but this covers up a self-centred, and, in many cases,

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criminal lifestyle. The essential distinguishing feature of APD is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. The DSM-IV-TR criteria for a diagnosis of APD present seven exemplars reflecting the violation of the rights of others: nonconformity, callousness, deceitfulness, irresponsibility, impulsivity, aggressiveness, and recklessness. Three or more of these must be met for a diagnosis to be applied, reflecting a polythetic approach.

The DSM-IV reports prevalence rates for APD of approximately 3 percent in males and 1 percent in females for community samples. Estimates of the prevalence of APD in Great Britain in Special Hospitals for the criminally disordered are approximately 25 to 33%. Hare reports a higher estimate in Canadian prisons of 40%.

Several lines of investigation have pursued the etiology of APD. Particular problems in childhood are strong predictors of adult antisocial behaviour. Disruptive family life might set the stage for children to show aggressive and otherwise antisocial behaviour. Family systems approaches to intervention appear promising.

Various psychological explanations have also been proposed that focus on APD patients’ inadequate self-regulation. The fearlessness hypothesis claims that those with APD have a higher threshold for feeling fear than do other people. Events that make most people anxious are thought to have little or no effect on those with APD. As a result, it has been suggested that those with APD may be indifferent to punishment, or oppositional to attempts to control them.

Research suggests that individuals with APD may be differentially responsive to different kinds of punishment, as a result of early learning experiences, rather than completely fearless or unresponsive to all punishment. Recent information-processing research suggests that psychopathy and APD may be different diagnoses with different etiology, intervention, and prognosis.

APD has a long course and prognosis is poor. The reported average duration of APD, from the onset of the first symptom to the end of the last, is thought to be 19 years. The remittance of

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symptoms over time has been called the burnout factor. Not all studies support the burnout notion.

Treatment is difficult. Studies suggest a responsivity factor, where treatment must be responsive to a particular client’s needs and interpersonal style. Interventions may be ineffective if they are of insufficient intensity, viewed by patients as irrelevant, or seen as involuntary. Another issue is the inability of people with antisocial personality disorder and psychopaths to develop an effective therapeutic alliance.

Psychopathy. Although not listed in DSM-IV-TR, there has been an enormous amount of research into psychopathy. Psychopaths are a distinct group of offenders (15-25% of federal inmates). They are egocentric, deceptive, callous, manipulative individuals characterized by a lack of remorse and emotional depth. There is a strong link between psychopathy and aggression, often heinous, cold-blooded violence. Hare (1993, 1996) estimates that 1% of the population is psychopathic.

Psychopaths differ from non-psychopaths in terms of underlying biological functioning and neurological processing. Brain abnormalities have been found in the prefrontal cortex, hippocampus, angular gyrus, basal ganglia, and amygdala. Neurotransmitters have also been implicated. Family factors, such as abuse and neglect, have also been suggested.

Two pathways to the development of psychopathy have been suggested. Fundamental psychopathy is the result of a biological disposition, while secondary psychopathy is the result of negative environmental experiences in childhood. Psychopathy is a lifelong condition, precursors of which can be seen in childhood. Because of a lack of motivation, the effectiveness of treatment is poor. Psychopathy has not been added to the DSM-5.

Borderline Personality Disorder (BPD). Fluctuations in mood, an unstable sense of their own identity, and instability in their relationships characterize BPD patients. This instability in all aspects of life makes borderlines unpredictable and impulsive and, along with their irritability

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and argumentative style, these features tend to seriously interfere with their relationships.

Considerable overlap and even confusion between borderline and schizotypal disorders remains.

BPD has a lifetime prevalence of approximately 2% of the population and is thought to be more common in women than in men. The etiology of BPD has been debated for many years with different views emphasizing childhood experiences, biological factors, psychodynamic processes, or social learning. Evidence strongly suggests a role played by disruptions in the family of origin and childhood abuse and neglect. For example, the relationship style that describes borderline patients is that of anxious ambivalent, who because of poor relationships with their parents as children, as adults they intensely fear abandonment and both desire and fear intimacy. Researchers have also suggested an association between minimal brain dysfunction and the development of BPD. Evidence also suggests a relatively high incidence of borderline features in the first-degree relatives of BPD patients.

Histrionic Personality Disorder. Attention-seeking behaviours distinguish people with histrionic personality disorder. They are flamboyant, overly dramatic, and overresponsive to events others would consider trivial. Their relationships are often short-lived and emotionally tumultuous.

They are often flirtatious, and seem unable to develop intimacy in relationships. There is considerable overlap between histrionic and borderline personality disorder.

Narcissistic Personality Disorder. Narcissistic people grandiosely consider themselves to have unique and outstanding abilities; egocentricity is the hallmark of these patients. They are so consumed with their own interests they seldom entertain any concern for others. Like histrionic patients, the typical behaviour of narcissists alienates others, and they are frequently lonely and unhappy. When frustrated or slighted, narcissists can become vengeful and verbally or physically aggressive. There is considerable overlap between narcissism and BPD.

X. Cluster C: Anxious and Fearful Disorders Avoidant Personality Disorder. A pervasive pattern of avoiding interpersonal contacts and an extreme sensitivity to criticism and disapproval characterize avoidant people. They actively avoid intimacy with others, although they clearly desire affection and suffer from

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loneliness. Some children who have poor parental bonds grow up to be so afraid of intimate relationships that they become avoidant of any depth in whatever relationships they form.

Researchers have found considerable overlap avoidant personality disorder and dependent disorder and borderline disorder. There is also considerable overlap with social phobia.

Dependent Personality Disorder. Dependent people seek advice and direction from others, need constant reassurance, and seek out relationships where they can adopt a submissive role.

Dependent patients not only allow, but seem to desperately need, others to assume responsibility for important aspects of their lives. Relatives of male dependent patients are more likely to experience depression, whereas the relatives of female dependents are more likely to have panic disorder.

Obsessive-Compulsive Personality Disorder. Inflexibility and a desire for perfection characterize this disorder. It is the centrality of these two features and, and the absence of obsessional thoughts and compulsive behaviours, that distinguish this personality disorder from the Axis I obsessive-compulsive Disorder. Most of the research on this disorder has been concerned with the psychoanalytic notion of the anal-retentive character, which has lost much of its credibility in recent years.

XI. Treatment Object-Relations Therapy The object-relations approach is aimed at correcting the flaws in the self that have resulted from unfortunate formative experiences. The relationship with the therapist serves as a vehicle for confronting, in a supportive way, the patient’s defences and distortions. This treatment is seen as necessarily long-term.

Cognitive-Behavioural Approaches These techniques are aimed at correcting cognitive distortions of patients suffering from personality disorder. Cognitive restructuring provides the basis for change, along with skills training and behavioural practices. Dialectical behaviour therapy has specifically targeted

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borderlines. One of the main features of this approach is the acceptance by the therapist of the patient’s demanding and manipulative behaviours.

Pharmacological Interventions Borderline patients have been treated successfully with a variety of pharmacological agents including: amitriptyline (an antidepressant), thiothixene (an antipsychotic), and carbamazepine (an anticonvulsant). Some antidepressants appear to be beneficial with schizotypal-disordered patients, however the gains are modest.

XII. Focus Boxes Bernardo and Holmolka Paul Bernardo and Karla Homolka are notorious for having kidnapped, sexually assaulted, and murdered two Ontario teenaged girls. Homolka accepted a plea bargain that scandalized the press and the public. She claimed to suffer from “battered woman syndrome,” arguing that her role in the rapes and murders was minimal. Yet when videotapes the couple had made of the rapes and murders were found, her claims of being under Bernardo’s control were found to be false.

Colonel Russell Williams In February 2010, Canadians were astonished to learn that Colonel Russell Williams, the 47 year-old commander of Canada’s largest air force base in Trenton Ontario, had confessed to sexually assaulting and murdering two women. Williams held one of the highest positions in the Canadian armed forces, making him a big fish indeed. In his role in the air force he flew the planes that carried Prime Minister Steven Harper and Queen Elizabeth II. He oversaw the deployment of troops and supplies to Haiti after the earthquake of 2010, he was briefed on security measures when Canada hosted the G20, and he carried the Olympic torch when it came to his community. He was active in community events and respected by people who worked with him in the air force.

Williams was convicted of two counts in the first degree murders of Cpl. Marie-France Comeau, and 27-year-old Jessica Lloyd of Belleville, two counts of sexual assault, two counts of forcible confinement, and 82 counts of break and enter and theft. He received a life sentence with no eligibility for parole for 25 years.

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Russell Williams showed many signs of obsessive compulsive personality disorder. For example, in university he kept extremely detailed records of his spending, and he insisted on a high level of cleanliness in the residence where he lived. He was extremely orderly and paid a great deal of attention to detail. As well, the trophies he kept from the burglaries – women’s underwear – were neatly organized and labeled, and placed in zip lock bags. He kept extensive computer records with dates and other details outlining his crimes. Williams also had several paraphilias. Based on the photographs and videotapes that Williams made of the assaults and of himself wearing lingerie, it is evident that he was a sexual sadist and that he had a fetish for women’s underwear. His burglaries targeted girls as well as woman, and he admitted to engaging in voyeurism.

Given the horrific brutality of his crimes, the question arises as to whether Russell Williams was a psychopath. In the initial part of the police interview that elicited his confession, Williams was cocky and self assured. When asked what he thought of the woman he tortured and killed, he said that he didn’t know them, but that he thought they were “very nice.” On the day that the body of Cpl. Marie-France Comeau was found, there is video footage showing him looking relaxed and happy as he is “arrested” and placed in a mock jail cell for being too young to be an air force base commander. He certainly did not come across as someone who felt anxious or ashamed of his actions at the time. Yet according to people who knew him, Williams cared about his wife, his friends, his cat, and even the frogs that might be harmed when he cut the grass.

Soon after his arrest he attempted suicide. At his sentencing he shook as he apologized for the suffering and pain he had caused, and said that he was truly ashamed. One has to wonder if his distress was all about being caught and facing the consequences of his actions, or whether he felt genuine remorse. Is Russell Williams a psychopath, incapable of truly caring about others? Does he truly feel remorse for the suffering he caused, or was he just sorry that he was caught?

According to Timothy Appleby, who did extensive research to write a book on this case, Williams is not a psychopath. We know, however, that some psychopaths are charming and extremely skilled at covering up, and that Williams presented such a good image that he was promoted to base commander while at the same time he was committing fetish break and enters.

We may never really know how Williams could do what he did.

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XIII. Key Points 1.

Personality disorders are essentially maladaptive personality traits.

2.

The DSM-IV lists ten specific personality disorders, organized into three broad clusters: (A) odd and eccentric disorders (paranoid, schizoid and schizotypal); (B) dramatic, emotional, or erratic disorders (antisocial, borderline, histrionic, and narcissistic); (C) anxious and fearful disorders (avoidant, dependent, and obsessive-compulsive). The DSM5 will retain these disorders.

3.

The best estimates suggest that approximately 6 to 9% of the population will have one or more personality disorders during their life.

4.

One of the major problems with the diagnosis of personality disorders is that many of the diagnoses of personality disorder overlap with each other.

5.

Psychoanalysts see personality disorder as resulting from disturbances in the parent-child relationship.

6.

Research on attachment theory suggests that the personality disorders may result in part from a history of poor parent-child relations.

7.

Cognitive-behavioural theorists see personality-disordered individuals as holding rigid and inflexible cognitive schema developed in childhood.

8.

A genetic influence has been found for antisocial, paranoid, schizotypal, and borderline.

9.

Paranoid personality disorder is characterized by a pervasive suspiciousness of other people’s motives and a tendency to see everything everyone does as a personal attack.

10.

Schizoid personality disorder is characterized by a determination in patients to avoid intimate involvement with others and they display little emotional responsiveness.

11.

The major presenting feature of patients with schizotypal disorder is eccentricity of thought and behaviour.

12.

Individuals diagnosed as having antisocial personality disorder appear to be charming and persuasive, but cover up a self-centred, and often criminal, lifestyle.

13.

The Hare Psychopathy Checklist -Revised (Hare, 1991), is a popular assessment tool that takes into account not only personality variables related to, but also behaviours characteristic of, psychopathy.

14.

Fluctuations in mood, an unstable sense of their own identity, and instability in their own relationships characterize borderline personality disorder patients.

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15.

Attention-seeking behaviours distinguish people with histrionic personality disorder.

16.

Narcissistic personality is characterized by people grandiosely considering themselves to have unique and outstanding abilities and an exaggerated sense of self-importance.

17.

A pervasive pattern of avoiding interpersonal contacts and an extreme sensitivity to criticism and disapproval characterize avoidant people.

18.

People with dependent personality disorder appear to be afraid to rely on themselves to make decisions.

19.

Obsessive-compulsive personality disorder in characterized by inflexibility and a desire for perfection. The centrality of these two features and the absence of obsessional thoughts and compulsive behaviours that distinguish this personality disorder from the Axis I disorder.

XIV. Key Terms

traits (p. 294) personality disorders (p. 294) clusters (p. 295) prevalence (p. 296) egosyntonic (p. 298) egodystonic (p. 298) comorbidity (p. 300) overlap (p. 300) attachment theory (p. 302) suspiciousness (p. 304) delusions (p. 304) emotional responsiveness (p.304) eccentricity (p. 305) psychopaths (p. 306) sociopaths (p. 306) polythetic (p. 306) fearlessness hypothesis (p. 308) oppositional behaviour (p. 308)

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responsivity factor (p. 309) instability (p. 313) anxious ambivalent (p. 315) cognitive restructuring (p. 319) dialectal behaviour therapy (p. 319)

Lecture Ideas/Activties

1.

Antisocial personality versus psychopath.

There was some controversy when DSM-III changed the way antisocial personality was defined.

That change, which is very similar to the present DSM-IV-TR, moved away from the view of psychopathy articulated by Hervey Cleckley. That view, which was the basis of DSM-II, focused less on illegal behaviors and more on personality. Cleckley saw people with psychopathic personalities as lacking in the normal range of emotion; they seldom became anxious, for example. These people had no sense of shame. Often suave and charming, they go through life conning and manipulating. The person with psychopathic personality, said Cleckley, seldom learns from being punished, and often does things for the pure thrill of it, even when the risk of capture is high.

Research has shown that 75 to 80 percent of convicted felons will meet the criterion for antisocial personality disorder, but only 15-25 percent of these will be the glib, unemotional, manipulator who has a psychopathic personality. Many feel that most people with psychopathic personality never get captured, at least for long, and that some of them are actually very "successful" in various walks of life. It is important to discuss with the class that not all criminals have antisocial personalities, and not all people with DSM-IV-TR antisocial personality disorder have psychopathic personality.

Hare, S. D., & Hare, R. D. (1989). "Discriminant validity of the psychopathy checklist in a forensic psychiatric population." Psychological Assessment, 1, 211-218.

2.

The passive-aggressive personality.

DSM-III-R included the passive-aggressive personality among the personality disorders. In DSM-IV-TR it is removed, or at least relegated to an appendix needing further study. The DSMIV-TR subtitles this the negativistic personality. Research criteria revolve around a pervasive pattern of "negativistic attitudes and passive resistance to demands for adequate performance."

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

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dependent or assertive.

Some argue that this should be again in the personality disorder list. Others believe it is more a style that cuts across disorders, rather than being a discrete category. Even the DSM-IV notes that passive-aggressive behaviors can occur in borderline, histrionic, paranoid, dependent, antisocial, and avoidant personality disorders.

Discuss with the class their experience with people with passive-aggressive/negativistic personalities. How do such people alienate others?

3.

The self-defeating personality.

Some personality disorders have aroused great political and theoretical controversy. One such storm has surrounded the self-defeating personality since it was suggested for inclusion in the DSM-III-R. This personality was thought to involve excessive self-sacrifice, where they are taken advantage of, and often reject offers to help them get out of these situations. Many felt this disorder was gender biased such that women would be more likely to receive this diagnosis due to sociocultural factors that encourage self-sacrificing behavior in women. In the end, the authors of DSM-III-R decided to place self-defeating personality disorder in the appendix as needing further study. The category has disappeared entirely from DSM-IV and DSM-IV-TR. Discuss with the class the implications that come when we label some behaviors as abnormal and fail to label others because of the concerns of specific subgroups. If we should not have a label for self-defeating personality disorder because it might apply mainly to women, should we have a label for antisocial personality disorder, which has been proven to apply overwhelmingly to men? Those who support the inclusion argue that, sad as it may be, there are people who behave in these ways, and that it does a disservice to ignore their need for psychological help.

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CHAPTER 13 Sexual and Gender Identity Disorders I. Chapter Summary II. Case Studies A. David sought therapy for impotence.

B. Joan sought therapy to overcome fear of sexual experiences.

C. Dr. Richard Raskin underwent a sex change and became Renee Richards.

D. Joseph Fredericks was a child molester who re-offended after being incarcerated.

III. Historical Perspective IV. Diagnostic Issues V. Sexual Response VI. Sexual Dysfunctions A. Sexual Desire Disorders B. Sexual Arousal Disorders C. Orgasmic Disorders D. Sexual Pain Disorders E. Hypersexual Disorder E. Etiology of Sexual Dysfunctions F. Treatment of Sexual Dysfunctions VII. Gender Identity A. Gender Identity Disorders B. Etiology of Gender Identity Disorders C. Treatment of Gender Identity Disorders VIII. The Paraphilias A. Paraphilic Disorders that Involve Consenting Adults B. Paraphilic Disorders that Involve Non-Consenting Persons IX. Focus Boxes X. Key Points XI. Key Terms XII. Lecture Ideas/Activities A. Performance anxiety B. Should committing rape be a DSM-IV-TR disorder?

C. Gender differences in personal space I. Chapter Summary

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Definitions of healthy or normal sexual behaviour are dependent upon social values, ethics, information and history. Research demonstrated that beyond anatomical differences, men and women have differences in fantasy life and sexual behavioural patterns. Male erectile disorder and female orgasmic disorder are the most common complaint for the respective sexes.

There is evidence that psychological treatments produce benefits for many clients. Success has also been reported with medication and some surgical procedures. Gender identity disorder is defined as a strong identification with the opposite sex. Paraphilias are disorders characterized by deviant sexual interests. The primary sexual variants are fetishisms, transvestic fetishisms, and sadomasochisms; the primary sexual offenses are exhibitionism, voyeurism, frotteurism, child molestation and rape.

II. Case Studies *

David had always doubted the adequacy of his sexual responsiveness. He had tried unsuccessfully to lose his virginity at age 20 with a prostitute but could not become sufficiently aroused. Later upon marrying Alicia, David found that he was anxious about being intimate with his wife and eventually sought therapy.

*

Joan had been reared in a strict religious environment in which sex was a taboo. She was totally unprepared for her first menstruation. Upon entering into a relationship with Ron, Joan found herself embarrassed and afraid of sexual intimacy. She ended the relationship.

Joan read some popular material about sexuality in the last several years that suggested she shouldn’t be afraid or ashamed of her sexuality. Joan became concerned that there was something wrong with her.

*

Richard Raskin was a professional tennis player and ophthalmologist. He dressed as a female since he was a child. Dr. Raskin underwent sex change surgery in the 70’s and became Dr. Renee Raskin. After the sex change, she was denied entry to the U.S. Open as a woman.

She appealed the decision, won the appeal, and was allowed to play in the U.S. Open in the women’s division.

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*

Joseph was charged repeatedly for child molestation. Eventually he served two-thirds of a five-year sentence in the Kingston Penitentiary. He was released because he was considered to pose no great risk to the community. They were tragically wrong, because within a few weeks he repeatedly raped and then murdered an 11-year-old boy.

III. Historical Perspective Discussions of sex, while one of the most discussed human behaviours, are often superficial and skirt substantive issues. Most people define abnormal sex as any sexual behaviour they do not themselves engage in, or wish to engage in. Christian notions of acceptable sexual behaviour evolved in the west primarily through the teachings of St. Augustine who declared that sexual intercourse was permissible only for the purpose of procreation, only when the male was on top, and only when the penis and vagina were involved. Science in the sixteenth and seventeenth centuries offered support for these Christian teachings by attributing all manner of dire consequences to so-called excessive sexual activity. Krafft-Ebing (1901) published the first strictly medical textbook on sexual aberrations called Psychopathia sexualia. Research by Alfred Kinsey, in the 1940s and 50s revealed that masturbation, oral-genital sex, and homosexuality, for example, were in engaged in by far more people and with far greater frequency than was previously believed. Both Kinsey and Masters and Johnson’s research in the 60s were greeted with much the same animosity.

IV. Diagnostic Issues Simple frequency, one method of determining what is “normal”, is not sufficient in the area of sexual dysfunction. At different stages in their lives, men and women at one time or another have sexual dysfunction, and even is something is statistically normal, it may not be acceptable to his or her partner. Satisfaction with present functioning is an important diagnostic criterion, reflected in the DSM-IV-TR’s definition of sexual dysfunctions. There are unfortunately no perfectly objective standards applicable in these cases. Paraphilias, fetishes in particular, may not cause distress at all, yet not be considered normal. In the DSM-IV-TR the notion of distress had been modified by adding “…causes marked distress or interpersonal

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difficulties”. For other paraphilias, such as exhibitionism and pedophilia, clinicians generally ignore this criterion of distress.

V. Sexual Response There are limitations in determining what is normal sexual functioning. For instance, because of the secrecy surrounding sex, it is hard to determine how frequently various sexual behaviours occur, even quite normal activities. Additionally, research has revealed considerable cultural differences in what is considered normal. Norms for sexual behavior also change over time. William Masters and Virginia Johnson (1966) were the first investigators to study and document the physiological stages that take place in the normal human sexual response. They referred to the sequence of changes that occur in the body with increased sexual arousal, orgasm, and the return to an unaroused state as the sexual response cycle. They divided this cycle into four stages: excitement, plateau, orgasm and resolution. Kaplan (1979) proposed an alternative model consisting of desire, excitement, and orgasm. An important contribution of Kaplan’s work was the distinction of desire as primarily a psychological component to the sexual response.

VI. Sexual Dysfunctions The DSM-IV-TR categorizes sexual dysfunctions according to which of the three phases is affected: desire, arousal, or orgasm. A separate category deals with instances in which pain is the primary complaint. Each of the sexual dysfunctions can further be classified into several subtypes, for example, lifelong sexual dysfunction, acquired sexual dysfunction, generalized sexual dysfunctions, or situational sexual dysfunctions.

Sexual Desire Disorders. In DSM-IV-TR, sexual desire disorders are subdivided into two categories: hypoactive sexual desire disorder and sexual aversion disorder. For a diagnosis of hypoactive sexual desire disorder, DSM-IV-TR requires a persistent or recurrent deficiency of sexual fantasies and desire for sex, causing marked distress or interpersonal difficulty. Sexual aversion disorder is diagnosed if there is persistent or recurrent, extreme aversion to, and avoidance of, almost all genital sex with a partner, causing marked distress or interpersonal difficulty.

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Sexual Arousal Disorders. In males, sexual arousal or lack of arousal is usually gauged by penile erection, not the only physiological response but certainly the most obvious. Female sexual arousal is less directly evident and women can have intercourse without arousal, perhaps for this reason, female sexual arousal disorder may be the least understood sexual dysfunction. The DSM-IV-TR diagnostic criteria for female sexual arousal disorder include a persistent or recurrent inability to attain or maintain arousal “until completion of the sexual activity,” and the presence of marked distress or difficulty. Male erectile disorder is present, according to DSMIV-TR, when there is a persistent or recurrent inability to reach or sustain an erection “until completion of the sexual activity” and resultant distress.

Orgasmic Disorders. The DSM-IV-TR diagnostic criteria for female orgasmic disorder, also known as anorgasmia, require a persistent or recurrent delay in, or absence of, orgasm, following normal excitement, causing marked distress or interpersonal difficulty. Male orgasmic disorder is defined in the same way as female orgasmic disorder, but is much less common.

Sexual Pain Disorders. Dyspareunia refers to genital pain associated with intercourse. Painful intercourse is rare among men, and usually is associated with infections, inflammation, or physical anomalies. For DSM-IV-TR diagnosis, dyspareunia must cause marked distress or interpersonal difficulty and must not be caused exclusively by lack of lubrication or by vaginusmus, which is a separate disorder. Vaginismus is the persistent involuntary contraction of the muscles in the outer third of the vagina upon attempts at penetration. If penetration is attempted, it may be extremely painful or impossible.

Hypersexual Disorder Some call this disorder “sexual addiction,” or “sexual compulsivity.” People with this issue have little control over their sexual urges, fantasies, and behaviours, and often engage in sexual activity to regulate negative emotional states such as anxiety and depression. This disorder is not in the DSM-IV-TR, but it has been proposed that it be included in the DSM-5. It is believed that 3-6% of the population has this disorder.

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Etiology of Sexual Dysfunctions. It is accepted that both physical and psychological factors are involved in the development of most, if not all, sexual dysfunctions. Almost everyone experiences some sort of sexual difficulty at one time or another. Some of these problems are situational and eventually disappear. However, there are etiological factors associated with some of the specific sexual dysfunctions. Hypoactive sexual desire, for example, could be caused by depression. Perhaps the most commonly reported factor associated with arousal disorders is what Masters and Johnson (1970) called performance anxiety, the response of individuals who worry that their performance will not live up to the expectations of their partners when expected to perform sexually. Also, a history of sexual abuse is associated with impaired sexual arousal in women and male erectile disorder might be caused by a variety of medical conditions (e.g., vascular disease, blood pressures, diabetes). Orgasmic disorders, premature ejaculation, and vaginismus are thought to have primarily psychological factors. More systematic research is required in order to clarify the etiology of these sexual dysfunctions.

Treatment of Sexual Dysfunctions. Treatment for sexual dysfunctions involves one or more of the following techniques: psychological interventions, communication and exploration, sensate focus (a form of desensitization), and physical treatments (which include medication, surgical interventions, and physical implants). Psychological treatments seem to produce the best results with vaginismus and premature ejaculation. Physical treatments are best used in conjunction with psychological approaches, even with physically based disorders such as erectile dysfunction.

Medications have been shown to be effective in some cases of sexual dysfunction. Alprostadil is the most common form of intracavernous treatment for erectile dysfunction, and is particularly effective for men who have difficulty with the transmission of nerve signals that regulate their erections. Use of PDE5 inhibitors, such as Viagra, appears effective for erectile disorder with only mild side effects. The most common physical treatment for sexual dysfunctions has been physical implants for men with erectile disorder, with the currently most popular approach is an inflatable silicone cylinder (Fig. 13.2)

VII. Gender Identity

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Three aspects of the development of gender identity are separable: sexual orientation, gender role, and gender identity. In some instances these “variables of gender” do not coincide.

In the rare cases where the actual biological variables are discordant, hermaphroditism occurs, with the reproductive structures being partly female and partly male.

Gender Identity Disorders. The DSM-IV-TR criteria for gender identity disorder (GID), previously known as transsexualism, requires strong and persistent cross-gender identification. If an individual feels like the opposite gender trapped in their present gender, this experience would be termed gender dysphoria. Thus, this group consists of men who like to dress as women but who are attracted to women; and women who like to appear as men but are attracted to men. GID is much more common in children than in adults, and is seen at higher rates with males than with females.

Etiology of Gender Identity Disorders. There exists an unresolved debate concerning whether or not gender is determined by nature or nurture. Some theorists have suggested that disturbances in gender identity may be caused by either genetically influenced hormonal disturbances or exposure during fetal development to inappropriate hormones. Psychodynamic and behavioural theories of human behaviour emphasize the importance of early childhood experiences and the family environment.

Treatment of Gender Identity Disorders. Attempts have been made to encourage genderappropriate and discourage cross-gender behaviour among gender-identity disordered children through behavioural, psychodynamic, and family therapies. Some heterosexual and more homosexual gender dysphorics eventually request hormonal treatment or surgery to reassign them to the opposite sex.

VIII. The Paraphilias

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DSM-IV-R describes unusual sexual interests as paraphilias, which are presented in this chapter in two sections: Paraphilic disorders that involve consenting adults, and paraphilic disorders that involve non-consenting others.

Fetishism. Fetishisms, according to the DSM-IV-TR, are sexual behaviours in which the presence of nonliving objects is usually required or strongly preferred for sexual excitement. An excessive attraction to particular body parts has been called partialisms, by which is meant a sexual fixation on specific parts of the body. There are reports of fetishism for underwear, shoes, leather, rubber, plastic, babies’ diapers, furs and purses. Indeed almost any object can become a fetish.

Transvestic Fetishism. When the articles worn by the fetishist are clothes of the opposite sex, it should be called transvestic fetishism. A person who cross-dresses in order to produce or enhance sexual excitement is said to be a transvestite.

Sadism and Masochism. People who derive sexual pleasure from inflicting pain or humiliating others (sadists) have a paraphilia that may be considered either a sexual variant (if it involves willing partners) or a sexual offense (if it involves unwilling partners). Masochists, on the other hand, who enjoy experiencing pain or humiliation, cannot usually force their desires on others.

DSM-IV-TR notes, under the category of sexual masochism, one particularly dangerous form, which they call hypoxyphilia, and others have called autoerotic asphyxia or asphyxiophilia.

This behaviour involves the deliberate induction of unconsciousness by oxygen deprivation, produced by chest compression, strangulation, enclosing the head in a plastic bag, or various other techniques.

Unusual Sexual Variants. Unusual sexual variants include klismaphilia (receiving enemas) urophilia, coprophilia, necrophilia, bestiality, and scatologia (obscene phone calls).

Paraphilic Disorders that Involve Nonconsenting Persons

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Exhibitionism. Exhibitionism is the most frequently occurring sexual offence in Western countries. Exhibitionists also have the highest rate of reoffending.

Voyeurism. Voyeurs seek excitement by observing unsuspecting people who are undressing, are already naked, or are engaged in sexual acts.

Frotteurism. Almost all detected frotteurs are male. Frotteurism refers to touching or rubbing up against a noncompliant person so that the frotteur can become sexually aroused and, in many cases, reach orgasm.

Pedophilia. In defining child molesters, the determining factor is the age of the abuser and the victim. When the offender is an adult and the victim is prepubescent, the issue seems clear enough; but when the offender is a child or an adolescent the issue seems less clear. For example, to date, there is no firm agreement on where the boundary lies between sexual abuse and exploration among children.

Rape. On Canadian law there exist three different subtypes of sexual assault defined by varying levels of forcefulness by the offender. These new subtypes have been aimed at parting from a previously accepted definition of rape defined narrowly as nonconsensual penile-vaginal penetration. Each subtype incurs increasing lengths of possible sentence. Sexual assault remains a markedly under-reported crime. Very few rapists appear to have been suffering from any disorder at the time they offended. Unless rapists meet the criteria either for sadism or for a personality disorder, they will not be given a DSM-IV-TR diagnosis. There is a proposal to add the diagnostic term paraphilic coercive disorder to the DSM-5 to define rapists. While most rapists do not exhibit a sexual preference toward non-consenting sexual activity, some do. As such, one hypothesis distinguishes among three distinct sexual arousal patterns seen in rapists, including biastophilia, a sexual preference toward non-consenting and resisting but not necessarily physically suffering victims, sadism, a preference toward the suffering or humiliation of others; and antisociality, a marked sexual indifference to the interests and desires of others.

Etiology of Sexual Offending. The speculated origins of sexual offending mainly lie in conditioning theories (including courtship disorder theory), feminist theories (which view rape

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as largely nonsexual), and comprehensive theories (which attempt to acknowledge childhood experiences, deficiencies in social skills, sociocultural factors, and transitory states of offenders).

Treatment of Sexual Offenders. Medical interventions aim to reduce sexual drive and increase control. Severe treatments such as castration have drawn ethical criticism. The use of SSRIs seem to give some sex offenders a sense of control over their deviant urges. Treatment of sexual offenders includes behaviour therapy (aimed at eliminating deviant sexual preferences through aversion therapy), and comprehensive programs (which attempt to overcome sexual offenders’ tendency to deny or minimize their offending).

In order to evaluate the effects of treatment it is necessary to follow treated offenders for several years. Treatment is associated with reductions in both sexual and general recidivism. These beneficial effects were found to be greatest among programs using broad cognitive-behavioural approaches.

IX. Focus Boxes 13.1 Previously available physiological measures of sexual arousal worked with men only, but Dr. Kukkonen has found a method that detects physiological arousal in women as well as men.

During sexual arousal, blood flow to the genitals increase. Increased blood flow causes increased temperature, and thermographic cameras measure temperature. Dr. Kukkonen compared thermographic readings while participants watched video clips that were funny, anxietyprovoking, and sexually arousing. The thermography cameras detected increased blood flow while participants watched the sexually arousing film, and subjective self reports of arousal were correlated with temperature increases of the genitals.

13.2 Dr. Meredith Chivers studied women’s and men’s physiological and psychological (reported) sexual responses and sexual orientation. She found that men who were heterosexual were physiologically aroused by and reported sexual arousal (psychological arousal) to stimuli depicting women, and men who were homosexual were physiologically and psychologically aroused by stimuli depicting men. In other words, men’s pattern of response is category specific.

Heterosexual women, on the other hand, did not show a clear pattern of physiological and

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psychological arousal that matched their sexual orientation. Heterosexual women were physiologically aroused by stimuli depicting men and women, but reported sexual arousal only for men. This is a nonspecific pattern of sexual arousal. Gay women, on the other hand, were more physiologically aroused by stimuli depicting women than by stimuli detecting men. In other words, gay women, like men, were category specific in their arousal.

13.3 Canadian Addiction and Mental Health Centre (CAMH) in Toronto have Gender Identity Clinics for adults and for children. Adults may attend the clinic to receive support for and explore issues around gender identity and gender dysphoria. Those who are considering hormone therapy or sexual reassignment surgery may undergo an assessment at the clinic in order to determine if this type of treatment is indicated. The CAMH GID clinic for children provides assessments and provides treatment recommendations to children and families. The numbers of children attending GID clinics has risen rapidly in the last few years. This change is attributed to increased knowledge about gender identity disorders, as opposed to an increase in the numbers of children with GID. There is a growing trend to provide puberty blocking and cross sex hormones to children and adolescents with GID. Dr. Gail Knudson at the Transgender health program in Vancouver indicated that there were 101 adolescents on puberty blocking or cross sex hormones at the clinic in March 2012. . Puberty blocking drugs and cross-sex hormones prevent or slow down the development of secondary sexual characteristics, and provide children and adolescents with the time to determine whether they want to undergo gender reassignment surgery. For those who go ahead with the surgery, delaying or limiting the appearance of the changes that occur with puberty results in better surgical outcome.

Sources: http://www.camh.ca/en/hospital/care_program_and_services/child_youth_and_family_program/ Pages/guide_gender_identitycyf.aspx

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http://www.camh.ca/en/hospital/care_program_and_services/cats_centralized_assessment_triage _and_support/pages/gid_guide_to_camh.aspx http://news.nationalpost.com/2012/03/03/sex-change-early-diagnosis-of-gender-identitydisorder-has-doctors-facing-tough-decisions/

X. Key Points

1.

Definitions of healthy or normal sexual behaviour are dependent upon social values, ethics, information and history.

2.

The sexual response cycle identified by Masters and Johnson consists of parallel stages in men and women: excitement, plateau, orgasm and resolution.

3.

Hypoactive sexual desire appears to be increasingly present at sex therapy clinics, particularly among women.

4.

Male erectile disorder is the most common complaint among men seeking therapy.

5.

Female orgasmic disorder is the most common sexual problem presented at clinics.

6.

Physical interventions are most commonly used for male erectile disorder, and are effective for many clients; surgical intervention, because it is typically irreversible, is seen as a last resort.

7.

Gender identity disorder is defined as a strong identification with the opposite sex, and is more common in children than adults.

8.

People who experience gender identity disorder may be homosexual or heterosexual.

9.

Paraphilias are disorders characterized by deviant sexual interests.

10.

The primary sexual variants are fetishism, transvestic fetishisms, and sadomasochisms

11.

The primary sexual offenses are exhibitionism, voyeurism, frotteurism, child molestation, and rape.

XI. Key Terms

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egodystonic homosexuality (p. 326) sexual response cycle (p. 327) lifelong sexual dysfunction (p. 331) acquired sexual dysfunction (p. 331) generalized sexual dysfunctions (p. 331) situational sexual dysfunctions (p. 331) hypoactive sexual desire disorder (p. 332) sexual aversion disorder (p. 332) female sexual arousal disorder (p. 333) male erectile disorder (p. 333) female orgasmic disorder (p. 334) anorgasmia (p. 334) male orgasmic disorder (p. 334) premature ejaculation (p. 334) dyspareunia (p. 334) vaginismus (p. 335) estrogen (p. 336) testosterone (p. 336) prolactin (p. 336) performance anxiety (p. 336) sensate focus (p. 338) intracavernous treatment (p. 339) gender identity (p. 341) gender role (p. 341) hermaphroditism (p.341) gender identity disorder (p. 341) gender dysphoria (p. 341) fetishism (p. 345) transvestite (p. 345) sexual sadism (p. 346)

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sexual masochism (p. 346) hypoxyphilia (p. 346) autoerotic asphyxia (p.346) asphyxiophilia (p.346) pedophilia (p. 347) exhibitionism (p. 347) voyeurism (p. 347) frotteurism (p. 347) child molester (p. 348) pedophile (p. 348) biastophilia (p. 350) courtship disorder theory (p. 350)

XII. Lecture Ideas/Activites 1.

Performance anxiety.

Some studies by Barlow (1986) seem to provide some insight into the role of performance anxiety in disorders of sexual function for men. "Normal" subjects and subjects who had reported difficulty achieving erection were asked to watch sexually arousing films. In one condition, subjects were instructed to "achieve their best erections." In the other condition, subjects were not pressured to perform (in terms of achieving an erection). Those subjects who experienced sexual dysfunction difficulties prior to the experiment produced their best erections when there was no performance demand and had difficulty achieving erection in the "performance" condition. This study offers clear evidence that performance anxiety can play an important role in male erectile failure.

Barlow, D. H. (1986). "Causes of sexual dysfunction: The role of anxiety and cognitive interference.” Journal of Consulting and Clinical Psychology, 54, 140-148.

2.

Should committing rape be a DSM-IV-TR disorder?

The DSM-IV-TR and its predecessors have often been criticized for diagnosing the victims of traumatic events and violence, but failing to diagnose perpetrators. For example, victims of

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

3.

Gender differences in personal space.

Have all the males in the class stand in two equal lines facing each other from across the room.

Instruct them to slowly walk toward the person opposite them, stopping at a place where they feel comfortable with the distance between themselves and their "partners." After noting the distance, ask the partners to approach each other as closely as they feel comfortable. Then have them sit down. Now repeat the procedures with the female students. If you have time, you might repeat the procedure again with mixed-gender couples. After you have completed the exercise, ask students to share their feelings and observations. Do you find that the males are more hesitant to get close to other males? Point out that in our society females tend to be more comfortable at closer distances with males and with females than males do.

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CHAPTER 14 Developmental Disorders I. Chapter Summary II. Case Studies III. Historical Perspective IV. A note about terminology V. Intellectual disability A. Prevalence VI. Diagnostic Issues A. The Challenges of Assessing Intelligence B. Measuring Adaptive Behaviour C. Proposed Changes to Diagnostic Criteria in the DSM-5 D. Interviewing Strategies VII. Etiology A. Genetic Causes B. Environmental Causes C. Postnatal Environmental Factors: Psychosocial Disadvantage VIII. Two Specific Disorders A. Down Syndrome B. Fragile X Syndrome IX. The Effect of Developmental Disorders On The Family X. Mainstreaming and Inclusion of students with Disabilities in Educational Settings A. Preparation for Community Living B. Evaluating Quality of Life XI. Deinstitutionalizaton and Community Integration or Inclusion A. The Issue of Sex Education XII. Challenging Behaviours and Dual Diagnosis XIII. Pervasive Developmental Disorders: Autism A. Prevalence XIV. Description A. Social Interaction B. Verbal and Nonverbal Communication C. Behaviour and Interests XV. Diagnostic Issues A. Asperger Disorder B. Child Disintegrative Disorder C. Rett Syndrome

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D. Assessment E. Changes in the DSM-5 XVI. Etiology XVII. Treatment and Intervention A. Medications and Nutritional Supplements B. Behavioural Interventions XVIII. Learning Disorders A. Historical Perspective B. Diagnostic Criteria C. Controversy In Diagnosis D. Changes in the DSM-5 D. Reading Disorder E. Mathematics Disorder F. Disorder of Written Expression G. Nonverbal Learning Disabilities H. Prevalence I. Etiology J. Social and Emotional Well-Being of Children with Learning Disorders K. Learning Disorders Across Cultures XIX. Focus Boxes XX. Key Points XXI. Key Terms XXII. Lecture Ideas/Activities A. Learning disabilities as psychological disorders B. Working with children with developmental disability C. To mainstream children or not?

I. Chapter Summary Developmental disorders are associated with varying degrees of damage to the brain occurring at different stages of development before, during, or after birth. Mental retardation refers to significantly subaverage intellectual functioning beginning before the age of 18, and accompanied by limitations in two or more areas of adaptive skill.

Mental retardation can be caused by biological and environmental factors. Intervention strategies for people with mental retardation tend to focus on developing social and community living skills and reducing or managing maladaptive behaviours. Autism is the best known of the pervasive developmental disorders and is characterized by a lack of responsiveness, unusual responses to the environment, and absent or unusual expressive language. Neurobiological and genetic factors are currently considered to play important

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roles in the development of autism. Learning disorders include problems with reading, mathematics, and writing.

II. Case Studies •

Joe was institutionalized at a young age when his parents could no longer manage his behaviour. At age 37 he was assessed and diagnosed with a mild developmental handicap. Joe also had a problem controlling his anger and interacting appropriately with others. He was eventually enrolled in a program where he learned the importance of personal space and strategies to manage anger. Joe finally moved into the community to live with a family and showed adequate adjustment.

•

Jessica, a 14-year-old with Down syndrome, was functioning intellectually in the upper half of the moderate range, but had significantly higher adaptive skills. As Jessica was entering high school it was decided that she would attend a special class for her weaker subjects but would be integrated for her remaining subjects. At a social level, Jessica was experiencing significant social isolation.

•

Ryan, a 10-year-old boy, has Fragile X syndrome. He lives with his parents and older brother, Kurt, who also has Fragile X syndrome. Ryan had a limited attention span and had frequent outbursts at school, especially during transitions from one task or setting to another. Environmental changes and a token program were implemented in an attempt to improve Ryan's behaviour.

•

Kevin, a 27-year-old man, was assessed as functioning at the top of the mild range of developmental handicap. His parents were concerned that some of Kevin's new friends may have been encouraging Kevin to join them in shoplifting sprees.

Whenever they tried to discuss his friends and activities, Kevin became very angry and clammed up.

•

Stevie was a four-year-old boy who had been diagnosed with autism. He had been referred to a community behaviour management team because of frequent tantrums, in which he screamed and hit his head and jaw. As Stevie learned to express his wishes and was reinforced for doing so appropriately, his tantrums and hitting gradually decreased.

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•

Matthew was an 18-year-old man with Asperger disorder. He was relatively high functioning, with fairly well-developed expressive language, and was able to read and write. He was able to interact socially to some extent, but in a rather rigid, stilted fashion. Matthew was assigned to a job coach who helped him develop his computer skills to prepare for a work placement.

•

Justin is a 13-year old boy diagnosed with reading disorder at age 8. A difficulty with phonological processing affected his reading and writing abilities, and he fell behind despite having an IQ in the 86th percentile. With the use of adaptive technology and a teacher who took an interest in him, his school performance improved.

III. Historical Perspective Throughout history and particularly since the mid-nineteenth century, changing attitudes toward people with developmental disabilities have been reflected in policies and models of service delivery. In the past, people with developmental disabilities were regarded as subhuman, a menace, or an object of dread. In ancient Greece, handicapped infants were left on mountaintops to die or were thrown from cliffs. More recently the philosophy of normalization has been adopted and policies designed to promote the use of the least restrictive practices and environments have been the result.

IV. DSM-5 changes and a note about Terminology The term Mental Retardation will be replaced by the term Intellectual Disability in the DSM-5. Developmental disorders may be manifested in a number of different ways. There may be unusual physical features, deficits in language, motor ability, and other skills, and patterns of behaviour such as hyperactivity, aggressiveness, or stereotypy (the repetition of meaningless gestures or movements).

V. Intellectual Disability Prevalence. The Canadian working group on the Epidemiology of Mental Retardation estimates the prevalence of Intellectual Disability to be at least 8 per 1000 when all levels of retardation are considered. Some Canadian surveys estimate the prevalence of major mental retardation in children aged seven to ten years to be 3.65 per 1000. Estimates of older mentally handicapped and developmentally disabled people range from 13,000 to 30,000 people in Canada and from 200,000 to 500,000 in the United States.

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VI. Diagnostic Issues While IQ as measured by standardized intelligence tests is the most basic criterion for mental retardation, there have been important changes in the definition over the years.

These include the level of IQ required and the inclusion of deficits in adaptive behaviour.

The American Association on Mental Retardation (AAMR) has strongly influenced the definition and classification of mental retardation. More recently the AAMR definition has been incorporated into the DSM criteria.

The Challenges of Assessing Intelligence. Although classification systems such as those adopted by DSM and AAMR place heavy emphasis upon IQ, the use of IQ tests has been the subject of considerable controversy in recent years.

Measuring Adaptive Behaviour. The assessment of adaptive behaviour has added greatly to the utility of psychological assessments. The Vineland Adaptive Behavior Scales, which are completed during interviews with parents, teachers, or caregivers, are frequently used for this purpose. Also, the Scales of Independent Behaviour – Revised, have been well-normed for use in similar assessments, and include an evaluation of the level of support needed in each domain of functioning. Finally, the Adaptive Behavior Assessment System has norms for adaptive behaviour and related skills from ages 5-89 years.

Proposed changes to diagnostic criteria in the DSM-5 The term mental retardation will be replaced with the term Intellectual Developmental Disability. It is expected that there will be more emphasis placed on cultural issues and adaptive behaviour.

Interviewing Strategies. Gathering information from people with developmental disorders is an important aspect of any assessment. However, it is critical that the information gathered be reliable.

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VII. Etiology Some developmental disorders have clear organic causes; some relate to environmental factors; and some reflect an interaction between genetics and environment.

Genetic Causes. There are three types of inheritance: dominant, recessive, and sex-linked (or X-linked). Dominant inheritance of mental retardation is very rare, but two such disorders are tuberous sclerosis and neurofibromatosis. Disorders associated with recessive inheritance include phenylketonuria, Tay-Sachs disease, and galactosemia.

Sex-linked transmitted disorders tend to primarily affect males and include Fragile X syndrome and Lesch-Nyah syndrome.

Chromosomal abnormalities are not inherited, but occur at conception. The best known chromosomal abnormality associated with mental retardation is Down Syndrome, which can be the result of having an extra chromosome on pair 21 (trisomy 21), translocation, and mosaicism. Prenatal screening for chromosomal abnormalities is possible through amniocentesis, and a more recently developed test known as chorionic villus sampling (CVS). These techniques can also identify inherited genetic abnormalities.

Phenylketonuria (PKU) is the best known of several rare metabolic disorders that can cause mental retardation. Dietary treatment beginning early in infancy typically results in intellectual functioning within the normal range. Other metabolic disorders include congenital hypothyroidism, hyperammonemia, Gaucher's disease, and Hurler's syndrome.

Environmental Causes. Mental retardation can result if the fetus is exposed to toxins or infections, or if the blood supply lacks nutrients or oxygen. Inadequate nutrition, the use of alcohol or drugs, infections such as rubella or HIV, and exposure to radiation can all affect infant development. Fetal alcohol syndrome (FAS) can result from prenatal exposure to alcohol. Brain damage or mental retardation can occur as a result of birthrelated trauma; however, advances in obstetrics have greatly reduced this type of risk.

Postnatal Environmental Factors: Psychosocial Disadvantage. Psychological and social deprivation, due to lack of stimulation and care, can impair intellectual development.

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Poverty, poor nutrition, large family size, lack of structure in the home, and low academic expectations can all contribute. In approximately 75% of people diagnosed as having a developmental handicap, no organic cause or brain dysfunction has been identified.

Results of many studies support genetic effects: The IQ scores of monozygotic twins are significantly more concordant than those of dizygotic twins. Findings from adoption studies suggest that intelligence scores are affected more by the genetic makeup of the biological parents and possibly prenatal environmental factors than by environmental input provided by adoptive parents.

Canadian studies of children from Romanian orphanages support the notion of the devastating effects of poor nutrition and limited physical and social stimulation. Early intervention can reduce these negative effects. The findings of early intervention studies suggest important ingredients for the development of young children. These include encouragement of exploration, assistance in basic skills; reinforcement of developmental achievements; guided rehearsal and extension of new skills; protection from inappropriate disapproval, teasing, or punishment; a rich and responsive language environment; and a supportive and predictable environment in terms of opportunities for learning and patterns of interaction.

VIII. Two Specific Disorders Down Syndrome. The physical features of Down syndrome are widely recognized. The degree of intellectual impairment can range from mild to severe, with the largest proportion functioning within the mild to moderate range. Although life expectancy is higher for people with Down syndrome than it used to be, adults with Down syndrome are at high risk for Alzheimer-type dementia. Early intervention and education have been shown to contribute to the development and adaptive functioning of people with Down syndrome.

Fragile X Syndrome. Fragile X syndrome is characterized by a weakened or "fragile" site on the X chromosome. It is the second most frequently occurring chromosomal

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abnormality causing mental retardation after Down syndrome, and the most common hereditary cause of mental retardation. Individuals with Fragile X syndrome display a number of cognitive, behavioural, and physical symptoms, but the degree to which they are affected in any of these varies. Moreover, these characteristics are often less pronounced in carrier females. Educational programs that include a good deal of visual information have been found to be particularly effective with students with Fragile X.

IX. The Effect of Developmental Disorders on the Family Parents of children with disabilities appear to experience more stress than other parents, but factors such as the type and degree of disability and the child's age can affect the degree of stress. Research has demonstrated that stress can be buffered by informal social support from friends, family members, neighbours, etc.. Family cohesion, open communication patterns, and patterns of organization and control can also help a family cope.

X. Mainstreaming and inclusion of students with disabilities in educational settings.

Social inclusion involves more than serving people with disabilities in the same place as those without developmental disabilities. Social inclusion is an active process that can enchance participation and development of individuals with developmental disabilities

Preparation for Community Living. In recent years, many educational programs for people with developmental disabilities have focused on developing social skills and independent living skills and on reducing or managing maladaptive behaviours.

Evaluating Quality of Life. The focus of attention in the 1990s has shifted to the quality of life of individuals with disabilities and their caregivers. There is no consensus and a number of different approaches have been taken to the measurement of this important construct.

XI. Deinstitutionalization and Community Integration or Inclusion

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Since the 1970s, services for people with developmental disabilities have been guided by the normalization principle, which suggests that the lives of individuals with disabilities should be as normal as possible. The influence of this principle has contributed to the deinstitutionalization of thousands of people with disabilities and the provision of community-based accommodation and services.

The Issue of Sex Education. Since the 1970s, there has been much debate about whether people with developmental disabilities should have the right to enjoy sexual activity, marriage, and children. Recent research indicates that both children and adults with developmental disabilities are at considerable risk for sexual assault and sexual abuse.

There is also an urgent need for specialized sex education programs for people with developmental disabilities.

XII. Challenging Behaviours and Dual Diagnosis People with developmental disabilities are now generally thought to be at increased risk of developing emotional and behavioural problems similar to psychiatric disorders. The co-occurrence of serious behavioural or psychiatric disorders in people with developmental disabilities has been labelled dual diagnosis. Behavioural approaches are generally the intervention of choice for maladaptive behaviours such as aggression, destructiveness, and self-injury.

XIII. Pervasive Developmental Disorders: Autism Autism is the best known of the pervasive developmental disorders. Others include Asperger Disorder, Rett Disorder, and Child Disintegrative Disorder. Autism was first identified as a childhood disorder by Leo Kanner in 1943. Canadian studies estimated the prevalence of autism at rates range from 1 to 3 per 1000 births. Some studies suggest higher rates of 1 in 150 births, perhaps reflecting changes in diagnostic criteria. Among higher IQ people, autism occurs three times more often in males than females; no such difference is found at lower IQ levels.

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Prevalence: Prevalence rates have risen steadily since the 1970s. Rate estimates range from 1-3/1,000 to 1/150 births, and autism is 3-4 times more common in males than in females. The increase in rates may be due to changes in diagnostic criteria and increasing awareness of the disorder.

XIV. Description: Social Interaction. Two critical features of autism are social dysfunction and unusual responses to the environment. Such deficits, while frequently described, are less well understood than other aspects of autism. The nature of the social interactions of autistic individuals differs according to developmental level; however, they continue to be deficient or unusual. Whereas the social environment is of particular interest to normally developing infants and young children, as well as to some children with mental retardation, children with autism are often much more responsive to the nonsocial environment. Studies of social orientation indicate that children with autism show little interest in the human face and often avoid eye contact.

Verbal and Nonverbal Communication. Approximately 50 % of children with autism are mute. Those who do develop speech often do not communicate meaningfully. Echolalia is one of the common characteristics of speech in children with autism. Pronoun reversal is also common; autistic individuals often refer to themselves as "he" or "she" rather than "I," perhaps because they have trouble shifting reference between speaker and listener or a third party.

Behaviour and Interests. Children with autism characteristically show abnormal responses to environmental stimulation. Research to date indicates that particular patterns of attention deficits are associated with autism. For example, people with autism have difficulty orienting, focusing, controlling, and maintaining attention. Approximately 25 % of individuals with autism function within the normal range of intelligence. Among the remaining 75 %, a small proportion, often called savants, display islets of exceptional ability in areas such as mathematics, music, or art, or unusual feats of memory. Overall, about 10 % of individuals with autism will be fully integrated into the community in adulthood, able to hold a job and live fairly independently.

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XV. Diagnostic Issues In the DSM-IV-TR, subgroups of autism have been classified according to a number of criteria, including level of intelligence, social functioning, and the presence of organic features. Subgroups include the "core syndrome" of autism, Rett syndrome, and Asperger syndrome.

Asperger Disorder. Unlike those with autism, individuals with Asperger disorder do not have significantly delayed cognitive development. Except for social skills, their adaptive behaviour and interests in the environment are age-appropriate, and they may indicate particular interest in social interaction. However, their interactions are frequently odd or eccentric.

Child Disintegrative Disorder. The major distinguishing feature of child disintegrative disorder (CDD) is later onset. After a period of several years of normal development, marked deterioration occurs. Individuals with CDD exhibit behaviours and deficits in social skill and communication similar to those found in autism.

Rett Syndrome. Rett syndrome is a distinct disorder primarily affecting females. In Rett syndrome there is a unique pattern of cognitive and functional deterioration, which has been divided into four stages.

Assessment. Due to the multifaceted nature of autism, assessments are usually carried out by a multidisciplinary team, including a psychologist, psychiatrist, speech and language specialist, occupational and physical therapist, and teacher.

Changes in the DSM-5. The DSM-5 will exclude the terms Asperger’s, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder Not Otherwise Specified.

These will all be identified as autism spectrum disorders. As previously noted, the term Mental Retardation will be replaced by the term Intellectual Disability.

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XVI. Etiology Psychogenic. The psychogenic hypothesis focused on family characteristics and the child's environment. However, research since the 1950s has not supported this view.

Biological. Researchers generally agree that neurobiological factors play an important role in the etiology of autism. In general, findings indicate that impairment is not limited to a single area of the brain, and there is considerable variability within different functional domains (e.g., attention, memory, language). Genetic factors are now thought to play a considerable role in the development of autism; however, the complexities of genetic transmission are not as yet understood.

XVII. Treatment and Intervention Medications and Nutritional Supplements. Although biological factors in the etiology of autism have received most attention in recent years, biologically based treatments have not been found to be generally effective. Drugs generally are used to regulate levels of neurotransmitters (e.g., serotonin, dopamine, norepinephrine) thought to contribute to abnormal behaviours frequently associated with autism. Alternative approaches including nutritional supplements have become popular because they do not have the side effects of prescription drugs. However, well-controlled research of their effectiveness is very limited.

Behavioural Interventions. Behavioural interventions focus on developing self-help skills, language, appropriate social interactions, and academic skills and on reducing maladaptive behaviours. The most common behavioural interventions are positive reinforcement, aversive stimulation, extinction, and a combination. Functional communication training techniques have been used as an alternative to aversive procedures such as contingent electric shock. Social skills training is another important area of intervention for people with autism. The most frequently addressed behaviours in this area are initiating contact, responding appropriately, and reciprocal interchange.

Language intervention programs often use operant conditioning principles, shaping, and modelling to teach verbal imitation, labelling, asking questions, and appropriate verbal

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responding. Improvements in behavioural approaches over the years have led to increasingly better results.

XVIII. Learning Disorders Historical Perspectives. Learning disorders were first identified in the nineteenth century when doctors observed patients who appeared to be intelligent and physically healthy except for their inability to read and write. Modern neuroimaging techniques have supported the view that reading disorders stem from a core deficit in phonological processing. In Canada, the Education Act (1990) included the term learning disability to define a subset of students with exceptionalities that required special education programming.

Diagnostic Criteria. The DSM subdivides learning disorders (LD) by functional impairment, including Reading Disorder, Mathematics Disorder, Disorder of Written Expression, and Learning Disorder Not Otherwise Specified. Criteria for learning disorders include discrepancy between achievement and IQ score and age, as well as significant interference with academic achievement or activities of daily living. Recently, however this criteria has been viewed as less relevant to the diagnosis of LD, with a growing body of empirical data suggests that the specific impairments in cognitive processing are the defining features of learning disorders.

Controversy In Diagnosis: According to the current Learning Disorders model, a learning difficulty is not a learning disability or disorder unless achievement is discrepant with what one would expect based on IQ. This model has been challenged as a “waiting to fail” approach.

Changes in the DSM-5: Learning disorders will be classified as neurodevelopmental disorders. Learning disorders will be identified as distinct disorders that interfere with one or more of the following: mathematics, written language, reading, oral language.

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Reading Disorder. Reading disorder, commonly known as dyslexia, involves difficulties not only in the recognition but also in the comprehension of words. It is estimated that from 2 to 8 % of children in the elementary grades have dyslexia.

Mathematics Disorder. Mathematical disorder, also known as dyscalculia, involves problems with recognizing and understanding numerical symbols, sequencing problems, and attention deficits. It is estimated that approximately 6 % of school-aged children have mathematical disorder.

Disorder of Written Expression. Disorder of written expression is the least well understood and most controversial of all the learning disorder subtypes, as they typically occur in the context of reading or mathematics problems.

Nonverbal Learning Disabilities. NLD was initially desribed as a “social perception” disability, these children are characterized by average verbal intelligence yet show impairments in reading facial expressions and body language, interpreting maps, and learning to tell time. There has been some controversy about the similarities between NLD and Apserger disorder.

Prevalence. Learning disorders are estimated at about 8 percent of the general population, although vary by subtype. The prevalence of different types of learning disorders has been difficult to establish because most of the research has not differentiated among disorders of reading, mathematics, and written expression. Reading disorders are the most common and account for nearly 80 percent of learning disabilities, with more boys than girls typically identified with reading disorders.

Etiology. Brain imaging studies of dyslexia show altered patterns of asymmetry in the language areas of the brain and minor malformations of the cortex. There is some evidence that dyslexia may be inherited; however, the mode of transmission remains unclear due to methodological problems in genetic research.

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Social and Emotional Well-Being of Children With Learning Disorders. Children and adolescents with learning disabilities experience greater peer victimization and bullying, social rejection, and more impoverished peer friendships. They are also at greater risk for associated mental health problems, including depression.

Learning Disabilities Across Cultures. Neurologically based learning disabilities are recognized globally, supporting the observation that core deficits in cognitive processing are universal.

XIX Focus Boxes •

Parents and caregivers who become strong proponents of alternative approaches frequently ignore concerns raised by professional and "nonbelievers." Interventions such as the Doman Delecato technique and facilitated communication have not been supported by research findings.

Despite the lack of empirical evidence, countless parents, caregivers, and educators became strong proponents of these techniques.

•

There is a high correlation between learning difficulties, academic failure, and criminal offences. The “school failure” hypothesis states that having a learning disability places a youth at higher risk for academic failure, leading to negative self-image, increased risk of school dropout, and higher rates of delinquency. In contrast, the “susceptibility theory” states that youth with learning disabilities and problems with impulse control, for example, are more vulnerable to opportunities to engage in delinquent behaviour.

XX. Key Points 1. Developmental disorders are associated with varying degrees of damage to the brain occurring at different stages of development before, during, or after birth. While IQ is the most basic criterion for mental retardation, there have been important changes over the years in the level of IQ required and deficits in adaptive behaviour.

2. Intellectual disability refers to significantly subaverage intellectual functioning beginning before the age of 18, accompanied by limitations in two or more areas of adaptive skill.

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3. Although the etiology of developmental disorders in general and intellectual disability in particular is complex, in some developmental disorders the etiology is clearly understood. Down syndrome and Fragile X syndrome are chromosomal abnormalities.

4. Intervention strategies for people with mental retardation tend to focus on developing social and community living skills and reducing or managing maladaptive behaviours. Genetic and supportive counselling for family members and parent training can reduce family stress and improve quality of life for individuals with developmental disorders and their families.

5. Autism is the best known of the pervasive developmental disorders and it is characterized by a lack of social responsiveness, unusual responses to the environment, and absent or unusual expressive language. Higher functioning individuals are often categorized as having Asperger syndrome. With the DSM-5 autism will be defined as a spectrum disorder and the term Aspergers will be excluded.

6. Neurobiological and genetic factors are currently considered to play important roles in the development of autism, although the causal processes are still not clearly understood.

7. Common components of learning disorders include disparity between estimated potential and current academic achievement, IQ greater than 70, problems due to dysfunctional learning processes rather than sociocultural or physical factors, and deficits apparent in both academic and social situations.

8. Intervention strategies for learning disabilities focus on self-esteem, motivation, cognitive processing styles, organizational patterns, self-instruction, and selfregulation.

XXI. Key Terms stereotypy (p. 358) intellectual disability (p. 359) behavioural phenotype (p. 363) Down syndrome (p. 363 trisomy 21 (p. 363) translocation (p. 363) mosaicisim (p. 363) amniocentesis (p. 364)

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chorionic villus sampling (CVS)(p. 364) phenylketonuria (PKU)(p. 3364) rubella (p. 365) HIV (p. 365) fetal alcohol syndrome (FAS) (p. 35) fetal alcohol effects (FAE) (p. 365) thalidomide (p. 366) deinstitutionalization (p. 371) quality of life (p. 372 diagnostic overshadowing (p. 374) dual diagnosis (p. 374) autism (p. 375) pervasive developmental disorders (p. 375) echolalia (p. 377) pronoun reversal (p. 377) savants (p. 377) Asperger disorder (p. 378) child disintegrative disorder (CDD) (p. 378) Rett syndrome (p. 378) facilitated communication (FC) (p. 382) learning disorders (p. 383) phonological processing (p. 383) dyslexia (p. 384) dyscalculia (p. 384) nonverbal learning disability (NLD) (p.385)

XXII. Lectures Ideas/Activities 1.

Learning disabilities as psychological disorders.

Ask students how they feel about labeling learning disabilities as psychological disorders.

Since many learning disabled students show few, if any, signs of emotional disturbance, some authorities question classifying learning disabilities as psychological disorders.

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2.

Working with children with developmental disability.

Invite someone who works with children with developmental disability to speak to your class. Now that these children have been deinstitutionalized in most provinces, many of them live in group homes and participate in supervised activities in the community.

Students in human service and social work often have experience with this population.

Having someone who is working in this area and who can speak from first-hand experience often gives students a more concrete, tangible account of the possibilities and problems for this segment of the population.

3.

To mainstream children or not?

As shown in the text, mainstreaming means that whenever possible children with disabilities are included in regular classrooms versus attending a special education school only for children with disabilities. Do you think that children with disabilities should be mainstreamed with children without disabilities, why or why not? Next, ask the students if they were a parent of a child without a disability would they want children with disabilities included in their child’s classroom (that may need extra assistance or more individual teacher attention)? Then after they have shared their feelings ask the students if they would change their mind if they were the actual teacher with 20 students in the classroom, if they would want a child with a disability mainstreamed into their class, why or why not? Lastly, ask the students if their feelings would change if it was their child with the disability? It may be helpful to have students record their thoughts to these different scenarios on an anonymous sheet of paper to turn in. Then calculate the responses of “yes” or “no” to each one of the above. After these have been calculated, use the data to discuss the controversial issue of mainstreaming and how the views may change depending on the role someone is playing.

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CHAPTER 15 Behaviour and Emotional Disorders of Childhood and Adolescence I. Chapter Summary II. Case Studies: A. Sam, child with difficult history, and possible ADHD and CD B. Megan Meir and other children, suicide related to bullying

C. Hanna, girl with separation anxiety disorder III. Historical Perspective of Child and Adolescent Mental Health A. Current Issues in Assessing and Treating Children and Adolescents IV. Prevalence of Childhood Disorders

V. Attention Deficit/Hyperactivity Disorder A. Clinical Description B. Etiology C. Assessment and Treatment VI. Oppositional Defiant Disorder and Conduct Disorder A. Clinical Description B. Etiology C. Treatment VII. Anxiety Disorders A. Clinical Description B. Etiology C. Treatment VIII. Focus Boxes IX. Summary X. Key Terms XI. Lecture Ideas/Activities A. Use of stimulants with children B. Whose Problem Is It Anyway?

I. Chapter Summary

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Attention deficit/hyperactivity disorder (ADHD) is likely the best studied of the childhood disorders, and is often comorbid with conduct disorder (CD). ADHD is frequently conceptualized as a biologically based problem, and stimulant medication is the most effective means of improving the behaviour. Psychological interventions such as teaching parents and teachers social learning techniques can also be beneficial.

Oppositional defiant disorder (ODD) is considered a younger version of CD. Children with CD often have other problems, such as substance abuse. Criminality, family violence, substance abuse, and other psychiatric disorders are often present in the families of children with CD. Separation anxiety disorder (SAD) is the only anxiety disorder unique to children. In general, less research has been conducted on anxiety disorders in children.

II. Case Studies •

Sam is a 13-year-old boy who was seen by a clinician but refused to admit he any problems, nor did he want to see the clinician again. Since he was in his kindergarten, his behaviour was problem. He was not able to sit still and he seemed to enjoy bullying his classmates. As he got older, his behaviour got worse. By 7, Sam started his first fire and would sneak alcohol from his mother by age 10. By 12, he regularly missed school, and continuing his pattern of substance abuse and destructive behaviour.

•

Megan Meir was a 13-year-old girl who developed an online romance with a boy named Josh Evans. It turned out, though, that there was no such person, and that the Josh Evans character was created by a former friend and her mother. Megan ended up committing suicide after “Josh” said that the world would be a better place without her. There have been several more bullying-related youth suicides in Canada and other countries.

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Hannah was an 8-year-old girl who was very reluctant to go to school, experiencing various aches and pains. Her parents decided to ignore her behaviour, but her anxiety

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increased, particularly if she was separated from her parents. She developed many fears and nightmares, and Hannah’s parents went to seek professional help.

III. Historical Perspectives of Child and Adolescent Mental Health All modern theories consider childhood years as critical in development; however, during the latter 19th century, children’s psychological attributes were simply seen as an extension of adult characteristics. Leo Kanner was the first to author a textbook of child psychiatry, providing a framework for assessing children and adolescents. The DSM-I included childhood disorders within the adult categories, DSMII recognized six independent categories for children, and the present DSM-IV-TR lists 44 categories of “disorders usually first diagnosed in infancy, childhood, or adolescence.”

Current Issues In Assessing and Treating Children and Adolescents Since children generally do not self-refer for help, parents’ and teachers’ reports are often considered more important in assessment than the child’s input. As well, children often do not have insight into their problems or the verbal capacity to describe them.

IV. Prevalence of Childhood Disorders Externalizing problems in childhood include behaviour problems and problems of undercontrol. Internalizing problems include disorders such as anxiety and depression. Separation anxiety disorder is an internalizing disorder that begins on childhood. Children can suffer from other internalizing disorders, but these are not seen to differ substantially from adults. These two types of disorders can coexist in the same person, reflecting comorbidity, the co-occurrence of two or more disorders.

Epidemiological studies indicate that anxiety disorders, conduct disorder, and ADHD are the most common psychiatric disorders among children and youth in North America.

Conduct disorder and hyperactivity were more frequent in boys; hyperactivity was higher in younger boys and conduct disorder was higher in older boys. Emotional disorders were higher among older girls.

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V. Attention Deficit/Hyperactivity Disorder Clinical Description The largest number of children seen in mental health clinics is diagnosed with attention deficit hyperactivity disorder (ADHD). This disorder is one of the most prevalent childhood disorders. These children create problems in schools and families.

Clinical Description Classification of Subtypes. In the DSM-IV-TR, ADHD symptoms are grouped into three categories – hyperactivity, inattention, and impulsivity, the primary symptoms of ADHD. The main type of symptom the child presents will determine the diagnosis: ADHD inattentive type (ADHD-I), ADHD hyperactive type (ADHD-H) or ADHD hyperactiveinattentive or combined type (ADHD-HI). ADHD-I is more common in girls than in boys, whereas ADHD-H and ADHD-HI are three times more common in boys than in girls and are associated with higher rates of comorbid conduct problems.

Comorbidity. 50% of children with ADHD have at least one other psychiatric disorder, most commonly oppositional defiant disorder or conduct disorder, learning disorders, anxiety disorders, and in later years, depression and substance abuse disorders.

Prevalence. The prevalence of ADHD in the general population is about 2 percent among preschool-aged children, 6 percent among children and adolescents, and 4 percent among adults. Among psychiatric populations, this rate increases tenfold.

Developmental Trajectory. Most children with ADHD continue to have symptoms that require a chronic approach to management through adolescence and adulthood. The most important long-term issue for youth with ADHD is increased risk for developing another psychiatric disorder. Nearly half of adults with ADHD also have a mood or anxiety disorder.

Etiology

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Although the exact cause is unknown, researchers tend to agree that a biological predisposition to ADHD is likely. Multiple risk factors interact to cause ADHD. Children with ADHD generally have reduced brain size (3 to 8 percent reduction), abnormalities in the metabolism of dopamine and noradrenergic neurotransmitters, and abnormalities in the functioning of genes that regulate these neurotransmitters. MRI studies have linked ADHD with abnormalities of the prefrontal cortex, associated with executive functioning, and the basal ganglia, associated with higher motor control, learning, memory and cognition, and emotional regulation.

The heritability of ADHD has been estimated to be as high as 77 percent. Several genes continue to be studied, yet no particular gene specific to ADHD has been identified to date. Prenatal toxin exposure, including poor diet, mercury, and lead exposure, pregnancy and delivery complications, and exposure to alcohol and maternal smoking is related to ADHD in offspring. As well, psychosocial risk factors such as low socio-economic status, large family size, paternal criminality, poor maternal mental health, child maltreatment, foster care placement, and family dysfunction are all associated with risk of ADHD.

The current understanding of many psychiatric disorders, including ADHD, points to gene-environment interactions (G x E), similar to the diathesis-stress perspective of disease. For example, maternal smoking during pregnancy is an environmental factor that increases the risk of developing ADHD in those with a genetic predisposition.

Assessment and Treatment More research has been conducted on the effects of stimulant medications on ADHD children. Ritalin (methylphenidate) is the most frequently prescribed, followed by Dexedrine (dextroamphetamine). The most likely symptoms to respond to medication are hyperactive, restless, impulsive, disruptive, aggressive, and socially inappropriate behaviours. Academic achievement does not always improve and children may require special assistance. Behavioural and psychological treatments appear less useful, although

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they may assist with social skills and behaviour control, and supportive counselling may be useful to parents.

VI. Oppositional Defiant Disorder and Conduct Disorder Clinical Description Oppositional defiant disorder (ODD) is diagnosed when children behave in a negative, hostile, or defiant manner to a greater degree than other children. Symptoms typically emerge before 8 years of age. About one in four boys diagnosed with ODD will go on to develop conduct disorder.

Children with conduct disorder (CD) show a “repetitive and persistent pattern of conduct in which the basic rights of others and major age-appropriate societal norms or rules are violated.” Aggression is the greatest concern. Children with CD often do poorly in school. CD children are also likely to have poor interpersonal skills, are often rejected by peers, and tend to be socially ineffective in their interactions, possibly due to deficiencies in problem-solving skills.

About 5–10% of children have ODD and about 3–6% have CD. Boys outnumber girls 2 to 1. Many young boys with ODD will never go on to develop CD, and only a minority of those with CD will later develop antisocial personality disorder as adults. Youngsters with CD are more prone to exhibit ADHD and/or substance abuse, and those with both CD and ADHD are more likely to display antisocial behaviour. Only a small group of CD children remain antisocial throughout life while another, larger group normalize their behaviour after adolescence. Some researchers there is evidence for heterotypic continuity, the notion that ODD, CD, and APD are really the same disorder that manifests itself differently over time.

Etiology Twin studies have demonstrated a strong genetic basis for antisocial and aggressive behaviour with heritability estimates for conduct problems that include

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aggression ranging from 44 to 72 percent in adults. Researchers have attempted to determine whether certain antisocial behaviours are heritable. Intergenerational patterns of criminal behaviour have been emerging. It has also been found that parents of aggressive children were themselves aggressive at the same age. Though there is accumulating evidence that indicate a strong link between CD and the family, it is difficult to determine whether the connection is genetic or environmental. Environmental factors such as marital conflict, divorce, and child abuse in the family have been implicated in the onset and maintenance of antisocial behaviour in youth.

A specific predictor of later conduct problems is specific child-rearing patterns, such as poor parental supervision and lack of parental involvement. Parents of antisocial youth show less warmth, acceptance, affection, and emotional support. A G x E interaction is suggested by the finding that about 80 percent of individuals who were severely maltreated in childhood and how had low monoamine oxidase A (MAOA) activity had CD in adulthood.

Treatment Research has consistently noted that CD in adolescents is difficult to treat, and effectiveness of treatment is difficult to determine.

Problem-solving skills training employs multiple strategies. Some of the procedures used are modelling and practice, role-play, and reinforcement contingencies. Data show that problem-solving skills can lead to significant improvements in children’s behaviour; however, they were not functioning at a normal level. Some questions remain on whether gains through problem-solving skills training can be maintained.

Pharmacological treatment includes mood stabilizers, typical and atypical neuroleptics and stimulants with evidence that they may help children and adolescents with CD. Lithium has been found to be an effective short-term therapy for inpatient aggressive children and adolescents.

Parent training (PT) programs are based on a social learning causal model, whereby interactions between the parent and the child are considered to maintain and promote

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conduct problems inadvertently, termed the coercive process. Goals include developing specific parental skills to promote prosocial behaviours in children, while using proper discipline to minimize undesirable behaviours. Data show that the training was effective in reducing levels of dysfunction and parental stress. This method has promise and but needs to be further researched.

School- and Community-Based Treatment target families through schools and the community, such as The Community Education Training Program (COPE) developed by Cunningham (2006). COPE has been successfully used to reduce symptoms of ADHD and conduct problems. The development of community programs is a significant step toward addressing the multiple dimensions of CD. Also such programs increase the likelihood of reaching children who are at high risk, and reduce stigmatization or labelling.

VII. Anxiety Disorders Anxiety disorders are observed less frequently in children seen in mental health clinics than are disruptive disorders. One possibility is that because the anxious behaviours are less likely to affect others negatively. DSM-III-R listed a number of anxiety disorders, however, in DSM-IV-TR, only separation anxiety disorder (SAD) remained as a childhood anxiety disorder. The most obvious sign of SAD is distress upon separation from the attachment figure. Among other fears, worries that parents will be harmed are reported frequently. In adolescence, the disorder is referred to as generalized anxiety disorder (GAD).

Clinical Description: Children diagnosed with SAD experience severe and excessive anxiety when faced with separation from parents or other attachment figures. SAD may be misdiagnosed since behaviour may be described as oppositional (i.e., temper tantrums, disobedience); however, in the case of SAD these behaviours occur in relation to anxietyprovoking situations involving separation from parents.

Most children are diagnosed with SAD before puberty and the qualifier early onset is made if SAD occurs before age six; one-third of these children go on to develop other anxiety or mood disorders. The primary difference between SAD and GAD is that, with

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GAD, the distress and uncertainty that the child feels becomes directed outward to the world around them. Children with anxiety disorders often have comorbid mood disorders, refuse to attend school, and have somatic complaints.

Children diagnosed with anxiety disorders are described by parents, teachers, and peers as socially withdrawn, maladjusted, and as having poor school performance. Little is known about the course of SAD if left untreated. Approximately 40% of children diagnosed with an anxiety disorder continue to display anxiety symptoms four years later.

There also is some speculation that children with SAD may develop agoraphobia and panic disorder in adulthood.

Although most children with anxiety disorders develop normally, a significant proportion continue to struggle with anxiety over time, suggesting that the homotypic continuity of anxiety disorders is robust. This means that it is important to monitor children with anxiety disorders given that behavioural issues tend to develop in middle childhood followed by depressive disorders in late childhood.

Etiology Compared to externalizing disorders, far less is known about the etiology of anxiety in children and adolescents. This is true despite the fact that they are more common to this age group and associated with significant impairment and distress.

Research supports the idea that high stress reactivity may be heritable. Temperament in early childhood may be related to anxiety disorders in later life. Jerome Kagan investigated the role of behavioural inhibition in children and reported that behaviourally inhibited children show profound avoidance of others in preschool and atypical autonomic nervous system responses when challenged by novelty. Behavioural inhibition may be due to abnormal functioning in the amygdale that alerts the person to threat and the response to it.

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Anxiety disorders runs in families, but this type of familial clustering can also be explained by shared environmental factors. Elevated levels of the stress hormone, cortisol, in the mother during pregnancy, may also pose a prenatal risk factor for childhood anxiety. A gene-environment interaction may be operating in children with behavioural inhibition or amygdala dysfunction (predisposition) when combined with a conditioned fear experience (environment) whereby the fear persists over time.

Treatment Cognitive-behaviour therapy has shown considerable success in the treatment of anxiety disorders in children. Behavioural therapy attempts to enhance self-efficacy, and utilizes exposure. Cognitive techniques help the individual reframe anxious thoughts, resulting in more assertive behaviours. These techniques can be used to help children cope with their anxious thoughts and develop more adaptive behaviours. The literature contains positive reports of significant improvement in the treatment of children with anxiety and depression.

Few studies have evaluated pharmacological treatments. Psychotropic medication has not demonstrated consistent evidence of usefulness. Tricyclic antidepressants and benzodiazepines have been widely used, despite lack of efficacy and undesirable side effects. Selective serotonin reuptake inhibitors show some promise, but further research is required.

VIII. Focus Boxes •

DSM-5 will include the new disorder of “Disruptive mood dysregulation disorder.” Children with this disorder experience irritability, anger, and behavioural outbursts at least 3 times a week for a year or longer.

Currently, children with these symptoms are often diagnosed as bipolar.

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However, not only do they not seem to respond to medication for bipolar disorder, they develop unipolar depression in adulthood rather than bipolar disorder.

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Suicide is the second-leading cause of death among Canadian youth aged 10 to 19. Deliberate self-harm (DSH) is used to describe purposeful attempts to injure oneself without causing death, and suicide ideation or attempts. DSH may be an important indicator that depression, substance abuse, and anxiety disorder are present. Youth with suicidal ideation require specific attention, but CBT for suicidal and self-harming youth may reduce future attempts by helping youth think of other options.

IX. Key Points 1. In the past, childhood disorders have been viewed as similar to adult psychopathology; however, the current DSM-IV-TR includes separate categories for childhood disorders.

2. The Ontario Child Health Study (OCHS) was an epidemiological study that attempted to estimate the prevalence of various emotional and behavioural problems in children four to sixteen years of age. The six-month prevalence for any of the four disorders (conduct disorder, hyperactivity, emotional disorder, and somatization) was 18%, although rates varied by age and sex.

3. Attention deficit/hyperactivity disorder (ADHD) is one of the most prevalent childhood psychiatric disorders and involves difficulties paying attention, disruptive behaviour, and difficulty controlling impulses.

4. Oppositional defiant disorder (ODD) and conduct disorder (CD) are frequently discussed together and involve hostile, negative behaviour (ODD), and aggressive behaviour where rules and social norms are violated (CD).

5. Separation anxiety disorder is the only distinct childhood anxiety disorder. It involves distress upon separation from parents or other attachment figures, and may involve fears of harm coming to the parent or fears of other objects.

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X. Key Terms externalizing problems (p. 392) internalizing problems (p. 392) comorbidity (p. 392) attention deficit/hyperactivity disorder (ADHD) (p. 394) gene-environment interaction (p. 396) diathesis-stress perspective (p. 396 methylphenidate (Ritalin) (p. 397) oppositional defiant disorder (ODD) (p. 399) conduct disorder (CD) (p. 399) assortative mating (p. 401) mood stabilizers (p. 404) neuroleptics (p. 494) coercive process (p. 404) separation anxiety disorder (SAD) (p. 406) homotypic continuity (p. 407) heterotypic continuity (p. 407) deliberate self-harm (DSH) (p. 408) behavioural inhibition (p. 409) selective serotonin reuptake inhibitors (p. 410)

XI. Lecture Ideas/Activities 1.

Use of stimulants with children.

The use of stimulant medications, such as Ritalin, has developed into one of the more effective treatments for attention-deficit/hyperactivity disorder. The drugs reduce activity-level problems, thereby making the child more manageable at home and in the classroom. The drugs appear to work in about 65 percent of children with overactive behavior symptoms. As indicated in the text, however, long-lasting effects, such as academic improvement and increased social skills, are not directly acquired via the use of medication.

Ask students to put themselves in the roles of parents, teachers, and children to discuss the implications, both positive and negative, of using stimulant medications to control children's behavior. The overuse of the stimulant drugs that occurred in the 1970s points

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up the potential for misusing these drugs with children. How would students develop a procedure to ensure that only children with critical levels of behavior impairment received the medication?

2.

Whose Problem Is It Anyway?

How big a problem is hyperactivity in children? How about oppositional defiant disorder? Have the class discuss what they view as the symptoms of psychological disorder in children. Discuss how problems may change depending on who is making the evaluation, for instance the teacher, parent, or child. Students can work in groups to complete worksheets about the various perspectives on problems with children. Ask them to identify the kinds of things that would bother each stakeholder in children’s behavioral and emotional functioning.

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CHAPTER 16 Mental Disorders and Aging I. Chapter Summary II. Case Studies A. Normal bereavement in the case of Laura S. B. Depression and the case of Mrs. S. C. Sleep disorder in the case of Rose.

D. Anxiety disorder in the case of Mr. Wallace.

E. Dementia in the case of Mrs. C. F. Delirium in the case of Mrs. L III. Changing Demography A. Vulnerability versus Resilience in Old Age IV. Prevalence of Mental Disorders in Older Adults V. Historical Perspective VI. Age-Specific Issues of Diagnosis and Treatment VII. Theoretical Frameworks of Aging A. Selective Optimization with Compensation B. Socio-Emotional Selectivity Theory C. Strength and Vulnerability Integration Theory VIII. Mood Disorders A. Suicide B. Etiology C. Depressive Disorders IX. Sleep Disorders A. Diagnostic Issues B. Normal Changes in Sleeping Patterns C. Primary Insomnia D. Restless Legs Syndrome E. Sleep Apnea X. Anxiety Disorders A. Diagnostic Issues B. Treatment XI. Schizophrenia XII. Delerium XIII. Dementia A. Mild Cognitive Impairment B. Alzheimer’s Disease C. Vascular Dementia

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D. Other forms of Dementia E. Caregiver Stress XIV. Focus Boxes XV. Key Points XVI. Key Terms XVII. Lecture Ideas/Activities A. Difficulty diagnosing Alzheimer's disease B. Grandparenting programs C. Geriatric assessment

I. Chapter Summary It is a widely held belief that mental disorders are more common in older than in younger adults, but the data suggest that the opposite is the case, with two notable exceptions - sleep disorders and dementia. Theoretical approaches to mental disorders do not offer specific insights into mental disorders in older people. Mood, anxiety, and psychotic disorders are less common in older than in younger adults. Sleep disorders become more common as people age. Dementia is truly a mental disorder of aging.

II. Case Studies •

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Just after Laura S. retired at age 65, her only daughter, Stephanie, was killed. At first Laura did not react emotionally but eventually she began to speak to Stephanie as though she were really in the room. A clinical psychologist reassured Laura that she was not mentally ill but was suffering from normal bereavement.

Mrs. S., 73, was referred to an outpatient psychological clinic by her family physician with symptoms of sleeplessness, appetite loss, and feelings of hopelessness and despair. Mrs. S. lost her husband of nearly 50 years about eighteen months ago. Mrs. S. worries that her memory might be failing, though tests show this not to be the case.

All her life Rose slept soundly, got up early, and was energetic. Now, in her seventies, she often finds it hard to fall asleep and then often awakens in the middle of the night, worrying about her family. Finally, at her husband's urging, she has made an appointment to discuss the problem with her physician.

Mr. Wallace, a 68-year-old widower, has been experiencing what he calls "attacks." During these attacks his heart pounds and sometimes he has pain in his chest and trouble breathing.

Despite the fact that a recent medical examination found no evidence of any medical

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conditions, Mr. Wallace remains convinced that he has an undiagnosed life-threatening disorder.

Mrs. C. is a 77-year-old-woman was brought to hospital by ambulance after having been found wandering. She was unable to provide personal information. The emergency room physician diagnosed Mrs. C as suffering from delirium caused by poor nutritional status and failure to take thyroid medication. She was released to her daughter’s care with instructions to monitor her food and fluid intake, and medication compliance.

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At 76 years of age, Mrs. L. and her family noticed that she was forgetful. Though her parttime job was of great satisfaction to her, she made many errors. On the recommendation of her family, she moved into a small apartment, but the problem worsened. She began to forget that her husband passed away and her self-care began to deteriorate. It was not expected that she could remain in independent residence for long, as her children were becoming concerned about her health and safety.

III. Changing Demography In all developed countries, older adults are the fastest growing age group. There are a number of reasons for this increase, including the aging of the large cohort of baby boomers and their low birth rate. Also, a major reason of course, is the improvement of health care. As the proportion of older adults in the population increases, there will be a disproportionate increase in older as opposed to younger adults with mental disorders.

Vulnerability versus Resilience in Old Age A person is more likely to develop a mental disorder at times of increased vulnerability. At some point in old age, most people experience increased vulnerability - both physically, as various organ systems begin to be compromised, and psychologically, with losses in areas such as social support and independence. At the same time, however, psychological well-being may actually increase with age, despite their vulnerability, and together, this constitutes what has been termed the paradox of aging.

IV. Prevalence of Mental Disorders in Older Adults Surveys suggest that, with the exception of dementia, mental disorders generally decrease with age. However, this depends on the type of disorder. Some mental disorders, such as schizophrenia, become less prevalent as people age; others such as obsessive-compulsive disorder do not appear to be related to age, and some are identified as much more related to age, e.g., dementia. Cross-sectional surveys cannot determine, however, whether people become more

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resilient over time (a period effect) or whether certain cohorts of individuals born at a particular time are more resilient (a cohort effect).

V. Historical Perspective Historically, older adults with mental disorders were typically seen as eccentric rather than ill.

When they became too disruptive, they were isolated, either in a variety of institutions or at home. Today there is at least nominal acceptance in clinical psychology of the value of treating older adults with mental disorders.

Misconceptions about treating older adults. One of the most common myths about aging is that the development of pathology must be accepted as a part of growing old, and therefore need not be treated. Although it is not yet clear exactly what governs the normal aging process, gerontologists believe there is a great deal of evidence to support the notion that there is a normal aging process. Another myth concerns treatment. It is widely believed, among health care professionals and among the general population that older adults are less likely to respond well to treatment for mental disorders.

VI. Age-Specific Issues of Diagnosis and Treatment Recognizing and treating mental disorders in older adults is complicated by a number of factors particularly relevant to this population. For example, co-morbid physical illness, vascular disease, arthritis, neurological disease, and polypharmacy can complicate diagnosis of mental disorders in older adults. Comorbidity is more likely to occur, and more likely to create treatment problems, for older than younger adults. Correct recognition, diagnosis and treatment of older adults with mental disorders requires more mental health professional with expertise in aging.

VII. Theoretical Frameworks of Aging With few exceptions, theorists have not extended, adapted, or refined any theoretical approaches to fit specifically the clinical experience of older adults. Erik Erikson extended psychoanalytic theory in a number of ways, one of which was to suggest that the critical issues for successful functioning are different at different points in development. Erikson did not, however, focus on the implications of his lifespan approach for understanding mental disorders at different points in the life course. There are two approaches that are relevant to conceptualizing mental disorders in older adults: selective optimization with compensation and socio-emotional selectivity theory.

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Selective Optimization with Compensation. This theory holds that loss of skills occurs within the context of normal aging, and that successful aging entails optimizing the remaining skills.

This theoretical framework could be used to maximize functioning in people with certain mental disorders by building on strengths and avoiding weaknesses.

Socio-Emotional Selectivity Theory. This theory assumes that as get older, we view time as limited and therefore, goals become focused on short-term and emotionally meaningfully matters, in contrast to the future-oriented goals of younger adults. One result of this, as shown by experiments, is that older adult process negative information less deeply than they do positive information.

Strength and Vulnerability Integration Theory. According to this approach, aging is associated with an increased ability to regulate emotions. However, aging is also associated with decreased physiological tolerance of stress.

VIII. Mood Disorders The data show that for major DSM-IV-TR mood disorders older adults are less likely to experience mood disorders. Although the clusters of symptoms that form the diagnostic criteria for the mood disorders may be seen less frequently in older individuals, symptoms of depression are not uncommon, especially among hospitalized or institutionalized individuals.

Suicide. Among older individuals, a number of factors (in addition to being male) place a person at greater risk of suicide including being divorced or widowed, having low income, alcohol abuse, having a mental disorder and being depressed. In general, older people seem to apply more lethal methods when attempting suicide and are more likely to succeed in killing themselves than younger adults.

Etiology It seems that the combination of a weak social support network and poor physical health places elderly people at particular risk for depression. Although heredity has also been shown to play a role in the development of both major depressive disorder and bipolar disorder, medical illness, vascular disease, and Parkinson’s disease play an increasing role in the etiology of latelife depression.

Depressive Disorders Depression is a frequent cause of emotional suffering among older persons and is associated with decline in their quality of life. Though the symptoms of depression are common, the rates of formal diagnoses are less common in older adults compared to their

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younger counterparts. Rates jump dramatically when older adults with health problems are considered. As with MDD, dysthymic disorder is more common in younger than older adults, and more common in women than men. Depressive symptoms can also be caused by diseases, medical conditions, and drugs that may be more common among older people. Short-term therapy has been shown to produce significant improvement in older MDD patients. Partly because of problems with drug treatments (drug interactions), electroconvulsive therapy (ECT) is often used to treat older people with either MDD or dysthymic disorder. Elderly MDD patients are significantly more likely to receive pharmacotherapy and ECT and significantly less likely to be treated with psychotherapy than patients of younger ages.

IX. Sleep Disorders It is clear from the literature on sleep and sleep disorders that older adults report much greater levels of dissatisfaction with the quality of their sleep than younger adults. The vast majority of sleep disorders research has been conducted with younger adults, and as a consequence it is not clear how much of what we know about sleep disorders can be generalized to older adults.

Diagnostic Issues. Diagnosing and treating sleep disorders in older adults is complicated by a number of factors which must be considered before a diagnosis of primary sleep disorder can be made. Although a 24-hour sleep-wake cycle assessment is rarely conducted, such an assessment might be useful in identifying a multitude of factors affecting sleep in older persons and devising a suitable treatment.

Normal Changes in Sleeping Patterns. Laboratory studies have shown age-related changes in EEG activity, in the organization of sleep stages, and in the circadian rhythms. There is also evidence that changes in endocrine and temperature rhythms also occur.

Primary Insomnia. Prevalence estimates of primary insomnia in older adults range from 12 percent to 50 percent. Primary insomnia can result from a wide variety of causes, occurring either alone or in combination (e.g., physical disorders, substances, circadian rhythm problems, psychological factors, and poor sleep environment or habits). Unfortunately, although primary insomnia is more common among them, older adults are less likely than young adults to be referred to sleep disorder clinics for full assessment and appropriate treatment. Instead they are commonly treated with sedatives or hypnotics prescribed by their family physician.

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Restless Legs Syndrome. The second most common sleep disorder in older adults is Restless Legs Syndrome (RLS), periodic leg movements during sleep. Prevalence estimates range from 4 percent to 31 percent in older insomniacs and from 25 percent to 60 percent in a general population of older adults. Treatment has been almost exclusively pharmacological and not tremendously successful.

Sleep Apnea. In sleep apnea there are periods of cessation of breathing. If sleep apnea is severe or left untreated, weakened cardiac functioning can occur and can be fatal. Between 25 percent and 33 percent of older adults have this disorder with it being markedly more common in men than in women and with increasing age. Sleep apnea can be due to blockage of the upper airways (obstructive apnea) or impairment of activation in the medullary respiratory centre in the central nervous system (central apnea). Obstructive apnea is the most common form and is easily recognized. Treatment involves losing weight, learning to avoid sleeping on one's back, and avoiding of respiratory depressants such as alcohol and hypnotic medication. In addition, respiratory stimulants are often helpful. Central apnea is less well understood.

X. Anxiety Disorders Anxiety symptoms are a serious problem for a large number of older adults. Older adults have been shown to have lower threshold for reporting anxiety symptoms. It is more likely that rates of anxiety are relatively stable across the life span, but that significant symptoms of anxiety are among the most common psychiatric problems experienced by older persons.

Diagnostic Issues. Accurately detecting and diagnosing anxiety disorders in older adults can be problematic. Most self-report instruments have been normed and validated with younger adults, and the interpretation of scores of older adults. Many of the symptoms endorsed by older adults are somatic and not related to anxiety. There is a need for anxiety scales developed especially for older people. Anxiety symptoms have been found to be associated with medical illnesses in older adults and may have physical causes. More studies are needed to clarify whether the development of physical illness is followed by the appearance of anxiety symptoms.

Treatment. Physicians’ preference for medication when treating anxious older adults is troubling because the research supporting this decision is lacking, and because of the risk of medication side effects with elderly patients. The newer SSRI’s are becoming increasingly common, although little is currently known about their long-term risks and benefits for older people.

XI. Schizophrenia

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It appears that early-onset schizophrenic symptoms either disappear or decrease substantially over time in a significant number of patients. Late-onset schizophrenia is not common. Late-onset cases of schizophrenia are less likely to have disorganized speech, lack of logical thought, and flattened affect; hallucinations and elusions are likely to be more florid and bizarre. Psychotic symptoms in older adults can also be caused by a number of medical illnesses, including Addison's disease, Parkinson's disease, and brain tumours. The etiology of late-onset schizophrenia is not well understood. Neuroleptic drugs are the treatment of choice for schizophrenics of all ages. Older patients are at a greater risk for dangerous side-effects, particularly tardive dyskinesia.

XII. Delirium Although this condition can occur at any age, it is most common in older persons. They can suffer from various conditions that precipitate delirium. Delirium is characterized by affective or cognitive confusion. If untreated, delirium leads to rapid deterioration and death, and even with accurate diagnosis mortality rate is nearly 40 percent. Although the cause is unknown, known risk factors include a wide variety of metabolic, infectious, and/or structural origins.

Identifying the underlying condition leading to delirium is crucial in devising treatment.

XIII. Dementia Dementia is the most common mental disorder in older adults. We now know that dementia is not simply the result of the normal aging process. Dementia is a pathology which, although relatively common in older adults, is not universally present. Pseudo-dementia can be caused by depression, nutritional deficiency and thyroid disorder, and is reversible. The two most common types of dementia are: Alzheimer’s disease and vascular dementia. Mild Cognitive Impairment is a new concept that is receiving a great deal of attention from researchers and clinicians.

Mild Cognitive Impairment (MCI): MCI is thought to represent a transitional state between normal aging and dementia. MCI involves memory complaints, objective evidence of impairment to short-term memory, otherwise normal cognitive functioning, unimpaired social or occupational functioning, and no dementia. However, individuals with MCI are at a higher risk for developing dementia.

Alzheimer’s Disease (AD:. AD is the most common cause of dementia, and the among the most common disorders among the elderly. In the early stages, AD is associated with memory difficulties, problems with concentration, and unclear thinking. In the middle stage, symptoms

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become more severe, and in the late stage the ability to communicate is lost and memory impairment is profound. AD is distinguished by distinct changes in the brain. In many cases, however, definitive diagnosis is difficult to make because the same individual can suffer from multiple forms of dementia. AD is associated with excessive plagues and neurofibrillary tangles, both related to poor functioning of the brain. Also, substantial atrophy in the cortex is often detected in AD patients. Evidence support genetic involvement in the development of AD. In addition, numerous non-genetic environmental and medical risk factors have also been identified (e.g., hypothyroidism, cardiovascular problems, head injury, and exposure to metals such aluminum and mercury). Treatment options include drug therapies to control symptoms or slow down the progression of the disease. An additional approach to treatment has been to focus on secondary symptoms such as anxiety, agitation, and depression. Behaviour modification, caregiver counselling, and changes to the physical environment to improve safety for AD sufferers are all used to improve quality of life.

Vascular Dementi: The second most common cause of dementia is cerebrovascular damage.

Vascular dementia also increases with age and is more common among men than women.

Vascular dementia can be diagnosed with neuroimaging. Evidence of local lesions or infarctions is a common sign. Vascular events will cause a stepwise progression in the course of the disease.

Stroke, diabetes, obesity, and smoking are among the risk factors for vascular dementia. The most effective treatment is managing the risk factors with lifestyle changes as well as medication.

Other Forms of Dementia: There other types of dementia that are not uncommon: Lewy body dementia and frontotemporal dementia. Parkinson’s disease patients have filaments of protein with dense core in their brain know as Lewy bodies. Key symptoms in Lewy body dementia are variation in alertness, recurrent well-formed hallucinations, and spontaneous features of Parkinsonism, including slowed body movements, muscle rigidity, resting tremor, and postural instability. Frontotemporal dementia is a term describing a heterogeneous group of disorders including Pick’s disease that affect the frontal and temporal lobes of the brain. Symptoms include marked personality changes and lapses in judgment.

Caregiver Stress: It is important to recognize the impact that dementia has on family members, friends, and professional caregivers. Research indicates that caregivers often suffer from stress, anxiety, depression, and have a high risk of health problems. Fortunately, multi-component programs aimed at reducing caregiver stress are effective.

XIV. Focus Boxes • Older adults are underrepresented as users of mental health services. It has been suggested that older people's mental health needs are underserved because of .

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client barriers, therapist barriers, and systemic barriers. Unfortunately, older clients are not likely to be better served by the next generation of therapists. Even now research indicates that students training as therapist underestimate the benefit of treatment for older adults.

•

Baycrest Centre for Geriatric Care is an academic health sciences centre affiliated with the University of Toronto. The centre is focused on improving quality of life for the elderly by integrating research, clinical care, and education. The Baycrest provides inpatient, outpatient, and day programs for more thatn 3000 older persons every day.

•

Neurosurgeons at Toronto Western Hospital are using MRI guided focused ultrasound in an experimental technique to treat the movement disorder known as essential tremor. Essential tremor can strike at any age, but is most common and most severe in older adults. Dr. Kullervo Hnynen of Sunnybrook Research Institute in Toronto developed an ultrasound device that is able to pass through the skull and destroy very small areas of the brain that are involved in the movement disorder known as essential tremor. 30% of patients with essential tremor do not respond to drug treatment, and surgical treatments are invasive and risky. In severe cases, the tremors can interfere with activities of daily life such as eating, driving, and writing. Five patients have been treated to this date, and results so far are very promising, with patients experiencing improvements in the range of 80-90%. One day this treatment may be used to treat other disorders such as Parkinson’s disease or perhaps even brain tumors. http://www.fusfoundation.org/Essential-Tremor/essential-tremor http://news.nationalpost.com/2012/12/18/tremors/

XV. Key points 1. It is a widely held belief that mental disorders are more common in older than in younger adults, but the data suggest that the opposite is the case with two notable exceptions - sleep disorders and dementia.

2. Theoretical approaches to mental disorders do not offer specific insights into these disorders in older people. Similarly, theoretical approaches to aging developed by gerontologists are of limited use when it comes to psychopathology, because they focus on successful aging and normal age changes.

3. Mood disorders are highly treatable and treatment is just as effective for older as it is for younger adults.

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4. Sleep disorders become more common as people age. Normal age-related changes in sleep greater difficulty falling asleep, less time spent in deeper sleep - increase the likelihood of sleep disorders.

5. Anxiety disorders are less prevalent in older than in younger adults, but they represent a substantial proportion of the mental disorders experienced by the older segment of the population.

6. Psychotic disorders are less common in older than in younger adults.

7. Alzheimer’s Disease is the most common cause of dementia, although dementia is also commonly associated with cerebrovasuclar disease. Frontotemporal dementia and Lewy body dementia are also involved in degeneration of cognitive and social functioning.

XVI. Key Terms baby boomers (p. 415) paradox of aging (p. 417) period effect (p. 418) cohorot effect (p. 418) gerontologists (p. 418) normal aging (p. 418) polypharmacy (p. 420) drug interactions (p. 425) primary insomnia (p. 427) restless legs syndrome (RLS) (p. 428) sleep apnea (p.428) late-onset schizophrenia (p. 430) dementia (p. 432) pseudo-dementia (p. 433) mild cognitive impairment (MCI) (p. 433) Alzheimer's disease (AD) (p. 434) brain lesion (p. 436) vascular dementia (p. 436) Lewy body dementia (p. 437) frontotemporal demential (FTD) (p. 437) XVII. Lecture Ideas/Activities 1.

Difficulty diagnosing Alzheimer's disease.

Because there is no clear-cut definitive test for Alzheimer's disease, the diagnosis is properly

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given after various causes of dementia have been eliminated. Thus, diagnosticians try to rule out other medical conditions that give rise to similar symptoms, as well as abnormal behavior patterns that might account for impaired thinking and memory loss. A confirmatory diagnosis of Alzheimer's disease can be made only upon a biopsy or autopsy. Yet, a biopsy, or inspection of brain tissue, is rarely performed because of the risk of hemorrhaging or infection; and an autopsy comes too late to be helpful to the patient. However, studies of autopsies are suggestive. Dr. Isadore Rosenfeld, in Modern Prevention (Bantam Books, 1986), contends that studies of autopsies show that about half the patients believed to have had Alzheimer's while they were alive are found to have some other condition(s) that would account for their symptoms. Bu,t since Alzheimer's disease is considered neither treatable nor reversible, it's all the more important that people suspected of having this disease be carefully evaluated for other possibilities that mimic Alzheimer's but, in fact, are more treatable.

2.

Grandparenting programs.

Many communities have begun "grandparenting" programs in which children from a local school or preschool "adopt" an elderly person from a local nursing home or retirement center and visit him or her regularly. These programs have often proved beneficial to both children and elderly persons alike. Ask students if they are aware of or have ever been involved in one of these programs. What do they think of the usefulness of programs such as this? Would they want their children involved in this type of program?

3.

Geriatric assessment.

Obtain a copy of the Mini Mental Status Exam adapted from Folstein, M.F., Folstein, S.E. & McHugh, P.R. (1975) “Mini-Mental State: A practical method for grading the cognitive state of patients for the clinician.” Journal of Psychiatric Research, 12, 89-198. Give the exam to the class as an exercise in what clinicians look for in cognitive assessment. Explain that although many of the questions seem painfully easy, people with dementia have great difficulty in accurately completing the orientation items.

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CHAPTER 17 Therapies I. Chapter Summary II. Case Studies A. Description of therapy for a depressed teenage girl III. Biological Treatments A. Electroconvulsive Therapy B. Psychopharmacology IV. Psychotherapy: A Definition V. Theoretical Orientations A. Psychodynamic Approaches B. Humanistic-Experiential Approaches C. Cognitive-Behavioural Approaches D. Eclectic and Integrative Approaches VI. Psychotherapy: Treatment Modalities A. Individual Therapy B. Couples Therapy C. Family Therapy D. Group Therapy VII. The Context of Psychotherapy A. Who Provides Psychotherapy?

B. Who Seeks Psychotherapy?

C. The Duration of Treatment VIII. Evaluating the Effects of Psychotherapy A. Historical Context B. Meta-analysis C. A Brief Review of Meta-analytic Evidence D. Effects of Psychotherapy for Specific Disorders E. Couple Distress F. Generalizing to Clinical Settings IX. Evidence-Based Practice X. Focus Boxes XI. Key Points XII. Key Terms XIII. Lecture Ideas/Activities A. Psychodynamic vs. learning approaches B. Length of treatment and client improvement

C. The therapeutic relationship

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D. Psychotherapy: Alternative views E. Which treatment?

I. Chapter Summary The most common biological treatments for mental disorders are electroconvulsive therapy (ECT) and psychopharmacology (drug therapy). Generally, ECT is used in the treatment of depression when nothing else works, while drugs have been used to treat mood disorders, schizophrenia, attention deficit/hyperactivity disorder, and anxiety disorders.

Psychotherapeutic interventions are from various orientations (humanistic-experiential, cognitive-behavioural, psychodynamic, eclectic and integrative) and various modalities (individual, couples, family, group). Psychotherapeutic interventions can be offered by various mental health professionals, whereas biological treatments can only be administered by physicians. Although there is much debate surrounding the efficacy of various approaches, evidence indicates that effective treatments exist for many Axis I disorders.

II. Case Studies • Stephanie’s mother felt her daughter was depressed since starting high school. Stephanie was moody, cried easily, was not getting along with her family, listened to music about despair and destruction, had scratch marks on her arms, and had written about death in her diary.

Stephanie began seeing a psychologist, and she admitted she was dissatisfied with her life and felt irritable and moody. Stephanie developed a safety plan with her therapist, learned problem-solving skills, and planned enjoyable activities. She began to identify stressors, so as to prevent episodes of depression.

III. Biological Treatments The first treatments for psychological disorders were biological. Practices such as bleeding and the use of physical strategies to deal with disturbed behaviour were common in past centuries.

Electroconvulsive Therapy Electroconvulsive therapy (ECT) was first used in the 1930s to treat schizophrenia. With the development of antipsychotic medication, ECT was no longer used for schizophrenia.

However, it is still used to treat severe depression that has not responded to other treatments.

Previously, ECT resulted in severe side effects. Recently, however, adverse effects are minimized. There is little research on the long-term effects of ECT, although short-term studies suggest it can be effective in treating severe depression.

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Psychopharmacology Psychoactive agents are drugs that affect the individual's psychological functioning. In medicine, the attempt is made to understand the process by which a disorder develops and to identify an agent that will change that process. This is difficult to do for psychological disorders.

Nonetheless, various medications have been shown to have beneficial effects for the treatment of psychological disorders.

Antipsychotics Antipsychotic medications, also known as neuroleptics or major tranquillizers, were first developed in the 1950s and are used to treat psychotic disorders such as schizophrenia.

Although these drugs have been effective in reducing psychotic symptoms resulting in the deinstitutionalization of many patients, their use is accompanied by risk of major side-effects known as extrapyramidal effects (e.g., tardive dyskinesia). Because schizophrenia is a chronic disorder, long-term adherence to medication is required. Newly developed antipsychotic drugs, such as olanzapine, show fewer extrapyramidal effects.

Anxiolytics Anxiolytics alleviate symptoms of anxiety and muscle tension by reducing activity in the sympathetic nervous system. Barbiturates were the first class of drugs widely used for the treatment of anxiety, although tolerance develops and large doses are highly toxic.

Benzodiazepines, another class of anxiolytics, are effective in treating panic disorder, generalized anxiety disorder, and social phobia. Unfortunately, benzodiazepines are also addictive.

Antidepressants Drugs used to treat depression fall into three classes: monoamine inhibitors (MAOIs), tricyclics (TCAs), and the selective serotonin reuptake inhibitors (SSRIs). Side effects include dietary restrictions for those on MAOIs, effects such as dry mouth and blurred vision for tricyclics, and less adverse effects (e.g., nausea, headache) for SSRIs. Improvement is typically evident by 1 to 2 weeks, with optimal response by the 3rd or 4th week. Antidepressants but may not, however, be effective for all patients.

Mood Stabilizers

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Lithium has long been used in the treatment of bipolar disorder. Side effects include nausea, dizziness, and weight gain. Physicians must carefully monitor the levels of lithium, as low doses are ineffective and high levels are toxic.

Stimulants Stimulants, such as Ritalin, are commonly used to treat children with attention deficit/hyperactivity disorder. Research has found a 70% response rate, with common side effects including appetite suppression and sleep disturbance.

Limits On Efficacy Several classes of drugs have been shown to be effective in reducing psychological symptoms, although no class of drugs is effective for all individuals with a particular disorder.

Combining medication with concomitant psychotherapy may be most effective in preventing relapse or chronic disorder.

IV. Psychotherapy: A Definition Psychotherapy is best defined as a process in which a professionally trained therapist systematically uses techniques derived from psychological principles to relieve psychological distress or facilitate growth. Psychotherapy may be practiced by professionals from many disciplines.

V. Theoretical Orientations The main types of psychotherapy are psychodynamic, cognitive-behavioural, humanisticexperiential, and eclectic or integrative.

Psychodynamic approaches Freud developed psychodynamic theory -- the notion that psychological problems have their roots in early childhood and in unconscious conflicts. The goal of Freudian psychoanalysis is to help patients understand the unconscious factors that control their behaviour. Classic psychoanalysis is intensive and long in duration. Patients obtain insight into their problems and learn how the past continues to affect them. The five basic techniques include free association, dream interpretation, interpretation, analysis of resistance, and analysis of transference. Many former followers of Freud modified his psychoanalytic approach,

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developing their own therapies. This family of therapies is referred to as psychoanalytic psychotherapy, psychoanalytically oriented psychotherapy, or psychodynamic therapy.

Some examples of psychodynamic therapies include brief psychodynamic psychotherapy, ego analysis, Adler's individual psychology, interpersonal psychodynamic therapy, and time-limited dynamic psychotherapy. Ego analysts use Freudian techniques to explore the ego rather than the id and help clients understand their reliance on defence mechanisms for coping with conflicts.

Harry Stack Sullivan developed interpersonal psychodynamic psychotherapy and believed that mental disorders resulted from maladaptive early interactions between child and parent.

Time-limited dynamic therapy (TLDP) is briefer and involves the client in face-to-face contact with the therapist who helps identify patterns of interactions with others that strengthen unhelpful thoughts about self and others. This form of therapy stresses the importance of developing a therapeutic alliance, as it is a recognized predictor of therapeutic outcome.

Humanistic-Experiential Approaches Humanistic and experiential approaches focus on the person's current experience, emphasizing free will and encouraging the client to take responsibility for personal choice. Client-centred therapy, developed by Carl Rogers, emphasizes the unconditional positive regard, empathy, and genuineness of the therapist. Clients are accepted and valued as unique individuals, not judged or diagnosed. Existential therapists also value the individual as unique, and are concerned with making the client aware of his or her potential for growth and making choices. Existential therapy is concerned with human existence and the lack of meaning in a person's life. Gestalt therapy was developed by Frederich Perls and emphasized the idea that distortions exist in an individual's awareness of his or her genuine feelings and these distortions are responsible for impairments in personal growth. Techniques include the empty-chair technique and dream interpretation. A recent development is emotion-focused therapy, in which the client enters into an empathic relationship with a therapist who is directive and responsive to his or her experience.

Cognitive-Behavioural Approaches The term behaviour therapy was first used in the 1950s to describe an operant conditioning treatment for psychotic patients. The core assumptions of the behaviour therapy approach are that problem behaviours are learned behaviours and that faulty learning can be reversed.

Systematic use of reinforcement to encourage and maintain effective behaviour works well in places where the therapist has control over the client (e.g., schools, institutions). Response shaping is used to shape behaviour in gradual steps toward the goal of learning new skills.

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Behavioural activation is used in the treatment of depression to help patients engage in more activity and experience positive reinforcement.

Exposure therapy, based on principles of extinction, entails gradually exposing the client to a series of anxiety-provoking stimuli. Systematic desensitization involves exposure to a hierarchy of anxiety-provoking stimuli while in a state of relaxation. Assertiveness training is used to develop assertive interpersonal skills. Other cognitive-behavioural approaches include teaching problem-solving skills, self-instructional training, and cognitive restructuring.

Eclectic and Integrative Approaches There are commonalities and overlap between different forms of therapy. Jerome Frank described similarities in the ingredients of methods of healing. These three ingredients include (1) hope, (2) an alternative explanation for a problem, and (3) that the client is expected to think, feel, or act in a different way. Frank’s analysis led to attempts to draw upon selected aspects of various dominant schools of therapy. Consistent with this approach, many clinicians try to combine or integrate the best elements of different schools of therapy

VI. Psychotherapy: Treatment Modalities Individual Therapy Early therapy is conducted in an individual format, with one client and one therapist.

Couple’s Therapy The focus is on the relationship, and the goal is to enhance each partner's satisfaction with the relationship. The best-known approach is based on behavioural and social learning principles, and involves enhancing communication and conflict-resolution skills, as well as helping partners develop realistic expectations about the relationship. A recent experiential approach -emotionally-focused couples therapy -- is also prominent. This approach seeks to modify distressed couples’ emotional responses by fostering a secure emotional bond.

Family Therapy The family is considered to be an important part of the solution to problems. A common goal is to identify interactions between family members that may contribute to problems. Family approaches involve reframing the problem, and family members are required to carry out various tasks, in order to enhance communication and negotiation within the family.

Group Therapy

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Many cognitive-behavioural treatments can be offered in group format. Benefits include the opportunity to derive feedback from the other people in the group and the awareness that others share similar experiences or feelings (universality), which can reduce feelings of stigma.

VII. The Context of Psychotherapy Who Provides Psychotherapy?

Clinical psychologists are among the main providers of psychotherapy, and the majority espouse an eclectic style. Clients should raise issues about the therapist’s training, experience, therapeutic methods, confidentiality, and also about financial considerations.

Who Seeks Psychotherapy?

People seek therapy for various reasons, including significant emotional distress, advice and assistance in coping with demands of social roles, aid in coping with trauma or loss, questions related to identity, values, and self-knowledge, and so on. Some groups are more likely to seek therapy, including females, those with university education, and young to middle-aged adults.

Duration of Treatment The majority of people attend fewer than 10 sessions. Many psychotherapies are short-term (20 or fewer sessions).

VIII. Evaluating the Effects of Psychotherapy Historical Context Treatment providers must demonstrate that the services they offer are effective in treating the problem. The history of research evaluating the effectiveness of psychotherapy is brief. Little evidence was available prior to 1960s, although more recently, empirical studies have been conducted on all forms of therapy. Eysenck's review argued that there was no evidence that psychotherapy had any demonstrable effect, which prompted a strong reaction and more treatment-outcome research. Treatment efficacy refers to evidence of treatment effects when delivered in the context of a controlled study. Treatment effectiveness refers to evidence of effects of treatment in a “real-world” context.

Meta-analysis Meta-analysis is a method of quantitatively reviewing previous research. The results of prior research are combined by calculating the effect size -- the difference between the means of the experimental group and control group, divided by the standard deviation of either the control

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group or the pooled sample of both groups. Statistical analysis is used to determine the pattern of findings, and the power of detecting an effect is enhanced due to the increased sample size offered by numerous studies.

A Brief Review of Meta-Analytic Evidence Meta-analyses conducted by Smith, Glass, & Miller (1980) revealed that overall psychotherapy is indeed effective, and that effectiveness appears not related to duration of therapy or therapists’ years of experience. Reviews have reported that all psychotherapies produce equivalent effects.

However, careful examination of comparative effectiveness is crucial, since some studies may be limited by methodological difficulties. There is more empirical evidence supporting the effectiveness of behavioural therapies; however, more research has been conducted assessing the effectiveness of this approach. Inconsistencies in findings imply that further research comparing the effectiveness of different therapies is necessary.

Effects of Psychotherapy for Specific Disorders There is extensive evidence that effective psychotherapeutic treatments exist for many Axis I disorders. Treatment for anxiety disorders typically involves exposure for phobias, and cognitive-behavioural treatment for panic disorder, obsessive-compulsive disorder, and generalized anxiety disorder. Family-based cognitive-behavioural interventions with children have been found effective in treating separation anxiety, overanxious disorder, and social phobia.

Cognitive-behavioural and interpersonal techniques are effective in treating depression.

Childhood disorders such as attention deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder have been treated with techniques focused on improving parenting skills. Effective psychological treatments also exist for sleep disorders. Treatment of Axis II disorders has not attracted much research attention. Linehan’s multicomponent cognitivebehavioural intervention for borderline personality disorder is one promising approach that has been well-investigated. The development of effective interventions must be a priority.

Couple Distress Behavioural marital therapy is the most researched method and appears effective. Recent investigations of emotionally focused marital therapy indicate its effectiveness in reducing marital conflict.

Generalizing to Clinical Settings

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The main limitation of the research on effective therapies is that all studies were conducted in a research context and the results may not generalize to actual clinical settings. There remains much we do not know about the effectiveness of psychotherapy in “real” settings.

IX. Evidence-Based Practice There is pressure from health care systems for basing health-care services on established scientific findings -- evidence-based practice. In 1993, the American Psychological Association's first Task Force on Promotion and Dissemination of Psychological Procedures set out criteria for empirically supported therapy, as well as those treatments which met the criteria. In addition, an empirically supported therapy relationships (ESR) task force found that therapeutic alliance, cohesion in group therapy, therapist empathy, and patient-therapist goal consensus and collaboration were all effective in influencing treatment outcome. Another important initiative with respect to evidence-based treatments is the development of clinical practice guidelines meant to be used as tools for clinical training and service delivery.

X. Focus Boxes • Many psychologists in the U.S. have advocated that psychologists be given privileges to prescribe medication. Arguments have been made for and against this position. At this

•

point the Canadian Psychological Association has not taken a stand on the issue of prescription privileges, although there is ongoing discussion of the issue. (p. 422) The majority of people who would benefit from therapy do not receive it. Therapy that is delivered on computers, over the internet, and on Smartphones has the potential to reach those who would otherwise go without therapy, and there is an accumulating body of evidence that indicates that these technological approaches are effective.

XI. Key Points 1. Common biological treatments include electroconvulsive therapy and psychopharmacological treatments 2. Various theoretical orientations exist in psychotherapy, including psychodynamic approaches, humanistic-experiential approaches, cognitive-behavioural approaches, and eclectic or integrative approaches.

3. Treatment modalities can involve individuals, couples, families, or groups.

4. Generally, clinical psychologists provide psychotherapy, although individuals from many disciplines may call themselves psychotherapists. Some individuals are more likely to seek

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therapy than others, particularly women, people with a university education, people who are middle-class. Duration of treatment tends to be relatively brief.

5. It is important that empirical evidence be provided for the efficacy of treatment.

6. Further research is required on the benefits of treatment, particularly the types of treatment and therapists best suited to different types of clients.

XII. Key Terms psychoactive agents (p. 342) extrapyramidal effects (p. 343) transference (p. 347) ego analysts (p. 348) interpersonal psychodynamic psychotherapy (p. 348) time-limited dynamic psychotherapy (TLDP) (p. 348) therapeutic alliance (p. 348) client-centred therapy (p. 348) emotion-focused therapy (p. 349) response shaping (p. 350) exposure therapy (p. 359) systematic desensitization (p. 350) problem-solving approach (p. 351) cognitive restructuring (p. 351) emotionally focused couples therapy (p. 352) reframing (p. 352) treatment efficacy (p. 354) treatment effectiveness (p. 354) meta-analysis (p.355) effect size (p. 360) evidence-based practice (p. 360) empirically supported therapy (p. 360) empirically supported therapy relationships (ESR) (p. 361) clinical practice guidelines (p. 362)

XIII. Lecture Ideas/Activities

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1.

Psychodynamic vs. learning approaches.

Psychodynamic and learning advocates have long argued about the efficacy of each other's therapeutic techniques. An issue is whether the behavioral "symptom" or the "underlying" cause should be treated. Consider the case of an autistic child with a pattern of repetitious, selfinjurious behavior. One could treat the behavioral symptom with operant conditioning techniques, but would that be sufficient to prevent a relapse of the behavior pattern, or some similar one, in the future? Or could it result in the substitution of a new, even more injurious behavior pattern for the original behavior that was eliminated? If there is an underlying cause and it is left untreated, might not a problem recur? If an underlying cause is identified and treated, how would this be done?

2.

Length of treatment and client improvement.

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

3.

The therapeutic relationship.

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

4.

Psychotherapy: Alternative views.

It can be provocative to discuss some of the writers who have taken shots at psychotherapy. You might ask students to find and report on some of these. Here are two that are interesting.

Psychoanalyst James Hillman argues that therapy causes people to look inward, thus ignoring worsening social and political conditions around them. Growth, a popular theme in many schools of therapy, is a fantasy that ignores the fact that the personality is relatively immune to change.

R. D. Rosen popularized the term "psychobabble" to denote the vague language, catchy terms,

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and cute phrases that are sometimes found in therapy jargon. Psychobabbling implies, says Rosen, that we can reach well-being immediately, just by asserting that we are no longer "uptight," or "hung up."

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

5.

Which treatment?

Come to class with several short case studies. A good source is the companion DSM-IV casebook. Ask students to pick from the various perspectives which treatment they would try first. You may want to make this a group activity; break into groups of four to six and assign each group a case for class presentation.

6. Trying out client-centred therapy.

When students see videos of therapist conducting client-centered therapy they are often highly critical, and claim that therapists are “parroting” back what the client says. After you have presented material on client-centered therapy and shown a video, have students work in pairs and practise skills such as reflection of feelings, paraphrasing, unconditional positive regard, refraining from giving advice or inserting their own feelings, etc. Afterwards have each person report on the experience in writing or to the class. Students will typically say that it is much more difficult to do this than they imagined.

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CHAPTER 18 Prevention and Mental Health Promotion in the Community I. Chapter Summary II. Case Studies: A. Difficulty treating postpartum depression B. Perry Preschool Project III. Community Psychology IV. Prevention and Mental Health: Some Definitions A. Primary, Secondary, and Tertiary Prevention B. Universal, Selective, and Indicated Prevention C. Mental Health Promotion V. Historical Perspective A. Pre-Germ Theory Era B. Public Health Approach C. Educational approach* VI. Resilience, Risk, and Protection A. Resilience, Risk, and Protective Factors B. Cumulative Risk C. Mechanisms of Risk and Protection D. Implications of Resilience, Risk, and Protection for Prevention VII. A Conceptual Framework for Prevention and Promotion A. The Contextual Field B. The Affirmation Field VIII. Research and Practice in Prevention and Promotion A. High-Risk (Selective) Prevention Programs B. Universal Prevention and Promotion Programs IX. Prevention and Promotion Policy in Canada A. The Federal Role B. The Provincial Role C. Return on Investment X. Future Directions for Prevention and Promotion

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XI. Focus Boxes XII. Key Points XIII. Key Terms XIV. Lecture Ideas/Activities A. Helping Communities

I. Chapter Summary Treatment and rehabilitation do not reduce the incidence of psychological disorders in a population. Thus, it has been suggested that promotion of mental health and prevention of disorders should be the focus. The direction of promotion/prevention programs has been provided by studying risk and protective factors, which operate at multiple levels. Although several effective promotion/prevention programs have been developed, there exist various barriers to their implementation, such as lack of funding, lack of emphasis in professional training, and the individualistic bias in Western culture.

II. Case Studies •

The birth of a baby is typically a happy event for most people. Some mothers, however, become depressed after giving birth, and experience a condition called postpartum depression. There are many forms of treatment for such women, but a study by Dennis (2003) show how difficult a condition postpartum depression can be treat effectively.

•

The children in slum neighbourhood in Michigan had difficulties when they entered school.

The Perry Preschool Project randomly assigned preschool children with a below average IQ to experimental and control groups. The experimental group had well-organized school activities and home visits from the teacher. After beginning school, the children showed more academic skills at first, but by grade 3 and 4 this increase had diminished. However, with follow-up, the children in the experimental group were more likely than those in the controls group to be employed, attending college, or receiving further training. Moreoever, the program was cost-effective.

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III. Community Psychology Community psychology has its roots in clinical psychology. Some clinical psychologists recognized that the prevalence of mental disorders outweighed the availability of professional help. Epidemiological studies show that the one-year prevalence rate of mental disorders for adults and the six-month prevalence rate for children is about 18% of the population. There could never be enough trained individuals to provide services for the large number of children and adults suffering from mental disorders. Moreover, no therapeutic approach is 100% effective; Community-based prevention may be a more effective method of reducing the rate of disorders.

Community psychology may be differentiated from clinical psychology on the basis of its emphasis on prevention, its application of an ecological perspective, its focus on people’s strengths and the promotion of wellness, its belief in the importance of informal social supports, and its orientation to social justice and change.

IV. Prevention and Mental Health Promotion: Some Definitions Primary, Secondary, and Tertiary Prevention Primary prevention (also called prevention) involves intervention that reduces the incidence of disorder, secondary prevention (also called early intervention) comprises treatment that reduces the duration of the disorder, and tertiary prevention (also called treatment or rehabilitation) covers rehabilitative activity that reduces the disability arising from the disorder.

Universal, Selective, and Indicated Prevention The typology of primary, secondary, and tertiary prevention has given way to a new typology of universal, selective, and indicated prevention. The universal approach is designed to include all individuals in a particular geographical area or particular setting. Selective prevention, also known as the high-risk approach, is based on the assumption that there are known risk factors for certain mental health problems, and prevention has the greatest effect in targeting individuals most exposed to these risk factors. Indicated prevention is similar to early intervention in that it involves programs designed to select individuals who show mild or earlydeveloping mental health problems.

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Mental Health Promotion Mental health promotion views mental health, or wellness, as the presence of optimal social, emotional, and cognitive functioning. Mental health promotion seeks to promote mental health before the problem occurs, focuses on populations and multiple dimensions, and it is an ongoing intervention. This approach de-emphasizes disorder and emphasizes protective factors toward the enhancement of mental health and wellness. Key pathways toward mental health promotion include attachment, competencies, social environments, empowerment, and resources to cope with stress.

V. Historical Perspective Pre-Germ Theory Era In the 18th century, it was believed that disease resulted from “miasmus,” or noxious odours, emanating from soil contaminated with waste products. The development of sanitation campaigns reduced the rates of disease. Nutritional diseases have been reduced without knowledge of the precise cause of the disease (e.g., British sailors learned to prevent scurvy by eating citrus fruits). This approach is useful for the mental health perspective, since etiology is complex and difficult to determine.

Public Health Approach The public health approach is based on epidemiology (descriptive, analytic, and experimental epidemiology). Public health researchers focus on three components: (1) characteristics of the person with the illness; (2) characteristics of the environment (i.e., stressors); (3) the agent (i.e., the manner in which the disease is transmitted to the host). The public health approach has been successful in reducing the incidence of many problems (e.g., general paresis). Many of the initial applications of the public health concept in the 1950s and 1960s were influenced by crisis theory which argued that when people are in a state of crisis they are very anxious, open to change, and oriented toward seeking help.

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Educational approach The educational approach is starting to generate more interest than it has in the past. Early childhood development (ECD) programs for preschool children improve outcome in the cognitive and academic realms. Long term effects include positive impacts on health, and are associated with reductions in crime.

VI. Resilience, Risk, and Protection Resilience, Risk, and Protective Factors The resilience approach focuses on the many risk and protective factors involved in the development of mental disorder. Resilience refers to the process of positive adaptation to significant adversity through the interaction of risk and protective factors. General risk factors include negative family circumstances, emotional difficulties, school problems, negative ecological context, constitutional handicaps, interpersonal problems, and skill development delays. The more risk factors present, the greater the vulnerability of the individual.

Protective factors help to offset risk factors. General protective factors include stable care from parents or other caregivers, problem-solving abilities, attractiveness to peers and adults, being and feeling competent, identification with competent role models, and aspirations and plans for the future.

The new mental health approach focuses on a stressful event or situation (a risk factor) that may affect the mental health of a population in various ways. It uses an ecological perspective that focuses on characteristics of the microsystem (family and social network) and the macrosystem (social norms, social class).

Cumulative Risk The effects of risk are cumulative: the more risk factors that are present, the more vulnerable a person becomes to developing a mental health problem. Research on cumulative risk has shown that the number of risk factors experienced by an individual often accounts for a greater proportion of the variation in outcomes than the sum of individual risk factors.

Mechanisms of Risk and Protection

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It is important to understand how these factors operate and how they interact, since they do not affect everyone the same way, nor do they have a direct impact on a person’s mental health. Four central mechanisms that help people cope with adversity and develop positive mental health include: (1) reducing risk impact; (2) interrupting unhealthy chain reactions stemming from stressful life events; (3) enhancing self-esteem and self-efficacy; and (4) creating opportunities for personal growth.

Implications of Resilience, Risk, and Protection for Prevention Prevention can be approached by reducing risk factors and by increasing protective factors. Elias’ (1987) equation views interventions to reduce the risk of mental health problems by emphasizing the need to change the social environment rather than the individual. Healthy environments should promote healthy development and prevent mental health problems.

VII. A Conceptual Framework for Prevention and Promotion The Contextual Field A contextual approach to well-being accounts for the role of both temporal and ecological variables. The ecological dimension covers the full range of interventions – from micro to macro levels. The temporal dimension ranges from tertiary or indicated prevention to universal or primary prevention. (Fig. 18.1, p, 447) The ecological dimension has led to programs based on an ecological perspective which considers multiple levels of analysis. The timing of the prevention, primary, secondary, or tertiary, is another important dimension of the conceptual framework of prevention and promotion.

The Affirmation Field To experience well-being, people must first experience affirmation, an acknowledgement of one’s strengths, voice, and choice, rather than a focus on one’s deficits and weaknesses. The affirmation field consists of two intersecting continua: the capability and participation dimensions. The former ranges from an exclusive focus on risk reduction and the prevention of deficits to an exclusive focus on the enhancement of protective factors and the promotion of strengths. The latter dimension ranges from expert-driven to community-driven participation in

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which professionals and community members collaborate to create the best prevention program model that fits the needs of particular communities. (Fig. 18.2, p. 449)

VIII. Research and Practice in Prevention and Promotion Prevention programs may be biological or psychological, and the majority of prevention programs work with children or youths and their families. Most prevention and mental health promotion programs, however, are primarily psychological or social in nature.

High-Risk (Selective) Prevention Programs The two major types of prevention programs are high-risk and universal. The high-risk approach is based on the assumption that there are known risk factors for certain mental health problems, and it is most effective to target individuals most exposed to these risk factors.

Selective high risk programs select participants on the basis of characteristics external to the individual (e.g., children whose parents have divorced, teenage mothers), while indicated high risk programs select participants on the basis of internal characteristics (e.g., low-birth-weight babies, rejected children, etc.).

The universal approach is designed to include all individuals in a particular geographical area or setting. Some programs focus narrowly on a small number of influences on the behaviour or a tightly defined number of outcomes. Comprehensive programs address a broad range of risk and protective factors, as well as a broad range of outcomes. Early programs were often small, poorly funded, and rarely evaluated. In 1982, the American Psychological Association established a task force to study these programs. The report profiled 14 soundly researched programs that had been effective in preventing different problems.

Most programs being implemented today are high-risk programs. The Perry Preschool Project is one example, providing enriched preschool experiences for high-risk children. Another example, the Head Start program, was established in the United States in 1966. David Olds’ Prenatal Early Infancy Project was established to prevent child abuse and neglect. Its positive effects were concentrated on groups who were at highest risk, mainly poor, unmarried teenaged mothers and their children.

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Universal Prevention and Promotion Programs The Better Beginnings, Better Futures project is a good example of a universal prevention program. The project emphasizes the importance of combining community development activities with family and child development. Similar American programs are the Comprehensive Child Development Program, and the Early Head Start Project.

The past two decades have seen tremendous growth in the research and practice bases of mental health promotion/prevention. Recently, two meta-analyses have supported the effectiveness of prevention programs. Prevention programs may be applied in a wide variety of settings for a wide range of problems.

IX. Prevention and Promotion Policy in Canada The Federal Role Canada has been a leader in promoting the concept of prevention. Federal documents have been published on prevention and promotion, but funding for the development of these programs is still required.

The Provincial Role A survey of the provinces showed a good deal of support for prevention, and many interesting projects. However, health funding had not been reallocated from treatment to prevention, and remains low in all provinces and territories.

Return On Investment It is now possible to compute the return on investment (ROI) of various programs and policies. Research indicates that the economic returns for a variety of early intervention programs with families and children at risk range from $1.50 to $17.00 for every dollar invested.

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X. Future Directions for Prevention and Promotion While the outcomes of many prevention programs have been well documented, their planning, implementation, and dissemination have not received as much attention. Promotion and prevention have historically received little attention in professional mental health training programs. Innovations are not disseminated quickly because few professionals are aware of them. As well, while many services agree that prevention is important, most local agencies have few or no resources to allocate for prevention.

Canada is an individualistic country, and mental health problems and their solutions are usually viewed as individual rather than community-wide. As well, there exists societal acceptance of wide differences among people’s life circumstances as natural and acceptable.

Belief in a just world leads to the assumption that those who have hard luck deserve it. People who have experienced oppressive conditions often do not believe that anything can be done to change the situation. A final obstacle is our orientation to the “quick fix” for crisis management, rather than long-term planning.

XI. Focus Boxes ▪

The Better Beginnings, Better Futures project is a 25-year longitudinal, universal prevention research project focusing on children from birth to eight years of age and their families. The three major goals are prevention, promotion, and community development.

Funding was provided to eight Ontario communities to develop a comprehensive program which involved parents and communities. The elements included home visiting, classroom enrichment, child care enrichment, and child-, parent-, and communityfocused programs. Evaluation of this program involves extensive home interviews with parents, direct assessment of the children’s physical, cognitive, social, and mental development, descriptions of the program activities and costs, and evaluations of the program. Studies of the short-term effects are underway and suggest positive effects.

▪

Programs that involve adults lecturing to students about the harmful effects of substance do not decrease the incidence of substance abuse in youths. On the other hand, programs that use an interactive format involving role playing, including practising drug refusal skills, goal setting, and stress reduction as in the Life Skills Training program are associated with a decreased incidence of substance abuse.

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▪

There are 100 Ontario Early Years Centres located throughout Ontario. These centres offer programs and support to children, parents, grandparents, and other caregivers.

Programs for adults include parenting courses, training in infant massage, nutrition programs, childhood education and information, support groups for parents, groups to help ESL caregivers to practice their English, and even a quiet place to read and do online research. Programs for children include a kindergarten readiness program, drop in playgroups for infants, toddlers, and preschoolers, and a group involving physical movement, songs and games for children ages 2.5-4. http://www.cfeyc.ca/forkids22.htm

XII. Key Points 1. Community psychology emphasizes promotion/prevention in order to reduce the prevalence of mental disorders.

2. Three types of preventive activity are primary prevention (prevention), secondary prevention (early intervention), and tertiary prevention (treatment or rehabilitation).

3. Mental health promotion views wellness as the presence of optimal social, emotional, and cognitive functioning.

4. Two interrelated approaches to prevention are currently popular: one focuses on risk reduction and the other on promotion of mental health.

5. Promotion/Prevention programs can be high-risk or universal, and narrowly focused or comprehensive.

6. Barriers to promotion/prevention include academic/scientific arguments, lack of knowledge among professionals, and the North American emphasis on individualism.

7. Critiques of promotion/prevention include lack of a focus on societal causes to problems, emphasis on expert status rather than the expertise of the community, and lack of documentation on the planning, implementation, and dissemination of the programs.

XIII. Key Terms community psychology (p. 466) prevention (p. 467) primary prevention (p. 467) secondary prevention (p. 467)

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tertiary prevention (p. 467) universal approach (p. 467) selective prevention (p. 467) indicated prevention (p. 467) mental health promotion (p. 467) mental health (p. 467) public health approach (p. 469) resilience (p. 470) risk factors (p. 470) protective factors (p. 470) microsystem (p. 470) macrosystem (p. 470) cumulative risk (p. 470) ecological perspective (p. 472) high-risk programs (p. 475) return on investment (ROI) (p. 480) implementation (p. 481) dissemination (p. 481) social justice (p. 482)

XIV. Lecture Ideas/Activites 1.

Helping Communities What are the responsibilities of community members to help others in the surrounding area?

Much of the debate over third-party payment of insurance, social program funding, volunteerism, and private underwriting of social services turns on people’s opinions about this question.

Handout 18.1 guides students through some of the major issues surrounding this question.

Handout 18.1

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Helping Communities

1. What are the responsibilities of community members to help others in the surrounding area? Should neighbors be aware of the mental health of other citizens?

2. What can be done by individuals to enhance the mental health of their neighbours?

3. Describe possible community involvement that would improve mental health conditions.

4. Should individuals with mental disorder live in the community? What arrangements are necessary?

5. Ask a neighbour if he or she feels some responsibility for the well-being of people he or she doesn’t know personally.

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CHAPTER 19 Mental Disorder and the Law

I. Chapter summary II. Case Study A. The Shutzman case III. Mental Disorder in Canadian Law IV. The Canadian Legal System A. Constitutional Law B. Statutory Law C. Common Law V. A Closer look at Civil Mental Health Law A. Involuntary Hospitalization B. Involuntary Treatment C. Reviews and Appeals D. Some Examples of Research on Mental Health Law in Canada VI. A Closer Look at Offenders Who Have Mental Disorders A. Criminal Responsibility: Mental State at the Time of the Offence B. Competency to Make Legal Decisions: Mental State at the Time of Trial C. Some Examples of Research on Mentally Disordered Offenders in Canada VII. Psychology in the Legal System VIII. Psychological Ethics A. General Ethical Principles of Psychology B. Specialized Ethical Guidelines IX. The Status of Psychology in the Legal System X. Focus box: Aboriginals in the legal system XI. Key Points XII. Dr. Christopher Webster, Researcher XIII. Key Terms XIV. Lecture Ideas/Activities A. The fundamental attribution error B. The insanity plea

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I. Chapter Summary People who suffer from mental disorders are often in contact with the law. The criminal code includes provisions for deciding whether people who committed offences while suffering from mental disorders should be held criminally accountable.

Practicing psychologists must abide by rules and meet the standards and expectations of their profession. Although psychologists have been involved in the legal system as professionals, the role of psychologists is limited by law, and medical practitioners play a more dominant role.

However, recent court decisions may expand the role of psychologists.

II. Case Study Scott Schutzman was an extremely bright man with a psychotic disorder. He considered himself to be the “son of stars”, and because of this, changed his name to “Starson.” His behaviour was odd and disturbing, and he made death threats and stalked Joan Rivers. Mr. Schutzman was hospitalized and arrested repeatedly. His symptoms improved with medication, but he felt that the drugs impaired his creativity and he turned down treatment. On charges of uttering death threats he was found not criminally responsible on account of a mental disorder (NCRMD) and detained in a secure facility, where he refused treatment. His psychiatrists received approval to treat him against his wishes from the Ontario Consent and Capacity Board (OCCB). Mr. Schutzman appealed the decision and won his appeal. Without medication his condition worsened until he refused to eat. His psychiatrists went before the OCCB again, and received permission to medicate Mr. Schutzman against his wishes. With treatment his condition improved.

III. Mental Disorder in Canadian Law Canadian law assumes that people can and do think and act in a deliberate and reasoned manner.

Canadian law recognizes that in some cases mental disorder may cause cognitive or volitional impairment. The law typically defines mental disorder as impairment of psychological

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functioning that is internal, stable, and involuntary, rather than situational or contextual. This is a much narrower definition than recognized by mental health professionals and the DSM-IV-TR.

IV. The Canadian Legal System Constitutional Law Constitutional law was strongly influenced by ties to the United Kingdom. The charter of Rights and Freedoms (Constitution Act, 1982) sets out fundamental freedoms of citizens, and those cannot be denied because of a mental disorder. Thus infringement of rights requires demonstration of functional link – sometimes referred in law as causal nexus – between a person’s mental disorder and legally relevant impairment. If people are found incompetent to make decisions due to their mental disorder, their rights can be restricted. The nature of the restrictions must be justified and be in accordance with the principles of fundamental justice.

Statutory Law Statutes are codes of law adopted by a government and supported by a monarch. These statutes govern almost every aspects of daily life. Mental disorders plays a role in two types of statutes: Civil mental health law (which varies across provinces and territories), and criminal law (which does not vary). These laws attempt to strike a balance between the right of people suffering from mental disorder and the responsibility of protecting citizens from harm. The criminal code includes provisions for dealing with people who may suffer from mental disorder that renders them not criminally responsible.

Common Law Common law is also referred to as case law, and includes both constitutional and statutory laws.

There are many levels of court that make decision based on interpretations of existing law.

Decisions made at lower level courts could be reviewed, with the Supreme Court of Canada being the highest court. Quebec differs from the rest of Canada in its reliance on civil code instead of common law. Quebec’s civil code is based on Napoleonic code and reflects the province’s ties to France.

V. A Closer Look at Civil Mental Health Law

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Involuntary Hospitalization Involuntary hospitalization, also known as civil commitment, is done only when meeting the following criteria: 1. People must suffer from a severe and treatable mental disorder 2. People must be either unwilling or incapable of consenting to hospitalization on a voluntary basis 3. People must be at risk of causing harm to self or others due to mental disorder Usually the process of voluntary commitment starts with emergency or short-term detention, and often ordered by the physician evaluating the patient. Release occurs when improvements are observed due to the passage of time or because of treatment.

Involuntary Treatment When a person is deemed incapable of making a decision for themselves, someone usually takes this responsibility for them and this person is referred to as a temporary substitute decision maker. These appointed decision makers must act in accordance with the best interests principle. That is, to make decisions which would best serve the interest of the patient. The second principle is known as capable wishes principle, which holds that the patient’s wishes should be given the greatest weight, especially when these wishes were expressed previously.

Involuntary treatment for people who are not hospitalized is referred to as compulsory treatment orders.

Reviews and Appeals Panels will review evidence from patients and from the hospital to which the person was committed. Patients do not have the right to release while their case is under review. Similar procedures apply to involuntary treatments, except treatment cannot begin until the dispute has been resolved.

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Some Examples of Research on Mental Health Law in Canada Who is involuntarily hospitalized? It appears that 15-20% of all hospitalizations for mental disorder in Canada are involuntary. Only about 14% of these cases request a review.

How can violence risk be evaluated? Violence risk is a key element in the decision making with respect to involuntary hospitalization. There are two basic approaches to violence risk assessment: discretionary and nondiscretionary. The discretionary approach is more informal or intuitive and uses clinical judgment, whereas the nondiscretionary approach is referred to as actuarial and uses strict rules of assessment producing probability estimates of committing violence.

VI. A Closer Look at Offenders Who Have Mental Disorders Criminal Responsibility: Mental State at the Time of the Offense Prohibited acts, actus reus, committed with bad intentions mens rea are punishable under Canadian law. Self-defense and the insanity defense are considered an acceptable explanation for an otherwise criminal offense, such as killing someone. People found not criminally responsible on account of mental disorder or NCRMD are acquitted.

Competency to Make Legal Decisions: Mental State at the Time of Trial According to fundamental justice people have the right to be present during their trial, to confront their accusers, and to make full answer to the accusation against them. In Canadian law people who are unable to participate actively and effectively are referred to as unfit to stand trial (UST).

Some Examples of Research on Mentally Disordered Offenders in Canada How are fitness evaluations conducted? Courts rarely disagree with the opinion of mental health professional regarding the individual’s mental health status. Research in Canada and the United States suggests that such opinions are usually based on the severity of the mental disorder.

Research has greatly contributed to the fields of forensic psychology and psychiatry. The development of revised Fitness Interview Test (FIT-R) greatly aided competency evaluations.

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Who is referred for evaluation of fitness or criminal responsibility? Fifteen percent of defendants are referred for a fitness evaluation, of those more than half are NCRMD. Defendants who are found NCRMD or UST are given indefinite commitment to secure hospitals.

VII. Aboriginals in the criminal justice system In Canada, aboriginal people comprise about 3% of the population, yet aboriginal men and women comprise approximately 20% of inmates in the federal system. Generational effects of colonization and residential schools, systemic discrimination, the high prevalence of substance abuse, and ongoing trauma are believed to be behind the disproportionately high levels of aboriginal incarceration. In 1996, the federal government passed an amendment to the Criminal code that requests that judges consider alternatives to prison when passing sentences. In all cases, whether the person is aboriginal or note, any mitigating circumstances of the individual’s background along with the nature of the crime are to be considered when sentencing takes place.

The Gladue report originated from this reform. When an aboriginal person is up for sentencing, a report (the Gladue report) is to be prepared that outlines the aboriginal individual’s unique circumstances. Judges are encouraged to consider the Gladue report in determining sentences, and to invoke restorative justice rather than prison sentences when possible. Restorative justice sentencing takes into account aboriginal views of justice, and encourages the integration and healing of the individual within the community. The recidivism rate is 8% lower for adults who are involved in a restorative justice program compared to those who receive regular sentences.

Restorative justice sentencing is not always possible, however, because judges are required to adhere to minimum sentencing requirements.

Sources: http://www.justiceeducation.ca/research/aboriginal-sentencing/gladue-effect/in-depth http://webcache.googleusercontent.com/search?q=cache:http://www.ocibec.gc.ca/rpt/annrpt/annrpt20052006info-eng.aspx http://www.publicsafety.gc.ca/res/cor/sum/cprs200301_1-eng.aspx VII. Psychology and the Legal System

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There are two types of psychologist who may be involved with the legal system “accidental visitors” and specialists or forensic psychologists. The field of forensic psychology is in a period of tremendous growth. Forensic psychologists may conduct custody evaluations, design programs to train correctional officers, study and better understand children as witnesses, evaluate the practices of large organization to determine evidence indicating discrimination, and provide expert advice in court concerning the assessment and management of violence risk in forensic psychiatric patients.

VIII. Psychological Ethics General Ethical Principles of Psychology Ethical codes are a fundamental part of the profession for psychologists. These codes are primarily descriptive, but they are also aspirational in the sense that they also describe preferred values. Professional standards put forward expectations regarding the day-to-day practice of psychologists. The principles of the code of ethics are, in many respects, a restatement of more general ethical principles, such as the principle of autonomy, principle of beneficence, the principle of fidelity, and the principle of justice.

Specialized Ethical Guidelines Two major organizations, the American Academy of Forensic Psychology and the American Psychology-Law Society collaborate to develop specialty guidelines for forensic psychologists.

These guidelines have a dual nature: they are a blend of professional and ethical principles.

IX. The Status of Psychology in the Legal System Psychologists are often asked to give evidence as professionals or as scientists. Though the criminal code excludes psychologists and specifies that assessments be conducted by medical practitioners, psychologists are often involved in evaluations related to involuntary hospitalization, fitness, or criminal responsibility.

X. Key Points 1. The Canadian legal system defines mental disorder as any impairment of psychological functioning that is internal, stable, and involuntary in nature.

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2. Courts must determine whether or not a person who is party to the proceedings has a mental disorder, according to how mental disorder is defined by the law.

3. In Canada, there are three primary sources of law: constitutional, statutory, and common law (and civil law in Quebec).

4. Civil commitment is often based on the patient’s risk of harm to self and others.

5. People suffering from mental disorders are overrepresented among those having contact with the law.

6. The criminal code has procedures governing the evaluation of criminal responsibility and fitness to stand trial.

7. Although psychologists often give evidence before courts, their role is restricted by law, however, an expansion of their role legal proceedings is expected.

XII.

Key Terms

constitutional law (p. 460) statutory law (p. 460) common law (p. 460) parens patriae (p. 461) civil code (p. 462) civil commitment (p. 457) temporary substitute decision maker (p. 464) best interests principle (p. 464) constitutional law (p. 488) statuary law (p. 488) common law (p. 488) paren’s patriae (p. 489) civil code (p. 490) civil commitment (p. 490) criminal commitment (p. 490) temporary substitute decision maker (p. 492) best interests priniciple (p. 492) capable wishes principle (p. 492)

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compulsory treatment orders (p. 492) deinstitutionalization (p. 493) actus reus (p. 497) mens rea (p. 497) not criminally responsible on account of mental disorder (NCRMD) (p. 497) M’Naghten standard (p. 497) unfit to stand trial (UST) (p. 498) forensic psychology (p. 501) ethical codes (p. 501) professional standards (p. 501) principle of autonomy (p. 502) principle of non-maleficence (p. 502) principle of beneficence (p. 502) principle of fidelity (p. 502) principle of justice (p. 502)

XII. 1.

Lecture Ideas/Activites

The fundamental attribution error.

Social scientists tend to regard human behavior as resulting from the interaction between the individual's dispositional tendencies (intentions, traits, etc.) and his or her situational influences or immediate environment. However, when it comes to explaining behavior, social scientists are well aware of the biases in the way we interpret behavior, depending mainly on whether it is our own or someone else's behavior. According to the fundamental attribution error, we tend to overemphasize personal, or dispositional, causes in accounting for other people's behavior, but underemphasize these causes in accounting for our own behavior. Expressed differently, we readily excuse our behavior because of unfavorable circumstances, while jumping to unwarranted conclusions about other people's motives in similar behaviors and circumstances.

Thus, in speaking about ourselves, we use words that denote our actions and reactions to a situation, such as "I get angry when" and "I become violent when." But, in talking about someone else, we generally use words that describe that person's traits or personality, such as "He has

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such a bad temper" or "She is a violent person" (McGuire and McGuire, Journal of Personality and Social Psychology, 1986, 51, 1135-1143). The risk of the fundamental attribution error occurs when jury members must decide whether an act of violence, such as an assault or shooting was malicious (due to dispositional factors) or in self-defense (situational influences).

2.

The insanity plea.

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

Do students feel that most people who are accused of crimes get off on the insanity defense? In fact, they don't! Only a small percentage of criminals use the defense (approximately 1 percent), and only a small percentage of these use the defense successfully (about 20 percent of those who try the defense are successful). In the end, only .2 percent of all cases successfully use this defense! Do students feel that people who are found not guilty by reason of insanity spend less time in confinement than those found guilty of the same crime? Again, they don't! The average person found not guilty by reason of insanity spends more time in a mental hospital than the person found guilty of the same crime spends in prison (when parole, probation, and early release programs are taken into account).

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

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Lynne M. Kemen Hunter College

INSTRUCTOR’S DSM-5 PRIMER FIRST EDITION

An instructor’s resource on teaching the expected changes to the DSM

Prentice Hall Upper Saddle River London Singapore Toronto Tokyo Sydney Hong Kong Mexico City

2 – DSM-5 PRIMER

© 2013 by PEARSON, INC. Upper Saddle River, New Jersey 07458

All rights reserved

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DSM-5 PRIMER - 3

INTRODUCTION The new changes to the DSM-5 are evolving even as the deadline for going to press approaches.

The changes made the front page of the New York Times and its placement there confirms that this is of interest to the general public as well as to the medical community.

“Addiction Diagnoses May Rise Under Guideline Changes” by Ian Urbina (New York Times, May 11, 2012) So the question of how we are to teach these changes is important and not precisely clear-cut. As of this writing, the final changes are not yet in place and it is entirely possible that the final copy may differ substantially from what has been proposed.

When I teach Abnormal Psychology, I always include an early lecture on how views of psychiatric conditions are very much influenced by the times, belief systems and cultures of the communities that are operating at that time. That lecture contains several examples of these influences. My students are alternately amused and horrified by the idea of trephination. But without an understanding of causes, without our ability to image the brain, and in a culture of fear of spirits, it makes sense to try to treat the patient by releasing the spirits in this manner. Looking at evidence of the skulls found, this method was used in many different areas of the world and ranged from single borings to multiple ones in a pattern. We do not know precisely why this was used, but there have been many guesses that it was used to treat convulsions, head injuries or swelling of the brain.

In a period when the Catholic Church had its nuns and priests getting up to pray every few hours (sleep deprivation), fasting and doing purification rituals, many individuals had religious visions. In a current context, we would probably prescribe medications and not see their experiences in a religious light. At the time that it was happening, however, there was a very different interpretation and the individuals were praised for their religious fervor.

During the Victorian times, sexuality was very repressed. Even pianos had limbs rather than legs and furniture and extremities were covered. As sexual desires, masturbation and homosexuality were abhorred in upper- and middle-class families, the repression created other outlets. In 1887, The Lancet, the British medical journal, estimated that in London, prostitutes accounted for 3% of the population during this time. Sigmund Freud’s case studies involved a large number of upper middle class women in Vienna who were suffering from hysteria. This is a diagnosis no longer used and the condition seems to have disappeared, as well.

And it took the DSM until 1972 to remove homosexuality as a psychiatric condition. In other times and other cultures, same-sex relationships were not considered abnormal. Thanks to psychologist Dr. Evelyn Hooker—who matched straight and gay men and then asked a panel of psychiatrists to determine the sexual preference of the person—the idea that a homosexual could be diagnosed or recognized in some way was disproven. Prior to Dr. Hooker’s work, all studies of homosexual men were drawn from cases of individuals who were already diagnosed with a psychiatric disorder.

Once Dr. Hooker did her work on homosexuals who were not suffering from a psychiatric disorder, the old views were disproven.

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4 – DSM-5 PRIMER I am certain that the DSMs will continue to evolve and change as our culture evolves and changes.

As instructors of abnormal psychology, it is our job to prepare our students for an understanding of what has been, what is and to anticipate what will be.

—Lynne M. Kemen, Ph.D., Department of Psychology, Hunter College

The DSM-5 proposed changes are listed in the following order: 1. Neurodevelopmental Disorders 2. Schizophrenia Spectrum and Other Psychotic Disorders 3. Bipolar and Related Disorders 4. Depressive Disorders 5. Anxiety Disorders 6. Obsessive-Compulsive and Related Disorders 7. Trauma- and Stressor-Related Disorders 8. Dissociative Disorders 9. Somatic Symptom Disorders 10. Feeding and Eating Disorders 11. Elimination Disorders 12. Sleep-Wake Disorders 13. Sexual Dysfunctions 14. Gender Dysphoria 15. Disruptive, Impulse Control, and Conduct Disorders 16. Substance Use and Addictive Disorders 17. Neurocognitive Disorders 18. Personality Disorders 19. Paraphilic Disorders 20. Other Disorders

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DSM-5 PRIMER - 5

1. NEURODEVELOPMENTAL DISORDERS The proposed group of neurodevelopmental disorders offers combined diagnoses that were previously categorized under several different groups. There are several changes that are significant.

First, there is a proposed language change under the first subcategory from Mental Retardation in the DSM-IV to Intellectual Development Disorder. Originally this was classed under dementia, and most abnormal psychology books placed this discussion in the disorders of childhood and adolescence since it was a condition that began with birth. The argument about not placing it within the category of dementia is that dementia normally occurs as a patient ages and there is a loss that occurs rather than a deficit at birth.

The second subgroup of Communication Disorders did not previously exist under the DSM-IV. Language, speech and social communication were not included in earlier versions of the DSM and are now addressed. There is acknowledgement that this is often combined with the autism spectrum disorders.

The third subgroup, Autism Spectrum Disorder, has generated much interest on the part of health professionals, educators and the public. Basically, the term spectrum addresses the wide range of abilities of the patient. Under the new spectrum, autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified are included in this grouping.

The fourth subgroup is Attention Deficit/Hyperactivity Disorder.

Significant changes include moving the age of onset to age 12 (from age 7). The DSM-5 also has proposed changes regarding removal of PDD (pervasive developmental disorder—including autism) from the exclusion criteria. Many mental health experts now believe that ADHD and Autism Spectrum Disorder often coexist.

The fifth subcategory is Specific Learning Disorder. This is in contrast to the general communication disorders of subcategory two (specific types of difficulty with math problems, for example).

The sixth subcategory is Motor Disorders. Here the major changes seem to be to bring consistency to disorders such as tics and to take away such subjective terms as “non-functional” for repetitive movement disorders. “Non-functional” is a pejorative term. Not understanding something is not the same as judging that it has no function.

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6 – DSM-5 PRIMER

2. SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS The first change is the description of the category. Formerly, it was Schizophrenia and Other Psychotic Disorders. This change in language indicates that there is a gradient of severity of the conditions discussed.

Other important changes are adding Attenuated Psychosis Syndrome in section 3 of the DSM-5.

This is the group that needs further consideration and is directed at making sure that patients who have this diagnosis are identified because of their increased likelihood of eventually having a diagnosis of schizophrenia.

The discussion and inclusion of a Schizotypal Personality Disorder being co-morbid with another Personality Disorder is high and the APA is recognizing that it is almost impossible to have a single clear diagnosis because of this. The Group of Personality Disorders is separate and explored at length later.

Finally, the separation of catatonia from schizophrenia allows catatonia to be included under Brief Psychotic Disorder, Schizophreniform Disorder, Schizoaffective Disorder, Substance-induced Psychotic Disorder as well as Neuro-Developmental Disorders.

Subgroup 1. Attenuated Psychosis Syndrome (APS) in Section 3 (Appendix) of DSM-5 “Psychosis Risk Syndrome” or “Attenuated Psychosis Syndrome” seeks to identify patients who are at risk for full-blown psychosis before it becomes such—i.e. the patients in this group are not yet diagnosed as schizophrenics but are more likely than the general population to develop schizophrenia in the future. Identifying these patients can be helpful in making sure that they are more closely monitored.

Schizotypal Personality Disorder Important issues that are discussed here are the extensive comorbidity of PD (Personality Disorders). The Personality Disorder is felt to be constant or trait-like over time and across situations. This is discussed at greater length in the section on PD itself.

Delusional Disorder There are several subtypes suggested: Erotomanic Type: Delusions that another person, usually of higher status, is in love with the individual.

Grandiose Type: Delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous individual.

Jealous Type: Delusions that the individual’s sexual partner is unfaithful.

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DSM-5 PRIMER - 7 Persecutory Type: Delusions that the individual (or someone to whom the individual is close) is being malevolently treated in some way.

Somatic Type: Delusions that the individual has some general medical condition.

Mixed Type: Delusions characteristic of more than one of the above types but in which no one theme predominates.

Unspecified Type:

Specify if delusions are bizarre.

Specify if delusions are shared.

The APA recommends three changes: 1) dropping the requirement that the delusion be non-bizarre 2) clarifying the body dysmorphic delusion from somatic type delusion 3) indicating if the delusion is shared with another and discarding the Folie a Deux diagnosis Brief Psychotic Disorder No substantial changes from DSM-IV. Substance-Induced Psychotic Disorder No substantial changes from DSM-IV. Psychotic Disorder Associated with Another Medical Condition No changes recommended.

Catatonic Disorder Associated with Another Medical Condition Recommendations include: Catatonia should be a specifier and not a subtype of schizophrenia in DSM-5. By making it a standalone diagnosis, it can be used for other conditions such as Brief Psychotic Disorder, Schizophreniform Disorder, Schizoaffective Disorder, and Substance-induced Psychotic Disorder. It can also then be used for Autistic Disorders and Neurodevelopmental Disorders.

Schizophreniform Disorder No substantial changes from DSM-IV. Schizoaffective Disorder “Major mood episode” has been replaced with “Major depressive episode or a manic episode.”

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8 – DSM-5 PRIMER Schizophrenia Most of the major parts of the DSM-IV diagnosis will be maintained. It is, however, proposed that the subtypes of schizophrenia (Paranoid Type, Disorganized Type, Catatonic Type, Undifferentiated Type and Residual Type) be eliminated.

Exclusions from the diagnosis of schizophrenia will include: Schizoaffective and Mood Disorder: Schizoaffective Disorder and Mood Disorder with Psychotic Features have been ruled out because either (1) no Major Depressive or Manic Episodes have occurred concurrently with the active phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

Substance/General Medical Condition: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder, another Pervasive Developmental Disorder, or other communication disorder of childhood onset, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month.

Psychotic Disorder Not Elsewhere Classified No substantial changes from DSM-IV. Catatonic Disorder Not Elsewhere Classified This category includes individuals who develop catatonia in the context of rare autoimmune and cancer disorders in which the cancer is a consequence but not a cause of the symptoms. It will also include patients on the Autism Spectrum or with Neurodevelopmental Disorders.

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DSM-5 PRIMER - 9

3. BIPOLAR AND RELATED DISORDERS Important changes in this section: Bipolar I Disorder & Bipolar II Disorder and Bipolar Disorder Not Elsewhere Classified.

Bipolar I Disorder & Bipolar II Disorder have some changes with the bereavement exclusion in Major Depressive Episode. Along with removing the exclusion, the work group is proposing the addition of a footnote to accompany the diagnostic criteria for Major Depressive Episode that would help clinicians differentiate bereavement and other loss reactions from Major Depression.

Furthermore, increased energy/activity has been added as a core symptom of Manic Episodes and Hypomanic Episodes.

Bipolar I Disorder Requires a history or the presence of a manic episode. It also requires ruling out other diagnoses such as Schizoaffective Disorder, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder NEC. The diagnosis also requires that the health care professional specify if the current episode is manic, hypomanic or depressive.

Bipolar II Disorder Requires a history or the presence of a depressive and hypomanic episode. It also requires ruling out other diagnoses such as Schizoaffective Disorder, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder NEC. The diagnosis also requires that the health care professional specify if the current episode is hypomanic or depressive.

Cyclothymic Disorder No significant changes from DSM-IV. Substance-Induced Bipolar Disorder No changes.

Bipolar Disorder Associated with Another Medical Condition Still being reviewed by the APA. Bipolar Disorder Not Elsewhere Classified The significant note here is that NOS does not give clinical information and is thought to be used too frequently. The APA urges clinicians to specify threshold symptoms indicating bipolarity.

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4. DEPRESSIVE DISORDERS Here are the important changes in this group: Disruptive Mood Dysregulation Disorder, Major Depressive Disorder Single Episode, Premenstrual Dysphoric Disorder (see below).

Disruptive Mood Dysregulation Disorder The section notes that in the case of children, with the DMDD diagnosis there is closely overlapping criteria for Oppositional Defiant Disorder. This is not the case for ODD diagnosis always having similarities with DMDD. The APA notes that DMDD is more severe and urges that in cases with both diagnoses present, that only DMDD be used.

Major Depressive Disorder, Single Episode The section acknowledges that bereavement symptoms can be extremely close to MDDSE. If symptoms such as suicidal ideas, feelings of worthlessness, and psychomotor impairment are present, this may be beyond the scope of “normal” grieving and should be considered as MDDSE. Major Depressive Disorder, Recurrent Episodes This section does not have significant changes from the previous DSM. Dysthymic Disorder May be combined with MDD since it is self-reported and difficult for a patient to remember over a period of time the differences between lesser and greater depression. This is still being discussed.

Premenstrual Dysphoric Disorder Previously in the Appendix. APA is recommending that it be moved to Depressive Disorder. It is felt that unless there are clear diagnostic differences between PMDD and MDD or dysthymia, the wrong diagnosis and treatment could be given.

Substance-Induced Depressive Disorder No proposed changes.

Depressive Disorder Associated with Another Medical Condition Still being considered.

Depressive Disorder Not Elsewhere Classified Noted as being an extremely common diagnosis that may be too broad to be useful, except for billing practices and may reflect an effort to avoid the stigma of a psychiatric label. In the future, short-term depression of a few days length may be used here.

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DSM-5 PRIMER - 11

5. ANXIETY DISORDERS Within the general grouping, there has been an effort to make the wording more consistent across the diagnoses. For example the terms “fear” or “anxiety” are used consistently across the criteria within Specific Phobia and across Anxiety Disorders. The term “almost always provokes” is intended to simplify the criteria in place of “almost invariably provokes an immediate anxiety response” and is consistent with new phrasing for Social Anxiety Disorder and Agoraphobia.

Generally, there is more sensitivity to the cultural aspects of a reaction.

Perhaps the most significant changes within Anxiety Disorders occur in Separation Anxiety. The age of onset is no longer there and the duration is now at least 6 months to differentiate from a transient event. With children, the anxiety about not having an adult, per se is omitted since significant others may not be adults.

In the category of Generalized Anxiety Disorder, the number of symptoms has been reduced from 6 to 2.

Agoraphobia Agoraphobia will now be a codable disorder (no longer a syndrome) and will no longer have a separate diagnosis of Panic Disorder with Agoraphobia. Agoraphobia will be a standalone condition and may be comorbid with Panic Disorder.

Social Phobia / Social Anxiety Disorder Social Phobia has been renamed Social Anxiety Disorder. Among other changes are the duration of at least 6 months to distinguish from a transient situation and the inclusion of children being uncomfortable with all people, not simply unknown people.

Substance-Induced Anxiety Disorders Section represents a large grouping but basically there are no substantial wording changes from DSM IV to the current issues.

Anxiety Disorder Attributable to Another Medical Condition No substantial revisions.

Anxiety Disorder Not Elsewhere Classified No substantial rewording.

There are now separate categories for Obsessive-Compulsive and Related Disorders and Traumaand Stressor-Related Disorders (#6 and #7 in the APA list).

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6. OBSESSIVE-COMPULSIVE AND RELATED DISORDERS This category contains diagnoses that were listed in DSM-IV under the chapter of Anxiety Disorders as well as the chapters of Somatoform Disorders and Impulse-Control Disorders Not Elsewhere Classified. The important changes mostly deal with a change of language that makes diagnoses less negative/prejudicial. “Mania” is replaced with “condition” and “inappropriate” is replaced with “unwanted.”

Obsessive-Compulsive Disorder The major changes involve replacing certain words—“impulse” with “urge” and “inappropriate” with “unwanted.” This does two things. In the former case, it clarifies that this is not an impulse control issue and in the latter, it is less judgmental.

Body Dysmorphic Disorder Not changed diagnostically, but there is increased emphasis on the fact that the source of BDD may be apparent only to the patient. Nevertheless, the discomfort is certainly experienced by the patient.

Hoarding Disorder This is being made a separate diagnosis and the APA feels that it is important to note that hoarding can create a danger to the hoarder.

Hair-Pulling Disorder (Trichotillomania) The APA feels that the term mania is inappropriate to this condition but has recommended using the term trichotillomania in parentheses to not confuse clinicians. It is their intention to drop the term mania in later versions of the DSM. Skin Picking Disorder Considered to be a condition that warrants its own diagnosis and should not be confused with BDD or with tactile hallucinations.

Substance-Induced Obsessive-Compulsive or Related Disorders There are no significant changes from the DSM-IV. Obsessive-Compulsive or Related Disorder Attributable to Another Medical Condition There are no significant changes from the DSM-IV.

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DSM-5 PRIMER - 13 Obsessive-Compulsive or Related Disorder Not Elsewhere Classified The DSM-5 diagnostic criteria for this disorder are similar to those in the analogous DSM-IV-TR section on Anxiety Disorders.

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7. TRAUMA- AND STRESSOR-RELATED DISORDERS This category contains diagnoses that were listed in DSM-IV under the chapters for Anxiety Disorders and Adjustment Disorders. The Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group has been responsible for addressing these revisions. Many of the disorders that were previously listed in the Anxiety Disorders chapter in DSM-IV have been distributed throughout this chapter as well as separate chapters on ObsessiveCompulsive and Related Disorders and Anxiety Disorders.

One of the most interesting additions in this discussion is the proposed disorder, Persistent Complex Bereavement Disorder. This is being proposed for Section III, a section of DSM-5 in which conditions that require further research will be included. Posttraumatic Stress Disorder now has a subtype for PTSD in preschool children rather than having this subtype exist as a separate diagnosis. A dissociative symptoms subtype has also been added to this disorder. In the Adjustment Disorders category, a 6-month requirement for children for the bereavement related subtype has been added, and the disorder includes minor wording changes, including changes to the bereavement related subtype. Finally, the work group has proposed criteria for Trauma- or Stressor-Related Disorder Not Elsewhere Classified.

Reactive Attachment Disorder The APA notes that almost all RAD is a result of extremely negligent and inadequate childcare but notes that not every abused child exhibits RAD. It is described as a pattern of disturbed and developmentally inappropriate attachment behaviors that a child manifests before the age of 5 in which the child stays emotionally unengaged with any adult caregiver.

Disinhibited Social Engagement Disorder Like the RAD diagnosis, DSED is a variant of pathological attachment disorder, and the opposite of RAD. In this case, this new diagnosis will fall into the broad category of Trauma- and StressorRelated Disorders. Children diagnosed with DSED display in which the child is extremely attached to any adult whether or not the adult is known to the child. To receive this diagnosis, the child must have experienced some form of pathogenic care that is responsible for this behavior. Pathogenic care can include persistent exposure to unsafe environments, frequently unmet basic needs, overly harsh punishment, and more.

Acute Stress Disorder The definition of traumatic event is made more general. The symptoms exhibited are made more consistent with those of Posttraumatic Stress Disorder, which is the next category.

Posttraumatic Stress Disorder Note: The following criteria apply to adults, adolescents, and children older than six. There is a Preschool Subtype for children age six and younger.

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DSM-5 PRIMER - 15 The subtype applies not only those who are directly affected or who have family and/or friends who are affected but also caretakers such as those who repeatedly deal with trauma professionally (police officers, members of Child Protective Care, etc.).

Subtype: Posttraumatic Stress Disorder in Preschool Children In children (under the age of 6), exposure to one or more of the following events: death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one or more of the following ways: direct experience, witnessing in person traumatic events occurring to others, learning that traumatic events occurred to a primary caretaker.

The child may experience persistent distressing memories of the event, keep reenacting the event in play or have recurrent nightmares of the event. The child’s behavior may include dissociation of the event. The child may also avoid any reminders of the event and exhibit hypervigilance, angry/aggressive behavior, show problems with concentration. Note the duration of these behaviors should exceed 1 month for the diagnosis. Also, a child can have comorbidity of preschool and dissociative subtypes if symptoms for both are exhibited.

Subtype: Posttraumatic Stress Disorder with Prominent Dissociative (Depersonalization/ Derealization) Symptoms Depersonalization: Often described as feeling that an experience is happening to someone else, watching a film rather than being directly involved.

Derealization: Often described as feeling that what is happening is not real or like being in a dream.

Note: The Dissociative and Preschool Subtypes are not mutually exclusive.

Adjustment Disorders Criterion unchanged from DSM-IV except for the addition of the Bereavement-Related Subtype.

Elimination of Bereavement Exclusion Addition of ASD/PTSD Subtype Addition of Bereavement-Related Subtype The concept of bereavement being a culturally varied issue is critical to the DSM-5. The differences in cultures concerning what is considered “appropriate behavior” are specifically noted.

Twelve months of emotional or behavioral stress for adults and six months for children is considered to be the norm for grieving.

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16 – DSM-5 PRIMER In this category, the individual is exhibiting discomfort for a longer period that is significantly impacting that individual’s ability to work, or take part in social activities. The specific manifestations are broken down as follows:

With Depressed Mood With Anxiety With Mixed Anxiety and Depressed Mood With Disturbance of Conduct With Mixed Disturbance of Emotions and Conduct With Features of Acute Stress Disorder or Posttraumatic Stress

Related to Bereavement: Following the death of a family member or close friend, the individual exhibits difficulty in moving forward. Intense preoccupation with the loss that exceeds expected cultural, religious and age-appropriate responses.

Unspecified For maladaptive reactions that are not classifiable as one of the specific subtypes of Adjustment Disorder.

Trauma- or Stressor-Related Disorder Not Elsewhere Classified The DSM-5 diagnostic criteria for this disorder are similar to those in DSM-IV-TR, with very minor wording changes being proposed.

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DSM-5 PRIMER - 17

8. DISSOCIATIVE DISORDERS Among the most recent revisions to these disorders include changes to Dissociative Identity Disorder. There are also proposed criteria for Dissociative Disorder Not Elsewhere Classified.

The changes in this category are interesting and important because they reflect a change in acknowledging cultural differences (trance states are common in some societies and would not be considered abnormal behavior in that context).

Depersonalization-Derealization Here it is necessary that two conditions be met: 1. The disturbance is not caused by substance abuse or another medical condition.

2. That other conditions such as schizophrenia, panic disorder, major depressive disorder or another dissociate disorder are not the cause of the diagnosis. This change allows for comorbid diagnoses to exist.

Dissociative Amnesia Minor wording changes for clarity.

Dissociative Identity Disorder This is the interesting section where the possibility of experience of possession is addressed. As noted above, this makes this diagnosis more culturally useful.

Dissociative Identity Disorder Not Otherwise Classified Only minor changes have been made for consistency with DDI.

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18 – DSM-5 PRIMER

9. SOMATIC SYMPTOM DISORDERS Illness Anxiety Disorder Currently, there are two populations of patients subsumed under the disorder: 1) the first group of hypochondriasis patients—approximately 75%—have somatic symptoms and are concerned about them; 2) the second group—approximately 25%—have minimal somatic symptoms but are concerned about having a mysterious and serious illness. Group 1 will be classified as having a new diagnosis of Somatic Symptom Disorder (SSD). Group 2 will remain in Illness Anxiety Disorder (IAD).

Conversion Disorder: Functional Neurological Symptom Disorder The major change is the name change. Most patients with this disorder are seen by neurologists and the name is preferred by patients. While it is noted that it would impossible to prove a patient was feigning the disorder, it is also noted that it is no more likely that the patient with this diagnosis is deliberately pretending to have the problem.

Psychological Factors Affecting Medical Condition Only minor wording changes.

Factitious Disorder Factitious Disorder, which once had its own category, is now grouped here. The APA notes that there is often diagnostic overlap with Conversion Disorders and other Somatic Disorders and feels it is appropriate to move it to this group.

Somatic Symptom Disorder Not Otherwise Classified This is the category where patients exhibiting pseudocyesis (false pregnancy) are placed.

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10. FEEDING AND EATING DISORDERS (REPLACES EATING DISORDERS IN THE DSM-IV) This new category allows clinicians to include infants, children and adolescents in addition to adults.

Pica This disorder was originally in Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. The recommendation has been to move it since this condition can occur at any age.

Rumination Disorder This disorder was originally in Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. The recommendation has been to move it since this condition can occur at any age.

Avoidant/Restrictive Food Intake Disorder This disorder was originally in Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. The recommendation has been to move it since this condition can occur at any age.

Further, the APA notes that there are 3 distinct categories: individuals who do not eat enough and/or show little interest in feeding or eating; individuals who accept only a limited diet in relation to sensory features; and individuals whose food refusal is related to aversive experience.

Anorexia Nervosa The major shift here is not using the word “refusal” since it is judgmental and indicates intention.

This clarification may help the patient.

Similarly, deletion of the term “fear of weight gain” is proposed, since many patients deny this.

Instead, the concept of behavioral change is recommended.

Amenorrhea as a condition has also been proposed for deletion since many patients do not manifest this problem.

The subtype of binge eating/purging or restricting is inserted here with a clarification of 3 months duration.

Bulimia Nervosa The important change is that this behavior occurs once rather than twice a week for a period of 3 months.

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20 – DSM-5 PRIMER Binge Eating Disorder Binge Eating Disorder is one of the disorders in the DSM-IV Appendix. It is recommended that it be formally included as a disorder in DSM-5.

Feeding or Eating Disorder Not Elsewhere Classified It is noted that there is not sufficient data available at present to justify designating these Conditions as Disorders. However, these Conditions may be associated with levels of distress and/or impairment similar to those associated with the recognized Feeding and Eating Disorders, and may require intensive clinical intervention.

Atypical Anorexia Nervosa All of the criteria for Anorexia Nervosa are met, except that, despite significant weight loss, the individual’s weight is within or above the normal range.

Subthreshold Bulimia Nervosa (low frequency or limited duration) All of the criteria for Bulimia Nervosa are met, except that the binge eating and inappropriate compensatory behaviors occur, on average, less than once a week and/or for less than for fewer than for 3 months.

Subthreshold Binge Eating Disorder (low frequency or limited duration) All of the criteria for Binge Eating Disorder are met, except that the binge eating occurs, on average, less than once a week and/or for fewer than for 3 months.

Other specific syndromes not listed in DSM-5: Purging Disorder Recurrent purging behavior to influence weight or shape, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, in the absence of binge eating.

Night Eating Syndrome The patient repeatedly consumes large amount of food after the evening meal or after awakening.

The patient is aware and remembers the behavior. It is not due to drugs or substance abuse, other medical problems.

Insufficient information: Other Feeding or Eating Condition Not Elsewhere Classified This is a residual category for clinically significant problems meeting the definition of a Feeding or Eating Disorder but not satisfying the criteria for any other Disorder or Condition.

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11. ELIMINATION DISORDERS This category contains diagnoses that were listed in DSM-IV under the chapter of Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.

Enuresis No revisions are being recommended for this disorder at the current time Encopresis No revisions are being recommended for this disorder at the current time.

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12. SLEEP-WAKE DISORDERS This category contains diagnoses that were listed in DSM-IV under the chapter of Sleep Disorders.

There is a recommendation of greater inclusion of disorders not listed in the mental disorder section of the International Classification of Diseases. This has been proposed primarily as a way to educate non-expert sleep clinicians (such as psychiatrists and general medical physicians) about Sleep-Wake Disorders that have mental as well as medical/neurological aspects.

Insomnia Disorder The Sleep Disorders Workgroup recommends seven changes to the Insomnia Disorder diagnostic criteria: 1. Replacing “Primary Insomnia” and “Insomnia related to another mental/medical disorder” with “Insomnia Disorder,” with specification of clinically comorbid conditions 2. Integrating the construct of sleep dissatisfaction to the definition of insomnia 3. Adding early morning awakening as a separate symptom 4. Adding a minimum frequency criterion (i.e., 3 nights per week) with sleep disturbance 5. Raising the minimum duration threshold from 1 to 3 months for chronic insomnia 6. Providing specific examples of daytime impairments 7. Specifying that sleep disturbance occurs despite adequate opportunity for sleep Hypersomnolence Disorders The Sleep Disorders Workgroup recommends the following changes to the Hypersomnolence Disorder diagnostic criteria for consideration in DSM-5: 1. Replacing the term “Hypersomnia” with “Hypersomnolence” 2. Replacing “Primary Hypersomnia” and “Hypersomnia related to another mental/medical disorder” with “Major Somnolence Disorder,” with specification of clinically comorbid conditions 3. Criterion A: Increasing the precision in the definition of excessive sleepiness symptoms 4. Criterion A: Adding sleep inertia as a symptom 5. Criterion B: Adding a minimum frequency criterion (i.e., 3 days per week) with excessive sleepiness 6. Criterion B: Raising the minimum duration threshold from 1 to 3 months for excessive sleepiness 7. Division of Hypersomnolence Disorders into 4 subtypes Narcolepsy/Hypocretin Deficiency Major suggested changes: Replacing “narcolepsy” by “narcolepsy/hypocretin deficiency.”

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DSM-5 PRIMER - 23 Obstructive Sleep Apnea Hypopnea Syndrome Two substantial changes are being suggested: 1. Provide specific diagnostic criteria for: Obstructive Sleep Apnea Hypopnea; Central Sleep Apnea and Sleep Related Hypoventilation rather than using only one set of criteria for “Breathing Related Sleep Disorder” 2. Inclusion of polysomnographic criteria in the diagnostic criteria Central Sleep Apnea The same substantial changes as for OSAHS are made: 1. Provide specific diagnostic criteria for: Obstructive Sleep Apnea Hypopnea; Central Sleep Apnea and Sleep Related Hypoventilation rather than using only one set of criteria for “Breathing Related Sleep Disorder” 2. Inclusion of polysomnographic criteria in the diagnostic criteria Sleep-Related Hypoventilation The same substantial changes as for OSAHS are made: 1. Provide specific diagnostic criteria for: Obstructive Sleep Apnea Hypopnea; Central Sleep Apnea and Sleep Related Hypoventilation rather than using only one set of criteria for “Breathing Related Sleep Disorder” 2. Inclusion of polysomnographic criteria in the diagnostic criteria Circadian Rhythm Sleep-Wake Disorder (formerly Circadian Rhythm Sleep Disorders) 1. The name change encompasses all aspects of the circadian rhythm 2. The inclusion of subtypes of circadian subtypes to include: 1) Advanced Sleep Phase type; 2) Irregular Sleep-Wake type and 3) Non-24 Hour Sleep-Wake Type, while removing Jet Lag type, and Unspecified type, that were included in the DSM-IV Disorder of Arousal Disorders of Arousal (Confusional Arousals, Sleepwalking, and Sleep Terrors) are considered to be variations of a single neurophysiologic phenomenon—namely the simultaneous mixture of elements of both wakefulness and NREM sleep, thereby resulting in the appearance of complex motor behavior without conscious awareness (sometimes termed “state dissociation”).

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24 – DSM-5 PRIMER Nightmare Disorder The changes are mostly changes in terminology, i.e. “repeated awakenings” to “repeated occurrences”; replace “extended and extremely frightening dreams, usually involving threats to survival, security, or self-esteem” with “extremely dysphoric and well-remembered dreams that usually involve efforts to avoid threats to survival, security or physical integrity.” Remove “(in contrast to the confusion and disorientation seen in Sleep Terror Disorder and some forms of epilepsy).”

Remove “The dysphoric dreams do not occur exclusively during the course of another mental disorder (e.g., a delirium, Posttraumatic Stress Disorder).” Change phrase “due to the direct physiological effects of a substance” to “attributable to the direct physiological effects of a substance.” Since Post Traumatic Stress Disorder is now a diagnosis, this allows for comorbidity with this disorder.

Rapid Eye Movement Sleep Behavior Disorder Emphasis on the possibility of injury to the patient or bed partner during these episodes.

Restless Legs Syndrome It is suggested that this be put into its own diagnosis.

Substance-Induced Sleep Disorder Changes are primarily in terminology: “medication” is replaced by “substance.”

Nicotine is included as a substance that may cause a sleep disorder.

Sleep-Wake Disorders Not Elsewhere Classified Insomnia Disorder Not Elsewhere Classified Shorter than 3 months but also causing disruption of sleep for the patient.

Major Somnolence Disorder (Hypersomnia Not Elsewhere Classified) All other sleep disorders responsible for excessive sleepiness have been eliminated.

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DSM-5 PRIMER - 25

13. SEXUAL DYSFUNCTIONS This category contains diagnoses that were listed in DSM-IV under the chapter Sexual and Gender Identity Disorders.

Sexual Dysfunctions In all these diagnoses, the terms marked distress or interpersonal difficulty will be replaced with clinically significant distress or impairment.

1.

Erectile dysfunction: In order to define homogenous groups for clinical research, a more precise definition is needed. The terms marked distress or interpersonal difficulty have been widely interpreted by various investigators and this has led to inconsistent definitions of syndromes. Separation of the reaction of a disorder from its definition should allow for more precise definitions of the entities being studied.

2.

Female Orgasmic Dysfunction: There is a suggested change to reflect more of a continuum regarding orgasm sensitivity. The condition must occur 75% of the time or more over a 6month period. Cultural prohibition regarding orgasm is also considered as a factor.

3.

Delayed Ejaculation replaces the term Inhibited Male Orgasm. As with Erectile Dysfunction, the terms marked distress or interpersonal difficulty have been widely interpreted and this is an attempt to make the definitions more clear and consistent.

4.

Early Ejaculation replaces the term Premature Ejaculation. “Substitute descriptive terminology for an inaccurate, pejorative term” shows increased sensitivity to these issues.

5.

Female Sexual Interest/Arousal Disorder: “The word ‘desire’ is changed to ‘interest.’ Desire connotes a deficiency and often implies a biological urge.” The APA also notes “There is no such thing as ‘spontaneous’ sexual desire.”

6.

Male Hypoactive Sexual Desire: The APA is recommending that the term Hypoactive Sexual Desire Disorder be switched to Male Hypoactive Sexual Desire Disorder.

7.

Genito-Pelvic Pain/Penetration Disorder replaces Vaginismus and Dyspareunia. The APA notes that it has been difficult to differentially diagnose these conditions and feels that it is important that the disorder be so reflected in the DSM-5.

8.

Substance/Medication Induced Sexual Dysfunction: All of these have been synched with the Substance Use and Addictive Disorders Category.

9.

Sexual Dysfunction Not Otherwise Classified is still being worked on as of this writing.

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14. GENDER DYSPHORIA Gender Dysphoria Gender Dysphoria is in two subgroups: 1. Children 2. Adolescents and adults The changes are that the child must have a minimum of 6 months of feeling that he/she is assigned the wrong sex. This is a must for this diagnosis, with several other combinations that may also add to the diagnosis.

The APA realizes that Gender Identity Disorder (GID) may be a stigmatizing diagnosis and has proposed that the term be changed to Gender Incongruence, as descriptive and to avoid a presupposition of the presence of a clinically significant acute distress in all cases as a requirement for the diagnosis.

Also of note, the committee discussed the issue of whether this was a psychiatric or medical condition and decided to leave that open in an attempt to help patients obtain insurance coverage for cross-gender hormones, sexual reassignment and other therapies.

The diagnosis involves a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration. The issue of medical versus psychiatric diagnosis was also raised here. It was noted that many of the individuals with Gender Incongruence ceased having distress once they were on cross-gender hormones or had had sexual reassignment. Ceasing the treatment would cause the individual to again experience distress.

Overall, there is an increased sensitivity to not stigmatizing the patient. There are many who feel that this is not a psychiatric condition at all and that it should not be listed as such.

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15. DISRUPTIVE, IMPULSE CONTROL, AND CONDUCT DISORDERS (PREVIOUSLY UNDER DISORDERS OF CHILDHOOD AND ADOLESCENCE) This category contains diagnoses that were listed in DSM-IV under the chapter Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence and Impulse Control Disorders Not Elsewhere Classified. Please note that the proposed criteria and rationale for Disruptive Mood Dysregulation Disorder can be found in the Depressive Disorders section.

Among the most recent revisions are changes in the frequency criterion for Oppositional Defiant Disorder and the addition of an age requirement (18 years) for the diagnosis of Intermittent Explosive Disorder. The Callous and Unemotional Specifier now includes clarified wording and some additional guidance on use. Finally, the work group has proposed criteria for Disruptive Behavior Disorder Not Elsewhere Classified.

Oppositional Defiant Disorder Four recommendations were made by the APA for changes in this diagnosis.

1.

2.

3.

4.

The major symptoms for ODD should remain the same.

Remove exclusionary criteria for Conduct Disorder.

Organize emotional and behavioral symptoms so as to distinguish between them.

Develop a severity scale.

Intermittent Explosive Disorder This diagnosis can be made in older adolescents and young adults aged 18 or older in addition to the diagnosis of Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder, or Autistic Spectrum Disorder when recurrent impulsive aggressive outbursts warrant independent clinical attention. Final changes are still under consideration.

Conduct Disorder An additional specifier for Callous and Unemotional Traits in Conduct Disorder has been proposed.

Dyssocial Personality Disorder (Antisocial Personality Disorder) The name of the disorder has been changed to DPD. The actual changes and rationale are still under consideration.

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16. SUBSTANCE USE DISORDERS (PREVIOUSLY SUBSTANCE USE AND ADDICTIVE DISORDERS) There are no major changes to the following. These disorders will be listed both in the Substance Use and Addictive Disorders chapter and in the chapter containing the induced disorder. Please see below for a list of these disorders.

Substance-Induced Psychotic Disorder Substance-Induced Bipolar Disorder Substance-Induced Depressive Disorder Substance-Induced Anxiety Disorder Substance-Induced Obsessive-Compulsive or Related Disorders Substance-Induced Sleep-Wake Disorder Substance-Induced Sexual Dysfunction Substance-Induced Delirium Substance-Induced Neurocognitive Disorder

Important changes to this category are the addition of Gambling to the Substance Use Disorders category (previously, this was in the OCD category).

This committee has also recommended that the following disorders be put into Category III, which contains conditions that require further study:

Neurobiologic Disorders Associated with Prenatal Alcohol Exposure Caffeine Use Disorder Internet Disorder

For the following substance problems, the APA has recommended combining Substance Abuse and Dependence into one disorder.

Alcohol-Related Disorders Caffeine-Related Disorders Cannabis-Related Disorders Hallucinogen-Related Disorders Inhalant-Related Disorders Opioid-Related Disorders Sedative/Hypnotic-Related Disorders Stimulant-Related Disorders Tobacco-Related Disorders Unknown Substance Disorders Gambling Disorder

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17. NEUROCOGNITIVE DISORDERS This category contains diagnoses that were listed in DSM-IV under the chapter Delirium, Dementia, Amnestic, and Other Cognitive Disorders. There has been a recommendation that the category be divided into three broad syndromes: Delirium, Major Neurocognitive Disorder, and Mild Neurocognitive Disorder. The APA has also modified the diagnostic criteria for Neurocognitive Disorder due to Alzheimer’s Disease to maintain consistency with newly published consensus criteria. Finally, Neurocognitive Disorder Not Elsewhere Classified has been newly added.

Delirium Terminology change: Consciousness is too nebulous a term to describe the symptoms of delirium.

Awareness has been deemed a better term. Visuospatial impairment and impairment in executive function are key symptoms of delirium; the group has also added a clarification that a preexisting neurocognitive disorder does not account for the cognitive changes.

Substance-Induced Delirium This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the symptoms fulfill full criteria for a DSM-5 delirium and when the symptoms are sufficiently severe to warrant clinical attention.

Mild Neurocognitive Disorder Minor Neurocognitive Disorder has been added to recognize the substantial clinical needs of individuals who have mild cognitive deficits in one or more of the same domains but can function independently (i.e., have intact instrumental activities of daily living), often through increased effort or compensatory strategies. This syndrome, known in many settings as Mild Cognitive Impairment, may be particularly critical, as it may be a focus of early intervention. Early intervention efforts may enable the use of treatments that are not effective at more severe levels of impairment and/or neuronal damage, and in the case of neurodegenerative disease, may enable a clinical trial to prevent or slow progression.

Major Neurocognitive Disorder Major Neurocognitive Disorder (including what was formerly known as Dementia) is a disorder with greater cognitive deficits in at least one (typically two or more) of the following domains:

Complex attention (sustained attention, divided attention, selective attention, processing speed) Executive ability (planning, decision-making, working memory, responding to feedback/error correction, overriding habits, mental flexibility) Learning and memory (immediate memory, recent memory (including free recall, cued recall, and recognition memory))

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Language (expressive language (including naming, fluency, grammar and syntax) and receptive language) Visuoconstructional-perceptual ability (construction and visual perception) Social cognition (recognition of emotions, theory of mind, behavioral regulation)

The cognitive deficits must be sufficient to interfere with functional independence. Important changes from the DSM-IV criteria include: change in nomenclature (MNCD or Dementia), not necessarily requiring memory to be one of the impaired domains, allowing cognitive deficit limited to one domain.

The term “dementia” is replaced by Major Neurocognitive Disorder, which is conceptualized as including what was formerly known as dementia as well as entities like amnestic disorder.

“Dementia” is an accepted term for older adults (e.g., with Alzheimer’s disease). Even in this setting, however, it has acquired a pejorative or stigmatizing connotation, it is less well accepted among younger adults with deficits related to e.g., HIV or head injury. The sensitivity to labeling is an important change in this category.

Subtypes of Major and Mild Neurocognitive Disorders There are 12 subtypes and there are some significant changes in the diagnoses and understanding of these diseases. In all cases, the understanding of and diagnostic tools available for this category is driving the changes suggested.

1. Neurocognitive Disorder due to Alzheimer’s Disease: It is suggested that there be even more specific diagnostic coding to include psychosis and depression. These may or may not be part of the patient’s symptoms.

2. Vascular Neurocognitive Disorder: The old concept of Multi-infarct Dementia, which the DSM-IV Vascular Dementia adhered to, has been replaced by a much broader concept of dementia due to both small and large vessel disease.

3. Frontotemporal Neurocognitive Disorder: Frontotemporal degeneration can be difficult to distinguish from primary psychiatric disorders and including them in DSM-5 should help clinicians make this distinction.

4. Neurocognitive Disorder due to Traumatic Brain Injury: This subcategory is currently under consideration.

5. Neurocognitive Disorder due to Lewy Body Dementia: The importance of this disease (it is now the second most common neurocognitive disorder) has increased. Further study is needed.

6. Neurocognitive Disorder due to Parkinson’s Disease: This subcategory is still under review.

7. Neurocognitive Disorder due to HIV Infection: This subcategory is still under review.

8. Substance-Induced Neurocognitive Disorder: This subcategory is still under review.

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DSM-5 PRIMER - 31 9. Neurocognitive Disorder due to Huntington’s Disease: This subcategory is still under review.

10. Neurocognitive Disorder due to Prion Disease: This subcategory is still under review.

11. Neurocognitive Disorder due to Another Medical Condition: This subcategory is still under review.

12. Neurocognitive Disorder Not Elsewhere Classified: This subcategory is still under review.

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18. PERSONALITY DISORDERS This group has some of the most significant changes of any category. The problems of comorbidity and lack of agreement for many diagnoses is finally being addressed by the APA. As an overall change for this group, the APA is noting the comorbidity of conditions within this category and the lack of agreement when assigning a diagnosis. Consequently, the APA is suggesting a hybrid dimensional-categorical model for personality and PD assessment and diagnosis is proposed for DSM-5. Family history, personal history (abuse), medical history (suicide attempts) and an assignment of the severity of the disorder seem to be more important than the actual former diagnoses within PD. Previously, PDs were grouped in clusters. Cluster A included the odd or eccentric disorders (Paranoid Personality Disorder, Schizoid Personality Disorder, Schizotypal Personality Disorder).

Cluster B included the dramatic, emotional or erratic disorders (Antisocial Personality Disorder, Narcissistic Personality Disorder, Borderline Personality Disorder, Histrionic Personality Disorder). Cluster C included the anxious or fearful disorders (Avoidant Personality Disorder, Dependent Personality Disorder, Obsessive-Compulsive Personality Disorder).

All of this has been revamped. Currently, the following PDs are still being listed:

Borderline Personality Disorder Obsessive-Compulsive Personality Disorder Avoidant Personality Disorder Schizotypal Personality Disorder Antisocial Personality Disorder (Dyssocial Personality Disorder) Narcissistic Personality Disorder

Personality Disorder Trait Specified Having the proposed trait system eliminates the need for a “Not Otherwise Specified” personality disorder diagnosis, because in all cases the patient’s personality disorder can be specified by a combination of core impairment in personality functioning and the particular set of pathological personality traits that are unique to that patient.

Paranoid, Schizoid, Histrionic and Dependent Personality Disorders will no longer be listed.

Instead, they will be subsumed under the PD traits category.

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DSM-5 PRIMER - 33

19. PARAPHILIC DISORDERS The APA is changing the name of this category from Paraphilias to Paraphilic Disorders.

There are some important changes in the way these conditions are being viewed.

Changes Affecting the Diagnostic Criteria for All Paraphilic Disorders The APA is now distinguishing between whether Paraphilias are necessarily mental disorders. This change is of major importance to this category. The entire category is retaining the distinction between normative and non-normative sexual behavior but stops at the labeling of non-normative sexual behavior as being psychopathological. This is a huge shift. A diagnosis such as transvestism no longer requires that the patient be either distressed or impaired by his behavior; i.e. the patient is neither harming nor being harmed by his behavior.

Another change is the ability to note that the patient is in a controlled environment or that the condition is in remission.

This applies to all of the following subcategories:

Exhibitionistic Disorder Fetishistic Disorder Frotteuristic Disorder Pedophilic Disorder Sexual Masochism Disorder Sexual Sadism Disorder Transvestic Disorder Voyeuristic Disorder Paraphilic Disorders Not Elsewhere Classified

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20. OTHER DISORDERS This category contains new diagnoses that were not listed in DSM-IV, such as those related to SelfInjury. The Childhood and Adolescent Disorders Work Group has been responsible for addressing the diagnosis of Non-Suicidal Self Injury, while the Mood Disorders Work Group developed draft criteria for the diagnosis of Suicidal Behavior Disorder. This category also includes Factitious Disorder, which was previously located in DSM-IV under the chapter Somatoform Disorders and is the responsibility of the Somatic Symptoms Disorders Work Group, and Other Substance-Induced Disorder, which was previously located in DSM-IV under the chapter Substance-Related Disorders and is the responsibility of the Substance-Related Disorders Work Group. Among the recent revisions to this category is the proposal for a new disorder, Suicidal Behavior Disorder.

Non-Suicidal Self Injury In the past, this kind of behavior that includes cutting, burning and other types of repeated injury to the self was subsumed under Borderline Personality Behavior. The behavior is almost always directed to the surface of the body rather than the infliction of internal injuries. It is felt that many patients who are engaging in this type of behavior do not, in fact have BPB. It is also noted that the repeated non-suicidal self injury diagnosis does not exempt the patient from the co-morbidity of suicidal behavior.

There are significant changes in the language. Previously, “self-mutilation” and “self-harm” were used in the BPB diagnosis. It is felt that “mutilation” involves loss of a body part and this is certainly not always the case. The term “self-harm” was considered to be too broad a term. There can be risky behavior that can harm the individual—compulsive gambling, for instance, can create financial situations that are harmful, but not self-injurious.

Suicidal Behavior Disorder It is noted that non-suicidal self injury is not mutually exclusive with suicidal behavior disorder.

The term “initiated by the patient” can include patients who survived because of the intervention of someone else or because the patient reconsidered and aborted the attempt.

There are exclusions for this behavior—political or religiously motivated suicidal behaviors are not included in this category. The patient must not be delirious or confused. Being under the influence of a substance or intoxication does not preclude this diagnosis.

It is noted that SBD is a great predictor for future suicide attempts, as well as non-suicidal behavior disorder, and that having the diagnosis listed may be important for flagging patients at risk.

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