Abnormal Psychology The Problem of Maladaptive Behavior, 11E Irwin G Sarason Solution Manual by Ace Test Banks

Abnormal Psychology The Problem of Maladaptive Behavior, 11E By Irwin G. Sarason

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Table of Contents Abnormal Psychology: The Problem of Maladaptive Behavior 11/e

Preface, Acknowledgments, and Author Biography

Organization of the Instructor’s Manual

Content Description

Media Services Locator

Chapter 1

Abnormal Psychology

Chapter 2

Theoretical Perspectives on Maladaptive Behavior

Chapter 3

Therapies

Chapter 4

Classification and Assessment

Chapter 5

Stress, Coping, and Maladaptive Behavior

Chapter 6

Bodily Maladaptation: Eating, Sleeping, and Physiological

Chapter 7

Disorders of Bodily Preoccupation

Chapter 8

Anxiety Disorders

Chapter 9

Sexual Variants and Disorders

Chapter 10

Personality Disorders

Chapter 11

Mood Disorders

Chapter 12

Schizophrenia and Other Psychotic Disorders

104

Chapter 13

Cognitive Impairment Disorders

114

Chapter 14

Substance-Related Disorders

120

Chapter 15

Disorders of Childhood and Adolescence

130

Chapter 16

Pervasive Developmental Disorders and Mental Retardation

139

Chapter 17

Society’s Response to Maladaptive Behavior

150

iii

Chapter 1 Abnormal Psychology OVERVIEW Chapter 1 provides the framework for the discussion of abnormal behavior. The chapter includes topics such as epidemiological factors such as prevalence, incidence, and risk factors. Sources of help for abnormal behavior are discussed including the different professional fields of psychology, psychiatry, social work, and psychiatric nursing. Research methods used to study both normal and abnormal behaviors are defined. Ethical considerations and regulations are discussed CONTENTS The Range of Abnormal Behavior What Is Abnormal Behavior? Triggers of Mental Health Problems The Stigma of Abnormal Behavior Adaptive and Maladaptive Behavior Historical Background of Modern Abnormal Psychology The Ancient Western World The Middle Ages The Renaissance The Age of Reason and the Enlightenment The Reform Movement Recent Concepts of Abnormal Behavior The Psychological Approach The Organic Approach Vulnerability, Resilience, and Coping The Epidemiology of Maladaptive Behavior – Incidence, Prevalence, and Risk Factors Seeking Help for Abnormal Behavior Reasons for Clinical Contacts Sources of Help Research in Abnormal Psychology Observing Behavior The Role of Theory The Research Journey Types of Research Research Design, Statistical Analyses, and Inference Ethical Aspects of Research Take-Away Message LEARNING OBJECTIVES After completing this chapter students should be able to: 1. Define the focus of “abnormal psychology” and “mental health.” 2. Describe differences among adaptive, maladaptive, and deviant behaviors. 3. Discuss the negative effects of stigma on mental health consumers and their families. 4. List several of the methods for treating mental disorders used in the ancient Western world. 5. Discuss the roles played by Dorthea Dix and Clifford Beers in the development of today’s mental health system in the United States. 6. Explain the differences between the psychological approach and the organic approach. 7. Describe the concepts of risk-vulnerability and resilience-protective factors, specifically with regard to an individual’s ability to cope with stress. 8. Describe a few of the epidemiological patterns of mental illness in the United States in identifying incidence, prevalence, and risk. 9. Describe the range of mental health treatment facilities available today. 10. Identify different mental health specialists. 11. List the four steps followed in the path of scientific understanding.

12. Compare the information gained from a correlational study with that gained from an experimental study. 13. State the two types of statistics most frequently used in psychological studies. 14. State four of the ethical responsibilities in human research. LECTURE AND DISCUSSION TOPICS 1. Describe differences between adaptive and maladaptive behavior. 2. What is mental illness? Who decides if someone’s behavior is maladaptive or deviant? (Ex. DSM-III designated homosexuality as a mental disorder.) 3. Are there broad categories like those defined in early England? 4. Encourage the students to discuss the following: When is unusual behavior not considered "mental illness?” 5. Can you name famous people whose behavior was "unusual"? Name several of the current films that depict a person with a mental disorder. 6. How does stigma affect people who have been diagnosed with mental illness? 7. Does our attitude toward individuals change if we hear they have been "mentally ill"? Do you have friends who have been diagnosed as "mentally ill"? Do your attitudes or behaviors toward them change? Do they hesitate to tell you? Why? 8. Guest Lecturer: Invite a consumer from the National Alliance for the Mentally Ill to talk sensitively about their illness. 9. Discuss behaviors that distinguish between the constructs of maladaptive and deviant (pg. 9). 10. Deviant behavior might be highly adaptive within a situation. Have class members list behaviors that could be deviant but adaptive. Create a similar list of deviant behaviors that are maladaptive. 11. Differences in Mental Health Professionals: Provide a list of the different professionals involved in diagnosis, treatment, and research in the field of abnormal psychology. These should include the psychologist, psychiatrist, social worker, psychiatric nurse, and other professionals such as psychotherapist, licensed counselor or family counselor. Include in the discussion the differences in schooling, licensing, responsibilities, and duties of the different professionals. Include in this discussion the different fields represented in psychology. List the percentage representation of each field. Briefly discuss the differences of each field. STUDENT ACTIVITIES Classroom 1. The State Decides Discuss the state-based requirements for commitment of a person to a mental facility. If possible provide a list of the criteria for committing a person to a state mental institution. Organize the class into groups of 4 to 8 students. Declare that each group is the Mental Health Commission in a state (each group can create a name for their state). Ask them to generate the requirements for commitment in their state. Review them or post them for discussion the next week. Ask several students to describe the difficulty in agreeing to the critical factors that decided whether a person should be hospitalized. 2.

Stigma - The Green NIMBYs Jane Elliott is well known for the "Blue Eyes, Brown Eyes" discrimination experiment she did with her third grade class in all-white, all-Christian Riceville, Iowa, immediately after Martin Luther King Jr. was assassinated in 1968. In her experiment, Elliott divided the class by something they couldn't control — the color of their eyes. She told her brown-eyed students they were superior to the blueeyed ones. She gave the brown-eyed students special privileges and told the blue-eyed children they had made mistakes because of the color of their eyes. (Javelina Bulletin. (1999, March). Texas A and M University-Kingsville.) (http://www.tamuk.edu/news/bulletin/1999/march/jane-elliot.html) (Note: This is a very effective exercise that is commonly used to increase sensitivity and selfexamination about prejudice. It is not as personal as separating blue-eyed students from the remainder of the class but it may not be as personally devastating because it allows students a level of control. Be certain that students agree to participate and that time is allotted for debriefing.)

NOT IN MY BACKYARD Neighborhood and community attitudes that want services for clients but refuse to permit them to be located in their neighborhoods. It is a reflection of the stigma associated with mental illness. • The Activity - Materials - white board and markers or chalk board and colored chalk, or poster paper taped to the wall and washable markers. Withhold green markers and chalk. • Depending upon the size of the class and available board space, assign white or chalk boards (large poster paper can also be used) to half the class. Select several students to be Mental Health Commissioners for the county and have them sit up front with you. • The paper or boards are neighborhoods. The architects of the neighborhoods have the right to establish the rules for the size, style, and locations of homes, stores, play yards and fields, and parking. Instruct the groups to plan and draw their development (about 10 minutes). • Next, instruct the Commissioners that they are to place two group homes (green markers or chalk) for persons with mental and drug disabilities in each neighborhood (near other homes) and that they have to ask permission from the Neighborhood Zoning Commission (the other students) to set up the group homes. Let them proceed. • Observe each group and the discussions taking place. • Stop the discussion after ten minutes and debrief the class. • Discuss the NIMBY issues, quality of life concerns for persons with mental disabilities (or any group with disabilities), and personal reactions to stigmatize or be stigmatized. • Using the same “neighborhoods,” review the “Incidence and Prevalence” statistics (attachment), ask the students to characterize their neighborhood. Given that 1,000 people (men, women, and children) live in their neighborhood, how many of them, past, present, and future are likely suffering from a mental disorder?

Assignment 1. Have students bring to class news reports that discuss the use of "mental illness" as a plea in a criminal justice case. 2. Ask students to locate recent famous cases. Discuss the probabilities of such an event using epidemiological terminology. 3. Ask the students to locate a recent case where an individual who has committed an offense used "mental disturbance" as a reason. Critical Writing Following the Littleton, Colorado, killings, Gary B. Larson (1999, April 24) paraphrased the writing of Martin Niemoller, 1892-1984, a Protestant pastor in Nazi Germany: “First they came for the blacks (and the Latinos and the American Indians and the Asians). I was silent. I was not black (or Latino or American Indian or Asian). Then they came for the gays and lesbians. I was silent. I was not gay or lesbian. Then they came for the kids with cleft palates, missing limbs, speech defects and other physical or mental defects. I was silent. I had no such defects. Then they came for the nerds, dweebs, and geeks. I was silent. I was not a nerd, dweeb or geek. Then they came for the fat, wimpy, and ugly kids. I was silent. I was not fat, wimpy or ugly. Then they came for the kids with attention deficit disorder. I was silent. I did not have the deficit disorder. And then they came for me. There was no one left to speak for me.” (http://members.home.net/garbl/writing/comment.htm) Those who suffer from mental disorders frequently face direct, implied, or imagined stigma (a narrow set of beliefs that applies to a broad group of people and damages their ability to live freely) against their illness. Whether considering a stranger, a friend, or yourself, write an essay from the perspective of the stigmatized person. What would you say to those who are ignorant or insensitive to help them understand? Consider name-calling, and power and control issues, fear, hate, and ignorance as possible motives for maintaining a prejudicial position toward the mentally ill.

Great Books to Read Beers, Clifford. (1981). A Mind that Found Itself. Washington, DC: National Mental Health Association. Geller, J., & Harris, M. (Eds.). (1994). Women of the Asylum: Voices from Behind the Walls, 1840-1945. New York: Alfred A. Knopf. ISBN: 0385474237. Lundin, Robert (2001) Don't Call Me Nuts: Coping with the Stigma of Mental Illness. Lake Forest, CA: Recovery Books. Starr, Randy and Lundin, Robert (1999). Not Guilty by Reason of Insanity: One Man's Story of Recovery. Lake Forest, CA: Recovery Books. ISBN: 096747940. Wahl, Otto F. (1999). Telling is Risky Business: Mental Health Consumers Confront Stigma. Rutgers University Press. ISBN: 0813527244. Wurtzel, Elizabeth (1999). Young and Depressed in America. New York: Berkley Publishing Group. ISBN:1573225126 VIDEO RESOURCES Professional A Class Divided. (1985). 60 min./color/videocassette/study guide. (PBS Video). In this documentary, Jane Elliott meets 15 years later with her class to talk about the classroom experiment and the effects it had on their lives. Eye of the Storm. (1970). 27 min./color/16mm. (Social Studies School Service). In 1970, Jane Elliott, a third grade teacher in a small Iowa town, divided her class into two groups for a lesson in discrimination-one group being superior to the other. Issues of prejudice, victims and victimizers, as well as human behavior, are central to this video documentary. Quiet Rage: The Stanford Prison Experiment, 50 min. (Insight Media). This video describes the famous Zimbardo experiment where a mock prison was created. The World of Abnormal Psychology: Looking at Abnormal Psychology, 60 min. (Annenberg/CPB). This film provides an excellent introduction for abnormal psychology. Video Back to Bedlam, 60 min. (NBC News Special with Geraldo Rivera). March 12, 1999. Recommended by NAMI. Geraldo discusses the current state of the 1960s mental health promise to America. Contrasts the corrections institutions now delivering “care” to the mentally ill. Vignette about quality care with Tipper Gore. Discovering Psychology: Psychopathology, 28 min. (Annenberg/CPB). This film provides an overview of the area of abnormal psychology. Discovering Psychology: Understanding Research, 28 min. (Annenberg/CPB). This film describes research techniques used in psychology. What Happened to Our Son, 14:10 min. (20/20: ABC News/Prentice Hall Video Library Abnormal Psychology Series III, Cassette One). A young patient with schizophrenia is included in a questionable research study. CHAPTER OUTLINE I. Chapter Overview A. Bob Cates - Brief Description: 1. New university student 2. Formerly energetic, now lethargic 3. Depressed 4. Unable to focus on important things 5. Counseling questions 6. Current self-evaluation 7. Self-assessment of the scope of the problem 8. Duration of problem - recent or long standing 9. Self-suggestion of positive solutions to the problem

10.

Contributing factors: a) Long-standing behavior pattern b) Questioning values, especially achievement c) Parental pressure to achieve d) Felt unable to live up to parents’ expectations 11. Therapist’s impression: a) Parent pressure is only one factor - there are others b) Depression is a factor c) Vulnerable due to confusion with values and culture d) Needs to be more in touch with needs and present goals 12. Summary – Bob is experiencing adjustment problems that are more intense than is typical for most college students. B. Comparing Bob Cates and Buford Furrow - some suggested comparisons Category

Bob Cates

Buford Furrow

Axis I

Depression - suicide thoughts Adjustment Disorder

Depression - suicide thoughts Aggressive/violent tendencies with control issues Externalizes distress creates roadblocks to help none/prior antidepressants member of hate group, alcohol

Axis II Axis III Axis IV Axis V medications MH services expectations

Internalizes distress none leaving home none noted - alienated positively seeks help no no none

yes yes yes

II.

The Range of Abnormal Behavior A. Identifying life events that result in unhappiness and/or disordered behavior. B. Actions and approaches that alleviate the problem. C. The continuum of normal-to-abnormal behavior: 1. Who decides where the line has been crossed? 2. The decision involves judgment calls by people and community agencies. D. Research helps to conceptualize mental disorders: 1. Research help to describe effective or new treatments. 2. Research establishes future directions for understanding abnormal behaviors.

III.

Working definitions - Abnormal psychology is the area within psychology that focuses on maladaptive behavior, its causes, consequences, and treatments. A. The study of abnormal behaviors looks at: 1. How it feels to be different. 2. The meanings that get attached to mental illness. 3. The social reactions to maladaptive behavior. B. Mental health refers to the capacity to: 1. Think rationally and logically. 2. Cope effectively with stress and life challenges. 3. Demonstrate emotional stability and growth. C. Mental health problems can include: 1. Low self-regard. 2. Distortion of reality. 3. Reduced competence. 4. Anxiety. 5. Depression. 6. Anger.

7. Heightened physiological reactivity. IV.

Triggers of Abnormal Behavior A. External factors in the environment B. Internal psychological factors in the individual

V. • • •

Stigma of Abnormal Behavior Prejudice and discrimination are common for people exhibiting abnormal behavior. Major goal of the mental health field is to overcome stigma. Box 1-2 (pg. 10). 1. Ways to overcome prejudice. 2. Ways to develop tolerance and compassion.

VI.

Adaptive and Maladaptive Behavior A. Adaptation refers to a dynamic process by which an individual responds to his/her environment, and the changes that occur in the individual and perhaps in the environment as a result of the interaction. 1. Subtle form of communication, problem-solving skills, social interactions are adaptive. 2. Social institutions work to support people whose inadequacies would prevent successful adaptation. B. Maladaptive behavior is behavior that deals inadequately with a situation. C. Maladaptive behavior is deviant, but deviant behavior is not always maladaptive. D. Maladaptive behavior suggests vulnerability, inadequate coping, or exceptional stress, and is a source of concern to the individual, family, or community. E. Maladaptive behavior lies on a continuum from socially acceptable to unacceptable.

VII.

Historical Background of Modern Abnormal Psychology A. Scientifically established causes and treatment of thinking, mood, and behavior disorders. 1. A review of past ideas and approaches in abnormal psychology provides a basis for understanding that much of today’s thinking is an outgrowth of the past, not a rejection.. 2. Theories and themes about abnormal psychology occur again and again. B. General approaches to abnormal behavior throughout history. 1. Mystical ideas that exist today: a. Exorcism - casting out evil spirits b. Shaman - a medicine man (Figure 1-4, pg. 11) c. Alternative medicine 2. Organic defect - the body is not working correctly - Today’s scientific approaches affirm that, in some disorders (ex. diabetes), correcting the biological problem results in improved behavioral functioning. 3. Trephination (Figure 1-5, pg. 11) - creating a hole (2 cm.) in the skull presumably to release demons (3000- 2000 B.C.) 4. Psychological perspective - behavioral disturbances are caused by inadequacies in the way a person thinks, feels, or perceives the world.

VIII.

The Ancient Western World A. Ancient Greece 1. Rational analysis of the natural world. 2. Concepts of motivation and intelligence. 3. Extending the boundaries of human understanding through reasoning. B. Behavior was a form of punishment for offenses against the gods. 1. Asclepius was the god of therapy - he attended to their dreams and healed them. 2. Hippocrates identified epilepsy as a disease of the brain, also depression delirium, psychosis, phobias, and hysteria. 3. Socrates, the Socratic method - self-exploration.

4. Plato, the organismic approach - behavior is the product of all the psychological processes. Disturbed behavior is the result of conflicts between emotion and reasoning. Championed separating the mentally ill from the rest of society. 5. Aristotle, reasoning and application, and body forces need to be in balance. 6. Galen, Greek physician - The Four Humors (Figure 1-6, pg. 13) describe personality and temperament. Imbalances caused various mental disorders: a. Blood - changeable b. Black Bile - melancholic c. Yellow Bile - hot tempered d. Phlegm - sluggish 7. The rational approach formed the foundation of modern science. IX.

The Middle Ages A. The Christian church in control, rational explanations for abnormal behavior were discarded and demonology was once again seen as the root of abnormal behavior. B. Magic, exorcism (Figure 1-7, pg. 14), and dance therapies became treatments for abnormal behavior. C. St. Augustine - roots of psychodynamic theory. 1. Wrote about mental anguish and human conflict. 2. Used introspection to examine mental conflicts. 3. Confessions reveal exploration of emotional conflicts and temptations as a source of psychological knowledge of the self. D. Religious dogma moved church toward demonology and away from rationality. E. English government had the right and duty to care for the mentally impaired. 1. A natural fool - mentally retarded individual. 2. Non compos mentis - “not of sound mind” for acquired mental disability. 3. By the 15th century the term “idiot” replaced natural fool. 4. The term “lunatic” replaced non compos mentis. F. During the 13th century legal competency hearings were held in England.

The Renaissance A. Demonology and exorcism persisted but humanism increased and scholarship increased. B. Johann Weyer (1515-1576), a physician, emphasized psychological conflict and disturbed interpersonal relations as causative of mental disorders. C. He emphasized a medical approach rather than a theological approach.

XI.

The Age of Reason and the Enlightenment A. Scientific method and reason became the means for studying the natural world. B. William Harvey (1578-1657) - relationships between psychological and physiological aspects of life. C. Baruch Spinoza (1632-1677) - the mind and body are inseparable. Psychological processes are of equal importance to the material processes of the natural world. D. Shakespeare (1564-1616) probed unconscious motives in Hamlet. E. Psychotic breakdown of King George III (1765) began movement toward more humane treatment of mentally ill. F. English “madhouses” were licensed in 1774. G. Physiognomy - the art of judging character, personality, and feelings from the shape of the body and the face. H. Joseph Gall (1758-1828) developed “phrenology.” (Figure 1-8, pg. 16) I. William Cullen (Scotland: 1712-1790) - neurotic behavior results from nervous system defects. J. Franz Anton Mesmer (Vienna: 1734-1815) - magnetism and strong emotional circumstances to effect mental and physical cures. Contributed to hypnotism. (Figure 1-9, pg. 16)

XII.

The Reform Movement A. In France, Phillipe Pinel (1745-1826) was a leader in providing more humane treatment of mentally ill in asylums. B. Britain's "Parliamentary Inquiry into Madhouses of England" (1815) (Figure 1-10, pg. 17) revealed a great deal of abuse and cruelty in asylums, Hospital of St. Mary of Bethlehem known as Bedlam. C. Opinion for treatment included removal from the damaging forces of family and community. D. Belief in “moral treatment” of medical, nutritional, and activity oriented care.

XIII.

The Reform Movement in America A. Benjamin Rush (1745-1813), founder of American Psychiatry, began treating mental illness in hospitals rather than in institutions, Pennsylvania Hospital (Philadelphia) was the first to admit mental patients. B. Dorthea Dix (1847) was responsible for the creation of 32 mental hospitals C. Clifford Beers (1908) fought for more humane treatment after his release from a mental institution. Wrote “A mind that found itself.” Founded the National Committee for Mental Hygiene - now the National Association for Mental Health. D. Recent deinstitutionalization increases humane treatment, but lowers the standard of care. Many homeless persons suffer from mental illness. (Figure 1-11. pg. 18)

XIV.

History Emphasizes Two Themes: A. The changing beliefs about abnormal behavior and its etiology. B. The need for humane and effective approaches to those with mental disorders.

XV.

Recent Concepts of Abnormal Behavior A. The Psychological Approach 1. Early 19th century promoted irrational thought and emotions as the basis for abnormal behavior. 2. Emotion and irrational feelings laid the groundwork for Sigmund Freud’s work. B. The Organic Approach 1. The approach in the 19th century emphasized diseases of the brain. 2. Structure deficiencies in the brain were sought and sometimes discovered. C. The Approaches Converge 1. Interactional or psychosocial approach currently directs the work of most researchers and clinicians. 2. The relative roles of genetic, biological, psychological, and social factors are studied for their roles and relationships.

XVI.

Vulnerability, Resilience, and Coping A. Stress - our reaction to a situation that imposes demands beyond our expectations or capabilities: 1. Risk factors increase one's vulnerability to stress. 2. Protective factors increase resilience. B. Vulnerability - how likely we are to respond maladaptively in situations: 1. Heredity, personality characteristics, lack of certain skills, overwhelming negative events. 2. Certain life factors can increase vulnerability in certain situations. C. Protective Factors (Table 1-1, pg. 21) - contribute to resilience. Child studies - resilient children engage others for support, are good communicators and problem solvers, and believe their actions will have positive results. D. Coping and Coping Skills 1. Thinking constructively, behaving flexibly, and providing behavioral monitoring for success or failure. 2. Coping behavior strengthens self-control and self-direction. 3. Coping may include assessment of desires, motivations, and conflicts.

XVII. Epidemiology of Maladaptive Behavior A. Epidemiological Research 1. Looking at patterns and relationships in maladaptive behaviors across populations and environments. 2. Table 1-2 (pg. 23) Epidemiological facts about mental illness. B. Incidence, Prevalence, and Risk Factors 1. Surveys and other data estimate the extent of a health problem. 2. Additional data on behaviors in the normal population to develop a context for interpreting the data. 3. Representative sampling - the selection of individuals from a larger population who, as a group, have the same distribution of the characteristic under study. 4. Kessler (1994) determined that 48% of Americans have experienced a mental disorder at some point in their lives. Study looked at 8,000 people across 34 states between ages 15 and 54. Survey found most prevalence disorders: a. Depression - 10% experienced depression in any given year while 17% experienced it at some point in their life. b. Alcohol - 7% in a given year, 14% at some point in a lifetime. c. Table 1-3 (pg. 24) definitions of epidemiological terminology: incidence, prevalence, lifetime prevalence, risk factor. C. Risk Factors - look at other, associated (causation is not implied) factors. D. Risk Factors - defined and used to predict possible future disorders. 1. Swanson, et al. (1990) - low rates of violence in anxiety disorder classification. 2. Hodgins et al. (1996); Torrey (1994) - higher rates of violence in psychosis (esp. schizophrenia) and drug and alcohol related disorders. 3. Relationship between socioeconomic status and violence (Swanson 1990). E. Epidemiological research has been able to correct some false assumptions about behavioral relationships: 1. Robins and Regier (1991) - high rates of arrest and incarceration in minority groups cannot be explained by diagnosis (anti-social personality) and substance related abuse disorders. 2. Men and women have similar rates of illnesses but different disorders: a. Women - Depressive and anxiety disorders. b. Men - Antisocial and substance abuse disorders. 3. Table 1-4 (pg. 24) - Common risk factors associated with mental disorders. XVIII.

Seeking Help for Abnormal Behavior - Reasons for clinical contact - Personal unhappiness A. The case of Jack Farmer B. The concerns of others - The Case of Mary Waverly C. Legal and community problems - The Case of Charles Clay

XIX.

Sources of Help A. Types of Treatment Facilities: 1. State and private mental hospitals. 2. Deinstitutionalization since the 1960s: civil rights of individuals and effectiveness of medications. 3. Community-based programs: a. Group homes b. Boarding houses c. Residential hotels d. Subsidized apartments B. Types of Mental Health Specialists: 1. Clinical psychologists 2. Counseling psychologists 3. Psychiatrists 4. Psychiatric social workers 5. Psychiatric nurses

6. General and Family Practitioners (M.D.’s) also prescribe medications C. Types of Treatment D. Obstacles to Treatment (Table 1-5, pg. 25) XX.

Research in Abnormal Psychology A. Observing Behavior 1. Observation is usually the first step in scientific research. 2. Setting objective guidelines must be set before observation begins (operational definition). B. Types of Observational Methods 1. Type used depends on the type of data collected. 2. Various participant and nonparticipant methods are used in observations. 3. Advantages and disadvantages to all forms of observation. C. Types of Observational Data - Four types: 1. Stimuli that elicit responses. 2. Subjective response to stimuli. 3. Behavioral response to stimuli. 4. Consequences of the behavior. D. Self-observations can be useful in clinical research. E. Figure 1-15 (pg. 30) – self-assessment of mood and activity. F. The Role of Theory 1. Path of scientific understanding: 2. Describe - informal and formal observations. 3. Explain - tentative hypotheses. 4. Predict - observation, data collection in controlled conditions. 5. Control - theory building and revision. 6. Good theories incorporate many existing facts in a broad framework: 7. Additional hypotheses may be developed. 8. Must be tested and may be refuted. G. The Research Journey 1. Specify the topic as clearly as possible. 2. Review the relevant literature. 3. Define the variables. 4. Develop a specific hypothesis. 5. Select a research strategy. 6. Conduct the study. 7. Analyze the results. 8. Report the research findings. H. Types of Research 1. Case studies. 2. Correlational studies. (Figure 1-17, pg. 32) 3. Assessment studies. 4. Longitudinal studies. 5. Follow-up studies. 6. Cross-sectional studies. I. Experimental studies - Type of experiments: 1. Hypothesis testing experiment 2. Figure 1-18 (pg. 34) - Conventional experimental design. 3. Behavior-change experiment. 4. Clinical trial (Box 1-3, pg. 36) 5. Experiments with animals. a. Comparative studies of animals and humans. b. Harry Harlow (Suomi and Harlow, 1972, 1978) (Figure 1-19, pg. 37) 6. Experiments with humans - Clinical trials a. Treatment and placebo categories b. Double-blind studies

XXI.

Research Design, Statistical Analysis and Inference A. Descriptive Statistics 1. Measures of central tendency. (Mean, Median, and Mode are the most common measures.) 2. Measures of Variability (Range and Standard deviation) B. Inferential Statistics 1. Methods based upon the laws of probability. 2. Observed differences are random or systematic. 3. Use of the Null hypothesis. 4. Statistical evaluation of data for significant differences based on probability tables. (Extend the findings beyond the sample to a larger group (population). C. Coefficient of Correlation 1. Measures the strength of a relationship but does not imply cause and effect. 2. Ranges from -1.00 to +1.00, -1.0 = perfectly inverse, 0.00 = no relationship. 3. The three types of correlational results: positive, negative, and zero. D. Interpreting Results of Research - validity of results. 1. Confounding variables - variables that are not controlled that could affect the dependent variable. 2. Reactivity - subject behaviors that change due to the experimental situation. 3. Demand characteristics - unintended information given to the subject. 4. Expectancy effects - experimenter bias, sampling bias. E. Ethical Aspects of Research – 1. Rights and dignity of subjects must always be protected. 2. Subjects should be informed of experiment and any risks involved. 3. Consent must be given by participants. 4. Opportunity to withdraw, debriefed if deception is used. 5. Data must be kept confidential.

XXII.

Take-Away Message

WEB LINKS American Psychological Association - http://www.apa.org American Psychological Society - http://www.psycscience.org American Psychiatric Association - http://www.psych.org Correlational Research http://trochim.human.cornell.edu/tutorial/lamar/ylamar.htm Extensive information about correlational research, including uses of the correlational method, how to plan various correlational studies, common mistakes in correlational studies, and understanding correlational statistics. Ethics - http://www.apa.org/ethics/code.html The American Psychological Association maintains this site dealing with the ethical principles of psychologists and how they pertain to assessment, treatment, and research. Experimental Research - http://trochim.human.cornell.edu/kb/desexper.htm Learn more about experimental methods and research. Generating Research Ideas - http://spsp.clarion.edu/RDE3/C2/C2Menu.html Learn how theories are formed, research hypotheses are generated and evaluated, and how science progresses. Internet Mental Health - http://www.mentalhealth.com An extensive and comprehensive site with information about mental health and mental disorders. Mental Help Net - http://mentalhelp.net/ A resource for information about all types of mental disorders and treatment. National Association of the Mentally Ill (NAMI) - http://www.nami.org/ The site of the National Association of the Mentally Ill, a resource for people suffering from mental illness and their families, has resources about treatment and support groups for every type of mental disorder. National Mental Health Association (NMHA) - http://www.nmha.org

Through its national office and more than 300 affiliates nationwide, The National Mental Health Association (NMHA) is dedicated to improving the mental health of all individuals and achieving victory over mental illnesses. The home page has links to information about disorders and treatment. National Institutes of Mental Health - http://www/nimh.nih.gov Substance Abuse and Mental Health Services Administration - http://www.samhsa.gov/ A government statistical and research website. The History of Psychology – http://www.library.yale.edu/socsci/subjguides/psychology/psyc124a.htm#Encyclopedias Explore the history of psychology by using the links provided by the Yale University Library. Today in the History of Psychology - http://www.cwu.edu/~warren/today.html An extensive chronology of events in the history of psychology, cataloged by day and date. Twin Research - http://www.psy.vu.nl/vakgroepen/psychonomie/ntr/twin_research.html Information and articles about twin research.

CRITICAL WRITING HANDOUT - STIGMA The Poem: Following the Littleton, Colorado, killings, Gary B. Larson (1999, April 24) paraphrased the writing of Martin Niemoller, 1892-1984, a Protestant pastor in Nazi Germany: “First they came for the blacks (and the Latinos and the American Indians and the Asians). I was silent. I was not black (or Latino or American Indian or Asian). Then they came for the gays and lesbians. I was silent. I was not gay or lesbian. Then they came for the kids with cleft palates, missing limbs, speech defects and other physical or mental defects. I was silent. I had no such defects. Then they came for the nerds, dweebs, and geeks. I was silent. I was not a nerd, dweeb or geek. Then they came for the fat, wimpy, and ugly kids. I was silent. I was not fat, wimpy or ugly. Then they came for the kids with attention deficit disorder. I was silent. I did not have the deficit disorder. And then they came for me. There was no one left to speak for me.” (http://members.home.net/garbl/writing/comment.htm)

Your Thoughts:

Summary of Incidence and Prevalence of Mental Health Disorders in the United States - The National Institutes of Mental Health, a division of the National Institutes of Health (http://www.nimh.nih.gov/publicat/numbers.cfm) The Numbers Count: Mental Disorders in America Mental disorders are common in the United States and internationally. An estimated 22.1 percent of Americans ages 18 and older—about 1 in 5 adults—suffer from a diagnosable mental disorder in a given year. When applied to the 1998 U.S. Census residential population estimate, this figure translates to 44.3 million people. 2) In addition, 4 of the 10 leading causes of disability in the U.S. and other developed countries are mental disorders– major depression, bipolar disorder, schizophrenia, and obsessivecompulsive disorder. 3) Many people suffer from more than one mental disorder at a given time. In the U.S., mental disorders are diagnosed based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Depressive Disorders Depressive disorders encompass major depressive disorder, dysthymic disorder, and bipolar disorder. Bipolar disorder is included because people with this illness have depressive episodes as well as manic episodes. Approximately 18.8 million American adults, or about 9.5 percent of the U.S. population age 18 and older in a given year, have a depressive disorder. Nearly twice as many women (12.0 percent) as men (6.6 percent) are affected by a depressive disorder each year. These figures translate to 12.4 million women and 6.4 million men in the U.S. Depressive disorders may be appearing earlier in life in people born in recent decades compared to the past. Depressive disorders often co-occur with anxiety disorders and substance abuse. Major Depressive Disorder Major depressive disorder is the leading cause of disability in the U.S. and established market economies worldwide. Major depressive disorder affects approximately 9.9 million American adults, or about 5.0 percent of the U.S. population age 18 and older in a given year. Nearly twice as many women (6.5 percent) as men (3.3 percent) suffer from major depressive disorder each year. These figures translate to 6.7 million women and 3.2 million men. While major depressive disorder can develop at any age, the average age at onset is the mid-20s. Dysthymic Disorder Symptoms of dysthymic disorder (chronic, mild depression) must persist for at least 2 years in adults (1 year in children) to meet criteria for the diagnosis. Dysthymic disorder affects approximately 5.4 percent of the U.S. population age 18 and older during their lifetime. This figure translates to about 10.9 million American adults. About 40 percent of adults with dysthymic disorder also meet criteria for major depressive disorder or bipolar disorder in a given year. Dysthymic disorder often begins in childhood, adolescence, or early adulthood. Bipolar Disorder Bipolar disorder affects approximately 2.3 million American adults, or about 1.2 percent of the U.S. population age 18 and older in a given year. Men and women are equally likely to develop bipolar disorder. The average age at onset for a first manic episode is the early 20s. Suicide In 1997, 30,535 people died from suicide in the U.S. More than 90 percent of people who kill themselves have a diagnosable mental disorder, commonly a depressive disorder or a substance abuse disorder. The highest suicide rates in the U.S. are found in white men over age 85. The suicide rate in young people increased dramatically over the last few decades. In 1997, suicide was the third leading cause of death among 15 to 24 year-olds. Four times as many men than women commit suicide; however, women attempt suicide 2-3 times as often as men.

Schizophrenia Approximately 2.2 million American adults, or about 1.1 percent of the population age 18 and older in a given year, have schizophrenia. Schizophrenia affects men and women with equal frequency. Schizophrenia often first appears earlier in men, usually in their late teens or early 20s, than in women, who are generally affected in their 20s or early 30s. Anxiety Disorders Anxiety disorders include panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, and phobias (social phobia, agoraphobia, and specific phobia). Approximately 19.1 million American adults age 18-54, or about 13.3 percent of people in this age group in a given year, have an anxiety disorder. Anxiety disorders frequently co-occur with depressive disorders, eating disorders, or substance abuse. Many people have more than one anxiety disorder. Women are more likely than men to have an anxiety disorder. Approximately twice as many women as men suffer from panic disorder, post-traumatic stress disorder, generalized anxiety disorder, agoraphobia, and specific phobia, though about equal numbers of women and men have obsessivecompulsive disorder and social phobia. Panic Disorder Approximately 2.4 million American adults age 18-54, or about 1.7 percent of people in this age group in a given year, have panic disorder. Panic disorder typically develops in late adolescence or early adulthood. About 1 in 3 people with panic disorder develop agoraphobia, a condition in which they become afraid of being in any place or situation where escape might be difficult or help unavailable in the event of a panic attack. Obsessive-Compulsive Disorder (OCD) Approximately 3.3 million American adults age 18-54, or about 2.3 percent of people in this age group in a given year, have OCD. The first symptoms of OCD often begin during childhood or adolescence. Posttraumatic Stress Disorder (PTSD) Approximately 5.2 million American adults age 18-54, or about 3.6 percent of people in this age group in a given year, have PTSD. PTSD can develop at any age, including childhood. About 30 percent of Vietnam veterans experienced PTSD at some point after the war. The disorder also frequently occurs after violent personal assaults such as rape, mugging, or domestic violence; terrorism; natural or humancaused disasters; and accidents. Generalized Anxiety Disorder (GAD) Approximately 4.0 million American adults age 18-54, or about 2.8 percent of people in this age group in a given year, have GAD. GAD can begin across the life cycle, though the risk is highest between childhood and middle age. Social Phobia Approximately 5.3 million American adults age 18-54, or about 3.7 percent of people in this age group in a given year, have social phobia. Social phobia typically begins in childhood or adolescence. Agoraphobia and Specific Phobia Agoraphobia involves intense fear and avoidance of any place or situation where escape might be difficult or help unavailable in the event of developing sudden panic-like symptoms. Approximately 3.2 million American adults age 18-54, or about 2.2 percent of people in this age group in a given year, have agoraphobia. Specific phobia involves marked and persistent fear and avoidance of a specific object or situation. Approximately 6.3 million American adults age 18-54, or about 4.4 percent of people in this age group in a given year, have some type of specific phobia.

Eating Disorders The three main types of eating disorders are anorexia nervosa, bulimia nervosa, and binge-eating disorder. Females are much more likely than males to develop an eating disorder. Only an estimated 5 to 15 percent of people with anorexia or bulimia and an estimated percent of those with binge-eating disorder, are male. In their lifetime, an estimated 0.5 percent to 3.7 percent of females suffer from anorexia and an estimated 1.1 percent to 4.2 percent suffer from bulimia. Community surveys have estimated that between 2 percent and 5 percent of Americans experience binge-eating disorder in a 6month period. The mortality rate among people with anorexia has been estimated at 0.56 percent per year, or approximately 5.6 percent per decade, which is about 12 times higher than the annual death rate due to all causes of death among females age 15-24 in the general population. Attention Deficit Hyperactivity Disorder (ADHD) ADHD, one of the most common mental disorders in children and adolescents, affects an estimated 4.1 percent of youths age 9-17 in a 6-month period. About two to three times more boys than girls are affected. ADHD usually becomes evident in preschool or early elementary years. The disorder frequently persists into adolescence and occasionally into adulthood. Autism Autism affects an estimated 1 to 2 per 1,000 people. Autism and related disorders (also called autism spectrum disorders or pervasive developmental disorders) develop in childhood and generally are apparent by age three. Autism is about four times more common in boys than girls. Girls with the disorder, however, tend to have more severe symptoms and greater cognitive impairment. Alzheimer's Disease Alzheimer's disease, the most common cause of dementia among people age 65 and older, affects an estimated 4 million Americans. As more and more Americans live longer, the number affected by Alzheimer's disease will continue to grow unless a cure or effective prevention is discovered. The duration of illness, from onset of symptoms to death, averages 8 to 10 years. National Institute of Mental Health (NIMH) Office of Communications and Public Liaison Public Inquiries: (301) 443-4513 Media Inquiries: (301) 443-4536 E-mail: nimhinfo@nih.gov Website: http://www.nimh.nih.gov * All material in this fact sheet is in the public domain and may be copied or reproduced without permission from the Institute. Citation of the source is appreciated. NIH Publication No. 01-4584

Chapter 2 Theoretical Perspectives on Maladaptive Behavior OVERVIEW Chapter 2 presents six perspectives of abnormal behavior: biological, psychodynamic, behavioral, cognitive, humanistic-existential, and community-cultural. Following the introduction of Fred Price, his situation and his history, questions are asked from each of the six theoretical perspectives of abnormal psychology. The authors suggest that behaviors have multiple determinants and that theories guide clinicians and the researchers in their investigations of maladaptation. Etiologies and treatment are considered within the discussion of each perspective. Beginning on page 80, the authors describe the interactional approach that guides the philosophy of the text. Many psychologists share the interactional approach because it is an approach that incorporates the many factors that affect an individual’s behavior. The factors discussed in the six perspectives are viewed as contributing to the vulnerability and resiliency of the individual. CONTENTS The Role of Theory in Abnormal Behavior The Biological Perspective Genetic Factors The Nervous System and the Brain The Endocrines The Neuroscience Revolution Integration of Biological and Psychological Systems The Psychodynamic Perspective Freud and Psychoanalysis More Recent Approaches to Psychoanalysis Evaluating Psychoanalytic Theory The Behavioral Perspective Classical Conditioning Operant Conditioning Social-Cognitive Theories The Cognitive Perspective Maladaptive Behavior and Cognition Cognitive Therapies The Humanistic-Existential Perspective The Humanistic View The Existential Views The Community-Cultural Perspective Social Roles and Labeling Contributions of the Community-Cultural Perspective An Interactional Approach Take-Away Message LEARNING OBJECTIVES After completing this chapter students should be able to: 1. Identify and apply the six theoretical perspectives used to study abnormal behavior. 2. Recognize the importance of genetics in the study of mental disorders. 3. Discuss the goals of the human genome project. 4. Name the elementary components of a neuron. 5. Describe the relationship between the new information about genetics and role that the information might play in the treatment of mental disorders. 6. Discuss the relationship between the brain and behavior. 7. Describe neuroplasticity. 8. Define Freud’s fundamental concept of psychic determinism and its relationship to the conscious, preconscious, and unconscious.

9. 10. 11. 12. 13. 14.

Describe the concept of the psychic apparatus, primary process thinking, secondary process thinking, and defense mechanisms. Define the essential elements of the behavioral perspective, including classical and operant conditioning, positive and negative reinforcement, punishment and modeling. Describe modeling and the role it plays in learning adaptive and maladaptive behaviors. Discuss the important features of the cognitive perspective and the role of cognitive therapy and rational emotive therapy in understanding how internal systems can guide external behaviors. Identify the significant contributors to the cognitive, humanistic, and existential perspectives. Describe several of the strengths of the Interactional Approach to understanding abnormal behavior.

LECTURE AND DISCUSSION TOPICS 1. What are some of the new techniques used in studying the causes of mental disorders. How are these techniques used in the diagnosis and proposed treatment of these disorders? a. Discuss techniques that have led to the discovery of the relationship between biological factors and abnormal behavior. Include the PT scan, MRI, and the CT scan. b. Find out if members of the class have undergone CT or PT scans and are these techniques superior to the older EEG or X-ray? In the past, if a brain tumor was suspected, what technique was used to verify the diagnosis? What illnesses can be diagnosed using these techniques? Include a discussion of brain tumors, strokes, multiple sclerosis, brain injuries, or schizophrenia. c. What are some of the ethical and social problems encountered by genetic research? 2. Discuss karyotypes and gene mapping. What are some of the disorders related to genetic abnormalities? Include a discussion of such disorders as Down syndrome (trisomy 21), Klinefelter's syndrome (a male with 2 X chromosomes), and Turner's syndrome (a female with 1 X chromosome). 3. Challenge the class to reconsider Freud’s ideas and constructs as if he were a researcher/clinician today. Would he be a behaviorist, a neuropsychiatrist, or a cognitive scientist? 4. Discuss the ethical dilemmas that would likely occur in the following situations: a. A mother finds that her unborn child has a chromosomal disorder, and therefore the child will not live a "normal" life. b. A young woman discovers that she is carrying genes that greatly increase her risk for breast cancer. Will her insurance company cancel her policy? Should she consider a mastectomy as a prevention measure even though her risk for developing the cancer is less than one hundred percent? c. In the future through genetic analysis, the prediction of certain illnesses may be possible. Should this information be provided to prospective employers? Should the prerequisite of a genetic analysis be present in certain types of employment? Could individuals be assured that these genetic records would remain confidential? Could this lead to discrimination? d. If a determination is made that homosexuality is genetic, should parents be informed of the presence of that genetic factor in their developing fetus? If prenatal genetic engineering were possible, should parents be given the right to request that? e. If genetic research clearly demonstrates the genetic etiology of certain disorders, should individuals who carry these genetic defects (that could be passed on to children) be allowed to reproduce? f. Should individuals in our society be forced to undergo genetic testing? Under what conditions should it be allowed? Does this violate a person's right to privacy? STUDENT ACTIVITIES 1. Freud's theory of personality, famous people. Using Freud's three structures of personality, the id, ego, and superego, have class members determine the dominance of each structure in each of the following famous people or characters. Have them give the reasons for their choices: Mother Teresa, Mike Tyson, Marilyn Manson, former President Clinton, Newt Gingrich, the "pre-baby" Madonna and the "post-baby" Madonna, the Spice Girls, Jimmy Lee Swaggert, Brad Pitt, Hillary Clinton. 2. Community programs and the community-cultural perspective.

The community-cultural perspective sees maladaptive behavior as a result of the inability to cope with stress. Discuss this concept and then divide the class into three groups and make the following assignments: Group 1: Develop a list of programs and facilities provided by your community for infants, preschool, and school age-children. Group 2: Develop a list of programs and facilities provided by your community for teenagers, young single adults, young married adults, and middle-aged citizens. Group 3: Develop a list of programs and facilities provided by your community for older citizens. Behavior Theory, Social Learning Theory, and Day-to-Day Living a. Discuss the following points: Using the behavioral approach, how would you get a child to refrain from coloring a wall by using the following approaches: positive reinforcement (give examples) and negative reinforcement (give examples). b. What are the side effects if severe punishment is used to control behavior? Are there any examples of these side effects that we see in everyday life? According to behavior theory, what is the best way to control undesirable behavior? How does our society deal with undesirable behaviors? What are the results? What improvements could be made? c. Have the class members discuss the implications of modeling and today's violence in children. Does violence on television affect children, boys and girls, younger or older children equally? Should television viewing be limited? Are there other examples of cultural violence that would confound a finding that television is highly related to violence? The Humanistic-Existential Perspective a. Discuss with the class how the humanistic-existential approach differs from most other perspectives. Also discuss free will vs. determinism. b. Discuss the role of the therapist as presented by Carl Rogers. What are some of the problems that might arise when using Rogerian therapy with schizophrenic patients, with individuals who are not extremely verbal, and with individuals of lower levels of intelligence? c. Discuss the differences between self-actualization (humanism) and self-determination (existentialism). d. How are authentic behaviors and inauthentic behaviors related to our choices of colleges and choices of careers? Develop a Role-Play Group students in pairs or teams to discuss and develop a role-play for each of the defense mechanisms mentioned in Table 2-4 (pg. 64) On note cards (or the role-play charts), list each defense mechanism, to be known only to that team or person. The goal of the exercise will be for the rest of the class to identify the defense mechanism that the team/person is role-playing. Allow about 5 minutes for the role-play development and 3-4 minutes for each role-play enactment.

Critical Writing Read about Fred Price. Using the Interactional Approach where all of the physical, psychological, and social factors may be considered, write an action plan for Fred. What are the steps he should take to resolve his problem? Think about the antecedents (pre-disposing factors) and consequences of any of the several actions that he could take. Read the concluding statements about Fred for each perspective. GREAT BOOKS TO READ Humanistic-Existential Bugental, James F. T. (1978, January). Psychotherapy and Process: The Fundamentals of an ExistentialHumanistic Approach. New York: McGraw-Hill Co. ISBN: 0075548275. Fromm, Erich. (1990, October). Man for Himself: An Inquiry into the Psychology of Ethics. New York: Henry Holt & Co. ISBN: 0805014039. Nye, Robert D. (1999, July). Three Psychologies: Perspectives from Freud, Skinner, and Rogers (6th ed.) Albany, NY: Delmar. ISBN: 053436845X Behavioristic Davidson, Jon R.(1978). Buying and Goodbying of Behaviorism's Way: Confessions and Perspectives of an Ex- Behaviorist. Boston: Libra Publishers.

Kohn, Alfie. (1999, September). Punished by Rewards: The Trouble with Gold Stars, Incentive Plans, A's, Praise, and Other Bribes. Boston: Houghton Mifflin Co. Watson, John B. (1997, October). The Study of Behavior. Somerset, NJ: Transaction Publishers. ISBN: 1560009942. Psychodynamic Vaughan, Susan C. (1998, April). The Talking Cure: The Science behind Psychotherapy. New York: Henry Holt & Co. Edition Description: REPRINT ISBN: 0805058273. Cognitive Beck, Aaron T. (1979). Cognitive Therapy and the Emotional Disorders. New York: N.A.L. ISBN: 045200928. Beck, Judith S. (1995, June). Cognitive Therapy: Basics and Beyond. (Foreword by Aaron T. Beck). New York: Guilford Publications, Inc. ISBN: 0898628474. The Human Genome Project. (2001, February 12). http://www.nature.com. VIDEO RESOURCES Professional Bandura, Albert: Interview With Richard Evans, University of Houston, Houston, TX B. F. Skinner and Behavioral Change, 45 min. (Research Press). The life and theory of B. F. Skinner is presented and behavioral therapy is discussed. Being Abraham Maslow, 30 min. (FLLMIB). Maslow describes his theoretical viewpoints and events leading the development of his personality theory. Erik Erikson: Interview, 50 min. (AIM). Erikson presents Erikson’s theory. Video Discovering Psychology: Learning, 28 min. (Annenberg/CPB). This film describes the basic principles of learning theory. Hormone Hell, 60 min. (2000). Discovery Channel. From menopause and PMS to job stress and sports. This film interviews teens, elderly people, and professionals in high stress positions who are living proof of the power of hormones. The Inner Workings of the Brain. (1999). (CD-ROM and online: http://www.nimh.nih.gov/publicat/braincd .cfm). Bethesda, MD: National Institutes of Mental Health. Fifty years of brain research at NIMH with Leonard Nimoy. Excellent animation of neurons in the brain. CHAPTER OUTLINE I. The Role of Theory in Abnormal Psychology A. Theories are never complete. B. Theories evolve in response to the prevailing situation. C. Six Influential Theoretical Perspectives: 1. Biological Perspective 2. Psychodynamic Perspective 3. Behavioral Perspective 4. Cognitive Perspective 5. Humanistic-Existential Perspective 6. Community-Cultural Perspective D. Freud was a neurologist who began seeing patients with problems that neurology could not solve. His theories evolved from a change in thought about the etiology of mental illness. E. Theories contain elements that should be combined to achieve a better explanation of human behavior. F. When and how to combine elements is a challenge to abnormal psychology.

The orientation of this book.

II.

The Biological Perspective A. Genetic Factors 1. Research provides evidence of genetic factors and various mental disorders. 2. Twenty-three pairs of chromosomes, one contributed by each parent equaling 46 chromosomes. 3. Chromosomal anomalies are often responsible for brain abnormalities. Although it was expected that the human chromosome would yield approximately 100,000 genes, the completion of the mapping in the genome project has reported that humans have more nearly 30,000-35,000 genes in their genomes. A definitive count of human genes must await further experimental and computational analysis (Nature, 2001, February 15). 4. About 60% of the genes are related to specific brain functions. 5. About 4,000 diseases are known to result from abnormalities of a gene or failure of a gene to work correctly. 6. Karotypes – maps of chromosomes. 7. Genome – the complete map of a human. 8. DNA - deoxyribonucleic acid; shaped like a double helix, encodes genetic information in genes. B. Heritability – degree to which a characteristic is affected by genetic influence. 1. Table 2-1 (pg. 49) – common terms used by geneticists 2. Table 2-2 (pg. 49)-milestones in genetic research C. Behavior Genetics 1. Behavior genetics are usually studied in one of two forms: a. Analysis of family histories b. Twin studies (Figures 2-2 and 2-3, pg. 50) 2. Behavior genetics gave birth to the nature-nurture controversy. 3. Current beliefs focus on nature and nurture together. D. The Nervous System 1. Central nervous system (Figure 2-4, pg. 51) 2. Peripheral nervous system (Figure 2-4, pg. 51) E. The Brain 1. The brain (Figure 2-6, pg. 53) is the most complex part of the nervous system. 2. Disturbances to a specific area will result in specific behavioral responses. 3. EEGs show brain wave patterns specific to different behaviors. (Figure 2-7, pg. 54) F. The Brain and Behavior -The brain reward system consists of two systems: 1. The hypothalamus 2. Structures of the limbic system G. Endorphins fit into the receptors of the reward system and provide pain.

III.

Frontiers of Brain Research A. Genes provide basic structure of the brain, but life experiences shape it. B. The Endocrine Glands (Figure 2-8, pg. 56) 1. Endocrine glands secrete chemicals directly into blood stream. 2. The endocrine system also plays an important role in response to life. C. The Neuroscience Revolution 1. Researchers strive to understand the relationship between the structure and function of the brain and human thoughts, feelings, and behavior. 2. The brain has three major aspects a. Physical system b. Chemical system c. Information system 3. Center of complex processes D. Brain Imaging - Various imaging techniques have been developed to provide a means for studying the structure and function of the living brain.

E. F.

1. CT 2. MRI (Figure 2-9, pg. 57) 3. MRS 4. SPECT 5. PT (Figure 2-10, pg. 57) Psychoneuroimmunology - studies interactions among the nervous, endocrine, and immune systems simultaneously. Integration of Biological and Psychological Systems 1. The development and refinement of antipsychotic drugs has been an important achievement. 2. Too many interacting factors are involved in mental illness to rely solely on the organic perspective.

IV.

The Psychodynamic Perspective A. Freud and Psychoanalysis - Freud focused on psychic determinism and consciousunconscious dimension (Figure 2-11, pg. 61). B. Intrapsychic conflicts determine awareness of mental events. 1. Stages of psychosexual development include: a. Oral b. Anal c. Phallic d. Genital e. Latency 2. Psychic apparatus is composed of (Figure 2-13, pg. 63): a. Id b. Ego c. Superego 3. Anxiety is a response to perceived danger or stress. 4. Defense mechanisms protect from anxiety. (Table 2-4, pg. 64) C. Clinician Psychoanalysis - Behavior is caused by childhood experiences; patients express any feeling or thoughts using free association; not all types of maladaptive behavior are suitable for psychoanalysis. D. More Recent Approaches to Psychoanalysis 1. Carl Jung and Alfred Adler disagreed with Freud's theory and had more optimistic views on human nature. 2. Erik Erikson outlined a life cycle of developmental stages. 3. Object relations theory states the mind consists of internal representation of others. 4. Heinz Kohut presented the self-psychological theory. E. Evaluating Psychoanalytic Theory

The Behavioral Perspective A. Classical Conditioning 1. Ivan Pavlov classically conditioned dogs. 2. Fears/anxieties can be explained by classical conditioning from the past. 3. Fears can be removed using systematic desensitization. B. Operant Conditioning 1. B.F. Skinner (Figure 2-15, pg. 68) developed the "Skinner box." 2. Organism operates on environment and reinforcement follows. 3. Shaping allows behavioral changes through reinforcement. 4. Various reinforcement schedules are used in research. 5. Clinical use of reinforcement C. Social-Cognitive Theories 1. People learn behaviors through modeling. (Figure 2-16, pg. 70) 2. A great deal is learned through implicit learning. 3. Clinical use of reinforcement 4. Goal is to change cognitive processing errors (Table 2-6, pg. 74)

Recent interest in the relationship between cognitive factors and social learning has developed.

VI.

The Cognitive Perspective A. Maladaptive Behavior and Cognition 1. Aaron Beck (Figure 2-18, pg. 72) put forth the concept of schemas and their role in behavior. 2. Cognitive disturbances are often the cause of maladaptive behavior. (Figure 2-19, pg. 73) 3. People must be taught a new way of thinking to prevent maladaptive behavior. 4. Albert Ellis: one's belief system influenced behavior in his rational-emotive therapy. B. Cognitive Therapies

VII.

The Humanistic-Existential Perspective A. The Humanistic View 1. All people are striving to reach self-actualization. 2. Anxiety occurs when there is a discrepancy between one's self-perceptions and one's ideal self. B. The therapist must fully accept the client rather than giving advice. C. The Existential View 1. Individual choice and self-determination are emphasized. 2. One has the choice to act authentically or inauthentically. 3. Therapist should help client expand by making constructive choices.

VIII.

The Community-Cultural Perspective A. Social Roles and Labeling 1. The extreme view states that there is no true self, only various social roles. 2. The most popular view states that there is a basic personality - overlapped faith and various social roles. 3. Labeling is an easy way to categorize others, but it is often discriminatory. B. Contributions of the Community-Cultural Perspective 1. The community-cultural perspective has brought attention to segments of the population that were not previously studied. 2. This perspective provided incentive for future research.

IX.

An Integrative Approach A. All six perspectives can be used to study deviant behavior. B. It is important to understand the interaction of various factors as the cause of maladaptive behavior.

X. Take-Away Message WEB LINKS Albert Bandura's Social Learning Theory – http://www.valdosta.peachnet.edu/~whuitt/psy702/behsys/social.html This article focuses on Bandura’s social learning views, especially observational learning. Includes a link to information about behaviorism. Bandura's Life and Work - http://erebus.bentley.edu/students/b/buryj_dani/ Read a biography of Bandura and explore his views on observational learning, television and violence, and personality development. B.F. Skinner - http://www.bfskinner.org/ and http://www.lafayette.edu/allanr/skinner.html These sites are devoted to the life and work of B.F. Skinner. Classical Conditioning - http://www.brembs.net/classical/classical.html Learn more about classical conditioning. Erik Erikson - http://snycorva.cortland.edu/~ANDERSMD/ERIK/welcome.HTML

Dedicated to Erik Erikson with tutorials on the eight stages of development, as well as links to resources about Erikson and his theories. Human Genome Project - http://www.ornl.gov/hgmis You can learn about how genes are "discovered" and keep up with the latest research findings. Netherlands Twin Register - http://www.psy.vu.nl/vakgroepen/psychonomie/ntr/index.html Repository for large-scale twin research conducted by behavioral geneticists. Neurolink - http://www.asktom-naturally.com/neuro.html Learn about how neurotransmitters affect your mood. Neurotransmitters in Living Color - http://micro.magnet.fsu.edu/micro/gallery/neurotrans/neurotrans.html See vivid color images of neurotransmitters as a result of photomicroscopy. News in Science - http://www.sciencedaily.com. Daily announcements from around the world about the newest research findings in neurobiology, neuropsychology, and more. Operant Conditioning - http://www.uwm.edu/~johnchay/oc.htm Demonstration/Simulation of operant conditioning using Macromedia Shockwave. Recent Developments in Human Behavioral Genetics – http://www.faseb.org/genetics/ashg/policy/pol-28.htm This article, written by a number of leading behavior geneticists, describes traditional and innovative methods in the field of behavior genetics. Schedules of Reinforcement - http://www.brembs.net/operant/schedule.html Learn more about operant conditioning reinforcement schedules. Self-Efficacy - http://www.emory.edu/EDUCATION/mfp/publications.html This site is devoted to the topic of self-efficacy with links to many self-efficacy research programs, how self-efficacy can be assessed, and the role of self-efficacy in motivation. Sigmund Freud - http://plaza.interport.net/nypsan/freudarc.html This site is devoted to Sigmund Freud and has links to other Freud sites. The Nurture Assumption - http://www.edweek.com/ew/vol-18/04parent.h18 This article evaluates the controversial book, The Nurture Assumption, written by Judith Harris that questions parents' influence and promotes the importance of heredity in children's development.

Role-Play Cards

Displacement

Intellectualization

Reaction Formation

Denial

Aggressor Identification Projection

Regression

Sublimation

Undoing

Rationalization

Chapter 3 Therapies OVERVIEW Chapter 3 covers various psychotherapies including psychodynamic, humanistic, and existential therapies. Also discussed are cognitive-behavioral therapies and group therapies. The effectiveness of such therapies is covered along with biological therapies and their outcomes. Finally hospitalization and dinstitutionalization are discussed. CONTENTS Psychotherapy Cognitive-Behavioral Approaches Integration and Extension of Psychological Therapies Integration of Psychologically Based Therapeutic Approaches Biological Therapies Hospitalization Take-Away Message LEARNING OBJECTIVES Upon completing this chapter students should be able to: 1. List the concerns voiced about all forms of therapy. 2. List the major characteristics of each of the major psychotherapies: including psychodynamic therapy, humanistic and existential therapies, cognitive psychotherapy, brief psychotherapy, and interpersonal. 3. Describe the three factors that are incorporated into a meta-analysis. 4. Discuss the preferred features of group therapy. 5. List three of the key features of research on psychotherapies. 6. Describe ECT, how it is administered, possible side effects, but its value to the retractable patient. 7. Discuss the use of drug therapy. 8. Discuss the changing practice of hospitalization for the mentally ill. LECTURE AND DISCUSSION TOPICS 1. Consumer Reports Controversy Slife (1998) presents two sides to the argument, "Does psychotherapy help" and "Is the Consumer Reports study valid?" Seligman (December 1995) argued that psychotherapy is effective by the fact that most clients felt satisfied. He based his argument on a 1995 Consumer Reports survey that found a 90% satisfaction level among people who responded to questions. Although the study used questionable methods, Seligman continues to support the reports. 2. Seligman provided the following data from Consumer Reports: a. Treatment by a mental health professional usually worked. b. Long-term therapy produced more improvement than short-term therapy. c. There were differences between psychotherapy alone and psychotherapy combined with medication. d. Psychologists, psychiatrists, and social workers did equally well and better than marriage counselors. e. Family doctors did as well as mental health professionals only in the short term. f. Alcoholics Anonymous (AA) did better than mental health professionals. g. Active "shoppers" and active clients did better in therapy than passive recipients. h. No specific type of psychotherapy was better than another. i. Clients limited by insurance coverage did worse. 3. Jacobson and Christensen (October 1996) argue that the Consumer Reports survey was flawed from the very beginning. They liken this survey to Freud's case studies, and suggest that a grave mistake would be made if this method is used in the fixture. Jacobson and Christensen argue in favor of controlled and well-designed experiments to study the effectiveness of psychotherapy. 4. Problems seen with the Consumer Reports survey are these: a. No control group existed, a fact that is considered a fatal flaw.

b. Consumer Reports survey results were unreliable and unrevealing. c. Survey did not assess which therapies had the best improvement and which did not. d. Results were misleading. After discussing the Consumer Reports survey, address the following questions with the class: a. What are the characteristics of a good experiment? b. Do you think psychotherapy is effective? Give examples. Is this scientific thinking? c. Do you think client satisfaction equates with client improvement? d. Now that many disorders have been identified as being biological in nature, do you think that clinical counseling psychologists will become extinct? e. What kind of problems will be treated by psychologists? f. What will be the focus of psychologists in the future? g. How will it be possible for psychologists to help clients with biologically based mental disorders? h. Ask the class members: When should drugs be used? (1) Antidepressant following the death of a spouse (2) Viagra for impotence in an eighty-year-old man (3) Ritalin for an excited child (going to summer camp the next day) (4) Antidepressant for a year-long unexplained depression (5) MAO inhibitor for a depressed wine taster (6) Sedative for a depressed alcoholic (7) Vicodine or Demerol for an ex-heroin addict (8) Lithium for a bipolar individual who is on kidney dialysis (9) Ritalin on a bipolar individual who is in a manic state (10) Electroconvulsive therapy on a patient suffering from epilepsy (11) Prefrontal lobotomy on a person with dependent personality disorder (12) Ask the class when these drugs or treatments should be used, if ever. (13) What are the problems with the drugs and the accompanying conditions? Discuss with the class the characteristics of ECT as it was used in the past. a. The current was administered to both sides of the brain. b. The length of the electrical current was poorly regulated. c. The intensity of the electrical current was poorly regulated. d. The number of treatments was unregulated (if no improvement, give more). e. No mouth protectors were provided and currents burned the mouth. f. No muscular relaxants were given, and injuries were common. g. Anesthesia was not administered, and patients dreaded treatments. h. Severe memory loss could result because of the method of application. i. Have students relate stories that they have heard about past problems with ECT. Discuss the improvements in ECT and its increased safety. a. Typically given in an acute care hospital. b. Current lasts for only 1/25 of a second. c. Treatments are administered only up to three times a week. d. Typically no more than 10 sessions are provided. e. Anesthesia and muscle relaxants are given before treatment. f. Brain activity and cardiac activity are monitored. g. Electrodes are placed only on the nondominant side of the head. When is ECT used today? Include such factors as: a. Severe depression. b. Other medications and therapies have not worked. c. Eating and sleeping habits are severely disturbed. d. The individual is suicidal. e. Delusions are present in many patients recommended for ECT. f. Is ECT relatively safe as it is used today? Include the fact that its administration may help the patient avoid suicide; most individuals see rapid improvement; death has occurred only 1 in 10,000 treatments; a chance for memory impairment exists; and a risk for spontaneous seizures may increase.

10.

11.

12.

Have class members discuss situations of which they have heard or read about regarding the uses of surgery in the treatment of neurological disorders or to regulate behavior. a. Brain tumor (have class give examples) b. Stroke (have class give examples) c. Traumatic injury (have class give personal accounts) d. Aneurysm (explain) e. Parkinson's disorder (experimental implantation of tissue) f. Epilepsy (only as last resort: removal of tissue or split brain method) g. Obsessive-compulsive disorder (experimental) h. Aggressive behavior (experimental) i. Chemical/surgical castration to regulate sexual predator behavior Ask the class to discuss controversial brain surgeries that have been performed. Include such procedures as seen in movies or television; an example would be the movie, One Flew Over the Cuckoo’s Nest. Interesting case of accidental surgery: Newspaper accounts reported an unusual case where a man suffering from obsessive-compulsive disorder was so depressed, he purchased a gun and intended to commit suicide. He shot himself in the head, but survived the gun wound. The path of the bullet evidently severed an area related to OCD and the man was never again bothered by obsessions or compulsions. Ask the class to discuss “Does therapy make you feel good or does it help you get better?” What is the difference? How could you measure this? Explain, if necessary, that “feeling good” is a subjective evaluation of a mental state. Feeling good may or may not be related to getting better. Often we feel good when someone listens to us or agrees with us. That does not mean that our ways of looking at and evaluating situations and behaving have changed. If our thinking and behavior have not changed, we'll end up in the same situation again. However, the test of the effectiveness of therapy is “do the patient's behavior and ways of thinking change in a way that is beneficial to the patient?” How would class members measure the effectiveness of “therapy”? Have members include objective measures, a control group, adequate sample, repeatability, and a comparison group. Explain the problems involved if their design is faulty.

STUDENT ACTIVITIES Classroom 1. The Psychologist - Have a psychologist from the college or university counseling center or a psychologist in private practice discuss his/her activities with the class. Have the visitor address such areas as training, clients’ problems, referrals, methods used, and successes. 2. The Hospital - Invite an administrator or public relations person from an acute care hospital to discuss his/her facility and the therapeutic services. Have the person include such points as the patients, the disorders, the treatments, the special programs, admissions procedures and reasons for admission, release procedures, follow-up programs, and successes in the neuropsychiatric program. 3. The Community Program - Have a representative from some community program (city or neighborhood) come to class and describe the program to the class. This person could represent a community mental health/mental retardation program, a work program for mentally retarded, an alcohol abuse program, or a group home program. Have the class ask questions after the presentation. Assignment Read the three cases presented at the beginning of the chapter. Think about the issues presented by the client and the approaches undertaken by the therapist. Is there an alternative approach that could have been taken? Could brief therapy have been used for all three of the clients?

Great Books to Read Baker, Sidney & Baar, Karen. (April 2000). The Circadian Prescription. Putnam Pub Group. ISBN: 0399145966. Dobson, Keith. (April 1990). Handbook of Cognitive-Behavioral Therapies. New York: Guilford Press. ISBN: 0898625246. Liebmann, Marian. (April 1986). Art Therapy for Groups: A Handbook for Themes, Games, and Exercises. Massachusetts: Brookline Books. ISBN: 0914797247. Lowenstein, Liana. (April 1999). Creative Interventions for Troubled Children & Youth. Washington: Champion Press. ISBN: 0968519903. Papolos, Demitri F., & Papolos, Janice. (1999). The Bipolar Child : The Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder. New York: Broadway Books. ISBN: 0767903161. Vertosik, Frank. (1996). When the Air Hits Your Brain: Tales of Neurosurgery. New York: Fawcett Crest. ISBN: 0449227138. Insight, humor, and poignancy in this diary of the making of a neurosurgeon in Pittsburgh, PA. VIDEO RESOURCES Professional Approaches to Therapy, 30 min. (sight Media). This video takes one client through three therapy sessions using three different types of therapy. B. F. Skinner and Behavioral Change, 45 min. (Research Press). The life and theory of B.F. Skinner is presented and behavioral therapy is discussed. Being Abraham Maslow, 30 min. (FLMLJB). Maslow describes his theoretical viewpoints and events leading to the development of his personality theory. Discovering Psychology: Learning, 28 min.(Annenberg/C PB). This film describes the basic principles of learning theory. Erik Erikson: Interview, 50min. (AIM). Erikson's theory is presented by Erikson himself. Everyone Rides the Carousel, 73 min. (PFP). Animated characters are used to demonstrate Erikson’s stages of development. Freud: The Hidden Nature of Man, 29 min. (Insight Media). This dramatized presentation examines the postulates of psychoanalysis, interviews "Freud" and demonstrates the analysis of dreams. Landmarks in Psychology, 45 min. (Human Relations Media). This video covers the major theories and applications of therapy. Rational Emotive Therapy, 30 min. (Research Press). Albert Ellis describes rational emotive therapy. Three Approaches to Psychotherapy, 6 parts/30-45 min. each. (Psychological Films, Inc.). Among therapies covered are those of Rogers, Perls, Ellis, Meichenbaum, and Beck. The World of Abnormal Psychology: Psychotherapies, 60 min. (Annenberg/CPB). This film covers different psychotherapies used in the treatment of mental disorders. Video Depression: Prozac, 5:30 min. (World News Tonight/American Agenda). Psychotherapy Under Scrutiny. (Nightline 4-27-92), (ABC News/Prentice Hall Library #2). The psychotherapist- patient relationships are discussed in light of recent cases where accusations of unethical and illegal conduct have been raised. Movie One Flew Over the Cuckoo's Nest (1974). Murphy gets out of going to prison by being admitted to a psychiatric hospital where Nurse Ratchet becomes very agitated with his effect on others. Lilith (1964). Warren Beatty, playing a young psychotherapist, experiences countertransference as he falls in love with his patient and nearly loses his own sanity. This film raises more than just ethical questions and is worth seeing for its often realistic exploration of the difficult relational issues that can arise during intense therapy.

CHAPTER OUTLINE I. Psychotherapy A. Psychodynamic Therapy and Psychoanalysis 1. Psychoanalysis is a prolonged process, spreading across a period of several years with four to five sessions a week. 2. During psychodynamic therapy, the analyst and the patient sit facing each another while the patient reviews early relationships with parents and significant others with the direction of the therapist. 3. Transference, both positive and negative, is an important aspect of psychotherapy. 4. In order to change one's behavior, the goal of psychoanalysis is to achieve insight into one's life. 5. Psychotherapists seek to uncover repressed or forgotten memories hidden in the unconscious. 6. There is a great deal of controversy surrounding the possibility of false memories. 7. Hypnosis is one form of gaining access to one's unconscious. B. Humanistic and Existential Therapies 1. Humanistic therapy emphasizes people’s desire to achieve self-respect. 2. Client-centered therapy, in which the therapist's role is to be a supportive facilitator providing no directions, is the main form of humanistic therapy. 3. Existential therapists work as partners with their clients in an attempt to provide direction to one's life and making choices that shape one's destiny. 4. Gestalt therapists are concerned with the person as an integrated whole. C. Cognitive Psychotherapy 1. Using conversation to achieve change, cognitive psychotherapists attempt to help clients correct misconceptions about the world. 2. Rational-emotive therapy seeks to help people see the flaws in their fundamental beliefs and to set new, more realistic goals for themselves. 3. Beck's cognitive therapy tries to terminate automatic thinking and teach clients to use critical thinking to rationally review alternatives. 4. Elements of cognitive therapy (Table 3-1, pg. 99) 5. Identifying cognitive thinking errors (Table 3-2, pg. 99) D. Interpersonal Therapy – focuses on the role of interpersonal relationships in causing psychological disorders. E. Brief Psychotherapies 1. Brief therapies have come about due mainly to changes in the health care systems. 2. There is usually a single, specific goal of brief psychotherapies. 3. Interpersonal therapy normally lasts 12 to 16 weeks and seeks to uncover how a client interacts with others and how these interactions affect the client's mood. F. How Effective Is Psychotherapy? 1. An investigation done by Consumer Reports revealed that the majority of people who have undergone psychotherapy feel they have made improvements. 2. It is difficult to perform research on the effectiveness of psychotherapy because there are many forms of psychotherapy and different individuals respond better to different forms. 3. Meta-analysis is used to summarize the results of several studies of effectiveness. (Figure 3-3, pg. 101) . In general, psychotherapy appears to be a positive factor in the lives of those who receive it. 4. Technique factors and interpersonal factors are important components in evaluating psychotherapy. II.

Cognitive-Behavioral Therapies A. Behavior Therapy - Basic Assumptions (Table 3-4, pg. 103): 1. Behavior therapy is based upon techniques developed by operant and classical conditioning. 2. Behavior modification uses operant learning principles to bring about a change in behavior. 3. Cognitive-behavior therapy attempts to integrate cognitive and behavioral therapies.

4. To influence emotions and behaviors, cognitive-behavioral therapists try to modify cognition. B. Components of Cognitive-Behavioral Therapy (Table 3-4, pg. 103) 1. Relaxation training (Table 3-5, pg. 104) was designed to help people who are anxious or tense and is often used for those with psychosomatic disorders, but it is usually not very effective alone. 2. Muscular relaxation teaches individuals to tense and relax various muscle groups. 3. Meditation is also used in relaxation training and involves concentration on a thought, word, or specific state of mind. 4. Exposure therapies (Figure 3-4, pg. 105) are based on the belief that continued exposure to an anxiety- provoking stimulus will gradually decrease one's anxiety. 5. In vivo exposure and fantasized exposure are both effective means of helping people overcome fearful situations. 6. Flooding is a form of exposure therapy in which the client is completely inundated with fear-provoking stimuli until extinction occurs. 7. Implosive therapy involves the client imagining fearful situations and stimuli. 8. Systematic desensitization (Table 3-6, pg. 105) combines cognitive activity of imagining the feared stimulus with relaxation techniques to overcome that fear. 9. Paradoxical intention requires clients to act the opposite of desired behaviors or goals. 10. Various forms of modeling are employed to teach people adaptive behaviors which are then positively reinforced. 11. Assertiveness training uses modeling and behavioral rehearsal to help individuals learn to stand up for themselves and not succumb to their own anxiety. C. How Effective Is Cognitive-Behavioral Therapy? 1. Research suggests that cognitive-behavioral therapy is an effective means of helping people overcome their fears and inhibitions as well as increasing their coping skills. 2. It is not clearly understood why this form of therapy is effective. D. Integrative Approaches to Therapy (Box 3-1, pg. 107) III.

Group Therapy A. Cognitive-Behavioral Group Therapy (Figure 3-6, pg. 107) 1. Increasing the skills and comfort of individuals in social situations is the primary goal of cognitive-behavioral group therapy. 2. Role-playing and modeling are both used in this form of therapy. 3. Cognitive-behavioral therapy is more structured than other group therapies, and the group is seen as an extension of one's family. B. Family and Marital Therapy (Figure 3-7, pg. 109) 1. Family therapy is centered around the belief that many problems are caused by family behavior patterns and are affected by them as well. 2. The family is encouraged to work as a group rather than as individuals to overcome their difficulties. 3. Family therapy usually begins with problems currently being experienced. 4. The family systems approach sees the family as a self-maintaining system. 5. Marital therapy attempts to help couples deal with and discuss their problems without becoming explosive. 6. The marital therapist is able to impartially observe a couple's interactions. 7. Expressing feelings and increasing communication are common goals of marital therapy. C. Psychodrama 1. Psychodrama involves a group of people directed by a therapist to enact events of emotional significance. 2. The goal of psychodrama is to resolve conflicts and release individuals from inhibitions which have limited their spontaneity and creativity. D. How Effective Are Group Approaches? 1. Difficult to assess the effectiveness of group therapy due the number of people involved 2. There is growing evidence that suggests family and marital therapies are effective. 3. Research on group therapies is becoming more rigorous.

IV.

Research on the Psychological Therapies (Table 3-7, pg. 112) A. Common and Unique Features of Therapies (Table 3-8, pg. 113) 1. The ability to instill hope in clients is a common feature of all therapies. 2. Research needs to separate therapists' personal traits from the form of therapy when trying to evaluate the effectiveness of various forms of therapy. 3. Procedural manuals help researchers define the independent variable. B. Therapeutic Outcomes 1. In studying outcomes of therapy, the desired outcome must first be defined. 2. It is difficult to compare studies that have different desired outcomes. 3. Three evaluations of improvement must be taken on each client: a. The personal evaluation from the client b. The therapist's evaluation of the client's improvement c. Family and friends' evaluations of the client's improvement C. Comparing Therapies a. Meta-analyses have shown that therapy as a whole is effective, with little or no difference between the types of therapies. b. Some studies have shown that cognitive and behavioral methods may be superior to other methods. c. It is important that comparative research have several measures of outcome. D. Recognizing Cultural and Ethnic Diversity a. Therapy techniques have paid little attention to cultural issues, which may play a large role in treatment success. b. Cultural differences account for differences in how events and emotions are perceived. c. Different ethnic groups have different values and their goals in therapy may vary widely from what the therapist believes the goals should be.

Integration of Psychologically Based Therapeutic Approaches A. Therapists from different schools of thought have very different opinions regarding the best forms of therapy. B. Research has shown that there is a growing trend for therapists to integrate their main form of therapy with that of other successful therapies.

VI.

Biological Therapies A. Electroconvulsive Therapy (ECT) (Figure 3-9, pg. 115) 1. Until recently, the use of ECT was declining over the last 20 years due to negative perceptions from the public. 2. Improved use of ECT has been successful in treating extremely severe depression. (Table 3-9, pg. 115) 3. ECT is relatively safe when used with anesthetics and muscle relaxants and when applied to only one side of the head. 4. It is still not understood how ECT can produce positive effects. B. Drug Therapies 1. There are four main types of drugs used in therapy: a. Antipsychotic drugs b. Antimonic drugs c. Antidepressant drugs d. Antianxiety drugs 2. There are differences among these drugs in their effectiveness and their side effects. 3. The effects of drug therapy cannot always be predicted. (Table 3-10, pg. 116) C. Managed health care determines a client’s course of treatment rather than the physician. D. Extensive testing, including animal testing, must be carried out before a drug can be used. E. How effective are biological therapies? 1. For many disorders, psychological therapies are not sufficient treatment plans.

2. Drug therapy combined with psychological therapy has been successful with many disorders. VII. Hospitalization A. Hospitalization provides continuous care along with complex therapies that may be necessary for treatment. 1. Many state hospitals do not have the funds for psychological treatment programs. 2. Re-socialization is an important area of research for chronic patients. B. Day hospitalization is available for patients who are able to live at home, but need the structure and guidance of the program. C. Deinstitutionalization has led to more mentally ill people living on the streets rather than in hospitals. VIII. Take-Away Message WEB LINKS Albert Ellis - www.rebt.org/. Links to information about different types of group therapy. Behavior Therapy for PTSD - www.apa.org/monitor/apr98/ptsd.html An article from the APA Monitor. Brief Psychodynamic Therapy - http://archpsyc.ama-assn.org/issues/v56n6/abs/yoa8378.html Cognitive-Behavioral Therapy - www.cognitivetherapy.com/ A site devoted to cognitive-behavioral therapy. Cognitive Behavioral Treatment for Anxiety - www.anxietynetwork.com/hcbt.html Deinstitutionalization - http://www.psychlaws.org/GeneralResources/Article2.htm An article by schizophrenia researcher E. Fuller Torrey about the failure of Deinstitutionalization. Deinstitutionalization and the Homeless Mentally Ill http://www.interactivist.net/housing/deinstitutionalization_1.html The link between homelessness, mental illness, and the Deinstitutionalization movement. Electro-Convulsive Therapy - http://text.nlm.nih.gov/nih/cdc/www/51.html Position paper on the use of ECT therapy from the National Institute of Mental Health. Group Psychotherapy Home Page - http://www.group-psychotherapy.com/ This site is for the clinician. It has links to articles, discussion groups, and bibliographies. History of Deinstitutionalization - http://mentalhelp.net/perspectives/articles/art09981.htm A history of deinstitutionalization, focusing on its failed promises. Psychoanalysis and Psychodynamic Therapy – http://members.aol.com/avpsyrich/txtypes.htm#Psychodynamic Psychodynamic Therapy - http://www.louisville.edu/a-s/psychology/psyc201/therapies/tsld004.htm A slide tutorial on psychodynamic therapy from the University of Louisville. A report from the American Medical Association. Research Concerning Psychodynamic Therapy – http://www.wheaton.edu/psychology/faculty/mwm/JPC_column.html An examination into research concerning psychodynamic methods. The National Association of Cognitive-Behavioral Therapists. How and which methods are used to treat anxiety. Links to articles about therapy with many different kinds of groups, treating various disorders. Theoretical Orientations and Therapy - http://psychcentral.com/therapy.htm A monograph on the types of therapies as they relate to theoretical perspectives. Types of Groups - http://www.group-psychotherapy.com/articles.htm

Chapter 4 Classification and Assessment OVERVIEW Chapter 4 covers the advantages and disadvantages of classification systems for abnormal behaviors. The chapter investigates the diagnostic process as it applies to behavioral, cognitive, and emotional problems. The problems are discussed in terms of an individual's stress, vulnerability, resiliency and coping skills. The Diagnostic and Statistical Manual of Mental Disorders-IV and its multi-axial approaches are covered in detail. Assessment techniques such as the interview, intelligence tests, personality tests and scales, behavioral assessments, cognitive assessments, and other related tools used in the field of abnormal psychology are also discussed. CONTENTS Classification: Categories of Maladaptive Behavior Advantages and Disadvantages of Classification Vulnerability, Resilience, and Coping The Multiaxial Approach The Major Diagnostic Categories Evaluation of the DSM Multiaxial Approach Research on Classification Assessment: The Basis of Classification The Interview Intelligence Tests Neuropsychological Tests Personality Assessment Behavioral Assessment Cognitive Assessment Relational Assessment Bodily Assessment Take-Away Message LEARNING OBJECTIVES After completing this chapter students should be able to: 1. Understand the importance of classification in studying abnormal behavior and the drawbacks involved. 2. Outline the improvements made in diagnoses using the multi-axial approach. 3. Identify the five axes of the DSM-IV. 4. Elaborate on the importance of using diagnostic tools to accurately describe clinical conditions. 5. Discuss the four factors important to clinical agreement or disagreement about a diagnosis. 6. Identify the four components of all types of interviews. 7. Compare and contrast different intelligence tests and the potential bias in them. 8. Differentiate between various personality assessment techniques and the value of rating scales. 9. Discuss how projective techniques could support objective assessments. 10. Discuss the importance of behavioral assessment, cognitive assessment, relational assessment, and bodily assessment in diagnosing clients. LECTURE AND DISCUSSION TOPICS 1. The DSM-I, the DSM-II, the DSM-III, the DSM-IIIR, and the DSM-IV as published by the American Psychiatric Association - discuss the continued refinement in describing clinical conditions. 2. Discuss the use of the approach, the use of accurate descriptions of clinical conditions, and the increased reliability and validity of the DSM-IV. 3. How has the shift away from psychoanalytic language and the DSM-IV's focus on description (and observation) rather than interpretation enhanced diagnoses? 4. When and where is the World Health Organization's International Classification of Diseases (ICD-10) used? Is there a relationship between the ICD-10(CM) and the DSM-IV? Discuss the differences between reliability (especially the Kappa Statistic) and validity. How does clinical judgment compare

to diagnosis using the DSM-IV? Explain in detail how the following factors increase disagreement and error in clinical research and diagnosis: A. Client Factors B. Assessment Factors C. Criteria Factors D. Clinician Factors 5. Projective vs. Nonprojective Techniques. Discuss the differences between projective techniques and nonprojective techniques. List the class examples of each. What are some of the problems involved with the validity and reliability of projective techniques? If the courts assigned you to a case where you were to determine the "sanity" of a person who was accused of a serious crime, what instruments would you use in your diagnosis? How would you explain that another psychologist using the same instruments but representing the other side of the case could come up with totally different results? Do these problems indicate that some action needs to be taken in the field of personality testing? What can be done to improve the situation? Can test results be trusted? Do culture-free tests exist? What affects test performance? How can examiner gender and client gender influence test performance? Are some children reluctant to readily communicate with some examiners? 6. What are some of the ethnic, cultural, geographical, and socioeconomic factors that affect test performance? Using the WISC, mention some items that might limit a rural child's performance on the examination. Point out some items that could penalize a rural Southern child's performance on the WISC. Indicate how this could seriously affect the classification of some children and how results are used incorrectly. Discuss the problems in developing “culture-free tests.” Are class members able to create items that would be totally “culture free”? Have the class members propose items. Which intelligence tests are the most reliable and valid? Is the examiner able to obtain other kinds of information from intelligence tests? Should a diagnosis be given after one test administration in one testing session? Why or why not? 7. IQ vs. Intelligence. Discuss with class members the following questions: What is the definition of intelligence? IQ? What is the relationship between the two? Under what conditions would you expect the IQ obtained on an intelligence test to reliably represent the intelligence of a client? What are the implications of "nature vs. nurture" when discussing intelligence? Ask the students to express their opinions on the issue. What are the reasons? Follow the discussion with actual research findings in regard to the nature and nurture issue. 8. Is Personality Inherited? Discuss the definition of personality. Discuss the definition of temperament. Ask the class members if they believe that temperament is inherited. Ask class members what their temperament is and from where do they thinks they obtained it. Most students will respond that temperament comes from the mother, father, or both. Follow the temperament discussion with a discussion of the origins of personality. 9. Why are we reluctant to attribute personality traits to heredity? 10. What do recent studies show? Include in the discussion information obtained from the Minnesota twin studies. Then discuss some of the methodological problems involved with the study. STUDENT ACTIVITIES Examples of Assessment Techniques: 1. Bring materials or videos to class to demonstrate different assessment tools. Include materials from intelligence tests such as the Wechsler or the Stanford-Binet. Also include materials from two different types of personality assessment instruments (the Rorschach and the TAT). 2. Demonstrate the use of the items. Follow with a discussion of other tests and their items. 3. Discuss how tests are administered using standardized methods, how tests are normed, and some of the problems involved in administering the tests. 4. Locate a mini mental status exam on the Web. Have paired students administer it. Discuss the results. Discuss why this exam is unlikely ever to be valid in the strictest sense. Explain the actual purpose of the exam. 5. What tests to use and when? Divide the class members into five groups and give each one of the following case histories. Have each group pick the appropriate assessment instruments to administer to that group's subject and report their recommendations to the class. 6. Lauren is in the third grade. She is having difficulty in all her subjects and has experienced similar problems since the first grade. Her parents have provided her with tutoring and work with her in the evenings, but she cannot seem to keep up. She sometimes appears to daydream and does not seem to hear when addressed. Lauren is very small for her age and was born prematurely.

7. Tim, a twenty-one-year-old, has been referred to you by the local criminal justice system. He is a smooth talker and very charming. He cannot seem to get along with any of his supervisors or fellow workers. He is aggressive and explosive. When he was a young boy, neighbors complained that he was cruel to their pets and was expelled from school several times for rule violations. Tim has a history of problems with the legal system and has on numerous occasions been arrested for minor offenses. He does not seem to feel remorse for any of his actions. 8. Bette is a sixty-five-year-old woman. She remained active in church and civic activities after her husband's death and enjoyed traveling with her friends. She has slowly withdrawn from many of these activities and has now stopped going on trips with her friends. She recently called the police to her house and reported to them that she had seen "small people" sitting in her house when she returned home from church. 9. Johnny is a twenty-one-year-old college student. Last year he was in an automobile accident and was in a coma for several days. Besides suffering a number of broken bones, he was diagnosed as having a closed head injury. He has returned to school this year, but is having trouble in school and cannot seem to concentrate. Things that used to be easy for Johnny are now very difficult. 10. Mike is a six-year-old child who cannot seem to sit still. He cannot progress at an acceptable rate in school; he is often removed from class because his behavior interferes with other children's learning; he even appears to be restless when he sleeps and he appears to need little sleep. 11. Amy is a college student who excelled academically in high school. Since her second semester in college, her grades have been dropping, Amy has quit attending a number of her classes, and she has stopped seeing her friends. She has begun to spend most of her time alone and she is rarely seen laughing. She complains that she awakens very early and is unable to go back to sleep. At times Amy does not get out of bed during the day, and she has told friends that "nothing seems to be going right and maybe life isn't worth living.” 12. DSM-IV Axes and Diagnosis - Divide the class into six groups and select three individuals to be moderators. In two games of Jeopardy (three teams per game) have the group members determine which axis would be used to diagnose the following illnesses or conditions: A. Moderate Mental Retardation B. Agoraphobia C. Histrionic Personality Disorder D. Bipolar Affective Disorder E. Hallucinations associated with Alzheimer's Disease F. Obsessive-Compulsive Disorder G. Sexual dysfunction associated with diabetes H. Angina associated with prior heart attacks I. Depression, mild mental retardation, and exhibitionism J. Lack of adequate housing K. Severity of symptoms of the disorder L. Family members involved with drug 13. In which diagnostic categories (DSM-IV) could the following symptoms be classified? A. Hallucinations, delusions, distortion of reality, inappropriate affect B. Paralysis with no physical cause C. Inability to eat enough to maintain healthy weight level D. Episodes of extreme discomfort, rapid heart rate, sweating, and panic E. Inability to stop smoking F. Low self-esteem, feelings of guilt, worthlessness, helplessness, hopelessness G. Loss of memory and identity with no identifiable physical cause 14. Which tests or techniques could be used in diagnosing the following disorders? A. Mental Retardation B. Brain Injury C. Alzheimer's Disease D. Antisocial Personality Disorder E. Depression F. Narcissistic Personality Disorder G. Tic Disorder H. Dementia

15. Students need to be reminded that more than one answer may be acceptable. Additional items may be added to these lists and the games may be expanded to include more categories. Assignments Read the American Psychiatric Association’s Fact Sheet for the Psychiatric Diagnosis and the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), DSM-IV located at http://www.psych.org/public_info/dsm.pdf Questions: A. Explain why the APA states that the DSM-IV is not a “cookbook.” B. The paper explains that the DSM-IV is arranged by phenomenology. What does this mean? C. How is the DSM-IV used in forensic settings? D. What is the origin of the DSM? Critical Writing Once you have considered the rather complex idea of assigning a person a diagnosis of a mental disorder, what are the advantages and disadvantages of assigning such a label? What tools would you use to collect the information? At what point would you assign a diagnosis? Would you consider the available treatments before assigning a diagnosis? How does the assignment of a DSM category help the person obtain treatment? What is the potential harm that a diagnosis brings? Great Books to Read Kutchins, Herb. (1997). Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders. New York: Free Press; ISBN: 0684822806. Lehman, Hannah. (1996). Pigeonholing Women's Misery: A History and Critical Analysis of the Psychodiagnosis of Women in the Twentieth Century. New York: Basic Books; ASIN: 046509533X. Walker, Sydney Iii, Md. (1997). A Dose of Sanity: Mind, Medicine, and Misdiagnosis. New York: John Wiley & Sons; ISBN: 0471192627. VIDEO RESOURCES Assessment and Diagnosis of Childhood Psychopathology, 26 min. (Penn State Univ.). This video provides an overview of assessments used in the diagnosis of disorders in children. Assessment/Therapy Connection, 29 min. (Research Press). Lazarus provides an assessment of a depressed patient. Intelligence: A Complex Concept, 28 min. (MGHF). This video presents a number of intelligence tests and some of the problems arising from their use. CHAPTER OUTLINE I. Classification: Categories of Maladaptive Behavior 1. Table 4-1, pg. 128, Contributions of diagnosis/classification 2. Table 4-2, pg. 128, Terms used to discuss clinical cases 3. Table 4-3, pg. 128, Milestones in attempts to classify maladaptive 4. Table 4-3, pg. 129, Characteristics of a good clinical classification system A. Advantages and Disadvantages of Classification 1. Robert Bjorklund - stigma, labeling, and loss of self 2. Classification allows effective communication and can be analyzed statistically. 3. Labeling is often a problem in diagnosing maladaptive behavior. 4. There is unreliability in diagnosing using a classification system. B. Vulnerability, Resilience, and Coping - person classified according to three factors: 1. Recent experiences 2. Vulnerabilities and weaknesses 3. Assets and strengths C. The Multi-axial Approach 1. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) was the first multiaxial system.

II.

2. This approach allows a diagnosis with several factors rather than a single label. 3. The DSM-IV consists of five axes that describe biological, social, and psychological aspects of the client. 4. The DSM-IV provides guidelines for coding subjective factors. The Major Diagnostic Categories (Table 4-5, pg. 132) 1. Axis I Categories - all clinical disorders except personality disorders and mental retardation are included in this category. 2. Axis II Categories - personality disorders and mental retardation. 3. Axis III Category – medical disorders that may be the cause of or result from an Axis I or Axis II disorder (relevant). 4. Axis IV Category - psychosocial and environmental problems. 5. Axis V Category - global assessment of psychological, social, and occupational functioning, currently, and in the past year. Evaluation of the DSM Multi-axial Approach - shorter periods of time between revisions are due to the extensive amount of research being done. The recent editions cover a much wider range of disorders. More emphasis has been placed on the description of disorders rather than on speculation over etiology. Research on Classification 1. Classification systems are tested for reliability by correlating diagnosis with clinicians. 2. Validation is tested by measuring the predictability of the clinical course and outcome and the effectiveness of treatment. 3. It is more difficult to establish validity because the etiology of many disorders is unknown. Clinical Judgment - Intensive training and clear diagnostic criteria increase the reliability of clinicians' diagnoses. 1. Clinicians often used research-based approach in diagnosing. 2. Several factors contribute to errors in diagnosing: a. Client factors b. Method factors c. Criteria factors d. Clinician factors

Assessment: The Basis of Classification A. The Interview - Content of the Interview (Table 4-6, pg. 137) 1. The goal is to obtain information on the client and learn how the client views his or her problem. 2. Behavior and appearance are important factors to be recorded. 3. The relationship between verbal and nonverbal behaviors is an essential observation. 4. The Role of the Interviewer a. The interviewer must interpret the behavior of the client; interpretations are not always completely accurate. b. It is important to establish a relationship with the client. 5. Mental Status Examination (Table 4-7, pg. 141) a. It is important to establish mental status before making a diagnosis. b. The examination is usually unstructured. c. The mental status examination involves conversation and mental tasks. 6. The Structured Interview (Table 4-8, pg. 141) a. This type of interview provides greater reliability. b. Structured interviews limit flexibility. c. Standardized questions and scoring are employed. 7. The Diagnostic Interview Schedule a. The diagnostic interview schedule is designed to assist in diagnosing selected disorders.

b. This interview can be administered by professional and nonprofessional interviewers. c. There is a high reliability of diagnoses. B.

Intelligence Tests (Table 4-9, pg. 142, Major Milestones in History of Intelligence Testing) 1. General Abilities – a global capacity to solve problems 2. Specific Abilities – in designated areas of intellectual functioning 3. The Binet tests - This was first test to consider age in measuring intelligence. a. The Binet Tests introduced mental age (MA), chronological age (CA), and intelligence quotient (IQ). IQ = (MA x 100)/CA. b. The newest edition includes several scores. 4. The Wechsler Tests (Figure 4-4, pg. 143) a. Intelligence is an aggregate of different abilities. b. There are three IQ scores: verbal, performance, scale. c. After the success of adult scale, tests for children were developed. 5. Kaufman Assessment Battery for Children - Designed to avoid cultural bias. 6. Neuropsychological Tests a. Measure cognitive, sensori-motor, and perceptual consequences of brain abnormalities. b. Various screening tests are used to detect brain abnormalities. c. Clients are restricted on their freedom of expression. 7. Personality Assessment (Table 4-10, pg. 144, Categories of Personality Disorders) a. These inventories are designed to gather information about certain characteristics that combine to form personality traits. b. MMPI is one of the most widely used personality inventories. (Table 4-11, pg. 146) 8. Rating Scales - Gather information on personal characteristics. a. Ratings are done on a continuum. b. Rating scales are subject to the halo effect. 9. Projective Techniques - Ambiguous stimuli are used to elicit a client’s responses. a. Rorschach inkblots (Figure 4-7, pg. 148) and TAT (Figure 4-9, pg. 149) are two widely known projective techniques. b. Word-association tests and sentence completion tests are alternatives. 10. Behavioral Assessment - Designed to recognize deficits in physical behavior. a. Both subjective and objective data are important. b. Baseline observations before treatment are becoming popular. (Figure 4-10, pg. 151) 11. Cognitive Assessment – (Figure 4-11, pg. 151) a. Used to study the thoughts surrounding behaviors. b. These are a fairly new development in behavior assessment. 12. Relational Assessment a. Relational assessment is used to evaluate significant social relationships within the client's life. b. Family is one of the most important relationships studied. 13. Bodily Assessment a. Involves physiological measurements under certain conditions. (Figure 4-12, pg. 152) b. Polygraphs and Galvanic Skin Response (GSR) tests used to measure responses. (Figure 4-13, pg. 153) c. Biofeedback is a technique that helps clients overcome certain physical complaints.

III. Take-Away Message

WEB LINKS Psychological Tests Online http://mentalhelp.net http://www.onlinepsych.com/index.html http://www.queendom.com http://www.psychtests.com These sites have a large number of online assessment instruments, none of which have any proven reliability or validity. However, they do give you a sense of how some instruments are organized, and taking a couple let you in on how it feels to be subject to labeling and categorizing based upon how you answer the questions. American Psychological Association Testing Site - http://www.apa.org/science/testing.html This is the American Psychological Association's page devoted to testing. Frequently Asked Questions about Psychological Tests - http://www.apa.org/science/faq-findtests.html The American Psychological Association has published answers to frequently asked questions about psychological tests. Psychological Testing - http://www.unl.edu/buros Scientific American on Intelligence - ttp://www.sciam.com/1998/1198intelligence/1198quicksummary.html Here is a summary of articles, and links to some full-text articles, on intelligence from Scientific American. Peruse those that interest you and get an overview of the main theories in human and animal intelligence.

STUDENT ACTIVITY SHEET - WHAT TESTS TO USE WHEN PART I - THE CASES A. Lauren is in the third grade. She is having difficulty in all her subjects and has experienced similar problems since the first grade. Her parents have provided her with tutoring and work with her in the evenings, but she cannot seem to keep up. She sometimes appears to daydream and does not seem to hear when addressed. Lauren is very small for her age and was born prematurely. B. Tim, a twenty-one-year-old, has been referred to you by the local criminal justice system. He is a smooth talker and very charming. He cannot seem to get along with any of his supervisors or fellow workers. He is aggressive and explosive. When he was a young boy, neighbors complained that he was cruel to their pets and was expelled from school several times for role violations. Tim has a history of problems with the legal system and has on numerous occasions been arrested for minor offenses. He does not seem to feel remorse for any of his actions. C. Bette is a sixty-five-year-old woman. She remained active in church and civic activities after her husband's death and enjoyed traveling with her friends. She has slowly withdrawn from many of these activities and has now stopped going on trips with her friends. She recently called the police to her house and reported to them that she had seen "small people" sitting in her house when she returned home from church. D. Johnny is a twenty-one-year-old college student. Last year he was in an automobile accident and was in a coma for several days. Besides suffering a number of broken bones, he was diagnosed as having a closed head injury. He has returned to school this year, but is having trouble in school and cannot seem to concentrate. Things that used to be easy for Johnny are now very difficult. E. Mike is a six-year-old child who cannot seem to sit still. He cannot progress at an acceptable rate in school; he is often removed from class because his behavior interferes with other children's learning; he even appears to be restless when he sleeps and he appears to need little sleep. F. Amy is a college student who excelled academically in high school. Since her second semester in college, her grades have been dropping, Amy has quit attending a number of her classes, and she has stopped seeing her friends. She has begun to spend most of her time alone and she is rarely seen laughing. She complains that she awakens very early and is unable to go back to sleep. At times Amy does not get out of bed during the day, and she has told friends that "nothing seems to be going right and maybe life isn't worth living."

STUDENT ACTIVITY SHEET - WHAT TESTS TO USE WHEN PART II - THE ASSESSMENT INSTRUMENT CATEGORIES AND INSTRUMENTS Clinical judgment involves the proper selection of objective, subjective, and projective instruments that provide additional information about the individual. It is important to select instruments that are reliable, valid, standardized on the appropriate group, and which adequately assess the individual. Listed below are some of the tests that are commonly used. An excellent source for all tests and categories is the Buros Mental Measurements Yearbook (http://www.unl.edu/buros/). Intelligence/Cognitive Ability Kauffman Adolescent and Adult Intelligence Test Kauffman Assessment Battery for Children (K-ABC) Wechsler Adult Intelligence Scale (WAIS III or WAIS-R) Woodcock-Johnson Psychoeducational Battery - Revised: Tests of Cognitive Ability Stanford-Binet Intelligence Scale-IV The Slosson Intelligence Test - Revised Academic Achievement - General Scholastic Abilities Test for Adults (SATA) Stanford Test of Academic Skills Woodcock-Johnson Psychoeducational Battery - Revised: Tests of Achievement Wechsler Individual Achievement Test (WIAT) Wide Range Achievement Test - 3 (WRAT-3) Academic Achievement - Specific Brigance Inventories Nelson-Denny Reading Skills Test Stanford Diagnostic Mathematics Test Test of Written Language -3 (TOWL-3) Woodcock Reading Mastery Tests - Revised Aptitude Tests Detroit Tests of Learning Aptitude Attention Deficit Surveys Adult Attention Deficit Disorder Behavior Rating Scale Attention Deficit Disorder Behavior Rating Scales Personality Assessment Minnesota Multiphasic Personality Inventory (MMPI) Childhood Personality Scale Projective Techniques Rorschach Inkblot Test Thematic Apperception Test Sentence Completion Test Draw-A-Person House-Tree-Person Specific Disorder Assessments Millon Clinical Multiaxial Inventory-III (MCMI-III)

Chapter 5 Stress, Coping, and Maladaptive Behavior OVERVIEW Chapter 5 discusses the concepts of stress and coping and covers situations and life transitions that create stress in the lives of those experiencing these conditions. Three reactions to stress, Adjustment Disorder, Acute Stress Disorder, and Dissociative Disorder, are discussed in detail. Different types of therapy, including supportive therapy, drug therapy, relaxation training, desensitization, and social intervention, are also discussed. CONTENTS Stress and Coping Coping Skills The Coping Process Social Support Stressful Situations and Life Transitions Stress-Arousing Situations Life Transitions Clinical Reactions to Stress Adjustment Disorders Acute Stress Disorders Dissociative Disorders Treating Stress-Related Problems Supportive Therapy Medications Relaxation Training Systematic Desensitization Cognitive Modification Social Intervention Challenges in Treating Stress-Related Problems Take-Away Message LEARNING OBJECTIVES After completing this chapter students should be able to: 1. Define coping skills and know how successful coping skills are developed. 2. Outline the process of coping. 3. Identify various stressful situations and the possible effects they may have on one's life. 4. List the characteristics of stress-arousing situations. 5. Describe the importance of bereavement and the grieving process. 6. Define adjustment disorder, acute stress disorder, and dissociative disorder. 7. Enumerate the methods for treating stress-related problems. LECTURE AND DISCUSSION TOPICS 1. Do Positive Events Cause Stress? A. Have the class discuss the differences between eustress (stress from positive events) and stress. B. What are some of the day-to-day events that cause negative stress? (exams, dates, not enough time, not enough money, roommate problems). C. What are events that cause great amounts of stress? (breaking up, death of friend or family member, failure in school, loss of job, serious accident, serious life trauma). D. What are some of life's transitions? (marriage, first job, big promotion, purchase of room, birth of baby, winning the lottery). E. Do these events cause stress? Have the class members give examples. Have you known anyone who actually got sick when they married? When they received a big promotion? When they got engaged? What is stressful about some positive events?

2. Dissociative Fugue: Is This Real? Discuss the difference between dissociative amnesia and dissociative fugue. Point out that fugue involves leaving a stressful situation and, at times, involves establishing a life in another place. Enlist the class to provide examples from TV or newspapers. After identifying individual cases of the disorder, discuss the possible benefits of dissociative fugue. Could there be reasons for a person's suffering from this disorder? The following case was reported in a number of newspapers. A well-known deacon in a large Protestant church was reported missing by his wife. He had five children and was struggling to maintain his small business that was suffering because of an economic recession. He was very dependable and seemed to be able to overcome most obstacles quietly and without relying on others. After a week, Mr. X's boat was found floating in a lake near his hometown. His car was on the shore, and his ID and credit cards were in the glove compartment. The assumption was made that Mr. X had gone fishing, had a boating accident and drowned. His wife and children continued to live in the same city and nothing more was heard for several years. Three years later, a gentleman from the church that Mr. X had attended was visiting a large city in another state. As he was walking down the sidewalk, he recognized Mr. X walking toward him. With Mr. X were a young, beautiful wife and a small baby. The gentleman from Mr. X's original hometown ran up to Mr. X and embraced him. Mr. X denied that he knew the gentleman and explained that the gentleman must be mistaken about his identity. The man with the young bride and baby was indeed Mr. X. Discuss this case. Was Mr. X really suffering from dissociative fugue? How could that be determined? What other explanation could be given? 3. When Stressed Suffer In Silence: Prescription For Disaster Using the text's emphasis on the need for social support during stress, point out the importance of a support system. 4. Palladino's (1998) discussion of Carey's (1997) article, "Don't Face Stress Alone," provides a number of points about social support and stress. Carey points out that isolation is one of the important factors in succumbing to stress. The following individuals have endured tremendous stress as a result of their physical disorders, yet they chose to share their situations with the public. Discuss the following individuals from Carey's article: • Michael J. Fox (Parkinson's disease) • Annette Funicello (multiple sclerosis) • Linda Ellerbee (breast cancer) • Ronald Reagan (Alzheimer's disease) • Christopher Reeve (spinal injury) • Greg Louganis (HIV positive) • William Styron (depression) a. Do you think their public revelation made their disorder less stressful? Do you think other average individuals suffering from these disorders are less stressed because these famous individuals have made their illnesses known? b. Do you feel better and have more successful behaviors after sharing your anxieties and worries with others? c. Are you able to see solutions after discussing stressful problems with others? Why? Carey, B. (1997 April) "Don't face stress alone." Health, 78 pp. 74-76 Time Publishing Ventures, Inc. Paladino, J.J. (Ed). (1998) Annual Editions: Abnormal Psychology 98/99.

5. Are Repressed Memories Real? One of psychology's and psychiatry's major controversies is that of the existence of "repressed memories" or "recovered memories." The theory of repressed memories for traumatic events provides the basis for the theory of Dissociative Identity Disorder (DID). The theory of the development of DID proposes that traumatic events (usually physical and sexual abuse) have been repressed and other identities develop in order to protect the individual from the horrors of reality and memory of those events. The origins of this theory may be traced to the works of Charcot when he hypnotized "hysterical" women, performed experiments such as puncturing their arms with pins, and later “awakening" them, after which they had no memory of the event. From that Freud progressed with his theory of repression. Questions regarding "recovered memories" have been raised because of findings in neuropsychology that suggest our memories from infancy and early childhood are lost because of changes in our nervous systems. Others question the accuracy of "recovered memories" because many of them seem to be realistically impossible. Some researchers believe that "recovered memories" are the creation of imagination, suggestion, or the by-product of hypnosis. Some therapists believe that repressed memories exist and confirm the prevalence of incest and sexual abuse. A series of sensational trials and accusations of satanic rituals, human sacrifice, and incest arose in the late 1970s and throughout the 1980s. Many of these cases have since been dismissed but the controversy remains. Good sources of discussion are presented by Slife's (1998) presentation of the controversy argued by Bass & Davis (1988), and Coleman (1992). Another article by Loftus and Ketcham (1998) that provides information about the controversy is presented in Sattler, Shabatay, and Irramer's Abnormal Psychology In Context (1998). Bass, B. & Davis, L. (1988) The courage to heal: A guide for women survivors of child sexual abuse. New York, NY: Harper & Row. Coleman, L. (1992) Creating ‘memories’ of sexual abuse. Issues in Child Abuse Accusations, 4, 169-176. Loftus, B. & Ketcham, K. (1998) The myth of repressed memory. In Sattler, D., Shabatay, V., & Kramer, U., (Eds). Abnormal Psychology in Context. 34-39. Slife, B. (1998) (Ed.) Are memories of sex abuse always real? Taking Sides, 10/e, 146-170. STUDENT ACTIVITIES Classroom 1. Coping Skills: The Ones That Help Discuss with the class successful coping skills and unsuccessful coping skills. Explain the difference between task-oriented coping and defense-oriented coping. Let the class give examples. An interesting case of two students in the same dormitory complex gives students a concrete example of differences in coping techniques. 2. Stressful Jobs Have the class members list professions that seem to be stressful. These will probably include EMS technicians, ER doctors, high-tech business people, firefighters, security officers, and politicians. a. Ask the class what is stressful about each profession. Ask the class about the psychological manifestations and the physical manifestations involved with stress. b. Now ask the class to list professions that appear to be less stressful. Most students will include manual laborers, construction people, priests and ministers, and professors. c. Ask the class why they see differences in these professions. d. Finally ask the class to explain why so many postal employees appear to "break" under the stress. What could be the explanations of so many murders being committed by postal workers at their places of employment? e. Are teachers now under more stress? f. Are drivers under more stress now? How do they express this stress?

3. Relaxation Techniques and Road-Rage Therapists. Discuss with the class the latest type of psychologist in California, the Road-Rage Therapist. Ask the class the following questions: a. Do you experience stress when you drive? What is the most outrageous situation you have witnessed on the road? b. Why do you think drivers are becoming so hostile? c. Do you think life today is more stressful than it was five years ago? Why? d. Are the behaviors of others on the road increasing your stress level? e. What can be done to teach people how to drive "kindly"? Do you have any suggestions for drivers' education? Public service announcements? f. What do you think the Road-Rage Psychologist is doing? Explain relaxation techniques, exercises to use while driving, cognitive retraining, and other innovative methods that these new therapists use. 4. Physical and Psychological Differences in Life's Stresses a. Have students list the physical and psychological symptoms of life's stresses including: b. A neighbor backs his car into yours and then screams at you for parking on the street. c. Your boss blames you for a mistake that she actually made. d. Your professor gives you an F on a paper that you felt was superior. e. Your seventeen-year-old cat dies in your arms as you're petting her. f. Your four-year-old child is diagnosed with cancer and dies. g. You receive the news that you have won the Publisher's Sweepstakes and you are presented with a $1,000,000 check. h. You witness a horrible automobile accident and try to assist the victim who, you discover, has been decapitated. i. Your fiancé informs you that the relationship is over and you adore this person. In each case, ask the class to list the manifestations. List them on the board. Point out to the class that grief and sadness are different from the rest. Ask why the class thinks that this is the case. Discuss the "fight or flight" response to certain situations and how grief does not evoke that response. Assignment Hand out the two dormitory scenarios to student groups of three to six students. Ask the class the following questions: A. What were the differences between the way Linda and Lauren coped? B. Who was most successful (create the operation definition of success)? C. Who took "task-oriented" steps to solve the problem? D. Was there a question of "control" involved? Does that help in handling stress? If Lauren felt that she was partially controlling the noise, even though she wasn't, would the stress be less? E. Did Lauren have a support group? Does this help us cope with stress? F. Could Linda's stress levels lead to physical illness? What physical responses to stress, if continuous, could lead to physical problems? Use Table 5-4 ( pg. 163) in the text for this discussion. Critical Writing: Remembering Something that Never Happened Elizabeth Loftus is a well-known researcher in the field of recovered memories. She and her students have conducted over 200 experiments to try to discover the etiology and the prevalence of false memories, how they resemble real memories, and how to tell the difference between the two. In the experiments, false memories were created in the participants. Using a variety of different conditions, the experimenters were able to create “imagination inflation” in situations that resembled real life situations. Kassin & Kiechel were able to so thoroughly confuse their participants that they signed confessions for damaging a computer, when in fact, it never happened (1996). Alan Alda, in Pieces of Mind, has a similar experience where he states “I shouldn’t say ‘this is what happened,’ I should say ‘it seems to me that I remember, this is what happened.’” The research strongly suggests that we falsely remember many events and that the brain can reveal the difference between false and real memories. What are the ramifications of these experimental findings for police and the courts? At what point in time would the

system be so accurate that it could be used in testimony? Would such a system be as vulnerable as the current polygraph system? Alda, A. (1997). Pieces of Mind [video]. Scientific Frontiers, PBS. Kassin, S. & Kiechel, K.(1996).The social psychology of false confessions: Compliance, internalization, and confabulation. Psychological Science, 7, (3),125-128. Loftus, E.(1997, September). Creating false memories. Scientific American, 277, (3). 70-75. (http://faculty.washington.edu/eloftus/Articles/sciam.htm). Great Books to Read Alderman, T., & Marshall, K. (1998). Amongst Ourselves: A Self-help Guide to Living with Dissociative Identity Disorder. Oakland CA: New Harbinger Pubs. Kabat-Zinn, J. (1990). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York: Delta. Mann, A. (1987). The Study of Fugue. Mineola, NY: Dover. Sapolsky, R. (1998).Why Zebras Don't Get Ulcers: An Updated Guide to Stress, Stress-related Diseases, and Coping. New York: W. H. Freeman. VIDEO RESOURCES An Excuse to Kill (20/20), 27:52 min. (ABC News/Prentice Hall Library #2). Learning to Live With Stress: Programming the Body for Health, 20 min. (DOCUA). Selye and Benson. Discuss stress and its effects on health. Managing Stress, 22 min. (CRM/McGraw-Hill). Sources of stress and coping techniques are discussed. Pieces of Mind [video]. 60 min. With Alda, A. (1997). Scientific Frontiers, PBS. Posttraumatic Stress Disorder, 28 min. (Films for the Humanities and Sciences). Individuals suffering from PTSD are interviewed. Progressive Relaxation, 20 min. (Research Press) The applications of relaxation techniques are presented. Stress: A Disease of Our Time, 35 min. (Time-Life Films). Research and life situations demonstrate the effects of stress. The World of Abnormal Psychology: The Nature of Stress (Tape 2), 60 min. (Annenberg/CPB). This film provides an excellent description of stress and its effects. CHAPTER OUTLINE I. Stress and Coping (Table 5-1, pg. 158, Milestones in the Development of the Concept of Stress) A. Coping Skills. Successful coping skills help one develop realistic views of situations which have an effect on personality and social relationships. 1. Vulnerablity increases likelihood of stress 2. The situation must be considered when evaluating one's coping style. 3. One of the most common coping styles used with physical and psychological stress. B. Denial is a serious roadblock to accepting stressful events and lifestyles. (Table 5-2, pg. 159) C. The coping process 1. Various personal abilities help one to develop coping skills. 2. Being prepared for future events decreases anxiety and assists in coping. 3. Specific behaviors increase coping skills (Table 5-3, pg. 161) 4. General coping skills include: a. Constructive thinking b. Problem solving c. Flexibility d. The ability to provide personal feedback e. Social support D. Interactions among body, psychological, and behavioral systems affect response to stressful situations and life transitions (Table 5-4, pg. 163) E. Maladaptive behavior is more common among those with little social support. F. Physical and psychological health improve with increased social support. G. There is a strong relationship between social skills and social support.

II.

Stressful Situations and Life Transitions A. Stress-arousing situations 1. Personal crises a. Personal crises include a wide variety of crises ranging from those that affect many to those that affect only one. b. Rape is an example of a personal crisis with a vast array of consequences. 2. Bereavement and grief a. Bereavement over the loss of a loved one can last up to a year. (Table 5-5, pg. 167 and Table 5-6, pg. 168)) b. Grief involves several alternating and overlapping painful emotions. c. Psychotherapy advisable when bereavement /grief exceed guidelines accepted as normal. B. Life Transitions 1. Adolescence - stage of the life cycle that can be particularly stressful 2. A breaking point can be reached after a sudden change or after gradual transitions.

III.

Clinical Reactions to Stress (Table 5-7, pg. 169) A. Adjustment Disorder (Table 5-8, pg. 171) 1. Adjustment disorder is diagnosed when a person has difficulty adapting to one or more stressors in the previous three months. 2. This is often the result of interacting factors. 3. Usually recovery is within six months and future prognosis is very good. B. Acute Stress Disorder Adjustment Disorder (Table 5-9, pg. 171) 1. This disorder is brought about by extreme fear or horror during a very traumatic event. 2. It is characterized by a sense of dissociation. 3. Acute stress must last between two days and four weeks for a diagnosis. C. Dissociative Disorders 1. The Dissociation Continuum (Table 5-10, pg. 172) a. It is normal for everyone to experience dissociation at some time. b. Ideas and emotions are no longer connected. c. Many societies view dissociative events as religious experiences. 2. Diagnostic Criteria for Dissociative Disorders a. Dissociative amnesia - extensive but selective memory loss in the absence of organic pathology. b. Change is the defining characteristic. c. Dissociative amnesia is usually preceded by physical injury or emotional trauma. 3. There are several types of amnesia a. Localized b. Selective c. Generalized d. Continuous e. Systematized 4. Dissociative Fugue - Dissociative fugue is characterized by an inability to recall true identity. a. Unexpected travel away from home is common. b. It is often preceded by unbearable stressors. c. Usually lasts for a brief duration. 5. Dissociative Identity Disorder (DID) a. DID is characterized by alternate personalities with separate behaviors and memories. b. Some believe DID develops in response to extreme childhood trauma. c. Some question the existence of DID. d. Research has shown a greater incidence of epileptic seizures among those diagnosed with DID.

Depersonalization a. No memory loss is involved with this disorder. b. Self-perception is altered. c. Loss of reality is common. Interpreting Dissociative Disorders (Table 5-11, pg. 176) a. Incoming information is not integrated and associated with other information. b. There is a great deal of difficulty surrounding defining and understanding dissociative disorders. c. Dissociative disorders are usually thought to follow extreme trauma.

IV.

Treating Stress-Related Problems A. Supportive Therapy - the therapist's role is that of supporter and encourager. B. Drugs and Sedatives - medications are helpful for short-term treatment of panic states and maladaptive behavior following a traumatic stressor. C. Relaxation Training - client learns to control parts of the ANS to reduce anxiety. D. Systematic Desensitization - fear is gradually eliminated using a hierarchy exposure system combined with relaxation training. E. Cognitive Modification - client learns new way of thinking to avoid maladaptive behavior. F. Social Intervention - home and work environment of the client are included in the treatment program

Take-Away Message

WEB LINKS Biofeedback - http://webideas.com/biofeedback/. Online magazine containing information about biofeedback research, news, meetings, and equipment. Cancer and Stress - http://www.apa.org/monitor/jun99/stress.html A large body of research is linking certain forms of cancer to stress. Exercise and Stress - http://www.niehs.nih.gov/odhsb/focus/spring98/stress.html Facts on exercise and stress from NIH. Posttraumatic Stress Disorder Site - http://www.long-beach.va.gov/ptsd/stress.html This site has information and links to other sites dealing with post-traumatic stress disorder Psychotherapy for Cancer Patients - http://helping.apa.org/therapy/breast.html Many cancer patients can gain physical and mental benefits from psychotherapy. PTSD from the National Institutes of Health - http://www.nimh.nih.gov/anxiety/ptsdri1.cfm From NIH facts and info about PTSD and how to get help. Social Support - http://www1.od.nih.gov/obssr/socsup.html Stress Related Disorders - http://www.stressdoc.com. This site specializes in stress disorders. Stress and Colds - http://www.npr.org/news.new/healthold/970624.colds.html Read a National Public Radio discussion about research on the relationship between stress and the cold virus. Stress and the Immune System - http://helping.apa.org/mind_body/pnia.html Learning how to cope with stress will help us to ward off illness. The Biology of Stress - http://www1.od.nih.gov/obssr/Stress.html Current research findings from NIH about the biology of stress. Includes findings about women, PTSD, and heart disease. Women and Stress http://www.psycport.com/2000/05/19/wstm-/1030-0085-MED-US-Stress-Women.html Women’s response to stress may be more adaptive than that of men, according to recent research.

Student Activities #1 - Dormitory Scenarios

Scenario A Linda, a graduate student at a local college, needed to study at night. A freshman student who lived across the hall played music loudly every night. Linda became very frustrated and began to feel very angry. She would study as long as she could, but after a short time she would become angry, shout at her neighbors, slam her door, and try to continue to study. She could still hear the music and feel the bass vibrating in her room even with everything closed. She became more angry and almost every night would call security and the Resident Assistant. The loud noise would be turned down before the security could measure noise level, and as soon as the security left, the music level would be turned up again. Linda became so “stressed out” that she eventually could not sleep and had to get medication from her physician. Linda cried often, was tired most of the time, and was irritable and tense. Her grades began to drop and she felt helpless.

Scenario B Danielle lived in the same dormitory complex. Freshmen students across from Danielle were similar in their listening habits to those of Linda's. Danielle's neighbors played their music very loudly. She could not study, practice her violin, or talk on the phone. Danielle went to talk to the students. She explained to them that she had to study. They stated that they had a right to play their music whenever they wished. Danielle asked them if they would agree to turn the level down whenever she called them. She explained that this might be a satisfactory solution. Danielle tried this for one week (a time limit she had given to the neighbors). The students did not respond to her request. Danielle visited them again and told them that the first proposed solution did not work. The students again said that they would try to “do better,” but the loud music continued. At this point, Danielle went to the Resident Assistant and the security department and obtained the dormitory policy regarding loud music. She had the Dean of Student Affairs interpret the policy. She then purchased a decibel meter and began taking decibel readings on the neighbor's sound level. At the same time, she spoke to a number of other students who lived nearby and asked them to join her in helping to regulate the sound levels in the dormitory complex. The group went to the Resident Assistant and requested that the noise level regulation be enforced. Danielle felt that she had accomplished her goal of having some control of the noise level. The group of students continued to meet and discuss other issues. The warning given by the Resident Assistant was sufficient to stop the noise.

Chapter 6 Bodily Maladaptations: Eating, Sleeping, and Physiological OVERVIEW Chapter 6 begins with the story of Valerie, a child with bronchial asthma. It relates how parental anxiety and overprotection actually increase the asthma attacks. The chapter inquires into the roles played by stress, personal vulnerabilities, and resilience in physical illness. Further, it discusses psychological, social, and bodily interactions and certain illnesses. Eating disorders and sleep disorders are examined. Psychophysiological disorders such as cardiovascular disorders, coronary heart disease, and cancer are considered. The chapter also covers diagnostic dilemmas such as chronic fatigue syndrome, irritable bowel syndrome, and headache. CONTENTS Psychological, Social, and Bodily Interactions The Biopysychosocial Behavioral Medicine and Health Psychology Stress and Illness Eating Disorders (DSM-IV) Anorexia Nervosa Bulimia Nervosa Binge Eating Can Eating Disorders be Prevented? Sleep Disorders Dyssomnias Parasomnias Psychophysiological Disorders Cardiovascular Disorders Cancer Diagnostic Dilemmas Chronic Fatigue Syndrome Headaches Irritable Bowel Syndrome Take-Away Message LEARNING OBJECTIVES After completing this chapter students should be able to: 1. Describe the interaction among biological, psychological, and social factors. 2. Discuss the role stress plays in health and illness. 3. Describe the population most affected by the disorders of anorexia and bulimia. 4. Describe the normal stage of sleep and the sleep cycle. 5. Compare the three sleep disorder groups: dyssomnias, parasomnias, and insomnia. 6. Explain the risk factors behind CHD and possible prevention strategies. 7. Describe the relationship between hypertension and heart attacks. 8. Identify the types of headaches, including tension, migraine, and cluster. LECTURE AND DISCUSSION TOPICS 1. Why Do You Believe Women Live Longer Than Men? As students suggest different reasons, mention the following factors: a. Women and men are different chromosomally. Women have 23 pairs of identical chromosomes. The 23rd pair (the sex chromosomes) contains the same materials in the two "X" chromosomes. If something is defective in one, often the second is able to compensate for the problem (color blindness, hemophilia, and perhaps some learning disabilities). Men on the other hand have 22 identical pairs of chromosomes but the 23rd pair (the sex chromosomes) contain an "X" chromosome and a "Y" chromosome. This may predispose men to exhibit some disorders more often than women. Allow the class time to discuss this proposal.

b. Introduce the hormonal difference between men and women. The effects of testosterone are very different from those of estrogen. Suggest the idea that testosterone is a hormone of aggression and sex drive. Does research show that estrogen decreases the incidence of heart attacks? Why do menopausal women's risk for heart attack rise after the production of estrogen ceases? Do those factors have anything to do with longevity? c. Introduce the factor of "lifestyle." Do the lifestyles of men and women differ? Does man's life style increase his risk for disease? What are the lifestyle factors that seem to be related to coronary heart disease? Discuss the nature vs. nurture issue in the debate. 2. When discussing anorexia and bulimia suggest famous persons who have had either disorder, such as Karen Carpenter and Princess Diana. 3. Can You Tell What "Type" You Are? -Type A/Type B Categories Develop a list of famous individuals and hand that out to the class. To the left of the name of each individual, leave a blank. List some of the following individuals and add names of other famous persons. Are they type “A” or type “B” personalities? ____ Rush Limbaugh ____ Magic Johnson ____ Hillary Clinton ____ Bill Gates (Microsoft) ____ Nancy Reagan ____ Regis Philben ____ Kathie Lee Gifford ____ Bobby Knight (basketball coach) ____ Mike Ditka (football coach) ____ Bob Newhart (actor) ____ Andy Griffith (any character he has ever played) ____ Mick Jagger 4. Name That Headache Ask four to six students who have headaches to volunteer for a class demonstration on distinguishing among different kinds of headaches. On overhead pages, have each student print the following information about their headaches: * Gender of the Sufferer * Age of Onset * Time of Year of Most Headaches * Time of Onset * Length of Headache (minutes, hours, days) * Location of Headache * Severity of Pain * Other Symptoms * Symptoms Associated with Onset * Other Symptoms Occurring During Headache * Precipitating or Aggravating Symptoms * Personality of Sufferer For the diagnosis of each type of headache, have on the board Table 5-11 from the text. Using these criteria, lead the class in a discussion and "diagnosis" of each type of headache presented by each of the students. STUDENT ACTIVITIES Classroom Sometimes anorexia begins shortly after a change occurs—the beginning of puberty, divorce of the parents, leaving home, breaking up with a boyfriend, moving to a different town, or something similar. The person feels an overwhelming lack of control over the changes. Dieting makes the person feel more in

control and, at first, better about him or herself. It seems one way to gain control in a socially acceptable way. However, food and losing weight soon become central to daily functioning. Dieting excessively extends beyond the point of all reason. Overly high expectations imposed by family, schools, and society may contribute to anorexia. Anorexia may be used to rebel against high expectations, or to attain feelings of control and independence. Distorted thinking often contributes to anorexia. All or nothing thinking, such as “If I don’t get an ‘A’ I’ll be a failure,” is common (irrational ideas). Magical and simplistic thinking, such as “If I am thin, I will be happy and others will like me,” also supports continued dieting. The National Institutes of Mental Health: “Eating disorders frequently co-occur with other psychiatric disorders such as depression, substance abuse, and anxiety disorders. In addition, people who suffer from eating disorders can experience a wide range of physical health complications, including serious heart conditions and kidney failure which may lead to death. Recognition of eating disorders as real and treatable diseases, therefore, is critically important” (NIH Publication No. 01-4901, Printed 2001). Ask the class for suggestions to design an anorexia-bulimia prevention/early intervention program for children. A. How early should the program start? B. What are health prevention strategies? C. Who can help in ensuring that prevention programs are followed? D. What are some engaging activities for children of that age group that help them understand the message? E. How can parents help? F. How can the school help? G. Community support? Assignment 1. Does our Society promote Eating Disorders? A. Television 1. Over the week, watch two or three sitcoms. 2. Categorize the show as a) family, b) teen/young adult, c) general audience. 3. Try to guess the actor’s/actress’s weight. 4. Watch the commercials. Do they promote dieting? Sex? Food? Alcohol? 5. Are there any public service announcements at the beginning, during, or end of the show? 6. Is healthful food promoted? B. Magazines - Pick up a teen/young adult magazine 1. How many articles show very thin women? 2. How many diet ads are shown? 3. Is healthy food promoted? 4. Is exercise promoted? 2.

A study conducted by the University of Minnesota found that 20% of all high school students fall asleep in school (Maas, 1995). The study also reported that over 50% of students report being most alert after 3:00 PM (Allen & Mirabile, 1989). From the “School Start Time Study,” researchers report that “as they [teenagers] move through their teenage years, adolescents need increasing amounts of sleep” (Carskadon, 1982). Maas (1995) reports that teenagers need nine hours of sleep nightly, compared to the eight hours needed by adults. The study further reports that “...a study conducted by Wolfson, Tzischinsky, Brown, Darley, Acebo & Carskadon, (1995), found that conduct/aggressive behaviors were highly associated with shorter sleep and later sleep start time. These results signal important relationships between sleep quantity and behavioral difficulties in adolescents.” (Center for Applied Research and Educational Improvement, (1998), http://carei.coled.umn.edu/Programs/time/start_time/volume_I/literature.html.) Keep a log of your sleep start times and length of sleep for a week or a month. a. What is the average time you went to sleep? b. What was your average length of sleep time?

c. Was your sleep time uninterrupted? d. If it was interrupted, what were the primary causes of the interruptions? e. If you live in a dormitory, what do you believe is the single biggest factor in sleep prevention or disruption? Critical Writing Can a Type A personality learn to be a Type B? Can the reverse happen? What are factors in both personalities that make one preferred over the other? If you could select the best of both personality types, what features would you choose? Support your choices with examples. Great Books to Read Balingasa, N., Balingasa, E., The Food Jungle. (1999). The Woodlands, TX: Printed Matters. Feldman, David, & Schwan, Kassie. (1994). How Does Aspirin Find a Headache: An Imponderables Book. New York: Harperperennial Library; ISBN: 0060925582. Sark. (1999). Change Your Life Without Getting Out of Bed: The Ultimate Nap Book. New York: Simon & Schuster/Fireside; ISBN: 0684859300. VIDEO RESOURCES Professional Body Dysmorphic Disorder, 15 min. (Films for the Humanities and Sciences). Two women discuss their experiences with BDD. Bulimia, 20 min. (Research Press). The causes and effects of bulimia are discussed. Mind Over Body, 49 min. (PBS Video). This video describes how one's state of mind can affect illnesses and injuries. Video Eating Disorders (World News Tonight) 4:20 min. (ABC News/Prentice Hall Video Library Abnormal Psychology Series III Cassette Three). Girls and Eating Disorders (American Agenda), (ABC News/Prentice Hall Library #2). Pressures from our culture and advertising are discussed as possible influences on girls who suffer from eating disorders. Patients as Educators: Case #1: Ann, Bulimia, (Prentice Hall Videos). The case of a forty-six-year-old teacher suffering from bulimia is presented. The World of Abnormal Psychology: Psychological Factors and Physical Illness (Tape 4), 60 min. (Annenberg/CPB). This video presents an in-depth discussion of the relationship between psychological factors in the development of physical disorders. The Princess Diana Few Knew. 60 min. ABCNEWS.com: 20/20, October 4, 2000. A sad story about Diana, her struggles, her bulimia, her inside fears from when she was a young teenager. The World of Abnormal Psychology: Psychological Factors and Physical Illness (Tape 4), 60 min., (Annenberg/CPB). This video presents an in-depth discussion of the relationship between psychological factors in the development of physical disorders. When You Hate Your Looks: People Suffer from Body Dysmorphic Disorder (20/20), 10:52 min. (ABC News/Prentice Hall Video Library Abnormal Psychology Series III Cassette Two).

Movie Superstar: The Karen Carpenter Story (1987). Anexoria Nervosa. In real life, Karen Carpenter was a highly successful 1960s popular singer who died at age 32 from complications of anorexia nervosa. This extraordinary 43-minute film features no human actors after the opening depicting Karen's death, but only "Barbie dolls" playing the roles of Karen and the often uncaring people around her. Karen dies from a lifetime of anorexia nervosa. This film can be hard to locate but is so unusual that it should definitely be seen as an introduction to eating disorders and the way in which society's expectations about behavior and appearance influence the way women live and die. Iced Tea Productions.

CHAPTER OUTLINE I. Research has shown that psychological and social factors play an important role in health and fitness. A. Acute and chronic stressors play a role in physical conditions. B. Vulnerability and resilience play a role in bodily function and illness recovery. C. Bodily complaints may be a way of coping with stress. D. There are wide and individual variations in bodily reaction to stress. E. The mechanisms of bodily reactions remain unclear. F. Involve interactions between personal variables and situational variables. II.

III.

Psychological, Social, and Bodily Interactions A. Eighteenth Century - Mesmer claimed that he could modify the course of physical symptoms by using “personal magnetism.” B. Integrating Freudian ideas into physical aspects of emotional experiences - the psychosomatic hypothesis. C. Recent research examines the bodily reaction to emotional stimuli, for example: 1. Perceptual systems trigger the “fight or flight” response. 2. Adrenal medulla releases hormones (adrenalin) to prepare the “fight or flight” response (part of the sympathetic system). D. The Biopsychosocial Model 1. The interactions among biological, psychological, and social variables are studied. 2. Few people still believe that becoming ill is due solely to outside influences on the body, rather it is due to an interplay of various factors contribute to one's state of health. 3. Homeostasis - maintaining equilibrium between internal and external states. Vulnerability and stress can lead to “getting sick.” 4. Relevant to prevention and treatment in the field of behavioral medicine and health psychology. E. Stress and Illness 1. Bodily systems are pushed to work harder during times of stress. 2. Prolonged periods of stress can wear the immune system down. 3. Doctor-patient relationship - contributes to positive patient morale or, conversely, negative emotions that can affect the outcome of the illness. 4. The relationship of gender to longevity. a. Male rates of mortality seem tied to societal expectations. b. Supportive social relationships c. High levels of trust 5. Biopsychosocial approach to the common cold. a. Event that caused stress were four time more likely to precede infections. b. Stress seems to decrease resistance to infections; social relations seem to increase resistance. 6. A greater ability to cope with stress leads to a decrease in the demands on one's body. Eating Disorders A. The relationship between psychosocial and biological factors is not well delineated. B. Three most studied: 1. Anorexia Nervosa - distorted body images, may even starve to death 2. Bulimia Nervosa - binge eating with purging 3. Binge Eating - out-of-control eating like bulimia but not purging C. Anorexia Nervosa (Table 6-1, pg. 191). 1. Refuse to allow body weight to be more than 85% of normal 2. Exaggerated desire to remain thin 3. Intense fear of gaining weight 4. Obsessive and ritualistic behaviors centering on food 5. Deliberate refusal of food 6. Absence of three menstrual periods 7. About 90% are female

8. 9.

Age of onset is puberty (age 14) or late teens (age 18), average is age 17 Epidemiology and Risk Factors in Anorexia: a. More prevalent that 50 years ago, possible three-fold b. Within 10 years death in 5% to 7% of patients c. Causes 1) Personality factors: met criteria for obsessive-compulsive disorder which may be predictive 2) Family factors: more prevalent is relations, mother’s concern about daughter’s weight, overly critical males in family 10. Treatment of Anorexia a. Early warning signs (Table 6-2, pg. 192) b. Cultural factors: more frequent in Caucasians, more susceptible in weight- based activities, social pressure c. Most treatment approaches use a combination of medication and behavior modification or psychotherapy. d. The use of medication has not been reliably demonstrated in changing eating behavior, altering body images, or allaying fear of weight gain. e. Behavior therapy is used to improve eating. f. Cognitive therapy attempts to replace thought patterns that exacerbate anorexic behavior. g. Family therapy provides better results over individual therapy. h. Early diagnosis results in better response to treatment. D. Bulimia Nervosa 1. Binge eating - much more food than is considered normal in a two-hour period, ex., an entire chocolate cake while feeling out of control. 2. Purging - elimination of food in inappropriate ways using laxatives, vomiting, or exercise as often as several times a day. 3. Table 6-3 (pg.194). Lists the criteria. 4. More common in women than men. 5. Occurs during late adolescence/early adulthood. 6. Differences between anorexia and bulimia a. Anorexia patients seem rigid and inflexible. b. Bulimia patients have poor impulse control and inadequate regulation of diet. 7. Epidemiological factors in bulimia a. Estimated to be between 4%-9% of high school and college age students b. Family discord and negative mood states are prevalent in the group. c. Do not seek help until ages 20s and 30s. d. Males have a higher incidence of bulimia than anorexia (10%-15% of cases). 8. Causes of bulimia a. Stress due to personal factors b. Recent negative life events c. Possible childhood sexual abuse is suggested. d. Extreme dieters report depression and anxiety. e. Caucasian girls are twice as likely to experience than African American girls. 9. Treatment of bulimia a. Antidepressants, some SSRI’s b. Self-monitoring c. Relaxation training d. Medication and cognitive-behavioral therapy seems to be the most effective E. Binge Eating (Table 6-6, pg. 198) 1. Recently described - not categorized in DSM-IV 2. Common snacking all day long and/or eating large amounts of food 3. Women with the disorder experience more negative moods than most. IV.

Sleep Disorders (Table 6-7, pg. 199) A. Sleep Processes

1. Neurotransmitters 2. Adenosine may build up over the day to cause drowsiness. 3. Sleep stages: 1, 2, 3, 4, and rapid eye movement (REM) sleep 4. First REM is 70-90 minutes after we fall asleep. 5. A complete sleep cycle of all five sleep levels lasts between 90-110 minutes. Sleep Related Problems 1. Problems like stroke and asthma attacks occur more frequently during sleep. 2. Sleep problems occur in almost all persons with a mental disorder. 3. Polysomnography records sleep behaviors and processes while a person is asleep. Dyssomnias 1. A sleep disorder adds to a person’s vulnerability. 2. Disturbances of sleep affect about 33% of the U.S. population. 3. Symptoms of dyssomnias include abnormalities in the amount, quality, or timing of sleep. Insomnia - trouble initiating or maintaining sleep, not feeling rested 1. As many as 30% of the population suffers some form of insomnia. 2. If the condition occurs for more than a month it is diagnosable Narcolepsy - sudden onset of sleep and REM at unexpected times 1. May experience hypnogogic hallucinations - vivid, terrifying dreams 2. Sleep paralysis may be a component of the attack. 3. Large genetic component. Genes on chromosome 6 Breathing-Related Disorders 1. Sleep Apnea - regular breathing stops for 10-30 seconds throughout the night 2. Treatment a. Antianxiety drugs, benzodiazepines b. Light treatments that shift the circadian rhythm c. Cognitive therapy d. Relaxation training Parasomnias are indicated by abnormal behavior or physiologic events during sleep, sleepwake transitions, and in specific sleep stages. 1. Nightmare Disorder - frightening dreams and elaborate, terrifying dream sequences. 2. Sleep Terror Disorder - occur early in the sleep cycle and do not produce dream recall. Heightened autonomic activation but cannot be awakened. 3. Sleepwalking Disorder a. Likely to occur in the first third of the sleep cycle. Involves motor behaviors, predominately walking about b. Diagnosed when it disrupts normal life areas and relationships 4. Causes a. Depression is frequently associated with the parasomnias. b. Anxiety may be present.

Psychophysiological Disorders A. Cardiovascular Disorders 1. Table 6-8, pg. 205, lists types of CHD. 2. Coronary Heart Disease - CHD is the leading cause of death and disability in the U.S., accounting for 40% of all deaths. 3. Coronary arteries become rigid and blocked by plaques. 4. Stress causes the release of epinephrine and norepinephrine which increase the rate of arterial damage. 5. Lifestyle and heredity are both major factors in determining one's risk for CHD. 6. Sex differences - leading killer in women after age 66 7. Leading killer of men beginning at age 39 8. Personal lifestyles contribute a. Type A personality - hurried, competitive, and hostile b. Type B personality - not as pressured

9. 10. 11. 12. 13.

14.

VI.

Stressful events will often increase the rate of one's cardiovascular system temporarily, but sometimes extreme cardiac events can result. Community lifestyle - the pace of the community strongly related to the number of cardiovascular disorders in the community. Cultures where tradition and family ties are predominant, CHD is considerably lower than in less cohesive societies. Cognitive-behavioral therapy has been studied as a means to decrease one's risk for CHD. Hypertension a. Hypertension is a major factor in CHD. b. People experiencing chronic anger and anger suppression are often the most likely to suffer from hypertension. c. Research has shown that a lack of assertiveness may be related to an increased risk for hypertension. d. Relaxation techniques have been found to help those with hypertension. Cancer a. Studies have shown that experiencing uncontrollable stress can promote the growth of tumors. b. It is suggested that cancer patients participate in group therapy to deal with the strong emotions brought about by the disease. c. Controversy surrounds the relationship between psychosocial factors and cancer.

Diagnostic Dilemmas A. Chronic Fatigue Syndrome (Table 6-9, pg. 213) 1. For a diagnosis to be confirmed inclusion and exclusion criteria must be met. 2. No cause of the disorder has been determined. 3. CFS is often preceded by a viral infection. B. Headaches - There are three components of a headache: 1. Physiological changes 2. Subjective experience of pain 3. Behavior motivated by the pain 4. There are several types of headaches (Table 6-10, pg. 241): a. Tension headaches are characterized by changes in the skeletal muscles and are the most commonly reported headaches. b. Migraine headaches: 1) Tend to be severe and localized headaches 2) May be accompanied by an aura (visual distortions) and nausea 5. Cluster headaches usually occur on one side of the head with extreme pain for a few minutes which disappears within an hour. C. Irritable Bowel Syndrome (IBS) 1. Gastrointestinal upset and altered bowel movements, the cause of which cannot be identified. 2. Reported in 9% to 22% of medical patients 3. Cause of high absenteeism at work 4. Co-morbid with depressive and anxious behaviors 5. Treatment includes altering of maladaptive thoughts, improving resilience and coping skills.

VII. Take-Away Message WEB LINKS Anger - http://helping.apa.org/daily/anger.html Cancer and Stress - http://www.apa.org/monitor/jun99/stress.html A large body of research is linking certain forms of cancer to stress.

Headaches - http://www.headaches.org The National Headache Foundation has information on causes and treatment of all types of headaches. Heart Disease - http://americanheart.org The American Heart Association has the latest information on heart disease and stroke. Hypertension and Stress - http://www.bloodpressure.com This site provides information about the relationship between hypertension and stress. Irritable Bowel Syndrome - http://www.niddk.nih.gov/health/digest/pubs/irrbowel/irrbowel.htm The National Institute of Health site with information about irritable bowel syndrome. Social Support - http://www1.od.nih.gov/obssr/socsup.html The Biology of Stress - http://www1.od.nih.gov/obssr/Stress.html Current research findings from NIH about the biology of stress include findings about heart disease. The Mind-Body Connection - http://helping.apa.org/mind_body/index.html This American Psychological Association website is devoted to the mind/body connection as it relates to mental and physical health and illness.

Chapter 7 Disorders of Bodily Preoccupation OVERVIEW Chapter 7 discusses somatoform disorders, that is, physical symptoms in the absence of identifiable physical disease. Disorders that involve pain disorders are discussed. Factitious disorder and malingering are surveyed as well. Often, the psychological overlay that accompanies real physical pain is expected and justified. In other cases, there is no observable physical disorder. Bodily somatization, an individual’s use of the body or bodily symptoms for psychological purposes or personal gain and do not appear to be consciously produced, is the purview of the DSM-IV. Factitious disorders, including Munchausen, and factitious disorder by proxy are discussed. Malingering is a condition where the patient seeks medical attention in order to achieve a goal. It is sometimes very difficult to determine if certain behaviors are under voluntary control. CONTENTS Somatoform Disorders Pain Disorders Conversion Disorders Hypochondriasis Body Dysmorphic Disorders Factitious Disorders Malingering Take-Away Message LEARNING OBJECTIVES After completing this chapter students should be able to: 1. Differentiate between psychophysiological disorders and somatoform disorders. 2. Describe the disorders that collectively are referred to as pain disorders. 3. Describe the five types of coping strategies. 4. Explain the use of the A-B-A-B research design where a person serves as his or her own control. 5. Give an example of a situation where biofeedback would be therapeutic. 6. State the criteria for identifying a cluster of symptoms as somatization disorder. 7. Distinguish between conversion disorder and hysteria. 8. Describe the cluster of symptoms in hypochondriasis and the three major characteristics. 9. Suggest several reasons why cognitive-behavioral therapy is effective with body dysmorphic disorders. 10. Differentiate between somatization disorder and factitious disorder. 11. Describe Munchausen syndrome and Munchausen (Factitious) disorder by proxy. LECTURE AND DISCUSSION TOPICS 1. Factitious Disorders: Munchausen Syndrome. An article that will enhance this class discussion is provided by Boros and Brubaker (1992). The article defines Munchausen Syndrome by Proxy and has a number of case studies detailed; warning signs and help aids for investigators are also included. A reprint of this article is provided by Palladino (1998). 2. Define Munchausen syndrome. Introduce the famous case of the woman from Texas who had over 20 surgeries. This woman's onset of the disorder started after a bout of diphtheria when she was a teenager. Shortly after this illness, the patient reported to have severe pains in her abdomen. An appendectomy followed. No sign of problems in the abdomen were present. Soon after the appendectomy, her pains returned and she had an additional surgery. Again, no problems were discovered. Soon after that surgery, the woman reported coughing often and would spit blood in front of friends and family. She was isolated in a hospital for tuberculosis but no evidence of tuberculosis was found. However, it was discovered that she had been taking great amounts of aspirin. After continued bleeding, surgery revealed no problems and again it was discovered that she had continued to take large amounts of aspirin. A hysterectomy that followed a number of complaints about menses and cramping produced no abnormalities. These surgeries continued over a period of

forty years through which the woman developed a number of unusual illnesses including that of "intestinal blockage." The woman was able to withhold bowel function for many days and this led to surgery for "probable" tumor blockage. Impacted fecal material was the diagnosis after the surgery, and again it was discovered that the woman had taken large amounts of anti-diarrhea medication. The woman continued to go to different cities, different hospitals, and different physicians seeking more surgery and hospitalization. She finally died as a result of shock suffered during a factitious episode that resulted in her final surgery and hospitalization. 3. Ask the class why individuals with Munchausen's would enjoy being in a hospital. Why would they enjoy the painful treatment? How could such a person as the woman above convince physicians of her factitious illnesses? Do you think this disorder will continue in view of new technologies in medicine? 4. Discuss the serious condition of Munchausen Syndrome by Proxy. Define this disorder. Introduce the case of Nurse Smith. In this case, Ms. Smith was a nurse in a large hospital unit for children. She later moved to a smaller community where she served as a nurse assistant for a pediatrician. Ms. Smith was first suspected of causing serious harm to her patients when several of the young children either died or became critically ill while receiving their annual vaccinations from Ms. Smith. An investigation followed and it was revealed that Ms. Smith was present during the untimely deaths of a number of children. Witnesses testified that Ms. Smith seemed to want to be the center of attention and became very excited when she was praised for her heroic efforts in either "saving" a dying child or trying to "save" a child who later died. Investigations revealed the children had probably been injected with a deadly medicine. Ms. Smith was convicted of this offense and is serving time in prison. 5. Ask the class what might be the motivation of Ms. Smith. Ask the class members if they have heard of other cases. Remind the class of the case of the mother who had been honored by a president of the United States as a mother of great character and devotion for her care of her chronically ill child. In this case, the mother would care for her daughter who had chronic stomach and colon problems. Later, physicians and nurses noticed that the child would become more ill after the mother visited or when the child returned home. Videos revealed the mother's introducing foreign material into the child's IVs and feeding tubes. What could the motivation be for such behavior? Boros, S. and Brubaker, L. (1992 June) Munchausen syndrome by proxy: Case accounts. FBI Law Enforcement Bulletin. United States Department of Justice, FBI, Washington, DC, pp. 16-20. Palladino, J.J. (1998) (Ed) Munchausen syndrome by proxy: Case accounts. Annual Editions: Abnormal Psychology 98/9,. pp. 164-167. Who Pays for Malingering? 1. Discuss the definition of malingering. Ask the class to give examples of malingering. Discuss what insurance companies are doing to stop this practice. Have you known anyone who malingered? Did you ever malinger as a child? Did you stay home an extra day after being ill? Did you ever malinger when you had been ill and wanted to stay home in order to avoid a difficult situation at work or school? How does malingering costs insurance companies millions of dollars? How does malingering cost the government millions of dollars? Who ultimately pays these costs? In what ways is malingering identified? How is it proven? 2. Example: A woman testified that she had been injured on an escalator. She felt that it had attacked her like a "sledge hammer" would have. She said that she was off balance, dizzy, and could not work. Her business was ruined. She sued the department store for her injuries, loss of income, and income potential. Her case was dismissed when investigators filmed her playing golf with her husband (she shot ten over par). An investigator also posed as a customer at her store and asked about the owner. He was told "This business is so successful because Mrs. Limpnomore works longer and harder than any of us every day." Mrs. Limpnomore also was filmed at a "playday" at her child's school running in the mother's relay race.

STUDENT ACTIVITIES Classroom Activities When Is Surgery Too Much Surgery? Body Dysmorphic Disorders Explain the meaning of body dysmorphic disorders. Discuss what individuals might do if they suffer from this disorder. Include avoidance behavior, isolation, plastic surgery, and the wearing of certain "disguising" items of clothing. Do you know of celebrities who have had numerous plastic surgeries? If the class members need assistance, help them by asking about Michael Jackson, who appears to have had facial features changed including chin dimple, nose, lips, eyes; Cher, Loretta Lynn, Roseanne, and perhaps Clint Eastwood. Then have the class members list other individuals who seem to have had numerous plastic surgeries to change their looks. Do you personally know any individuals who have done this? When is plastic surgery useful? When is it too much? Critical Writing The term hypochondriasis is a medical term that is often misunderstood. It means the same thing as “An intense illness concern.” In hypochondriasis the patient is overly concerned with having a serious illness despite many reassurances that there is no physical illness present. If you were a psychologist presented with a patient that had intense worries, what steps would you take to develop a differential diagnosis for this patient? What therapies would be appropriate in the treatment of a person with this disorder? Great Books to Read Allison, David, & Roberts, Mark. (1998). Disordered Mother or Disordered Diagnosis? Munchausen by Proxy Syndrome. Hillsdale, NJ: Analytic Press. ISBN: 0881632902. Cantnor, Carla. (1996) Phantom Illness: Shattering the Myth of Hypochondria. New York: Houghton Mifflin. Feldman, Marc, & Ford, Charles. (1995). Patient or Pretender: Inside the Strange World of Factitious Disorders. New York: John Wiley & Sons. ISBN: 0471120138. Merskey, Harold, & Bogduk, Nikolai. (1994). Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. Seattle, WA: International Association for the Study of Pain. ISBN: 0931092051 . VIDEO RESOURCES Professional The World of Abnormal Psychology: Psychological Factors and Physical Illness (Tape 4), 60 min., (Annenberg/CPB). This video presents an in-depth discussion of the relationship between psychological factors in the development of physical disorders Video Body Dysmorphic Disorder, 15 min. (Films for the Humanities and Sciences). Two women discuss their experiences with BDD. Facing Themselves. (20/20, segment #02). Date: Jul 11, 1999. Categories: Medical/Health, Social Studies. Obsessive mirror checking may seem normal for many teens in their formative years, but is the image some see causing severe angst to the point of contemplating suicide in some cases? John Stossel reports on teenagers struggling with body dysmorphic disorder. Mind Over Body, 49 min. (PBS Video). This video describes how one's state of mind can affect illnesses and injuries. Munchausen. (20/20, segment #01). Anchors: John Stossel, Connie Chung. Date: Aug 11, 2000. Categories: Crime & Justice, Medical/Health. The hospital claimed that Julie Patrick was inflicting Munchausen Syndrome by Proxy on her son and allowed only limited, supervised visits with her son while his health continued to deteriorate. She denied the allegations of the child abuse and is suing for malpractice. When You Hate Your Looks: People Who Suffer from Body Dysmorphic Disorder (20/20),10:52 min. (ABC News/Prentice Hall Video Library Abnormal Psychology Series III Cassette Two).

CHAPTER OUTLINE I. Somatoform Disorders A. Alice Kenton and Valerie Harris B. Table 7-1 (pg. 220) describes the major somatoform disorders identified in the DSM-IV. C. Pain Disorders 1. Temporal relationship among actual, threatened, or fantasized interpersonal loss or complaints of pain 2. Acute or Chronic 3. Table 7-2 (pg. 220) lists DSM-IV criteria for pain disorder. 4. Criteria include a duration of 6 months or longer. D. What Is Pain? 1. Psychological state is involved along with physical state. 2. Historically thought to be a simple biological alert system with a direct connection to the brain 3. It is now known that pain signals are amplified, diminished, before being relayed to the brain. 4. Table 7-3 (pg. 221) lists interview questions used to assess pain. E. Coping with Pain 1. Active coping - staying active and ignoring pain 2. Passive coping - resting and social withdrawal 3. Table 7-4 (pg. 222) provides coping strategies. 4. Various factors play a role in how one perceives pain. F. Treating Pain Disorders 1. Chronic pain disorder may result in diagnosable psychiatric disorder. 2. Treatment Options a. Operant conditioning - verbal reinforcement b. A-B-A-B research design (repeated measures) c. Cognitive-behavioral therapy and components 1) Relevance of thought and situations to the pain experience 2) Encouragement to challenge contributing maladaptive thoughts 3) Behavioral skill to lessen pain experience (relaxation, pacing, etc. 4) Identify high risk situations 5) Return to daily functioning 6) Adaptive self-management, Table 7-5 (pg. 224) d. Biofeedback 1) Technology used to measure autonomic arousal ant other physiological responses 2) Knowledge about the response is the reinforcer 3) Limitations of biofeedback training a) May not last long b) May not be consistently successful across all problems 4) Psychotherapy a) Useful in achieving compliance with treatment regimens b) If pain is comorbid with psychiatric condition it may be helpful 5) Medication a) Pain relievers b) Antidepressant medication 3. The Realities of Pain Disorders a. Focus on patient response, not on symptoms b. Understand the patient’s vulnerabilities c. Awareness of patient demoralization G. Somatization Disorders (Table 7-6, pg. 226, Guidelines for Treatment) 1. Multiple, recurring complaints 2. Briquette’s syndrome - described in 1859

a. b.

Wide range of physiological complaints Figure 7-5 (pg. 226) location and frequency of somatizing patient surgeries c. DSM-IV criteria: four pain symptoms in different bodily sites, two gastrointestinal complaints without pain, one sexual symptom without pain, and one symptom or deficit indicative of a neurological symptom d. Patients take large quantities of medicines. e. Reasons for somatizing (Table 7-7, pg. 226) f. Share histrionic personality traits g. Disorder occurs mainly in women - 1% population Conversion Disorders 1. These disorders are characterized by the claim that one has lost part or all of a particular bodily function. 2. The symptoms are not voluntary, but cannot be explained by medical science conversion disorders usually follow a stressful event. 3. DSM-IV limits conversion disorder to conditions where one or more symptoms of motor or sensory dysfunction that suggest but cannot be related to a medical problem. Hypochondriasis 1. Hypochondriacs continue to believe that they have a severe medical problem even after all testing and examinations have proved otherwise. 2. An intense obsession over bodily functions is a characteristic of hypochondriasis. 3. Characteristics a. Physiological arousal b. Bodily focus c. Behaviors designed to avoid or check for physical illness (ex. taking notes) 4. Treatment a. Establish therapeutic relationship b. Acknowledge the distress c. Elicit fears and beliefs about illness d. Present alternative rational explanations 5. Cognitive therapy may be beneficial. Body Dysmorphic Disorders 1. This disorder is characterized by an obsession over a minor or imagined defect of one's body. 2. In therapy these individuals will rarely mention their preoccupation of their “defect.” 3. Body image a. Large discrepancy between desired body image and actual body image b. Men experience a condition called Muscle Dysmorphia. c. Therapy - cognitive behavioral therapy Factitious Disorder and Malingering 1. Factitious means artificial or unnatural. 2. Patient history frequently reveals childhood emotional insecurity, neglectful parents, broken homes. 3. Munchausen syndrome - Repeated, knowing simulation of disease for the purpose of obtaining medical treatment. 4. Factitious disorder by proxy (Munchausen disorder by proxy) - Parent (usually mother) feels the need for attention but expresses it by inducing illness in the child and presenting the child for medical attention. 5. Malingering - Different from factitious disorders because the behavior is goal oriented, aimed at receiving some form of compensation or reward.

WEB LINKS Are you a hypochondriac? - http://www.uib.no/med/avd/med_a/gastro/wilhelms/whiteley.html Find out with this widely used hypochondria assessment. Dealing with Pain - http://helping.apa.org/mind_body/psychosocial.html This APA monograph discusses the psychosocial issues in chronic pain patients. Hypochondriasis - http://www.diseaseworld.com/hypochon.htm Learn more about hypochondriasis and Munchausen syndrome. Hysteria in History - http://www.historyhouse.com/stories/hysteria.htm Read about the historical beliefs relating hysteria to a woman's "wandering womb." Interview with author of Phantom Illness - http://www.usatoday.com/life/enter/books/leb487.htm Carla Cantor, author of Phantom Illness, a book about hypochondria, talks with a USA Today correspondent. Munchausen Syndrome by Proxy - http://www.medicine.uiowa.edu/pa/sresrch/Huynh/Huynh/sld001.htm A slide show tutorial on Munchausen syndrome by proxy. Muscle Dysmorphia - http://www.bodybuildernutrition.com/new196.html An article on body dysmorphia and muscle dysmorphia. The Mind-Body Connection - http://helping.apa.org/mind_body/index.html This American Psychological Association website is devoted to the mind/body connection as it relates to mental and physical health and illness.

Chapter 8 Anxiety Disorders

OVERVIEW Chapter 8 covers the general description of anxiety and the major anxiety disorders. The major disorders discussed include generalized anxiety disorder, panic disorder, phobias, agoraphobia, obsessivecompulsive disorder, and posttraumatic stress disorder. The chapter ends with the interpretation of each disorder using the main perspectives in psychology and includes the treatment provided by each perspective. CONTENTS The Experience of Anxiety Generalized Anxiety Disorder Acute Stress Disorder Panic Disorder Phobias Specific Phobia Social Phobias Agoraphobia Obsessive-Compulsive Disorder Posttraumatic Stress Disorder Vulnerability Factors Epidemiological Evidence The Postttraumatic Experience Interpreting and Treating Anxiety Disorders The Psychodynamic Perspective The Behavioral Perspective The Cognitive Perspective The Biological Perspective Take-Away Message LEARNING OBJECTIVES After completing this chapter students should be able to: 1. Define anxiety and name the physical symptoms that accompany it. 2. Differentiate between generalized anxiety disorder and panic disorder. 3. Outline the clinical features of generalized anxiety disorder (GAD). 4. List the general features of panic attack. 5. Describe the effect phobias can have on one's life. 6. Explain difference between specific phobias and social phobia. 7. Describe the fears experienced by a person with agoraphobia. 8. Identify obsessive-compulsive disorder symptoms and outline possible treatment programs. 9. Understand the events that precede PTSD and their effects on PTSD suffers. 10. List the symptoms of intrusive thinking in PTSD. 11. Differentiate among the psychodynamic perspective, the behavioral perspective, the cognitive perspective, and the biological perspective in treating anxiety disorders. LECTURE AND DISCUSSION TOPICS 1. Explain to the class that a certain number of obsessions and compulsions are normal but that in some cases, an obsessive-compulsive illness develops. Point out a typical childhood ritual of walking down the sidewalk and singing "step on a crack, break your mother's back." As a child, we walk along singing this song (the obsession), what behavior follows? Also discuss children's behavior of walking along and having to touch a certain brick or pull a leaf from the same tree each day. Describe how these behaviors generally go away in adulthood. Also let the class discuss some of their behaviors that seem to continue or reappear when they return to their old familiar haunts. Ask the class to describe some thoughts and behaviors that continue and may be

listed as either obsessive or compulsive. (An example could include how when we are getting ready for school and hear a song on the radio, that song plays over and over in our mind all day, no matter how we try to stop it, or how sometimes after we've driven away from home, we have to go back and check the locks). Explain how that thought is the obsession and then define compulsion (avoiding cracks when walking, checking). Who was Phobos ? (Greek God of Fear) Define the difference between social phobia and specific phobia. Let the class members discuss phobias that they have or that they know others have (fear of flying, speaking in public, mice, snakes, spiders, etc.). Develop a list on the board and allow the class to rate them according to their perceived incidence and prevalence. Using a computer projector or computer laboratory, visit http://www.phobialist.com to view a large list of named phobias. Let the class determine which of the phobias would be the most debilitating (flying if employment requires it, speaking if employment requires it, signing one's name in public if one wants to charge at a store). Gender differences exist (more women than men have phobias). Why does the class think this is true? Are there any evolutionary explanations for phobias? (Do they provide some kind of protection for the species?) What are examples of some of these? Does that explain gender differences? What kind of treatment will help? How did John Madden (football coach and sports reporter) solve his problem? (He had a panic attack on a plane and now rides a fully equipped bus to all his games.) Is that solution possible for the average citizen? What can an average person do if he/she develops a phobia? Is self-help possible? Let the class discuss this and guide the members to suggest methods that will work: practice, selfdesensitization, flooding, self-talk, etc. What kinds of therapy are available? Where would one find help? Does medication help with phobias? Posttraumatic Stress Disorder Define PTSD to the class in terms of the following criteria: a. Nature of the event: Actual or threatened death or serious injury to one's self or others. b. A feeling of helplessness, horror, and intense fear that accompany the event. c. Re-experiencing of the event that is distressing. Reliving the event, feeling as if the event is recurring when reliving the event, or reacting in the same way. d. When a reminder of the event occurs. e. Persistent avoidance of stimuli associated with event. f. A numbing experience that hinders feelings of happiness and tenderness. g. Exaggerated startle response, hypervigilance, and irritability. h. Sleep difficulties and concentration difficulties. i. Inability to plan for the future. j. Distress and impairment of relationships and work. After going over these characteristics of PTSD, ask the class to list incidents in which PTSD may result. Include in the discussion such events as: • natural disasters • plane crash • witnessing a murder • being wounded or threatened • being held hostage • sexual assault • automobile accident • emergency surgery

Discuss the nature of events that generally don't lead to PTSD. Include in their discussion the following: death of a loved one, loss of a job, loss of a relationship. What separates these events from those that lead to PTSD? The Most Debilitating Anxiety Disorder: Agoraphobia Explain to the class the Greek meaning of the word (agora: marketplace and phobia: dreaded fear = fear of the marketplace (open spaces)). List the symptoms of agoraphobia. Ask them what are the most defining symptoms (fear of fear, fear of panic attack, fear of losing control in a

crowd). How can agoraphobia interfere with the average college student? What kind of problems would occur? How would an average student like "you" try to help yourself? After an individual is house-bound, will medication alone solve most of the problems? (Behavioral therapy will help change the behavior [get the person out of the house]. The medication will change the physiology.) 8.

The Future of the Psychology in Illness-Based Mental Disorders If medication is used today in the treatment of most illnesses and the origins of most illnesses seem to have either biological and/or genetic correlates, will the need for psychologists, psychotherapists, and counselors decrease? Include in the discussion the fact that many problems result from psychological sources such as indecision, poor decisions, need for behavioral retraining, need for cognitive retraining, need to learn successful strategies or avoid self-defeating behavior, environmental problems, and family system problems.

STUDENT ACTIVITIES Classroom Activities 1. Obsessive-Compulsive Disorder - As Good as It Gets Show the video or parts of the movie (available in most video stores) As Good As It Gets. Have the students view the movie and keep an observation rating form on which they can list and define behaviors they might feel are "unusual." Also discuss the main character's relationship with his psychiatrist. Have the class explain the behavior and the treatment. Discuss parts of the movie As Good as It Gets and how they noticed the main character in that movie avoids cracks. Ask the class to describe other behaviors of Melvin Udall (Jack Nicholson) that are unusual. Point out his counting, locking, and the fact that he takes plastic utensils when he eats at restaurants. How does Melvin explain his behaviors? What treatment is offered this character in the movie? Do animals also exhibit this kind of behavior? Give examples: cats or dogs licking the same spot over and over; elephants swinging their trunks over and over, dogs circling many times before lying down.

What medications are used to treat this compulsive behavior in other animals? (Prozac). Why do you think Prozac is used? Do the class members think the disorder in other animals is related to OCD in humans? Because medication helps humans and animals, and because the behavior is similar in humans and other animals, is it biological? Show the video, “The Boy Who Couldn't Stop Washing.” (Phil Donahue: OCD: The boy who couldn't stop washing.) Answer such questions as: a. What treatment seems to work the best in treating OCD? b. What are some of the most common behaviors found in OCD? c. What is the gender distribution? d. Is a genetic factor suspected? e. What were some of the historical explanations for this disorder? Show the educational video, “Phobias” with Phil Donahue, or “David's Journey.” After viewing the movie, have the students ask questions that they may have. Then announce an out-of-class assignment. Have the class members develop their own list of actual names of specific phobias (heights: acrophobia). Have the class members bring their lists to class on the following class day. The professor will develop a master list on the board. Have class members add their phobias to the list. A master list can then be developed and reproduced by the professor and provided to the members of the class. The professor may reward individuals who develop the most extensive list for the class. The Best Therapy Divide the class into four groups (each group represents one of the following perspectives: the psychodynamic perspective, the behavioral perspective, the cognitive perspective, and the biological perspective). Have the groups diagnose, interpret, and recommend treatments for the following illnesses: a. Fear of spiders b. Fear of speaking in public

c. d. e.

Inability to stop washing one's hands after hearing the number "thirteen" A constant state of anxiety, worry, pacing behavior, sweating, "nervousness" A sudden feeling of disaster, a feeling of terror, rapid heartbeat, having to escape the situation, fear that episode will occur again f. Because of dire fear, the inability to leave one's house or neighborhood, the inability to drive, go out of town, to shop in malls g. The re-experiencing of a traumatic event, recurrent of distressful thought or dreams of the event, avoidance of similar situations, hypervigilance, inability to feel tender feelings. Fear Itself: Treatments of Some Anxiety Disorders a. Show the educational video, "Fear Itself." b. After viewing the movie ask about the forms of treatment used in the video (medication, desensitization, retraining). c. Why is it necessary for a therapist to go with the patient on certain assignments? d. Should individuals worry about becoming addicted to medication? (compare anxiety disorder medication to diabetes medication and treatment) e. Which individuals seem to be affected by anxiety disorders? Compare the careers, gender, and personalities of the individuals in the video.

Assignment The Strange Case of Howard Hughes Explain to the class some of the history of Howard Hughes. (Describe only his great accomplishments, movies, sonar device and machine developed for the Navy to recover the nuclear submarine, the giant airplane, Spruce Goose, and the circumstances of his death. Be sure not to describe his unusual traits). Divide the class into five groups and have each group do research on Mr. Hughes. The purpose of this investigation will be for each group to propose various diagnoses for Mr. Hughes. Have each group report back to the class. These reports may include video snippets, pictures, etc., in order that the group may document its diagnosis. Then let the class decide which diagnosis is the most accurate. Expect to get diagnoses that include the following: OCD, panic disorder, fetishism, agoraphobia, and schizotypal disease. Let the class describe Hughes' most unusual behavior. Ask why they believe the man with so much money never received proper treatment. Mention his lasting gifts to science through the Howard Hughes Institute (http://www.hhmi.org/). Critical Writing Recent research at the National Institutes of Mental Health (http://www.nimh.nih.gov) has led researchers to new discoveries about the etiology of obsessive compulsive disorder (OCD). The first was the discovery of rapid onset of OCD in children who had contracted strep throat. An OCD syndrome, PANDAS. (http://intramural.nimh.nih.gov/research/pdn/web.htm), was recently characterized. “One of the newest developments is the identification of a pediatric subtype of OCD characterized by prepubertal acute onset after group A beta-hemolytic streptococcal pharyngitis. Investigation trials with these children include immunomodulatory therapies and penicillin treatment and prophylaxis. If a unique subgroup of children with OCD can be identified, then novel treatments may prove effective and have a role in longterm prophylaxis. (Leonard, HL. (1997). Department of Psychiatry and Human Behavior, Brown University School of Medicine, Rhode Island Hospital, Providence 02903, USA. J. Clinical Psychiatry 58 Suppl 14:39-45; discussion 46-47. The second discovery based on the observation that many women contracted OCD at the time of the birth of a child. The circuitry of the hormone “oxytocin” is suggested as a source for the disorder. Men have the same circuitry as well but it is not as active in men. (National Institutes of Mental Health. Advancing Research on Developmental Plasticity: Integrating the Behavioral Science and Neuroscience of Mental Health. (1998). Bethesda, MD: Author (NIH 98-4338). In your critical writing, discuss these new findings with respect to the future of OCD research, where it could lead and new treatments that could result from additional research. Also, discuss the approaches to identification for diagnosing OCD currently used in the DSM-IV. Given the new data, is the current diagnostic approach sufficient to identify OCD? What needs to be changed?

Great Books to Read Baer, L. (2001). The Imp of the Mind - Exploring the Silent Epidemic of Obsessive Bad Thoughts. New York: Dutton Press. Foster, Constance H. (1994). Polly's Magic Games: A Child's View of Obsessive-Compulsive Disorder. Ellsworth, ME: Dilligaf Pub; ISBN: 0963907085. Granoff, Abbot Lee. (1996, January). Help! I Think I'm Dying! Panic Attacks & Phobias: A Consumer's Guide (New Supplement for 1999). Taos, NM: Mind Matters. ISBN: 0938423045. Phillips, K.A. (1996). The Broken Mirror - Understanding and Treating Body Dysmorphic Disorder. New York: Oxford University Press. Stewart, Evelyn (1996). Life with the Panic Monster: A Guide for the Terrified. New York: Thomas Rutledge Publishing; ISBN: 0962796352. Zal, H.Michael. Panic Disorder: The Great Pretender. Needham, MA: Perseus Press. ISBN: 0306432978. VIDEO RESOURCES Professional Anxiety: Decision at the Synapse, 27 min. (Abbott Laboratories). The physiology of anxiety is presented. Fear Itself, 26 min. (Films for Humanities & Sciences). Patients are interviewed. Treatments, proposed etiologies, and characteristics of anxiety disorders including agoraphobia are presented in the video. Obsessive Compulsive Disorder: The Boy Who Couldn't Stop Washing. 28 min. (Films for Humanities & Sciences). Phil Donahue interviews several individuals who suffer from OCD. Current theories of etiology and treatments are also discussed. Panic Attack: Causes and Treatment, 30 min. (Films for the Humanities and Sciences). This video addresses the debilitating symptoms of panic attack, along with the possible causes and treatments of the disorder. Patients as Educators: Case # 7, Ed, Obsessive/Compulsive, 11:25 min. (Prentice Hall Videos). Patients as Educators: Case #8, Jerry, Panic Disorder, 11:05 min. (Prentice Hall Videos). The Touching Tree. Callner, Jim. Awareness films. Distributed by the O.C. Foundation, Inc., Milford, CT. (about a child with OCD). The World of Abnormal Psychology: Anxiety Disorders (Tape 3), 60 min. (Annenberg/CPB). An overview of the various anxiety disorders is provided in this video. Video David's Journey, 60 min. (2001, Mar 22). CBS 48 hours with Erin Moriarity. An in-depth look at what it means to have an obsessive-compulsive disorder. David describes his existence in a bathroom for over two years. His OCD began when he was eight years old. Dan Rather discusses the relationship with strep throat and PANDAS. The Fragile Mind, 53 min. (ABC-TV). Cases of disabling anxiety are presented by Joanne Woodward. Movies Vertigo (1958). James Stewart. Scottie is a “retired” detective who has acrophobia - a fear of heights. He is drawn into a suspenseful plot when he is hired to watch Madeleine. James Stewart as John 'Scottie' Ferguson, Kim Novak as Madeleine Elster/Judy Barton, Barbara Bel Geddes as Marjorie 'Midge' Wood, Tom Helmore as Gavin Elster. An Alfred Hitchcock movie. Madeline may well be suffering a dissociative fugue. What About Bob? Dr. Leo Marvin has everything going for him: a great job, “Baby Steps,” his new book, a wonderful family, but all of that is about to change when a referred patient, Bob Wiley, arrives at his door. Bob suffers from a variety of phobic disorders. He is obsessive, filled with anxiety (separation), claims he has Tourette’s syndrome, agoraphobia, claustrophobia, and more. After one visit with Bob, Dr. Marvin tells him that he is vacationing for a month. Bob finds his new "shrink" on vacation at Lake Winnipesaukee, New Hampshire, and spends “quality time” with the doctor's family. In the process, he drives Leo, the stuffy psychiatrist, to distraction and catatonia. Bill Murray as Bob 'Bobby' Wiley, Richard Dreyfuss as Dr. Leo Marvin, Julie Hagerty as Fay Marvin.

CHAPTER OUTLINE I. The Experience of Anxiety A. Anxiety is defined as a diffuse, vague, and very unpleasant feeling of fear and apprehension. B. Worries about unknown dangers C. Physical symptoms of rapid heart rate, shortness of breath, diarrhea, loss of appetites, fainting, dizziness, sweating, sleeplessness, frequent urination, and tremors D. Intrusive thoughts in the form of worries that accentuate the negative E. Unaware of the source of one's fear is a central characteristic. F. The diagnosis of neuroticism was the predecessor of the diagnosis of anxiety disorders. G. Table 8-1 (pg. 238) Common anxiety symptoms H. Table 8-2 (pg. 239) Overview of milestones in history of concept of anxiety I. Table 8-3 (pg. 239) Overview of anxiety disorders II.

Generalized Anxiety Disorder (GAD) A. GAD is characterized by prolonged feelings of vague, but intense fears, which cannot be explained. B. Danger does not seem to play a role in the fears. C. Several symptoms are apparent in GAD, either alone or in combination. 1. Worry about the future 2. Hypervigilance 3. Motor tension 4. Autonomic reactivity D. GAD often has a prolonged span throughout one's life. E. The case of John Valle F. Table 8-4 (pg. 240): Clinical features of GAD

III.

Panic Disorder A. An abrupt surge of intense anxiety rising to a peak that either is cued by the presence, or thought, of particular stimuli or that occurs without obvious cues and is spontaneous and unpredictable B. Recurrent and unexpected and at least one month of persistent concern C. Stressful events have been found to trigger major panic attacks D. May occur with other obsessions, compulsions, and phobias E. Periods of psychotic disorganization may occur following a severe attack. F. Suicide cognition and suicide attempts in 20% of people experiencing panic attacks G. Studies show that heredity plays a big role in the occurrence of panic disorder. H. Table 8-5 (pg. 242): Clinical features of panic attacks I. Table 8-6 (pg. 244): Symptoms of GAD and panic attacks J. Imipramine is of help in panic attack triggered by sodium lactate evoked attacks. Sodium lactate is converted to carbon dioxide and carried to respiratory control center. The rise in CO2 signals suffocation and a panic response is precipitated. K. Cognitive interpretation of bodily responses is one form of cognitive psychotherapy.

IV.

Phobias A. Phobias grouped into three categories: Specific Phobia, Social Phobia, and Agoraphobia. B. Specific Phobias 1. Evoked by the actual, and the perceived threat of a specific stimulus 2. Focus may not be on the stimulus per se, but on the disturbing quality of the stimulus or event. 3. Phobia may begin with GAD but quickly crystallize around an object. Processes at work: Classical conditioning, stimulus generalization. 4. Phobic fears fall into five categories: a. Separations b. Animals c. Bodily mutilations

d. Social situations e. Nature 5. Phobias progressively broader in scope if not identified and controlled 6. Incidence and prevalence a. Twice as great for females b. Higher rates in African-Americans c. Onset in childhood d. Average duration 24-31 years Social Phobia 1. Characterized by fear and embarrassment in dealings with others (Table 8-8, pg. 241, Situations which Cause Social Phobia) 2. May begin early in life and crystallize in late adolescence 3. Shyness is not social phobia. 4. Most social phobias include at least one of the following: a. Fear of asserting oneself b. Fear of criticism c. Fear of making a mistake d. Fear of public speaking 5. There are two types of social phobia that are extremely persistent: a. Fear of eating in front of others b. Fear of blushing Agoraphobia 1. The fear of entering unfamiliar or anxiety-provoking situations is the defining characteristic of agoraphobia. 2. On average 50% of persons who experience panic attacks will acquire agoraphobia unless helped with medications. 3. A high number (50%) experience separation anxiety when young. 4. Behavior techniques have been found to be helpful in treating agoraphobia. Helping Those with Phobias 1. Table 8-9 (pg. 249) Self-help techniques 2. Table 8-10 (pg. 249) Guidelines for interpersonal help and understanding

Obsessive-Compulsive Disorder A. Most people with OCD suffer from obsessive thoughts accompanied by compulsive behaviors. B. There is a possible genetic factor (vulnerability) in OCD. C. OCD sufferers realize their behaviors are irrational D. About 25% do nothing about the behaviors. E. Obsessions - cannot get a recurring idea out of their thoughts F. Compulsions - performing an act or series of acts over and over again G. More common among upper-income individuals. H. As high as 50% never get married. I. Onset is in the mid 20s. J. Most common features: 1. The OCD behavior intrudes insistently and persistently. 2. Feelings of anxious dread if the thought or behavior is prevented. 3. Thought or behavior is experienced as foreign to oneself. 4. The absurdity of the thought/behavior is recognized. 5. Individual feels the need to resist it. K. OCD sufferers respond to selective serotonin reuptake inhibitors (SSRIs). These medications may help normalize the brain's balance of serotonin—one chemical linked to OCD. L. Diagnosis of OCD (Table 8-11, pg. 256)

VI.

Posttraumatic Stress Disorder A. PTSD is preceded by an extremely traumatic event beyond everyday experience.

B. C. D. E. F. G.

VII.

Table 8-12 (pg. 257) describes the diagnostic criteria for PTSD. Acute PTSD has a better prognosis for recovery than delayed PTSD. Intrusive thoughts of the event and hypervigilence are two common characteristics. (Table 8-13, pg. 259) Emotional difficulties experienced before PTSD increase one's vulnerability to developing PTSD. Psychological therapies tend to be the most successful treatment. Epidemiological Evidence 1. Estimates 1-14% of the U.S. population 2. More prevalent than previously thought 3. Wounded Vietnam veterans experienced it at the rate of 20%. 4. Observed violence, terror, or tragedy can result in observers later meeting the criteria for PTSD. The Posttraumatic Experience 1. Re-experiencing the event 2. Symptoms include sleep difficulty, difficulty in concentrating, autonomic arousal, concentrating on tasks. 3. Cues often trigger the re-experience.

Interpreting and Treating Anxiety Disorders A. The Psychodynamic Perspective 1. Intrapsychic events and unconscious motivations are the causal factors of anxiety disorders. 2. The objects involved in phobias are symbolic of another fear. 3. OCD is an attempt to avoid distressing unconscious thoughts. (Table 8-14, pg. 259) B. The Behavioral Perspective 1. Exposing clients to stressful or feared situations is used to overcome anxiety disorders and phobias. 2. There are three types of exposure therapy. a. Systematic desensitization b. Implosive therapy c. In vivo exposure - flooding 3. Modeling behavioral skills along with exposure therapy is a helpful treatment. C. Comorbidity (Table 8-15, pg. 260) D. The Cognitive Perspective 1. Thinking disturbances cause anxiety. (Table 8-9, pg. 263) 2. Unrealistic appraisal of situations and consistent overestimation of their dangerous aspects 3. Various cognitive therapies are employed to treat anxiety disorders: a. Cognitive restructuring b. Thought stopping c. Cognitive rehearsal 4. Aaron Beck's cognitive therapy has been very influential. E. Combining Cognitive and Behavioral Approaches - Treatment of anxiety disorders 1. Provide information about the disorder and therapy expectations 2. Cognitive self-identification component 3. Use if relaxation and distraction techniques to cope with the anxiety producing situation 4. Exposure training 5. Confidence building and learning self-reward F. The Biological Perspective 1. Genetic studies a. Effect of temperament on vulnerability and coping b. Evidence links between anxiety and the serotonin gene 2. Brain Function a. Amygdala - home of emotions, particularly negative emotions

b. Hippocampus - important in memory recall and emotional-laden information c. Evidence that stress may result in atrophy of areas in the hippocampus Drug Therapies 1. Benzodiazepines are the most common drug treatment for anxiety disorders, especially alprazolam combined with cognitive-behavioral treatment. 2. Antidepressants - panic attacks and OCD are often treated by antidepressants. 3. Research has found that a combination of psychological and biological treatments have the highest success rates.

VIII. Take-Away Message

WEB LINKS Agoraphobia and Panic Attacks - http://www.anxietynetwork.com/pdfacts.html Facts and reports from sufferers from The Anxiety Network. Anxiety Disorders - http://helping.apa.org/therapy/panic.html Answers to questions about anxiety disorders. Anxiety Disorders - http://www.stressdoc.com This site specializes in anxiety and stress disorders. Facts about Obsessive-Compulsive Disorder - http://www.nimh.nih.gov/anxiety/anxiety/ocd/ This resource from the National Institute of Mental Health discusses symptoms and treatment for obsessive-compulsive disorder. Generalized Anxiety Disorder - http://www.nimh.nih.gov/anxiety/anxiety/gad/index.htm Get the facts and learn more about treatment options for generalized anxiety disorder. Help for Children Victims of Violence - http://www.albany.net/~deavila/ptsd.html A resource for teachers who deal with children exposed to school violence focuses on preventing posttraumatic stress disorder. National Institute of Mental Health - http://www.nimh.nih.gov/anxiety/anxiety/index.htm The page from the National Institute of Mental Health focuses on anxiety disorders. Obsessive-Compulsive Disorder - http://www.ocdresource.com/ Excellent resource for current news about OCD. Posttraumatic Stress Disorder - http://www.nimh.nih.gov/anxiety/anxiety/ptsd/index.htm Facts about PTSD from the National Institute of Mental Health. Posttraumatic Stress Disorder - http://helping.apa.org/therapy/traumaticstress.html How to cope with the aftermath of a trauma. Posttraumatic Stress Disorder in Children and Adolescents - http://www.albany.net/~deavila/ptsd.html A literature review about effective treatment for PTSD in children and adolescents. Rape-Related PTSD - http://www.nvc.org/infolink/INFO39.HTM Information on rape-related PTSD from the National Center for Victims of Crime (NCV). The Anxiety and Panic Internet Resource - http://www.algy.com/anxiety/index.shtml The Anxiety and Panic Internet Resource has a wealth of information and help for people suffering from or interested in anxiety and panic disorders.

MOVIE - As Good as It Gets (Obsessive-Compulsive Disorder)

Movie Questions

What did the dog “Virdel” do to end up down the garbage chute? Why is Melvin Udall (Jack Nicholson) antagonistic toward Mr. Frank Saks? How many times does he lock the locks and flip the light switches? What does he do with the soap? What is Melvin’s prejudice toward homosexuals? Perhaps homophobic? What is Melvin’s vocation? When he goes out, how does he feel about touching other people? Why does he walk down the sidewalk in such a curious manner? Why does he bring his own plastic silverware to the restaurant? What is Melvin’s psychiatrist’s name? How long had it been since Melvin had last seen him? “I think of men. And I Take-Away reason and accountability.” He is describing what? What TV show is he up so late watching? What does he have to do before he slips on his shoes? How long does his shower take in the hotel? Can he wear the “house” coat and tie? Does he ever go through his door without the counting ritual?

Chapter 9 Sexual Variants and Disorders OVERVIEW Chapter 9 discusses the changing views of sexual behaviors in our society. This chapter also outlines various sexual dysfunctions and their treatments, gender identity disorder in children and adults, and the paraphilias. An overview of sexual victimization including rape, child sexual abuse, and incest is provided. CONTENTS Changing Views of Sexual Behavior Surveys of Sexual Behavior Homosexuality: An Example of Changing Views of Sexual Behavior Bisexuality: An Understudied Sexual Variant Sexual Dysfunction Types of Sexual Dysfunctions Treatment of Sexual Dysfunction Gender Identity Disorder Gender Identity Problems in Children Gender Identity Disorder in Adults Possible Causes of Gender Disorder The Paraphilias Fetishism Transvestic Fetishism Sexual Sadism and Masochism Voyeurism Exhibitionism Pedophilia Perspectives on the Paraphilias Sexual Victimization Sexual Victimizers Sexual Harassment Take-Away Message LEARNING OBJECTIVES After completing this chapter students should be able to: 1. Discuss the origins of sexual behavior. 2. Discuss how society's views regarding homosexuality affect homosexuals. 3. Define the more prevalent sexual dysfunctions including erectile dysfunction, inhibited sexual arousal, retarded ejaculation, and dyspareunia. 4. Differentiate among the Masters and Johnson approach, the behavioral and cognitive approaches, and the Kaplan approach to treating sexual dysfunctions. 5. Describe the effects gender identity disorder in childhood can have on an adult sexual identity. 6. Differentiate transsexual and nontranssexual gender identity disorder. 7. Identify the various paraphilias including fetishism, transvestic fetishism, sadomasochism, voyeurism, exhibitionism, and pedophilia. 8. Describe the different perspectives on the paraphilias. 9. Outline the different forms of sexual victimization including rape, child sexual abuse, and incest. LECTURE AND DISCUSSION TOPICS 1. The Viagra Explosion Explain to the class the recent promotion and use of the drug, Viagra. Explain the use of the drug (increased blood circulation to the blood system of the male genitalia enabling erection and recovered sexual activity). What sexual dysfunction is this drug often successful in helping? (erectile dysfunction) Discuss with the class some of the newspaper articles, TV programs, and materials that discuss some of the events associated with the use of Viagra. Discuss such events as the seventyyear-old woman who is leaving her seventy-year-old husband because, after taking Viagra, he

chased his wife around, and when she became “tired out,” he left her in search of a younger woman. The wife is suing the drug company that makes Viagra. 2. Suggest other problems that may arise from the use of Viagra. Take into account that: a. Older women's sex drive may not resemble that of their male partners. b. Older men may suffer from other problems (heart attack, respiration) during the recovered sexual activity. c. The changing nature of the relationship may interfere with the long-standing stability and expectations of the couple. 3. Ask the class, "Do you think the introduction of Viagra in our society (particularly to older men) is going against ‘nature’? Is it normal for a seventy-year-old man to have sex several times a day? Several times a week? What do you think is normal"? After the "What is normal?" question, lead a class discussion about what is meant by normal. Look at such norm groups as age groups, ethnic groups, social class groups, different cultures, etc. 4. How do some societies relate their "norms" to their "laws"? Discuss the changing legal status of homosexuality in the United States. Discuss the changing status of birth control availability in this country (in this century, in Boston, selling birth control devices was illegal). 5. Why was Viagra developed for men and not women? Why do most drug studies relate to problems with men? Is this trend changing? Will the use of Viagra in men lead to the development of a drug for women who have some similar sexual dysfunction? Men will demand it! 6. Discuss the difference in the Kinsey Report (survey method) and the Masters-Johnson studies (observation). Include the fact that the Kinsey study had major structural flaws. While being the first study, it contained some built-in problems such as a nonrandom sample. This could have greatly influenced the results. Do you believe all the responses were honest? What kinds of individuals usually respond to a survey in a newspaper or magazine? Have you ever responded to a survey? 7. Have you ever responded to a telephone survey? Were you honest? Do you think surveys have builtin problems? 8. Discuss why the Masters-Johnson study is classified as an observational study. How were their observations conducted? (electrodes, videos, blood samples, physiological responses) What resulted from the Masters-Johnson study? (better understanding of sexual responses, understanding of sexual behavior, and successful treatment of sexual dysfunctions). 9. Discuss the concept of "Zeitgeist" and the fact that Masters and Johnson were able to carry out their research. Could this research have been done during the time period that Kinsey conducted his survey? Could Masters-Johnson research be conducted today? Who might object? 10. What do you think about sex experiments and sex therapy? Would you participate in the research? Would you participate in a survey? Would you participate in a drug study? 11. Discuss the differences among homosexuality, bisexuality, and heterosexuality. 12. Discuss the commonly held ideas about what causes each (modeling, early exposure, sexual abuse, genetics, prenatal hormones, etc.). Discuss how our society treats individuals in each of these categories. If people could choose, what sexual orientation would most people choose? Why? Discuss how our legal system treats individuals in each category. What do you think is the etiology of each of these sexual orientations? 13. Discuss the differences among transsexuality, gender identity disorder in children, and the adult manifestations of transsexual and nontranssexual gender identity disorder. After this discussion is concluded, ask about the differences between transvestic fetishism and cross-dressing. (Billy Tipton: jazz musician; King Henry III of France; Joan of Arc; Marlene Deitrich) Ask the class to think of other individuals. Is this more acceptable today than earlier? STUDENT ACTIVITIES Classroom 1. Paraphilias: What kind have you experienced or witnessed? Was there ever an incident where you witnessed one of the paraphilias and did not recognize it for what it was? A. Transvestic fetishism B. Sexual sadism C. Sexual masochism D. Voyeurism

E. Exhibitionism F. Pedophilia G. Frotteurism (a masher, or groper) After handing out the response form, tell the class that this requires no names, no identification, and if a student objects, that student doesn't have to participate in the survey. This is not a requirement. Also discuss the exact description of each paraphilia. After receiving the surveys, tabulate the results. Discuss the proposed etiology of each of the disorders. Which are the least tolerated? Why? Most of these are first noticed when? (often in the legal system). Are there gender differences in the perpetrators and the victims of each? 2. Teenagers and Homosexuality The suicide rate among teenage homosexuals is quite high. Ask the class members why they feel that this is a fact. After having asked this question, have each class member develop a list of programs and facilities available to young people who think they are or may be homosexual. Include such programs as "Out Youth," "Pride," "CornerStone," and other local programs available to assist young people in need of guidance. After the class members bring their reports to class, have a discussion about what they have discovered. Ask a speaker from one of the help programs to come to class and speak about the problems facing the young homosexual. 3. Prosecution of Victim vs. Nonvictim Sexual Crimes: Some Famous and Not So Famous. • George Michael (singer caught exposing self in men's restroom) • Lance Renflel (Dallas Cowboy who flashed young kids in parks) • PeeWee Herman (actor who masturbated in a theater) • Ben Sargent (Pulitzer Prize-winning cartoonist who peeped and exposed) • Bill Clinton (adultery in the White House). Sexual addiction, found to exist solely on its own without any related primary Axis I disorder, can be classified as Sexual Disorder NOS with addictive features according to the DSM-IV. Assignment Sexuality, Society, and the Law in the U.S., Denmark, China, England, and Russia. Divide the class into five groups. Tell the class that they will be assigned to groups that will investigate how individuals who are sexually deviant are treated socially and legally in five countries. Each group will be responsible for investigating the legal and social aspects of sexual deviance in one country. Have students draw names (of countries) to determine in which group they will work. Have the students use newspapers, library articles, books, and Internet searches. Have the class add to the list and discuss the way that our society looks at these problems. What usually happens to the perpetrator? Which of the offenses do we consider most serious? Are all of these equally serious? What is the difference? What happens to the person who commits the offense? How does the country compare to U.S. laws or state laws? Critical Writing After reading the chapter, consider one of these two questions that Americans have yet to answer. 1. Is homosexuality an aberration or natural variation of natural events? 2. Are pedophiles mentally ill or societal deviants? Our society treats such behavior as deviant, but should the deviants be incarcerated or committed to a mental institution? Great Books to Read Berry, Jason. (1994). Lead Us Not into Temptation: Catholic Priests and the Sexual Abuse of Children. Wilton, CT: Image Publishing. ISBN: 0385473052. Oumano, Elena. (1999). Natural Sex. New York: Plume (Penguin-Putnam). ISBN: 0452280486. MacKenzie, Gordene Olga. (1994). Transgender Nation. New York: Popular Press. ISBN: 0879725974. Masters, William H., et al. (1998). Masters and Johnson on Sex and Human Loving. New York: Little Brown & Company. ISBN: 0316501603.

Michaud, Steven. & Hazelwood, Roy (contributor). (1999). The Evil That Men Do: FBI Profiler Roy Hazelwood's Journey into the Minds of Sexual Predators. New York: St Martins Press (Trade). ISBN: 0312198779. Stuart, Kim Elizabeth. (1994). The Uninvited Dilemma: A Question of Gender. Portland, OR: Metamorphous Press. ISBN: 1555520138. VIDEO RESOURCES Professional Balboa Park (Prime Time Live), 12:31 min. (ABC News/Prentice Hall Video Library Abnormal Psychology Series III. Cassette Two). This video provides actual interviews with Mexican boys and pedophiles who prey on them in a city park. Homosexuality, 26 min. (Films for the Humanities and Sciences). The origins of homosexuality and basis of sexual orientation are covered. Love and Sex, 52 min. (Films for the Humanities and Sciences). Heterosexuality, homosexuality, and monogamy are discussed by Masters, Reinisch, and the general public. Origins of Homosexuality, 28 min. (Films for the Humanities and Sciences). Phil Donahue examines the basis of sexual orientation. Patient as Educators: Case # 9 Denise, Transsexual, 21:36 min. (Prentice Hall Videos). Pink Triangles, 35 min. (Cambridge Documentary Films). Attitudes toward lesbians and gay men are discussed. The Last Taboo: Incest, 28 min. (Motorola Teleprograms). The long-term damage of sexual abuse and recovery are described. The World of Abnormal Psychology: Sexual Disorders (Tape 7), 60 min. (Annenberg/CPB). An overview of sexual disorders is presented in this video. Video When Yes Means No (20/20), 12:56 min. (ABC News/ Prentice Hall Video Library Abnormal Psychology Series III Cassette One). A college incident leads to the question "What is rape?" The topics of sexual harassment and rape are covered. Movies The Mark (1961). A study of pedophilia, this film effectively presents scenes from the life of a convicted child molester on his release from prison. From the early 1960s, but still a convincing portrayal and a moving film. CHAPTER OUTLINE I. Changing Views of Sexual Behavior A. Homosexuality: An Example of Changing Views of Sexual Behavior. 1. Social and legal mistreatment has stigmatized the gay community. 2. There is a vast difference between America's attitude toward homosexuality and Denmark's attitude. 3. Homosexuality is not a psychiatric condition (as it was in the DSM-III). B. Origins of Sexual Orientation 1. Some research has found structural differences in the brains of homosexual men. 2. Sexual orientation is most likely due to both genetics and the environment. 3. Perhaps sexuality in nature is on a continuum where gender in culture is male or female. 4. Bisexual behavior is the topic of much research. II.

Surveys of Sexual Behavior A. Self-reports are the only ethical way to study the frequency of sexual practice. B. Alfred Kinsey conducted the first major survey of sexual practices. C. The National Opinion Research Center at the University of Chicago performed a much larger and more diverse study. D. Table 9-1 (pg. 273): Frequency of sexual intercourse by age and gender E. Table 9-2 (pg. 273): Survey of homosexual experiences F. Table 9-3 (pg. 274): Appeal of sexual practices

G. “Gay” is currently in vogue for self-referencing to homosexuality. H. Origins of Sexual Orientation - Experienced in complex ways III.

Sexual Dysfunction A. Table 9-4 (pg. 277) Information needed to diagnose/treat sexual dysfunctions B. Table 9-5 (pg. 278) Types of sexual dysfunctions C. Sexual dysfunctions can be defined by the inability or impairment during sex that causes distress. (Table 9-6, pg. 278) 1. Erectile dysfunction in men and inhibited sexual arousal in women are two sexual problems that occur during the arousal stage. 2. Several dysfunctions can occur during the orgasm phase: a. Premature ejaculation b. Retarded ejaculation c. Female orgasmic disorder 3. Treatment of sexual dysfunction a. The Masters and Johnson Approach 1. Masters and Johnson studied the sexual responses of men and women in a controlled setting over a ten-year period. 2. There is an emphasis on treating couples rather than individuals. 3. Masters and Johnson teach sensate focus so that couples can enjoy being touched as well as touching. b. The Behavior and Cognitive Approaches 1. Relaxation, modeling, and a variety of cognitive elements are introduced by behavioral treatments. 2. Sexual fantasies are the subject of a great deal of research in the cognitive approach. c. The Kaplan Approach - The focus is on the combination of a behavioral approach as well as psychodynamically oriented therapy for one or both partners. 4. The effectiveness of sex therapy a. Long-term effectiveness is unknown due to the poor criteria used to define success. b. More research is needed to determine what elements of sex therapy are effective. c. Sex therapy can reveal additional problems that need attention.

IV.

Gender Identity Disorder A. Gender Identity Problems in Childhood. 1. A prepubescent child expresses a great desire to be the opposite sex. 2. Counseling may be appropriate when parents unknowingly encourage this behavior. 3. Research has shown that young boys who prefer to act as girls have a greater tendency to later become either bisexual or homosexual. B. Gender Identity Disorder in Adults 1. There are two forms of gender identity disorder in adults. a. Transsexualism b. Nontranssexual gender identity disorder 2. Transsexuals feel an intense desire to become the opposite sex including anatomy changes. 3. Adults with nontranssexual gender identity disorder are uncomfortable with their gender, but are not compelled to change. 4. It is more difficult for a female to surgically become a male than it is for a male to become a female. 5. There is a high incidence of psychological disturbance among candidates for sex reassignment surgery. C. Causes of Gender Identity Disorder (Case Study pg. 290)

The Paraphilias (Table 9-7, pg. 289, Clinical Features of Major Paraphilias) A. Fetishism 1. Sexual arousal is focused on a nonliving object. 2. Fetishism is more prevalent in males. 3. Fetishism is usually chronic and most fetishists do not seek therapy. B. Transvestic Fetishism 1. Sexual arousal is brought about by clothing. 2. Transvestites are described in the DSM-IV only as males. 3. Transvestites are aroused by wearing women's clothing, but are happy being males. 4. Covert sensitization is an effective means of treatment for transvestic fetishes. C. Sexual Sadism and Masochism 1. Sadists must humiliate or inflict extreme pain on their partner to achieve orgasm. 2. Masochists must be humiliated or subjected to bondage or pain at the hands of their partner to achieve orgasm. 3. The prevalence of sadomasochist behavior is equally distributed among heterosexuals, bisexuals, and homosexuals. D. Voyeurism 1. Voyeurs are sexually gratified by watching others, usually strangers, who are unaware of their presence. 2. Watching others have sex is particularly appealing to most voyeurs. 3. In rare instances, after becoming extremely aroused, the voyeur may try to assault the victim. E. Exhibitionism 1. Exhibitionism involves exposing one's genitals to unsuspecting strangers in public places. 2. Exhibitionists are always males. 3. Treatment success for exhibitionists is unpredictable. F. Pedophilia 1. Pedophiles are overcome with sexual fantasies about children who have yet to reach puberty. 2. Pedophiles must be at least 16 years old for a diagnosis and must be at least 5 years older than the target children. 3. Repeat offenses are common even after apprehension. G. Perspectives on the Paraphilias. 1. The Psychodynamic Perspective - Long-term treatments are used to change one's personality structure and alter behavior and fantasies that are due to unresolved conflicts during psychosexual development. 2. The Behavioral Perspective a. Sexual variance is due to conditioning, modeling, reinforcement, generalization, and punishment. b. Aversion therapy is the most common form of behavioral treatment for sexual variances. 3. The Cognitive Perspective a. Treatment focuses on teaching clients interpersonal skills to form satisfactory relationships. b. Covert sensitization is also employed to discourage sexual variance. 4. The Biological Perspective a. Events during fetal development are looked to as possible explanations for sexual deviance. b. Treatments often involve hormonal therapies and surgeries. 5. The Interactional Perspective a. No one perspective alone has provided a strong treatment program. b. It is difficult to discover the most effective means of treatment because most people with paraphilias are reluctant to seek help.

VI.

Sexual Victimization A. Sexual offenders B. Sexual Victimizers C. Sexual harassment

VII.

Take-Away Message

WEB LINKS American Associate of Sex Educators, Counselors, and Therapists - http://www.aasect.org/ Information about sex education and counseling, with links to other resources. APA Lesbian, Gay and Bisexual Concerns - http://www.apa.org/pi/lgbc/office/2000report.html The APA promotes diversity within its organization. APA Response to Sexual Abuse - http://www.apa.org/releases/csa799.html Press release details the APA's position on child sexual abuse. Cancer and Sexuality - http://www.apa.org/monitor/jun99/sexual.html Cancer treatments can interfere with normal sexuality for cancer survivors. Change in Sexual Orientation - http://www.apa.org/monitor/mar00/sexualid.html An article from the APA Monitor discusses research about changes in sexual orientation among women. Child Sexual Abuse - http://www.apa.org/releases/childsexabuse.html The effect of childhood sexual abuse. Facts about Sexual Orientation for Educators - http://www.apa.org/pi/lgbc/publications/justthefacts.html A tutorial on the development of sexual orientation for educators. Foundation for the Scientific Study of Sexuality - http://www.uno.edu/~fsss/ Gender Identity Disorder - http://www.dmc.org/health_info/topics/ment3146.html How gender identity disorder differs from occasionally wishing to be the opposite sex. Homophobia and Homosexuality - http://www.apa.org/releases/homophob.html Homophobia may stem from repressed homosexual tendencies. Lesbian and Gay Parenting - http://www.apa.org/pi/parent.html Can lesbians and gays be good parents? Men's Rape Prevention Project - http://www.mrpp.org/ What men can do to stop rape. Prevention of Sexual Violence - http://www.apa.org/monitor/julaug00/haugaard.html Sex offenders have often been abused themselves. Treatment may prevent the cycle of abuse. Relational and Sex Therapy -http://www.mastersandjohnson.com/relationship_sex_therapy.html A description of the Masters and Johnson approach. Sex in the News - http://www.aasect.org/sexinthenews.cfm Sexual Orientation - http://www.apa.org/pubinfo/answers.html Answers to questions about sexual orientation and homosexuality from the APA. Sexual Health Network - http://www.sexualhealth.com/ Information on sex, STDs, and sexual disorders. Talking with Children about Sex - http://www.talkingwithkids.org/sex.html A tutorial for parents contains practical advice about talking to children about sex. The Kinsey Institute - http://www.indiana.edu/~kinsey/index.html Site of the institute established by Alfred Kinsey, a pioneer in sexual research. The site of APA Division 44 - .http://www.apa.org/divisions/div44/ APA Division 44 News and information Society for the Professional Study of Lesbian, Gay, and Bisexual Issues. Violence Against Women Act (VAWA) - http://www.apa.org/ppo/vawatp.html Information on the federal law providing civil penalties for violence against women. Links to articles about sex and sexual violence from the national media.

Chapter 9 Handout - Cultural Variations in Response to Sexual Deviance NAME OF THE COUNTRY: _________________________________________________ List of sources consulted:

Answer the following: What usually happens to the perpetrator?

Which of the offenses are considered the most serious? Are all of them considered equally serious? If there are differences, why do these exist?

What happens to the person who commits the offense?

Typical sentence for rape.

Typical sentence for a convicted pedophile.

Typical sentence for overt heterogeneous sexual behavior in public. Typical sentence for overt homosexual behavior in public.

Other legal or social infringements regarding public sexual behavior or deviance.

In your opinion, is the country under study more or less stringent than the legal sanctions in the U.S. or in your state?

Chapter 10 Personality Disorders

OVERVIEW This chapter presents personality disorders as long-standing, maladaptive, inflexible ways of responding. These disorders are included on Axis II of the DSM-IV and include three cluster categories: 1) odd or eccentric behavior; 2) dramatic, emotional or erratic behavior; and 3) anxious or fearful behavior. Current treatments are not yet considered successful, and new classification systems may emerge in the near future. CONTENTS Classifying Personality Disorders Odd or Eccentric Behavior Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder Dramatic, Emotional, or Erratic Behavior Histrionic Personality Disorder Narcissistic Personality Disorder Borderline Personality Disorder Antisocial Personality Disorder Anxious or Fearful Behavior Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder Treatment of Personality Disorders The Outlook for Personality Disorder Classification Take-Away Message LEARNING OBJECTIVES After completing this chapter students should be able to: 1. Explain how personality disorders are classified in the DSM-IV. 2. Identify paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder and outline their defining characteristics. 3. Describe the behaviors associated with histrionic personality disorder, narcissistic personality disorder, borderline personality disorder, and antisocial personality disorder . 4. Distinguish borderline personality disorder from other personality disorders. 5. Discuss the conditions that precede a diagnosis of antisocial personality disorder and the prognosis for recovery for persons with this disorder. 6. Differentiate among avoidant personality disorder, dependent personality disorder, and obsessive- compulsive personality disorder. 7. Describe several treatment options for personality disorders. 8. Discuss the use of Axis II as a classification system of personality disorders and the likelihood of comorbid Axis I disorders. LECTURE AND DISCUSSION TOPICS 1. Discuss the evolution of the category "Antisocial Personality Disorder." a. Early literature listed the person with the disorder as a "moral moron." This conveyed the idea that the person was slow in moral development and did not learn the moral lessons of the culture. Introduce the old "medical' terms of "moron," "imbecile," and "idiot" as historical classifications for mental retardation. These terms represented the current categories of mild, moderate, and severe/profound. Ask the class to discuss this early description of antisocial personality disorder.

b. Later literature referred to the person with antisocial personality disorder as a "psychopath." This suggested that the psychological development was faulty. Have the class discuss the term "psychopath" as they commonly know it and ask why they believe this term was used. c. Another term used to refer to this person was “sociopath." This indicated a combination of faulty factors related to the diagnosis. The first implication was that the individual had a faulty social development and had not learned the moral values of the society. And a second suggestion was that society had failed to teach its value system to the individual. Discuss the term "sociopath" and how it differs from “psychopath.” d. Introduce the term "antisocial personality disorder" and have the class go over the behaviors that are necessary for the diagnosis. Use the DSM-IV in the class discussion (characteristics include: failure to conform to social norms, deceitful, manipulative, impulsive, lack of planning, irritable, aggressive, reckless, irresponsible, lack of remorse, and guilt). 2.

Introduce the first cluster category of personality disorders and describe how each differs from the other in terms of behavior. Cluster I: Odd or Eccentric Behavior. Explain to the class that this category includes three types of personality disorders: paranoid, schizoid, and schizotypal. Give examples first and then have the class members describe example behaviors of each type of personality disorder. Examples could include the following: Paranoid Discuss the case of a man who always thinks that people have a motive when they are nice to him. He is suspicious of his neighbor because the neighbor has trees growing close to his property line and he "stews" over the possibility that the roots of the trees are getting water from his backyard. He becomes upset when he goes to a restaurant and he perceives that the customer at the next table gets his food faster and the portions appear to be larger. He purchases "El Patio Mexican Food Tacos" and writes to the company because his tacos are much smaller than those pictured on the package. He is sure that the professor is stricter with her grading of his papers because she does not like him and wishes him to fail. He is humorless, devious, and scheming. He is constantly on guard for people trying to take advantage of him or betray him. Schizoid Discuss the case of a woman who is quiet, reclusive, and withdrawn. She had no close friends and resents when people try to intrude on her solitude. She works in a library in the stacks and prefers not to deal with the public. Her co-workers find her to be unresponsive, unemotional, and she does not seem to be interested in interacting with them. She reads at night and rarely goes out. She is often described as a "loner." Schizotypal Discuss the case of the man who speaks in clichés, and collects overalls and coupons. When he eats out and food is left, he will have the waiter package the food to take with him and will state, "Waste not, want not." When someone dies who was a big game hunter he will say, "What goes around comes around." When he finds that a friend has left too much tip at a restaurant he picks up the extra change and says, "A penny saved is a penny earned." He attributes all behaviors to astrology. If someone is killed in an automobile accident, his explanation will be, "Oh well, the moon was in Leo, the sun was in Cancer, and the rising sign was Virgo." Everything is attributed to the magical movement of the planets, and his speech is in clichés. This gentleman is reclusive, odd, and eccentric. He lives alone on a farm in a dilapidated house. He drives an old pickup and has unusual bumper stickers covering its exterior. He sets about undertaking one task each day and will not attempt to perform anything else. He takes one day each week to visit rural country stores where he purchases canning jars with a specific characteristic. He purchases only one kind, and he stores them in a small shed. He now has hundreds of jars. On occasion he will call acquaintances and tell them that he has been picking up "vibrations" from them. He believes that he has the ability to "pick up" others' thoughts. Ask the class to describe the differentiating characteristic of the three personality disorders. Have the class note the main differences between the schizoid and the schizotypal personality disorders.

Discuss the antisocial personality disorder and relate it to the term "psychopath" as it is used in criminal justice literature. Using the DSM-IV, list the characteristics of the antisocial personality disorder. Include the following: failure to conform (violating laws), deceitful, impulsive and manipulative behavior. Including: • Irritability/aggression • Recklessness • Consistent irresponsibility • Lack of guilt and remorse Introduce the concept of "psychopath" as used by Hare (1993). Hare states that many psychopaths are criminals. Many simply charm, manipulate, and destroy lives without being arrested and convicted for their activities. At times their behaviors leave total devastation but still are not classified as criminal. Hare includes the following symptoms of "psychopathology." In addition to deceitful and manipulative behavior, the following behaviors may characterize the disorder. Include: a. glib and superficial b. egotistical and grandiose c. lack of guilt d. lack of empathy e. superficial and shallow emotions f. impulsive g. poor behavioral controls h. need for stimulation and excitement i. lack of responsibility j. early behavioral problems k. adult antisocial behavior Hare (1993) describes these individuals as charmers, he believes that they operate under their own special laws, are extremely self-centered, have no guilt for their devastating behavior, and do not have the ability to feel another's pain. The person is capable of mortgaging his/her grandmother's house for money and then feeling no guilt when he does not pay the mortgage payments and the grandmother is left homeless. He/she might say, "I deserved the money because I'm special and she should have planned better." He accepts no blame. This person may easily latch onto a middle-aged person whose husband or wife has died, charm the person, sleep with her/him, and as the person sleeps ransack the house and steal jewelry and money. He/she then will say, "That old rag shouldn't be so stupid." He/she feels no remorse. This person is often driven to excitement. He/she will commit crime just for the thrill. He/she also may have a dozen children to whom he/she pays no child support nor provides any care. The persons feels no obligation to pay debts and goes from one job to another. The psychopath refuses to pay parking tickets, speeding tickets, and fines. Even if arrested, he/she will continue in this irresponsible behavior. One of the most defining characteristics of the "psychopath" is the early childhood behavior. Even in preschool years, most of these children will lie, steal from the family members or neighbors, try to burn the neighbor's house or his/her own house, treat animals with cruelty, and have difficulties at home and later at school. During the school years, these children may be truant, call in bomb threats to the school, steal the class money, and graduate to crimes such as auto theft and assault. Class members, in small groups, could compare the characteristics of the antisocial personality disorder with the psychopath. What are the major differences? Are all individuals with antisocial personality disorder psychopaths? Are all psychopaths individuals who exhibit antisocial personality disorder? Hare, R. (1993) Predators: The disturbing world of psychopaths among us. Without conscience: The disturbing world of psychopaths among us. New York: Pocket Books/Simon & Schuster.

Social and Biological Risk Factors in Criminal Behavior Gibbs (1995) presents a series of studies that focus on factors that may predict criminal behavior and thus provide preventive interventions. Those factors include the social correlates: a. early age of arrest b. drug use c. family dysfunction d. childhood behavioral problems e. deviant peers f. poor school performance g. inconsistent parental supervision h. inconsistent discipline i. separation from parents j. poverty k. alcoholism l. childhood abuse m. low verbal IQ n. witnessing violent acts The following biological factors were also identified as possible correlates in a series of studies presented by Gibbs (1995): testosterone, low resting heart rates, uninhibitedness (lack of temperament control), and low levels of serotonin. Have the class discuss how identifying risk factors may help with future behavior. What intervention programs would be possible? Give some examples of possible programs. If factors are identified, should testing programs for young children be made mandatory? What are the constitutional and legal implications? Should parents be required to enroll at-risk children in intervention programs? Would these children, if identified, be exposed to discrimination? Gibbs, W.W. (1995) Seeking the criminal element. Scientific American, 272, pp.100-107. Also reprinted in Lilienfeld's (1998) Looking into Abnormal Psychology. Brooks/Cole. pp.117-127.

Discuss the following question: If biological research establishes beyond a doubt that the antisocial personality disorder is of biological origin should a person diagnosed as such be held responsible and punished for his/her criminal activity? Ask the members of the class to respond in two groups: those going into law enforcement and those going into psychology.

STUDENT ACTIVITIES Classroom 1. Conduct a student survey of attitudes about personality disorders. List all personality disorders and have each student indicate whether he/she believes more women or men suffer from the disorder, or whether the student believes that an equal number of men and women suffer from the disorder. The survey results may be placed on an overhead or the board using the following table. After the results are tabulated, have the class discuss why their responses seem to be sexist. More Men with Disorder

More Women with Disorder

Equal Numbers

Paranoid Schizoid Schizotypal Histrionic Narcissistic Antisocial Borderline Avoidant Dependent Compulsive 2.

Personality Disorders: Short Descriptions Have class members propose possible diagnoses for the following (point out that one swallow does not a spring make):

• • • • • • • • • 3.

Ted Bundy (killed women, felt no guilt, believed he could represent himself). The man who lives with his mother and depends on her for all decisions. The woman called "drama queen" and frets about her attractiveness. The man who is so afraid of failure and timid that he won't take any chances. The bag lady who speaks in parables, has fifty cats, and resents intruders. The accountant who stays to herself rarely speaks to others, and lives alone. The man who spends hours preening, feels entitled, and thinks only of himself. The woman who explodes unpredictably, self-mutilates, and is extremely moody. The man who can't stand messy desks, dirty ashtrays, or magazines on the table.

Compare the similarities of disorders listed on Axis I with the personality disorders listed on Axis II. Divide the class into three groups. Assign each group a personality disorder cluster. • Cluster 1: Group 1 • Cluster 2: Group 2 • Cluster 3: Group 3

Assignments Divide the class into small groups. Using the DSM-IV or text, correlate disorders on Axis I with disorders from the appropriate Cluster (1, 2, or 3) listed on Axis II. The correlations should reflect similarities in symptoms of specific disorders. Example: Axis I schizophrenia/Axis II schizotypal, etc. Each group presents their proposals with a class discussion to support their points. Critical Writing Is personality disorder learned, physiological, or both? Defend your argument with two current resources. Could you apply the same criteria that you have developed to multiple personality disorder?

Great Books to Read Black, Donald W., Lindon, C. (1999) Bad Boys, Bad Men: Confronting Antisocial Personality Disorder. London: Oxford University Press (Trade); ISBN: 0195121139. Hare, R. (1993). Predators: The Disturbing World of Psychopaths Among Us. Without Conscience: The Disturbing World of Psychopaths Among Us. New York: Pocket Books/Simon & Schuster. Olson, Sarah E. (1997). Becoming One: A Story of Triumph over Multiple Personality Disorder. LPC; ISBN: 0962387983. Mason, Paul T., Kreger, Randi, & Siever, Larry J. (1998). Stop Walking on Eggshells; Coping When Someone You Care about Has Borderline Personality Disorder. Oakland, CA: New Harbinger Publishers. ISBN: 157224108X. VIDEO RESOURCES Professional Patients as Educators: Case # 2, Paul, Antisocial Personality, 11:15 (Prentice Hall Videos). This video presents the case of a man who is aggressive, reckless, has a violent temper, and has been jailed on numerous occasions. The Mind of a Serial Killer, 60 mm: (Films for the Humanities and Sciences). This video presents the FBI program portrayed in Silence of the Lambs. Video The Violent Mind, 90 min. (PBS Video). This video discusses the anatomy and chemistry of the brain that are related to antisocial behavior and violent behavior. The World of Abnormal Psychology: Personality Disorders (Tape 5), 60 min (Annenberg/CPB). An overview of the area of personality disorders is covered in this video.

Movie Equus (1977) A psychiatrist, Dr. Martin Dysart, works with a young male patient (Alan Strang) who had blinded six horses with a metal spike. Dr. Martin uncovers Alan's religious and sexual issues and is troubled by them. He begins to evaluate his own stagnant life. Girl, Interrupted (1999) An informative movie and well worth watching. Susanna (Winona Ryder) is admitted to a psychiatric hospital after a suicide attempt. She is diagnosed with borderline personality disorder. As she comes to terms with her personal issues she becomes involved with other young woman on her ward. Perhaps what is best about this movie is that the characters have more dimensions than we typically see portrayed. Filmed at Harrisburg State Hospital in Pennsylvania, location of the Dorthea Dix Museum. The Fisher King (1991). Mental health issues seem to affect about everyone in this film. Jack (Robin Williams) drops out of society and becomes an alcoholic after a listener to his radio program goes on a killing spree. Parry becomes a homeless man envisioning a ghost horseman after he witnesses his wife being shot. While dealing with their issues Jack tries to help Parry to romance his dream woman, Lydia (who has her own apparent mental health issues). What Ever Happened to Baby Jane? (1962) Paranoid Personality Disorder Bette Davis as Jane Hudson, Joan Crawford as Blanche Hudson. Two sisters who were screen legends (Blanche and Jane Hudson) live together years after the height of their fame. Blanche lives on the second floor of the home though she uses a wheelchair. Jane deals with mental health issues and tortures herself and Blanche. Remade for TV in 1991. CHAPTER OUTLINE I. Classifying Personality Disorders A. It is difficult to classify personality disorders because little is known about their origins and development. B. Personality disorders fall on Axis II of the DSM-IV C. It is common for someone with a personality disorder to also show symptoms of an Axis I disorder. D. There is a great deal of overlap between the Axis II disorders. E. Table 10-1 (pg. 304) list the milestones in the conceptualization of personality disorders. F. Table 10-2 (pg. 305) list the features of personality disorders. G. Table 10-3 (pg. 306) lists the three major groupings of personality disorders. H. Table 10-4 (pg. 307) summarizes the major clinical features of personality disorders. II. Odd or Eccentric Behavior A. Paranoid Personality Disorder 1. Table 10-5 (pg. 308) lists clinical features of paranoid personality disorder 2. The common characteristics involve unwarranted feelings of mistrust towards others, hypersensitivity, and the expectation of being exploited by others 3. It is difficult for people with paranoid personality disorder to form interpersonal relationships. 4. These people rarely seek treatment, and if they do they are usually suspicious of the therapist. B. Schizoid Personality Disorder 1. Table 10-6 (pg. 309) lists clinical features of schizoid personality disorder 2. People who suffer from schizoid personality disorder are very withdrawn and reclusive. 3. They are unable to and uninterested in forming close relationships. 4. Schizoid individuals are emotionally withdrawn. C. Schizotypal Personality Disorder 1. Table 10-7 (pg. 311) lists clinical features of schizotypal personality disorder) 2. Oddities of thinking, perceiving, communicating, and behaving are central characteristics.

3. 4.

Schizotypal individuals are socially withdrawn, often due to their oddities of speech, which may make them difficult to understand. There is a greater risk for developing schizophrenia among schizotypal individuals.

III. Dramatic, Emotional, or Erratic Behavior A. Histrionic Personality Disorder 1. Table 10-8 (pg. 312) lists clinical features of histrionic personality disorder. 2. Histrionic individuals are obsessed with obtaining attention. 3. Others perceive histrionic individuals as vain and immature. 4. Histrionic individuals tend to react too quickly and don't think through their actions. B. Narcissistic Personality Disorder 1. Table 10-9 (pg. 313) lists clinical features of narcissistic personality disorder. 2. There are several defining characteristics of narcissistic personality disorder: a. An extreme sense of self-importance b. The expectation of special favors c. A need for constant attention d. Fragile self-esteem e. Lack of empathy or caring for others 3. Not all characteristics must be met for a diagnosis to be given. 4. There has been little research done on narcissistic personality disorder. C. Borderline Personality Disorder 1. Table 10-10 (pg. 313) lists clinical features of the borderline personality disorder. 2. About 20% of the psychiatric population is diagnosed as borderline and about 2/3 of these patients are women. 3. Several factors characterize this disorder: a. Unstable personal relationships b. Threats of self-destructive behavior c. A chronic range of cognitive distortions d. Fears of abandonment e. Impulsivity 4. Borderline individuals are extremely dependent on others yet strongly deny this dependence. 5. Self-mutilation and drug overdosing are common self-destructive techniques employed by borderline individuals. (Table 10-11, pg. 314, presents number self-destructive acts.) 6. Some believe that borderline personality disorder represents the boundary between personality disorders and mood disorders. 7. Research into the etiology of borderline personality disorder points to a combination of neurobiological, early developmental, and later socializing factors. 8. Three problems have been defined in borderline personality disorder. a. Identity disturbances b. Affective disturbances c. Impulse disturbances 9. Borderline individuals tend to retain their symptoms for a prolonged period of time with little or no change. 10. Table 10-12 (pg. 315) comorbidity of borderline personality disorders and other disorders 11. Table 10-13 (pg. 316) variables associated with poor prognosis of borderline personality disorder IV. Antisocial Personality Disorder A. Table 10-14 (pg. 317) presents clinical features of antisocial personality disorder. B. Crime, violence, and delinquency occurring after the age of fifteen are associated with antisocial personality disorder. C. Symptoms appear before the age of fifteen in the form of chronic conduct disorder. D. Antisocial individuals have a high disregard for other individuals. E. There is a possible genetic link in antisocial personality disorder, however there are several other factors involved.

F. Psychotherapy is not usually an effective means of treatment. V. Anxious or Fearful Behavior A. Avoidant Personality Disorder 1) Table 10-16 (pg. 323) presents clinical features of the avoidant personality disorder 2) Avoidant individuals desire close relationships but usually have very few successful relationships. 3) Several characteristics are common in avoidant personalities: a. Low self-esteem b. Fear of negative evaluation c. Pervasive behavioral, emotional, and cognitive avoidance of social interaction 4) Avoidant individuals are extremely hypervigilent and only participate in a narrow range of activities. B. Dependent Personality Disorder 1) Table 10-17 (pg. 324) presents clinical features of the dependent personality disorder. 2) There are two basic characteristics of people with dependent personality disorder. 3) They passively allow other people to make all important decisions for them due to their lack of confidence. 4) They subordinate their own needs to the needs of others. 5) Dependent individuals fear rejection and feel they must be taken care of by others. 6) Assertiveness training is a possible treatment option. C. Obsessive-Compulsive Personality Disorder 1) Table 10-18 (pg. 326) presents clinical features of the obsessive-compulsive personality disorder. 2) Obsessive-compulsive personality disorder differs from OCD in that those with the personality disorder feel that their rigid behaviors and thinking patterns are under control. 3) Extreme perfectionism and an inability to express warm emotions are two characteristics. 4) Individuals with obsessive-compulsive personality disorder tend to be very indecisive, yet they insist that everything must be done their way. VI. Treatment of Personality Disorders A. It is difficult to treat people with personality disorders because they believe that any difficulties they face are due to their environment rather than their own behavior. B. People with personality disorders have periods of normal behavior. C. The use of MAO inhibitors and lithium are fairly new drug therapies used to treat personality disorders. D. Research has shown a combination of therapies may be the most effective. VII. The Outlook for the Personality Disorder Classification A. More research needs to be done to study the overlapping characteristics of the personality disorders. B. Axis II uses a categorical model of classification. C. A dimensional model may be more appropriate to classify personality disorders. D. Further research needs to be done to understand and describe the etiology of personality disorders. VIII. Take-Away Message WEB LINKS All About Borderline Personality - http://www.bpdcentral.com/ This site is devoted exclusively to borderline personality disorder. Antisocial Personality Disorder and Psychopathy - http://www.mhsource.com/pt/p960239.html An analysis of the distinction by Robert Hare, researcher involved in assessing psychopathy and antisocial personality disorder. Avoidant Personality Disorder - http://www.geocities.com/HotSprings/3764/welcome.html Help for sufferers of avoidant personality disorder.

Facts on Personality Disorders - http://www.nmha.org/infoctr/factsheets/91.cfm Facts on personality disorders from the National Mental Health Association. Journal of Abnormal Psychology - http://www.apa.org/journals/abn.html Links to abstracts and full-text articles on personality disorders. Narcissistic Personality Disorder - http://www.npd-central.org A resource for narcissistic personality disorder. Online Assessment - http://www.med.nyu.edu/Psych/screens/pds.html Take an online assessment for personality disorders from New York University School of Medicine. Personality Disorders - http://personalitydisorders.mentalhelp.net/ Symptoms, treatment, links, support groups, and other resources related to personality disorders. Personality Disorders Foundation - http://pdf.uchc.edu/ Educational resources for personality disorder sufferers and their families. Preventing Violence by the Severely Personality Disordered – http://www.homeoffice.gov.uk/cpd/persdis.htm .This document on managing the dangerous personality disordered individual is from the government of the United Kingdom. Tutorial on Borderline - http://www.stanford.edu/~corelli/borderline.html A tutorial from a Stanford University psychologist.

Chapter 11 Mood Disorders OVERVIEW Mood disorders are the central topic of Chapter 11. The chapter begins with a discussion of depression and its risk factors. Depressive disorders including dysthymic disorder and major depressive disorder are covered. A thorough explanation of the various perspectives and treatments available for depression follows. The chapter then goes on to cover bipolar disorders including cyclothymic disorder, bipolar I disorder, and bipolar II disorder. The chapter ends with a discussion of suicide and its risk factors and possible prevention methods. CONTENTS Depressive Disorders Dysthymic Disorder Major Depressive Disorder Bipolar Disorders Bipolar I Bipolar II Cyclothymic Suicide Take-Away Message LEARNING OBJECTIVES Upon completion of this chapter students should be able to: 1. Define depression and distinguish between depressed mood and depressive disorders. 2. Name the risk factors for depression. 3. Differentiate between dysthymic disorder and major depressive disorder. 4. Explain the role of neurotransmitters in the causes of depression. 5. Outline the various techniques used to search for markers of depression. 6. Identify biologically based treatments including antidepressant drugs and ECT. 7. Discuss the various perspectives on depressive disorders including the psychodynamic theories, behavioral perspective, and the cognitive perspective. 8. Define bipolar disorders and differentiate between cyclothymic disorder, bipolar I disorder, and bipolar II disorder. 9. Outline the most common form of treatment for bipolar disorders. 10. Identify the risk factors for suicide and explain how suicide affects others. LECTURE AND DISCUSSION TOPICS 1. Discuss how to distinguish among "normal depression," SADs and depressive disorder. a. Explain to the class that "normal depression" is a temporary condition that will improve when the situation improves or time passes. Ask for suggestions about events or situations that could lead to "normal depression." These will probably include the following: • death of a loved one • missing a loved one on a special holiday • break-up of a relationship • losing a job • not being accepted to a graduate school • losing property in a fire • death of a loved pet b. Ask the class members, “What are some of the common symptoms of "normal depression"?” Let the class members list their own symptoms that they experience during a period of "normal depression."

2. Define depressive disorder. Ask the class if they can identify differences in symptoms between "normal depression" and depressive disorder. Their list of symptoms of depressive disorder should include such factors as: • changes in sleep • changes in eating habits • dissatisfaction • anxiety • changes in psychomotor function • loss of interest and energy • feelings of guilt • feelings of worthlessness, helplessness, and hopelessness • thoughts of death • diminished concentration Point out to the class that a number of individuals report these symptoms even though they are not diagnosed with depressive disorder. Also point out to the class that depression is easily treated today. Let the class discuss examples of depression that they have seen in friends and relatives and how they were treated (therapy/medication). 3. Discussion: Age as a Risk Factor in Depression in Women Let the class discuss their ideas on age and depression. At what age do the members of the class believe that depression has the highest incidence? Is this age of highest incidence for both men and women? Point out to the class that for women depression is the highest in the 20-29 age group and for men the age group with the highest incidence in 40-49. Discuss depression in women first. Why do the class members think that depression is the highest for the 20-29 age group? Do the class members know of any friends or acquaintances to whom this has happened? What is going on at this time in the lives of women? The class members hopefully will mention these factors: • marriage • having to choose between career and marriage • birth of a baby • having to choose between career and taking care of a baby • moving away from support system (women still move with husbands) • hormonal changes with pregnancy • family pressures (to marry, to have a baby, to live in a hometown, to move) • career changes (new employment, graduation, promotions) • changing a peer group • assuming additional responsibilities Have the class discuss the possible impact of each of these. Example: How can the birth of a baby produce depression? After graduating from a university in Houston, TX, and moving to a great job in Chicago, a young woman suffers from depression. Why? 4. How can listening to Dr. Laura on the radio precipitate depression in a young mother who is the vice president of Dell Computing? (Dr. Laura belittles women who work and provide day care for their children. She says that leaving a small child can be very harmful and if the mother can, she should stay home and rear the child.) Is the depression precipitated in the above cases "normal depression" or depressive disorder? Does every woman become depressed when one or more of these precipitating factors appear? 5. Discussion: Age and Depression in Men Point out to the class that men have the highest incidence of depression when they are between the ages of 40 and 49. List the factors that might precipitate depression in men of ages 40-49. The list of situations could include the following:

• • • • • • • • • • •

body changes (weight, muscle) age changes (wrinkles, gray hair) negative career changes (early forced retirement, company downsizing) promotions (feelings of inadequacies in new job) children leaving home relationship problems (previously hidden by life with children) feelings of “life has passed me by" changes in energy level (lower levels) sexual changes (decreased drive, dysfunctions) health changes (high blood pressure, arthritis, heart problems) boredom (same old job, same old house, same old friends)

What impact could each of these have on a man of this age group? Would this necessarily lead to depression? Would the depression be "normal" or depressive disorder? Some people overcome these factors without becoming depressed; others may become depressed temporarily; while others are diagnosed with depressive disorder. 6. Discuss the correlation between bipolar disorder and creativity. Lead into this discussion with a definition of bipolar disorder. Include the characteristics in the following two categories: Manic Behavior • elation • euphoric • impatient • racing thoughts • impulsiveness • delusions of grandeur • talkative • hyperactive • does not tire • needs little sleep • increased sex drive • fluctuating appetite

Depressive Behavior • • gloomy, hopeless • • withdrawn • • irritable • • slowness of thoughts • • inability to make decisions • • delusions of guilt and disease • • nontalkative • • decreased motor activity • • tired • • difficulty in sleeping • • decreased sex drive • • decreased appetite

Begin the discussion of the relationship between bipolar disorder and creativity. Have the class name famous and creative individuals whom they believe have been diagnosed with bipolar disorder. Jamison (1995) mentions the creativity and extreme mood swings of such individuals as Edgar Allan Poe, William Blake, Lord Byron, and Alfred, Lord Tennyson. She also lists modem American poets John Berryman, Robert Lowell, Sylvia Plath, Theodore Roethke, Delmore, Schwartz, and Anne Sexton. Other creative artists included are Vincent van Gogh, Georgia O'Keeffe, Charles Mingus, and Robert Schumann. Other creative people who have had mood disorders are Ernest Hemingway, Truman Capote, and Tony Orlando. After naming these individuals with the help of the class, ask the class, "Does the disorder cause creativity, or does the suffering produced by the disorder produce the creativity?" Jamison illustrates that periods of high productivity seem to correlate with periods of hypomania. She argues that past and current research corroborates other findings that the characteristics of hypomania are conducive to original thinking, sharpened creative thinking, expansive thought patterns, fluency, and increased quantity and quality of work. Jamison also reports that the bipolar illness produces the ability to work for hours, the need to work intensively, bold decision making, and an alert system that reacts strongly and swiftly. A fascinating table (Adapted from Slater and Meyer, 1959) is presented by Jamison (1998). This table provides a visual representation of Robert Schumann's musical work as it correlated with the mood

swings of his bipolar disorder. The table demonstrates a surprising relationship between Schumann's periods of hypomania and his unbelievable production of compositions. Jamison, K.R. (1995) Manic-depressive illness and creativity. Scientific American, pp.62-67. Also reprinted in Palladino, J. J. (Ed.) (1998) Annual Editions: Abnormal Psychology 98/99, pp. 70-74. STUDENT ACTIVITIES Classroom 1. Different Treatments For Major Depressive Disorder Divide the class into three groups and instruct each group to develop treatments for major depressive disorder according to the assigned model/models. Group 1: medical model (three treatment suggestions) Group 2: psychoanalytic model/interpersonal model (two treatment suggestions) Group 3: cognitive/behavioral model (two treatment suggestions) Have the three groups report to the class on their proposed treatment methods. Have the class discuss each, the probable success of each, and how those methods of treatment measure up to today's knowledge about major depressive disorder. How are most people you know who are depressed being treated? 2. The SAD Past (Recurrent Mood Disorder With Seasonal Pattern) Have class members discuss why a number of people seem to get depressed around Christmas. Point out how in the past psychiatrists, psychologists, and psychotherapists blamed the holidays on the "Christmas Blues." Rates of suicide increased and people rushed to therapy. Newspapers, radio shows, and television programs addressed the problems that the "experts" thought contributed to the increased rates of depression. Assumptions included the rates were due to "Christmas not being like it used to be," missing loved ones no longer present, broken dreams, and disappointments. These of course do lead to "normal depression," but numbers of individuals seemed to be more severely depressed. Researchers started to notice seasonal patterns and geographical patterns. The rates of depression in the northern hemisphere seemed to increase from fall to winter and then decrease from spring to summer. Also noted was the higher rates varying with latitude (the farther north, the higher the rates of depression). Also point out that some individuals seem to the "winter blues" but do not suffer from full-blown SAD. A majority of individuals appear to have seasonal mood changes, but only a small percent suffer from severe depression. After introducing seasonal affective disorder with the above discussion, ask the class members to discuss whether or not they feel "blue" in the winter. Do they recognize some individuals who become depressed every winter? What seem to be the symptoms? Include the following symptoms for the students to discuss: • mood change • loss of energy • increased anxiety • irritability • weight gain • craving for foods high in carbohydrates • increase in hours of sleep Which of these symptoms appear to be the opposite of symptoms in depressive disorder? (weight loss, difficulty in sleeping, food craving) Discuss the probable etiology of SAD and relationship of light to SAD. A good article of reference is provided by Hawkins (1992). Hawkins presents an excellent description of circadian rhythms, the importance of the pineal gland, and the importance of melatonin. He points out the fact that even Hippocrates and Pinel acknowledged that seasons influenced certain affective disorders.

3. Discuss the three hypotheses regarding the etiology of SAD: A. The melatonin hypothesis: The shortening of days leads to depression by lengthening the nighttime secretions of melatonin. B. The circadian rhythm phasing hypotheses: Shorter winter periods of light shift the circadian rhythm patterns. Depression appears because the body's rhythms are delayed because of the later morning onset of light. C. The circadian rhythm amplitude hypothesis: Low levels of light in winter cause amplitudes of circadian rhythm to decrease and "even out." These low, low levels of amplitudes of circadian rhythms are proposed to be related to depression. D. Let the class relate SAD to hibernation behaviors of other animals. Are there similarities between SAD behaviors and hibernation? Critical Writing Consider the class handout from the “True Blue Friends” website. (http://www.truebluefriends.au.com). Write a brief opinion paper discussing why the ‘best things’ are the best, and the difficulties that you could encounter or precipitate by saying a few of the ‘worst’ of the worst things. Be prepared to discuss your thoughts in class. Great Books to Read Cobain, Bev & Verdick, Elizabeth, (1998) When Nothing Matters Anymore: A Survival Guide for Depressed Teens. Minneapolis: Free Spirit Publishing. ISBN: 1575420368. Heckler, Richard A. (1996). Waking Up, Alive: The Descent, the Suicide Attempt, and the Return to Life. New York: Ballantine Books. Kazmierczak, Jeff D. (2000). Neural Misfire: A True Story of Manic-Depression. Chicago: KODA Services. ISBN: 0967880602. Rosenthal, M. Sara (1999). Women and Sadness: A Sane Approach to Depression. Montreal: CDG Books. VIDEO RESOURCES Professional Biochemistry of Depression, 29 min. (CRM). The biochemistry underlying depression is discussed. Depression, 19 min. (Films for the Humanities and Sciences). How to distinguish between realistic mood changes and depression is discussed. Depression, 59 min. (Kent State Univ.) This video follows the lives of individuals suffering from bipolar disorder. Depression and Manic Depression, 28 min. (Films for the Humanities and Sciences). This program describes depression and manic depression, and provides an overview of medications and treatments. Dying to be Heard: Is Anybody Listening? 25 min. (Films for the Humanities and Sciences). Advice on how to recognize suicide warnings and intervention techniques are provided. One Man's Madness, 31 min, (BBC). A documentary of a writer who suffers from bipolar disorder is discussed. His wide range of symptoms, his treatment, and his condition following hospitalization are also described. Patients as Educators: Case #3, Helen, Major Depression, 14:05 min. (Prentice Hall Videos). A case of major depression in an eighty-three-year-old female is provided. ECT, insulin shock therapy, and antidepressive medications are discussed and symptoms are described. Prozac Diary, 40 min. (Films for the Humanities and Sciences). Four artists are followed over a period of weeks to assess the effects of Prozac. The Mind: Depression (Episode 6), 60 min. (WNET/New York). This film follows individuals suffering from depression and bipolar disorder. Also presented are treatments and support programs. This is excellent for class presentations and discussions. The Only Way Out: Teen Suicide in New Hampshire Town (Day One, 2-28-94), (ABC News/Prentice Hall Library #2). This video presents the story of a New Hampshire town in which a number of teens committed suicide. The World of Abnormal Psychology: Mood Disorders (Tape 8), 60 min. (Annenberg/CPB).

Video Beating Depression, Nightline, (3-17-94), (ABC News/Prentice Hall Library #2). ABC News Bureau Chief discusses his depression, treatment, and recovery. Depression: Prozac (Peter Jennings, 1-4-94), 5:30 min. (World News Tonight/American Agenda). This video discusses the increased use of Prozac and questions whether the drug is over-prescribed. Depression: Beyond the Darkness, 47 min. (ABC News/Prentice Hall Library #1). Cases of clinical depression are presented. Patients describe their emotional states and experiences while suffering from depression or bipolar disorder. Therapies covered include psychotherapy, antidepressant medication, and ECT. Desperate for Light, 11 min. (ABC News Series, 1988). Seasonal affective disorder is discussed and treatments are investigated. New Mother's Nightmare (20/20), 15:13 min. (ABC News/Prentice Hall Video Library Abnormal Psychology Series III Cassette Three). Postpartum depression that affects 10% of mothers following the birth of their child is discussed. Characteristics, biochemistry, and treatments are covered. Movie Shine. (1996). Based on the true story of Australian pianist David Helfgott. David, a child prodigy, has an unhappy childhood. After going overseas to study he has a 'breakdown' which causes him to return to Australia and a life in an institution. After he is released, he starts to play again and gets back to the concert halls. Nuts (1987). Barbra Streisand as Claudia Draper, Richard Dreyfuss as Aaron Levinsky. Claudia (Streisand) is a prostitute accused of murder. After assaulting an attorney hired by her parents, a public defender (Dreyfuss) is assigned to her case. Claudia struggles to keep from being found incompetent so she can have her case tried, risking prison rather than indefinite time at a psychiatric hospital. Flashbacks gradually reveal the source of Claudia's issues. CHAPTER OUTLINE I. Mood Disorders A. Table 11-1 (pg. 332) Percentage of population reporting mood disorders B. Mood disorders are common. C. There are high rates of mood disorders in our society, but many go untreated. D. Three reasons for the lack of treatment have been named. 1. Personal feelings of being socially stigmatized. 2. Failure of health care providers to recognize disorders. 3. Lack of awareness of the potential effectiveness of the treatment and its benefits to the individual. E. Women suffer from depressive disorders at a much higher rate than men. F. Rates of depressive disorder and bipolar disorder vary across cultures, but the symptoms remain the same. II. Depression A. Table 11-2 (pg. 333) Prevalence of depressive and bipolar disorders B. Figure 11-2 (pg. 335) Hereditary risk of developing major depressive disorder C. Depressed Mood 1. Feeling depressed is not the same as experiencing a depressive disorder. 2. Grief following the death of a loved one is not considered a depressive disorder. 3. Depressed moods result from life stress or physical change. D. Life Events and Depression 1. Stressful life events may cause depression, especially in vulnerable individuals. 2. There is a genetic vulnerability to depression. 3. Figure 11-3 (pg. 335) Lifetime prevalence of major depressive disorder E. Risk Factors for Depression 1. Twin and family studies have found a genetic component to mood disorders.

2. The younger a person is that experiences depression, the more likely that person's family members will also suffer from depression. 3. Women are more likely to experience their first episode of depression between the ages on 20 and 29; men are between 40 and 49. 4. The more recently people have been born, the more likely they are to experience depression. 5. Women are at least twice as likely to suffer from depression as men. 6. People with little or no social support are at a higher risk for experiencing depression than those with strong social support networks. 7. Figure 11-4 (pg. 337) prevalence of major depressive disorder by demographic data III. Depressive Disorders A. Dysthymic Disorder 1. Mild and chronic depressive symptoms are the defining feature of dysthymic disorder. 2. Dysthymic disorder appears to be related to major depressive disorder. 3. Antidepressants have been found to be an effective treatment for dysthymic disorder. 4. Table 11-3 (pg. 338) Diagnostic criteria for dysthymic disorder 5. Table 11-4 (pg. 338) Personal characteristics associated with dysthymic disorder B. Major Depressive Disorder 1. Figure 11-5 (pg. 339) Symptom comparisons between individuals with dysthymic and major depressive disorders 2. Major depressive episode relies on the presence of a depressed mood and at least four other defined symptoms: a. Marked change in weight not due to diet b. Constant sleeping problems c. Agitated or extremely slowed-down behaviors d. Fatigue e. Inability to think clearly f. Feelings of worthlessness g. Frequent thoughts of death or suicide 3. At least half of all people diagnosed with a major depressive episode will experience a recurrent episode. 4. Approximately 15% of people suffering from major depression also experience delusions. 5. Table 11-5 (pg. 339) Diagnostic criteria for major depressive disorder 6. Table 11-6 (pg. 344) Diagnostic criteria for mood disorders with seasonal pattern 7. Table 11-7 (pg. 346) Sleeplessness associated with major depressive disorder IV. Theoretical Perspectives and Treatment of Depression A. Biological Theories 1. Monoamine neurotransmitters, including dopamine and serotonin, are affected by the MAO inhibitors and tricyclic antidepressants in the treatment of depression. 2. Scanning techniques have revealed that depression is linked to abnormalities of brain regions. 3. Seasonal affective disorder (SAD) is related to seasonal rhythms. B. Biologically Based Treatment 1. The effectiveness of antidepressant drugs varies by individual and by the severity of the depression. 2. Antidepressants can have uncomfortable side-effects. 3. ECT provides a more rapid effect than antidepressant drugs. (Figure 11-2, pg. 348) 4. ECT is most effective on the severely depressed and for those who have not responded to medication. C. Psychodynamic Theories 1. Although the current psychodynamic theory has little in common with early psychoanalysis, its roots begin with this discipline. 2. Episodes of depression are the result of an event that triggered an unpleasant view of oneself from the past.

G. H.

3. Some research has shown that a combination of traumatic childhood events and stressful experiences as an adult leave one more susceptible to a depressive episode. Interpersonal Psychotherapy 1. It is used to prevent relapse in those recovering from a major depressive episode as well as a treatment for acute depression. 2. There is a focus on recent stressful life events. 3. It is one of the most effective means of treatment of depression. The Humanistic-Existentialist Perspective 1. Existentialist theorists focus on one's loss of self-esteem. 2. Humanistic theorists focus on the discrepancies between one's ideal self and one's actual self. The Behavioral Perspective 1. There is a focus on how one obtains social reinforcement and deals with stressful situations. 2. During stressful times, depressed people look to others for a great deal of emotional support and they tend to delay making decisions. 3. Many depressed people are perceived negatively by others. Behavioral Treatment for Depression - Behavioral therapists use social skills training to help clients develop satisfying relationships with others. The Cognitive Perspective 1. Depressed people perceive the causes of events in a way that is unfavorable to themselves. 2. Beck's cognitive distortion model, which focuses on a cognitive triad of negative thoughts, has been the most influential cognitive approach. 3. There are three general ways to measure cognitions in depression: a. Cognitive product variables b. Cognitive process variables c. Cognitive schemata 4. According to the attributional model, depressed individuals attribute anything bad to themselves and anything good to luck. 5. Learned helplessness encourages depressed individuals to feel helpless in controlling their environment. 6. Hopelessness depression has been suggested as a subtype of depression. 7. Research has found that the more depressed one is, the more inaccurately the person views their own competencies. 8. Table 11-8 (pg. 352) Topics discussed in cognitive therapy sessions Cognitive-Behavioral Therapy 1. CBT strives to help the client think more adaptively and experience positive changes in mood, motivation, and behavior. 2. Clients are taught to monitor their automatic thoughts. 3. The therapist assists the client in changing his/her schemata. (Figure 11-5, pg. 353) The Vulnerability-Resilience Perspective 1. Genetic predisposition and social support networks combine to form one's vulnerability and resilience factors to life stressors. 2. Abraham Lincoln is a prime example of how one's resilience can help them overcome depression and stressful life events. How Should Depression be Treated? 1. CBT and IPT are the most common forms of treatment for mild cases of depression. 2. The Treatment of Depression Collaborative Research Program was the most comprehensive American study of the various treatment options for severe depressive disorder. 3. There are still many questions surrounding the treatment of depression.

V. The Bipolar Disorders A. Table 11-9 (pg. 357) Moods found in bipolar disorder B. Table 11-10 (pg. 358) Diagnostic criteria for manic episode C. Bipolar I Disorder 1. Bipolar I disorder is characterized by the experience of manic episodes and sometimes major depressive episodes.

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D. E. F.

2. There is a much higher incidence of bipolar disorder among highly creative people than in the general population. 3. It is important to rule out other possible causes of mania before making the bipolar disorder diagnosis. Bipolar II Disorder -- the manic states associated with bipolar II disorder are much less severe and can be managed in day-to-day life. Table 11-11 (pg. 359) Diagnostic criteria for bipolar II disorder Cyclothymic Disorder 1. Cyclothymic disorder involves chronic mood disturbances of both hypomanic behavior and depressive behavior. 2. The symptoms do not meet the DSM-IV criteria for a manic episode or a depressive episode. 3. Cyclothymic disorder appears to be more closely related genetically to bipolar disorder than to unipolar disorder. 4. Table 11-12 (pg. 361) Diagnostic criteria for cyclothymic disorder Causes of Bipolar Disorder 1. Genetic factors and stress have important roles in the development of bipolar disorders. 2. Research has shown that bipolar I disorder has a very strong genetic component. 3. It has been found that bipolar I disorder is a separate disorder from unipolar disorder. Treatment of Bipolar Disorder 1. Medication containing lithium is the most common treatment used for bipolar disorders. 2. Antidepressants may bring about manic episodes in individuals with bipolar disorder. 3. Lithium has many negative side effects. 4. Atypical antipsychotics are now being studied as potential medications for bipolar disorder. Family Stress and Bipolar Disorder 1. Research has shown that stress can precipitate manic episodes. 2. As the functioning ability of an individual with a bipolar disorder fluctuates, the roles within the family fluctuate as well. 3. Bipolar disorders are the cause of a great deal of stress for the family members of the patient.

VI. Suicide A. Risk Factors for Suicide 1. Most people who commit suicide have seen a general physician within three months of their death. 2. The highest suicide rates are in elderly men and in women ages 45 to 65. 3. There is an increasing number of suicides among those ages 15 to 34. 4. Table 11-13 (pg. 368) Warning signs of suicide in adolescents 5. Individuals that attempt suicide feel hopeless and believe suicide is their only alternative. 6. Perfectionism may play a bigger role than helplessness in influencing one to commit suicide. 7. There is a great deal of cultural differences in regards to the interpretation of suicide. B. Parasuicide 1. Suicidal behavior that does not result in death is referred to as parasuicidal. 2. More women than men are parasuicidal, usually because less lethal measures are taken. C. Primary Prevention of Suicide 1. Crisis centers are important assets in helping suicidal individuals. 2. The medical field must become more knowledgeable about the warning signs of suicide. 3. Cultural attitudes need to be addressed so that is acceptable for one to seek psychiatric help. D. The Impact of Suicide on Others 1. Suicide causes a great deal of grief among the loved ones of the deceased. 2. Survivors must also contend with feelings of shame or embarrassment regarding the suicide. 3. Postvention is a means for survivors to deal with their grief. VII. Take-Away Message

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WEB LINKS Depression Resources - http://www.depression.com/ This is one of the largest Internet resources on depression, supported by Bristol-Myers Squibb, a pharmaceutical company. Efficacy of Depression Treatments - http://www.ahcpr.gov/clinic/deprsumm.htm Read a summary (and access the full report) of the government's meta-analysis of hundreds of studies about the efficacy of depression treatment. National Depressive and Manic-Depressive Association - http://www.ndmda.org This is the site of the National Depressive and Manic-Depressive Association. It has links to information about and treatment for mood disorders. National Foundation for Depressive Illness - http://www.depression.org/ National Institute of Mental Health - http://www.nimh.nih.gov/publicat/depressionmenu.cfm The National Institutes of Mental Health site devoted to depression and bipolar disorder. Site of the National Foundation for Depressive Illness, Inc., this is another large depression site. Note that only the top-level domain name (org vs. com) separates this site from the previous site. Suicide Facts - http://www.nimh.gov/research/suicide.htm

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HANDOUT - THE BEST AND WORST THINGS TO SAY TO A DEPRESSED PERSON THE BEST Please be yourself and be honest about how you are feeling. You are a wonderful, beautiful, lovely, smart, clever, talented person. I understand (if it's meant!). I'm sorry you feel that way. I love you no matter what. You are a great friend and a special person. You are a survivor. I love you and will stand by you. Please call any time if you need to talk. It is okay to need and get help. You are not alone. You are just fine as you are! I love you. What can I do to help? I am here for you regardless. THE WORST Snap out of it! What's your problem? What do YOU have to be depressed about? You are a psycho, I just don't understand why you hurt yourself. There are a lot of people worse off than you are. You will end up in a mental home. You are not ill! I just don't understand why you feel that way. Wake up and smell the roses! Did you have electroshock? Quit being so self-centered and think of the other people in your life, don't ruin their lives too. It's all in your head, just decide to be happy. Pull yourself out of it. Just get on with your life. It's no big deal. No one will hold your hand, you have to do it alone. Everyone gets depressed sometimes, you just have to think positive. It will get better, cheer up!

Reprinted with permission (2001) from the True Blue Friends website at http://truebluefriends.au.com.

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Chapter 12 Schizophrenia and Other Psychotic Disorders OVERVIEW Chapter 12 covers the positive and negative symptoms found in schizophrenic disorders and describes the major subtypes of schizophrenia including paranoid, catatonic, disorganized, undifferentiated, and residual. Other topics discussed in Chapter 12 include genetic factors, biological factors, vulnerability, resiliency, and stress as they relate to schizophrenic and other psychotic disorders. CONTENTS Causes of Schizophrenia Schizophrenia Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type Schizophreniform Disorder Schizoaffective Disorder Delusional Disorder Brief Psychotic Disorder Shared Psychotic Disorder Psychotic Disorder NOS Take-Away Message LEARNING OBJECTIVES After completing this chapter students should be able to: 1. Outline the characteristics of the major psychotic disorders 2. Identify and define the DSM-IV subtypes of schizophrenia. 3. Differentiate between positive and negative symptoms of schizophrenia. 4. Discuss the possible causes of schizophrenia including genetic factors, schizophrenic spectrum disorders, and other biological factors. 5. Discuss how research is transforming our knowledge of the possible genetic and environmental factors of schizophrenia. 6. Describe the role stress plays in the development of schizophrenia and possible high-risk markers that have been identified. 7. Explain the various treatment approaches to schizophrenia including antipsychotic drugs, skills training, family programs, and community support. 8. Discuss the utility and the research in the expressed emotion concept of treating psychotic disorders. 9. Identify other related psychotic disorders including schizoaffective disorder, delusional disorder, and shared psychotic disorder. LECTURE AND DISCUSSION TOPICS 1. The Positive and Negative Symptoms of Schizophrenia. a. Lead the class in a discussion about the positive and negative symptoms of schizophrenia. Allow the class to arrive at the following list of symptoms. (As one symptom is mentioned and listed, have students define in behavioral terms what that symptom is and give examples of each.) b. Positive Symptoms: Point out that positive symptoms represent excesses of functions, and they are usually present in the early stages of schizophrenia. • delusion • hallucination • disorganized speech • disorganized and bizarre behavior c. At least one positive symptom must be present for a diagnosis of schizophrenia. An article by North (1998) describes the positive symptoms she suffered as she attended medical school and sought treatment. North heard barking dogs when she listened through her stethoscope; her pet

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bird transmitted messages to her brain when he sat on her head; voices told her how to answer her exam questions. She believed that plants were growing out of her carpet and that they would eventually take control of her. d. Negative Symptoms: Negative symptoms indicate deficits in behavior or a loss decrease in functions. They usually appear during later stages of schizophrenia. • flat affect • loss of direction or motivation • loss of energy • loss of feelings of pleasure North, C.S. (1998.) Welcome silence: My triumph over schizophrenia. In Stattler, D., Shabatay, V. & Kramer, 0. (Ed.) (1993) Abnormal Psychology in Context: Voices and Perspectives. NY: Houghton Mifflin Company. 121-130. 2. Possible Etiologies of Schizophrenia: Neurotransmitter Involvement. a. Use a good overhead or computer production of the brain structure. The overhead should show the areas to be discussed (frontal cortex, anterior cingulate gyrus, left globus pallidus [dorsal and ventral]). b. O'Conner (1994) provides an excellent discussion of the possible structural and biochemical implications in the etiology of schizophrenia. c. Discuss how new techniques make the study of schizophrenia much easier. Discuss the fact that MRIs allow us to look closely at brain structure. PET scans allow us to look at functions in specific areas of the brain. In the past, X-rays and autopsies allowed only superficial glances at the brain, but allowed no functional analyses. d. Discuss the following neuropsychological problems that schizophrenics have in: 1) spatial attention, 2) language, and 3) thought processes. e. O'Conner cites growing bodies of evidence that point to the frontal cortex (the anterior cingulate gyrus which is involved in all three of the above processes). Neurons in this area seem to be involved in the attention system; this area appears to be involved in the control of language; the area also is involved in our thought process. f. O'Conner also discusses high blood flow in the left globus pallidus in recently diagnosed patients (those who have not been treated). The globus pallidus is involved with the activity in the anterior cingulate. What O'Conner finds interesting about these findings is that neurons in this region of the brain carry dopamine, and dopamine has been implicated in the possible etiology for several decades. g. The older antipsychotic drugs such as haloperidol (that block dopamine receptors) seemed to decrease the occurrence of positive symptoms in schizophrenic patients, but over time, produced motor symptoms produced by lack of dopamine). These results have indicated the importance of dopamine in schizophrenia. h. The new drugs, like clozapine, do not seem to produce the motor symptoms associated with the older drugs. It is believed that clozapine blocks only the dopamine receptors on the ventral pathway of the pallidus and does not interact with dopamine activity in the dorsal (motor) pallidus. O'Conner, W. (1994) A disorder of brain circuitry. The Decade of the Brain, Winter. The National Alliance for the Mentally Ill. 1-4. Reprinted in Palladino, J.J. (Ed) (1998.) Annual Editions ”Abnormal Psychology” 98/99. STUDENT ACTIVITIES Classroom 1. Show the video from the series, The Brain: Madness (60 minutes). This video, “Madness,” demonstrates the symptoms and characteristics of schizophrenia. The cases presented in the video represent the lower third of the individuals who suffer from the most debilitating symptoms of schizophrenia. One patient, Jerry, is interviewed, filmed on a visit to his family, and followed for a short period of time. His mother and father are both interviewed and the total devastation of the family is apparent. Another patient, Heather, presents severe symptoms of longterm schizophrenia and the accompanying symptoms associated with long-term use of some of the

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earlier antipsychotic drugs. This video also discusses some of the biological hypotheses on the etiology of schizophrenia. Some students will be shocked to discover that schizophrenia is not caused by faulty parenting or poor psychological adjustment. Have the students discuss the different types of schizophrenia or the mixtures of symptoms presented by the patients. Discuss both positive and negative symptoms. Discuss the types of hallucinations and delusions seen in patients in the video. Discuss the "loosening of associations" seen in Jerry's speech. Because this video is approximately sixty minutes long, a second day lecture period may be necessary for discussion. Usually this video evokes strong affective responses and students have many questions regarding schizophrenia, the cases presented, and often mentioned friends and family members who have been diagnosed with schizophrenia. The fact that around 60 percent of individuals who are diagnosed with schizophrenia do not suffer from schizophrenia as severe as shown in the video should be discussed. 2. Video: Phil Donohue: Schizophrenia Have class members view the video of Phil Donohue interviewing individuals who had suffered from episodes of schizophrenia but the symptoms were in remission. This group of individuals represents the portion of individuals who suffer from schizophrenia but recover enough to spend much of their time as healthy, functioning members of society. A number of people are interviewed including a retired Green Bay Packer football player, a gentleman representing the rights of mentally ill individuals, and two sisters, one who had suffered schizophrenia for years (residual type) and the other who was "normal." The illness is discussed openly and frankly and will indicate to the class that these individuals are quite different from the individuals presented in the first video, “Madness.” 3. List on an overhead, computer screen, or board the following cases. Discuss and classify each. a. Two brothers live together and one seems to be smarter and dominate the younger brother. The brothers believe that they have been selected by secret agents from another planet to assist in colonizing the earth. Both brothers are confident that the future event is approaching. (Ans: shared psychotic disorder) b. Janie hears voices telling her what to do and believes that she is an earthly representative of the Virgin Mary. Janie can't concentrate because of continuous noise from ``noisemakers'' in her head. At times Janie becomes very depressed, and at other times she becomes very energetic, sings, dances, and needs very little sleep. These mood changes occur both when Janie is hearing voices and when she is not. (Ans: schizoaffective) c. Jim was hospitalized for mental illness. He heard voices and believed that he was a CIA agent for the government. He often could be seen taking notes on suspicious activity. Jim is now back at home and gets along fairly well. Jim takes his medication, but seems to be rather emotionless and flat, and at times people find him staring blankly. (Ans: residual schizophrenia) d. Jill has been brought into the hospital. She does not speak and remains standing in an awkward stance for hours. When the doctor moved her arm above her head, she remained in that position for over an hour. Her family reported to the physician that she had been hospitalized before for this condition and on one occasion Jill became very agitated, jumped, talked, and shouted continuously. In this state, she was very violent. (Ans: catatonic schizophrenia) e. Amy has become very suspicious during the past year. She often hears voices and noises and is convinced that they ultimately will destroy her. She also suspects that her dentist has implanted tiny electrodes in her teeth and her enemies are able to read her thoughts and control her behavior through those electrodes. Amy always checks her food for poison, is convinced that her telephone is tapped, and that agents are sitting in the apartment across the way spying on her. (Ans: paranoid schizophrenia) f. Shirley is a woman who has been hospitalized for some time. Her speech is often incoherent, her behavior is disorganized, and her emotional reactions are inappropriate. She hears voices interrupting her thoughts and often talks as if someone is present. At times she appears to be irritable and at other times she appears to be frightened. She has been arrested for urinating on a public street and for disrupting the peace. (Ans: disorganized type of schizophrenia)

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4. It could be better. This exercise is for a small class or a class where there are a few willing volunteers. Materials: Two miniature kaleidoscopes (Oriental Trading Co.) Cheap clear plastic glasses. Reverse the kaleidoscope and tape each to one lens of the glasses (large side toward the lens). A small tape player, a cassette with exercise music or a hard rock song, disposable headphones, a pharmaceutical information sheet (or similar with very tiny print). Participants: Ask for two volunteers. Demonstration: Ask the participant to apply the headphones and the glasses. You will control the tape on-off, volume, and speed of the played music. Quietly instruct the second volunteer to ask questions of the first, what is the name of the drug, what is its use, repeat the chemical name, etc. Ask the first participant to begin reading the pharmaceutical package insert. As the participant begins to read, play the tape, turn it on and off, increase and decrease the volume and adjust the speed if possible. After about 30 seconds, ask the participant to recall the content of what he/she read. Use this to demonstrate how perceptions and hallucinations interfere with thought processing. Mention also that the visual effects mimic some forms of learning disability. Assignment Ask students to select one of the popular films from the list below. While watching the film ask students to record the behaviors that are supposed to represent “schizophrenic” or “delusional” behavior. Using the text or the Web, ask the student to attempt to locate a more complete description of the behavior they have recorded. Critical Writing Researchers at Johns Hopkins School of Medicine published the results of a study in which viral pieces were found (2001, April 10). “In this week’s Proceedings of the National Academy of Sciences, Children’s Center neurovirologist Robert Yolken, M.D., and his colleagues report the molecular "footprint" of a retrovirus in the cerebrospinal fluid of about 30 percent of people with acute schizophrenia and about seven percent of people with a chronic form of the disease. The footprint was absent in the brains and cerebrospinal fluid of all people who did not have schizophrenia” (http://www.stanleylab.org). A viral culprit has long been sought as the basis for schizophrenia. For this critical writing, argue successfully that the retroviral particle present in many schizophrenics is either a) environmental or b) genetic (in the broadest sense of the term–passing along one’s genetic material (and more) to another person. Great Books to Read Alexandra, Christina & Brady, John Paul. (2000) Five Lost Years: A Personal Exploration of Schizophrenia. San Francisco: Dry Bones Press ISBN: 1883938465. Heinrichs, R. Walter. (2001) In Search of Madness : Schizophrenia and Neuroscience. London: Oxford Univ Press; ISBN: 0195122194. Seager, Stephen B. (2000). Street Crazy: America's Mental Health Tragedy. New York: Westcom Press. ISBN: 0966582772. Simon, Fritz B. (1996). My Psychosis, My Bicycle, and I: The Self-Organization of Madness. New York: Jason Aronson, Inc. Torrey, E. Fuller. (1995). Surviving Schizophrenia: A Manual for Families, Consumers, and Providers. New York: Harperperennial Library; ISBN: 0060950765.

VIDEO RESOURCES Professional Nervous Breakdown, 30 min. (Films for the Humanities & Sciences). This video focuses on a family whose son has been diagnosed as schizophrenic. This provides an excellent example of schizophrenia in a young man and the family's struggle to cope with it. Negative Symptoms in Schizophrenia, 60 min. Univ. of Iowa Hospitals, Procom Div: Wheelis Communications Group). The negative symptoms of schizophrenia are presented and etiology is discussed. Patients as Educators: Case #6, Georgianna, Schizophrenic, 12:35 (Prentice Hall Videos). The case of a thirty- three-year-old woman who has suffered from schizophrenia for many years is described. The Brain: Madness, 60 min. (Annenberg/CPB). This classic video presents several patients who suffer

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from schizophrenia and its effects on their parents. Theories of the etiology are also covered. These patients suffer from the most debilitating form of schizophrenia. Video Almost Home, 24 min. (Primetime Live, 12-2-93) (ABC News/Prentice Hall Library #2). Diane Sawyer interviews Lori Schiller who has experienced schizophrenia since her teen years. New medication enables her in her recovery. Schizophrenia: 28 min. (Films for the Humanities and Sciences). Phil Donahue interviews several individuals who have suffered from schizophrenia. The individuals in the video represent the individuals who suffer from a milder form of schizophrenia and are able to spend most of their time outside of a hospital. Schizophrenia (Prime Time Live), 13:24 min. (ABC News/Prentice Hall Video Library Abnormal Psychology Series III Cassette Three). Schizophrenia: Out of Mind (48 Hours) 52 min. (Films for the Humanities and Sciences). This 48 Hours program shows schizophrenia from patients', families', and professionals' perspectives. The Heaven's Gate (Lighthner), 10.06 min. (ABC News/Prentice Hall Video Library Abnormal Psychology Series III Cassette Two). Shared delusional disorder is presented in this video. The case of "Heaven's Gate" followers are detailed. The World of Abnormal Psychology: The Schizophrenias (Tape 9), 60 min. (Annenberg/CPB). An excellent presentation of the schizophrenic disorders is provided in this video. Movie Through a Glass Darkly (1961). One of Ingmar Bergman's most somber films; about a young schizophrenic woman, her husband, her family, and a remote Swedish island. A visually remarkable film by one of the 20th-century's great film makers. A dark film that seeks existential truth perhaps more than mere psychological accuracy. Angel Baby (1995). Harry and Kate meet in a therapy group at an outpatient clinic where they fall in love. This is about the relationship between two persons with schizophrenia who meet in therapy. Harry hears voices but on medication is functional enough to write computer software. Kate is more seriously disturbed and has a complex delusional system. When Kate becomes pregnant, she decides to stop her antipsychotic medication to avoid potential fetal damage. Harry stops his as well, and their ensuing psychoses spiral to a catastrophic conclusion. Benny & Joon (1993). Sam works to support Joon, his sister who has schizophrenia. (Johnny Depp as Sam, Mary Stuart Masterson as Juniper "Joon"). Sam, who is an unusual character, a little detached from reality, comes into the picture and develops a relationship with Joon, eventually falling in love. The Saint of Fort Washington. (1993). Matthew is out on the streets when his apartment building is demolished. He meets Jerry, a veteran, and the two adjust to being homeless. Matthew appears to have schizophrenia. This is a very interesting movie, more emphasis is on the homeless issue than the mental health issue David and Lisa (1962). David is in a mental institution for teens. He becomes close to Lisa, who is a young woman with schizophrenia. Remade as a TV movie in 1998. They Might Be Giants. (1971). This film can be hard to find but makes a good antidote to the extreme seriousness of films such as Through a Glass Darkly. Starring Joanne Woodward as a psychiatrist who treats actor George C. Scott for delusions of grandeur: He believes he is Sherlock Holmes. It serves as a good introduction to grandiose delusions. Universal Pictures.

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CHAPTER OUTLINE I. Psychotic Disorders A. Table 12-1 (pg. 374) Principal psychotic disorders B. Psychotic disorders alter one's perceptions, thoughts, or consciousness by means of hallucinations or delusions. C. Psychotic symptoms include disorganized speech and behavior. D. Hallucinations and delusions with no known cause are the defining feature of psychotic disorders. II. Schizophrenia A. Twenty million people worldwide have had a schizophrenic episode. B. Two million sufferers in the United States C. Estimate that 1% or 1 in 100 persons will encounter the disorder D. DSM-IV Subtypes of Schizophrenia (Table 12-3, pg. 375) 1. Paranoid schizophrenia is the most common form of schizophrenia diagnosed and is characterized by extreme suspiciousness. 2. Catatonic schizophrenia is characterized by psychomotor disturbances ranging from immobility to uncontrollable movements. 3. Disorganized schizophrenia is characterized by flat or inappropriate emotions, incoherence, and disorganized behavior. 4. If a person meets the symptom criteria for schizophrenia, but does not fit into a specific category, that person is diagnosed as undifferentiated type schizophrenia. 5. Someone who has recovered from schizophrenia, but still retains some negative symptoms, is considered to have schizophrenic disorder of the residual type. E. Positive Symptoms (Table 12-4, pg. 378 ) 1. Positive symptoms are most common in the early stages of schizophrenia and are characterized by an excess of normal functions. a. Delusions are faulty interpretations of reality that are maintained despite evidence to the contrary. (Table 12-5, pg. 378, Content of delusions in schizophrenic patients) b. Hallucinations are projections of internal experiences onto the external world. c. Disordered speech is characterized by loose associations and the switching from one topic to another unrelated topic. d. Auditory hallucinations, increased activity in Broca’s area, decreased activity in Wernicke’s area (Figure 12-3, pg. 379, location of Broca’s and Wernicke’s areas in the brain) e. Visual hallucinations, other sensory hallucinations 2. Disordered Speech a. Perseveration b. Looseness of association in speech 3. Disorganized behavior, characterized by behaviors seemingly unrelated to the surroundings, is common in schizophrenia. a. Catatonic excitement b. Catatonic rigidity F. Negative symptoms (Table 12-6, pg. 382) dominate the later stages of schizophrenia and are characterized by behavioral deficits and a loss of normal functions. Negative symptoms include flattened affect, poverty of speech, loss of motivation, loss of energy, loss of feelings of pleasure. G. Table 12-7 (pg. 383) Prognosis predictors of schizophrenia based on symptomology H. Schizophrenic spectrum disorders III.

What Causes Schizophrenia? A. Genetic Factors 1. Table 12-8 (pg. 84) Prevalence of schizophrenia 2. There is a strong genetic link in the development of schizophrenia. 3. Other factors are also responsible for the development of schizophrenia as there is not a perfect correlation between identical twins.

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4. Approximately 89% of people with schizophrenia have no known relatives with the disease. 5. No gene has been specified as the location for schizophrenia. 6. Monogenic models, polygenic models, and multifactorial polygenic models are all the subject of research into the development of schizophrenia. 7. Multifactorial Polygenic Models - compatible with the vulnerability concept 8. Prenatal Factors a. Increased risk as a result of influenza epidemics (Figure 12-10, pg. 388) b. Extreme environmental stress (war) c. Birth trauma 9. Neurodevelopmental Model a. Time spans are an issue in attempting to study the trauma or neurological event and the appearance of schizophrenic symptoms. b. Epidemiological studies, home movies, and other records are reviewed. 10. Prenatal Developmental Processes a. Cell migration patterns and processes that disrupt the migration paths b. Synaptic pruning (Figure 12-11, pg. 389) c. Minor physical anomalies (Figure 12-12, pg. 390) d. Development of the neuromotor system e. Biochemical brain abnormalities - biochemical factors: 1) The dopamine hypothesis 2) Enlargement of the cerebral ventricles (figure 12-14, pg. 391) 3) Recently Dr. Linda Brzustowicz of Rutgers University in New Jersey localized a schizophrenia susceptibility gene to a small region of chromosome 1, likely the "address" of the susceptibility gene. (http://www.newsandevents.utoronto.ca). 4) Twin differences - ventricular size and cortical folding Other Biological Factors 1. There is a possible connection between the season in which one is born and one's risk for developing schizophrenia. 2. Complications at birth may be linked to schizophrenia. 3. People with schizophrenia have significantly larger cerebral ventricles. 4. The dopamine hypothesis states that schizophrenia is associated with an excess of dopamine at certain areas in the brain.

IV.

Studying Vulnerability to Schizophrenia A. Family Studies 1. Family studies are usually done by mapping out a family tree and recording symptoms of any disorder among family members. Incidence and prevalence. 2. Assortive mating is also studied in family research. 3. Twin studies allow researchers to study environmental factors in the development of disorders: a. Monozygotic b. Dizygotic 4. Adoption studies help researchers to better understand the roles of environment and heredity.

Vulnerability and the Environment A. Hospitalization (Table 12-9, pg. 399, Factors which affect the decision to hospitalize) B. Diathesis (predisposition)-stress theory of schizophrenia, an interplay of the genetic and environmental factors and the amount of stress past which a person cannot cope. C. Vulnerability and Adoptive Family Characteristics (Fig. 12-16, pg. 395) 1. A Finnish adoption study has revealed that children born to a parent with schizophrenia and raised in an unhealthy environment are much more likely to develop schizophrenia or a psychosis. 2. Psychologically healthy environment appeared to decrease the risk for developing schizophrenia.

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D. Community Factors and Stress 1. People of lower social economic status are more likely to be diagnosed as schizophrenic. 2. The increased-stress theory states that a lower SES results in the experience of a great deal of stress, which may correlate with schizophrenia. 3. The social selection theory states that because people with schizophrenia lack coping skills, they fall to lower SES. E. High-Risk Studies and the Search for Markers 1. High-risk studies try to pinpoint certain markers that are indicative of the later development of schizophrenia. 2. There are two types of high-risk studies: a. Studies of children that appear to be at risk due to family history and complicated pregnancies and births b. Studies of individuals that appear to be at risk due to their potential symptoms of mental illness 3. Impaired attention has been one of the most consistently found markers in the search for markers of schizophrenia. 4. New York high-risk project F. High-Risk Markers of Attention and Cognition 1. The Digit Span Subtest from the WISC has been used as an attempt to identify high-risk markers for schizophrenia. 2. Children scoring poorly on the Continuous Performance Test (CPT), which measures one's sustained visual attention, are believed to be at a higher risk for developing schizophrenia. 3. Eye tracking of smooth-pursuit eye movements may help identify high-risk children. G. Caveat: The schizophrenias may have many different origins - a family tree may not be useful. VI.

Therapeutic Approaches A. Antipsychotic Drugs 1. Medications are the most common treatment for schizophrenia. 2. Antipsychotic drugs often produce a strong improvement, but this improvement can be temporary as it does not alter one's biological vulnerability. 3. Traditional antipsychotic drugs often caused tardive dyskinesia and an emotional numbing of the patient. 4. Atypical antipsychotics target multiple neurotransmitters and lessen the negative side effects. 5. Issues of compliance and maintenance on antipsychotic medication 6. A high number of patients discontinue their medications after their release from care. 7. Does a seriously ill person have the right to refuse medication? B. Psychosocial Approaches 1. Social skills training helps individuals to learn socially appropriate behaviors, affect regulation, and self-awareness. 2. Cognitive skills training is used to help schizophrenic patients process their auditory hallucinations. (Table 12-10, pg. 402, Strategies for treating cognitive deficits) 3. Self-care skills training strives to teach people with schizophrenia how to better care for themselves (also known as ADL’s or Activities of Daily Living). 4. Stress management skills. 5. Table 12-11 (pg. 403) Skills areas targeted by psychosocial treatment C. Family Programs 1. For people who have experienced an acute attack of schizophrenia, family educational programs have been found to reduce the rate of relapse. 2. Psycho-educational family interventions usually cover four main topics: a. Education about what schizophrenia is b. Information regarding the treatment of schizophrenia c. Identification of the possible causes of schizophrenia d. Instruction in problem solving and crisis management

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3. Expressed negative emotion - an early controversial theory in family therapy stated that the expressed emotions of the family members toward a schizophrenic were essential to the patient's prognosis. Table 12-12 (pg. 405) shows an example of survey that measures emotions. 4. Relapse recognition - Family programs try to teach both individuals with schizophrenia, as well as their family members, how to recognize the cognitive and perceptual symptoms that typically precede a relapse. D. Community Support 1. Most community support services attempt to assist the schizophrenic patient after release from the hospital, but do not attempt to improve the patient's level of performance. 2. Residential facilities allow people with schizophrenia to live outside of a hospital environment, without the social and financial stressors of living independently. 3. Case management is vital in helping the client to survive in a nonresidential setting by linking the client to various support services. (Table 12-13, pg. 407, Features of comprehensive case management of schizophrenia) E. Combined Treatment Approaches 1. There is almost universal agreement that antipsychotic medications are the best initial treatment for schizophrenia. 2. There is controversy over whether the medication should be continued once the symptoms dissipate. 3. Research has shown that social and interpersonal skills training are beneficial to people with schizophrenia. F. Long-Term Outcome Studies 1. Kraeplin's concept of schizophrenia leads one to believe that schizophrenia is a nonreversible degeneration of the brain. 2. Bleuler's concept of schizophrenia leads one to believe that schizophrenia ranges from a permanent and severe disease to a curable disorder. 3. Currently, it is believed that there are rare individuals who recover from schizophrenia, but no one is actually cured. 4. The prognosis for people who develop schizophrenia is generally poor, with no treatment approaches found to have consistent success. VIII.

Other Psychotic Disorders A. Schizoaffective Disorder 1. Schizoaffective disorder is characterized by a combination of symptoms both of schizophrenia and mood disorders. 2. Delusions or hallucinations must be present for this diagnosis to be made. (Table 12-14, pg. 408, Types of delusions) 3. A major depressive episode and/or a period of mania must also be present to diagnose one as having schizoaffective disorder. B. Delusional Disorder 1. The delusions present in this disorder are unlike those in schizophrenia as they are realistic delusions that could actually occur. 2. Delusional disorder is very rare and the cause is unknown. 3. Older adults are particularly affected by this disorder. C. Shared Psychotic Disorder 1. Shared psychotic disorder is also known as folie-a-deux. 2. Only rare instances of this disorder have been reported. 3. Two people living very closely share the same delusion.

IX. Take-Away Message WEB LINKS Atypical Antipsychotic Medications - http://www.nimh.nih.gov/research/schedito.htm A research report on the newest schizophrenia medications. For Families of People with Schizophrenia - http://www.mentalhealth.com/book/p40-sc01.html

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Read an entire book devoted to families of people with schizophrenia, courtesy of the Canadian government. National Alliance for Research on Schizophrenia and Depression - http://www.narsad.org/ Fact sheets, research, and links relating to schizophrenia and other brain-based disorders. National Alliance for the Mentally Ill - http://www.nami-nyc-metro.org This page has links to recent research and media reports on schizophrenia and other serious mental illnesses. Schizophrenia - http://www.schizophrenia.com/ The home page of schizophrenia.com, a nonprofit organization providing information, support, and education about schizophrenia. Schizophrenia in Children - http://www.nimh.nih.gov/events/earlyrecognition.cfm A summary of a NIMH conference on recognizing schizophrenia in children. Schizophrenia Research at NIMH - http://www.nimh.nih.gov/publicat/schizresfact.cfm A summary of past, present, and planned schizophrenia research conducted under the auspices of the National Institute of Mental Health. Schizophrenia Resources for Physicians - http://www.pslgroup.com/SCHIZOPHR.HTM This site about schizophrenia is geared toward physicians. When Someone Has Schizophrenia - http://www.nimh.nih.gov/publicat/schizsoms.cfm A one-page fact sheet prepared by the National Institute of Health for the 2000 White House Conference on Mental Health.

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Chapter 13 Cognitive Impairment Disorders OVERVIEW Chapter 13 provides an in-depth look into the various cognitive impairment disorders. It begins by explaining the factors that lead to increased vulnerability to these disorders as well as how brain disorders are assessed. Delirium and dementia are covered as are amnestic disorders. Delirium tremens, Alzheimer’s disease, and Parkinson's disease are all covered in the chapter. Chapter 13 also explains the diversity of cognitive disorder by covering cerebrovascular disorders, Korsakoff’s syndrome, and epilepsy. The chapter concludes by discussing the integrative nature of treating and assessing brain disorders. CONTENTS Delirium Delirium Tremens (Korsakoff’s syndrome) Dementia Alzheimer’s Disease Pick’s Disease + Axis III Huntington’s Disease + Axis III Parkinson’s Disease + Axis III Brain Trauma: Injuries, Tumors, and Infections Amnestic Disorders Diverse Cognitive Impairment Disorders Cerebrovascular Disorders Korsakoff’s Syndrome Epilepsy Take-Away Message LEARNING OBJECTIVES Upon completing this chapter students should be able to: 1. Describe the factors that may make some individuals more vulnerable to brain disorders than others. 2. Outline the techniques used to assess brain damage. 3. Explain the symptoms of delirium and delirium tremens. 4. Identify and describe the various forms of dementia including Alzheimer's disease, Pick's disease, Huntington's disease, Parkinson's disease, and the dementias associated with brain trauma. 5. Discuss the research being conducted to characterize, diagnose, and treat Alzheimer’s disease. 6. List coping strategies that help caregivers for Alzheimer patients. 7. Understand amnestic disorders and their possible causes. 8. Differentiate among cognitive impairment disorders including cerebrovascular disorders, Korsakoff's syndrome, and epilepsy. 9. Discuss the advantages of using operant conditioning to control some symptoms of epilepsy and pseudo- epilepsy. 10. Understand the importance of integrating the person's life prior to the development of a cognitive impairment with their current treatment and prognosis. LECTURE AND DISCUSSION TOPICS 1. Define Alzheimer's disease and ask the following question: "How can a person tell if some memory loss is due to normal aging or to Alzheimer's?" 2. An excellent discussion of this topic is provided in “Consumer Reports on Health” (1995) and reprinted by Palladino (1998). This article points out that most forgetfulness does not indicate Alzheimer's disease. At least 20% of individuals who live to be 80 years old will suffer from Alzheimer's. The report also points out that we do tend to have more memory problems as we age and if we worry about "going senile" we probably are not. Other factors complicate the diagnostic picture:

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a. Age related memory problems are often related to problems with encoding new data. Older people have more difficulty in remembering new faces, and the neural activity in the hippocampal region of the brain is less active. b. Older people seem to do better on memory tests administered in the morning. Test results may not be accurate if exams are administered in the afternoon or evening. c. Memory loss may be due to other factors such as: alcohol abuse, depression, nutrient deficiencies, sleep disorders, stroke, and other physical problems. d. Memory loss may be a result of medication, especially heart medications. e. The interpretation of memory loss may be incorrect and what seems to be a cognitive problem may be a problem of diminishing sensory capability, seeing, hearing, touching, tasting, or smelling. f. Discuss some of the following factors that may point to serious impairment (Consumer Reports, 1995): 1) Memory loss: You might misplace your keys from time to time, but an Alzheimer's patient may not "recognize" the keys. 2) Disorientation: You might get lost when you're away from home, but the Alzheimer's patient may get lost in his/her house or backyard. 3) Changes in mood or personality: A person suffering from Alzheimer's might suddenly change from laughing to crying or become irritable and suspicious without cause. 4) Speech problems: A person suffering from Alzheimer's often cannot find the right words for objects and mixes up words. 5) Reasoning: A deficit in reasoning may be indicated by the person's inability to reason logically and the person may be unable to understand the meaning of proverbs. 6) Inappropriate behavior: An individual suffering from Alzheimer’s may forget his/her pants, skirt, or forget to wear a coat in cold weather. Consumer Reports on Health, (1995). Is it normal aging---or Alzheimer's? October, Consumers Union of U.S., Inc., Yonkers, NY. 114-116. Palladino, J.J. (Ed) (1998) Is it normal aging---or Alzheimer's? Consumer Reports, Abnormal Psychology 98/99 Guilford, CT: Dushkin/MeGraw-Hill. 141-143. STUDENT ACTIVITIES Classroom 1. Remember dearie? This exercise emphasizes the confusion and desperation that is sometimes felt by Alzheimer victims. Collect a series of common items: a phone, a glass, a cup, a pencil, a small toy, a tablet, a telephone book, etc. Try to collect about 10 items. Give each item a new name. The name should be 2-3 syllables long. Practice using the item in conversational context but with the new name to create a story. At the end of the story ask for a few volunteers to come up to the table where all of the items have been displayed. Point to the items and ask a volunteer the name of the item and what it is used for. Act as if you do not understand and ask for clarification. After a few instances, ask the other volunteers to discuss the frustration felt by the first student. Discuss the depression that often accompanies patients with the relentlessly destructive Alzheimer’s disease. 2. Show the video from the series, “The Mind: Aging” (60 minutes). Lead a class discussion of the process of aging, normal memory problems, Alzheimer's disease, genetic implications, and other interesting points of the video. Discuss family responses, especially the stress and depression that are experienced by the caretakers. 3. Whose stem cell is it? Read any of the new research on generating stem cells at http://www.nhgri.nih.gov/NEWS/Stem_Cells/links.html . Discuss the use (Parkinson’s disease) and various methods of collecting stem cells: bone marrow, umbilical cords, and human embryos. Ask the class to consider the ethical dilemmas involved in each of the methods. What sort of ethical statements would be needed to ensure that the owner of the stem cells received proper remuneration

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for the use of his/her cells? Should the donor receive remuneration? Could the recipient of the stem cells be sued by the owner? Critical Writing Locate and read the two articles on epileptic pseudo-seizures. In the “Discover” article, Angela says that the pseudoseizures are part of “her.” The American Family Physician article suggests that the pseudo events are very real to the patients. Choose one of the following arguments and write a justification for it. a. Pseudo seizures are somatizing disorders. It indicates that the patient is deeply disturbed and should undergo extensive talk therapy and medications. b. Pseudo seizures relieve stress and are acquired through classical and operant conditioning paradigms. The patient, through biofeedback and replacement conditioning, can learn other, more acceptable, responses. Dajer, T. (2000, November). Altered States: Sometimes when a seizure hits, even the doctor doesn't know whether it's real. Discover, 21, (11). Retrieved from the World Wide Web: http://www.discover.com/nov_00/featvital.html Shaibani, Aziz & Sabbagh, Marwan N. (1998, May). Pseudoneurologic syndromes: Recognition and diagnosis. American Family Physician, 57, (10), 2485+.Retrieved from the World Wide Web: http://www.aafp.org/afp/980515ap/shaibani.html Great Books to Read Ewing Wayne, & Ewing, Dasha Wright. (1999). Tears in God’s Bottle: Reflections on Alzheimer’s Caregiving. Albany, NY: Whitston Publishing; ISBN: 0966754700. Freeman, John Mark, Freeman, Jennifer B., & Kelly Millicent T. (2000, August).The Ketogenic Diet: A Treatment for Epilepsy, 3rd Ed. New York: Demos Medical Publishing. ISBN: 1888799390. Lebow, Grace Kane, Barbara, & Lebow, Irwin. (2000). Coping with Your Difficult Older Parent: A Guide for Stressed-Out Children. New York: Avon Books. ISBN: 038079750X. Schachter, Steven. (1993). Brainstorms-Epilepsy in our Words: Personal Accounts of Living with Seizures. New York: Raven Press; ISBN: 0881679976. VIDEO RESOURCES Professional Aging, 59 min. (Kent State Univ.) This video demonstrates what happens to the brain and mind during the aging process. Strokes are also covered. Alzheimer's Disease, 28 min. (Films for the Humanities and Sciences). Phil Donahue explores Alzheimer's disease by interviewing families and a patient. Alzheimer's Disease: The Long Nightmare, 19 min. (Films for the Humanities and Sciences). Recent medical findings related to the possible causes and treatments of Alzheimer's disease are discussed and the emotional and financial costs relating to Alzheimer's disease are presented. Parkinson's Disease, 19 min. (Films for the Humanities and Sciences). This video covers treatments for Parkinson's disease. The World of Abnormal Psychology: Organic Mental Disorders (Tape 10), 60 min. (Annenberg/CPB). Video Alzheimer's Disease, 10 min. (Annenberg/CPB). This video traces the changes in cognition and behavior of a woman in the early stages of Alzheimer's disease. Desperate for Anything , 20/20, 8-16-91), (ABC News/Prentice Hall Library #1). The treatments for Alzheimer's disease are investigated with an emphasis on nonapproved drugs. The Mind: Aging (Episode 3), 60 min. (Annenberg/CPB). This film covers the effects of aging, the genetics of such disorders as Alzheimer's disorder, and diagnostic techniques. Beating Alzheimer’s: The Nuns' Gift (Nightline, 8-5-94), (ABC News/Prentice Hall Library #2). Researchers studying Alzheimer's disease and dementia have begun to study a group of nuns from the Sisters of Notre Dame who have been willed their brains for future research. Stealing Time: Precious Memory, (PBS, 60 min., (Annenberg/CPB). Alzheimer's disease is a major threat to the nation and the world's older populations, and the only solution is continued basic and clinical research.

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Movie Folks! (1992). Tom Selleck. Selleck plays a perfectly contented Chicago stock market trader whose life begins to fall apart when he goes to visit his parents in Florida. His father is senile (dementia? Alzheimer’s?) and his mother can no longer take care of the old man. Various disasters and contrivances bring the whole family, including Selleck's selfish sister (Ebersole) and her two obnoxious sons back home to Chicago. Life gets interesting when Pops (Don Ameche) begins to continuously complain about “Mcdonald’s.” When Selleck stresses out, his parents suggest that he help them kill themselves so they'll no longer be a burden to him. Kotch (1971). An excellent film starring Walter Matthau and directed by Jack Lemmon about the relationship between aging parents and their children. Kotch Company Productions.

CHAPTER OUTLINE I. The Brain: An Interactional Perspective A. The brain develops in unique ways throughout life. B. There is no standard psychological effect for each type and degree of brain defect. C. Vulnerability to Brain Disorders 1. Several factors influence how one is affected by organic brain damage or tumors: a. Age b. Social support c. Stress d. Personality factors e. Physical condition 2. One's social emotional state prior to an organic brain condition can be a strong predictor to their rate of success in recovery. D. Assessing Brain Damage 1. It is difficult to assess brain damage because damage to a specific area of the brain can cause diverse effects. 2. Mental status exams are used to gain information on one's level of consciousness and their mental functioning. (Table 13-1, pg. 416, Questions asked in MSE) 3. Brain imaging techniques allow physicians and psychologists to view the actual areas of damage in the brain. (Figure 13-3, pg. 418, Techniques used to scan the brain) II. Delirium A. Delirium is characterized by cognitive impairment, disorientation, and confusion along with volatile emotions. (Table 13-3, pg. 418, Clinical features of delirium) B. Four causes of delirium have been identified: 1. Brain disease 2. A disease or infection in another part of the body that affects the brain 3. Intoxication 4. Withdrawal C. Most believe that delirium results from an imbalance in brain metabolism along with an imbalance of neurotransmitters. D. Vulnerability to developing delirium is highest between older adults and those with brain lesions or a long history of drug or alcohol addiction. E. Delirium tremens is one of the most drastic examples of delirium. III.

Dementia - (Table 13-4, pg. 420, Distinguishing features between dementia and depression; Table 13-5, pg. 421, Diagnostic criteria for dementia) A. Alzheimer's Disease 1. Alzheimer's disease is characterized by memory loss and confusion with dementia worsening over time (Table 13-6, pg. 422, cognitive decline in Alzheimer’s patients)

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IV.

2. Almost complete deterioration both physically and mentally is expected in the final stages of the disease. 3. Alzheimer's patients often suffer from several behavioral problems: a. Depression b. Hostility, belligerence, and aggression c. Disorientation d. Wandering e. Anxiety and suspiciousness 4. Alzheimer's disease is the leading cause of mental deterioration among the elderly. 5. Alois Alzheimer discovered that the disease results from tangled clumps of nerve cells and plaques in the brain. 6. People with Alzheimer's disease lose up to 80% of their cholinergic cells in key areas of the brain. (Box 13-2, pg. 425) 7. There appears to be a strong genetic link in Alzheimer's disease. 8. Caretakers of Alzheimer's patients experience extreme amounts of stress, often due to a lack of control. 9. The diagnosis of Alzheimer's disease cannot be confirmed until after death. 10. There has been little progress in discovering an effective treatment for the disease. Pick's Disease 1. People between 60 and 70 years have highest risk for developing Pick's disease. 2. The symptoms of the disease are very similar to those of Alzheimer's disease and an autopsy is often required for the diagnosis. 3. Men are more likely to develop the disease than women. Huntington's Disease 1. Four symptoms characterize the disease: a. Dementia b. Irritability and apathy c. Depression d. Hallucinations and delusions 2. People with Huntington's disease also experience involuntary, spasmodic jerking and twitching called choreiform movements. 3. By studying a Venezuelan family with an abnormally high incidence of the disease in their family, researchers were able to locate the gene that carries the disease. 4. Great psychological burden for those who are at risk for developing the disease Parkinson's Disease 1. Parkinson's disease is characterized by rigidity, a mask-like facial appearance, and the loss of vocal power. 2. It seems as if these individuals have over-control of their emotions. 3. Parkinson's disease thought to be related to a deficiency of dopamine in the brain Brain Trauma: Injuries, Tumors, and Infections 1. Over 500,000 people in the U.S. suffer from severe brain injuries every year. 2. Table 13-8 (pg. 431) Factors that contribute to effects of brain trauma 3. Brain injuries are classified into three groups: a. Concussions b. Contusions c. Lacerations 4. The brain can also be injured from the pressure of a tumor growing within the brain. 5. People with AIDS may also suffer from HIV-associated cognitive impairment characterized by forgetfulness, difficulty concentrating, and mild motor difficulties. 6. Untreated syphilis may result in general paresis which is characterized by a progressive deterioration of psychological and motor functioning and ultimately death.

Amnestic Disorders A. Amnestic disorders are disturbances of memory which result from a medical condition or from prolonged exposure to a substance.

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B. C.

People with these disorders are unable to learn new information and have great difficulty in remembering previously learned information. Most individuals with amnestic disorders deny that they have an impairment.

The Diversity of Cognitive Impairment Disorders A. Cerebrovascular Disorders 1. Strokes are blockages or ruptures of the blood vessels in the cerebrum which deprive portions of the brain of blood and oxygen. 2. Aphasia, a partial or total loss of speech, and paralysis can result from a stroke. 3. The best prevention of strokes is control of one's blood pressure. B. Vascular Dementia - caused by a series of small strokes which occur at different times. C. Korsakoff's syndrome is a form of vascular dementia caused by a combination of alcoholism and thiamin deficiency. D. Epilepsy 1. Epilepsy is not considered to be a disease. Rather it is a symptom characterized by a transitory disturbance of brain functions that develops suddenly, ceases spontaneously, and is likely to recur. 2. Epileptic seizures are described as an electrical storm in the brain which results in a seizure. a. Grand mal seizures usually last from two to five minutes and are very severe. b. Petit mal seizures are common in children and are characterized by a lack of responsiveness and a blank stare. c. Psychomotor epilepsy causes one to lose the capability to exercise good judgment, but motor functioning remains under control. 3. Medications are available to reduce the frequency and severity of epileptic seizures. 4. Operant conditioning, biofeedback, and desensitization and relaxation training can be helpful for an individual with epilepsy.

VI.

An Integrative Approach to Brain Disorders A. When studying brain injuries, personal factors such as family history, personality, and biophysical factors must be considered. B. Because organic disturbances of the brain cause behavioral changes, behavioral psychologists are very interested in the effects. C. Cognitive psychologists attempt to help those with early signs of dementia deal with their lessening abilities.

VII.

Take-Away Message

WEB LINKS Alzheimers.com - http://www.alzheimers.com A website for people with Alzheimer's and their caregivers. American Epilepsy Society - www.aesnet.org/ - Information about epilepsy research and treatment. Epilepsy Foundation - http://www.efa.org - Information about epilepsy. Fetal Cell Therapy for Parkinson's disease - http://www.nih.gov/news/pr/apr99/ninds-21.htm Read about fetal cell transplants for people with Parkinson's disease. Huntington's Disease Information from NIH http://www.ninds.nih.gov/health_and_medical/disorders/huntington.htm Answers to frequently asked questions about Huntington's disease. Parkinson's Disease Foundation - http://www.pdf.org/ Information and links for Parkinson's sufferers and their families. The Alzheimer's Association - http://www.alz.org. Information about Alzheimer's research and treatment. The Dana Organization - http://www.dana.org/brainweb/ The Dana Organization sponsors research into all types of brain disorders, including Alzheimer's, Parkinson's, strokes, and other brain diseases and traumas.

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Chapter 14 Substance-Related Disorders OVERVIEW Chapter 14 takes a look at various commonly abused substances, their effects on the abuser, and possible treatment options. Alcohol-related disorders are covered in depth with a description of the different perspectives on the development of these disorders as well as the various treatments. Several other drugs are also covered including barbiturates, uploads, amphetamines, PCP, and nicotine. The chapter concludes with a discussion of possible common pathways for substance abuse and the social policies affected by new findings regarding substance abuse. CONTENTS Substance-use Disorders Substance Dependence Substance Abuse Substance Induced Disorders Alcohol-Related Disorders Excessive Alcohol Use Theories and Treatment Preventing Alcohol-Related Disorders Other Drugs Barbiturates The Opoids Cocaine Amphetamines Hallucinogens Phencyclidine (PCP) Inhalants Cannabis Nicotine Caffeine Is There A Common Pathway? Substance Dependence and Public Policy Take-Away Message LEARNING OBJECTIVES After completing this chapter students should be able to: 1. Differentiate between substance dependence and substance abuse and explain the controversy surrounding the differentiation. 2. Describe the symptoms associated with substance-induced disorders. 3. Outline the criteria for excessive alcohol abuse. 4. Identify and define the various perspectives and treatment options for alcohol-related disorders. 5. Discuss possible prevention programs for alcohol-related disorders. 6. Describe the effects of commonly abused drugs including cocaine, hallucinogens, inhalants, cannabis, and caffeine. 7. Understand the hypothesis of a common pathway for all substance abuse. LECTURE AND DISCUSSION TOPICS 1. A Discussion about College Binge Drinking Introduce the topic of college binge drinking by conducting an "on the spot" survey of the members of the class. Explain the definition of binge drinking. Ask the following questions: a. How many of you drink any alcohol? b. How many of you drink only on special occasions? Which ones? c. How many of you drink at least once a week? d. How many of you drink more that once a week? e. How many of you have drunk 4 to 6 drinks/beers in a row during the past two weeks?

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How many of you drink until you're "buzzing" at least once a month? Twice a month? Once a week? More than once a week? g. How many of would say that you "binge" drink? After a discussion of the results obtained from this class, present and compare this class' results with those presented by Wechsler (1994) and reprinted by Palladino (1998). Wechsler conducted a national survey of 17,592 college students from 140 campuses of 4-year colleges. Sixty-nine percent of the students responded to the questionnaires. The self-reports of students yielded the following results: * 44% classified themselves as binge drinkers. * 19% considered themselves as frequent binge drinkers. * 47% of binge drinkers had five or more problems related to drinking. These included injuries, unplanned/unprotected sex, hangovers, missed classes, school problems, relationship problems, damaged property, campus or police trouble, driving while drinking, etc. * Most binge drinkers do not believe that they have a problem. * Binge drinkers cause others problems (insult others, argue, are physically aggressive, damage property, have to be cared for, disrupt others' studying or sleep, become sexually aggressive). 2. Ask students if they are aware of the type of regulations that existed thirty years ago. Do they know that smoking was allowed in classrooms, planes, movie theaters, restaurants, airports, and most public buildings and offices? What are some reasons that the laws changed? What effect does public opinion have on the changes? What changed public opinion? 3. Discuss the Immediate and Long-Term Effects of Cocaine. Discuss some of the possible immediate effects of cocaine on the body: Have the class add to this list and discuss these and other symptoms. • increased blood pressure • increased energy • increased sex drive • decreased need for sleep • increased heart rate • euphoria • increased cardiovascular-respiratory activity • possible seizure or death 4. Discuss some of the possible long-term effects of cocaine on the body. Add to this list and discuss these and other symptoms. • respiratory distress • cardiac distress • nasal septum damage • insomnia • paranoia • sexual dysfunction • seizures • need for sedative drugs, "downers" • possible death • shortened life span 5. Mixing Drugs and Health Have class members discuss their knowledge of "drug mixing" and some of the effects. Include the following: a. Alcohol and barbiturates (depressed CNS, possible death) b. Alcohol and acetaminophen (liver problems)

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c. d. e. f. g.

Cocaine followed by barbiturates (rebounding effect) Amphetamines and cocaine (severe cardio/respiratory reaction, possible death) Nicotine and alcohol (cardiac-pulmonary problems, possible cancer) Cocaine and heroin (possible seizure and death) Barbiturates and tranquilizers (depressed CNS and possible death)

Have the class name famous individuals who have suffered from some type of drug overdose or drug mixing. Some of those include John Belushi, River Phoenix, Chris Farley, and Robert Downey, Jr. Ask the class if they personally know of any such cases. What were the drugs mixed? 6. Discussion about Tobacco Addiction, Community Attitudes, and Congress Have the class discuss nicotine addiction. Include the following questions: Is there evidence that nicotine is addictive? What were the findings of the large tobacco companies as revealed in their internal memos? Is there biological evidence? What is your personal evidence about nicotine addiction? Do you know someone who has quit? What were their withdrawal symptoms? Do you know someone who has tried to quit but failed? Do you know someone who has been unable to even try to quit? 7. Have students discuss their community's attitude toward smoking. Does the community have laws in place that regulate smoking in public places? Restaurants, theaters, airports, clubs, public buildings? Does the university have regulations in place? What are they? Are the laws obeyed? 8. In 1998 members of Congress wrote a comprehensive bill that would regulate tobacco as a drug (by FDA), regulate tobacco advertising, initiate education programs, and hold tobacco companies liable for increased teenage smoking. Even though this bill was favored by a majority of members, it never reached a vote because of the refusal of a committee chair to release the bill. The bill was also favored by the majority of the American people. Why do you think this happened? 9. Should illegal drugs be legalized? Discuss some of the pros and cons regarding the legalization of heroin and marijuana. Have the class discuss each drug separately: a. Heroin: problems and solutions involved in legalization b. Marijuana: problems and solutions involved in legalization. Include such factors of increases/decreases in crime, increases/decrease in addiction rates, increases/decreases in HIV infection, increase/decreases in costs generated by the criminal justice system, increases/decreases in single parent homes, and increases/decreases in unemployment. Have the class identity other factors that might be involved with the legalization. Flynn, J.C. (1998). Cocaine: Helen's story. In Sattler, D.N., Shabatay, V. & Kramer. 0. (Eds.) (1998). Abnormal Psychology in Content. New York, NY: Houghton Mifflin Company. 180-185. Palladino, J.J. (1998). Reprint of Wechsler's [1994 December] Health and behavioral consequences of binge drinking in college. Annual editions: Abnormal Psychology. Guilford, CT: Dushkin/McGraw-Hill. 112-117 Wechsler, H. (1994 December). Health and behavioral consequences of binge drinking in colleges. Journal of the American Medical Association. 1672-1677. STUDENT ACTIVITIES Classroom 1. From the video series, The Mind, show the video, “Addiction.” Discuss the following points addressed in the video: a. Is alcoholism inherited? b. If a person has a parent who is alcohol dependent what recommendation would you make? Do all cases of alcohol dependence have the same etiology? c. What are some of the negative effects of drug addiction? d. What techniques are being used in research to delve into the causes of drug dependence?

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What kinds of treatments are being used in treating individuals who are drug dependent?

How TV and Movies Handle Drug Dependency and Drug Abuse Divide the class into three or four groups. Have each group work independently and give each group this assignment. Identify movies and TV programs that have included topics related to alcohol dependence and abuse. Also identify movies and TV programs that have characters who abuse or are dependent on alcohol. List the following factors: a. What was the title? b. When was the program/movie made? c. How was the abuse/dependency handled? (Positive or negative) d. How was the character portrayed? (Positive or negative) After each group has compiled its list, have them determine whether or not the public's attitude toward alcohol abuse/dependence has changed through the years. Then have the group explain whether or not the portrayal of alcohol dependent individuals has changed. Is the portrayal realistic? Ask each group to name a spokesperson to present that group's findings to the class.

Assignment 1. Project to Identify Community Facilities Divide the class into three groups and give each an assignment: Group 1: Identify and describe community facilities/treatments for alcohol abuse/dependence. Group 2:Identify and describe community facilities/treatments for other drug dependencies and abuses (cocaine, heroin, barbiturates). Group 3: Identify and describe community facilities/treatments for tobacco dependence/abuse. Group 4: Identify the government (county) human services for drug and alcohol. Find out the process for treating a person with a dual-diagnosis (substance abuse and a mental health problem). After locating the types of programs and facilities, discuss the ability of the program to meet the needs of the consumer of the service. Are there programs that overlap services and catchment areas? Are there gaps in service provision? Are there issues with consumers that have a dualdiagnosis? 2.

Binge Drinking “Our youth are an especially vulnerable part of America’s alcohol problem,” said Dr. Gordis. “It is time that we face underage drinking head on. While protracted alcohol involvement may cause neuropsychological impairment, it also is probable that cognitive deficits are a risk factor for alcohol disorders,” said Dr. Sandra A. Brown. The comments are from research conducted by the University of California at San Diego and VA San Diego Healthcare System. The study, published in “ Alcoholism: Clinical and Experimental Research” (2000 February, Vol. 24, No. 2), presents the first concrete evidence that protracted, heavy alcohol use can impair brain function in adolescents. Researchers assessed the neuropsychological function in thirty-three 15- and 16-year-old adolescents with more than 100 lifetime alcohol use episodes. The study could not confirm whether it was the type of damage that was irreversible. From the national study, Binge Drinking on Campus: Results of a National Study, reports that 61% of the men and 39% of the women drank alcohol on ten or more occasions in the past 30 days, and 70% of the men and 55% of the women reported they were intoxicated three or more times in the past month. Binge drinking is commonly defined as five drinks in a row for men or four drinks in a row for women in the past two weeks. Wechsler, H., Dowdall, G.W., Davenport, A. & DeJong, W., 1993, Higher Education Center for Alcohol and Other Drug Prevention, Publication No. ED/OPE95-8. a. Read the binge drinking article located at (http://www.edc.org/hec/pubs/binge.htm). Further reading is available at the National Institute on Alcohol Abuse and Alcoholism (NIAAA) website (http://www.niaaa.nih.gov/ ).

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b. Address the following questions in preparation for a class discussion. 1) Why do students work so hard in class and then destroy it by drinking? 2) What is rewarding about drinking? 3) How do students get “drunk” by unknowingly drinking nonalcoholic beer? 4) If you were responsible (ethically and legally) for student drinking policy, what policy would you write that would be safe and acceptable to most of the student body? 5) Some colleges have instituted student pseudo-courts to help students manage their college community. Responsibilities include sanctions for excessive drinking. What are the positive and the negative aspects of this approach? 6) Recently, researchers found that brain regions may stimulate alcohol craving. Would your view of drinking change knowing that wanting to “go drinking” was really driven by physical needs and not by “choice”. Would you be offended knowing that you do not have willful control over drinking choices? Critical Writing Approximately 179,788,000 people (of an estimated population of 284,078,674) in the U.S. have used alcohol once in their lifetime. Alcohol addiction is second only to nicotine addiction in incidence and prevalence in the United States today. A conservative estimate is that five million Americans are alcoholics, but figures of as high as seven to nine million alcoholics and "problem drinkers" are also cited. The NIAA estimated that alcohol abuse and alcoholism cost the U.S. $148 billion in 1992. Rather than banning marijuana use, should the government re-think alcohol prohibition? Great Books to Read Charles N. (December 1999). High Bottom Drunk: A Novel ... and the Truth about Addiction & Recovery: Small Change Publishing Co. ISBN: 0967752906. Connelly, Elizabeth Russell. (May 1999). Psychological Disorders Related to Designer Drugs (Encyclopedia of Psychological Disorders Series) Broomall, PA: Chelsea House Pub (Library). ISBN: 0791049574. Robertson, Roy. (December 1998). Management of Drug Users in the Community: A Practical Handbook. New York: Edward Arnold. ISBN: 0340700130. Robson, Philip. (September 1999). Forbidden Drugs. New York: Oxford University Press. ISBN: 0192629557. Roper, Tucker, Jalie A (April 1999). Changing Addictive Behavior. New York: Guilford Press. ISBN: 157230439. VIDEO RESOURCES Professional Addiction and the Family, 19 min. (Films for the Humanities and Sciences). The effects of alcoholism on the family are discussed and the effectiveness of counseling is evaluated. Alcohol Addiction, 28 min. (Films for the Humanities and Sciences). The nature of alcohol addiction is described as a biochemical disorder and behavioral intervention is proposed as the best treatment. Crack Craving, 26 min. (Films for the Humanities and Sciences). This video describes the 1980s popularity of cocaine and the physiological effects of cocaine on the brain. Crack Street, USA: First Person Experiences, 29 min. (IM). Bx-users describe the devastating effects of crack. Drugs and the Brain/Alcoholism (Health Show 9-10-89), (Prentice Hall Videos) This program examines the effects of drugs on the brain. Cocaine, heroin, PCP, marijuana, and alcohol are discussed. Heroin: The New High School High, (Turning Point) 39:08 min. (ABC News/Prentice Hall Video Library Abnormal Psychology Series III Cassette One). The Mind: Addictions (Episode 4), 60 min. (Annenberg/CPB) This film provides an excellent description of different types of addiction, the genetics of addiction, and different treatments. The World of Abnormal Psychology: Substance Abuse Disorders (Tape 6), 60 min. (Annenberg/CPB). An overview of substance abuse is provided in this video.

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Video Alcoholism: Out of the Shadow, 30 min. (ABC-TV). This documentary provides interviews with alcoholics telling their personal stories in order to help others. Movie Clean and Sober (1988). Morgan Freeman turns in a fine supporting performance as Michael Keaton plays a substance-abusing real estate salesman who struggles to kick his habit. A tough film that depicts the very real desperation that accompanies addiction and substance abuse. The Fisher King (1991). Mental health issues seem to affect about everyone in this film. Jack (Robin Williams) drops out of society and becomes an alcoholic after a listener to his radio program goes on a killing spree. Parry becomes a homeless man envisioning a ghost horseman after he witnesses his wife being shot. While dealing with their issues Jack tries to help Parry to romance his dream woman, Lydia (who has her own apparent mental health issues).

CHAPTER OUTLINE I. Substance-Use Disorders A. Substance Dependence (Table 14-1, pg. 442, Diagnostic criteria for substance dependence) 1. People diagnosed with substance dependence exhibit a maladaptive pattern of substance use that leads to clinically significant impairment or distress. 2. Individuals with substance dependence are affected cognitively, behaviorally, and physiologically. 3. Tolerance for the substance is usually experienced by the individual. 4. People with substance dependence can experience withdrawal symptoms ranging from mild to severe when the substance is withdrawn. 5. Dependence on a substance can cause an individual to act in a manner known as compulsive substance use in which obtaining the substance and the use of the substance become one's primary focus. B. Substance Intoxication (Table 14-2, pg. 442, Diagnostic criteria for substance intoxication) C. Substance Abuse (Table 14-3, pg. 443, Diagnostic criteria for substance abuse) 1. People diagnosed with substance abuse do not exhibit symptoms of tolerance, withdrawal, or compulsive substance use, but they have shown significant negative reactions and behaviors due to their substance use. 2. There has been a great deal of argument regarding the distinction between substance dependence and substance abuse. II. Substance-Induced Disorders A. Behavioral, psychological, and physiological symptoms can follow the recent ingestion of certain substances in a condition known as substance intoxication. B. Delirium and psychotic behavior are symptoms of substance-induced disorders which mirror symptoms of other mental disorders. C. Researchers have focused on the differences between people's reactions to various substances. D. Table 14-4 (pg. 444) Substances, effects and symptoms, consequences of overdose III. Alcohol-Related Disorders A. Excessive Alcohol Use (Table 14-5, pg. 446, Diagnostic criteria for alcohol intoxication) B. Approximately 12% of Americans who drink alcohol do so excessively, becoming intoxicated several times a month. C. More men than women are considered to be heavy drinkers. D. Alcohol is involved in 40% of all traffic fatalities and also plays a prominent role in nontraffic accidents.

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E. F.

Alcohol abuse and dependence can lead to a number of physical and mental impairments including brain damage. (Table 14-6, pg. 446, Effects of alcohol on the body) There is a high rate of comorbidity for other mental disorder among alcoholics.

IV. Perspectives on Alcohol-Related Disorders A. E.M. Jellinek proposed that alcoholics are essentially different from nonalcoholics in that they have an innate physical craving for alcohol and their only hope to overcome their disease is through abstinence. B. There is strong evidence that alcoholism develops as a result of heredity and environment; researchers are attempting to locate a gene or genes that are linked to alcoholism. 1. There are several theories regarding the role neurochemicals may play in predisposing one to alcoholism. 2. People have differences in their metabolism which account for the differences in people's sensitivity to alcohol. 3. Psychodynamic theorists believe alcoholics are suffering from an oral-dependent personality which is expressed by the need for oral gratification. 4. Behavioral therapists feel that people become alcoholics after being positively reinforced over time by alcohol. 5. According to cognitive therapists, alcoholics expect their experiences with alcohol to be pleasant and therefore interpret all alcoholic experiences as positive. 6. Sociocultural conditions have been found to largely affect one's drinking habits. C. Treatment (Table 14-7, pg. 448, Effects of drinking and willingness to admit a problem) 1. Detoxification is usually the first step in treating an alcoholic. 2. Physiological symptoms mark the beginnings of withdrawal. 3. Most alcoholics who are able to recover successfully do soon their own through programs such as Alcoholics Anonymous. 4. Naltrexone is a drug which has been found to reduce the rate of relapse of heavy drinking. 5. Disulfiram is another drug that causes one to become physically ill after consuming alcohol, however, because it is self-administered the success can be limited. 6. Alcoholics Anonymous is a community-based program that promotes total abstinence from alcohol and provides a strong social support network. 7. Psychodynamic therapists attempt to treat the patient by looking at the family as a whole. 8. Aversive conditioning and covert sensitization are used by behavioral therapists in an attempt to remove the positive association one has with alcohol. 9. In cognitive therapy, patients are taught controlled drinking skills so that they may continue to drink at an acceptable level. 10. Relapse is common among recovering alcoholics. 11. There is a great deal of controversy behind the argument for abstinence and the argument for controlled drinking. 12. Research has revealed that different treatment programs work better for different individuals. D. Preventing Alcohol-Related Disorders 1. Very little is known about how to successfully prevent alcohol-related disorders. (Table 14-8, pg. 454, Learning from relapse) 2. Some communities have raised the price of alcohol and limited the amount of alcohol advertising. 3. Legal restrictions and punishments surrounding the abuse of alcohol are used to prevent accidents and alcohol-related problems. 4. In order to design successful prevention programs, more research needs to be done on the risk factors for the overuse of alcohol. 5. Table 14-9 (pg. 458) Understanding how drinking behavior leads to alcoholism V. Other Drugs A. Barbiturates and Tranquilizers 1. Barbiturates and tranquilizers both have a depressing effect on the central nervous system.

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2. Tolerance for these drugs is developed very quickly. 3. Barbiturates used at high dosages can cause an initial feeling of excitement followed by slurred speech, loss of coordination, severe depression, and impairment of thinking and memory. 4. Three types of barbiturate abuse have been identified: a. Chronic intoxication b. Episodic intoxication c. Intravenous injections 5. Tranquilizers are prescribed to reduce anxiety and their overuse is very common. The Opioids (Table 14-10, pg. 461, Clinical features of opiod intoxication and withdrawal) 1. Endorphins, enkephalins, and dymorphins are natural opioids found in the brain. 2. People with an addiction to opioids may have less natural opioids being produced in their bodies. 3. Opium and its derivatives were first used in the seventeenth century as a miracle cure for pain, coughs, diarrhea, fever, epilepsy, and a variety of other disorders. 4. Heroin was developed in 1874 as a safe alternative to morphine which many had realized was addictive. 5. Opioids have severe physical effects including mood changes, sleepiness, mental clouding, constipation, and slowing of the brain's respiratory center. 6. It has been found that many people are able to successfully abstain from opioid use even after long periods of abuse. 7. There are two competing views regarding opioid addiction: a. Exposure orientation b. Interactional orientation 8. The most widely used treatment for opioid addiction is methadone maintenance. 9. There is controversy surrounding the use of methadone as many believe that it merely transfers one's dependence to a different drug. 10. Others are treated by using gradual detoxification with the assistance of other drugs. Cocaine (Table 14-11, pg. 463, Clinical features of cocaine intoxication and withdrawal 1. At one time cocaine had a positive image and was widely used by well-known figures such as Sigmund Freud and was included in many brands of soda. 2. Cocaine stimulates the central nervous system causing an increase in heart rate, blood pressure, and body temperature along with a decrease in appetite. 3. Cocaine psychosis can result from high doses of the drug. 4. Crack is a concentrated form of cocaine which offers a much more potent form of the drug and has resulted in a great deal of social problems. 5. Physical tolerance to cocaine is developed very quickly; a history of a dysfunctional family is common among cocaine users. 6. Treatment is difficult due to the high rate of relapse. 7. Amphetamines Amphetamines are psychomotor stimulants like cocaine. 1. Moderate use can cause increased alertness and elevation of mood. 2. Amphetamines are used in the medical field to suppress appetite and to improve mood in cases of mild depression. 3. High doses of amphetamines for a prolonged period of time can result in malnourishment, exhaustion, paranoid thinking, and hallucinations. 4. Withdrawal symptoms are mild, if they occur at all. Hallucinogens 1. Hallucinogens alter one's conscious so that perceptions are distorted. 2. Many cultures have used hallucinogens for religious purposes. 3. LSD is one of the most commonly used hallucinogens. 4. Post-hallucinogen perceptual disorder is characterized by the experience of flashbacks to the LSD experience. PCP (Phencyclidine) 1. PCP was initially introduced as an anesthetic, but was taken off of the market after reports of hallucinations and disorientation.

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2. PCP can cause increased heart rate and blood pressure, flushing, sweating, dizziness, and numbness. 3. PCP can cause death by causing repeated convulsions, heart and lung failure, or ruptured blood vessels in the brain. 4. People who take PCP feel dissociated or detached from their surroundings. 5. Researchers have discovered that PCP can protect the brain from permanent damage following a stroke or a heart attack. Inhalants 1. Gasoline, lighter fluids, spray paints, and cleaning fluids are common inhalants. 2. Inhalant users often experience distorted perceptions of stimuli and time as well as hallucinations and delusions. 3. Inhalant abuse is believed to be an introductory drug for many and its use is believed to be more prevalent among younger people. Cannabis 1. Marijuana consists of the dried leaves and flowering tops of the cannabis plant and is the most common form used in the U.S. 2. Laughter, grandiosity, lethargy, impairment in short-term memory, impaired judgment, and distorted sensory perception and time perception are common effects of marijuana. 3. Controversy has surrounded the debate for legalizing marijuana in the U.S. 4. Marijuana has been found to suppress the production of male hormones, decrease the size and weight of the prostate gland and testes, and to inhibit the production of sperm in males. 5. Marijuana is helpful in controlling nausea resulting from chemotherapy and can help treat glaucoma. 6. People dealing with family disorganization and stress are more likely to use marijuana. Nicotine 1. Nicotine stimulates certain neurotransmitters which exert powerful effects on the brain and spinal cord, the peripheral nervous system, and the heart. 2. Smoking can cause heart attacks, reduced birth weight of babies, and lung cancer. 3. Psychological and physiological symptoms affect a person trying to quit smoking. 4. Changing social attitudes have prompted many people to try to quit smoking. 5. Nicotine gum, inhalers, and transdermal nicotine patches have been developed to help people quit smoking. Caffeine 1. Caffeine is the most widely used mind-altering drug. 2. Small doses of caffeine can produce a feeling of well-being and alertness. 3. Larger doses of caffeine can cause anxiety and nervousness. 4. People who are dependent on caffeine will experience withdrawal symptoms including headaches, lethargy, and depression.

VI. Is There a Final Common Pathway? A. Research has shown there is a significant biological basis behind substance abuse. B. Substance abuse revolves around activating pleasure circuits in the brain. C. Dopamine appears to be particularly important in substance abuse but may not be the final molecule that stimulates the “pleasure circuits.” VII. Substance Dependence and Social Policy A. New findings related to various substances may cause certain policies to be reviewed regarding legislation of drugs. B. Advances in the understanding of the human genome and the role that genes play in addition may lead to changes in government programs and insurance policies for addiction treatment and counseling. C. Presidential policy on the “War on Drugs” is being reviewed to evaluate its success at removing illicit drugs from the United States. VIII. Behavioral Addictions (Table 14-13, pg. 474, Characteristics of pathological Gambling) IX. Take-Away Message

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WEB LINKS Addiction is a Brain Disease - http://usinfo.state.gov/journals/itgic/0697/ijge/gj-2.htm The director of the National Institute of Drug Abuse explains addiction as a brain disease. Brain Research - http://www.dana.org/brainweb/ The Dana Organization sponsors research into brain-based disorders. Cocaine - http://www.nida.nih.gov/researchreports/cocaine/cocaine.html Drug and Crime Facts - http://www.ojp.usdoj.gov/bjs/dcf/contents.htm Data about the relationship between drugs and crime from the U.S. Department of Justice. Drugs and the Brain - http://www.nida.nih.gov/Teaching/Teaching.html Watch a slide show that depicts how and where opiates, cocaine, and marijuana act on the brain. Drug Control Policy - http://www.whitehousedrugpolicy.gov/prevent/prevent.html The White House Office of National Drug Control Policy maintains this site with extensive resources and links about drugs and drug-related problems. Drug Craving - http://www.nih.gov/news/pr/oct96/nida-14.htm. The origins of drug craving. Drug Facts - http://www.whitehousedrugpolicy.gov/drugfact/factsheet.html Fact sheets on drug use from government resources. Drug Treatment in the Criminal Justice System Drinking and Smoking are Gateways to Drug Abuse – http://www.whitehousedrugpolicy.gov/drugfact/gateway.html. A research report about pathways to drug abuse. Heroin - http://www.nida.nih.gov/ResearchReports/Heroin/Heroin.html A tutorial on heroin use and addiction. Methamphetamine - http://www.nida.nih.gov/ResearchReports/Methamph/Methamph.html Monitoring the Future - http://monitoringthefuture.org. Ongoing study of drug use in American youth. National Drug Control Strategy http://www.whitehousedrugpolicy.gov/policy/ndcs01/strategy2001.pdf. From the White House Drug Policy Office, plans and budgets for 2001. The dangers of methamphetamine use. http://www.whitehousedrugpolicy.gov/drugfact/treatfact/treat.html. A report from the White House Drug Policy Office. Why People Get Hooked - http://www.time.com/time/magazine/1997/dom/970505/medicine.addicted.html The dopamine connection links all kinds of addictions.

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Chapter 15 Disorders of Childhood and Adolescence OVERVIEW Chapter 15 covers disorders that develop during childhood and adolescence. This chapter begins with a look at externalizing behavior. It has a strong focus on attention deficit hyperactive disorder (ADHD) and also includes tic disorders, Tourette's disorder, oppositional defiant disorder, and conduct disorder. Internalizing disorders are covered, including separation anxiety disorder, other disorders found in childhood including social phobia, generalized anxiety disorder, obsessive-compulsive disorder, and depression. CONTENTS Externalizing Disorders Attention-Deficit/Hyperactivity Disorder Tic Disorders Tourette’s Disorder Oppositional Defiant Disorder Conduct Disorder Internalizing Disorders Separation Anxiety Disorder (SAD) Other Disorders Found in Childhood (disorders of eating, elimination, and others) Treatment of Anxiety Disorders in Children Depression Take-Away Message LEARNING OBJECTIVES Upon completion of this chapter students should be able to: 1. Describe the three different subtypes of attention-deficit/hyperactivity disorder. 2. Discuss why there cannot be a clear genetic separation from environment in ADHD. 3. Discuss the general etiologies of tic disorders. 4. Compare the behavioral differences between oppositional defiant disorder and conduct disorder. 5. Discuss the interactional view that relates to conduct disorder. 6. Discuss the situations and family factors that are most often involved in separation anxiety disorder. 7. Identify and define other anxiety disorders found in children including social phobia, generalized anxiety disorder, and obsessive-compulsive disorder. 8. Understand the implications and long-term effects major depressive disorder can have on children. 9. Explain the relationship between accurate assessment and successful therapy in the treatment of childhood disorders. 10. Outline the different therapy options available for children including play therapy, behavioral and cognitive-behavioral therapy, and family therapy. LECTURE AND DISCUSSION TOPICS 1. If your child were diagnosed with ADHD would you allow your child to take Ritalin or other stimulants? A. Positive points to consider: 1. Drug allows up to 70% percent of children to respond favorably. 2. Drug makes child "slow down." 3. Drug allows child to focus attention. 4. Drug allows child to attend to and complete tasks. 5. Drug allows child's thinking to become clearer. B. Negative points to consider: 1. Effects of drugs may be of short duration. 2. Drug may be over-prescribed. 3. Patient taking Ritalin must be closely monitored. 4. Drug may cause loss of appetite, insomnia, and tics. 5. Drug may retard growth.

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Use Bloch, Cole and Willwerth's (1994) article to enhance your discussion. This article is also available in Lilienfeld (1998). Bloch, H., Cole, W. & Willwerth, J. (1994 July 18). Is ADD truly a disorder? Just because something responds to a drug doesn't mean it's a sickness. Time, 144, 42-50. STUDENT ACTIVITIES Classroom Give the class the following ADHD Rating Scale. Other, more detailed rating scales may be found at ADHDnet (http://www.adhd.net). A. Using an overhead or computer presentation ask the class to read the brief case studies presented at the end of this chapter. Cases 1 and 2 are ADHD. Case 3 is childhood depression. B. Use the rating scale to determine whether the child should have further evaluation. In order for a diagnosis of ADHD a child must have eight or more of the behaviors listed below (from The ADHD Rating Scale provided by Bloch, Cole and Willwerth, 1994). 1. Often fidgets or squirms in seat 2. Has difficulty remaining seated 3. Is easily distracted 4. Has difficulty awaiting turn in groups 5. Often blurts out answers to questions 6. Has difficulty following instructions 7. Has difficulty sustaining attention to tasks 8. Often shifts from one uncompleted activity to another 9. Has difficulty playing quietly 10. Often talks excessively 11. Often interrupts or intrudes on others 12. Often does not seem to listen 13. Often loses things necessary for tasks 14. Often engages in physically dangerous activities without considering consequences Critical Writing Page 470 asks some very difficult questions about ADHD. What is “normal” childhood behavior? Where is the boundary that separates normal behavior from a classifiable disorder? There are others. Can a child be hyperactive only in school and not in the neighborhood or in Sunday school? What are the long-term effects of the medication? Do the causes of ADHD all belong to the child or should parents and society share some of the responsibility? Write briefly about these difficult questions addressing these questions from one of three viewpoints: the classroom teacher, the parent, or the child. Use additional resources as necessary. Is adolescent substance abuse a form of self-medication? The combination of mental illness and substance abuse is so common that many clinicians now expect to find it. Studies show that more than half of young persons with a substance abuse diagnosis also have a diagnosable mental illness. Teens with bipolar disorder or depression frequently “self-medicate” in an attempt to feel better or to be motivated to accomplish something. Unfortunately the approach frequently has the opposite effect. In an effort to cast off the depression the drinking becomes an addiction with all of the tragic outcomes of a regular addiction. Think about acquaintances or friends who drink. When they are not under the influence are they typically happy and thinking positively? Are they energetic? Task oriented? Getting good grades? Socially communicative? If you suspect a person may be self-medicating, jot down the behaviors or conversations you have observed. Bring them to class for discussion. Great Books to Read Easley, Jennifer & Glasser, Howard (April 1999). Transforming the Difficult Child: The Nurtured Heart Approach. Center for the Difficult Child; ISBN: 0967050707. Lask, Bryan & Waugh, Rachel Bryant. (September 1999). Anorexia Nervosa and Related Eating Disorders in Childhood and Adolescence. New Jersey: Lawrence Erlbaum Assoc. ISBN: 0863778038.

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Moe, Barbara (March 2000). Coping with Tourette’s Syndrome and Tic Disorders. Rosen Publishing Group; ISBN: 0823929760. Penn, Audrey (December 1993). The Kissing Hand. Washington DC: Child Welfare League of America. ISBN: 0878685855. Sutton, James D. (February 1997). If My Kid's So Nice... Why's He Driving Me Crazy?: Straight Talk About the 'Good Kid' Disorder. Friendly Oaks Publications; ISBN: 1878878530. VIDEO RESOURCES Professional Abuse, 20 min. (Insight Media). Physical, emotional, and sexual abuse, and neglect are described as a young man talks about his abuse and recovery. Aphasia in Childhood, 30 min. (USC). The case of a twelve-year-old girl who develops aphasia after a head injury is presented. All About ADD, Part 1. 108 min., Part 2: 85 min. (Insight Media). These two videos present symptoms, effects on home and school, and ways of diagnosing and treating ADD. Catch’em Being Good, 30 minutes. (Research Press). A behavioral program for treating hyperactive children in a classroom is detailed. Family and Survival, 52 min. (Films for the Humanities and Sciences). The effects of the changing American family on children are presented. Interview with a Mother and a Teacher of a Hyperactive Child, 50 min. (Media Guild). Different views of the hyperactive child are discussed. The World of Abnormal Psychology: Behavior Disorders in Children (Tape 11), 60 min. (Annenberg/CPB). Video Attention Deficit Disorder (20/20), 15:19 min. (ABC News/Prentice Hall Abnormal Psychology Series III Cassette Three). Girls and Eating Disorders (American Agenda), (ABC News/Prentice Hall Library #2). Pressures from our culture and advertising are discussed as possible influences on girls who suffer from eating disorders. Journey to Tragedy: The Joel Steinberg Case (Primetime Live), 20:38 min. (ABC News/Prentice Hall Video Library Abnormal Psychology Series III). Hedda Nussbaum tells her story of the psychological and physical abuse she suffered at the hands of her husband and the eventual death of her child. Little Beauties (20/20) 7:24 min. (ABC News/Prentice Hall Video Library Abnormal Psychology Series III). This video presents little girls as "beauty contestants." Patients as Educators: Case #1: Ann, Bulimia, (Prentice Hall Videos). The case of a forty-six-year-old teacher suffering from bulimia is presented. You Can't Pay Attention (20/20), (ABC News/Prentice Hall Library #2). Researchers and doctors discuss attention deficit disorder in children and adults. Movie Lorenzo’s Oil (1992). This film describes one family’s real-life struggles to find a cure for their child’s rare neurological disorder. This is a good film for health professionals to watch because it portrays hospitals, doctors, and nurses as they too often appear to anxious families in need: unhelpful, impersonal, and uncaring. Although a physical disease, this film shares the agony of diagnosis that a family sustains when a child has an illness. Shine. (1996). Depression. Based on the true story of Australian pianist David Helfgott. David, a child prodigy, has an unhappy childhood. After going overseas to study he has a 'breakdown' which causes him to return to Australia and a life in an institution. After he is released, he starts to play again and gets back to the concert halls.

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CHAPTER OUTLINE I. Externalizing Behavior (Table 15-4, pg, 483, Diagnostic criteria for ADD/ADHD) A. Attention-Deficit/Hyperactivity Disorder 1. There are three subtypes of ADHD. a. Difficulty staying focused on tasks at hand b. Overactive and sometimes impulsive behavior c. A combination of attentional and hyperactivity problems 2. ADHD is usually diagnosed during the early school years. 3. The prevalence of ADHD ranges from 3% to 9%. 4. Boys are more likely than girls to receive the diagnosis. 5. Many questions have been raised regarding the criteria for "normal" childhood behavior and the diagnosis of ADHD. 6. Deficiencies in both academic and social skills can result from ADHD. (Table 15-5, pg. 485, Areas of impairment for children with ADHD) 7. There is no known cause for the disorder. 8. Drugs are by far the most common treatment. 9. ADHD tends to extend into adulthood regardless of medical treatment as a child. 10. Table 15-6 (pg. 486) Comorbidity of ADHD 11. Table 15-7 (pg. 487) ADHD-related interview C. Oppositional Defiant Disorder (Table 15-8, pg. 490, Diagnostic criteria for ODD) 1. ODD is commonly found among ADHD children and is characterized by defiance, negativism, disobedience, and hostility toward authority figures. 2. ODD rarely occurs before the age of 10 and is not diagnosed very frequently after the mid teens. 3. There is little difference between the sexes in the prevalence of ODD. D. Conduct Disorder (Table 15-9, pg. 491, Behavioral features of CD) 1. Conduct disorder is diagnosed when important social norms are violated and the basic rights of others are also severely violated. 2. Typical behaviors include aggression towards people or animals, property damage, and theft. 3. Conduct disorder is often associated with a history of ADHD and/or ODD. 4. A lack of social and academic skills has been proposed as a possible cause of the disorder. 5. Genetic factors appear to be involved in the development of conduct disorder. 6. Parents showing a great deal of hostility and little warmth may be more likely to have children with conduct disorder. 7. It is believed that prevention is the best treatment. (Table 15-10, pg. 495, Areas of focus when treating OD) II.

Internalized Disorders A. Separation Anxiety Disorder (Table 15-11, pg. 496, Diagnostic criteria for SAD) 1. This disorder is characterized by an extreme amount of anxiety or panic when a child is separated from major attachment figures or a familiar environment. 2. Children with separation anxiety disorder often complain of nausea, headaches, abdominal pains, or rapid heart rate. 3. Children coming from caring, close-knit families are the most likely to suffer from this disorder. B Other Anxiety Disorders Found in Children 1. Children with social phobia are extremely reticent to engage in contact with anyone other than familiar people. 2. Generalized anxiety disorder is diagnosed after six months of symptoms which are brought about by situations involving pressure to perform or situations which carry the potential for a loss of self-esteem. 3. Although compulsive and repetitive behaviors are common in childhood, excessive ritualistic behaviors call for a diagnosis of obsessive-compulsive disorder. (Table 1512, pg. 501, Common OC symptoms found in children with OCD)

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III.

Treatment of Anxiety Disorders in Children A. Cognitive-behavioral therapy has been found to be an effective treatment for specific phobias and simple fears. B. Medications along with family therapy, behavior therapy, and psychotherapy are used to treat obsessive-compulsive disorder.

IV.

Depression (Table 15-13, pg. 503, Symptoms of depression in various stages of childhood) A. Self-reports from children usually report higher rates of depressed mood than the reports from family and school administrators. B. A child diagnosed with depression is at a higher risk for later developing bipolar disorder. C. There is a 70% chance of another episode of depression within five years of an initial episode in childhood. D. Both genetic and environmental factors play a role in the development of depression. E. Antidepressants have been ineffective in treating depression in children. F. Interpersonal therapy and cognitive therapy have been successful in helping adolescents suffering from depression. G. Group therapy programs have been designed to help children at-risk for depression.

Other Childhood Disorders A. Tics (Table 15-14, pg. 505, Diagnostic criteria for Tics) B. Tourette’s syndrome (Table 15-15, pg. 506, Diagnostic criteria for Tourette’s syndrome)

VI.

Therapy for Children and Adolescents A. Play Therapy 1. Children are better able to communicate through their play rather than through verbal interactions with a therapist. 2. The child controls the direction the play will take as the therapist encourages the child. 3. Play therapy helps children who have experienced a traumatic event by allowing them to reenact the event. B. Behavioral and Cognitive-Behavioral Therapy 1. Gerald Patterson has developed a popular means of behavioral therapy for families with overly aggressive children. 2. In other forms of therapy children are taught to recognize problems, decide how to handle the problems, and then monitor their behavior as they work through the problems. C. Family Therapy 1. The system of the family is believed to be the basis for an individual's problem, rather than the individual alone. 2. The focus is often on the meanings behind the behaviors of the family members. D. Effectiveness of Therapy 1. Research has found that the various forms of therapy are beneficial to children. 2. Researchers must now find the key concepts that are increasing success in treatment.

VI. Take-Away Message WEB LINKS Abuse of Ritalin - http://www.add-adhd.org/ritalin.html The federal Drug Enforcement Administration issues a warning about the overuse, abuse, and addictive properties of Ritalin. ADHD—Personality or Disorder? - http://www.mentalhealth.com/mag1/p51-adhd.html. An article that discusses diagnostic and treatment issues related to ADHD. ADHD - http://www.sciam.com/1998/0998issue/0998barkley.html. Attention Deficit/Hyperactivity Disorder - http://www.add-adhd.org/ Behavioral Disorders - http://www.conductdisorders.com/. A website devoted to ADHD, ADD, ODD, and conduct disorder. CHADD - http://www.chadd.org. The most well-known ADHD organization for families and professionals.

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Diagnosis and Treatment of Child and Adolescent Depression – http://www.baltimorepsych.com/cadepress.htm Facts for Families with Conduct Disordered Children – http://www.aacap.org/publications/factsfam/condct.htm. Information for families from the American Academy of Child and Adolescent Psychiatry. Fact Sheet on Conduct Disorder - http://www.nmha.org/infoctr/factsheets/74.cfm Information from the National Mental Health Association. Genetic Origins of Tourette’s Disorder - http://www.mentalhealth.com/mag1/p5m-tor1.html. Examines the genetic link to Tourette’s disorder. Information about Childhood Depression - http://www.mentalhealth.com/book/p40-tour.html Information from the Merck Manual on risks and interventions for suicidal children and adults. Obsessive/Compulsive Disorder, Tics, and Strep Throat – http://www.mentalhealth.com/mag1/p5m-ocd1.html. Examines connection between strep bacteria and origins of obsessive compulsive and tic disorders. Questions and Answers about Tourette's Syndrome - http://www.mentalhealth.com/book/p40-tour.html School Refusal - http://www.aacap.org/publications/factsfam/noschool.htm. Information about why children become reluctant to go to school, and its relationship to separation anxiety disorder. Separation Anxiety Disorder - http://www.mentalhealth.com/dis/p20-ch03.html Causes, symptoms, and treatment of separation anxiety disorder. Suicide in Adolescents and Children – http://www.merck.com/pubs/mmanual/section19/chapter274/274e.htm The Anxious Child - http://www.aacap.org/publications/factsfam/anxious.htm. Descriptions of child anxiety disorders from the American Academy of Child and Adolescent Psychiatrists. The Merck Manual on Childhood Depression – http://www.merck.com/pubs/mmanual/section19/chapter274/274c.htm The National Information Center for Children and Youth with Disabilities - http://wwwnichcy.org Website that contains legal and advocacy information for a variety of childhood disabilities. This organization specializes in information and support groups related to ADD and ADHD.

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ADHD Demonstration Rating Scale

Behavior 1. Often fidgets or squirms in seat 2. Has difficulty remaining seated 3. Is easily distracted 4. Has difficulty awaiting turn in groups 5. Often blurts out answers to questions 6. Has difficulty following instructions 7. Has difficulty sustaining attention to tasks 8. Often shifts from one uncompleted activity to another 9. Has difficulty playing quietly 10. Often talks excessively 11. Often interrupts or intrudes on others 12. Often does not seem to listen 13. Often loses things necessary for tasks 14. Often engages in physically dangerous activities without considering consequences

Often

At times

Never

If eight or more behaviors are present in the “Often” category, the child should be referred to a physician or psychologist for further evaluation.

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Case 1: Justin My son’s name is Justin, he is nine years old. Before kindergarten, Justin knew his ABCs, 123s, colors, shapes, and his address before he started kindergarten. His favorite show was Reading Rainbow and, although he couldn’t read, he thumbed through just about every book in the house, making up stories from the pictures in the book. He was busy all of the time. His pre-school teacher expressed concerns about him getting bored in public school. About six months into the kindergarten year, our world turned upside down. His behavior changed radically, he was constantly disruptive to his classmates and he never completed his assignments. He was ridiculed and was called names like pest and monster. He would come home feeling frustrated and angry. We took him to the physician who though he might have allergies. We traveled 50 miles to see the pediatric allergist. Justin had no allergies that the physician knew of. We took him to a psychologist and paid a lot of money to find out that he was very bright. We knew that. The psychologist said he was probably bored. But how do you fix boredom and “make” a kid follow the crowd. By now, Justin really was marching to the beat of a different drummer. His grades were slipping. He dropped out of baseball and just vegged in front of the TV. When prompted about doing homework he nearly always replied with an angry outburst. Except for the anger directed at pestering parents he never seemed overly hyperactive, he never MOVED! His food habits were terrible. Pre-adolescent junk food, mostly. His table manners were very rude. He interrupted family members a lot and frequently his statements had nothing to do with the ongoing conversation. They seemed so impulsive! There were many times I would catch him playing with his food and have to remind him to eat. It was as if he started to play and forgot to eat. He does have “regular days” where he doesn’t get yelled at in school or he hasn’t been called names at school. Those days are very special to us. Justin is in the fourth grade now. They didn’t flunk him, but I don’t think they fixed it either. Case 2: William I was a misfit student. I was bright enough to begin first grade when I had just turned 4 years old, more than a year younger than the rest of my class. I caught on quickly to things, but was still less mature than my peers. I always felt a little behind them, not necessarily in academics - more in our differing interests. I was more of a daydreamer than an organized-game participant. I believe I didn't like the rules, the structure, and the amount of attention it took to succeed in sports. I never developed the instincts for baseball, basketball, or football. It wasn't a matter of uncoordination, I just couldn't think in the context of the game: I'd throw to second when a runner was headed for home, wouldn't anticipate teammates actions, etc. Somehow the pictures in my head about what to do never matched up to the real thing. I also loved the thrill of danger, of doing the unpredictable, of bending the rules. Coaches used to bench me for sliding headfirst, tackling with my head down and taking unnecessary long shots and risks. I taught myself to swim by jumping off a stump into deep water when I was 5. Surviving breaking that taboo encouraged me to break others. In school, I did okay in some subjects, excelled in others and failed miserably in a few. I managed to pass all my courses until high school. There I struggled unsuccessfully with Spanish and a Sophomore Religion class (yeah, Catholic school - where they didn't diagnose you, they either beat or booted you). I couldn't - still can't, for that matter - comprehend the need to learn a second language since I had a perfectly usable primary one. Nor would my thinking adapt to conform with the Church's party line. I got into several fights with other students. Then I had the big yelling match with a Sister over having to finish a stupid project. I was invited to not return for my Junior year and went on to a public school. There the lack of disciplinary options resembled being on a holiday. (Adapted from Jerry’s story, (retrieved 4/10/01 from http://user.cybrzn.com/~kenyonck/add/stories/jerry_gov.htm)

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the

World

Wide

Web:

Case 3: John I have a 5-year-old son who has always been rather shy and withdrawn. Of late this has gotten much worse. In school he gets lost in the crowd. He never answers questions although the teacher says he knows the answers. He sits in the corner in the cafeteria. The teacher says he looks very stressed after lunch. A few times he’s gotten into fights with other boys on the way back from lunch. Once a week he has a PE class. My son has grown to dread this. He cannot stand the noise and is very overwhelmed by all of the kids. In Sunday School he has steadily gotten worse to the point that he will no longer go. The kids are too loud, he says and he is sure that when they laugh they are all laughing at him. He sleeps quite a lot for a 5-year-old (can take 3-hour naps and still sleep 10 to 12 hours at night). He frequently gets directions wrong on tests and he has trouble completing a task. Does he have ADD?

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Chapter 16 Pervasive Developmental Disorders and Mental Retardation OVERVIEW Chapter 16 discusses the characteristics, behaviors, and treatments of pervasive developmental disorders including autistic disorder, Asperger's disorder, Rett's disorder, and childhood disintegrative disorder. Historical views of mental retardation are discussed, causes of mental retardation are presented, and prevention and intervention programs are described. CONTENTS Pervasive Developmental Disorders Autistic Disorder Asperger’s Disorder Childhood Disintegrative Disorder Rett’s Disorder Is There an Autistic Spectrum? Mental Retardation Causes of Mental Retardation Historical Views of Mental Retardation Genetically-Based Disorders Fragile X Syndrome Down Syndrome The Fetal Environments and Mental Retardation Fetal Alcohol Syndrome Problems During and After Birth Psychosocial Disadvantage Types of Prevention in Mental Retardation Early Intervention Programs Vocational and Social Skills Training Programs Recognition and Treatments of Psychological Problems The Families of Mentally Retarded Children Take-Away Message LEARNING OBJECTIVES After completing this chapter students should be able to: 1. Identify and define the various pervasive developmental disorders including autistic disorder, Asperger's disorder, Rett’s disorder, and childhood disintegrative disorder. 2. Identify several of autism’s “red flags” for parents. 3. Differentiate between the diagnoses of autistic disorder and Asperger’s disorder. 4. Discuss the difficulties involved in differentiating Asperger’s disorder, Rett’s disorder, and childhood disintegrative disorder from autistic disorder. 5. List the four types of spectrum disorder suggested by Wing. 6. List the causes of mental retardation. 7. Identify the physical characteristics associated with fragile X syndrome, Down syndrome, and fetal alcohol syndrome. 8. Recognize prenatal conditions that may cause mental retardation. 9. Describe the impact psychosocial disadvantages can have on a child's cognitive development. 10. Outline the types of prevention and intervention programs for mental retardation. 11. Describe some of the issues that families face when they have a child with mental retardation.

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LECTURE AND DISCUSSION TOPICS 1. The Relationship Between Autism and Mental Retardation Some students have difficulties in understanding the differences between mental retardation and autism. Explain the following: a. A diagnosis of mental retardation indicates that the person has a subaverage intellectual function and that is accompanied by limitations in adaptive functioning. The usual IQ level required for a diagnosis of mental retardation is an IQ of 70 or below. b. Autistic disorder involves marked difficulties in social interactions and communication, a restricted range of interests, disturbances when routine is changed, and repetitive and stereotypic motor activity or speech (if present). c. It is estimated that 70% of individuals with autism have intellectual retardation, the remaining 30% can range from normal through gifted intelligence. d. As a visual aid, reproduce for overhead or computer presentation Frith's (1993) chart (or similar) showing the IQ range and the proportion of individuals within that range who exhibit the social impairments of autism. The chart shows that at higher levels of intelligence, few children exhibit the characteristics of autistic disorder, but at lower levels of functioning, many more individuals exhibit the characteristics of autistic disorder. e. The chart provides the following information: 1) At the 0-19 IQ range 86% of 44 children were affected with autism. 2) At the 20-49 IQ range 42% of 96 children were affected with autism. 3) At the 50-69 IQ range 2% of 700 children were affected with autism. 4) At the 70+ IQ range 0.013% of 34,100 children were affected with autism. (Lilienfeld, 1998) 2.

Terminology for the Categories of Mental Retardation a. Names used for classifying individuals' levels of intellectual functioning have changed through the years to avoid negative connotations. Have class members discuss some of the names they have heard used when addressing someone who is mentally retarded or when referring to someone who is mentally retarded. Ask the class members to be frank with their responses. Then introduce the old category names that were used even into the 20th century. A psychologist is still able to review old reports and see these terms frequently used. They are: 1) "moron" designating the highest level of mental retardation (55-70 IQ) 2) "imbecile" designating the second category of mental retardation (35-55 IQ) 3) "idiot" designating the lowest category of intellectual functioning (0-35 IQ) b. What do these terms mean today? c. Later terms included the following three classifications: 1) "educable" referring to the highest level of mental retardation (55-70 IQ) 2) "trainable" referring to the second level of mental retardation (35-55 IQ) 3) "institutional" or "custodial" referring to the lowest level of functioning (0-35) d. What do these terms mean to you? Do they have negative connotations? e. Current terms are: 1) "mild" indicating the highest level of mental retardation (55-70 IQ) 2) "moderate" indicating the second level of mental retardation (35-55 IQ) 3) "severe" indicating the third level of functioning (20/25-35 IQ) 4) "profound" indicating the lowest level of functioning (20/25 IQ and below) f. Do these terms have a negative meaning? Do you think they will stand the test of time? g. Do you think the earlier used term "mental deficiency" developed negative connotations? What about the term "mental retardation"? Does this have a negative connotation? Do you believe that every term used will eventually develop a negative connotation? Why is this?

The Unusual Traits of Autistic Disorder a. Displays indifference b. Indicates needs by using an adult's hand c. Parrots words d. Laughs and giggles inappropriately

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e. f. g. h. i. j. k. l. m. n.

Does not make eye contact Does not pretend in playing Joins in only if adult insists and assists Does not play with other children Prefers sameness Is one-sided in interactions Talks incessantly about one topic Behaves in bizarre ways Handles or spins objects repetitively Yet some do certain things well if the task does not involve social understanding

Discuss the characters from the movies, Rain Man and Forrest Gump. What are the differences in the behaviors of these two characters? Was each equally sociable? Did either like or dislike change? How would you diagnose each? Were these disorders present at birth?

Discuss Down syndrome - What are the three variations of chromosomal abnormalities involved in Down syndrome? (trisomy 21, translocation, and mosaicism) a. What are the physical characteristics of Down syndrome? (flat face, small nose, and eyes that appear to slant, protruding lips and tongue, small ears, small square hands with short fingers, curved fifth fingers, short limbs, chubby bodies) b. What do you think about cosmetic surgery to change facial characteristics of children with Down syndrome? c. What are the physical/intellectual development patterns in Down syndrome? (poor coordination, poor muscle tone, delayed physical development, deficits in short-term memory, poor auditory memory, telegraphic speech, high level abstraction, usually moderately mentally retarded) d. What is unique about the aging process in some individuals with Down syndrome? (They suffer from decline in cognitive ability beginning at age 40. Autopsies of individuals, even before the age of 30, also indicate the formation of plaques and neurofibrillary tangles as seen in Alzheimer’s.) e. Have you seen individuals with Down syndrome in films or television? How do you think they are able to perform at that level?

STUDENT ACTIVITIES Classroom Activities 1. Show snippets from three movies and a TVprogram: Rain Man, Forrest Gump, What's Eating Gilbert Grape? and Life Goes On. Have the class discuss the different characteristics seen in the characters in the programs. Are the portrayals authentic? Are the situations realistic? Were any inconsistencies noted? 2. Rett’s syndrome gene located - the announcement/abstract is located at http://www.nichd.nih.gov/new/releases/retgene.htm. Read the article and address the following questions: a. If gene modification would be able to correct Rett’s syndrome would you favor it? b. If the procedure was expensive, how would you determine who received the treatment and who would not? Assignment 1. Geraldine Dawson, at the 2001 meeting of the Society for Research in Child Development, reported the results of a study that indicates that an impairment in face recognition may turn out to be one of the earliest indicators of abnormal brain development in autism (http://www.sciencedaily.com/releases\2001\04\010418072256.htm). Facial recognition seems to occur in an area of the brain, the right middle fusiform gyrus, and may be different from recognition of other objects but may be used in the recognition of novel objects. Using the “eskimo or face” illusion, ask a few students to participate in a brief recognition experiment. Ask them the following questions:

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• • • • • • • • 2.

What is your earliest memory of a face? Whose face was it? How old were you at the time of the memory? How easy is it for you to recognize familiar faces? How easy is it for you to recognize unfamiliar faces? Do you have trouble remembering faces? Which faces are easiest for you to remember? Which faces are most difficult for you to remember?

Watch the original movie, Charly or the re-make of Flowers for Algernon. For class discussion answer the questions given in the Student Activity Handout.

Critical Writing Asperger’s syndrome was characterized in the DSM-IV in 1994. Rett syndrome was identified in 1965. More and more refined descriptions of symptoms that form a “syndrome” are going to be identified. What is the effect of the ever increasing identification of new syndromes. If a child is identified with a syndrome, does it really help the child? If so, how? If not, what are your reasons? Does our society really need to have a highly specialized way of identifying different syndromes? Will children be sorted by ability and syndrome and educated according to our “perceived” limits of their talents? Are they being sorted now? Should the way we teach in school be changed to accommodate all types regardless of “syndrome”? Great Books to Read Blatt, Burton, & Kaplan, Fred. (June 1974). Christmas in Purgatory. Syracuse, NY: Human Policy Press. ISBN:0937540005. Davalos, Sandra. (November 1999). Making Sense of Art: Sensory-Based Art Activities for Children with Autism, Asperger Syndrome, and Pervasive Developmental Disorders. Shawnee Mission, KS: Autism Asperger. Fowler Mary Cahill. (1999). Maybe You Know My Kid : A Parent's Guide to Identifying, Understanding, and Helping Your Child with Attention Deficit Hyperactivity Disorder. New York: Birch Lane Press/Carol Publishing Group. ISBN: 0967251443. Kleinfeld, Judith, Morse, Barbara, & Wesscott, Siobhan. (November 2000). Fantastic Antone Grows Up : Adolescents and Adults with Fetal Alcohol Syndrome. Fairbanks, AK: Univ of Alaska Press. ISBN: 1889963119. Peek, Kim & Peek, Frank (1997). The Real Rain Man. Salt Lake City: Harkness Pub Consultants; ISBN: 0965116301. Quinn, Barbara,& Malone, Anthony. (April 2000). Pervasive Developmental Disorder: An Altered Perspective. London: Jessica Kingsley Publishers. ISBN: 1853028762. Waltz, Mitzi. (July 1999). Pervasive Developmental Disorders: Finding a Diagnosis and Getting Help. Cambridge, MA: O'Reilly & Associates. ISBN: 1565925300. VIDEO RESOURCES Professional A Boy Named Terry, 58 min. (IU). This video describes the treatment of an autistic boy. Autism, 29 min. (Insight Media). This video explores causes, symptoms, and treatments of autism. Coming to Terms with Pervasive Developmental Disorders, 50 min. (University of Pennsylvania). Two families with children diagnosed as having PDD learn to cope with their situations. May's Miracle: A Retarded Youth with a Gift for Music, 28 min. (FL). A child who is blind and suffers from mental retardation, with cerebral palsy, and who is described as a "savant," demonstrates her outstanding musical talents. One Child in a Hundred, 20 min. (Time-Life Films). This video shows techniques used in working with. children who are mentally retarded and the problems that arise when living with a mentally retarded child. Patient as Educators: Case #5, Billy, Autism, (Prentice Hall Videos). This video presents a three-year-old child who displays some of the common symptoms of autism. The World of Abnormal Psychology: Behavior Disorders in Children (Tape 11), 60 min. (Annenberg/CPB).

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Video Autism (20/20), 12 min. (ABC News/Prentice Hall Video Library Abnormal Psychology Series III, Cassette Three). Free from Silence (Primetime Live), (ABC News/Prentice Hall Library #1). Facilitated communication with autistic children is examined. This technique used a keyboard and a facilitator to guide the child. The method is highly controversial and many authorities doubt its validity. Intelligence, 30 min. (Insight Media). The differences between mental retardation and the gifted are discussed. The use of IQ tests are also investigated. Silent Angels. (2001) 60 min. With Julia Roberts (a Discovery Health film). Silent Angels tells the tale of courageous families and determined genetic researchers as they strive to find answers to a debilitating neurological condition called Rett syndrome. Rett syndrome is estimated to affect more than 200,000 girls and women worldwide - International Rett Syndrome Association (2001). The Real Rain Man: Kim Peak, Savant (20/20, 1-7-94), (ABC News/ Prentice Hall Library #2). Kim Peak, the model for Rain Man, is profiled. Williams' Syndrome (60 Minutes 7-5-98) 20 min. (CBS). This outstanding program presents adults who suffer from Williams' syndrome. Their intelligence, personality traits, and problems are profiled through interviews with the individuals themselves. Movie Flowers for Algernon (2000) or Charly (1968). A content, developmentally disabled man is chosen for an experimental operation which results in his becoming a genius. The main character, Charly Gordon, keeps a journal of his progress throughout the story. The treatment works for a while and Charly passes through a “normal” life to that of a highly intelligent “professorial” type. At some point in time the treatment not only fails to sustain the level of intelligence, but the process begins to reverse itself. Forrest Gump (1994).Tom Hanks plays Forrest, a boy turned man with a marginal IQ. He discovers that he is a very fast runner and that the skill has helped him manage his way out of many situations. He has a unique philosophy of life that keeps him sailing through good and bad. Forrest lives his life not for this, but for his friends and for his childhood sweetheart, Jenny (Robin Wright). Rain Man. (1988). Charlie Babbage (Tom Cruise) discovers he has a brother Raymond (Dustin Huffman). Raymond suffers from autism and has been institutionalized since he was a small child. As first Raymond is an incredible pain but Charlie soon learns about Raymond’s special savant skills. Through a Glass Darkly. (1961). One of Ingmar Bergman's most somber films about a young schizophrenic woman, her husband, her family, and a remote Swedish island. A visually esthetic film by one of the 20th-century's great film makers. A dark film that seeks existential truth through more than psychological accuracy. CHAPTER OUTLINE I. Pervasive Developmental Disorders (Table 16-1, pg. 516, Characteristics of developmental disorders) A. Autistic Disorder (Table 16-2, pg. 517, Characteristics of autistic disorder) 1. Autistic disorder is characterized by an unusual pattern of social and cognitive development beginning in childhood, with marked difficulties in social interactions and communication. a. Boys are four to five times more likely to be autistic. b. Many cases of autism are associated with mental retardation. 2. Characteristics of Autistic Disorder a. Autistic individuals show very little, if any, awareness for others around them. Approximately half of all autistic children never learn to speak, and those that do, usually have odd patterns of speech. b. Routine is extremely important for people with autism. c. Reject cuddling and being held

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3. Cognitive Deficits a. Theory of mind and in executive functions have been the focus of research in autism. It refers to the ability to attribute mental states such as desire, knowledge, and belief to oneself as well as others as a way of explaining behavior. b. Temple Grandin - development of the squeeze box to alleviate anxiety c. Most people with autism have cognitive deficits, likely in the prefrontal cortex where the executive functions are located. d. Children with autism appear incapable of participating in symbolic play because they cannot derive second-order or meta-representations. e. Autistic individuals have difficulty in perspective taking. f. Uneven development in cognitive abilities - perhaps savant development g. A lack of interest in or avoidance of social activities can be an early sign of autism. 4. Language Difficulties a. Many remain mute. b. Egocentric speech - lack of taking another’s perspective. 5. Social and Affective Deficits - Children with autism are unable to form secure attachments to care givers, despite their difficulties making emotional and physical connections with others. 6. Diagnosis of Autism a. No one is sure which aspects of neurobiological makeup and function are involved in autism. b. Genetic factors may be important in the development of autism. c. Diagnostic predictors: (Table 16-3, pg. 522, Parental concerns for autism) 7. Biological Perspective a. Brain structure and function b. Larger temporal, parietal, occipital lobes c. Relationship between epilepsy and autism d. Genetic research on autistic disorder 1) MZ twins do not have 100% correlation for autism (Figure 16-, pg. 424, Results of twin studies) 2) At-birth injuries are a factor 3) Suspect gene found (http://www.nih.gov/news/pr/nov2000/nichd-27.htm) 4) Biochemical markers 8. Treatment a. Behavioral training b. Sensory integration training c. TEACCH 9. High-functioning Autism a. Above 70 IQ b. Rigidity in behavior c. Social interaction problems 10. Autistic disorder is sometimes confused with childhood schizophrenia. (Table 16-4, pg. 525, Comparisons between autism and childhood schizophrenia) 11. There is no known cure for autism, but early interventions have been found to improve later development. B. Asperger's Disorder (Table 16-5, pg. 529, Diagnostic criteria for Asperger’s disorder) 1. Asperger's disorder is similar to autistic disorder in that there are significant impairments in social interactions and restricted and repetitive patterns of behavior; however, there are no language or cognitive delays. 2. There has been controversy surrounding the diagnosis since its introduction to the DSMIV. May be part of autism spectrum or a separate disorder. 3. Characteristics: a. No delay in language but it may be stilted, and repetitive b. Motor clumsiness c. Fine motor difficulties

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d. Social interactions, may be the “loner” 4. Biological Factors: a. CT scans similar to autism b. Parent shows similar responses in a task to understand the feelings of others. 5. Some differences in brain functioning have been found between control group children and children with Asperger's disorder. C. Childhood Disintegrative Disorder (Table 16-6, pg. 530, Diagnostic criteria for Asperger’s disorder) 1. The first symptoms of the disorder appear around the age of 3 or 4 after the child has progressed through normal developmental stages. 2. It appears to be associated with a deterioration of the central nervous system. 3. The disorder is extremely rare, occurring only once in every million births. D. Rett’s Disorder (Table 16-7, pg. 531, Diagnostic criteria for Rett’s disorder) 1. The disorder first appears between 5 and 48 months of age when the child gradually develops microcephaly. 2. Previously learned skills are lost during this time and peculiar motor functioning develops. 3. Seizures are common by age four. 4. It is very rare for boys to develop Rett's disorder. 5. Because most children with this disorder become severely mentally retarded, behavioral treatments tend to be the most common techniques used to treat the disorder. E. Is There an Autistic Spectrum? (Table 16-8, pg. 532, Components of programs for person’s with Autistic spectrum) 1. Same causes, different evolution and presentation 2. Many have commonalities between symptoms 3. Suggested classification system: a. Aloof - indifference to others b. Passive - accept the approach of other c. Active but Odd - social advances but they are odd or inappropriate to the situation d. Loners - concerned primarily with their own interests II.

Mental Retardation (Table 16-9, pg. 532, Diagnostic criteria for mental retardation; Table 16-10, pg. 533, Categories of mental retardation) A. Historical Views of Mental Retardation 1. In 1877 John Down was the first to suggest that mental retardation is not a homogeneous disorder. 2. Gregor Mendel's work with genetics spawned the idea that mental retardation was inherited. 3. The eugenics movement sought to sterilize people who were mentally retarded so that the genetic stock of the population could be improved. 4. Alfred Binet's tests for selecting students for specialized education were used to diagnose and institutionalize people with mental retardation in the U.S. 5. Much of the terminology associated with the diagnosis of mental retardation is thought to be degrading. B. Causes of Mental Retardation 1. Factors prior to birth, including alcohol, chemicals, and radiation, can also cause mental retardation. 2. Trauma during birth, causing a lack of oxygen for the baby, can play a role in the development of mental retardation. 3. Tuberous sclerosis is a disorder in which two-thirds of all children with the disorder are diagnosed as mentally retarded and their cognitive skills deteriorate over time. 4. Phenylketonuria involves an inability to metabolize phenylalanine, which can cause mental retardation once levels become too high in the body. 5. Streptococcus/Type B C. Fragile X Syndrome 1. Many forms of mental retardation are linked to genes on the X chromosome. (Figure 1612, pg. 536, Mutated X-chromosome)

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2. Fragile X syndrome is the most common form of inherited mental retardation. 3. The gene responsible for fragile X syndrome has recently been identified. 4. The typical appearance of people with this disorder includes a long face, prominent forehead, and large ears. Down Syndrome 1. Down syndrome is caused by a chromosomal abnormality in the twenty-first chromosome pair. (Figure 16-13, pg. 536) 2. The physical features characteristic of this disorder include a flat face, small nose, eyes that appear to slant upward, slightly protruding lips and tongues, small ears, and small square hands with short fingers and a curved fifth finger. (Figure 16-14, pg. 537) 3. Nondisjunction is by far the most common abnormality that causes Down syndrome. 4. Translocation and mosaicism are two other chromosornal abnormalities responsible for the disorder. 5. Throughout preschool, children with Down syndrome are usually only slightly behind their peers cognitively, but their physical coordination lags far behind. 6. By the time these children reach school age, their cognitive abilities become noticeably less than those of their peers. 7. Intervention programs have attempted to increase the cognitive and physical skills of individuals with Down syndrome. 8. There is a high risk for people with Down syndrome to develop Alzheimer's disease. Figure 16-15, pg. 538) The Fetal Environment and Mental Retardation. 1. Prenatal factors can cause a child to be born mentally retarded. 2. Approximately half of all children born to mothers who contract the rubella virus early in pregnancy are born mentally retarded. 3. A variety of bacterial infections suffered by the mother, including HIV, herpes, or syphilis, can cause mental retardation. 4. An incompatibility between mother and fetus Rh, chemical factors, and chronic medical conditions can also play a role in the development of mental retardation. Fetal Alcohol Syndrome (Figure 16-16, pg. 539, Child affected by FAS) 1. Children with FAS can be recognized by their small eyes, drooping eyelids, short upturned nose with a low bridge, flat cheeks, thin upper lip, low-set ears, bulging forehead, and an unusually large distance between the nose and mouth. 2. Approximately 4% of children born to mothers who are heavy drinkers will be diagnosed with FAS. 3. Children born to mothers who were lighter drinkers may also face cognitive difficulties even if they do not exhibit the facial deformities. Problems During and After Birth 1. Approximately 10% to 20% of all people who are mentally retarded experienced some trauma or accident during the birth process. 2. Premature birth, low birth weight, lack of oxygen during birth, and a too rapid progress through the birth canal have all been associated with mental retardation. 3. Many factors can damage an infant's nervous system after birth and cause mental retardation. Psychosocial Disadvantage 1. Some people may receive a diagnosis of mental retardation because they are born to parents with lower than average IQs and they are not born into an intellectually stimulating environment. 2. Some research has shown that 20% to 50% of all variations in intelligence can be attributed to the environment. Types of Prevention and Interventions in Mental Retardation. 1. Primary prevention seeks to prevent mental retardation from occurring in such ways as warning pregnant women about the dangers of alcohol to the fetus. 2. Secondary prevention attempts to help children born at risk for mental retardation such as children born with PKU.

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3. Tertiary prevention tries to improve life situations for those already diagnosed as mentally retarded by providing intervention programs and community living programs.

Early Intervention Programs 1. These programs are typically aimed toward children believed to be at a high risk for mild retardation. 2. Children from economically deprived homes with a mother whose intelligence scores are in the mildly retarded range are considered to be high risk. 3. Due to many legal rulings, public schools are required to provide skills training to the mentally retarded. 4. Many people are fighting to allow children with mental retardation to be taught in the regular classrooms. K. Vocational and Social Skills Training Programs 1. Many programs strive to teach job skills, hygiene skills, and social skills to survive in the "real world." 2. Behavioral methods are commonly used in these programs. L. Recognition and Treatment of Psychological Problems. 1. As many as 40% of people with mental retardation also meet the criteria for a diagnosis of a psychological disorder. 2. Some psychological disorders have been found to be linked to the same central nervous system damage that caused the mental retardation. 3. The social isolation that often accompanies mental retardation may be a factor in developing personality disorders. M. The Families of Mentally Retarded Children 1. Upon finding out that a child is mentally retarded, many parents experience a grieving period similar to that following the death of a loved one. 2. Many parents have such high hopes for their child's development, that they overestimate the child's abilities. 3. Moving through different developmental stages appears to cause a great deal of stress to the families of the mentally retarded. 4. Aging parents have difficult choices to make regarding their own health and the future of their retarded child. III. Take-Away Message WEB LINKS Asperger’s Disorder - http://www.ummed.edu/pub/o/ozbayrak/asperger.html A site devoted to Asperger’s syndrome. Asperger’s Resources - http://www.udel.edu/bkirby/asperger/#Education Information about support groups and other resources relating to Asperger’s syndrome. Autism Society - http://www.autism-society.org/ Information on autism and Asperger’s syndrome. Autism Center of the University of Washington - http://depts.washington.edu/uwautism/ Autism Resources - http://www.autism-resources.com/ A compilation of Internet resources related to autism. Cognitive Assessment of Children with fragile X Syndrome - http://www.nfxf.org/Testing/testing.htm This article explains the types of assessments used, and what we know about the cognitive deficits of children with fragile X syndrome. Controversial Topics Related to Autism - http://www.autism-resources.com/autismfaq-cont.html Controversies about the origins and treatment of autism. Fetal Alcohol Syndrome Family Resource Institute - http://www.accessone.com/~delindam/ For Children with Asperger’s Syndrome - http://www.udel.edu/bkirby/asperger/#Education Strategies for children suffering from Asperger’s. FRAXA Research Foundation - http://www.FRAXA.org/. Information about fragile X research.

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Frequently Asked Questions about Mental Retardation - http://www.thearc.org/faqs/mrqa.html Information from the ARC organization. Genetic Causes of Mental Retardation - http://www.thearc.org/faqs/causeq&a.html History of Autism - http://www.autism-resources.com/autismfaq-hist.html How perspectives of autism have changed over time. History of Mental Retardation in the United States - http://members.aol.com/MRandDD/introhx.htm How perceptions about MR have changed over the years. Lead Poisoning and Mental Retardation - http://www.thearc.org/faqs/leadqa.html How exposure to lead affects a child’s physical and mental development. Maternal Alcohol Use and Risk for Mental Retardation - http://www.thearc.org/faqs/fas.html National Association for Down Syndrome (NADS) - http://www.nads.org/ National Down Syndrome Society - http://www.ndss.org/ - National Fragile X Foundation – http://www.nfxf.org/.Information for families with fragile X children. National Institute of Child Health and Human Development - http://www.nichd.nih.gov/autism/ Federal website that maintains information and statistics about developmental disorders Pervasive Developmental Disorders - http://www.udel.edu/bkirby/asperger/#Education A scholarly introduction to the topic of pervasive developmental disorders. PKU - http://thearc.org/faqs/pku.html - The cause of PKU and how it is treated. Rett’s Syndrome Organization - http://www.rettsyndrome.org/ The ARC - http://www.thearc.org/ - National organization serving people with mental retardation. The Autism Continuum - http://www.udel.edu/bkirby/asperger/#Education A scholarly examination of Autistic disorder, Asperger’s syndrome, ant the autism continuum.

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Student Activity - Flowers for Algernon or Charly While watching the film answer the following questions: What is Charly's IQ in the beginning of the story? Why does Charly go to Miss Kinnian's class? What does Charly see the first time he is given the Rorschach test? Why is Charly chosen for the experiment? Before the operation, what does Charly think of Joe Carp and Frank Reilly? How do they treat him? What does it mean to "do a Charly Gordon"? What are the differences between the two doctors? How can the reader tell that Charly is getting smarter after the operation? Explain Charly's feeling toward Algernon before and after the operation. What is the significance of Charly' second outing with Joe and Frank? Why does Charly lose his job? How do Charly's feelings toward Miss Kinnian change throughout the story? How do Charly's feelings toward the doctors change after the operation? Why was Charly upset about the incident with the dishwasher? What is the Algernon-Gordon Effect? What does Charly do when he realizes he will lose his intelligence? When Charly returns to the factory, how do his co-workers react? How does Miss Kinnian react when Charly returns to night school? Why? Whom does Charly blame for his loss of intelligence? Why? What happens to Charly's personality once he becomes a genius? How does he relate to other people? How do Charly's progress reports change after the operation?

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Chapter 17 Society's Response to Maladaptive Behavior OVERVIEW Chapter 17 discusses avenues of prevention for mental disorders in our society. Primary prevention is concerned with a reduction in new cases of disorders; secondary prevention is concerned with the reduction of potential disability in high risk groups. Tertiary prevention is directed toward people already diagnosed as having a disorder. Areas of prevention discussed include the family, school, and community. Diverse paths of prevention include paraprofesionals, self-help groups, and community psychology programs. Problems and solutions related to community treatment systems are described and the legal aspects of institutionalization, the rights of patients, confidentiality, and the "duty to warn" are also discussed. CONTENTS Types of Prevention Levels of Preventions Situation-Focused and Competency-Focused Prevention Sites of Prevention The Family The School The Community Diverse Paths to Prevention Community Psychology Paraprofessoinals Self-Help Groups Treatment in the Community Problems with Community Programs Improving Treatment in the Community Legal Aspects of Treatment and Prevention Institutionalization The Rights of Patients Confidentiality and the Duty to Warn A Final Word Take-Away Message LEARNING OBJECTIVES After completing this chapter students should be able to: 1. Outline the different levels of prevention and give examples of each. 2. Describe the importance of the family, the school, and the community in preventing disorders. 3. Understand the importance of paraprofessionals, self-help groups, and community psychology in prevention. 4. Discuss the problems in today's community treatment programs. 5. Offer suggestions for improving treatment in the community. 6. Discuss the legal aspects of treatment and prevention including institutionalization, the rights of patients. 7. List three myths about the insanity defense (pg. 611). LECTURE AND DISCUSSION 1. Discuss examples of primary prevention programs in your community. Have the class discuss some of the programs in the community that provide primary prevention of mental disorders. Include the following programs: a. Commercials on buses, TV, radio, and newspapers that warn women about the dangers of smoking while pregnant. (low weight birth is related to smoking and is sometimes related to later difficulties in the child)

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b. c.

Commercials on buses, TV, radio, and newspapers that warn women about drinking and pregnancy. Fetal alcohol syndrome. Ad council ads, March of Dime ads. Public service ads that encourage women to obtain prenatal care and instructs them to seek the advice of their physicians about taking any drug during their pregnancy.

2. Investigate prevention programs targeting students and faculty. Are signs up regarding hepatitis shots? Meningitis vaccination? Other communicable diseases? Do you have health information programs scheduled throughout the semester? Are there any stress management programs running on campus? Does your college run any special stress management programs before midterms and finals? 3. Discuss the impact of child abuse on mental disorders. Discuss some of the results of physical abuse to children. a. Brain injury b. Mental retardation c. Posttraumatic stress d. Anger and aggressive patterns e. Continuation of poor parenting patterns f. Conduct disorder g. Juvenile delinquency 4. How do these problems impact the community? Discuss some community programs and family center programs that might assist in aiding parents with their parenting skills. a. Counseling programs for couples prior to marriage b. Counseling programs for pregnant women and their spouses c. Counseling programs for parents that focus on stress/anger management d. Counseling programs for parents in trouble e. Group counseling for parents f. Support groups that provide suggestions and encouragement 5. Discuss juvenile delinquency. Discuss what are believed to be factors related to juvenile delinquency and the rising incidence of violence in children. a. Availability of drugs b. Availability of guns c. Early exposure to violence d. Exposure to antisocial role models e. Lack of parental direction f. Absence of father from household g. Poor neighborhood environment h. Lack of internal control i. Influence of violence on TV j. Lack of hope or aspiration k. Unstable home environment l. Lack of encouragement for school achievement m. Lack of "favorable" expectations from others 6. Discuss how a community can assist in overcoming high rates of juvenile delinquency. Include programs for social development, education, sports, music, counseling, after-school care, jobs, afterschool involvement, parental help, city-wide participation. 7. Discuss some of the myths about suicide and some of the warning signs. Myth: People who say "I wish I'd never been born"; "I wish I were dead"; "I feel like killing myself'; or "You're going to be sorry one of these days when I'm not here" are not at risk for suicide. These

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statements indicate that the person will not commit suicide. What is the truth? These are warning signs. Myth: People who are really going to kill themselves give no warnings. What is the truth? People usually give warning statements and signs. Warning signs: a. Verbal comments: “I wish I were dead.” b. Behavioral changes: giving away possessions and treasured mementos. c. Taking life threatening risks, having accidents, physical complaints and complaints of loneliness, agitation, irritability, eating changes, sleep changes, withdrawal, lack of pleasure, changes in relationships, employment, etc. Have the class list other warning signs. What ways of helping a suicidal individual do they suggest? 8. Have the class discuss the relationship between "Client-Therapist" confidentiality and “Duty to Warn.” Pose this question to the class: “You are a psychologist for a large state university. A student makes an appointment with you. When he arrives, he is sweating, agitated, and tells you that he has been having severe headaches. During the interview, he also relates to you a desire to ‘go to the campus quad and shoot as many people as I can.’” What would you do? Ethically should you be quiet and try to help the young student through psychotherapy? Wait a week and see if he feels better? Refer him to someone else very quickly? Legally, should you call the police? Should you warn the university administration? Do you know of similar situations like this? Mention the text's discussion of the University of California case, the University of Texas tower incident where a student killed or wounded over 40 individuals, and the recent public school shootings. STUDENT ACTIVITIES Classroom 1. Ask the class members to form groups of up to 6 students. Each group will engage in the following tasks: a. The group is a mental health/mental retardation service provider in the community. b. The group develops a mission statement that states their service population, the type of service they provide, and their prevention program. c. The group develops a statement of prevention for their target population. d. The group selects one person to be their representative on the Health & Welfare Council (HWC). e. The HWC meets to develop service cooperation and identify service overlaps and service gaps. f. The analysis is returned to the groups for them to redefine their mission and their prevention program. This exercise quickly brings the issues in service provision to the forefront where it becomes obvious that planning for services 1) cannot be a solitary activity and 2) consumer needs should drive the provision of services, not the preferences of the providers. 2. Have an invited speaker from a homeless shelter (example: Salvation Army) to give a presentation to the class. Have the speaker include: estimated numbers of homeless people, causes for homelessness, percentages of individuals with alcohol problems, percentages of individuals with mental disorders, and percentages of individuals who are mentally retarded or have borderline intelligence. Have the speaker discuss the programs provided with the agency and specific programs aimed at individuals with some of the above mentioned problems. Critical Writing One of the most difficult programs the government has had to implement is the welfare-to-work program. It will be extremely hard for the mentally disabled to survive in a job-driven environment. The minimum wage in this country is not sufficient to provide a “living wage” - enough to pay rent, buy food, clothing,

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etc. Write about the dilemma of the mental health consumer, his/her needs, capabilities, and vulnerabilities. Are there services that can be provided to enable the consumer to live independently? Great Books to Read Devencenzi, Jayne & Pendergast, Susan (March 1999). Belonging: Self and Social Discovery for Children and Adolescents : A Guide for Group Facilitators. Carson, CA: Jalmar Press; ISBN: 0965602524. Eastman, Nigel & Peay, Jill (December 1998). Law Without Enforcement: Integrating Mental Health and Justice. London: Hart Publishing; ISBN: 1901362752. Kraizer, Sherryll & Kornblum, Mary (August 1996). The Safe Child Book : A Commonsense Approach to Protecting Children and Teaching Children to Protect Themselves. New York: Fireside; ISBN: 0684814234. Pilisuk, Marc & Pilisuk, Phyllis (May 1973). How We Lost the War on Poverty. Somerset, NJ: Transaction Publishers; ISBN: 0878555749. Valentine, Bill (October 1995). Gang Intelligence Manual :Identifying and Understanding Modern-Day Violent Gangs in the United States. Denver: Paladin Press; ISBN: 0873648447. VIDEO RESOURCES Professional Commitment Evaluation, 20 min. (IU). This video demonstrates the process a patient follows while being committed to a psychiatric hospital. Crime and Insanity, 52 min. (Films, Inc.). The issue of releasing patients from mental hospitals when they are deemed to be no longer dangerous is discussed. The World of Abnormal Psychology: An Ounce of Prevention (Tape 13), 60 min. (Annenberg/CPB). This film covers proposals for the prevention of disorders. Video What Ever Happened to Our Son? (20/20 8/2/98 ABC News/Prentice Hall Library #1). Movie King of Hearts (1966). French WWI town abandoned by everyone except people from an insane asylum. The Dream Team (1989). Four people from a mental institution go to a baseball game with their psychiatrist. The psychiatrist witnesses a murder, then gets knocked down and taken to the hospital. The four men are on their own in the city and work against the 'bad guys' to save the psychiatrist who is in danger as a witness. The movie is going for laughs and is funny at times, but it appears that there was not much thought put into the story. CHAPTER OUTLINE I. Types of Prevention- Levels of Prevention A. Primary prevention is concerned with reducing the number of new cases of disorders and is aimed toward everyone in a given population. B. Secondary prevention is limited to a subgroup of the population believed to be at a higher risk than the general population. C. Tertiary prevention strives to reduce the level of impairment for those already diagnosed with a disorder. D. Juvenile delinquency is a problem that may be targeted with all three forms of prevention. (See Figure 17-1, pg. 553) E. There are two different perspectives on prevention. 1. Situation-focused prevention targets environmental causes of a disorder. 2. Competency-focused prevention seeks to improve one's coping skills. II. Sites of Prevention A. The Family 1. Because much of a child's early learning and development take place in a family setting, prevention in the family is extremely important. 2. Self-help groups for parents of young children have been found to be useful.

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Certain parenting practices can increase aggression in children. (Table 17-1, pg. 556, Parenting practices linked to aggression) 4. Parental disorders may also affect a child's development. 5. Children who have been abused or neglected are at a much higher risk for maladaptive behaviors and other disorders. (Table 17-2, pg. 557, Characteristics of abusing families) 6. Spousal abuse occurs in several million U.S. homes every year. 7. Preventative steps taken before a divorce can greatly reduce the detrimental effect on the children. 8. Parental training has been helpful in teaching parents to respond therapeutically to their children. 9. A mentally ill family member can place a great deal of stress on the entire family. B. The School 1. Early detection programs are implemented in schools to detect children who may be at a higher risk for severe adjustment problems. 2. Many long-standing problems are not recognized until a child reaches school age. 3. Once a problem is recognized by the school, treatment may be difficult if the families resist. 4. Table 17-3 (pg. 559) Methods for preventing school failure/dropout C. The Community 1. Children living in unfavorable conditions respond very positively to early intervention programs such as Head Start. 2. After school is out, many children are left with little to do in their communities. 3. How communities function is important in trying to establish adaptive behavior in it's members. 4. Finding a gratifying job is very important to one's satisfaction with life. 5. Community agencies are able to reach a wide variety of people and provide support both formally and informally. 6. Many community centers have been established to prevent suicide. III. The Diverse Paths to Prevention A. Community Psychology 1. Social systems as prevention for distress are the main focus of community psychology. 2. Community psychologists work directly with a community to make it more livable. 3. Community psychology can take place in existing community institutions or in specially developed centers. B. Paraprofessionals 1. Nonprofessionals and paraprofesionals have been trained to play significant roles in the community. 2. Paraprofessionals are often very successful due to their similarities to the clientele. 3. Early research has shown that paraprofesionals may be as effective as professionals. C. Self-help groups (Table 17-4, pg. 563, Self-help groups) 1. Many people find support in self-help groups that they cannot find in formal health care or social and community service programs. 2. Self-help groups allow a person to feel supported as well as feeling helpful for others. 3. Alcoholics Anonymous is one of the most well-known self-help groups. D. Treatment in the Community (Problems with community programs): 1. The mental health system has been described as disjointed, fragmented, and ineffective. 2. A chronically ill patient may encounter several different therapists who give several different diagnoses and prescribe several different treatments over their treatment period. 3. Bouncing from institution to institution is a serious problem for the chronically ill. E. Improving Treatment in the Community 1. Experiments designed to improve treatment options are greatly needed, but are rarely performed. 2. Partial hospitalization is a possibility that may improve care in the U.S. 3. Deinstitutionalized patients must be provided with vocational training, guidance in self-care, and recreational activities. 4. Public education on mental illness is extremely important.

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IV. Legal Aspects of Treatment and Prevention A. Institutionalization 1. Commitment is the act of placing a person in an institution. a. Criminal commitment may occur when a crime is judged to have been committed as a result of insanity. b. Civil commitment occurs when a person is unwilling to be committed, but it has been determined that the individual is a risk to himself or to others. 2. The insanity defense (Table 17-5, pg. 571, Myths about insanity defense) a. The M'Naughten rule is applied in determining insanity. b. Durham rule related to responsibility for crime by insanity c. The number of successful insanity defenses is very small. 3. Parens Patriae is the doctrine which allows the state to commit someone against their will if it is in his/her best interests. B. Civil Commitment Parens patriae is the doctrine which allows the state to commit someone against their will if it is in his/her best interests. C. Involuntary Commitment. 1. Most involuntary mental patients are prescribed various drug treatments and behavior control. 2. Recent court rulings have supported the right to the least restrictive treatment available. 3. Patients must give informed consent before treatment can be administered. 4. The institutionalization of children has caused much controversy over the rights of the parents in determining treatment. D. The rights of patients - Informed consent and receiving adequate information about treatment E. Confidentiality and the Duty to Warn 1. Confidentiality is not an absolute value. 2. Each state has specific laws. 3. A consumer can sign a waiver. 4. Therapists have a legal responsibility to warn potential victims of their client's dangerousness. 5. Many debates surround this ruling. V. A Final Word A. Theme of interaction throughout the book. B. Many researchers and therapists today have an optimistic outlook. C. The public appears increasingly willing to reevaluate the care provided to the mentally ill. D. Stigma reduction, education, prevention, research, and society's will to change are key ingredients in improving treatment. VI. Take-Away Message

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